Scenarios for Lower

G.I.
Case 1
A 20 years male presented with frequent passage of
blood mix stool for last 2 months. Frequency was about
8 to 10 times per day, associated with low grade
intermittent fever, abdominal pain, weight loss, joint
pain. Patient was treated several times by different
physicians without any improvements.

 How will you proceed to reach the diagnosis?

 What blood tests would you order?
 You order a colonoscopy.
 Biopsy done shows
 A diagnosis of UC is made. What is the
management?
 Your GI colleague refers the patient back to your
after 2 years because he has regular relapses despite
maximum medical therapy.
 What are different surgical options available?
 Is surgery curative?
Clinical Updates
 Medical management is effective in controlling ulcerative colitis, but ultimately 30–40% of
patients will require surgical intervention.
 Diagnosis is confirmed through a combination of history, exmaination, endoscopy and biopsy.
Imaging is not generally indicated but does prove useful in selected cases.
 Incidence rates for the development of cancer correspond to cumulative probabilities of 2% by 10
years, 8% by 20 years and 18% by 30 years.
 Surveillance colonoscopy every 1–2 years starting 8–10 years after a diagnosis of pancolitis, or
15 years after leftsided colitis.
 Chromoendoscopy (CE) has been repeatedly shown to increase the chance of detecting dysplasia
compared to standard colonoscopic surveillance.
 Any form of dysplasia (low or high grade) merits resection as the risk of malignancy is markedly
increase (24% in LGD vs 42% in HGD).
Clinical Updates
 Surgery is the only curative treatment.
 Indications for elective surgery consist of medical unresponsiveness, intolerability or
intractability, dysplasia or malignancy, growth retardation in children, and for the attempted
improvement of some extraintestinal manifestations.
 For elective surgery Subtotal colectomy with end ileostomy, Total proctocolectomy with
continent ileostomy or Total proctocolectomy with Ileorectal anastamosis are all valid options.
 Ileal pouch–anal anastomosis has become the most common continence-preserving procedure
performed in patients who are appropriate candidates. Contraindications include incontinence,
poor sphincter function and low rectal cancer.
CASE 2
Case 2

 A 34 years old male presents to you with perianal discharge.

 Ask relevant questions in history?

 Patient has a history of I & D for perianal abscess 1 year back.
 PR exam reveals an external opening at 8 o clock position. No internal opening
could be identified.
 How would you investigate?
 A fistulogram done reveals

 What is a better investigation for

perianal fistula?

 A diagnosis of trans sphincteric fistula is made. What are the management options?
 Operative vs non operative management?
 Fistulotomy vs Fistulectomy ?
 Seton vs LIFT vs Mucosal Advancement?
 You do an EUA and put a seton .
 What are cutting and draining setons and their issues?
 What is VAAFT and its problems?

Clinical updates
 80% of perianal fistula are due to cryptogenic anal gland abscesses.
 Other causes are Crohn’s disease, trauma, tuberculosis, immunosuppression, lymphogranuloma
venereum, rectal duplication and perianal actinomycosis.
 Fistulography is simple to perform but for complex fistula,it is largely been replaced with STIR
Sequence MRI and Endo-anal Ultrasound.
 Treatment depends on the location and anatomy of the fistula tract, amount of anal sphincter
involved in the fistula and the underlying disease process
 Anterior fistulas in women are dangerous and should only rarely be laid open.
 All modalities of treatment adhere by a few general principles:
 Obliteration of the internal opening is key to the success of treatment
 There should be good local sepsis control
 The part of the fistula tract that is outside the sphincter should be opened and drained
 If <30% of the sphincter muscle length is enveloped by the fistula tract, it can be safely cut without fear
of major incontinence.
 If >30% of the sphincter muscle length would be cut, then it would be safer to use a seton.
 Biopsies should be performed from the tract to rule out malignancy.
 For high fistula, Rectal mucosal advancement flap and Seton are associated with low
recurrence rates.
 Glue and Bioprosthetic plugs have higher recurrrence.
 The long term effectiveness of LIFT and VAAFT have not yet .
Case 3
75 Male presents to you with history of weight loss and anemia.
O/E he has a mass palpable in RIF. No other significant findings.

 How would you investigate?

 His Hb is 6.0. CEA is 2.
 Colonoscopy done showed a
growth in the caecum.

 Biopsy done showed mod diff adenoca.

 CT done shows

 What is the management plan?

 Patient underwent a right hemicolectomy with Central Vessel Ligation and complete mesocolic
resection. Explain the terms CVL and CME.
 Biopsy revealed a 9 cm T3N2 tumor with clear resection margins. 11/16 LNs were positive.
 What is the required pathological resection criteria for colon cancer?
 What is the next management plan?
 Which chemo would you offer this patient?
 What if the biopsy revealed an involved distal resection margin?
Case 4
 45yrs/male presented in emergency with H/O abdominal pain, vomiting & absolute
constipation for the last 7days.
 On examination there is abdominal distention and mild tenderness.

 What questions would you like to ask in history?

 How will you investigate this case?
 CEA level is 14.
 X ray abdomen shows
 Colonoscopy done shows

 CT done
 What is the management plan?
 Discuss the role of stenting in this case.
 Stenting facility isn't available. You perform an exploratory laparotomy. There is an obstructing
lesion at the sigmoid colon. What are the surgical options?
 You perform a hartman’s procedure. Biopsy of the specimen reveals a T3N2 tumor with 8/14 LNs
positive.
 What is the next treatment plan?
 When will you reverse her stoma.
 His father and a cousin died from colorectal cancer. What advise will you give to this patient and
her family?
Case 5
 A 30 year old female presents to you with history of abdominal pain, vomiting and altered bowel
habits with bleeding PR. She has had a significant weight loss is last 2 months.
 PR exam reveals a stenotic lesion 6 cm from the anal verge.
 Abdominal examination reveals distended abdomen.

 What is your provisional diagnosis?

 How would you investigate?
 Colonoscopy showed a lesion at 7 cm from the anal verge. Scope passed with difficulty. Rest of
the colon was unremarkable. Biopsy revelaed a Poorly Diff Adenocarcinoma.
 What is the next plan?
 What is the ideal investigation for local staging and metastatic workup for rectal cancer?
 CT Chest abdomen is negative for any mets.
 MRI pelvis shows a T3N1 tumor.
 What are the management options for Rectal Cancer?
 You send the patient to an oncologist for neoadjuvant chemoradiation but he refers her back to
you that the patient is obstructed.
 What are the options available to relieve her obstruction?
 You perform a loop ileostomy on your patient and send her for her neoadjuvant therapy.
 Your patient returns to you after treatment. What is the next plan?
 Assesment for surgery is done by repeating MRI pelvis and doing a PR examination.
Examination reveals a mobile stenotic lesion. MRI shows reduction in bulk of disease.
 What is the next plan?
 LAR vs APR??? How to decide?
 You plan your patient for a low anterior resection. Is bowel prep required?
 Stapled vs hand sewen anastamosis?
 Is a covering ilesotomy required?
 You performed an LAR with a colorectal anastamosis and a covering ileostomy. Histopath shows
a T2N1 tumor with complete mesorectal excision. All margins cleared. 3/15 LNs positive.
 What is Total Mesorectal Excision?
 What is your next plan?
 How will you do surveillance on this patient?
 When will you reverse her stoma?
 Open vs. Lap vs. Robotic resections for rectal cancer. Is there a difference? Which
is better and why?
UPDATES & RECOMMENDATIONS
FOR COLORECTAL CANCER
 SCREENING
 Current recommendations are that individuals at high-moderate risk should be offered colonoscopy 5-yearly
5

starting at 50 years of age; those in the low-moderate risk group should be offered a one-off colonoscopy aged
55 years.
 PREOP STAGING
 All patients should have screening (preoperative where possible) for lung and liver metastases by CT scanning.
 PERIOP BLOOD TRANSFUSIONS
 Transusions have been reported to increase the risk of recurrence in bowel cancer
 BOWEL PREP:
 Bowel prep doesn’t prevent an anastamotic leak.
 Leaks happen due to technical failure or ischemia.
 Most leaks happen after the patient has started oral feeding making the concept of bowel prep useless.
 However if a leak does happen it will have worse clinical outcomes if bowel is full of stool.
 ANTIBIOTIC PROPHYLAXIS
 All patients should receive antibiotic prophylaxis, as there is good evidence from several randomised
trials that systemic antibiotics reduce the risk of sepsis after colorectal surgery
 A single dose of cephalosporin plus metronidazole is just as effective as a three-dose regimen in
preventing wound infection
 RESECTION FOR COLON CANCER
 Resection removes the lymphatic drainage that lies along the named arterial blood supply, thereby
rendering the associated colon ischaemic; thus, right hemicolectomy removes the ileocolic and right
colic arteries, transverse colectomy removes the middle colic artery and left hemicolectomy removes
the left colic artery.
 RECTAL CANCER
 Any tumour with a distal margin at 15 cm or less from the anal verge using a rigid
sigmoidoscope should be classified as rectal.
 ANASTAMOSIS
 The interrupted serosubmucosal method is adaptable to all colonic anastomoses and has the
lowest reported leak rate in the literature.
 STAPLER VS HANDSEWN ANASTAMOSIS
 There is no significant difference in outcomes.
 LAP VS OPEN
 Laparoscopic resection is not inferior to open resections.
 Laparoscopic surgery for colorectal cancer should be performed only by experienced
laparoscopic surgeons who have been properly trained in colorectal surgery
 DRAINS
 Drains do not serve any purpose and are not required after colonic or colorectal anastamosis.
 HISTOPATH
 All resected specimens should not be open and sent for histological evaluation intact.
 POST OP RECOVERY
 Fast Track or ERAS protocols are now followed for all patients undergoing colorectal surgery reducing
mean hospital stay to 3 days.
 ANASTAMOTIC LEAKS
 Pyrexia, Tachycardia and abdominal distention are early signs.
 CT with water soluble contrast enema is the investigation of choice.
 ADJUVANT THERAPY
 Adjuvant 5 FU is recommended for all Stage 3 colon cancers.
 Addition of oxaliplatin to 5-FU improves survival
 ADVANCED COLORECTAL CANCER (LIVER METS)
 With careful patient selection, hepatectomy for colorectal metastases can be associated with a 5-year
survival of around 33%,
 the most widely accepted criterion for resection is one to three resectable metastases in one lobe of the
liver, many surgeons are now extending their indications
 INOPERABLE DISEASE
 Palliative chemo 5 FU
 RECTAL CANCER
 STAGING
 MRI is the standard investigation to assess the status of the mesorectal fascia (the potential CRM), aiding selection for
neoadjuvant treatment.
 SURGERY
 Optimal outcome for rectal cancer requires adequate TME.
 Consider defunctioning stoma in low anterior resection.
 Extralevator APE (ELAPE) is recommended for advanced low rectal cancer and the prone position is increasingly
favoured.
 Patients should be warned that urinary and sexual dysfunction may follow rectal excision, whether for benign or malignant
disease.
 NEOADJUVANT THERAPY
 There is a strong evidence base demonstrating that preoperative radiotherapy reduces the risk of local recurrence after
resection of rectal cancer.
 All patients with T3 lesion or node positivity require neoadj chemoradiotherapy.
 Surveillance: H&PE with DRE, Proctoscopy q 3-6m, CEA & Colonoscopy & CT CAP at 1y. MRI for stage 2 and
3, PET scan is not recommended.