Transcript 3rd year Surgical Clerkship 546 Seminar

3rd year Surgical Clerkship 546 Seminar
Or
Why All-Bran is the
Panacea for (nearly all)
Coloanal ills
Haemorrhoids
Fissures &
Fistulae
Diverticular disease
Colorectal
cancer
Daily Recommended Fibre
Intake
Women
25 grams per day, < 50
21 grams per day, > 50
Men
38 grams per day, < 50
30 grams per day, > 50
Constipation
Ideal
Diarrhoea
Lewis SJ, Heaton KW (1997). "Stool form scale as a useful guide
to intestinal transit time". Scand. J. Gastroenterol. 32 (9): 920–
4.
So why constipation is bad and
how it may produce disease
• Haemorrhoids
– Hard stool (+ straining) traumatises anal mucosal cushions ->
oedematous & friable -> bleeding & prolapse
• Fissures
– Hard stool tears anal mucosa below dentate line -> exposes
internal sphincter -> anal spasm (+ ischaemia) -> pain & poor
healing -> opiate analgesia -> constipation……
• Diverticular disease
– “rabbit pellet” stools -> hypersegmentation -> high pressure
zones -> outpouching at sites of vessel penetration through
serosa -> diverticula
• Colorectal cancer (theoretical – evidence mixed)
– Constipation -> slow colonic transit -> longer time potential
carcinogens in contact with colonic mucosa (esp recto sigmoid)
-> polyp formation….
Anatomy
History & Physical
• Symptoms
– Bleeding
• bright/dark red on/on stool
• Painful/painless
– Discharge
• colour
– Itch
– Bowel habit
• Consistency
• Shape
– Family history
– Anal surgery
– Continence
• Stool
• Air
• Urgency
– History of IBD
• Signs
– “if you don’t put your finger in it –
you’ll put your foot in it”
– Inspect
• Prolapse
• Tags
• Pruritis
• patulousness
– DRE
• Anal canal 2-5cm
• Note anal tone
• Squeeze pressure
• Prostate/cervix
• Rectal mass
• Tenderness vs discomfort
– Proctosigmoidoscopy & anoscopy
Initial Management Algorithm of Bright
Rectal Bleeding
•
•
If < 50 years and bright red rectal bleeding and no change in bowel habit
• Rigid proctsigmoidoscopy
– Likely anal cause
If < 50 years family history of CRC (esp if occurred young), change in
bowel habit, pus or mucus
– Colonoscopy & rigid proctsigmoidoscopy
•
• r/o neoplasm or IBD
If > 50 years bright red rectal bleeding, no change in bowel habit
– Barium enema & rigid proctsigmoidoscopy
• Low suspicion for neoplasm
• Likely anal cause
•
– May identify diverticular diisease, IBS
If > 50 years and dark and bright blood, change in bowel habit or stool
– Colonoscopy (with call to GI otherwise might wait 5 months!)
• If –ve rigid proctsigmoidoscopy
NB what ever GI tell you the anal canal can not be
adequately be inspected by the colonoscope!
Rectal Bleeding: A Management Algorithm
< 50 yrs
BRRB + Alarm
Symptoms
Bright Red Rectal
Bleeding(BRRB) Only
Anal Cause
Rigid
Proctosimoidoscopy
Ensure Symptoms
are gone!
If No
> 50 yrs
Colonoscopy
Treat
Bright Red Rectal
Bleeding(BRRB) Only
Barium enema
Colonoscopy
Anal Cause
Warn pt of 10% error
If No
Rigid
Proctosimoidoscopy
Anal Cause
Rigid
Proctosimoidoscopy
Treat
Treat
BRRB + Alarm
Symptoms
Rigid
Proctosimoidoscopy
Treat
Treat
Colonoscopy
Alarm Symptoms: Change in bowel habits, blood on stool, mucus/puss, change in shape of stool, family history of CRC/polyps < 60
Note: Just because patient has a polyp/cancer, doesn’t mean they don’t have anal pathology!
Treat
Hemorrhoid (h m – roid) n.
dictionary.com definition
An itching or painful (only if thrombosed) mass of
dilated veins (No – bright red rectal bleeding) in
swollen anal tissue
Also called piles
Thrombosed external (veins)
[from Middle English emoroides, hemorrhoids, from Old
French emoroides, from Latin haemorrhoidae, from
Greek haimorrhoides, pl. of haimorrhois, from
haimorrhoos, flowing with blood: haimo, hemo- +
rhein, to flow]
Hemorrhoids
• St Fiacre’s Curse
– Patron saint of gardeners
– His prolapsed hemorrhoids cured by sitting
on a stone and prayer
• Aetiology myths
–
–
–
–
Prolonged driving
Cold benches
Spicy food
Manual labour
• Definition
– Dilated mucosal cushions
• Assist in differentiating liquid, solid and air
– Chronic straining leads to engorgement,
overlying mucosa becomes friable, bleeding
occurs from arterio-venous connections in
the mucosal cushions
Hemorrhoids
• Classification
– 1st degree
• Painless bleeding
– 2nd degree
• Prolapse on defecation
• Spontaneous reduction
• bleeding
– 3rd degree
• prolapse
• Manual reduction
• bleeding
– 4th degree
• Irreducible
• bleeding
PPH Stapled Hemorrhoidectomy
Ethicon J & J
Ligasure
Hemorrhoidectomy
Tyco Valleylab
Harmonic Scalpel
Thrombosed Hemorrhoid (pile)
Active Ingredients: Mineral Oil 14% (Protectant),
Petrolatum 71.9% (Protectant), Phenylephrine HCI
0.25% (Vasoconstrictor), Shark Liver Oil 3.0%
(Protectant)
Inactive Ingredients: Beeswax, Benzoic Acid, BHA,
Corn Oil, Glycerin, Lanolin, Lanolin Alcohol,
Methylparaben, Paraffin, Propylparaben, Thyme Oil,
Tocopherol, Water
Active
Ingredients: contains: Pramoxine
Hydrochloride (1%), Zinc Oxide
(12.5%), Mineral Oil
Inactive Ingredients: Benzyl Benzoate,
Calcium Phosphate Dibasic, Cocoa
Butter, Glyceryl Monooleate, Glyceryl
Monostearate, Kaolin, Peruvian Balsam,
Polyethylene Wax
Anal Fissure - Fissure-in-ano
•
•
•
•
•
•
•
•
Tear in anoderm
– Usually posterior
– Below dentate line
Acute
– Severe anal spasm
– Unable to sit
Chronic
– Pain (85%) on or following defecation
– Pruritis (15% – 40%)
Bright red blood on toilet paper (80%)
– Small amount
– cf hemorrhoids – drip into the toilet bowl
Anal spasm
– Tends to heal over days to weeks, but recurs (30%)
– Typical history 3 – 5 months
Associated with passage of constipated stool
– But localised ischemia plays a part
Anal tag (sentinel pile) (30%)
& fibrous anal polyp
Fibrous anal polyp 25%
Fissure
Anal tag (sentinel tag/pile) 70%
Associated findings: anal spasm 75%, hemorrhoids 35%
Anal fissure - non operative Rx
• Traditional
– Acute
•
•
•
•
•
Diet
Stool softeners
Sitz (salt baths)
5% xylocaine gel
NSAIDS
– Chronic
• Diet
• Stool softeners
• Sitz (salt baths)
– 50% heal 4-8 weeks
– 75% recur
• Newer
Chemical sphincterotomy
– Based on ischaemia and Nitric Oxide
• Vasodilatation
• Internal sphincter relaxation
– Topical 0.2% GTN paste 6 weeks
• 50% – 80% healing
• 15% Headaches
– Topical 2% diltiazem 9 weeks
• 65% – 75% healing
• Fewer side effects
– Botulinum Toxin injections
Recurrence rate 5%
Incontinence
air 5 -10% usually temporary
feces < 5% (beware the patient with poor tone pre-op
Bleeding, hematoma, abscess
Abscess & Fistula in Ano
• Fistula
– “ an abnormal connection between to
epithelial lined surfaces”
• Abscess
– A localized collection of pus
• Pus
– Fluid composed of bacteria and dead cells
– If perianal will contain fecal organsim e.coli, strept
fecalis etc cf “boil” staph
Rare – difficult to Rx, think IBD, Seton
2nd commonest – lots
of pus esp. in
diabetics, I&D in OR
Commonest – can be I&D in ER
Infrequent – often difficult to
diagnose, lots of pain nothing to
see, boggy on DRE, TRUS
True perianal sepsis is due to faecal organisms with over 50% recurrence rate with I&D alone
screening
Examination of people with no
symptoms, to detect unsuspected
disease.
surveillance
Oversight; watch; inspection
Origin: F, fr. Surveiller to watch
over; sur over + veiller to watch,
L. Vigilare. See Sur-, and Vigil.
Colorectal Cancer
•
Diagnosis
– Colonoscopy
• Routine wait time 5-6months!
• Risk of perforation 1 in 2-4,000
• Failure to reach ceacum rate 5 -15%
– Ba enema
• Not that bad but ………..
– 10 - ?% false negative rate
– Esp for polyps < 1cm
• Easier and quicker to get
– Polyp
• 2cm > 50% chance invasive ca
• Benign to malignant transformation 2-5yrs
Clinical Risk Factors for Colorectal
Cancer
• Polyposis syndromes
– Familial polyposis coli
– Gardner syndrome
– Peutz-Jeghers syndrome
(hamartomas)
– HNPCC
• 5% of CRC
• 80% will get
–
–
–
–
3 relatives with CRC
2 successive generations
CRC in relative < 50
Other cancers ovarian,
endometrial, bladder
• Pre-existing disease
– Ulcerative colitis
– Crohn’s disease
– Prior colorectal cancer
– Neoplastic polyps
– Pelvic irradiation
– Breast or genital tract
cancer
• General
– Age > 40 years
– Family history of CRC
Prognostic Risk Factors in Colorectal Cancer
•
Age
– Patients < 40 years of age often present with more advanced stage disease
• BUT stage for stage same prognosis
•
Symptoms
– Symptomatic patients tend to have more advanced stage disease
•
Obstruction and perforation
– Poorer prognosis when present
•
Location of primary
– Rectosigmoid & rectal cancers lower cure rates compared with colon cancer
•
Tumor configuration
– Exophytic tumors less advanced stage cancer compared with ulcerative tumors
Prognostic Risk Factors in Colorectal Cancer
• Perioperative blood transfusions during resection of primary
tumor
– Poorer survival rates
– Independent variable
• Not just worse tumours – bigger surgery
• anergy
• Poorer Prognosis
–
–
–
–
–
Blood vessel invasion
Lymphatic vessel invasion
Perineural invasion
Lymphocytic infiltration
Carcinoembryonic antigen
• when elevated pre op
History of Staging
• 1932 Dr Cuthbert Dukes of St Marks
Hospital City of London
– Links prognosis of patients with rectal
cancer to pathological stage
• Stage A – confined to bowel wall
90% survival
• Stage B – through bowel wall
60% survival
• Stage C – metastases to (resected) lymph
nodes
30% survival
Colectomy
Partial or complete removal of the colon
• Aim
– Remove symptoms
• bleeding
• obstruction
– Cure patient
• Take tumour and nodal basin
– Left hemicolectomy
– Right hemicolectomy
– Subtotal colectomy
• NEVER EVER transverse
• Question
– If N3 disease does extent of surgery
matter
• Surgical oncology principals – yes
• Biologic principals - ?
R
L
Colon Cancer Surgery
Colectomy
– 50% overall 5 year survival
• 90% if early
– Right or Left hemi-
• Ileocolic anstomoses leak less
than colo-colic
• (leak means fecal peritonitis,
intraperitoneal abscess, septic
shock, death - mortality equal
to age of pt)
– Subtotal
• If multiple polyps or cancers
– Never transverse
• High anastomotic failure
• High local recurrence
Ostomies loop or End
• Colostomy
– Semi-solid intermittent
– Left sided anastomotic failure
– Left sided obstruction
– Never Never Ever transverse
– Big and Smelly and liquid and bad position
– Loop for easier reversal need enough length and when distal
obstruction eg ca rectum
• Ileostomy
– Liquid - constant
– Right side obstruction
– Right hemicolectomy anastomotic failure
– End following total colectomy
– Loop to protect a distal anastomosis ie anterior rectal
resection
Resected Colon Cancer
• Expect in hospital stay
length 3 – 10 days
– Best patient 3 days
Laparoscopic
– Longer if elderly with
comorbidity (most pts)
– Takes 3 months to fully
recover
• Follow up
– History & physical
• 3 – 6 monthly (IV)
– CEA
• 3 monthly for 2 yrs (II)
• 6 monthly for 2yrs
• Then yearly ? How long
– CT thorax and abdo
scan
• yearly (II)
• Ultrasound good for
liver mets but less so
for local recurrence
– CBC LFTs
– CXR
– Fecal occult blood
– Colonoscopy
• No value (IV)
• No value (II)
• No value (II)
• Peri-operatively
• Alternate yearly
– 3-5 years (I)
Rectal Cancer
• Important differences compared with colon
cancer
– Overall 10% poorer prognosis
• Rectum has no serosa
• Mesorectal envelope
–
–
–
–
Anal canal 2 – 5cm
Rectum 12 – 15 cm from anal verge
Local recurrence very serious
If cancer palpable on DRE (ie 6cm from anal verge)
likely permanent colostomy
– If anastomosis possible – leak rate 18%
• Esp if pre – op radiotherapy given
• Temporary ie 4 months colostomy or ileostomy
Rectal Cancer Surgery
• Local (transanal) resection
– Very few patients have small enough
and low enough cancer to even
consider
• Could be node positive
• Easy to not achieve complete
resection
– ie leave cancer behind
– Potentially may save patient a
permanent colostomy
• BUT BUT BUT
– Never compromise chance for cure
» 82 yr old multiple medical
problems very different from 56
yr old accountant
– Upto 20% local recurrence rate
» With only 50% salvage rate
Rectal Cancer Surgery
Abdominoperineal Resection
– If the cancer is palpable on DRE especially in males
(narrow pelvis)
– Anus, rectum and sigmoid colon removed
– Permanent end colostomy using descending colon
– Patient may require pre or post operative
radiotherapy + chemo
W. Ernest Miles 1908
& Lloyd-Davis
Rectal Cancer Surgery
Anterior Resection
– If cancer not easily palpable
on DRE
– May require defunctioning
colostomy or ileostomy
– Total mesorectal excision
• Realistic local recurrence
rate 8 – 10%
– Pre or post operative
radiotherapy + chemo
Claude Dixon 1946
mesorectum
The Management of Rectal
Cancer
• Emergency
– Obstructing cancer
– Hartmann’s Procedure
– Rectosigmoidectomy, oversew
rectal stump and descending colon
colostomy
Henri Hartmann 1924
Rectal Cancer Surgery
• Outcomes
– Overall 5 yr survival 45% (80% if early)
– Low anterior resection
• Total mesorectal excision
• Since 18% leak rate 1/3rd require temp colostomy or ileostomy
especially if had pre op radiotherapy
– Local (transanal) (III)
• May compromise cure
– Up to 20% local recurrence
» Only 50% salvagable
– “I don’t want a bag”
• Quality of life (don’t forget sex & urine issues) may be better with
colostomy than with low anterior resection (II) (esp if peri op RT)
– Which worse getting out of bed 3 times a night or emptying a bag
in the morning
Diverticular disease
Diverticular abscess
Diverticular Disease
(nb diverticulosis means having diverticula)
80-85% remain asymptomatic
5% develop diverticulitis
15-25% with diverticulitis develop complications requiring surgery
abscess formation
CT/US percutaneous drain
Resect rectosigmoid when settled (weeks to months)
perforation
Urgent laparotomy & Hartmann’s
peritonitis
fecal
Urgent laparotomy & Hartmann’s
Purulent
Urgent laparotomy resect rectosigmoid consider anastomosis
+ ileosotomy
fistula
Resect and anastomosis
bleeding
90% will settle
Diverticulitis – more fast facts
Recurrent diverticulitis 50% at 7 years surgery required in
8% at 7 years to 14% by 13 years
Recurrence after surgery 1-3%
Of these patients with complicated diverticulitis, 53%
presented on a first event.
Patients with diverticulitis who are managed
conservatively (ie, do not receive surgery) have a
recurrence rate of 20-35%.
Haemorrhoids
Fissures &
Fistulae
Diverticular
disease
Colorectal
cancer