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Gastrointestinal
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Upper GI
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Esophagus
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Anatomy, physiology, and testing
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Anatomy
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Length = 25 cm; Abdominal part = 0.5-2.5 cm in length
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Major Constrictions:
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1. Cricopharyngeal (narrowest constriction)
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2. Bronchoaortic (at level of T4-T5)
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3. Diaphragmatic (at level of T9-T10)
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Curves:
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1. Behind Lt primary bronchus: Lies to the left of midline at T1
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2. Below tracheal bifurcation: Lies to the right of midline at T6
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3. Behind the pericardium: Lies to the left of midline at T10
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Pharyngoesophageal junction
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Pharyngeal muscles: superior, middle, & inferior pharyngeal constrictors
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On EGD: GEJ is where the rugae start; the squamocolumnar junction is where the mucosa turns from white to pink
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The fat pad
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Nerve supply
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Intrinsic
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Meissner’s plexus: in the submucosa
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Auerbach’s plexus: between the circular & longitudinal muscular externa
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Extrinsic: cerebrospinal, sympathetic, & parasympathetic (vagal)
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Blood supply
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Azygos vein may be ligated with impunity
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Lymphatics
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Cervical → IJ, supraclavicular, upper paratracheal nodes
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Posterior thoracic → posterior mediastinal, intercostal, & paraesophageal nodes
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Anterior thoracic → tracheal, hilar, subcarinal, paracardial, & celiac nodes
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Lymphatic channels at the cardia follow the arteries
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Physiology
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Swallows generate pressure of 40-80 mmHg
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Normal LES
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1. Resting pressure: 6-26 mmHg
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2. Length 2-5 cm
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In normal individuals, there is complete relaxation of the LES after a swallow (to a level <8 mmHg above gastric pressure)
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Contractions
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1. Primary
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Initiated after swallowing, travel the entire length of esophagus, generate 40-80 mmHg
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2. Secondary
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Initiated by the presence of food
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3. Tertiary
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Uncoordinated contractions, nonperistaltic
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Normal amplitude pressure 50-120 mmHg
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Reflux
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Antireflux mechanisms
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Mechanically effective LES
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Efficient esophageal clearance
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Adequately functioning gastric reservoir
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On pH testing: DeMeester score < 14.72 (95 percentile) is normal
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Physiologic reflux is:
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Postprandial
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Asymptomatic
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Not nocturnal
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Testing
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UGI contrast study
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Suspected leak
Gastrografin is preferred over barium because of the risk of mediastinitis; however, barium has been shown to have better resolution for contained injuries
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Start with gastrograffin
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Risks catastrophic with aspiration
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Followed by barium
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Has better sensitivity
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Risks thick pleural effusion & peritonitis
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EUS: the gold standard for T & N staging
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Manometry
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The gold standard for assessment of esophageal motor function
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Recordings: 10 consecutive swallows of 5ml of water
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Conventional manometry uses eight sensors
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HRM has sensors positioned Q1cm
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Acid exposure testing / pH monitoring
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pH monitoring also may be used while the patient is on acid-suppressing therapy to determine whether there is adequate acid suppression with the current medication regimen
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The Bravo probe is placed at the time of EGD and does not require an extended time with a nasopharyngeal catheter. It is placed 5 cm above the LES and transmits wirelessly. It measures pH for 48 hours while a wired probe is worn for 24 hours, which gives a larger sampling of pH changes in the esophagus and is more accurate
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Information is expressed with use of six standard parameters to calculate a DeMeester score, or a composite pH score. A score of less than 14.72 (95th percentile of normal) is considered physiologic reflux
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% total time pH < 4
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% upright time pH < 4
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% supine time pH < 4
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Number of reflux episodes
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Number of reflux episodes ≥ 5 minutes
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Longest reflux episode (in minutes)
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Esophageal impedance
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Measures bolus transport by measuring the resistance to electrical conductivity of the esophagus and its contents
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Useful in detecting bile (nonacid) reflux
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An adjunct to pH testing
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Gastric Scintigraphy
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Normal residuals:
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<60% in 2h
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<10% in 4h
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Role: done preoperatively to identify iatrogenic vagal nerve injury vs preexisting gastroparesis
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Functional disorders
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Dysphagia scoring scale
Data from Ogilvie AL, Dronfield MW, Ferguson R, Atkinson M. Palliative intubation of oesophagogastric neoplasms at fibreoptic endoscopy. Gut. 1982;23(12):1060-1067
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0 = Able to consume normal diet
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1 = Dysphagia with certain solids
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2 = Able to swallow semi-solid soft foods
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3 = Able to swallow liquids only
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4 = Unable to swallow saliva
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Achalasia
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Achalasia may be associated with increased risk of malignancy. SCC being the most common type
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Defined as:
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Failure or incomplete relaxation of LES
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Absence of peristalsis in the body
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Pathology: destruction of inhibitory postganglionic neurons in the myenteric plexus of the distal esophagus & the LES
Chagas disease may cause achalasia. It’s associated with megacolon and dilated cardiomyopathy. Transmitted by Reduvide bug (kissing bug)
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Dysphagia and regurgitation are the most frequent symptoms. Dysphagia begins with liquids and progresses to solids
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Chest pain is more common in younger patients and often fails to respond to treatment, but tends to diminish over the course of several years
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Severity is assessed by Eckardt score
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Dx
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The normal gastric air bubble may be absent due to the failure of lower esophageal sphincter relaxation that prevents air from entering the stomach
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Contrast esophagram: bird’s beak = dilated esophagus with smooth tapering at GEJ
In patients with equivocal esophageal manometry results (eg, incomplete LES relaxation but some preserved peristalsis; some complete LES relaxation with aperistalsis), barium esophagram should be performed to assess esophageal emptying and EGJ morphology
Other features include esophageal dilatation, a contrast filled esophagus with slow or absent emptying, an air-fluid level, and a “corkscrew appearance” in the subset with vigorous distal esophageal contractions.
In advanced cases the dilated tortuous esophagus may show substantial deviation from its normal straight axis, termed a sigmoid esophagus
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Manometry (usually HRM) is the gold standard
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Conventional manometry cannot reliably identify the type II and III achalasia, an important distinction as the prognostic implications for these entities are different
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Chicago Classification
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Absence of normal peristalsis or disorded paristalsis in lower ⅔ of esophagus
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↑ Integrated LES resting pressure ≥ 15 mmHg
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A hypertensive resting LES is not a criteria for Dx, but is suggestive of achalasia
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Low-amplitude peristaltic waveforms are often seen (~40 mmHg)
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There is failure of LES to relax to a level < 8 mmHg above gastric pressure
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Manometry may not be accurate if the patient has a paraesophageal hernia (the hernia pushes on the esophagus
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Chicago classification v3.0
DCI = distal contractile integral = an index of the strength of distal esophageal contraction
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Type I: classic achalasia
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Swallowing results in no change in esophageal pressurization
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Has 100% failed peristalsis
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Distal Contractile Integral < 100mmHg
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Bird-beak appearance on esophagram
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Type II
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Swallowing results in simultaneous pressurization that spans the entire length of the esophagus
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Has 100% failed peristalsis
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Panesophageal pressurization with ≥ 20% of swallows
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Type III: spastic achalasia
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No normal peristalsis
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Premature (spastic) contractions with Distal Contractile Integral > 450mmHg with ≥ 20% of swallows
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Corkscrew appearance on esophagram
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Pseudoachalasia
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Often caused by malignant disease
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EGD demonstrates a classic ‘popping’ feeling as the scope passes into the stomach
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Rapid progression of dysphagia and profound weight loss are suggestive of pseudoachalasia due to a malignancy
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Management
Results of medical, interventional, and surgical procedures all point to surgery as the safest and most effective treatment of achalasia
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Medical management is limited to those non-candidates for more invasive therapies
The occurrence of significant side effects of the medications, development of tolerance, uncertain efficacy, and poor absorption because of the disease itself preclude routine use
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CCB
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Nitrates
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Sildenafil (phosphodiestrase-5 inhibitors)
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Endoscopic
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Per-Oral Endoscopic Myotomy (POEM)
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Feasible and safe, with equivalent short-term outcomes similar to laparoscopic Heller’s myotomy with initial success rate > 90%
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The submucosal tunnel is carried onto the stomach for a distance of at least 3 cm
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Pneumatic dilatation
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Using a handheld manometer, the selected balloon (30, 35, or 40 mm) is inflated to a pressure of 7-15 psi until the waist is fully flattened, and held for 15-60 seconds.
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Produces relief of symptoms in 60-90% of patients
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Within 5Y, > ⅓ will relapse and require additional dilatations
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Outcomes are best in Type II achalasia
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Botulinum toxin
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Its use is limited to non-candidates for either pneumatic dilatation or a laparoscopic Heller myotomy
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Administration: 100U just above the Z-line, at 4 quadrants— lasts 3-4 months
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Surgical
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In type III achalasia, success with traditional surgical treatment is known to be around 50%, compared with 85-95% for types I and II, respectively
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Lap. Heller’s myotomy + partial fundoplication = the gold standard
Fundoplication is not obligatory, mostly because now we have PPIs
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Intraoperative endoscopy is performed to locate the exact site of obstruction at the GEJ by using a combination of transillumination and slight esophageal insufflation
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Dissection is done sharply. Once the circular muscle fibers are identified, they are elevated and divided until the submucosal plane is identified
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Extension of myotomy
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Proximal: 4-5cm above GEJ
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Distal: 2.5cm into the gastric cardia until the large veins of the transverse submucosal plexus are identified
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It is important to emphasize that the critical aspect of the myotomy involves the transition from the distal esophagus toward GEJ
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For accidental perforation, primarily repair the perforation, perform a myotomy on the opposite side, and use a fundoplication to cover it
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Endoscopy is performed at the end of the procedure to confirm the integrity
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Transthoracic myotomy
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Esophagectomy
Esophagectomy is considered in any symptomatic patient with tortuous esophagus (megaesophagus), sigmoid esophagus, failure of more than one myotomy, or an undilatable reflux stricture
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Patients who undergo esophageal perforation are not candidates of conservative management given the distal obstruction
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Surgical success
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Type I & II
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85-95%
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Type III
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~50%
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Endoscopic myotomy is preferred
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Hyertensive LES
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Dx = LES pressure > 95 percentile + dysphagia/chest pain
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Dx only by manometry (high-resolution manometry is the gold standard)
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Unlike achalasia, peristalsis & LES relaxation are present
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Botox injections provide temporary relief
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Hydrostatic balloon dilation may provide long-term relief
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Laparoscopic Heller myotomy is offered for those who fail medical management
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Diffuse Esophageal Spasm
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Characterized by uncoordinated contractions: repetitive, simultaneous, and of high amplitude.
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Dx with manometry
Because of the spontaneous contractions and intermittent normal peristalsis, standard manometry may not be enough to identify DES. An ambulatory motility record has been identified as being able to diagnose this disease with a sensitivity of 90% and a specificity of 100% based on an identified set of abnormalities.
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Normal integrated relaxation LES pressure + distal latency < 0.4 second in 20% of swallows
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Remember: ↓ latency → ↑ state of contraction
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Management
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1st Line: Nitrates, CCB, sildenafil, TCA, avoid triggering foods/drinks
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2nd Line: Valium & ativan
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May require periodic dilations
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Botulinum toxin may be tried
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If refractory: long esophagomyotomy, but has high morbidity
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Hypercontractile “Nutcracker” Esophagus
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Dx criteria:
Sabiston: The gold standard of diagnosis is the subjective complaint of chest pain with simultaneous objective evidence of peristaltic esophageal contractions 2 standard deviations (SDs) above the normal values on manometric tracings.
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> 180 mmHg or swallow response >7 seconds
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Dysphagia or chest-pain
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LES relaxes appropriately; peristaltic contractions propagate normally
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Management
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Diltiazem, nitrates, sildenafil, PPI, TCA
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Surgery is of questionable value
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Ineffective Esophageal Motility
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May be secondary to inflammatory injury caused by reflux
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Characterized by
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↓ Distal esophageal peristaltic wave pressures (< 30 mmHg), or
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Esophageal contractions in absent in > 30% of wet swallows
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Resting LES pressure is ↓, as compared to achalasia
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Management: PPI and lifestyle modifications may help
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Nonspecific Esophageal Motility
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Disorders that have no named disorder
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Examples: triple-peaked and retrograde contractions.
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Associated with systemic diseases: DM, hypothyroidism, eosinophilic esophagitis, and amyloidosis
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These abnormalities also may be seen in patients with paraesophageal hernia who have a shortened esophagus.
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Diverticula, rings, and webs
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Esophageal diverticula
Memory tip:
- All but mid-esophageal: likely needs myotomy
- Dysphagia requires myotomy
- Large size requires diverticulectomy
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Zenker’s diverticulum
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General
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Occurs through Killian’s triangle: between the inferior pharyngeal constrictor & the cricopharyngeus muscles
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Thought to be a result of high pulsion forces
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It’s the most common type of esophageal diverticulum
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It’s a false diverticulum, only the mucosa protrudes
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Rarely harbor malignancy
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Clinically
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Affects elderly patents
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♂ > ♀
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Dysphagia is the most common symptom; occasionally weight loss & malnutrition. May also develop halitosis, regurgitation, choking, hoarseness
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Boyce’s sign: cervical borborygmus in the setting of a palpable neck mass & emaciation
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May develop ulceration requiring intervention
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Dx
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Best imaging: esophagram with video fluoroscopy
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EGD is reserved for suspicion of malignancy
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Management
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Endoscopic
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Diverticula < 3 cm are not amenable to endoscopic stapling
These are too shallow to accommodate the anvil of the stapler and allow for complete transection of the septum and the performance of an adequate myotomy (recurrence rates as high as 35% have been reported for these smaller diverticula).
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Even with diverticula > 3, Gutschow et al. showed improved symptom relief with the open technique (86% vs 50%)
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Sabiston: it is mostly advocated for diverticula between 2-5 cm
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Requires maximal extension of the neck & can be difficult in older patients
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Rigid
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Firing of the stapler simultaneously divides and seals the anterior wall of the diverticulum and the posterior wall of the esophagus.
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Dohlman’s transoral technique divides the cricopharyngeus muscle using electrocautery or, more recently, CO2 laser
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A more recent technique uses the endoscopic harmonic scalpel to divide the partition between diverticulum and the esophagus
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Flexible
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The diverticulotomy then can be made using the monopolar forceps, hook cautery, argon plasma coagulation, and needle knife.
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Multiple sessions may be required to avoid perforation and mediastinitis
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Surgical
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It is widely accepted that a complete cricopharyngeal myotomy must be performed no matter what technique is used to deal with the diverticulum because incomplete myotomy is associated with a high rate of recurrence. During the myotomy, the cricopharyngeal muscle is divided completely.
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A myotomy alone may be sufficient for treatment of small diverticula (<2 cm)
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Approach:
- Left cervical incision
- Esophagus is exposed after division of platysma
- SCM & carotid sheath are retracted laterally to expose the diverticulum
- Myotomy is done down to the upper cervical esophagus
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Diverticulectomy with myotomy: A stapler can be used for diverticulectomy or it can be divided with a scalpel & the defect closed. Appropriate for diverticula > 5 cm
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Diverticulopexy with myotomy: Mobilization of the diverticulum with
suture fixation above the neck of the diverticulum (nondependent position) to the prevertebral fascia — has lower leak rate than diverticulectomy
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Midesophageal diverticula
Mid-esophageal diverticulae should not be operated on — Surgical Review Course
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Usually caused by infections in the mediastinum causing traction diverticula
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Small (< 2cm): can be observed
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Diverticulopexy may be required for symptomatic or large diverticula
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Epiphrenic diverticula
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Etiology is usually related to increased luminal pressure
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Small asymptomatic diverticula are observed
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Small symptomatic diverticula are managed with diverticulopexy to the vertebral fascia
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Dysphagia may require long esophagomyotomy contralateral to the diverticula
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If a diverticulectomy is pursued, a vertical stapling device is placed across the neck and the diverticulum is excised
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Esophageal rings (Schatzki’s rings)
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Consists of concentric symmetrical narrowing
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Consists of mucosa that lie precisely at the squamocolumnar junction: esophageal above the web, gastric below it
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Does not have a component of true esophageal muscle
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Dysphagia is usually to solid foods only, and is episodic in nature
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Dx is made with esophagram
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Management
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Asymptomatic: no treatment
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Acute obstruction requires immediate intervention
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Symptomatic dysphagia: disruption of the ring by oral dilation
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Surgery is not indicated and can cause devastating strictures
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Esophageal webs
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Usually involve the mucosa & part of the submucosa
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Composed of squamous cell epithelium above and below the web
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Seen with Plummer Vinson syndrome
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Management
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Thin webs: disruption with EGD, balloon, or bougie
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Laser lysis may be done
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Thick webs: surgical mucosal resection through a myotomy
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GERD
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Physiologic reflux: usually is limited and not nocturnal
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Reflux injury
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Damage by gastric acid alone is minimal
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Gastric acid + pepsin + bile acid together are highly deleterious
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20% of the US population has GERD
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A mechanically defective LES is diagnosed with either:
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Pressure < 6mmHg
Normal pressure 6-26 mmHg
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Total length < 2cm
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Abdominal length < 1cm
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Causes / risk factors of reflux
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Obesity
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Pregnancy
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Related to diet (amount & type)
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Anatomical: hiatal hernia
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Delayed gastric emptying
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Associated with systemic illness (autoimmune diseases)
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Scleroderma
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Interstitial lung disease
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Emphysema
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Manifestations
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Typical esophageal symptoms
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Atypical extraesophageal symptoms are due to irritation of structures other than the esophagus and include cough, wheezing, hoarseness, sore throat, postnasal drip, dental erosion, and ear pain.
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Alarm symptoms: dysphagia, early satiety, hematemesis, melena, vomiting, or weight loss
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If GERD presents with classic symptoms with absence of ‘alarm’ symptoms, medical management can be initiated
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Los Angeles Classification of Esophagitis
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Grade A: ≥ 1 mucosal break < 5mm does not extend between the tops of two mucosal folds
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Grade B: ≥ 1 mucosal break > 5mm does not extend between the tops of two mucosal folds
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Grade C: ≥ 1 mucosal break extends between the tops of ≥ two mucosal folds but involves < 75% circumference
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Grade D: ≥ 1 mucosal break involves ≥ 75% of circumference
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Management
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Daily PPI & lifestyle modification
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If treatment is not effective, proceed with diagnostic workup to confirm Dx & rule out complications. Once the diagnosis is confirmed, the PPI dosage can be increased and given twice daily in addition to adding nighttime
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Assessment
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Acid exposure test is the gold standard (‘heartburn’ is not always GERD).
A reflux episode is defined when the esophageal pH drops below 4. A DeMeester score > 14.72 is diagnostic
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Manometry helps in
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Assessment if dysmotility is contributing to reflux
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Deciding if partial fundoplication is better than complete
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Ruling out achalasia
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Barium swallow
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Identify and characterize hiatal hernias
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Identify short esophagus, if present
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EGD
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Identify Barrett’s esophagus
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Rule out malignancy
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Anti-reflux surgery
LOTUS RCT: Acid suppression is equivalent to antireflux surgery for control of GERD; they only enrolled PPI responders
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Indications for surgery
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Failed medical managment
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Patient preference
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GERD complications
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Contraindications to PPI
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Lung transplant patients or candidates with GER
The presence of GER after lung transplant has been associated with an increased risk of acute and chronic rejection and diminished graft survival. Evidence suggests a benefit to ARS in this group of patients if done either before or within 6 months of lung transplant.
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Medical complications attributable to a large hiatal hernia
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Atypical symptoms with reflux documented on 24h pH monitoring
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GERD with non-malignant esophageal stricture failing medical management requires dilation followed by anti-reflux surgery with Nissen fundoplication
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High-grade dysplasia (or cancer) is a contraindication for anti-reflux surgery
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Relative contraindications
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Surgeon inexperience
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Hostile abdomen
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Morbid obesity: GERD with BMI > 35 = the surgery for GERD is R-en-Y gastric bypass
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Causes of failure
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Recurrent GERD: managed medically or with surgical revision
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Esophageal dysmotility: preOp condition vs obstructive wrap
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Gastroparesis: preOp condition vs vagal injury
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Anatomic failures
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Transhiatal herniation (33% of failures)
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Disrupted/undone wrap (18% of failures): usually secondary to ↑ intarabdominal pressure
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Slipped (off the esophagus) wrap (10% of failures)
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Malpositioned wrap
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Wrap too tight (13% of failures) → dysphagia
Avoid this by performing EGD post-procedure
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Barrett’s esophagus
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General
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Defined by the presence of an endoscopically visible segment of columnar-lined esophagus with goblet cells on histology (alcian blue stain)
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Reflux is the only known cause Barrett’s esophagus. pH testing is generally not necessary
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Risk for cancer:
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General population cancer incidence: 0.1-0.4% per year
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Low-grade dysplasia: 0.7%
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High-grade dysplasia: 4-8% per year
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Dx = columnar mucosa 1cm above GEJ on EGD + columnar metaplasia on Bx
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Antireflux surgery often leads to regression of dysplasia
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Failed antireflux surgery is a significant risk factor for progression of disease
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Evaluation
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EGD using white-light and narrow band imaging
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Prague classification is used to record the extent of metaplasia in regards to circumference & the maximal length (from GEJ) — “C” indicates circumferential extent; “M” indicates maximum ‘tongue’ length
Prag-Klassifikationen-des-Barrett-Oesophagus-ENG
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Seattle protocol: 4-Quadrant Bx, using jumbo forceps, are obtained Q1-2cm throughout the columnar segment
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Management
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Nondysplastic Barrett’s = manage like any other GERD
The role or benefit of mucosal ablation with radiofrequency or other devices is unproven in patients with nondysplastic BE
“The efficacy of RFA of preventing cancer in patients with nondysplastic Barrett’s esophagus has not been established in long-term studies”
In the setting of ultra-long segment (≥8 cm) BE ablation may reduce the tedious complexity of appropriate four-quadrant surveillance biopsies every 1 to 2 cm throughout the length of the columnar segment
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Low grade dysplasia
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Once LGD is detected, ensure that adequate EGD with 4-quadrant Bx were obtained to confirm absence of more advanced disease. Ask for repeat pathologic assessment
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Change PPI to BID if already on PPI daily. Start daily PPI if not taking it already
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Repeat EGD in 6-12m vs endoscopic ablation
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Persistence of LGD is an indication for mucosal ablation
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High grade dysplasia
Proponents of intensive endoscopic surveillance argue that not all patients with HGD will go on to develop cancer.
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Once HGD is detected, repeat EGD and search for nodules/lesions. Ask for repeat pathologic assessment
“If the biopsies show dysplasia or intramucosal carcinoma, we suggest that the diagnosis be confirmed by another pathologist with expertise in Barrett’s esophagus-related neoplasia”
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Lesion ≥ 1-2 cm require EUS to assess depth of invasion & assessment of LN ± FNA
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CT should be performed to assess LN involvement or tumor extension beyond the submucosa before proceeding with endoscopic therapies
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Small lesions should undergo endoscopic resection (full thickness of the mucosa and submucosa)
Multiple endotherapy sessions are usually necessary to eradicate all the intestinal metaplasia, long-term surveillance endoscopy is necessary to evaluate for recurrent mucosal disease, and recurrence or inadequately treated cancer is a risk
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EMR is done for the visible lesions
Endoscopic resection techniques should not be used on lesions that are known to be deeper than the submucosa or do not lift on submucosal injection
(1) raising the mucosal/submucosal target area by intramural saline injection or suction and (2) endoscopic snare resection.
For endoscopic mucosal resection, a diathermic snare is used to resect a segment of esophageal mucosa and underlying submucosa, which is submitted for pathological evaluation. This procedure is used both as a therapy to remove neoplastic mucosa and as the most accurate means available to delineate the depth of invasion (T staging) of early neoplasia in patients with Barrett’s esophagus
Adverse event rate of 12% with the most frequent complication being bleeding. Venous bleeding is not uncommon but usually can be managed endoscopically. The most common long-term adverse event associated with EMR is stricture formation, which is seen in 38% of patients. The risk of stenosis increases particularly after multiple or circumferential treatments. Stenosis can take months to develop and often can be managed with serial dilations.
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ESD is done for flat, large (>2cm) or ulcerated tumors
The procedure includes multiple steps, including marking the tumor circumferentially, lifting it off the submucosa by injection of glycerol, saline, and methylene blue dye, a circumferential mucosal incision, and dissection in the submucosal plane beneath the lesion, allowing for removal.
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Mucosal ablation (photodynamic therapy or RFA) is done for the residual flat columnar mucosa
The most common serious side effect is esophageal stricture, which occurs in approximately 5%
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NCCN: Areas of nodularity or ulceration should be resected rather than ablated
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Indications for esophagectomy & LN dissection:
The risk of lymph node metastases is 2% or less for T1a lesions but increases to approximately 25% with submucosal invasion
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T1b (inasion into submucosa) — has high risk of LN involvement
T1a: Tumor invades the lamina propria or muscularis mucosa
T1b: Tumor invades the submucosa
T2: Tumor invades the muscularis propria
T3: Tumor invades adventitia
T4a: Tumor invades the pleura, pericardium, azygos vein, diaphragm, or peritoneum
T4b: Tumor invades other adjacent structures, such as the aorta, vertebral body, or airway
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⊕ LVI
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Poor differentiation of the tumor
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Strong consideration for esophagectomy is appropriate for
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Ultra-long segment Barrett’s esophagus
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Multifocal adenocarcinoma
*
Poor esophageal body function with large hiatal hernia or dysphagia symptoms
*
Patients who repeatedly develop dysplasia on follow up despite appropriate treatment
>
Ablation techniques
>
Argon plasma coagulation
*
Depth of penetration is 1-3 mm, but may reach 6 mm
*
Complications: chest pain, odynophagia, ulceration, stricture (4-10%), bleeding, perforation, pneumatosis
*
Cryotherapy
>
Photodynamic therapy — no longer used as first line because of AE profile
*
Employs photosensitizing drug (photofrin) that is absorbed & rertained at higher concentrations in neoplastic tissue
*
Complications: cutaneous photosensitivity, chest pain, candida esophagitis, AFib
*
Esophageal strictures occur in 5-50%, usually responds to endoscopic dilataion
V
>
RFA — the ablative treatment of choice in dysplastic Barrett’s
Among the currently available ablative therapies, the long-term data regarding the safety and efficacy of RFA are most conclusive, making it the ablative modality of choice in the treatment of BE
*
Energy is applied circumferentially or focally
*
Ensure that the mucosa is flat to allow for effective application
*
At 12 months follow-up, complete eradication of dysplasia was achieved in 81% of patients with RFA, compared with only 19% patients in the sham group
>
Limitations:
*
High cost
*
Requires multiple treatments
*
Suboptimal therapy with tortuous esophagus (such as those with hiatal hernia)
>
Limitations of ablative therapies
*
Require multiple treatments
*
Require lifetime intensive surveillance
*
Greatest success is with metaplasia < 8 cm
*
Strictures can be managed with dilations (balloons vs bougie) as long as cancer is ruled out
*
3-5-year failure rate of a fundoplication is increased in patients with BE up to 15% to 20% compared with 5% to 10% in patients without BE
>
Surveillance
*
GERD with ≥ 1 risk factor (see diagram): EGD to assess for BE
*
Patients with GERD and no Barrett’s require no surveillance
*
Nondysplastic: Q3-5Y, 4-quadran Bx Q2cm
*
LGD: “more frequent than Q3-5Y”, usually follow up in 12 months and act accordingly
*
HGD: “surveillance is seldom appropriate given available therapies”
>
Eosinophilic esophagitis
*
Strongly associated with food allergies, environmental allergies, asthma, & atopic dermatitis
*
Presents with dysphagia & food impactions in teenagers & adults
*
Strictures are noted in up to 30%
>
Dx is made on Bx. Diagnostic criteria:
*
Esophageal symptoms
*
Bx: eosinophil-predominant inflammation ( ≥15 eosinophils per high power, or 60 eosinophils per mm3)
*
Exclusion of other causes
*
Endoscopic findings: circular rings, strictures, sub epithelial vascular pattern, whitish papules, small caliber esophagus
>
Management
*
Dietary modification
*
PPI — double the dose if no response is seen in 8w
>
Topical steroids:
*
Fluticasone (using MDI, sprayed to mouth then swallowed)
*
Budesonide (using turbuhaler)
*
Esophageal dilation may be needed in high-grade strictures
V
Paraesophageal hernia / hiatal hernia
V
*
Types
The most common is Type III
The most common organ herniating in Type IV is the transverse colon
C21-FF1-3.gif
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PreOp assessment
*
Anatomic: upper GI contrast study vs CT with oral contrast
*
Functional: esophageal motility; manometry shows a ‘double hump’ sign
*
EGD: exclude concomitant PUD, Barrett’s esophagus, stricture, neoplasm…
V
Management
*
Any symptomatic hernia (pain, bloating, anemia) in good surgical candidates should be surgically corrected.
V
*
Repair is considered for asymptomatic patients with incidental finding of a paraesophageal hernia who are otherwise in excellent health
The small but real risk of catastrophic complication related to strangulation outweighs the minimal surgical and anesthetic risk in these otherwise healthy patients
*
Only fix Type I if has refractory GERD
*
Ensure that a 2-3-cm, tension-free length of esophagus resides below the diaphragm and within the abdominal cavity after the hernia repair is complete
*
If a bougie is needed, use a 56F
*
“If the crura are thinned out or if we feel we cannot obtain a tension-free, durable repair with primary cruroplasty alone, then we consider the placement of a prosthetic reinforcement”
V
>
Considerations for antireflux surgery & paraesophageal hernia repair
LOTUS RCT: Acid suppression is equivalent to antireflux surgery for control of GERD; they only enrolled PPI responders
V
>
Indications for surgery
Dr. Al Amri: “Any time you dissect the hiatus, perform a fundoplication because ⅔ patients who have complete dissection of the hiatus will have reflux”
*
Failed medical managment
*
Patient preference
*
GERD complications
*
Contraindicationsto PPI
V
*
Lung transplant patients or candidates with GER
The presence of GER after lung transplant has been associated with an increased risk of acute and chronic rejection and diminished graft survival. Evidence suggests a benefit to ARS in this group of patients if done either before or within 6 months of lung transplant.
*
Medical complications attributable to a large hiatal hernia
*
Atypical symptoms with reflux documented on 24h pH monitoring
*
High-grade dysplasia (or cancer) is a contraindication for anti reflux surgery
>
Relative complications
*
Surgeon inexperience
*
Hostile abdomen
*
Morbid obesity
>
Approach
*
Laparoscopic
>
Low left posterolateral thoracotomy
>
Consider Left thoracotomy for:
*
Severely obese
*
Hostile abdomen
*
Conversion from laparoscopy may be better managed with thoracotomy
>
Technique
*
Thoracotomy through 7th-8th ICS
*
Silk stay sutures are placed in the left hemidiaphragm to retract it
*
Hernia sac and content are dissected free from chest structures and mediastinum
*
Hernia sac is incised if needed down to the level of the crus and then the sac released circumferentially from the crus & excised
*
The proximal-most 3-4 short gastric vessels are divided to provide mobility to the fundus
*
56F bougie is inserted
*
Posterior crural repair sutures are placed (0-Silk in figure-of-8 fashion) but not tied until after fundoplication
*
Fundoplication is performed using 2-0 Silk, 1cm apart X3
*
Chest tube is left in place
V
*
Phrenoesophageal ligament must be divided in dissecting the hiatus
Screen Shot 2020-03-08 at 9.55.53 AM
V
>
Lengthening procedures for short esophagus
Paraesophageal dissection in the mediastinum can deliver 3 to 4 cm of esophagus below the diaphragmatic hiatus without tension
Cameron: the most important part of the procedure is “Ensuring that a 2-3-cm, tension-free length of esophagus resides below the diaphragm and within the abdominal cavity after the hernia repair is complete”
*
Dividng the short gastric will provide a loose fundus for fundoplication
*
Removal of the esophageal fat pad helps with length
*
Wedge gastrectomy
V
*
Collis gastroplasty
Pasted_Graphic_25
*
Division of the vagus
*
Consider gastrostomy for gastropexy, especially in elderly patients with acute presentation
V
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Wrap
“Fundoplication is commonly done with PEH repair, but it is not mandatory”
>
Nissen: 360 degree posterior wrap
*
Use 3 non-absorbable sutures
*
Floppy enough to allow passage of an instrument
*
Short (only 2-3 cm) in length
*
Straddles the LES and not the stomach
*
Incorporate esophageal muscularis in at least one of the ‘bites’
>
Avoid in cases of
*
Esophageal dysmotility
*
Weak peristalsis
*
Toupet: 270 degrees posterior wrap
*
Belsey: 270 degree anterior wrap
*
Dor: 180 degree anterior wrap
*
Some surgeons prefer to place a 50F to 56F bougie while fashioning the wrap to avoid making it too tight
V
>
Use of mesh
Screen Shot 2020-04-01 at 2.09.56 PM
*
Randomized trial demonstrated a significant reduction in the incidence of hernia recurrence when using biologic porcine small intestine submucosa at 6 months; but longterm follow-up revealed loss of this benefit
*
Use prosthetic mesh only if there is evidence of diaphragmatic attenuation or tension on the crural repair
>
PostOp
>
PostOp care
*
± Baseline barium swallow POD1
V
*
Dysphagia and ‘gas bloat syndrome’ usually resolve within 6w. Further workup includes upper GI series and endoscopy.
Gas-bloat syndrome occurs in 40% after Nissen fundoplication
*
Discharge on soft diet until 6w
*
PPI are stopped
*
All pills are crushed
*
Avoid valsalva
*
Observe & reinvestigate if symptomatic
V
*
Persistence of symptoms can be managed with endoscopic dilatation (can be done safely after 6 weeks from surgery)
Dr. Al Amri: it’s safe to dilate a Nissen wrap two weeks postOp
*
Rule out acute reherniation with any sudden onset distress
>
For PEH repair
*
1. Aggressive scheduled antiemetics to avoid early recurrence or disruption of fundoplication
>
2. Diet
*
POD1-2: NGT is removed
*
POD3: Clear liquids diet
*
POD4: Full Fluid diet
*
POD7: Soft diet until 3 weeks postop
>
PostOp outcomes
*
Longterm outcome: within 10Y, only 5-25% require PPI
*
The rate of revisional surgery after laparoscopic anti reflux surgery is 3-7%
*
Follow up at 3 weeks and 6 months for symptoms
>
Causes of failure
*
Recurrent GERD: managed medically or with surgical revision
*
Esophageal dysmotility: preOp condition vs obstructive wrap
*
Gastroparesis: preOp condition vs vagal injury
V
>
Anatomic failures
BE7D7317-1E67-4937-A852-A710E0332505
*
Transhiatal herniation (33% of failures)
*
Disrupted/undone wrap (18% of failures): usually secondary to ↑ intarabdominal pressure
*
Slipped (off the esophagus) wrap (10% of failures)
*
Malpositioned wrap
V
*
Wrap too tight (13% of failures) → dysphagia
Avoid this by performing EGD post-procedure
>
Tumors
>
Benign tumors & cysts
>
50% are leiomyomas
*
Found in distal ⅔ of the esophagus more then 80% of the time
*
They are classified as GISTs; slow growing
*
Malignant transformation occurs rarely
*
They are usually asymptomatic; when symptomatic, they cause dysphagia and pain
V
*
Esophagram: characteristic appearance of smooth, well-defined, non-circumferential mass with distinct borders
74f50fcf12304863a5d2344aad982125
*
EGD shows normal mucosa and extrinsic compression
*
EUS shows hypo-echoic mass in the submucosa or muscularis propria
*
Bx is avoided because subsequent mucosal adherence to the mass increases the chance of mucosal perforation at the time of surgery
>
Management
*
Small (< 2cm) asymptomatic = observe
*
Surgical enucleation is advocated for most patients
>
Cysts are the 2nd most common benign lesion in the esophagus
>
Congenital vs acquired; acquired cysts are a result of obstruction of the excretory ducts of the esophageal glands
*
Esophageal duplication cysts are rare inherited lesions usually diagnosed in early childhood
*
Lined with simple columnar, pseudostratified ciliated epithelium or stratified squamous epithelium
*
Over time they fill with mucus and increase in size causing mass effect
*
Dx is made with esophagram or CT
*
EUS helps differentiate cyst from mass and aids in aspiration & Dx
>
Management
*
Untreated, cysts enlarge and cause obstruction, infection or rupture
*
Cyst aspiration is not adequate management, as it will re-accumulate
*
Surgical resection is considered for all patients
*
Fibrovascular polyps should all be removed. Endoscopic removal is appropriate for small (< 2 cm) polyps. The stalk tends to be richly vascular
>
Malignant
>
General
>
SCC is the most common type globally
*
High prevalence in the esophageal cancer belt: China, Central Asia, India
*
Adenocarcinoma is the most type in North America & Western Europe
>
Risk factors
*
Dietary: ↑red meats, ↑iron, saturated fats
>
SCC
*
Tobacco
*
EtOH
*
Achalasia
*
HPV
*
Celiac disease
*
Caustic injury
*
♂3:1 ♀
*
Predominantly affects African Americans
*
Plummer Vinson syndrome
>
Adenocarcinoma
*
Chronic GERD ± Western diet
*
Obesity
*
♂15:1 ♀
*
Caucasian race
*
Smoking
V
>
Dx & staging
Pasted_Graphic_18
T1a: Tumor invades the lamina propria or muscularis mucosa
T1b: Tumor invades the submucosa
T2: Tumor invades the muscularis propria
T3: Tumor invades adventitia
T4a: Tumor invades the pleura, pericardium, azygos vein, diaphragm, or peritoneum
T4b: Tumor invades other adjacent structures, such as the aorta, vertebral body, or airway
*
Initial workup: esophagram
*
EGD: NCCN: Multiple biopsies, six to eight, using standard size endoscopy forceps should be performed to provide sufficient material for histologic interpretation
>
Localization of the tumor
V
*
Middle esophageal tumors are those between the lower border of azygos vein to lower border of inferior pulmonary vein
Screen Shot 2020-04-01 at 3.54.14 PM
V
>
Siewert Classification
Drawing-showing-Siewert-classification-AC-anatomical-cardia
*
Siewert tumor type should be assessed in all patients with adenocarcinomas involving the GEJ
*
Type I: center located within 1 cm to 5 cm above the anatomic GEJ
*
Type II: tumor center within 1 cm above and 2cm below GEJ
*
Type III: center between 2-5 cm below GEJ
*
The treatment of Siewert types I and II are in accordance to esophageal & GEJ cancers (not gastric cancers)
>
CT: chest/abdomen/pelvis
*
Assess for metastasis
*
Esophageal thickening > 5mm is abnormal
>
PET
*
Indicated for all non-M1 disease
*
PET imaging is considered the gold standard for identification of patients with nonmetastatic disease because most esophageal tumros are FDG avid
*
PET will identify M⊕ disease in 20% that was not seen on CT and bone scan
*
PET-positive foci must be confirmed with biopsy and histologic evaluation
*
Also used to stage patients post NACRT
*
EUS (±FNA of LN) to assess locoregional extension
V
*
EMR: can resect entire lesions when < 2cm (diagnostic ± therapeutic)
NCCN: Endoscopic resection is essential for the accurate staging of early-stage cancers (T1a or T1b)
V
*
Diagnostic laparoscopy improves accuracy of staging for tumor close to GEJ. It is offered for non-metastatic disease
It’s not considered for tumors other than those at GEJ.
V
*
Staging is based on: TNM, cell type, histologic grade, & location of epicenter
Celiac, mediastinal, and supraclavicular nodes are defined as regional lymph nodes
⊕ Extraregional LN (mesentery/para-aortic) is an indicator of unresectability
Patients with GEJ and supraclavicular lymph node involvement should be considered unresectable
*
T4a tumors with involvement of pericardium, pleura, or diaphragm are resectable
>
Management
*
NCCN: Cervical or cervicothoracic esophageal carcinomas <5 cm from the cricopharyngeus should be treated with definitive chemoradiation
>
C/I to esophageal-preserving therapy:
*
⊕ Multifocal disease (possible sampling error)
*
⊕ Submucosal invasion beyond the outer third
*
Squamous histology (↑ risk LVI)
*
⊕ LVI
*
Poorly differentiated tumors
*
Nodules diameter > 3 cm
>
Evaluate for indicators of unresectability (NCCN):
V
*
cT4b tumors
Involvement of the heart, great vessels, trachea, or adjacent organs including liver, pancreas, lung, and spleen are unresectable
*
Most patients with multi-station, bulky lymphadenopathy should be considered unresectable
*
Patients with GEJ and supraclavicular lymph node involvement should be considered unresectable
*
Stage IV (includes non-regional LN)
*
NCCN: Endoscopic resection is essential for the accurate staging of early-stage cancers (T1a or T1b)
NCCN: For small, nodular lesions ≤2 cm, ER is encouraged as it provides a more accurate depth of invasion than the results of EUS
>
HGD or T1a, N0
V
>
RFA, PhotoDynamic Therapy, Cryotherapy, EMR or ESD
A complication unique to RFA is the persistence of metaplastic epithelium under the normal squamous epithelium that cannot be detected on endoscopic evaluation and may serve as the focus for the development of cancer.
The most common complication after RFA is chest pain.
The most common complications of PDT are the development of strictures, cutaneous photosensitivity, candidal esophagitis, atrial fibrillation, and odynophagia.
Cryotherapy is associated with high rates of strictures.
EMR: A cauterizing snare is used to resect the polyp down to the submucosal level
>
Endoscopic surveillance
*
Q3m EGD with Bx Q1cm X 1Y
*
After 2 ⊖ Bx (no dysplasia), ↑ interval
*
Consider ablation after endoscopic resection
V
>
T1b, N0
T1b cancers are further classified as sm1, sm2, and sm3, by dividing the thickness of the submucosa into equal thirds
>
SM1
V
*
With no high risk features*, rate of ⊕LN is 6% with acceptable 5Y survival following esophageal-sparing
* SM1 with tumor < 2cm, well- or moderately-differentiated, LVI⊖
*
NCCN suggests esophagectomy for all T1b SCCs
*
For adenocarcinoma T1b (superficial) that receives endoscopic resection, ablation should also be used
>
SM2/SM3*
*
Esophagectomy + regional lymphadenectomy
*
cT1b-cT2,N0 (SCC or adenoCa) < 2cm, well differentiated, low risk lesion: upfront surgery unless it’s cervical SCC
>
(T3-4a or N⊕) locally advanced, resectable disease
>
NACRT/NACT
>
Benefit:
*
↑R0 resection
*
↑Survival at 2Y
*
± Complete regression
*
No difference in periop morbidity/mortality
*
RT Dose: 40-50Gy over 5-6w
>
CROSS Trial (esophageal & GEJ):
*
Q7d X 5w of carboplatin/paclitaxel + 41.4 Gy then surgery within 4-6w
*
Survival is improved for both, but SCC > adenocarcinoma
>
FLOT4 Trial (gastric & GEJ adenoCa) (Fluorouracil, leucovorin, oxaliplatin, and docetaxel):
*
4 cycles (2w each) PreOp
*
4 cycles (2w each) PostOp
*
Surgery scheduled 3-8w after completion of therapy and restaging
>
T4b or M1
>
Palliative
*
Stenting: although the effect is immediate, it is often short lived, and dilatation is required every 10-14 days
>
Chemoradiation achieves long-term disease control and prolongs survival
*
Radiation (EBR or brachytherapy) is indicated for local symptoms
*
Chemotherapy alone is appropriate when the predominance of symptoms is due to disseminated disease
*
APC for bleeding
>
Surgical considerations
*
Safe resection margin requires 6-10 cm
*
Adequate LN harvesting = 15+
>
Approach
>
Procedure based on Siewert’s classification
*
I: esophagectomy
*
II: esophagectomy or gastrectomy
*
III: gastrectomy
>
Ivor Lewis esophagectomy = laparotomy + right thoracotomy
*
Appropriate for middle & lower third esophageal tumors
*
The esophagus is transected at the level of the azygos vein and an intrathoracic esophagogastric anastomosis is performed
*
Because of the improved blood supply to the midstomach, where the anastomosis is placed, the rate of anastomotic leak is the lowest of all esophageal resections and is 3-4% in most centers. But once leak occurs, it’s difficult to manage
*
Major morbidity: 30%
*
Mortality: 10%
>
McKeown esophagectomy / three-hole esophagectomy
*
Appropriate for upper & middle-third esophageal tumors & for SCC
*
After completion of the abdominal portion of the operation, an oblique left neck incision is made along the anterior border of the sternocleidomastoid muscle
*
The esophagus is separated from the trachea, taking care to remain close to its wall to avoid injury to the recurrent laryngeal nerve
*
Application of gentle but firm pressure allows the esophagogastric specimen and gastric conduit to be drawn into the neck
*
The proximal esophagus is divided, and an anastomosis between the esophagus and gastric conduit performed. Either a side-to-side functional end-to-end stapled anastomosis or an end-to-end hand-sewn single layer anastomosis using absorbable suture is performed
V
>
Transhiatal esophagectomy
Literature indicates that this is the safest type of esophageal resection. Limitations stand with incomplete lymphadenectomy & high rates of strictures.
*
Appropriate for patients who will not tolerate the pulmonary sequela of the thoracic component of an Ivor Lewis or McKeown esophagectomy
*
Midline abdominal incision & an oblique left neck incision (cervical esophagus circumferentially dissected free)
*
The right hand is introduced through the hiatus and the esophagus bluntly dissected into the superior mediastinum. Simultaneously the left hand dissects into the mediastinum via the cervical incision until the fingers meet, indicating that circumferential mobilization of the esophagus in the mediastinum has been achieved
*
The membranous part of the trachea may be injured during the dissection causing a large air-leak. This needs to be repaired immediately via a right thoracotomy. It is not appropriate to use the stomach to control the leak.
*
Accessible lymph nodes in the neck, lower chest, and abdomen are removed, but there is no additional attempt to perform an extensive lymphadenectomy.
*
If leak occurs, it’s easily managed
*
Left thoracoabdominal esophagectomy: appropriate for bulky tumors in the region of the hiatus
>
Complications
*
Perioperative mortality: 3-12% — 3 fold increase in mortality when performed in a low-volume center
*
Serious postOp complications: 30-50% — respiratory complications being the most common
*
RLN injury is more common when a cervical anastomosis is performed as with a McKeown esophagectomy
>
Management of leaks
*
CT defines a leak, locates abscess, & provides a roadmap for IR drainage
*
EGD will be needed to rule out conduit necrosis & assess size of the leak & direct management
*
Limited leaks can be drained and treated expectantly
*
Small leaks require repair
V
*
Free leaks / large leaks require revision of the anastomosis
When there is a delay in diagnosis and there is significant inflammatory response of the surrounding tissue, a repair is not possible because of the friable nature of the tissue. This requires resection of the anastomosis and proximal diversion
*
The repair/re-anastomosis is buttressed with vascularized tissue
>
Esophageal stenting may be feasible
*
Stent should extend at least 2 cm beyond the lesion in each direction
*
May be successful in up to 85%
*
No specific stent design is superior
*
SCC with postOp R1-2 resection are not offered surgery, but receive chemoradiation if they have not done before. If they have received it before, options are to observe vs palliate
*
Adenocarcinoma with R1 resection who have already received NACRT/NACT are offered adjuvant therapy (± radiation) vs re-resection vs observation until progression
*
Recurrent disease is offered surgery vs chemotherapy (preferred if not received before)
>
Neoadjuvant & adjuvant chemoradiotherapy considerations
*
Re-staging post NACRT includes CT, PET, & EGD
*
SCCs tend to respond more favorably to chemoradiation and relapse locoregionally when compared with adenocarcinomas
V
*
The Bedenne trial adopted a selective definitive chemoradiation approach for SCC (5FU/cisplatin/RT), and the researchers concluded that there was no benefit for the addition of surgery after CRT
Selective definitive chemoradiation implies definitive treatment with CRT followed by a formal evaluation of clinical response during or at the completion of the therapy. Only those whose tumors have not responded to CRT are offered surgical resection
*
NCCN: SCCs & adenocarcinomas that show complete response to NACRT may be offered surveillance or esophagectomy. But with adenocarcinoma, esophagectomy is preferred by NCCN
*
NCCN: Systemic therapy regimens recommended for advanced esophageal and EGJ adenocarcinoma, SCC of the esophagus, and gastric adenocarcinoma may be used interchangeably (except as indicated)
*
NCCN: Trastuzumab should be added to chemotherapy for HER2 overexpressing metastatic adenocarcinoma
*
PostOp therapy is considered more difficult to tolerate than preoperative therapy.
>
Prognosis
>
5Y survival
*
90% for pTis
*
75% for pT1
*
45% for pT2
*
30% for pT3
*
15% for pT4
*
30-40% for N⊖
*
15-25% for N⊕
>
Follow up
*
Hx & physical exam Q3m X 2Y, then Q6m X 3Y, then Q1Y
*
Imaging, labs and EGD ‘as clinically indicated’ as per NCCN
>
On stents
>
May be used for
*
Benign strictures
*
Esophageal perforations (idiopathic, iatrogenic, traumatic)
*
PostOp leak
*
As a bridge to surgery while NACRT is delivered
*
Management of malignant esophageal fistula with 70-100% success
V
>
Cancer perforation:
Just don’t sew cancer tissue
*
Advanced cancer → stent & drain
*
Early stage & stable → esophagectomy & reconstruction
*
Unstable: damage control or stent/drain
*
Palliation
*
Stenting across the GEJ is controversial
>
Complications
>
Immediate
*
Aspiration
*
Malposition denotes technical failure
>
Early - occur within 1w
*
Hemorrhage
*
Pain
*
Nausea
>
Late
*
Migration
*
Recurrent dysphagia
>
Esophageal perforations
*
Mortality 10-40%, highly dependent on time to surgery
>
Causes
*
Majority is iatrogenic during EGD & TEE (echo) (60%)
*
Boerhaave’s syndrome (30%)
*
Foreign body ingestion
*
Malignancy
*
Trauma
*
Cervical perforations may present with neck ache and stiffness caused by contamination of the prevertebral space
*
Thoracic perforations present with SOB and chest pain lateralizing to the side of perforation
*
Abdominal perforations present with epigastric pain that radiates to the back if the perforation is posterior
*
CXR & CT scan
V
*
EGD is considered for nondiagnostic radiologic imaging
Caution for inducing tension pneumothorax with insufflation
V
>
Management
Screen Shot 2020-01-05 at 11.25.15 AM
>
Contained leak + no sepsis = nonoperative management
*
ICU admission X 48-72h
*
NPO with bed-elevation
*
Broad spectrum Abx X 72h,
*
PPI
*
± Stent
*
± TPN
*
Antifungal therapy for distal perforations with potential gastric reflux
*
Repeat imaging in 72-96h
*
In an unstable patient with a contained perforation, a temporary stent may be placed and conservative measures initiated
>
Operative management
V
*
Goal: extend the myotomy to assess extent of mucosal injury, debried nonviable tissue, ANASTOMOSE in two layers, patch the repair, & place drains
Cameron: For patients who require operative intervention, we recommend aggressive surgical management with primary repair, even in patients presenting more than 24 hours from the time of perforation
Edges of the perforation are debrided
*
Given the morbidity of esophageal exclusion, cervical esophagostomy and gastrostomy for delayed perforation is not recommended. This procedure should be reserved for unstable patients with severe ongoing sepsis and those with malignant perforations in which an esophageal stent is not applicable. A gastrostomy tube should be avoided if the stomach may be used later for reconstruction
>
Approach
>
Cervical esophagus: left neck incision along anterior border of SCM
*
If the perforation is identified, the defect is repaired primarily with absorbable suture.
If the defect is not clearly identified, closed drainage is performed
*
Strap muscles can be used to buttress the repair
>
Upper ⅔ esophagus: right thoracotomy
*
To buttress the repair, a vascularized intercostal muscle flap harvested from the fifth interspace is used
>
Lower ⅓ esophagus: left thoracotomy
*
Again, primary repair is preferred and the repair should be buttressed with either an intercostal muscle flap or diaphragmatic flap
>
Abdominal: upper midline
*
Once debrided, the perforation should be closed primarily and buttressed with omentum, a rotational flap, or the fundus of the stomach via a Dor or Thal-type fundoplication
*
Esophagram POD5: if there is failure to show progression to resolution, surgical exploration is warranted
*
Most patients treated with an esophageal stent benefit from early VATS 1-2 days after stent placement for débridement of the pleural space
*
Perforations in achalasia: the perforation is closed in two layers with absorbable suture and buttressed with a rotational flap. They also require myotomy on the side opposite to the esophageal perforation for adequate healing
*
Perforations after Nissen’s fundoplication: laparotomy, dismantling of the fundoplication, primary repair of the esophagus, and repeat Nissen
*
Esophagogastrostomy leak after esophagectomy: management depends on the viability of the conduit, size of the leak, & degree of contamination. Gangrenous conduits require resection via a right thoracotomy & the gastric remnant reduced into the abdomen. Cervical esophagostomy & gastrostomy are performed with delayed reconstruction
>
Caustic ingestion
>
Acid ingestion → coagulative necrosis
*
Ingestion of acid is difficult because its ingestion causes an immediate burning in the mouth
*
Coagulative necrosis forms eschar that limits tissue penetration
*
Within 48h, the extent of injury is determined
*
Symptoms of respiratory distress, such as hoarseness, stridor, and dyspnea, suggest upper airway edema and are usually worse with acid ingestion
>
Alkali ingestion → liquefactive necrosis
*
The consequences of alkali ingestion are much more devastating and almost always lead to significant destruction of the esophagus, resulting in long-term dysfunction
>
Phases
>
Phase 1: Acute necrotic phase
*
Lasts 1-4 days
>
Phase 2: Ulceration & granulation phase
*
Begins 3-5 days after injury
*
Lasts 3-12 days
*
The esophagus is weakest during this phase
>
Phase 3: Circatrization & scarring phase
*
Results in esophageal narrowing
*
Occurs 3 weeks after injury
*
Symptoms alone are not a reliable guide to the severity of injury
>
Grading & management
>
EGD is recommended within 24h of ingestion
V
>
Zargar classification to assess severity
Screen Shot 2020-01-06 at 11.00.28 AM
Memory tip:
Grade 1: hyperemia
Grade 2: ulceration
Grade 3: necrosis
*
Grade 0 – Normal
*
Grade 1 – Mucosal edema and hyperemia
*
Grade 2A – Superficial localized ulcers, bleeding, exudates
*
Grade 2B – Deep focal or circumferential ulcers
*
Grade 3A – Focal necrosis with multiple and deep ulcerations and small scattered areas of necrosis
*
Grade 3B – Extensive necrosis
*
CT is done in all patients to assess for depth of necrosis
V
>
Acute phase
feec883e75e4421b9e0fb467d4fdc6f2
>
Regarding neutralization
>
Sabiston: If a patient presents within the first hour of ingestion, neutralization is attempted
*
For alkali injury: use ½-strength vinegar or citrus juice
*
For acid injury: use milk, eggs whites, or antacids
*
UTD: Neutralizing agents (weakly acidic or basic substances) should not be administered because damage is generally instantaneous. Furthermore, neutralization releases heat that adds thermal injury to the ongoing chemical destruction of tissue
*
No role for antiemetics or steroids therapy
*
Abx are started for patients with suspected perforations
>
Clinical signs of perforation and CT evidence of transmural necrosis are indications for emergency surgery
*
Viable stomach & esophagus are left in situ, with feeding jejunostomy insertion and esophageal stenting intraOp
*
Questionable esophagus & stomach are left in situ, and 2nd look planned for 36h
V
*
Full-thickness necrosis warrant resection of all affected surrounding organs with end esophagostomy and feeding jejunostomy
Approach usually through a trans-hiatal esophagectomy
*
UTD: Asymptomatic patients with no oral burns & Hx of low-volume, low-concentration agents, EGD is not necessary. Discharge from the hospital is safe
>
First degree burn
*
Observation X 48h
*
Resume diet when able to swallow saliva painlessly
*
Repeat EGD & esophagram at 1, 2, & 8 months to assess for strictures
>
Second and third degree burns
V
*
Triage as per burn patients
Massive fluid shifts, renal failure, and sepsis can occur rapidly, and underestimation of the extent of injury can lead to fatal outcomes.
*
PPI
>
Chronic phase
>
Strictures
*
Sabiston: Strictures are best prevented by early stent placement (after epithelialization)
*
UTD: Esophageal stenting is not routinely recommended for prevention of an esophageal stricture
*
Esophagram is done at 3w, 3m, and 6m to assess for strictures
V
*
Patients with esophageal strictures undergo bougie dilation regardless of their symptoms
Dilations are performed daily for 2 to 3 weeks, every other day for 2 to 3 weeks, and then weekly for months
*
Reconstruction is delayed until 6-12m
V
>
Peptic Ulcer disease
For different types of ulcers, see section on UGI bleeds
>
General
*
At acute presentation: always rule out HPB pathology & AAA
V
*
The majority are related to H. pylori & NSAID use
90% of duodenal ulcers and approximately 75% of gastric ulcers are associated with H. pylori infection
When compared with the general population, NSAID users have a 2- to 10-fold increased risk for GI complications.
Other causes: ZES, smoking, & steroid use
V
*
Medical management of PUD
Most H. pylori infected individuals are asymptomatic
H. pylori testing should also be done in all patients with suspected PUD.
Serology is the test of choice for initial diagnosis when endoscopy is not required.
Antibody titers (ELISA) can remain high for 1 year or longer; consequently, this test cannot be used to assess eradication after therapy
Urea breath test: False-negative results can occur if the test is done too soon after treatment, so it is usually best to perform this test 4 weeks after therapy is finished. The urea breath test is the method of choice to document eradication.
Management: antacids, H2 antagonists, PPI, sucralfate
PPIs require an acidic environment within the gastric lumen to become activated; thus, using antacids or H2 receptor antagonists in combination with PPIs could have deleterious effects by promoting an alkaline environment and thereby preventing activation of the PPIs.
Eradication of H. pylori has shown recurrence rates as low as 2%, with initial healing as high as 90%. This compares with recurrence rates of up to 25% with ulcer-healing medications alone
*
Giant gastric ulcers (> 2 cm) have a higher incidence of malignancy (10%) than smaller ones
>
When Dx is made:
V
*
Confirm healing with EGD 8-12w after initiation of treatment
Giant ulcers in the stomach require 8 Bx specimens at the edge of the ulcer base to rule out malignancy
*
Only stop PPI after healing is confirmed
V
*
Eradication of H. pylori should be confirmed after 4-6w using urease breath test
H.Pylori eradication reduces ulcer recurrence rate at 8 weeks & 1 year postoperatively & reduces the risk of adenocarcinoma
>
Treat with PPI with a maximum of 12w. If persists:
V
*
Rule out malignancy as a cause of the ulcer
Ulcer > 2 cm → ⅓ will harbor malignancy
Perforated ulcer more likely to harbor malignancy than obstructive ulcer
Gastric ulcers have higher risk of cancer than duodenal
*
Consider surgical acid suppression
V
>
Type / modified Johnson classification of gastric ulcers
Pasted_Graphic_5Pasted_Graphic_6
Type I: the cause is not well understood, but H. pylori is commonly implicated. For type I gastric ulcers, even with appropriate preoperative evaluation, malignancy remains a major concern, and excision of the ulcer is necessary
Type I is the most common type, making up 60% of benign gastric ulcer
V
>
Treatment by type / classification
In the setting of perforation, many ulcers can be wedged out with primary repair and/or a Graham patch rather than a formal gastric resection with an acid-reducing operation. However, if the patient has been on antacids and already had H. pylori eradication, then an operation involving removal of the acid-producing parietal cells of the stomach combined with an acid reducing operation may be prudent
Location of ulcer dictates extent of dissection
Screen_Shot_2019-02-16_at_16.18.14
Csandes’ procedure = subtotal gastrectomy R-en-Y esophagogastrojejunostomy
>
Type I:
*
1. PPI
V
*
2. If failed PPI: (resection of the ulcer alone) Vs (Antrectomy + vagotomy + Billroth I)
Sabsiton: Distal gastrectomy without vagotomy can also be performed but has a morbidity of 3% to 5%, with mortality rates ranging from 1% to 2%. Recurrence is less than 5%.
>
Type II & III (hypersecretion)
*
Sabiston: Procedure of choice: distal gastrectomy + vagotomy
*
Cameron: Vagotomy recommended only if failed antacid therapy or in unreliable patient
*
Recurrence can be prevented by antacids & eradication of H. pylori
*
Billroth I is preferred, but the distal location of type III ulcers may necessitate a Billroth II or R-en-Y
V
*
Type IV: if failed PPI: Pauchet’s or Csandes’ procedure to preserve as much stomach as possible
The preferred approach is to resect the ulcer without gastrectomy and the resultant morbidity of a small gastric remnant. The most aggressive approach is to perform a gastrectomy that includes a small portion of the esophageal wall and ulcer followed by a Roux-en-Y esophagogastrojejunostomy to restore intestinal continuity
Ulcer 2-5cm from GEJ → Pauchet’s
Ulcer 0-2cm from GEJ → Csandes’
*
Type V: PPI + cessation of NSAIDs/steroids
>
Surgical acid suppression
V
>
Vagotomy (± pyloroplasty) → ↓ acid output by 50%
Vagus → parasympathetic → G-cell stimulation
Screen_Shot_2019-02-16_at_15.02.57
V
*
Pyloroplasty (Heineke-Mikulicz) = longitudinal pyloroplasty with transverse closure
When the duodenal bulb is scarred, a Finney pyloroplasty or Jaboulay gastroduodenostomy may be a useful alternative
V
>
Types:
7e001cf441b948c88e282badcaafc711
>
Truncal + pyloroplasty
*
Requires mobilization of 5 cm of the esophagus
*
Divides Rt posterior & Lt anterior vagus nerves 4 cm proximal to GEJ
>
Selective + pyloroplasty
>
Site of division (just proximal to GEJ) is just below the:
*
Posterior celiac branches (innervate the pancreas & SB)
*
Anterior hepatic branches (innervate the liver & GB)
*
Advantage over truncal vagotomy: ↓ diarrhea & ↓ dumping - (unchanged ulcer recurrence rate)
>
Highly selective (AKA parietal cell vagotomy AKA proximal gastric vagotomy)
*
Preserves Latarjet’s nerves (motor function to pylorus)
V
*
The branches are identified at the junction of the corpus & antrum, 6 cm proximal to the pylorus
These branches have a characteristic “crow’s foot” appearance
*
It’s the only procedure that doesn’t require a drainage procedure (Heineke-Mikulicz pyloroplasty)
*
All types lead to ↑ gastrin level
V
*
Recurrent ulcer disease due to incomplete vagotomy is common with selective vagotomies
The criminal nerve of Grassi, a branch of the posterior vagus nerve, must be included in the resection as it has been frequently associated with recurrent ulcer disease
V
*
Antrectomy → remove G-cell → ↓ gastrin → parietal cell stimulation → ↓ HCl
When located on the distal aspect of the stomach, frozen section helps identify the extent of resection needed by identifying G-cells
The distal extent of dissection is nearly universally transection through healthy duodenal tissue just distal to the pylorus.
Presence of Brunner’s glands on histology can be used to prove adequate antrectomy
*
Vagotomy + antrectomy = ↓ acid output by 85%
V
>
Complications
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>
Bleeding
*
¾ of patients will stop bleeding with IV fluids & PPI infusion
*
Deep posterior bleeding ulcers in the proximal duodenum are particularly worrisome because they may involve the GDA, which can cause exsanguinating hemorrhage.
V
*
Rockall score is still useful to help stratify re-bleeding risk and mortality risk in patients with upper GI bleeding
Screen_Shot_2019-02-16_at_17.58.11
V
>
Management options
Definitive operation is particularly appropriate for patients with bleeding duodenal ulcer larger than 2 cm.
Sabiston: In all cases, the ulcer should ideally be excised with the addition of vagotomy dependent on ulcer type
V
*
1. PPI ± EGD
Current 2003 guidelines for endoscopic control of bleeding advocate the use of epinephrine plus an additional method.
For patients who have rebleeding, repeat endoscopy does not increase their mortality and should be attempted prior to surgical intervention.
All high-risk patients should be placed in a monitored setting, preferably an intensive care unit, until all bleeding has stopped for 24 hours
*
2. IR embolization
V
>
3.1 Duodenum: “Open” & sew (3-point ligation) ± vagotomy with pyloroplasty
The vessel most likely to be bleeding is the GDA because of erosion from a posterior ulcer
*
Kocher maneuver to facilitate manual control of bleeding
>
Luminal access:
*
3.1 Anterior gastrotomy
*
3.2 Longitudinal duodenotomy or pyloroduodenotomy for bleeding duodenal ulcer
*
Closure: longitudinal closure pyloroplasty
*
If unable to oversew, perform ligation of GDA
*
image00736-1
*
Screen_Shot_2020-01-10_at_8.24.59_AM
TPA: transverse pancreatic artery
PDA: pancreaticoduodenal artery
RGEA: right gastroepiploic artery
*
3.2 Gastric: Usually excision is required (resection > wedge). Oversewing the ulcer is associated with high rate of re-bleeding.
>
4. Resection + vagotomy
*
4.1 Gastric ulcer: as per location (see type / classification)
*
4.2 Duodenal ulcer: antrectomy
>
Perforated ulcer
>
General
V
*
Perforation is the most common complication of gastric ulcer. Most perforations occur along the anterior aspect of the lesser curvature
SCORE module
*
Perforation has the highest mortality rate of any complication of ulcer disease, approaching 15%
V
>
Boey score: a prognostic index for perforated peptic ulcer contains 3 risk factors
Boey-score-and-outcomes
*
PreOp Shock
*
ASA III-V
*
Duration of symptoms (> 24h)
*
EGD not recommended in patients with clinical evidence of acute perforation
*
NGT should be inserted once the Dx is made
*
For patients who are known to be negative for H. pylori, are on chronic NSAIDs that they cannot discontinue, or have failed medical therapy in the past for their ulcer disease, an acid-reducing procedure can be added at the time of repair
>
Stomach
>
Have higher risk of malignancy than DU
*
When patch closure is performed, biopsy of the ulcer is necessary to rule out malignancy
*
Perforated ulcer is more likely to harbor malignancy than an obstructive ulcer
*
Ulcer > 2 cm → ⅓ will harbor malignancy
>
Management considerations
*
Posterior antral perforations may not be amenable for plication
*
If for technical reasons a sound plication cannot be constructed, gastric resection is mandatory, regardless of the risk, as a recurrent gastric leak into the peritoneal cavity is almost always fatal
*
UTD: Patch closure alone is associated with postoperative gastric obstruction in approximately 15% of cases.
>
Cameron: Most ulcer can be managed by either:
V
*
1. Bx/wedge + cleaning the edges + primary repair ± omental patch
Sabiston: types II and III gastric ulcers can be simply treated with patch closure, with or without truncal vagotomy and pyloroplasty
*
2. If already on PPI & H. pylori has already been eradicated: perform an operation for removal of acid-producing cells + acid-suppression procedure
V
*
EGD follow-up is performed 6 weeks after surgery to rule out the possibility of cancer
The same is not recommended for duodenal ulcer due to the low incidence of duodenal cancer.
>
Choice of procedure:
V
>
For benign ulcer, Billroth-I is preferred over BII or R-en-Y
Sabiston: For perforated type I gastric ulcers that occur in stable patients, distal gastrectomy with a Billroth I anastomosis is recommended.
In unstable patients, simple patching of the gastric ulcer with biopsy and treatment for H. pylori, if positive, is recommended
>
Advantage
*
No duodenal stump leak
*
No afferent loop obstruction
*
No retained antrum syndrome
>
Billroth-II
>
Advantage
*
If patient already had a vagotomy, Billroth-II is preferred over R-en-Y (to ↓ Roux stasis syndrome (gastric atony))
*
BII & R-en-Y are appropriate if extensive kocherization has not created sufficient mobilization
>
The duodenal stump
*
Leak rate 1-3%
*
Leak with BII usually occurs POD6-10
*
A drain is usually placed next to the stump with BII
*
Internal drainage is advised if the stump viability is questionable
*
Afferent limb ideally no longer than 20 cm to prevent afferent limb syndrome
>
R-en-Y
>
Advantage
*
↓ Bile reflux than BI or BII
*
Without previous vagotomy, R-en-Y may be preferred because of ↓ GERD/esophagitis & remnant gastritis
*
Roux limb of ≥ 40 cm helps prevent bile reflux
>
Duodenum
>
General
*
The perforation is usually in the first portion of the duodenum
*
Perforated DU mortality = 2-10%
*
50% Are sealed by the time of the operation (emphasizes appropriate patient selection & non-operative management)
*
Routine Bx for perforated duodenal ulcer is not necessary
>
Surgical options
>
Small ulcer
>
Omental patch
*
Ensure it is well vascularized
*
Ensure it is tension-free
*
There is no need to push the omentum into the perforation because this can strangulate the omentum
*
If there is paucity of omentum: falciform ligament (or any ‘peritonized surface’) can be taken down and used as a patch
V
*
Primary repair with omental patch
Primary repair is usually avoided to decrease the risk of sutures tearing through the duodenum
*
Thal patch: jejunal serosal patch
V
>
Large ulcer (full thickness; > 2 cm)
Large ulcers are more associated with NSAID use than H. pylori
*
May be mistaken on imaging for a duodenal diverticula or deformed duodenal bulb
V
*
Ulcer resection procedures have high risk for CBD injury
If the ampulla is deemed to be at risk, a biliary Fogarty can be advanced from above via the cystic duct or common bile duct. The decision to perform a cholecystectomy to catheterize the cystic duct should be done with impunity.
V
>
Perforations > 2 cm are more likely to fail primary closure or graham patch repair and might require resection
Soreide K, et al. Perforated peptic ulcer. Lancet. 2015;386(10000):1288–98.
>
Risks often resulting from simple closure with omental patch:
*
Invaginating the omentum and causing a gastric outlet obstruction
*
High rate of leak
V
*
Debridement of duodenum + 2-layer anastomosis to a jejunal Roux limb + gastrostomy + jejunostomy
Cameron preferred this over a serosal patch
>
Perforation close to the pylorus: Pyloroplasty incorporating the perforation & truncal vagotomy
V
*
Heineke-Mikulicz technique
Screen_Shot_2019-02-14_at_23.26.42Screen_Shot_2019-02-14_at_23.26.52
V
*
Finney technique
clip_image004_thumb
V
*
Jaboulay technique
clip_image006_thumb
*
High risk for leak: Patch + pyloric exclusion
>
Large ulcer that is unlikely salvageable
*
Stable patient: antrectomy + vagotomy + Billroth II
V
*
Unstable: resection of perforation + pyloric exclusion + gastrojejunostomy + double jejunostomy (antegrade & retrograde) + tube duodenostomy
Screen_Shot_2019-02-14_at_22.48.12
*
Proximal gastrojejunostomy and/or vagotomy may be electively added to these procedures to provide diversion and a definitive acid reducing procedure respectively
*
The presence of a “kissing” ulcer should lead to serious consideration of a definitive ulcer operation (to avoid the possibility of bleeding postoperatively)
*
Last resort: close stump around a tube (end duodenostomy) — Leakage is the rule
V
>
Criteria for nonoperative management
There is high failure rate of nonoperative management in patients older than 70 years of age
*
Hemodynamic stability
*
No generalized peritonitis
*
No contrast extravasation on CT
>
Operative considerations / pitfalls / technique
>
Approach
>
Laparoscopic
V
*
Positioning: supine, split legs
Screen_Shot_2019-02-16_at_14.19.13
*
Insert NGT
>
Port placement
*
Infraumbilical Hassan for the camera
*
11 mm at Lt midcalvicular line, just above the umbilicus: to allow introducing sutures
*
5 mm at Rt midclavicular line, just above the umbilicus
>
Benefit
V
>
Laparoscopic versus open repair for perforated peptic ulcer: A meta analysis of randomized controlled trials
Screen_Shot_2019-02-14_at_23.48.45
*
Lower SSI rate
*
Less postoperative pain
*
Shorter NGT duration
*
No difference in reoperation, leak, abscess, ileus, pneumonia, UTI, or LOS
V
*
Conversion rate: up to 60%
Most likely reason for conversion is inability to identify the perforation
>
Open
*
Upper midline laparotomy
>
Operative exploration
*
1. Anterior duodenal bulb is the most common site of duodenal perforation, if negative:
*
2. Inspect anterior & posterior wall of the stomach, if negative
*
3. Run the bowel
*
If the perforation seems healed at the time of surgery, consider testing it with with air/liquid via NGT
*
The sutures are inserted approximately 0.5-1 cm away from the edge of the perforation incorporating healthy tissue
V
*
The needle should be retrieved and reintroduced from within the perforation during suture placement
This minimizes torque or undue force on the duodenum itself and helps prevent inadvertent worsening of the perforation.
*
Patients with several of the previously noted risk factors should not undergo Graham patch alone
*
The repair may be tested for air leak
*
Irrigate the abdomen with 6-10 liters of warm NS
*
The use of a closed suction drain at the end of the procedure may not be necessary
V
>
Pyloric exclusion methods
Pyloric exclusion with a gastrojejunal anastomosis permits continued oral feeding. In most cases, the pyloric closure will open spontaneously within several weeks, by which time the ulcer repair would have healed.
>
Gastrotomy method
*
Gastrotomy along the greater curvature
*
Pylorus can be grasped and sutured closed with a nonabsorbable suture
*
The gastrotomy can then either be closed primarily or used to complete the gastrojejunostomy
*
Stapler method: Linear (TA) stapler across the pylorus
>
PostOp care
*
Watch out for leak & gastric outlet obstruction
*
Abx: continue 3-5 days or until fever & ↑WBC resolve
*
NGT is removed with the return of bowel function and then the patient fed orally
*
Closed suction drain is removed after resumption of oral diet
*
H.Pylori eradication reduces ulcer recurrence rate at 8 weeks & 1 year postoperatively & reduces the risk of adenocarcinoma
*
Patients with reperforation in the immediate postoperative period require more definitive repair
>
Obstruction
V
*
EGD dilatation of chronic ulcers (in addition to H. pylori treatment) with stenosis may delay the need for surgery for years
A study with an almost 5-year follow-up has shown that patients who have an identifiable cause (e.g., H. pylori infection) that could be treated, have good long-term results with endoscopic dilation, with a median of five dilations required, but no subsequent surgical therapy
>
Surgical management:
V
*
Gold standard: vagotomy + antrectomy
Decreases recurrence rate, but is associated with high mortality
>
Alternative: vagotomy + gastrojejunostomy
*
Has potential for reversal if dumping becomes intolerable
*
May be done laparoscopically
*
Does not provide a specimen to rule out malignancy
>
Intractable PUD being evaluated for surgery
*
For any intractable ulcer, adequate duration of therapy, H. pylori eradication, and elimination of NSAID use must be confirmed
*
A serum gastrin level should also be determined in patients with ulcers refractory to medical therapy to rule out gastrinoma
>
Stomach
V
*
Histology
Screen Shot 2019-12-10 at 15.47.16
>
Gastric polyps
>
Hyperplastic polyps
*
Account for 75% of gastric polyps in geographic areas where H. pylori is common
*
Result from hyper-regenerative epithelium in response to an underlying chronic inflammatory stimulus
*
Malignancy develops in hyperplastic polyps through a dysplasia/carcinoma sequence
*
Hyperplastic polyps measuring > 0.5 cm should be resected completely
*
In addition, the normal-appearing antral and corpus mucosa should be sampled to assess for the presence of dysplasia and H. pylori
*
In patients with dysplasia or carcinoma beyond the confines of the polyp, a subtotal gastrectomy or EMR should be performed
>
Follow up
*
High risk patients: Q1-2Y
*
Low risk patients: just ensure H. Pylori eradication & do 1 EGD
*
Heterotrophic pancreatic tissue may be found in the stomach. Treatment is with excision
>
Sporadic fundic gland polyps
*
Benign lesions that are thought to result from glandular hyperplasia and decreased luminal flow
*
Strongly associated with PPI use and occur in up to ⅓ of patients by one year
*
Typically small (0.1 to 0.8 cm), hyperemic, sessile, and have a smooth surface contour
*
Somatic APC gene mutations have been detected in over 70% of syndromic fundic gland polyps without dysplasia, but in <10% of sporadic lesions. Sporadic fundic gland polyps and those associated with PPI use have virtually no malignant potential, but may rarely show dysplasia
*
Generally do not require excision, regular surveillance, or cessation of therapy.
>
Indications for resection
*
Ulcerated polyps require resection
*
Polyps at the antrum require resection
*
Polyp ≥ 1 cm
>
Indications for cessation of PPI
*
> 20 polyps
*
Size > 1 cm
>
Gastric adenomas
*
Typically occur in a background of chronic atrophic gastritis
*
Associated with a relatively low but real risk of progression to cancer
*
All gastric adenomas should be resected
*
Because of the association of gastric dysplasia with synchronous gastric carcinomas, the remainder of the stomach must be examined carefully
*
Testing for H. Pylori is done
*
UTD: We perform an upper endoscopy for surveillance one year after initial resection of adenomatous gastric polyps to assess recurrence
V
>
Stress gastritis
Stress is considered present when hypoxia, sepsis, or organ failure occurs. When stress is present, mucosal ischemia is thought to be the main factor responsible for the breakdown of these normal defense mechanisms. There is little evidence to suggest that increased gastric acid secretion occurs in this situation. More than 50% of patients develop stress gastritis within 1 to 2 days after a traumatic event
*
Coagulopathy and prolonged ventilation (> 48 hours) put patients at greatest risk for stress ulcers
*
Cushing’s ulcers occur in the setting of CNS disease (↑ICP)
*
Curling’s ulcer occurs with thermal burns involving > 30% BSA
*
Lesions are almost always seen in the fundus of the stomach and only rarely in the distal stomach
*
Early lesions are typically multiple and shallow, with discrete areas of erythema along with focal hemorrhage or an adherent clot
*
Late lesions are characterized by a tissue reaction or organization around a clot, or if an inflammatory exudate is present (seen 24-72h after developing the lesions)
*
There is little evidence to suggest that endoscopy with electrocautery or heater probe coagulation has any benefit in the therapy of bleeding from acute stress gastritis. However, some studies have suggested that acute bleeding can be effectively controlled by selective infusion of vasopressin into the splanchnic circulation through the left gastric artery. Vasopressin is administered by continuous infusion through the catheter at a rate of 0.2 to 0.4 IU/min for a maximum of 48 to 72 hours
*
In facilities with the requisite expertise, angiographic intervention may be used to treat bleeding stress ulcers as well
>
Prophylaxis:
*
PPI
*
Continuous infusions of H2 receptor antagonists provide more consistent maintenance of intraluminal gastric pH than standard intermittent infusions.
*
Sucralfate (1g Q6h)
>
Malignancy
>
Adenocarcinoma
>
General
*
The 5th most common malignancy; rare before the age of 40Y
*
It is now the most common cause of GOO (as opposed to PUD, previously)
V
>
Types
The c-met proto-oncogene is the receptor for the hepatocyte growth factor and is frequently overexpressed in gastric cancer, as are the k-sam and c-erbB2 oncogenes
V
*
Intestinal (well differentiated)
APC gene mutations tend to be more frequent in intestinal-type gastric cancers
The intestinal type is also the dominant histology in areas in which gastric cancer is epidemic, suggesting an environmental cause
>
Diffuse (poorly differentiated)
*
↑ Aggressive
*
Associated with E-Cadherin/CDH1 mutations & loss of cellular adhesions
*
Has an association with blood type A and familial occurrence, suggesting a genetic cause
>
Linitis plastica
*
Extremely poor prognosis
*
Tends not to light up on PET
>
WHO has used a different classification since 2010:
*
Papillary
*
Tubular
*
Mucinous
*
Poorly cohesive
*
Signet ring
>
Risk factors
V
*
H.Pylori → ↑ risk only for distal stomach cancers
It is clear that intestinal metaplasia is a risk factor for the development of gastric carcinoma; however, not every patient with intestinal metaplasia develops invasive cancer
The presence of the cytoxan-associated gene A (cagA) is associated with increased virulence and risk of gastric cancer.
>
Exposure to nitrosamines — Used in the manufacture of some:
*
Cosmetics
*
Pesticides
*
Most rubber products
>
Latex, found in
*
Balloons
*
Foods
V
*
High dietary salt
The increase in refrigeration over the past 70 years has likely contributed to the decrease in gastric cancer by reducing the amount of meat preserved by salting alone and allowing the increased storage and consumption of fresh fruits and vegetables
*
Tobacco
*
Previous gastric surgery
>
Gastric polyps (see section above for details)
*
Presence of ≥ 2 cm & multiple adenomatous polyps → ↑ risk by 10-20%
*
If the polyp is > 2 cm, is sessile, or has a proven focus of invasive carcinoma, operative excision is warranted (as opposed to endoscopic)
*
Hyperplastic polyps = no malignant potential
*
Fundic gland polyps are benign lesions that are thought to result from glandular hyperplasia and decreased luminal flow. They are strongly associated with PPI use and occur in up to a third of patients by one year. As such, they do not require excision, regular surveillance, or cessation of therapy.
V
*
Pernicious anemia
Patients with pernicious anemia are at increased risk for developing gastric cancer. Achlorhydria is the defining feature of this condition; it occurs when chief and parietal cells are destroyed by an autoimmune reaction. The mucosa becomes very atrophic and develops antral and intestinal metaplasia. The relative risk for a patient with pernicious anemia developing gastric cancer is 2.1 to 5.6 of the general population.
>
Family Hx
V
*
FAP & HNPCC syndromes
FAP (and AFAP) have a 1% to 2% lifetime risk for gastric cancer
Individuals with Lynch syndrome have a 1% to 13% risk of developing gastric cancer
V
*
Prophylactic total gastrectomy is recommended between ages 18 and 40 for E-cadherin/CDH1 mutation carriers
CHD1: autosomal dominant syndrome characterized by the development of diffuse (signet ring cell) gastric cancers at a young age. Risk for gastric cancer by age 80 is estimated to be at 67% for men and 83% for women. Truncating mutations in CDH1, the gene encoding the cell adhesion molecular E-cadherin, are found in 30% to 50% of cases.
CDH-1 patients also develop lobular breast cancer
*
Li-Fraumeni syndrome is associated with risk of numerous malignancies, including gastric cancer
*
Screening is done in the East, but not recommended in Western countries (rare disease)
V
>
Dx & staging
Pasted_Graphic_1
V
>
EGD: Dx accuracy = 95% when ≥ 4 Bx are obtained
NCCN: Multiple (6–8) biopsies using standard size endoscopy forceps should be performed to provide adequately sized material for histologic interpretation, especially in the setting of an ulcerated lesion. Larger forceps may improve the yield.
*
NCCN: Endoscopic resection is essential for the accurate staging of early-stage cancers (T1a or T1b)
V
>
Assess Siewert Classification
Drawing-showing-Siewert-classification-AC-anatomical-cardia
*
Siewert tumor type should be assessed in all patients with adenocarcinomas involving the GEJ
*
Type I: center located within 1 cm to 5 cm above the anatomic GEJ
*
Type II: tumor center within 1 cm above and 2cm below GEJ
*
Type III: center between 2-5 cm below GEJ
*
The treatment of Siewert types I and II are in accordance to esophageal & GEJ cancers (not gastric cancers)
V
*
EUS for early stage disease (determines T & N stage; determines NACRT candidates)
The overall accuracy of EUS has been reported to be as high as 85% for T stage and 80% for N stage
*
CT (C.A.P)
V
*
PET if not no evidence of metastasis
PET response to neoadjuvant therapy strongly correlates with survival, with PET response seen within 14 days of treatment
>
Diagnostic laparoscopy
*
1. Detects unresectable disease
>
2. Obtain peritoneal washings → prognostic information
*
Candidates for 1. NACT then restaging, or 2. Peritoneal-directed therapy
*
Patient selection is an area of debate. Reasonable to offer laparoscopy for >T1 on EUS
*
Identifies metastasis in as high as 40% with ⊖CT
*
Minimum adequate LN for staging = 15, but > 30 is desirable
>
Management
V
>
Surgery
Memory cue:
< T1b → endoscopic resection
T1b → upfront surgery
> T1b → NACRT/NACT
>
Unresectability criteria
*
Distant metastasis
*
Involvement of LN at the root of the mesentery or para-aortic LN
>
Invasion of major vessels
*
Aorta
*
Celiac axis
V
>
Guidelines for endoscopic resection
NCCN: EMR or ESD of early-stage gastric cancer can be considered adequate therapy when the lesion is ≤2 cm in diameter, is shown on histopathology to be well or moderately well differentiated, does not penetrate beyond the superficial submucosa, does not exhibit LVI, and has clear lateral and deep margins.
A submucosal injection of epinephrine with indigo carmine hydrodissects the lesion and an insulation-tipped knife is used to remove the lesion in a submucosal plane. Any bleeding is controlled with electrocautery
Screen Shot 2020-03-18 at 5.25.07 PM
V
*
Only T1a (may also be offered surgery)
(T1b are not candidates)
*
LVI ⊖
*
Tumor < 2 cm
*
No ulceration
*
Well- or moderately-differentiated
*
Negative resection margins
>
No difference in survival between total & subtotal gastrectomy
*
Note: If the left gastric is divided, it's a subtotal gastrectomy rather than a distal gastrectomy
*
For subtotal gastrectomy: preserve the left gastroepiploic, some of the short gastrics, & the spleen
*
Laparoscopic approaches are acceptable as long as oncologic resection is not compromised. Large, bulky tumors are likely better managed with open resection
V
>
Resection margin = aim for ≥ 5 cm
2019 NCCN: Adequate gastric resection to achieve negative microscopic margins (typically ≥4 cm from gross tumor).
*
They tend to spread submucosally
*
R1 resection carries a poor prognosis only in T1-2 disease with limited nodal involvement
*
For Siewert III, the appropriate margin is distal esophagus (with frozen section evaluation)
*
With no invasion into other organs, multiorgan resection only increases morbidity. When invasion is present, multiorgan (R0) resection improves survival compared to palliative surgery
V
>
LN dissection
LN dissection with total gastrectomy D345F72E-1CBE-486F-B055-38ADDBFF9BE6_1_105_c
LN dissection with subtotal gastrectomy 1E26610E-755D-4AA7-A43A-B759CBA81CF2_1_105_c
*
D0 = anything less than D1 → appropriate in a palliative intent
V
*
D1 = Perigastric LN dissection = stations 1-6
Pasted_Graphic_4
V
*
D2 = D1 + Left gastric artery (7) + hepatic artery (8) + splenic artery & hilum (10-11) + celiac axis LN dissection (9)
Screen Shot 2019-11-25 at 1.17.59 PM
*
D3 = D2 + periportal + periaortal LN dissection
*
D2 dissection is advised as long as it is done in a center with high-volume and low perioperative mortality
>
D1 is appropriate for:
*
T1 lesions not amenable to endoscopic resection
*
Elderly patients
*
Palliative surgery
>
Reconstruction options
>
R-en-Y esophagojej (RY)
*
Easiest technically
*
60 cm Roux limb for total gasstrectomy
*
40 cm Roux limb for subtotal gastrectomy
>
R-en-Y with pouch (RP)
*
Have better QOL & nutritional measures than RY
*
Has the lowest postprandial symptoms
>
Pouch with interposition (PI)
*
Worse than RY
*
Locoregional recurrence is considered for surgery, if medically fit
>
Palliative surgery carries 50% morbidity & mortality → patient selection is paramount
*
Only 10% of elective gastrectomies aborted 2ry to detection of IntraOp metastases required operative interventions
*
Dr. Mueller: Severely distended stomach (even with metastatic disease) is best managed with emergency resection. It will either bleed, perforate, or obstruct. This is palliative surgery
V
>
Neoadjuvant & Adjuvant therapy
Screen Shot 2020-03-18 at 5.02.02 PM
*
Request MUGA scan to document cardiac function & monitor cardiotoxicity
V
>
NACTx: recommended for loco-regional advanced disease.
2019 NCCN recommends NACT (vs NACRT) for ≥ cT2
NCCN: Perioperative chemotherapy, or postoperative chemotherapy plus chemoradiation is the preferred approach for localized gastric cancer
*
Improves respectability & survival
>
NCCN: NACT regimen options:
*
Fluoropyrimidine & oxaliplatin
*
FLOT-4: 5-FU, leucovorin, oxaliplatin, docetaxel
*
5-FU & cisplatin
>
NCCN: NACRT regimen options:
*
5-FU & oxaliplatin
*
5-FU & cisplatin
*
RTOG 9904: 5-FU & paclitaxel
V
>
Adjuvant therapy is the standard of care after curative gastrectomy except for T1N0 disease
Screen Shot 2020-03-18 at 5.31.37 PM
>
Adjuvant only systemic therapy:
*
After D2 surgery: (CLASSIC) CapeOx
*
After < D2 surgery: (McDonald) chemoradiotherapy is indicated: fluoropyrimidine (5-FU or capecitabine before and after fluoropyrimidine-based chemoradiation)
*
After starting neoadjuvant therapy, the postOp regimen is continued (MAGIC or FLOT-4)
*
Trastuzumab a should be added to chemotherapy for HER2 overexpressing metastatic adenocarcinoma
V
*
Resection for positive margin is considered for R1 disease only if NACRT/NACT was given — vs chemoradiation if not given preOp
Screen Shot 2020-03-18 at 5.35.52 PM
*
R2 resection is offered adjuvant therapy (+ radiation if not received before)
>
Managing complications
>
Gastric outlet obstruction
*
Venting gastrostomy is considered
*
Stenting may be feasible, but tumor progression and stent migration limit the long-term efficacy
*
Chemoradiotherapy may alleviate obstruction in 50%
*
For patients with predicted longer survival, bypass with gastrojejunostomy or palliative gastrectomy is reasonable
>
Perforation
*
Primary closure is generally not possible
*
Closure with healthy omentum is a reasonable approach
*
Gastrectomy can be performed in select patients
>
Bleeding in metastatic disease may be managed with:
*
Endoscopic tumor ablation can be performed for the short-term control of bleeding
*
Radiation therapy
*
Palliative gastrectomy
*
Recurrence: consider surgery for resectable locoregional recurrence, otherwise (unresectable or M⊕) offer palliative care
>
Prognosis
V
*
Even after R0 resection, the recurrence rate is as high as 30%, the majority occurring within 2Y postOp
Sabiston: Recurrence rates after gastrectomy remain high, from 40% to 80%, depending on the series
*
Mortality rate after recurrence = 94%; mean survival time after recurrence < 9 months
>
For curative resection, overall 5Y survival = 24-57%
*
Early gastric cancer, cure rates are higher than 80%
*
Isolated distant metastases are uncommon because most patients with distant failure also have locoregional recurrence
>
Markers may improve accuracy of nomograms predicting survival
*
E-cadherin
*
HER2
*
p53
>
Follow up
*
“For patients who have had a partial gastrectomy, we perform surveillance endoscopy every 6 to 12 months for the first two years since survivors are at higher risk for a second primary gastric cancer, but these patients may likely have a lower risk of gastric cancer for many subsequent years.”
*
Annual EGD for those who have undergone a subtotal gastrectomy
>
NCCN 2019
*
H&P Q3–6m X 1–2Y, Q6–12m for 3–5Y, and then Q12m
*
CBC and chemistry profile as clinically indicated
*
For patients who had endoscopic resection, EGD Q6m X1Y then Q12m
*
For patients who had partial or subtotal gastrectomy, EGD as clinically indicated
*
CT Q6–12 months X 2Y, then Q12m up to 5Y (consider FDG-PET/CT as clinically indicated)
*
Monitor for nutritional deficiency (eg, B 12 and iron) in surgically resected patients (especially after total gastrectomy) and treat as indicated
>
GIST
>
General
*
Origin: Interstitial Cells of Cajal (ICC) (CD117+)
V
>
Genotypes
Mutation-frequency-in-GIST_Kier1
V
>
75-95% have ⊕KIT (CD117) protocongene mutations
Fine-needle aspiration (FNA) is 70% to 80% sensitive, usually revealing spindle cells that are CD117 (KIT) positive by immunohistochemistry. FNA may help differentiate GIST from other diagnoses such as leiomyoma, lymphoma, or adenocarcinoma, each of which requires different treatment
Several ancillary techniques are useful in support of GIST diagnosis, including IHC (97% CD117 expression, 99% DOG1 expression, and 81% CD34 expression) and molecular genetic testing (for mutations in KIT or PDGFRA).
*
Mutations are frequently seen in exon 11 (more common) and exon 9
*
10% have PDGFR mutations (tend to be imatinib resistant)
V
*
‘wild type’ GISTs may be associated with other mutations: BRAF, SDH, & NF1
Testing for germline mutations in the SDH genes should be considered for patients with wild-type GIST (lacking KIT or PDGFRA mutations)
>
Other mutations seen in GIST include
V
*
DOG-1+
NCCN: DOG1 immunostaining may be useful for cases that cannot be categorized as GIST based on CD117 immunostaining
Tumors such as renal oncocytomas, chondroblastomas, acinic cell carcinomas, chromophobe renal cell carcinomas are reported to be immunohistochemically positive for DOG1 in over 80% of those cases. Some other tumor types including adenoid cystic carcinomas, glomus tumors, synovial sarcomas also might show positive result for DOG1 IHC. Thus, DOG1 immunopositivity is not considered to be specific for GIST
V
*
CD34+
Over 90% of gastric GISTs are positive for CD34, but approximately half of GISTs other than gastric GISTs are negative for CD34
*
Median age: 60Y
*
♂ > ♀
*
Incidence: 5,000/year in US
>
Presentation
>
Location
*
Stomach (40-60%) > SB (25-30%) > rectum > esophagus
*
Rarer in large bowel & esophagus
*
Median size: 5-7 cm
>
Symptoms
*
Most present symptomatically, typically with bleeding or vague abdominal pain or discomfort. May cause bleeding as they erode into mucosa
*
Usually displace structures but don’t cause obstruction
>
Metastasis
*
Liver or peritoneal cavity
*
Rare LN involvement
>
Workup
V
>
Endoscopy: EUS-FNA
NCCN: GISTs are soft and fragile tumors. EUS-FNA biopsy of primary site is preferred over percutaneous biopsy (due to the risk for hemorrhage and intra-abdominal tumor dissemination).
*
Arises from the muscular layer
*
Hypoechoic on US
*
Mass covered by normal mucosa ± central ulceration
>
FNA 70-80% sensitive
*
Shows: spindle cells + ⊕ KIT (CD117) immunohistochem + DOG1 (90%)
*
Not diagnostic? → Core Bx
*
Tunnelled Bx have higher chance for diagnosis (sequential biopsies in the same site)
*
CT Chest/Abdo/Pelvis with IV & PO contrast: enhancing lesion arising from the wall + rule out metastatic disease + GIST size + assess organ invasion
*
MRI: helpful if suspicious for involvement of adjacent structures
*
PET: reserved for assessment of metastatic disease when there is heterogeneity of response to TKI
V
*
Genotyping is required for Gleevec candidates
NCCN: Testing for mutations in KIT and PDGFRA is strongly recommended.
V
>
Risk stratification
Presence of mitotic rate > 5/50 hpf or size > 5 cm indicate at least “intermediate risk”
Screen Shot 2020-06-10 at 5.34.44 PM
V
>
↑ Risk recurrence with (in decreasing order of importance)
Screen Shot 2020-03-18 at 20.49.15
>
1. Mitoses rate > 5/50 hpf
*
Mitotic index is the most predictive prognostic indicator
*
Although mutations such as Ki-67 correlate with risk of recurrence, mitotic count predicts clinical outcomes more accurately than does mutational status
*
2. Size > 5 cm
*
3. Non-gastric site
*
Perforations
*
↑ Metastasis or recurrence is associated with deletion of codons 557 & 558 of Exon 11 in KIT⊕ patients
*
Exon 9 mutations in KIT ⊕ → Have worse natural history & require ↑ imatinib dose
>
Non-gastric GIST have more aggressive behavior
*
GIST of the colon is most commonly seen in the rectum; colonic GIST tends to have an aggressive biological behavior, and tumors with mitotic activity can recur and metastasize despite a small size of <2 cm
*
GIST of the small intestine tends to be more aggressive than its gastric counterpart
V
*
TNM Staging
Screen Shot 2019-12-31 at 19.55.18
>
Management (also applicable for non-gastric GISTs)
V
*
Gastric GIST < 2 cm → EUS-FNA with staging imaging → if no high-risk features: Observe with serial EGD or imaging, otherwise resect
NCCN: Possible high-risk EUS features include irregular border, cystic spaces, ulceration, echogenic foci, and heterogeneity.
>
Surgery
>
NCCN: GIST > 2 cm should be resected
*
Surgery alone cures 70% of tumors ≥ 3 cm
*
Always operate unless patient is not expected to tolerate the procedure or expected to have short life expectancy
>
Considerations
*
Aim for at least 1 cm margin
*
GISTs are friable, especially after NACTx; apply a “no-touch” technique
*
Spillage → inevitable peritoneal recurrence
V
>
Doesn’t require wide resection margin (negative microscopic resection margin are adequate) or LN dissection
NCCN: The surgical procedure performed should aim to resect the tumor with histologically negative margins.
*
Z9001 trial: microscopic R1 may not affect RFS (regardless of imitanib Rx)
*
NCCN: Re-resection is generally not indicated for microscopically positive margins on final pathology
V
>
Approach
When resection involves a high-morbidity procedure, neoadjuvant therapy with Gleevec is indicated
*
At GEJ → neoadjuvant imatinib → gastrostomy + resect with 1 cm margin
*
Lateral D2 → wedge resection + primary closure, if tension-free
>
D3 or D4 → Reconstruct with either
*
A. Jejenunal anastomosis
*
B. Close stump + R-en-Y at D2
>
Low rectal → transanal local resection vs radical resection
*
2004 data suggests local recurrence (but not distant metastasis) may be higher with local excision (77% vs 31%).
2017 data: as per National Cancer Data Base, for tumors < 5 cm, no difference in 5Y-survival by surgical approach was observed
*
Tumors within 5cm from AV are appropriate for local excision, if R0 resection is obtainable
*
For rectal GISTs, Akiyoshi et al (DCR 2014) described a combined laparoscopic and transanal approach to dissect in a manner identical to a complete TME but with preservation of the IMA. Dissection is directed towards the intersphincteric plane, veering slightly towards the internal sphincter. This is followed by a transanal approach to meet the dissection planes and extraction of the rectum through the anus. Then a full-thickness excision of the tumor with adequate margins, and finally completed by a hand-sewn anastomosis
>
Tyrosine Kinase Inhibitors: imatinib, sunitinib, regorafenib
>
Competitively binds to c-KIT → shuts down signaling capability
V
*
Works best for Exon 11 patients. Less effective with Exon 9 mutations
Studies have consistently shown that patients with GISTs harboring KIT exon 11 mutations achieve the best responses to imatinib therapy and longer median overall and progression-free survival compared with other GIST mutations. For example, the presence of KIT exon 9-activating mutations is an adverse prognostic factor for response to imatinib
In patients with KIT exon 9 mutations, treatment with higher dose imatinib (800 mg/day) resulted in a significantly superior median progression-free survival relative to treatment with imatinib 400 mg/day, with a 61% reduction in the relative risk of progression
*
It is not effective for Wild Type GIST
>
Imatinib (Gleevec®), a selective TKI: an inhibitor of:
*
KIT
*
PDGF Receptor
*
ABL
*
BCR-ABL
V
>
NACTx
Screen Shot 2020-03-18 at 20.33.31
>
Indications
*
Difficult location (e.g GEJ)
*
Duodenal site (unless small & away from pancreas)
*
Large size (> ‘few cm’)
*
When a multivisceral resection is required
>
Response
>
Expectation:
*
May take time to show response
*
Tumor may swell initially
*
Reassessment: CT at 4w, then 3-6m. Unlikely to shrink afterwards
*
Rx may be continued up to the time of surgery; resume PostOp when able to take PO
>
Adjuvant
*
Offered to intermediate & high-risk patients (knowing it may not alter OS)
*
Patients who are started on imatinib as NACTx are considered for continuation postOp
>
Rx duration: ≥ 3Y, possibly indefinitely
*
Argument is: imatinib may delay recurrence, but once recurrence develops, it is less responsive to therapy. The other option is give it for shorter duration and reserve it then in case of recurrence
>
Highly effective for:
*
Neoadjuvant imatinib treatment may improve resectability
V
*
1. Recurrence post-resection (without previous therapy)
In the adjuvant setting after complete resection, imatinib prolongs RFS
V
>
2. Metastasis at initial presentation
In patients with metastatic disease, imatinib prolongs median survival to more than 5 years from a historical median of 18 months
In patients with metastatic or unresectable disease, imatinib (400 mg daily) showed an overall 2-year survival of 70% compared with 25% for those on traditional chemotherapy
*
Expected outcome: partial response or stable disease
*
Patients may develop 2ry KIT mutations & become resistant to 1st line TKI
>
AE
*
BM suppression
*
Heart failure & LV dysfunction
*
Dermatologic Rxn
*
Fluid retention
*
Dose: 400mg PO Daily; double the dose if no response
*
R2 resection should be followed always by imatinib with consideration for re-resection if imatinib was given preOp
>
Metastatic disease → TKI
*
Metastatic disease + responsive to TKI → metastasectomy can ↑PFS & OS
*
Metastatic disease + nonresponcive to TKI → metastasectomy is not helpful
V
*
There is limited role for surgery in progressive disease on imatinib. If disease is limited, consider resection of progressing lesions if feasible
Screen Shot 2020-03-18 at 20.39.32
>
Surveillance PostOp
*
Hx & physical examination Q3-6m X5Y, then Q1Y
*
Imaging
>
Prognosis
*
50% recur or metastasize despite initial optimal treatment of the primary lesion. Recurrence can occur as late as 20 years
>
Lymphoma
*
The stomach is the most common site of lymphomas in the GI system
*
Overt bleeding is rare, but patients present with anemia
*
Peak incidence in the 6th-7th decade, ♂2:1♀
>
The most common type are:
V
*
1. Diffuse Large B-Cell Lymphoma (55%)
Risk factors include H. pylori & immunodeficiencies
UTD:
For patients with limited stage gastric DLBCL, we treat with either six cycles of R-CHOP alone or three cycles of R-CHOP followed by IFRT.
We suggest reserving surgery for patients with complications such as perforation, obstruction, or intractable bleeding. GI perforation is uncommon, but occasional patients may benefit from surgical consultation for bleeding or gastric outlet obstruction
>
2. MALT lymphoma (40%)
*
Gastric MALT lymphoma is usually preceded by H. pylori–associated gastritis
*
Characterized by the translocations t(1;14)(p22;q32) and t(11;18)(q21;q21)
*
It has been suggested that early-stage MALT lymphomas and some cases of limited, diffuse, large B cell lymphoma may be effectively treated by H. pylori eradication alone
V
*
UTD suggest no therapeutic role for surgery
ManagementgastricMZL
*
3. Burkett’s lymphoma (associated with EBV)
*
4. Mantle cell & follicular lymphomas
>
Work up
*
Bone marrow Bx
*
CT chest/abdomen
*
H. pylori testing
>
Management
V
*
Most patients are now treated with chemotherapy (CHOP) alone
The risk for perforation in patients treated with chemotherapy has been overstated in the past and is now approximately 5%
>
Role for surgery
V
*
Limited gastric disease
If isolated stage IE or IIE lymphoma is encountered, surgical removal of all gross disease is ideal
*
Symptomatic recurrence of treatment failure
*
Complications
>
Gastric carcinoid
*
8% of NET occur in the stomach
V
>
Types
Screen Shot 2020-02-22 at 00.35.40
>
Type I (70-80%)
*
Associated with chronic atrophic gastritis (high gastric pH) → ↑gastrin → neuroendocrine cell hyperplasia → multifocal polypoid NETs
*
Clinical behaviour is indolent. Most are grade 1 tumors with Stage I disease & no mortality with prolonged follow up
>
Type II (5%)
*
Caused by gastrin hypersecretion stimulating multifocal NETS, but the underlying cause is ZES
*
Clinical behaviour is indolent
>
Type III (20%)
*
Occurs in the absence of atrophic gastritis or ZES
*
Sporadic lesions with few enterochromaffin-like cells
*
> 50% metastasis rate
*
5Y survival < 35%
V
>
Management
Screen Shot 2020-03-19 at 4.45.48 PM
>
Type I-II
*
Small (< 1-2 cm) pedunculated → endoscopic removal → surveillance Q6-12m
V
*
Antrectomy is a reasonable option for Type I gastric if there are numerous progressive tumors
Antrectomy reduces hypergastrinemia by reducing the gastrin-producing cell mass in the antrum of the stomach; in most cases, this leads to tumor regression
*
More aggressive surgical therapy is rarely needed for type 1 gastric NETs unless there is extensive tumor involvement of the gastric wall (which increases the risk for a coexisting adenocarcinoma), tumor size >2 cm (which increases the risk for metastases), poorly differentiated histology, or emergent bleeding
V
*
Type III: require oncologic resection with LN harvest
UTD: Some have suggested that endoscopic resection alone may represent adequate therapy for intraepithelial tumors <2 cm and perhaps for tumors <1 cm invading the lamina propria or submucosa, while others suggest wedge resection or endoscopic therapy alone only for those with a well-differentiated (grade 1) gastric NET no larger than 1.5 cm and without lymphovascular invasion. However, this is not a standard approach, and we generally advocate gastrectomy/lymphadenectomy for all type 3 tumors, regardless of size and histologic differentiation
V
*
Advanced & metastatic disease
Screen Shot 2020-03-19 at 4.49.25 PM
V
>
Ménétrier’s disease (hypoproteinemic hypertrophic gastropathy)
s3lgmd_69_48
*
Rare, acquired, premalignant disease
*
Characterized by massive gastric folds in the fundus and corpus of the stomach, giving the mucosa a cobblestone or cerebriform appearance.
*
Histologic examination reveals foveolar hyperplasia (expansion of surface mucous cells), with absent parietal cells.
*
Associated with protein loss from the stomach, excessive mucus production, and hypochlorhydria or achlorhydria.
*
Associated with CMV infection in children and H. pylori infection in adults.
*
Medical treatment has yielded inconsistent results; however, some benefit has been shown with the use of anticholinergic drugs, acid suppression, octreotide, and H. pylori eradication.
*
Total gastrectomy should be performed in patients who continue to have massive protein loss despite optimal medical therapy or if dysplasia or carcinoma develops.
>
Gastric volvulus
V
>
⅔ Occur in a longitudinal (organoaxial) axis:
Along the GEJ & pyloric axis
Screen Shot 2019-12-26 at 10.10.42
*
Usually occurs acutely
*
Usually associated with diaphragmatic defect (traumatic vs paraesophageal hernias)
V
>
⅓ occur in a vertical (mesenteroaxial) axis
Screen Shot 2019-12-26 at 10.10.46
*
Tends to be partial (<180 degree), recurrent, and not associated with a diaphragmatic defect
>
Borchardt’s triad:
*
Sudden severe abdominal pain
*
Recurrent retching with little vomitus
*
Inability to pass a NGT
*
Dx: CXR, barium study, or EGD
>
Management
*
Attempt NGT decompression of all gastric volvulus. If failed, attempt EGD decompression as long as the patient is not unstable
>
Acute volvulus requires emergency surgery
*
Abdominal approach
*
Stomach is reduced & uncoiled ± resection if strangulation
*
Diaphragmatic defect is repaired
*
Fundoplication is done in the setting of a paraesophageal hernia
*
Spontaneous volvulus, without an associated diaphragmatic defect, is treated by detorsion and fixation of the stomach by gastropexy or tube gastrostomy.
>
Bezoars
*
Phytobezoars (vegetable origin) are most commonly found in patients who have undergone surgery of the stomach and have impaired gastric emptying
>
Phytobezoars management
V
*
Adolph’s Meat Tenderizer (AMT), is given in a dose of 1tsp in 150 to 300 mL water several times daily
The sodium concentration in AMT is high, so hypernatremia may result if large quantities are administered
V
*
Generally, enzymatic débridement is followed by aggressive Ewald tube lavage or endoscopic fragmentation
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*
Failure of these therapies would necessitate surgical removal
>
Trichobezoars
*
Small trichobezoars may respond to endoscopic fragmentation, vigorous lavage, or enzymatic therapy
*
Large trichobezoars require surgical removal
*
Refer to psychiatry
>
Zollinger Ellison Syndrome
>
General
*
A syndrome of gastrin hypersecretion → parietal cell stimulation → severe peptic ulcer disease
*
It is the underlying cause in 0.1%-1% of patients with PUD
*
They are slow growing and well differentiated
>
60-90% are malignant as defined by metastasis (present in most patients at presentation)
>
Liver metastasis have a significant negative impact on survival
*
20Y survival without liver metastasis: 95%
*
20Y survival with bilobar metastasis: 15%
*
LN metastasis have minimal impact on survival
>
Occurrence
*
Sporadic
>
Familial
*
20% of ZES have MEN1
*
50% of MEN1 have ZES (gastrinoma is the most common functional NET in MEN)
>
Location and associations
V
*
80% of gastrinomas are located in the gastronome triangle
2-Figure1-1
*
70-95% of gastrinomas are found in the duodenum
*
Duodenal gastrinomas more commonly spread to LN (often smaller than pancreatic gastrinomas)
*
Pancreatic gastrinomas more commonly spread to liver
>
Manifestations
*
Severe PUD
*
Diarrhea. 20% with ZES have only diarrhea and not peptic ulceration
*
Malabsorption
*
Reflux disease & esophagitis ± stricture
*
The Dx is usually delayed several years
>
Evaluation (all are needed)
>
Biochemical testing
V
>
Fasting Gastrin > 100 pg/mL (usually ten fold) +
Fasting serum gastrin levels are measured, and if greater than 1,000pg/ml in the setting of hyperacidity and ulcer disease, it is pathognomic for gastrinoma
Causes of false-positive results: histamine antagonists, PPI, and Achlorhydria
>
Other causes of ↑ gastrin
*
Pernicious anemia
*
PPI therapy (patient may fail to stop PPI because of severe symptoms)
*
Renal failure
*
Atrophic gastritis
*
Retained/excluded antrum
*
Gastric outlet obstruction
V
*
Basal Acid Output > 15 mEq/hr +
Measurements are done to rule out achlorhydria
V
*
Gastric pH < 3
pH > 3 excludes ZES
*
PPI & H2 Rx must be stopped prior to testing
>
During the workup of ZES, MEN1 must always be excluded
*
Rule out MEN1 by Sr.Ca & PTH levels
>
If the fasting gastrin is less than tenfold elevated with a gastric pH of 2 or less, it is recommend that a secretin test and gastric acid secretory test be performed if possible.
*
1. Measure fasting gastrin level
*
2. Administer IV secretin (2 IU/kg)
*
3. Measure gastrin level at 2, 5, 10, & 20m after secretin
*
4. ↑ Gastrin > 200 pg/mL is found in 87% of patients
>
Localization
>
US
*
US is the initial test, but has very low sensitivity
*
EUS has a sensitivity of 85% for pancreatic gastrinomas, but only 43% for duodenal gastrinomas
>
CT
*
Reliably detects gastrinomas > 3cm
*
CT scanning identifies only 50% of liver metastases.
*
MRI: usual to differentiate gastrinoma liver metastases from hemangiomas
>
Somatostatin Receptor Scintigraphy (SRS)/Octreotide Scan/ DOTA Scan
*
The sensitivity of octreoscan for gastrinoma exceeds all other imaging modalities combined (angiography, MRI, CT, ultrasonography), except for the new and very promising DOTA scan
*
DOTA scan is the preoperative imaging study of choice for gastrinomas
>
Operative
*
Intraoperative ultrasounds is helpful for primary and metastatic lesions < 5mm
V
*
Duodenotomy is a critical maneuver to detect small duodenal gastrinomas
Duodenal wall gastrinomas occur in greatest density more proximally in the duodenum but may still occur in the distal duodenum
Surgical exploration and duodenotomy should be performed even in patients without an identifiable tumor on preoperative imaging, but with clear biochemical evidence of ZES because of the high probability of an occult duodenal gastrinoma
>
Management
V
*
1. Initiate PPI & confirm BAO < 15
Measuring BAO after initiating drug therapy is necessary because relief of symptoms alone is not a reliable indicator of effective acid control.
V
*
2. Treat hyperparathyroidism
In MEN1, hypercalcemia resulting from primary hyperparathyroidism can exacerbate significantly the signs and symptoms of ZES
In MEN1 ZES patients with coexistent primary hyperparathyroidism, neck exploration for 3 and gland parathyroidectomy should be performed first before surgery aimed directly at gastrinoma removal.
V
>
3. Surgery is indicated for:
Pancreatic head and neck tumors not involving major ductal or vascular structures are enucleated.
Otherwise, a Whipple or pylorus-preserving Whipple’s is performed.
V
*
3.1. MEN1 ⊕ with tumor > 2cm
In patients with MEN1 and ZES, surgical resection is seldom curative (0 to 10%) but may be effective to prevent or decrease the development of liver metastases
The operation should include resection of body and tail pancreatic NETs, enucleation of palpable pancreatic head tumors, duodenotomy with excision of duodenal tumors, and peri-pancreatic lymph node sampling. The goal of such an operation is to prevent liver metastases and thus decrease tumor-related mortality, not to cure ZES.
*
3.2. All sporadic resectable tumors (even metastatic)
*
4. Cytoreductive surgery if all disease can be resected
*
5. TACE/RFA for liver metastases
>
Postoperative
*
Postgastrectomy diet: 6 small meals/day
>
Post-Gastrectomy complications
*
Acute abdomen (leak) from duodenal stump, gastrojejunostomy, jejunojejunostomy, or gastroduodenostomy
>
Obstructive symptoms
>
Afferent & efferent loop syndrome
>
Etiology (mechanical):
*
Kinking of loops
*
Anastomotic narrowing
*
Adhesions
*
Anastomotic ulcers
*
Dx is made with CT scan or upper GI series
>
Afferent loop:
*
Refers to the duodenojejunal loop proximal to the GJ anastomosis
V
*
Caused by excessive length of the afferent loop
Afferent loop syndrome may be prevented by keeping the distance from the ligament of Treitz to the gastrojejunostomy <12 to 15 cm
>
Presentation
>
Acute
*
Presents with severe abdominal pain and vomiting
*
Requires immediate operation to prevent bowel necrosis or duodenal blowout
>
Chronic
*
Associated with postprandial epigastric pain & intermittent bilious vomiting
*
Blind loop syndrome may develop leading to megaloblastic anemia
*
Dx is suggested by failure to observe the afferent loop on EGD
>
Management
*
Revision of gastrojejunostomy or conversion to R-en-Y anastomosis
V
*
Alternative: Braun’s enteroenterostomy
Pasted_Graphic_18
>
Efferent loop:
*
Refers to the jejunal segment distal to the gastrojejunostomy
*
Presents as typical bowel obstruction with bilious vomiting
*
> 50% occur within the 1st month postoperatively
*
Management is by surgical correction
>
Jejunal intussusception
*
Afferent or efferent loops of a Billroth II can intussuscept into the gastric remnant
*
Intussusception is generally not reducible
*
Management is by revision of the gastrojejunostomy or conversion to a R-en-Y anastomosis
>
Internal hernia
*
Seen after Billroth II or R-en-Y gastrectomy
*
Presents with acute pain with/without distention or vomiting
*
Can cause closed loop small bowel obstruction
V
*
They can be prevented by closure of all mesenteric defects
The mesocolon should be sutured to the stomach at the gastrojejunostomy, and the space between the mesentery of the retrocolic jejunal limb and mesocolon (ie, Peterson's defect) needs to be closed.
aman1_april2015
>
Chronic dysmotility
>
Rapid transit — manifesting as diarrhea
>
Dumping syndrome
*
Caused by destruction or bypass of the pyloric sphincter
*
Occurs in 20% of patients after pyloroplasty or distal gastrectomy. Occurs more commonly after Billroth II reconstruction
*
Caused by rapid emptying of hyperosmolar chyme into the small bowel → draws fluid into the intestines → release of vasoactive hormones
>
Clinical presentation
>
Early dumping
*
Early dumping is more common than late dumping
*
Occurs within 20-30 mins of meals
*
Is secondary to hyperosmolar food boluses
*
Manifest as GI discomfort, N/V, cramps, & diarrhea
*
May also present with vasomotor symptoms: diaphoresis, palpitations, & flushing
>
Late dumping
*
Occurs 2-3 hours after meals
*
Is secondary to high carbohydrate dumping
*
Symptoms of hypoglycemia (indistinguishable from insulin shock) following a postprandial insulin peak
V
*
Dx is made on clinical grounds
A monitored glucose challenge, upper GI series, or gastric emptying study may support the Dx
>
Management
*
Dietary change: frequent small meal, high in fiber & protein, low in carbohydrates. Separation of liquids from solids during meals
*
Octreotide for severe cases (rarely required)
*
Intractable dumping may require conversion into R-en-Y reconstruction
>
Postvagotomy diarrhea
*
Develops in 30% of patients following truncal vagotomy
*
It’s related to rapid passage of unconjucated bile salts into the colon
*
Oral cholestyramine can be effective in persistent cases
*
Surgical management (rarely employed) involves placement of a 10-cm anti peristaltic jejunal loop in continuity 100 cm distal to the LoT
>
Slow transit — manifestations: early satiety, weight loss
>
Gastric stasis / gastric atony / gastroparesis
>
Result of:
*
Edema/hematoma
*
Postsurgical gastric atony
*
Vagal denervation
*
Small gastric remnant
*
Usually develop emesis of undigested food, abdominal pain, & weight loss
>
Work up:
*
Upper GI series to rule out mechanical obstruction
*
EGD to rule out anastomotic stricture or marginal ulcers that could cause/exacerbate gastric stasis
*
Best Dx is quantitatively with a nuclear gastric emptying study
*
Other causes of delayed gastric emptying, such as diabetes mellitus, electrolyte imbalance, drug toxicity, and neuromuscular disorders, must also be excluded
V
>
Management
Pasted_Graphic_15
*
Usually improves with small, frequent feedings
*
May respond to Rx: metoclopramide, erythromycin, domperidone, ondansetron, prochlorperazine
*
Usually resolves by 6 weeks postOp in nearly all patients
>
Failure of Rx may be managed with
*
Gastric pacing
*
Gastrostomy tube (decompression) + feeding jejunostomy
V
>
Roux stasis syndrome
Because Roux stasis syndrome is seen more often in patients with a generous (over 50 percent) gastric remnant, as well as in patients with truncal vagotomy, alternative reconstructive techniques such as Billroth II reconstruction with or without Braun enteroenterostomy should be used to avoid Roux-stasis syndrome, when feasible
*
Caused by disordered motility of the Roux loop with net propulsive activity towards the stomach
*
May occur in up to 20-30% after R-en-Y reconstruction
*
Seen more often with jejunal limb of > 40 cm
>
Work up:
*
Upper GI series to rule out mechanical obstruction
*
EGD to rule out anastomotic stricture or marginal ulcers that could cause/exacerbate gastric stasis
*
Nuclear gastric emptying study
>
Management
*
Medical: Prokinetic agents: metoclopramide & erythromycin
>
Surgical (when medical fails): resecting the exiting Roux loop & replacing it with a new R-en-Y reconstruction
*
To prevent recurrence, further resection of the remnant stomach is also carried
V
*
Chronic gastritis
85% Develop chronic gastritis of varying degree within 20Y after resection
>
Alkaline gastritis
*
Bile reflux gastritis is a diagnosis of exclusion because of the low specificity of endoscopic findings and histologic findings (intestinalization of gastric glands with inflammation)
*
Most patients suffering from alkaline reflux gastritis have had gastric resection performed with a Billroth II anastomosis
*
HIDA scan may be used to demonstrate biliary secretions into the stomach
*
Medical therapies have not proven effective
>
Surgical therapy is aimed at separating the remnant stomach from duodenal content:
*
R-en-Y reconstruction with roux limb of at least 40cm
*
Henley Loop (interposition of a 40 cm isoperistaltic jejunal loop between the gastric remnant and the duodenum)
V
*
Braun’s enteroenterostomy
Pasted_Graphic_18
>
Gastric stump cancer
*
Overall risk post-partial gastrectomy = 8 fold over normal population
>
Etiology
*
Enterogastric reflux
*
Acholrhydria
*
Bacterial overgrowth
*
H. Pylori
>
Dietary & metabolic
*
The most common metabolic defect appearing after gastrectomy is anemia related to iron deficiency or impaired B12 metabolism
V
>
Patients should be discharge on
Patients prone to
• ↓B12
• ↓Vit-D
• ↓Ca
• ↓Fe
*
Iron
*
B12
*
Multivitamin
*
Folic Acid
*
Monitor vitamin D
>
Bariatrics
>
Assessing obesity:
*
BMI is mostly widely accepted
*
Waist-circumference & waist-to-hip ratio are helpful/acceptable
*
Other methods: DEXA scan, skin fold thickness
>
Morbid obesity is defined as either:
*
BMI > 35
*
100 lbs above ideal weight
>
Indications for bariatric surgery
*
BMI ≥ 40, or more than 100 pounds overweight
V
*
BMI ≥35 + ≥ 1 obesity-related co-morbidity
DM2, HTN, OSA/other respiratory disorders, NAFLD, osteoarthritis, dyslipidemia, or heart disease
>
Inadequately controlled DM2 or metabolic syndrome with:
*
BMI 30-34.9
*
BMI > 27.5 ‘in suitable Asian candidates’
*
Inability to achieve sustained weight loss from prior weight loss efforts
V
>
Contraindications (some are relative)
The 1991 NIH Consensus Conference Statement did not include an upper age limit for surgery for obesity.
As the effects on maturation and growth are unknown, metabolic and bariatric surgery in the preadolescent is considered experimental and is not recommended.
Screen Shot 2020-08-15 at 2.50.36 PM
*
Uncorrectable coagulopathy
V
*
Limited life expectancy
Including metastasis or inoperable malignancy
*
Irreversible cardiopulmonary or other end-organ failure
*
Active tobacco, drug or EtOH abuse
V
*
Uncontrolled psychiatric illness
Major depression, psychosis, untreated eating disorders
*
Inability to commit to regular follow up or taking vitamins
V
*
Cirrhosis with evidence of portal hypertension
When cirrhosis is an incidental finding at surgery, it is recommended to proceed in the absence of findings of significant portal hypertension including severe ascites and perigastric varices.
If evidence of portal hypertension is encountered unexpectedly, the procedure should be aborted.
*
Metabolic and bariatric surgery should be postponed in patients with active peptic ulcer disease until successful treatment has been confirmed.
*
Patients who are pregnant or who expect to be pregnant within 12 months of surgery should be deferred.
*
Crohn’s disease are candidates for sleeve procedures only
V
*
Overall outcomes
In the Swedish Obese Subjects prospective controlled study, medical management over ten years was associated with 1.6% increase in body weight compared with 13.2% weight loss after gastric band and 25% weight loss after gastric bypass. Surgically induced weight loss is associated with resolution or improvement of comorbid diseases in 75-100% of patients, and reduced mortality compared with medically treated patients.
Weight-loss surgery is the most effective treatment for morbid obesity, producing durable weight loss, improvement or remission of comorbid conditions, and longer life (level I, grade A)
>
PreOp work up
V
*
Psychological evaluation
Relevant conditions: somatization, social phobia, obsessive-compulsive disorder, substance abuse/dependency, binge-eating disorder, post-traumatic stress disorder, generalized anxiety disorder, and depression
V
>
Nutritional consultation
No evidence-based, standardized dietary guidelines exist for either pre-or postoperative nutritional management of the bariatric patient.
*
Preoperative very-low-calorie diet for 6 weeks has been shown to reduce liver volume by 20% and to improve access to the upper stomach during laparoscopic surgery, with 80% of the volume change occurring in the first 2 weeks
*
Patients who are able to achieve 10% EBWL preoperatively have shorter hospitalization and more rapid weight loss.
*
PreOp medical evaluation
V
>
Procedures
Screen Shot 2020-03-29 at 3.52.33 PM
V
*
VBG
Pasted_Graphic_23
V
>
Adjustable Gastric Band (AGB)
Advantages
-No cutting of the stomach or rerouting of the intestines
-Is reversible and adjustable
-Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures
-Has the lowest risk for vitamin/mineral deficiencies
-Allows normal surveillance of the stomach/duodenum in patients requiring it
Disadvantages
-Slower and less weight loss than other surgical procedures
-Greater % of patients fail to lose at least 50 % of EBW compared to other surgeries
-Requires a foreign device to remain in the body
-Band slippage or band erosion =  serious complications
-Can have mechanical problems with the band, tube or port  
-Can result in dilation of the esophagus if the patient overeats, GERD
-Requires strict adherence to the PO diet and to postoperative follow-up visits
-Highest rate of re-operation
V
*
Band is placed via a pars flaccida approach (between the pars flaccida medially & the angle of His laterally)
This has equivalent efficacy to the initially described perigastric approach, but has a significantly decreased rate of band slippage (i.e., gastric prolapse).
V
*
Requires frequent follow up for band adjustments
Fluid should be removed for vomiting, coughing, choking, or significant solid food intolerance.
*
Bands may be adjusted with or without radiographic guidance with acceptable results
*
Mean explantation or major revision rate by 9 years: 33%
V
>
Sleeve Gastrectomy (LSG)
Advantages
-Restricts the amount of food the stomach can hold
-Weight loss of >50% for 3-5+ year data
-Requires no foreign objects, and no bypass or re-routing of intestines
-No special vitamins
-Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety
-No risk internal hernia
Disadvantages
-Is a non-reversible procedure
-Has a higher early complication rate than the AGB
-GERD!!
-Higher weight regain than malabsorptive procedures
>
Technique considerations
*
Removes ~75% of the stomach
*
A 34-60F bougie is passed towards the pylorus
*
Stapling is started 5 cm proximal to the pylorus, proceeding all the way to GEJ
*
The effect on gut hormones seems to have greater impact than the reduced gastric size
V
>
R-en-Y Gastric Bypass (RYGB)
Advantages
-Produces significant long-term weight loss (60 to 80 % EWL)
-Restricts the amount of food that can be consumed
-Produces favorable changes in gut hormones that reduce appetite and enhance satiety
-Typical maintenance of >50% excess weight loss (better than restrictive operations)
Disadvantages
-Technically more complex operation than AGB or LSG
-Higher complication rates
-Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron, calcium, and folate
-Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance
-Dumping, avoidance NSAIDs, smoking, PUD!!
-Internal hernia
V
Technical considerations
V
*
Stomach is divided to form a small gastric pouch (10-30cc)
The first firing is usually horizontal beginning no more than 5 cm distal to the esophagogastric junction; subsequent firings are vertically oriented to the angle of His.
V
V
Jejunum is divided ~40-100 cm distal to the LoT
Cameron: The jejunum then is transected approximately 40 cm distal to the LoT
ASMBS: The length of the Roux limb should be at least 75 cm as we have seen bile reflux in patients with 60 cm Roux limbs
*
The distal segment is connect to the gastric pouch = Roux limb
V
*
The proximal bowel segment (biliopancreatic limb) is connected to the small bowel 75-150 cm distal to the gastrojejunostomy
ASMBS: The length of the biliopancreatic limb is not critical, usually just long enough to provide mobilization of the Roux limb to the gastric pouch without tension
ASMBS: Likewise, creating a Roux limb of 150 cm does not impart greater effect than one of 75 cm. Although there are studies that have shown short-term benefit of pouch and/or stoma reduction and lengthening of the Roux limb to enhance weight loss, results have been inconsistent and without longterm benefit.
V
*
Complications
The most frequently reported perioperative complications associated with laparoscopic RGB are wound infection (2.98%), anastomotic leak (2.05%), gastrointestinal tract hemorrhage (1.93%), bowel obstruction (1.73%), and pulmonary embolus (0.41%), while the most frequently reported late complications are stomal stenosis (4.73%), bowel obstruction (3.15%), and incisional hernia (0.47%).
V
>
BilioPancreatic Diversion - Duodenal Switch (BPD-DS)
Pasted_Graphic_20Pasted_Graphic_22
Screen Shot 2020-08-15 at 3.19.59 PM
Advantages
-Results in greater weight loss than all other procedures. 80% EWL 
-Allows patients to eventually eat near “normal” meals
-Reduces the absorption of fat by 70 percent or more
-Causes favorable changes in gut hormones to reduce appetite and improve satiety
-Is the most effective against diabetes compared to RYGB, LSG, and AGB
Disadvantages
-Highest complication rates and risk for mortality  
-Has a greater potential to cause protein + vitamin deficiencies 
-Strictest Follow Ups and compliance required
-Lots of vitamins to take (ca, vit d, b12, iron, vit a, d, e)
-More frequent bowel movements and gas
-Internal hernia
>
Technical considerations
*
Duodenum is divided 3 cm distal the pylorus
*
Divide small bowel 250 cm from ICV and anastomose to the stomach
*
Anastomose the biliary limb to the small bowel 100 cm proximal to ICV
V
*
Outcomes: BPD ± DS initiates dramatic weight loss during the first 12 postoperative months, which continues at a slower rate over the next 6 months
BPD dramatically impacts comorbidities. At least 90% of patients with type 2 diabetes will cease diabetic medications by 12-36 months. Of hypertensive patients 50-80% will be cured, with another 10% experiencing improvement. Up to 98% of patients with obstructive sleep apnea symptoms will have resolution.
V
*
Single-Anastomosis Duodeno Ileal Bypass (SADI) — Experimental procedure
Screen_Shot_2019-03-14_at_22.11.02
>
Complications
>
Complications specific to the band
V
>
Slippage/pouch dilation (24%)
It seems likely that the risk of band slippage persists during the patient’s lifetime and thus that the incidence will continue to increase as follow-up extends over longer periods.
An early technique (involving perigastric dissection with placement of a Lap-Band directly on the stomach wall) was associated with frequent gastric prolapse. The modern technique (via pars flaccida without exposure of the stomach wall) has decreased this complication significantly
>
May be detected if Xray shows the band is lying flat or less than 30-45 degrees to the horizon
*
Anterior prolapse: migration of the band cephalad
V
*
Posterior gastric prolapse: stomach migrates cephalad
Screen Shot 2020-03-17 at 11.01.55 AM
>
Management options:
*
First intervention is deflation of the balloon
V
*
Surgery is required urgently or emergently
Persistence of pain after deflation of the balloon may warrant emergency reoperation
*
Removal of the band ± insertion of a new band
*
Alternatives: unlocking, mobilizing, or repositioning the band
*
Esophageal dilation (8%)
*
Stomal obstruction (14%)
>
Port infection (occurs in up to 9%)
*
Need to assess for band erosion with EGD
*
Isolated port infection is treated with surgical removal with implantation of a new port once the infection clears
>
Band erosion (occurs in up to 7%)
>
Etiology:
*
Excessively tight band causing ischemia
*
Mechanical trauma
*
Thermal injury
*
Occurs at a mean of 22 months postOp
*
Signs: failure of weight loss, N/V, ± epigastric pain & hematemesis
*
Dx is made with EGD
*
Treatment is with laparoscopic removal of the band
*
UTD: It is generally recommended that revision to another bariatric procedure be delayed for at least 2-3 months after an episode of band erosion, as the complication rate with immediate revision is increased
*
Esophagitis is infrequent and managed with deflation of the band & PPI
>
Leak
>
Incidence:
*
0-4.3% in RYGB
*
2.2% in LSG
>
Most common sites:
*
The gastojejunostomy is the most common site (owing to the tension associated with the anastomosis)
*
When occurs during LSG: the most common site is the upper end of the staple-line, near the angle of His
>
Presentation & Dx
*
Tachycardia is very sensitive for leaks
*
CRP > 229 mg/l reliably identifies leak
*
When upper GI and CT are combined, up to ⅓ of patients with leaks will have both studies interpreted as normal
*
Consider laparoscopy or re-exploration even when imaging is negative
V
>
Management
Some surgeons make an attempt at closure of the defect; however, these closures tend to break down due to poor tissue integrity at the leak site. Leaks at the jejunojejunostomy or the gastric remnant may be more amenable for primary closure, and revision of the anastomosis is rarely needed
*
Late leaks (> 6 weeks) will require resection & reconstruction
>
Early leaks may be considered for:
*
Nonoperative management
>
Endoscopic stenting
*
Has almost 50% success rate
>
Principles of stenting:
*
Localize leak — only leaks at the proximal and mid-aspect of sleeve gastrectomy should be stented
*
Needs to be supplemented by drainage procedures (percutaneous or surgical)
*
US or fluoroscopy can be used to deploy the stent
*
Ensure a proper ‘landing zone’ for stent deployment
*
Use only fully covered metal stents
*
Almost 50% will have stent complications: migration, obstruction, hematemesis
*
T-tube drainage for 4-6 weeks then withdrawn 1-2 inches/week
*
Laparoscopic washout and drainage
>
Fistula management options
*
Endoscopic stenting
*
Endoscopic clipping
*
Endoscopic injection of fibrin glue
*
Surgical takedown of the fistula with proximal gastrectomy & esophagojejunostomy
>
Obstruction
>
After bypass or BPD-DS
>
Stricture of the gastrojejunostomy
*
Etiology: likely related to ischemia, suture material or staples (CDH size 21 or smaller)
*
Is one of the most common complication after gastric bypass
*
Most present within 90 days postoperatively
*
Usually manifests as progressive intolerance to solids then liquids
>
G-scope is the primary mode of diagnosis, and allows for balloon dilatation
*
Balloon dilatation is safe (usually up to 12-15 mm)
*
Usually one session of dilatation is sufficient
*
Barium studies are generally not useful
V
>
Internal hernia
A Mount Sinai study from 2005 found that sutured closure of the defects reduced the internal hernia rate from 3.3 to 1.2 %
*
Is the most common cause of bowel obstruction in gastric bypass patients (up to 41% of all obstruction)
>
In antecolic R-en-Y, two types of internal hernias occur:
V
*
Distal anastomosis mesenteric hernia
Pasted_Graphic_24
V
*
Peterson hernia
Pasted_Graphic_25
V
*
Cannot be ruled out by CT scan
But may be diagnostic, and may show signs of vascular swirl signs
It should be repeated and emphasized that the patient with abdominal pain but no distended bowel on CT imaging may be suffering from an internal hernia. Internal hernias cause pain due to compression and ultimately obstruction of the intestinal vasculature and thus present with symptoms more suggestive of intermittent bowel ischemia than obstruction.
Clustering of small bowel in the RUQ is suggestive of the Dx
*
Bowel obstruction may be even absent with severe internal hernia causing intestinal ischemia
V
*
The only diagnostic modality is laparotomy or laparoscopy
Once the herniated bowel is reduced, the hernia defect should be securely closed with a nonabsorbable running continuous suture
V
*
Adhesions
Some argue that it is a more common cause of obstruction than internal hernias
V
*
Incisional hernia
Concomitant mesh repair of preexisting mesh hernia is controversial but now is gaining more acceptance.
>
Intussusception
*
The distal anastomosis can serve as a lead point for intussusception
*
May be precipitated by a wide anastomosis
*
Management usually requires reduction followed by revision of the anastomosis
*
Intraluminal blood clot or bezoar
>
After sleeve gastrectomy
>
Stenosis
*
Usually the location is at the mid-body of the sleeve, near the incisura
>
Management:
*
Patients in this cohort were all treated with endoscopic balloon dilatation with a 15–18 mm balloon.
*
Laparoscopic adhesolysis
*
Conversion into gastric bypass
*
Stent implantation
*
Nutritional/dietary deficiencies
>
The intestines
V
>
Gastrografin reduces the need for additional surgery in postoperative small bowel obstruction patients without long tube insertion: A meta-analysis (2018)
Screen Shot 2020-09-12 at 11.01.56 AM
*
12 RCTs including a total of 1153 patients with PSBO were regarded as suitable for inclusion in the data synthesis
*
Among 580 patients who received Gastrografin, 100 (17.2%) underwent surgery, whereas among 573 patients who did not receive Gastrografin, 143 (25.0%) underwent surgery. Giving Gastrografin significantly reduced the need for surgery for postOp SBO (RR, 0.66; 95% CI, 0.46- 0.95; P = 0.03; I 2 = 52%) in comparison with patients who did not receive Gastrografin
*
In terms of their components, there is, in fact, no difference between Gastrografin (sodium diatrizoate 59.73 g and meglumine diatrizoate 15.924 g in 100 mL) and 76% Urografin (sodium diatrizoate 59.73 g and meglumine diatrizoate 15.924 g in 100 mL)
>
Enterocutaneous fistulas
>
Etiology
>
Iatrogenic (75%)
*
As a result of bowel leak (50%)
*
As a result of a missed enterotomy (45%)
*
As a result of erosion of foreign body — mesh, vascular graft, …etc
>
Risk factors for iatrogenic enterocutaneous fistulas
*
Crohn’s disease
*
Malnutrition
*
Immunosuppression
*
Traumatic injury
*
Infection
*
Smoking
*
Hx of radiation
>
Spontaneous
*
Foreign body
*
Radiation
*
Inflammation (Crohn’s disease, TB, diverticulitis, appendicitis)
*
Epithelialization
*
Neoplasia
*
Distal obstruction
V
*
Favorable and unfavorable factors predictive of nonoperative fistula closure
IMG_0202
>
Stages of management
V
1. Stabilization
>
Resuscitation
*
Restoration of blood volume
*
Gastrointestinal fistulas are likely to require albumin/plasma/FFP
*
Duodenal or pancreatic fistulas may require bicarbonate replacement to prevent metabolic acidosis.
>
Sepsis control (within 24-48h)
V
*
Abscesses should be drained
Even in the absence of overt sepsis, 50% of patients with ECFs harbor intra-abdominal abscesses, most of which are amenable to percutaneous drainage.
Source: Enterocutaneous Fistula: Proven Strategies and Updates. Irena Gribovskaja-Rupp, MD, Genevieve B. Melton, MD, PhD
V
*
Abx as indicated
Antibiotic management should follow the Surviving Sepsis guidelines, and empiric coverage should not exceed 4 to 7 days.
There is no role for antibiotic coverage in a patient with ECF whose sepsis is fully controlled with percutaneous drainage.
Source: Enterocutaneous Fistula: Proven Strategies and Updates. Irena Gribovskaja-Rupp, MD, Genevieve B. Melton, MD, PhD
V
Operative sepsis control
V
Indications
*
Peritonitis
*
Free/uncontrolled perforation
*
Thick purulence that cannot be aspirated
*
Operative sepsis control should focus on infection drainage and exteriorization of any leaking small or large intestine. It is rare that an enterocutaneous fistula can be resected or closed primarily in the acute phase, particularly if it is a postoperative complication
*
A common mistake is to repair or primarily redo the anastomosis in the infected field in order to avoid a stoma
*
Diversion of the fecal stream by ostomy is often required and the preferred approach
*
Surgery may be considered if the Dx is made within 5-10d of surgery. The risk of mortality rises to ~40% for patients operated between day 11-42.
>
2. Investigation
*
CT with & without IV and PO contrast at least 7-10d after resuscitation ± GI series or rectal contrast ± fistulogram
>
Classify output volume
*
Low output: <200 ml/d
*
Moderate output: 200-500 ml/d
*
High output: > 500 ml/d
>
Favorable features suggesting spontaneous closure:
*
Surgical etiology
*
Ileal, jejunal, nonsurgical etiology
*
Appendicitis, diverticulitis
*
Transferrin > 200 mg/dL
*
No obstruction, bowel in continuity, no infection, no inflamed intestine
*
Length > 2 cm, end fistula
*
Output < 200 mL/24 h
*
No sepsis, balanced electrolytes
*
Initial referral to tertiary care center and subspecialty care
V
3. Interventions
*
Transfer to a tertiary center is likely necessary
V
*
Once source control is obtained by operative or catheter drainage, empirical antibiotics should be discontinued after another five to seven days.
UTD: Antibiotic management in nonseptic patients with an enterocutaneous fistula is controversial. Because no studies have demonstrated improved outcomes with antibiotic therapy in these patients and there are increasing concerns for multidrug-resistant bacteria, we suggest against routine antibiotic coverage for patients who are not septic.
V
Nutrition
*
Nutritional support cannot be delayed because patients may lose 500 g of protein daily.
*
Supplying the patient with enteral nutrition as meeting the entire needs of the patient may not be possible, but there is reasonable evidence that the combination of enteral and parenteral nutrition may result in better anabolism
*
Calories: 2200 calories to 3600 calories (depending on fever, sepsis)
*
Fazio et al showed that mortality is 0% when serum albumin is > 3.5 mg/dL
V
Monitor nutritional support Week
*
Serum albumin
*
Prealbumin
*
Transferrin
*
C-reactive protein
*
Weight
*
Anthropometrics
*
For low-output fistulas trying enteral feeding, the goal enteric output is <1.5 L/day
V
Consider targeted therapy: provide nutrition that is appropriately absorbed by the functional remnant bowel - this may allow provision of higher nutrition volume than routine feeding
*
Small bowel absorbs fats and proteins
*
Terminal ileum absorbs fats
*
Large bowel absorbs carbohydrates
V
Wound care
*
A cleaner healthier abdominal wall around the fistula may aid spontaneous closure
>
Management according to output volume
*
NGT used solely for enterocutaneous fistulas do not improve outcomes
>
Low-output
*
Try NPO & monitor output
>
If fistula output is not changed, diet is resumed
*
Polymeric formula is tried first, and, if not tolerated or fistula output increases significantly, semielemental formula can be introduced. If semielemental feeds are not tolerated, an elemental feeding regimen should be attempted
*
If fistula output increases substantially, start TPN
*
Wound care for most low-output fistulas requires nothing more than a gauze cover
>
Moderate & high-output
>
Output from the fistula may decrease with an elemental diet
*
Limit intake of low sodium fluid to 500 mL/day
*
Provide patient with oral solution high in sodium (at least 90–120 mmol/L sodium content)
*
Small volume of fluid intake with solid meals,
>
When output is > 1.5 L/d, consider:
*
Loperamide & lomotil
*
Cholestyramine
*
Codeine
*
H2 antagonists and PPI — although they have not been shown to increase the rate of spontaneous closure
V
*
Octreotide if output > 1L/d: intestinal failure units typically utilize a trial of somatostatin analogues for 3d in an effort to decrease output in a fistula that produces >1L/day. If successful within 72h, the treatment is then utilized over a longer period of time.
UTD: A systematic review identified eight trials and found that somatostatin analogues decrease the duration of enterocutaneous fistulas (weighted mean difference [WMD] -6.37 days, 95% CI -8.33 to -4.42) and duration of hospital stay (WMD -4.53 days, 95% CI -8.29 to -0.77) but did not increase the rate of spontaneous closure
Source: Enterocutaneous Fistula: Proven Strategies and Updates. Irena Gribovskaja-Rupp, MD, Genevieve B. Melton, MD, PhD:
Highest output fistulas seem to be affected the most by octreotide (twice the effect than on low-output ECF).
Two recent meta-analyses summarize their results:
- somatostatin analogues and somatostatin do not improve mortality, but they
- seem to decrease fistula output,
- allow faster spontaneous closure, and
- decrease hospital stay.
Somatostatin analogues versus control resulted in
- greater success of spontaneous fistula closure (relative risk [RR] 1.36) and
- shorter time interval to closure.
*
Moderate-output fistulas can be controlled with an ostomy appliance
*
The adjacent skin should be protected with semipermeable barrier dressing or other skin protectants
V
*
Consider VAC-dressing if support and expertise are available
There is no clear evidence that negative pressure wound management system leads to an improved fistula closure rate, and, in some cases it, may cause harm.
>
4. Definitive therapy
*
As long as fistula output is gradually decreasing and the wound (or tract) shows signs of healing, surgery should be delayed
V
Spontaneous closure
*
Occurs in approximately 30% to 35% of patients in 4-6w
*
Reber et al (1987) reported that 90% of spontaneous closures occurred in the first month after sepsis resolution and 10% in the second month. No spontaneous closures took longer than that
V
V
Adjuncts therapy that may close or better control fistulas
Endoscopic manipulation may transiently increase intraluminal pressure, which may increase the risk of sepsis acutely. Thus, endoscopic therapy should only be pursued in stable, nonseptic patients by experienced providers.
V
*
Endoscopic placement of covered stents
Used successfully for early postop leaks of the colon and esophagus
Stent migration occurs in ⅓ of patients
*
Endoscopic clipping of the intraluminal end of the fistula is suitable for acute, but not chronic, fistulas
*
Fistula plugs — made from porcine submucosa
*
Fibrin sealant: An ideal fistula for treatment wound be long, narrow, low output, devoid of distal obstruction and IBD
>
Surgery
>
Prerequisites to surgery
*
Nutritionally repleted: albumin > 3.5 mg/dL
V
Rule out causes limiting fistula healing:
*
CT to rule out intraabdominal sepsis & distal obstruction
*
Consider scope to rule out Crohn’s
*
Rule out malignancy
*
Presence of supple soft tissue adjacent to the fistula
*
Stoma marking should be done
>
Time to operate:
*
The absolute minimal waiting interval after original surgery to return to the operating room is 6 weeks
*
Surgical fistula repair should not be attempted for at least three to six months from the inciting event to allow time for spontaneous healing and patient conditioning.
*
60 days for an infected field
*
120-150 days for a clean field
*
It is sometimes not unreasonable to delay surgery for 6-12 months
*
Site of incision: clean, soft, safe (away from adhesion) area
*
Performing a stoma rather than an anastomosis may decrease fistula recurrence rate by half
*
As much as 50 cm of small bowel, which is dissected in and around the fistula, will likely be sacrificed
*
Recurrence rate after surgery: 20-35%
*
Mortality rate: 10-20%
*
The abdominal wall may require complex reconstruction with plastic surgery
>
5. Healing
*
Do not initiate PO diet postOp. Keep the patient NPO for a prolonged period. Wait for repeated bowel movements
*
Do not rush to stop Abx
*
Allow 4-6m of rehabilitation before the patients should think about returning to work
*
Maintain nutrition and start rehabilitation 6 months
*
Mortality rate: 15-25%
V
Crohn’s disease — for full details, see Colorectal Surgery section
V
Principles
*
Crohn’s disease of the duodenum occurs in 2-4% of patients. Operative intervention is uncommon. The primary indication for surgery in these patients is duodenal obstruction that does not respond to medical therapy. The use of gastrojejunostomy to bypass the disease rather than duodenal resection is the procedure of choice
*
The success of nonoperative management can often be predicted based on the chronicity of symptoms at the affected site. In patients for whom it is difficult to determine whether the site of obstruction is caused by an acute exacerbation or a chronically strictured segment, CRP levels may help identify acute inflammation and predict potential success of medical therapy
V
Generally, if a segment of diseased bowel has caused intraperitoneal collections that is sufficient indication for surgical resection.
*
Resolving sources of sepsis (e.g percutaneous drainage) prior to operative intervention allows the bowel to ‘cool down’ and probably allows for smaller resections
*
When intestinal obstruction is caused by an acute flare (rather than chronic fibrosis disease) the episode can likely be managed non operatively
*
Always resect the cecum when the terminal ileum is involved unless ≥ 15cm of ileum proximal to the ileocecal valve is healthy and uninvolved
V
Prior to elective or semi-elective surgery, evaluate the full extent of the disease:
V
CT or MR enterography
V
CTE requirements:
*
1L PEG followed by 1L H2O given 1h before scanning
*
IV contrast is used
*
Anti-spasmodics are often given to reduce bowel motion artifact
V
MRE is more sensitive to motion artifacts than CTE
*
Breath hold is necessary for most sequences
*
Image acquisition time: 30-35 mins
*
Presence of bowel wall thickening in conjunction with asymmetric mural hyper-enhancement is pathognomonic for CD on imaging
*
The ability of MRE and CTE to detect CD lesions is similar, but MRE may be better in distinguishing inflammatory, fibrotic, and mixed inflammatory/fibrotic strictures
*
Video Capsule Endoscopy has near excellent yield but has the rare and feared complication of capsule retention which occurs in 13% of CD patients
*
Colonoscopy
*
± EGD (indicated in the presence of any small bowel disease)
*
To the extent possible, steroids should be reduced before surgery
*
Current practice is to continue anti-TNF agents perioperatively
*
A standard bowel preparation should be performed preoperatively unless the patient has a long-term, high-grade obstruction. If not possible, prolonged periods of clear liquid diet only is likely to suffice
*
Patients undergoing strictureplasty are at a risk for recurrence, which, in general, is comparable to patients undergoing resection
V
>
Strictures
Screen Shot 2022-02-09 at 11.04.50
*
Strictures are classified as either inflammatory or fibrotic
>
Endoscopic dilatation
>
Typical indication
*
Short segment (< 5cm) small bowel stricture in absence of penetrating disease (abscess/fistula)
*
Anastomotic strictures
*
≥ 2 dilatations are required to achieve latency over 5Y
*
Success rate ~90%
*
5Y clinical recurrence after dilatation: ~36%
*
Within 2-5Y after dilation of primary or anastomotic strictures, surgical intervention is required in ⅓ of patients
*
Complication rate (bleeding and perforation): 2-4%
V
Principles of stricturoplasty
*
Strictureplasty is the treatment of choice for symptomatic non-phlegmonous jejunoileal fibrotic strictures
*
Strictureplasties have been reported in the treatment of isolated colonic strictures: however, the length and thickness of colonic strictures is usually not conducive to strictureplasty techniques
V
Strictureplasties are contraindicated in
>
1. The presence of local sepsis
*
The presence of enteric fistulae was viewed previously as a contraindication for performing a stricturoplasty, but more recent reports have suggested that stricturoplasty may be performed in the presence of fistulae surrounded by chronic, rather than active, inflammation without increasing postoperative morbidity
*
It originally was thought unsafe to perform a stricturoplasty in a segment of bowel with active disease; however, recent studies have shown this is feasible and safe
*
2. The presence of constant low-grade hemorrhage associated with the diseased, strictured loop
*
3. Severe malnutrition
*
4. High suspicion for malignancy
*
5. Multiple adjacent strictures
*
Suspicion for neoplasm is managed with frozen biopsy, and if confirmed, resection is performed
V
IntraOperative plan
*
Assessment of the complete small bowel for strictures, fistulas, masses, & abscesses
>
Techniques
V
>
Heineke-Mikulicz
Screen Shot 2019-12-11 at 19.32.23
*
It’s the most common technique
*
Appropriate for short strictures (≤ 7cm)
*
Performed by making a longitudinal incision on the antimeseteric side
*
Extend the incision 2 cm proximal and distal to the stricture
*
Enterotomy is closed in a transverse fashion, in one or two layers
V
*
A variation of this type of stricturoplasty is the Moskel–Walske–Neumayer stricturoplasty and is ideal for those strictures that have a dilated proximal bowel with a stricture that is <10 cm. A “Y”-shaped incision is made over the stricture with the upper portion of the “Y” over the dilated portion of the bowel. This is then closed by advancing the dilated portion of the bowel to the base of the “Y,” thus creating a “V” suture line. The advantage of this technique is that it addresses the bowel size discrepancy and is relatively easy to perform
Untitled
V
>
Finney
Screen Shot 2019-12-11 at 19.37.46
*
Appropriate for strictures >7 cm and ≤15 cm
*
A longitudinal enterotomy then is performed halfway between the mesenteric and the antimesenteric side on the folded loop
*
The opposed edges of the bowel are sutured together to create a short side-to-side isoperistaltic enteroenterostomy
V
>
Jaboulay
11812tn
As the length of the side-to-side enteroenterostomy increases, so does the chance of developing a lateral diverticulum or blind loop, bacterial overgrowth, malabsorption, malnutrition, and persistent low-grade inflammation.
*
Appropriate for strictures of 10-20 cm
*
The stricture is folded into a U-shape
*
Two enterotomies are created facing each other to allow for a side-to-side enteroenterostomy (not extending to the tip of the folded loop) — performed halfway between the mesenteric and the antimesenteric side on the folded loop
*
The side-to-side enteroenterostomy is performed with a running continuous single layer or double layer
V
>
Michelassi side-to-side isoperistaltic
Screen Shot 2019-12-11 at 19.47.58
*
It’s the technique of choice to address multiple short strictures clustered over a lengthy small bowel segment >15 cm
*
The small bowel loop affected by the stricture and its mesentery first is divided at its midpoint
*
Care is taken to ensure that stenotic areas of one loop are placed adjacent to the dilated areas of the other loop
*
The two loops are then approximated by a layer of interrupted seromuscular Lembert stitches, using nonabsorbable 3-0 sutures
*
A longitudinal enterotomy is performed on both loops, with the intestinal ends tapered to avoid blind sumps
V
PostOp outcomes
V
Short term
>
13% develop complications
*
4% septic complications
*
3% hemorrhage
*
The early postOp complication rate of strictureplasty is lower than resection
*
In regard to functional outcomes, efficacy of strictureplasties has been largely demonstrated, with satisfactory relief of obstructive symptoms, improved food tolerance, and subsequent weight gain
V
Long term
V
Several studies have shown that recurrence may be lower at strictureplasty sites than intestinal resection sites
*
Stricturoplasty recurrence rate was 3%
*
The incidence of adenocarcinoma is < 0.4%
>
Principles of resection
*
Determine length of healthy bowel
*
Resect only segments causing complications
*
Determine whether resection vs stricturoplasty is more appropriate
*
Resect to grossly negative margins (include only 2cm of grossly uninflamed bowel proximal and distal to the diseased segment)
>
Bypass only if:
*
Duodenum is involved
*
Resection is technically impossible
*
Short gut syndrome
*
‘Divert liberally’
>
Kono-S anastomosis may reduce disease recurrence
V
*
Developed in Japan (2003)
When compared to historical cohort, Kono-S had lower rate of anastomotic recurrence at 5 years (0% VS 15%; P < 0.0013)
>
SuPREMe-CD Study
*
RCT: 79 patients with ileocolic Crohn's Disease
Kono-S (36 patients)
Conventional group (43 patients)
*
No differences in postoperative outcomes
*
Primary endpoint: endoscopic recurrence at 6 months
22.2% vs 62.8%
13.8% Vs 34.8% (severe recurrence)
>
Rationale
*
Both resection ends are not involved within the anastomosis
*
Supporting column prevents anastomotic distortion
*
Preservation of the mesenteric vascularization and innervation
V
>
Technique
Supporting column423_2020_1998_Fig1_HTML
*
1.Small window in the mesentery is created at the proximal and distal resection margins
*
2. Mesentery is divided adjacent to the intestinal wall
*
3. The bowel is divided transversely
*
4. The corners of the two stapled lines are imbricated and the two staple lines are sewn together creating the "supporting column"
*
5. An antimesenteric longitudinal enterotomy or colotomy is performed on each end
*
6. Transverse lumen of cm on the small bowel and 8 cm on the colon, 1 cm away from the staple line
*
7. Two layer hand sewn anastomosis
Inner layer 3-0 absorbable Connell suture
Outer layers of 4-0 silk Lembert interrupted
*
Typhoid fever — Hyperplasia of the reticuloendothelial system, including LNs, liver, and spleen, is characteristic of typhoid fever. Peyer patches in the small bowel become hyperplastic and may subsequently ulcerate, with complications of hemorrhage or perforation. Treatment is with Abx (amoxicillin or cotrimoxazole is sufficient)
*
CMV is the most common viral cause of diarrhea in immunocompromised patients. Patients may present with abdominal pain, peritonitis, or hematochezia. Diagnosis of CMV is made by demonstrating viral inclusions. The most characteristic form is an intranuclear inclusion, which is often surrounded by a halo, producing a so-called owl’s eye appearance. There may also be cytoplasmic inclusions. Treatment is with gancyclovir or foscarnet
V
*
DDx for small bowel ulcerations
Infections
Tuberculosis, syphilis, cytomegalovirus, typhoid, parasites, Strongyloides hyperinfection, Campylobacter, Yersinia
Inflammatory
Crohn’s disease, systemic lupus erythematosus, celiac disease, ulcerative enteritis
Ischemia
Mesenteric insufficiency
Idiopathic
Primary ulcer, Behçet’s syndrome
Drug induced
Potassium, indomethacin, phenylbutazone, salicylates, antimetabolites
Radiation
Therapeutic, accidental
Vascular
Vasculitis, giant cell arteritis, amyloidosis (ischemic lesion), angiocentric lymphoma
Metabolic
Uremia
Hyperacidity
Zollinger-Ellison syndrome, Meckel’s diverticulum, stomal ulceration
Neoplastic
Lymphoma, adenocarcinoma, melanoma
Toxic
Acute jejunitis (β-toxin–producing Clostridium perfringens), arsenic
Mucosal lesions
Lymphocytic enterocolitis
>
Diverticulosis of small bowel
*
Most are asymptomatic
>
Classification
*
True vs false diverticula
*
Congenital vs acquired
V
*
Most commonly (80%) occur in the duodenum; usually periampullary in location. Up to ¾ of duodenal diverticula are found in the periampullary region (within 2cm of the ampulla) & project from the medial wall of the duodenum
Screen Shot 2019-12-23 at 10.32.57
*
Frequently, pseudodiverticula are associated with other congenital anomalies: malrotation, omphalocele, annular pancreas, congenital biliary cysts, and various cardiac and urinary congenital abnormalities.
*
Zani and colleagues calculated that 758 patients with incidental Meckel’s diverticulum would need to undergo intestinal resection to prevent 1 death
>
Meckel’s divertula
*
It’s the most common congenital small bowel abnormality
V
*
It’s a result of the failure of obliteration of the proximal vitelline duct (connects embryonic midgut to the yolk sac). It occurs only on the antimesenteric border of the ileum
Vetilline definition: relating to the yolk (or yolk sac) of an egg or embryo, or to yolk-producing organs
V
>
It may exist in different forms:
Screen Shot 2020-08-05 at 19.43.05
*
Small bump that may be easily missed
*
Long projection that communicates with the umbilicus by a persistent fibrous cord
*
Less commonly, a patent fistula
*
It’s a true diverticulum
*
Located 2 feet from ileocecal valve
*
50% contains heterotropic tissue: gastric (75%) or pancreatic
*
Symptomatic in 2%, usually within the first 2Y of life
*
The most common presentation (25-50%) is with bleeding
*
In children, the single most accurate diagnostic test for Meckel’s diverticula is scintigraphy with sodium 99mTc-pertechnetate. The 99mTc-pertechnetate is preferentially taken up by the mucus-secreting cells of gastric mucosa and ectopic gastric tissue in the diverticulum
*
In adult patients, when nuclear medicine findings are normal, barium studies should be performed. In patients with acute hemorrhage, angiography is sometimes useful.
>
Symptomatology
*
Duodenal diverticulosis most commonly presents with postprandial epigastric abdominal cramping pain and vomiting due to partial or intermittent duodenal obstruction.
*
Jejunoileal diverticula are the most likely to be symptomatic or develop complications
*
Bacterial overgrowth may present with early satiety, bloating, and chronic upper abdominal discomfort and diarrhea/steatorrhea — this may be the most common symptomatic presentation
*
Obstruction secondary to volvulus or enterolith impaction,
*
Diverticulitis
*
Bleeding secondary to ulceration (usually on the mesenteric border in the case of Meckel’s), rupture, or AVM
*
Obstructive jaundice/recurrent pancreatitis in periampullary diverticula
*
Identification is through CT/MR enterography and endoscopy. Meckel’s scan uses technetium and detects gastric mucosa (not hemorrhage) with a sensitivity of 80%
>
Management
*
Asymptomatic: do not require treatment
>
Symptomatic:
*
Bacterial overgrowth is managed with Abx
>
Diverticulitis:
*
Nonoperative management as long as there is no perforation
*
For symptomatic intraluminal duodenal diverticula duodenotomy and excision are usually necessary for removal, although endoscopic resection has also been successful
*
When a perforation of a jejunoileal diverticulum is encountered, resection with reanastomosis is required because lesser procedures such as simple closure, excision, and invagination are associated with greater mortality and morbidity rates
>
Obstruction
*
Volvulus requires resection
*
Enterolith impaction is treated with enterotomy and stone extraction
*
Biliary obstruction is managed with ERCP then cholecystectomy
>
Meckel’s diverticula
*
Although reduction of an intussusception secondary to Meckel’s diverticulum can sometimes be performed by barium enema, the patient should still undergo resection of the diverticulum to negate subsequent recurrence of the condition
>
Indications for prophylactic resection:
*
Pediatric population
*
Length > 2 cm
*
Palpable abnormality/ectopic tissue
*
Hx of diverticulitis, hemorrhage, or intussusception
*
Presence of mesodiverticular bands
*
Segmental intestinal resection is required for treatment of patients with bleeding because the bleeding site is usually in the ileum adjacent to the diverticulum
*
Obstruction is managed with wedge resection
*
Diverticulitis & hemorrhage are manage with segmental resection
>
Operative technique
*
For diverticula embedded deep within the head of the pancreas, a duodenotomy is performed, with invagination of the diverticulum into the lumen, which is then excised, and the wall is closed
*
The treatment of a perforated duodenal diverticulum may require procedures similar to those described for patients with massive trauma-related defects of the duodenal wall
*
Most recommendations support segmental resection of jejunoileal diverticula, when necessary, especially to prevent narrowing of the small bowel
>
Tumors
>
Benign tumors
*
Most benign neoplasms are asymptomatic and therefore are not found unless as an incidental finding
V
*
Leiomyomas (GISTs) and adenomas are the most frequent benign tumors
Adenomas are the most common benign tumors reported in autopsy series, but GISTs are the most common benign small bowel lesions that produce symptoms
V
*
Hemangiomas are most common in the jejunum; they are multiple in 60% of patients
Hemangiomas of the small bowel may occur as part of an inherited disorder known as Osler-Weber-Rendu disease
Patients with Turner’s syndrome are likely also to have cavernous hemangiomas of the intestine.
*
More common in the distal small bowel
*
Dx is often delayed due to lack of associated symptoms
*
~10% of all occult GI bleeds are due to small bowel tumors
*
The presenting symptom of jejunal and ileal tumors often is obstruction (followed by hemorrhage)
*
Duodenal tumors often present with pain, biliary obstruction, gastric outlet obstruction, or occult bleeding
>
Predisposing conditions
*
FAP
*
HNPCC
V
*
Peutz-Jeghers Syndrome
The entire jejunum and ileum are the most usual portions of the gastrointestinal tract involved with these hamartomas.
Although once considered a purely benign disease, adenomatous changes have been reported in 3% to 6% of hamartomas
The treatment of complications of Peutz-Jeghers syndrome is directed mainly at the complication of obstruction or persistent bleeding. Resection should be limited to the segment of bowel that is producing complications and usually involves a limited resection. Because of the widespread nature of intestinal involvement, cure is not possible, and extensive resections are not indicated.
*
Crohn’s disease
V
*
Celiac sprue
In a study of 12,000 patients:
The most common malignancy was lymphoma. The risk of other digestive tract cancers was also increased, including oropharyngeal (mostly esophageal squamous cell), small intestinal adenocarcinoma, colorectal, and hepatocellular. In contrast, there was a significantly reduced risk of breast cancer
*
Possibly Meckel’s diverticulum
*
EtOH consumption
*
Smoked or cured meats
*
Refined sugars
>
Small bowel tumors in according to prevalence
>
1. Neuroendocrine tumors (for details, see section for Appendix NET)
*
Arise from enterochromaffin cells (Kulchitsky cells)
*
The primary importance of carcinoid tumors is the malignant potential of the tumors themselves
*
Characterized by the expression of somatostatin receptors
>
Predisposing conditions
*
MEN1
*
Neurofibromatosis
*
Presence of breast or colorectal cancer
V
>
For nonfunctional tumors, some tumor markers are helpful:
It appears that the combination of 24-hour urine 5-HIAA and serum chromogranin A levels provides the best biochemical diagnostic accuracy
*
5HIAA
*
Chromogranin-A
*
Pancreatic polypeptide
*
Neuron-specific enolase
*
Cases should be referred to high-volume centers
*
Tumors that bypass the liver, specifically ovarian and retroperitoneal carcinoids, may produce the syndrome in the absence of liver metastasis.
*
30% have synchronous lesions. Synchronous colon adenocarcinoma occurs in 10-20% of patients with carcinoid tumors
>
Duodenal NET management:
*
< 1 cm → endoscopic resection
*
1-2 cm → enucleation via an open approach
*
≥ 2 cm → complete resection with lymphadenectomy (Whipple if necessary)
*
Sporadic gastrinomas should be resected
*
Gastrinomas associated with MEN1 should not be resected
*
For primary tumors smaller than 1 cm in diameter without evidence of regional lymph node metastasis, a segmental intestinal resection is adequate. For patients with lesions larger than 1 cm, with multiple tumors, or with regional lymph node metastasis, regardless of the size of the primary tumor, wide excision of bowel and mesentery is required
*
In patients with carcinoid tumors and widespread metastatic disease, surgery is still indicated. In contrast to metastases from other tumors, there is a definite role for surgical debulking, which often provides beneficial symptomatic relief
*
Interferon-α (IFN-α) has also been shown to provide symptomatic relief in patients with carcinoid syndrome
*
The role of chemotherapy is confined predominantly to patients with metastatic disease who are symptomatic, unresponsive to other therapies, or have high tumor proliferation rates. The most frequent combination used is streptozotocin plus 5-FU or cyclophosphamide, which may result in some tumor regression in up to ⅓ of the patients
*
Carcinoid tumors have the best prognosis of all small bowel tumors, whether the disease is localized or metastatic
*
Elevated level of chromogranin A, which was found to be an independent predictor of an adverse prognosis.
>
2. Adenocarcinomas
*
Small bowel adenocarcinomas are more likely than colorectal cancer to have mutations in SMAD4 (indicating a MMR pathway)
*
All patients with adenocarcinoma of the small bowel should be evaluated for an occult underlying condition
*
Most of the tumors are located in the duodenum and proximal jejunum
*
Adenocarcinoma of the small bowel is mostly encountered in the setting of Crohn’s disease (> 100X the risk) and are usually ileal in origin
>
For nonmetastatic disease, the goal is complete resection with lymphadenectomy (at least 8-10 LN)
*
Duodenum (D1-D2) may require Whipple
*
Duodenum (D3-D4) may be amenable to segmental resection with the associated mesentery
*
Terminal ileum may require right hemicolectomy
*
The indications for adjuvant chemotherapy are mostly extrapolated from data regarding colorectal cancer
>
3. Lymphoma
*
Areas with the most lymphoid tissue (i.e., jejunum and distal ileum) have the highest rate of tumor formation
V
*
Commonly associated with celiac disease & AIDS
In a study of 12,000 patients:
The most common malignancy was lymphoma. The risk of other digestive tract cancers was also increased, including oropharyngeal (mostly esophageal squamous cell), small intestinal adenocarcinoma, colorectal, and hepatocellular. In contrast, there was a significantly reduced risk of breast cancer
>
The most common histologic Dx is NHL of B-cell variety
*
Diffuse Large B-Cell Lymphoma (DLCBL) and MALT are the most common
V
*
Burkett’s lymphoma develops in HIV patients. Usually presenting with ileocolic intussusception
Burkitt’s has a characteristic cytogenetic abnormality with rearrangement of the c-Myc oncogene located on chromosome 8
>
Workup
*
CT: neck, chest, abdomen, pelvis
*
PET
*
Endoscopy
*
LDH
*
β-2 microglobulin
*
Bone marrow Bx
V
*
Lugano Staging
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>
Management
*
For most small bowel B-cell lymphomas with localized disease (Lugano stage I, II 1 ), surgical resection with adjuvant chemotherapy (CHOP or R-CHOP) continues to be the treatment of choice.
*
Those with advanced disease (Lugano stage II 2 and greater) undergo chemotherapy only
*
B cell lymphomas are more chemosensitive than T cell lymphomas and have high remission rates with or without surgery. T cell lymphomas are traditionally more resistant to therapy and will progress to symptoms of obstruction or perforation if not resected. Regardless of cell type, resection is indicated at any onset of symptoms because progression to life-threatening hemorrhage or perforation portends a dismal prognosis.
*
4. Mesenchymal tumors, including GIST (see section for stomach GIST)
>
Metastatic disease
>
Most common primary:
*
Melanoma (30%)
*
Colon
*
Breast
*
Kidney
*
Lung
*
Resection of melanoma and RCC small bowel metastases have been shown to increase survival
V
Management
*
Hamartomas (often associated with PJS) and lipomas should be resected only if causing significant symptoms
*
Leiomyomas cannot be distinguished from GISTs & leiomyosarcomas and should be resected
*
Lipomas do not have malignant potential and therefore, when found incidentally, should be removed only if the resection is simple.
V
Adenomas
*
For sporadic duodenal adenomas, endoscopic or open polypectomy can be performed if technically feasible (lesions < 1-2 cm are usually amenable for endoscopic resection). Although both these treatment strategies are associated with a recurrence rate of 30% to 50%, especially in adenomas larger than 3 cm, postpolypectomy surveillance remains possible. Invasive changes or a recurrence after polypectomy necessitate more of a definitive resection, such as a pancreaticoduodenectomy.
*
Adenomas without carcinomas can be managed with endoscopic resection
*
Brunner’s gland adenomas have a malignant potential similar to that of tubular adenomas and can be resected endoscopically
*
Carcinomas should be resected formally
V
V
In the setting of FAP: duodenal adenomas have varying degree of malignant potential. They are assessed according to the Spigelman classification
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Stage 0: Every four years
Stage I: Every two to three years
Stage II: Every one to three years
Stage III: Every 6 to 12 months
Stage IV: In the absence of surgery (duodenectomy), surveillance every six months
*
FAP-affected patients carry a 5% lifetime risk of developing duodenal adenocarcinoma
*
Screening endoscopy with a forward- and side-viewing endoscope is performed at Q3Y with biopsy of all suspicious, villous, or large (>3 cm) adenomas, in addition to random duodenal biopsies
*
The presence of high-grade dysplasia, carcinoma in situ, or a Spigelman IV classification necessitates pancreaticoduodenectomy or pancreas-preserving duodenectomy
>
Lymphomas should be resected if (either):
*
Symptomatic
*
T-cell subtype (poorer response to chemotherapy than B-cell subtypes)
>
Short gut syndrome
*
> 180 cm small bowel remaining will require no TPN
*
> 90 cm small bowel often require TPN for < 1Y
*
< 60 cm small bowel will require permanent TPN
*
Specific nutrient deficiencies must be prevented and levels must be monitored closely; these nutrients include iron, magnesium, zinc, copper, and vitamins
*
Separating solid & liquid meals aid in absorption of solids
*
Initially a high-carbohydrate, high-protein diet is appropriate to maximize absorption. Fat absorption requires more digestion unless the fat is supplied in the form of medium-chain triglycerides
*
Provide a diet that will maximize the intestinal adaptive response. Provision of fat, particularly long-chain triglycerides, and dietary fiber may be particularly important in this regard
*
Growth factors (e.g., growth hormone and GLP-2) also may stimulate intestinal adaptation and are currently available in the clinical setting — contraindications include Hx of polyps in the GIT
V
>
Rx for short gut (partially applicable to high-output stoma):
For high output stoma:
↓ motility: Loperamide, lomitil, codein/opioids,
↑ absorption: Bulking agent (H2O absorption), elemental diet
↓ secretion: PPI (stomach), octreotide (pancreatic), cholestyramine (bile)
↑ viscosity: pectin, guar
>
Slow Transit
*
Loperamide, Lomotil, narcotics
>
Reduce GI Secretion
*
H 2 receptor antagonists
*
Proton pump inhibitors
*
Octreotide
*
Clonidine
>
Treat Bacterial Overgrowth
*
Antibiotics
*
Probiotics
*
Prokinetics
>
Treat Pharmacologically
*
Growth hormone
*
Teduglutide
>
Potential complications of short gut
*
Metabolic: dehydration & renal dysfunction
*
Nutritional deficiencies
*
Catheter related sepsis
*
TPN-induced liver disease
*
Bacterial overgrowth
*
Cholelithiasis
*
Nephrolithiasis
*
Gastric hypersecretion
V
*
Management
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>
Blind loop syndrome
*
Manifests as diarrhea, steatorrhea, megaloblastic anemia, weight loss, abdominal pain, neurologic disorders and deficiency in fat-soluble vitamins
*
The underlying cause is bacterial overgrowth in a stagnant area of small bowel produced by strictures, stenosis, fistula, or diverticula
V
*
Dx is confirmed with cultures or indirectly via breath tests.
After bacterial overgrowth and steatorrhea are confirmed, a Schilling test (57Co-labeled vitamin B12 absorption) may be performed, which should reveal a pattern of urinary excretion of vitamin B12 resembling that of pernicious anemia, a urinary loss of 0% to 6% of vitamin B12 compared with the normal of 7% to 25%). In patients with blind loop syndrome, vitamin B12 excretion is not altered by the addition of intrinsic factor, but a course of a broad-spectrum antibiotic (e.g., tetracycline) should return vitamin B12 absorption to normal.
>
Treatment:
*
Parenteral B12 vitamin therapy
*
Broad-spectrum Abx: tetracycline, amoxicillin-clavulanate, cephalexin/metronidazole, or chloramphenicol
*
Surgical correction of the condition causing stagnation and blind loop syndrome produces a permanent cure and is indicated for patients who require multiple rounds of antibiotics or are on continuous therapy
>
Pneumatosis intestinalis
*
Most commonly occur in the jejunum then in the ileocecal region
>
Associated conditions
*
Immunocompromised patients: AIDS, transplantation, leukemia, lymphoma, vasculitis, steroid therapy
*
IBD
*
Infectious enteritis
*
Obstructive pathology
*
Iatrogenic
*
Spontaneous rupture gives rise to pneumoperitoneum
*
Pneumatosis intestinalis represents one of the few cases of sterile pneumoperitoneum and should be considered in the patient with free abdominal air but no evidence of peritonitis.
*
No treatment is necessary unless one of the very rare complications supervenes, such as rectal bleeding, cyst-induced volvulus, or tension pneumoperitoneum
>
Radiation enteritis
*
A previous history of laparotomy increases the risk for enteritis, presumably because of adhesions that fix portions of the small bowel into the irradiated field
*
Sucralfate has been shown to be of value in preventing the diarrhea associated with abdominal radiation
*
Superoxide dismutase, a free radical scavenger, has been used successfully to reduce complications
*
The most effective radioprotectant agent appears to be amifostine (WR-2721)
*
Indications for operation include obstruction, fistula formation, perforation, and bleeding, with obstruction being the most common presentation.
*
If resection and reanastomosis are planned, at least one end of the anastomosis should be from intestine outside the irradiated field
*
Almost 50% of patients who survive their first laparotomy for radiation bowel injury require further surgery for ongoing bowel damage. Up to 25% of these patients die of radiation enteritis and complications from its management.
>
Intussusception in pediatrics
>
Pneumatic (air reduction) techniques are now generally preferred to the hydrostatic methods if fluoroscopy is used for guidance. The pneumatic technique cannot be used with ultrasonography, because the air interferes with ultrasound visualization
*
A sphygmomanometer can be used to monitor colonic intraluminal pressure (typically not to exceed 120 mmHg) to aid in reduction
*
CO2 can also be used instead of air
>
A successful reduction of the intussusception is indicated by:
*
Rush of air reflux into the terminal ileum
*
Sudden drop in the intraluminal pressure
*
Disappearance of the mass at the ileocecal valve
*
Risk of bowel perforation is < 1%
>
Recurrence
>
Recurs in approximately 10% after successful nonoperative reduction
*
½ of the recurrences are within the first 72h
*
Recurrence is not necessarily an indication for surgery
*
In general, each recurrence should be handled as if it were the first episode, provided that each attempt at nonoperative reduction is successful and the patient remains stable
*
Imaging studies should be reviewed carefully for the possibility of a pathologic lead point. If a lead point is identified, the patient may still be treated with nonoperative reduction, particularly if the lead point is diffuse
*
Surgical exploration should be performed for any patient who is unstable, and should also be considered for those with a focal lead point or multiple recurrences
>
Sclerosing mesenteritis
*
Rare disease
*
Usually discovered incidentally on imaging for nonspecific symptoms
*
CT may demonstrate a fat ring or halo sign and pseudocapsule
>
Definitive Dx requires histologic evaluation (usually laparoscopy) to rule out other etiologies
*
Non-hodgkin’s lymphoma
*
Carcinoid
*
Desmoid tumor
*
Peritoneal carcinomatosis
>
Initial treatment in non-obstructive symptoms:
*
Prednisone 40mg QD
*
Tamoxifen 10mg BID
>
Colorectal surgery
>
Embryology, anatomy, physiology
V
V
Embryology
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*
The mucosa arises from the endodermal layer
*
The muscular wall, connective tissue, & outer serosal surface arises from the mesodermal layer
*
Endoderm gives rise to the primitive gut tube
>
At the 3rd week of development, the gut tube has 3 discernible segments: foregut, midgut, and hindgut
*
Foregut-derived structures end at D2 (rely on celiac artery for blood supply)
*
Midgut-derived structures extend from duodenal ampulla to the distal transverse colon (rely on SMA for blood supply)
*
Hindgut-derived structures extend from distal transverse colon to the rectum (rely on IMA for blood supply)
*
The dentate line represents a true division between embryonic endoderm and ectoderm
>
Normally present in the 4–5-week old embryo, the cloaca is a derivative of hindgut endoderm
*
Embryologically, the cloaca is a transient organ that becomes divided to separate the gastrointestinal tract from the genitourinary tract
V
*
The cloaca originates at the portion of the rectum below the pubococcygeal line while the hindgut originates above it.
embryology
V
*
At the 6th week of development the cloaca divides & differentiates into anterior urogenital & posterior anal & sphincter elements
The muscles of the pelvic floor, like those of the anal sphincter mechanism, arise from the primitive cloaca
*
During the 10th week of development, the external anal sphincter is formed from the posterior cloaca
*
During the 12th week of development, the internal anal sphincter develops from the circular muscle layers of the rectum
V
*
By the 16th week of development: the female genital organs form from the Müllerian ducts and join the urogenital sinus. In contrast, in males, the urogenital membrane obliterates with fusion of the genital folds while the sinus develops into the urethra.
uterus
V
*
The appendices epiploicae are non-mesenteric fat protruding from the serosal surface of the colon. They are likely residual from the anti-mesenteric fat of the embryologic intestine which dissipates (unlike the omentum on the stomach)
Untitled
V
>
Normal rotation of the intestinal tract
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V
V
First stage (6-8w GA): rapid elongation of the midgut results in physiologic herniation through the umbilical cord
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V
*
During the 8th week, contents move in a counterclockwise fashion, turning 90° from the sagittal to the horizontal plane
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V
Second stage (8-9w GA): return of midgut to the abdomen
V
*
During the 10th week, the midgut loops return to the peritoneal cavity and simultaneously rotate an additional 180° in the counterclockwise direction
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V
Third stage (11-12w GA): fixation of the midgut
*
The cecum migrates to the right lower quadrant from its initial position in the upper abdomen
*
After the completion of this 270° counterclockwise rotation, fusion begins, typically at week 12–13
V
Abnormalities in intestinal rotation
V
*
Non-rotation
Screen Shot 2020-04-21 at 1.07.06 PM
V
*
Malrotation rotation
There is normal initial rotation, but the cecum fails to complete the normal 270° rotation around the mesentery
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*
Reversed (clockwise) rotation: transverse colon posterior to SMA
*
Omphalocele
V
*
Internal hernias
These are considered failures of the process of fixation (the third stage of rotation). This can be the result of an incomplete fusion of the mesothelium or when structures are abnormally rotated. Retroperitoneal hernias can occur in various positions, most notably paraduodenal, paracecal, and intersigmoid.
V
Congenital malformations of the colon and small intestines
>
Colon duplication, types:
V
Mesenteric cysts
*
Lined with intestinal epithelium and variable amounts of smooth muscle
*
They are found within the colonic mesentery or posterior to the rectum (within the mesorectum)
*
They generally present as a mass or with intestinal obstruction as they enlarge
V
Diverticula
*
Found on the mesenteric or antimesenteric sides of the colon and are outpouchings of the bowel wall
V
Long (true) colon duplication
*
The rarest form of duplication
*
They parallel the functional colon and often share a common wall throughout most of their length
*
They usually run the entire length of the colon and rectum and there is an association with other genitourinary abnormalities
V
>
Atresia of the colon
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*
Represent only 5% of all gastrointestinal atresias
*
They are likely the result of vascular compromise during development
*
They vary in severity from a membranous diaphragm blocking the lumen to a fibrous cord-like remnant, on to a complete absence of a segment
*
Hirschsprung’s disease
V
>
Anorectal malformations
Malformations are attributed to developmental arrest at various stages of normal development
Skeletal and urinary anomalies are associated in up to 70%.
Other associated abnormalities: digestive tract anomalies, cardiac, & abdominal wall abnormalities
V
*
Anal stenosis
While anal stenosis in a newborn is relatively common, noted in 25–39% of infants, symptomatic stenosis is only noted in 25% of these children
V
*
Membranous atresia
Very rare
Characterized by the presence of a thin membrane of skin between the blind end of the anal canal and the surface
V
*
Anal agenesis
The rectum develops to below the puborectalis where it either ends in an ectopic opening (fistula) in the perineum, vulva, or urethra, or it ends blindly (less commonly). The sphincter is present at its normal site.
V
*
Anorectal agenesis
The most common type of “imperforate anus.”
More common in males
In most cases, there is a fistula to the urethra or vagina
V
*
Rectal atresia
The rectum and the anal canal are separated from one another by an atretic portion
V
*
Persistent cloaca
Only occurs in female infants, is the result of total failure of descent of the urorectal septum.
>
Anatomy
V
*
Taeniae of the colon are situated: anteriorly, posteromedially, and posterolaterally
Though they run along the full length of the colon, they are not as long as the bowel wall. This difference in length results in outpouchings of the bowel wall between the taenia referred to as haustra.
9781626231689_f0372
IMG_0307
V
*
Intersigmoid fossa: though which the left ureter & gonadal vessels travel through
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>
Vasculature
*
Arc of Riolan directly connects the proximal SMA with the proximal IMA AKA the meandering mesenteric artery) and is highly variable in size. Flow can be forward (IMA stenosis) or retrograde (SMA stenosis). Such obstruction results in increased size and tortuosity of this meandering artery, which may be detected by arteriography; the presence of a large arc of Riolan thus suggests occlusion of one of the major mesenteric arteries
*
Artery of Moskowitz is found in the region of the splenic flexure and tends to run more proximal to the artery of Moskowitz
>
From its left side, the SMA gives rise to up to 20 small intestinal branches while the colic branches originate from its ride side.
*
The right colic artery can arise from the ileocolic vessels or from the middle colic vessels
*
The middle colic artery arises from the SMA near the inferior border of the pancreas. It branches early to give off right and left branches
*
In ~ 33% of patients, the left branch of the middle colic artery can be the sole supplier of the splenic flexure
*
The marginal artery has been shown to be discontinuous or even absent in some patients, most notably at the splenic flexure (Griffiths’ critical point), where it may be absent in up to 50% of patients
*
Another potential (though controversial) site of ischemia is at a discontinuous area of marginal artery located at the rectosigmoid junction termed Sudeck’s critical point. Surgical experience would question whether this potential area of ischemia exists; a recent fluorescence study indicates that it does, though its clinical importance remains in doubt.
V
>
Rectum
Pasted_Graphic_8
V
V
Superior rectal artery (superior hemorrhoidal) < IMA
The IMA becomes named the superior rectal artery after the IMA crosses the left iliac vessels
*
After giving off a rectosigmoid branch, an upper rectal branch, it bifurcates into right and left terminal branches in 80% & descends caudally in the mesorectum
*
Middle rectal artery (paired) (absent in 40-80%) < internal iliac artery
V
*
Inferior rectal artery (paired) < internal pudendal artery < distal branch of the internal iliac artery
The artery originates in the pudendal canal and is entirely extrapelvic (caudal to the levator ani) in its distribution.
*
Dr. Liberman: Internal pedundal artery is usually recognized from a TaTME approach but not from a peritoneal approach
>
Lymphatic drainage
>
Drainage is divided into 4 main groups
*
Epiploic group: adjacent to the bowel wall
*
Paracolic group: along the marginal artery & the vascular arcades
*
Intermediate group: on the primary colic vessels
*
Main or principal group: on the SMA & IMA
*
Once lymph leaves the main nodes, it drains into the cisterna chili via the para-aortic chain
V
>
Fascia
ac-2017-12-15f6
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V
Endopelvic/endovisceral fascia
*
Located between the visceral peritoneum and parietal fascia of the levator ani
*
Contains neurovascular bundles, smooth muscles, collagen, and elastin
*
It fans out to envelop the pelvic organs and anchors them to the surrounding pelvic sidewall structures.
V
A thin layer of investing fascia (fascia propria) coats the mesorectum and represents a distinct layer from the presacral fascia (endopelvic fascia) against which it lies = “the Holy Plane”
*
The fascia propria of the rectum is a thin condensation of the endopelvic fascia that forms an envelope around the mesorectum and continues distally to help form the lateral rectal stalks
*
As the presacral fascia extends laterally, it becomes continuous with the fascia propria & contributes to the lateral ligaments of the rectum
V
V
The lateral rectal stalks or ligaments are actually anterolateral structures containing the middle rectal artery. The stalks reside in close proximity to the mixed autonomic nerves, containing sympathic and parasympathetic nerves, and division of these structures close to the pelvic sidewall may result in injury to these nerves, resulting in impotence and bladder dysfunction
ASCRS:
“It is interesting to note that at least one modern cadaveric dissection study identified the presence of a middle rectal artery in only 22% of specimens”
“In an extensive review of the anatomy of the lateral ligament, Church notes that it is a common misconception that the lateral ligaments contain the middle rectal artery at all. It appears that the lateral ligaments comprise “primarily nerves and connective tissue””
“Other modern cadaveric investigations note the rarity of middle rectal arteries and the absence of clinically relevant neurovascular structures in the lateral ligaments”
*
The stalks are trapezoid structures originating from mesorectum and anchored to the endopelvic fascia at the level of the midrectum
*
The urogenital bundle runs just above the lateral ligament at its point of insertion on the endopelvic fascia
V
The rectosacral fascia, or Waldeyer’s fascia, is a thick condensation of endopelvic fascia connecting the presacral fascia to the fascia propria at the level of S4 that extends to the anorectal ring.
*
It extends anteriorly to the posterior layer of the fascia propria 3-5 cm proximal to the anorectal junction
*
The space posterior to the retrosacral fascia is referred to as the supralevator or retrorectal space
*
ASCRS: While the debate continues regarding “Waldeyer’s fascia”, it is important to simply understand that the phrase can have the potential to mean presacral fascia, rectosacral, or retrorectal fascia
>
Denonvillier’s fascia = rectogenital fascia
*
Extends from the deepest point of the rectovesical pouch to the pelvic floor
*
It is also present in females as part of the rectovaginal septum and is sometimes referred to as rectovaginal fascia. It is found immediately beneath the vaginal epithelium and is clearly what most would consider as part of the vaginal wall
V
*
Relations to seminal vesicle, vas deferens, and urethra
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V
>
Pelvis & pelvic floor
1B7E08F1-7C5A-4D9B-8D08-B3622B30D94A
>
“Building a pelvis”
V
*
1. Bony & ligaments; greater & lesser sciatic foramina
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*
2. Pelvic muscles
ED2AB180-AE51-400C-BAE4-CDD52AAA77E7_1_105_c
V
*
3. Ext. iliac vessels course on the medial border of psoas
F2A08E2A-E036-4AE2-9539-954CCA46E972_1_105_c
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*
4
FA5A260E-7C81-4846-8CC7-44B5F9200C09_1_105_c
IMG_0258
V
*
5. Umbilical & inferior vesical artery
IMG_0259
V
*
Posterior and lateral to the obturator internus muscle are the nerve roots of the sacral plexus S1, S2, S3 and the lumbosacral trunk
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>
Through the greater sciatic formina exits:
*
Piriformis muscle
*
Sciatic nerve (L4-S3)
*
Pudendal nerve (S2-4)
*
Gluteal nerves & vessels
>
Through the lesser sciatic foramina exits:
*
Pudendal nerve
*
Internal pudendal vessels
*
Obturator internus muscle
V
*
Vasculature in the pelvis
ImageImage_1
V
>
Levator ani = pubococcygeus, iliococcygeus, puborectalis
The pubococcygeus and iliococcygeus most likely participate in continence by applying lateral pressure to narrow the levator hiatus
Screen_Shot_2019-08-14_at_11.06.51_AM
>
The puborectalis
*
It is in a state of continual contraction. This is widely considered the most important contributing factor to gross fecal incontinence
*
Originates from each side of the pubic bone
*
Forms a U-shaped sling that courses above the EAS and around the anorectal junction
V
>
The pubococcygeus muscle
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*
Originates from the inner surface of the pubic bone
*
It’s the portion of the levator ani that is typically injured during traumatic vaginal delivery
*
Posterior & medial fibers of the muscle form the anococcygeal ligament
>
Contains 3 divisions
*
Pubovaginalis
*
Puboperinealis
*
Puboanalis
*
The muscle forms the levator hiatus as it ellipses the lower rectum, urethra, & (vagina or dorsal vein of the penis)
*
Hiatal ligament = fascial condensations connecting the levator hiatus to the intrahiatal organs
*
Enlargement of the levator hiatus is implicated as a cause of ♀ pelvic organ prolapse
V
Iliococcygeal raphe
*
Formed by the converging iliococcygeal muscle fibers
*
Forms the levator plate, an anatomic shelf on which the rectum, proximal vagina, and uterus rest
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Innervation:
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Pudendal nerve branches
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Perineal nerve
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Inferior rectal nerve
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Direct S3 &/or S4 (levator ani nerve)
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The perineal body (See Anatomy of the anus & perineum)
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Nerves
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Enteric nervous system
Hirschsprung’s disease: the ganglia of the myenteric and submucosal plexuses are congenitally absent.
Nearly 20 types of enteric neurons have been identified and every class of CNS neurotransmitters has been identified in the enteric nervous system
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The distal last portion of the rectum (0.5-1cm proximal to the dentate line) normally lack ganglionic cells and thus this area should be avoided when planning a biopsy to rule out Hirschsprung’s disease
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Meissner’s plexus: in the submucosa
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Auerbach’s plexus: between the circular & longitudinal muscular externa
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Intrinsic primary afferent neutrons (IPANs) function to sense changes in luminal chemistry and pressure as well as colonic muscular tone. IPANs are present in the myenteric and submucosal plexi
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Enterochromaffin (EC) cells represent a type of this sensory transducer cell. EC cells contain large quantities of serotonin. Nearly 95% of serotonin is found in the gut and most of that is stored in the EC cells. When EC cells are stimulated, serotonin is secreted
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Serotonin can be excitatory or inhibitory depending on which type of serotonin receptor with which it interacts.
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Serotonin is not catabolized by enzymes, but is taken up by specific serotonin reuptake transporters (SERT) present in serotonergic neurons
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In patients with IBS, mucosal expression of SERT is reduced
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5-HT3 antagonist, alosetron, has been approved for treatment of IBS-associated diarrhea in women
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The pelvic plexus lies on the lateral side of the pelvis at the level of the lower third of the rectum adjacent to the lateral stalks (but several cadaver studies demonstrate lack of any neurovascular structures in the lateral rectal stalks)
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Superior hypogastric plexus (sympathetic)
• Arise from T12-L3
• Norepinephrine is a neurotransmitter that is known to exert inhibitory effects via a-2 adrenergic receptors in the myenteric plexus
• Injury:
• Highest risk at time of:
• Ligation of IMV
• Posterior mesorectal dissection at the level of the sacral promontory
• Lateral mesorectal dissection
• Consequence:
• ↑ Bladder tone (female urgency and stress incontinence)
• ↓ Bladder capacity
• ♂ Retrograde ejaculation
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Nervi erigentes & inferior hypogastric plexus (parasympathetic)
• Arise from S2-S4
• Acetylcholine is the major cholinergic parasympathetic neurotransmitter.
• Join the sympathetic hypogastric nerves on the pelvic sidewall to form the inferior hypogastric plexus
• Injury:
• Highest risk at time of:
• Distal anterolateral mesorectal dissection
• Consequence:
• ↑ Voiding difficulties (atonic bladder)
• ♂ Erectile dysfunction
• ♀ Impaired vaginal lubrication
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Management of retrograde ejaculation
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Imipramine (antidepressant)
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Midodrine (vasoconstrictor)
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Ephedrine; pseudoephedrine; phenylpherine (decongestants)
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The internal anal sphincter is innervated by sympathetic (L5) and parasympathetic (S2, S3, and S4) nerves
Internal sphincter is innervated by L5–S4 mixed autonomic function in crossed fashion so that unilateral injury still results in preserved function
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Pudendal nerve
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Originates from nerve roots of S2-S4
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Motor supply: pelvic floor muscles, the external urethral sphincter and the external anal sphincter
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Sensory innervation: external genitalia of both sexes and the skin around the anus, anal canal and perineum
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Injury, commonly by childbirth, leads to sensory loss (decreased bladder sensitivity and impotence) & fecal incontinence
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There is substantial overlap in the pudendal innervation of the external anal sphincter muscles on the two sides which enables re-innervation to be partially accomplished from the contralateral side following nerve injury
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Gently touching the anal verge will elicit the anocutaneous reflex (anal wink), which is indicative of an intact pudendal nerve.
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Colonic epithelial cell types
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Columnar epithelium & goblet cells comprise ~ 95% of the cells in the colonic epithelium
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In general, epithelial cells become increasingly differentiated the farther they are from the crypt base. Thus, the base of the crypts forms the source of continually regenerating epithelial cells.
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The interstitial cells of Cajal (ICC), are specialized, C-KIT positive cells that are thought to primarily serve as the pacemaker cell of the enteric nervous system, linking the colonic submucosa electrochemically with the myenteric plexi
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Rectosigmoid junction/sphincter
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Identified by the confluence of the taeniae coli & the end of epiploicae appendices
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The narrowest portion of the large intestines
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Measures 2-2.5cm
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Endoscopically, it is noted as a narrow and often sharply angulated area above the relatively capacious rectum, and above the three rectal valves
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Historically, it has been variably named the sphincter ani tertius, rectosigmoid sphincter, and pylorus sigmoidorectalis
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A more recent evaluation of the rectosigmoid junction utilizing anatomic and histologic studies as well as radiographic evaluation concluded that there was an anatomic sphincter at the rectosigmoid junction. Microscopic evaluation of the area does reveal thickening of the circular muscle layer as it progresses toward the rectum.
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Anatomy of the rectum
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Division of the rectum into thirds serves for surgical considerations, however the rectum may extend beyond 15 cm from the anal verge
ASCRS
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Lower rectum: anal verge to 7 cm
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Middle rectum: 7-12 cm
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Upper rectum: 12-15 cm
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Rectum is distinguished from the sigmoid by the absence of Tania coli & epiploic appendages
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The location of the anterior peritoneal reflection may be altered by disease such as rectal prolapse. On average it is 9-10 cm from the AV
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The rectal curves, known as valves of Houston, are more properly called folds because they have no specific function as impediments to flow.
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The superior and inferior valves are located on the left side of the rectum and the more prominent middle rectal valve on the right; however, this is not uniformly the case
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Only 45.5% of patients will have the classic three
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The middle vale is one most consistently found. It corresponds to the level of the peritoneal reflection
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~Distance of valves from the anal verge: 5, 8, 12 cm
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They are lost after full surgical mobilization of the rectum and provide ~5cm of additional length to the rectum
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Anatomy of the anus & perineum
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Extension of the surgical anus: from the anorectal ring to the anal verge
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Anal canal begins where the rectum passes the puborectalis (anorectal ring)— 1-2 cm above the dentate line
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Extends distally to the junction of squamous mucosa & perianal skin — roughly at where the intersphincteric groove is palpable
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Length of the anal canal: 4.5cm in ♂; 4.0cm in ♀
On MRI studies, the external anal sphincter is shorter in ♀ compared to ♂
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Extension of the anatomic anus: from the dentate line to the anal verge
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Dentate line is the junction of ectoderm and endoderm
The pectinate line (dentate line) is a line which divides the upper two thirds and lower third of the anal canal. Developmentally, this line represents the hindgut-proctodeum junction.
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Anal glands empty into the rectum through 10-15 crypts of Morgagni, located circumferentially at the dentate line
Knowledge of the anatomy also explains why the internal opening of a “crypto glandular anal fistula should typically be at the dentate line — ASCRS Textbook
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Anal transition zone (ATZ)
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0.5-1.0 cm strip of mucosa above the dentate line
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Above this area, the epithelium changes to single layered cuboidal cells (pink colored mucosa)
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The muscular layers & sphincters
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The internal anal sphincter
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Is the continuation of the circular smooth muscle of the rectum
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Length of the muscle: 2-4 cm
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Terminates approximately 1 cm proximal to the distal aspect of the external anal sphincter
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In the unstimulated state, it is chronically contracting and contributes approximately 50–75% of the resting tone of the anus
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Studies have demonstrated proximal anterior defects in nulliparous women
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Internal sphincter is innervated by L5–S4 mixed autonomic function in crossed fashion so that unilateral injury still results in preserved function
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The outer muscular layer is forms the external anal sphincter
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It’s a continuation of the puborectalis & levator ani muscles
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The proximal part of the external anal sphincter forms part of the perineal body
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The mid external anal sphincter has posterior attachment to the coccyx via the anococcygeal ligament
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When stimulated under voluntary control, it more than doubles the tone of the anus above the resting state
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Innervated from branches of S2–3 via the inferior rectal branch of the pudendal nerve and the perineal branch of S4.
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The conjoined longitudinal muscle represents the joining of the puborectalis fibers & the longitudinal muscle fibers of the rectum. It lies between the internal and external sphincter muscles & is 0.5-2.0mm in thickness. It is evident on MRI. It’s this outer muscular tube that is strengthened during Kegal exercises.
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The muscle ultimately does extend into the anus and turns medially through the internal sphincter to comprise the muscles of Treitz that support the internal hemorrhoids.
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Distally, the conjoined muscle extends to the anoderm and through the external sphincter radially to form the corrugator cutis ani
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Imaging studies demonstrate that the normal female external anal sphincter has a variable natural defect occurring along its proximal anterior length below the level of the puborectalis sling that was demonstrated in 75% of nulliparous volunteers
This natural defect of the anterior sphincter provides some justification as to why anterior anal sphincterotomy is not routinely recommended in women
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In the absence of sphincter injury, significant shortening of the anterior external anal sphincter can be seen after vaginal delivery
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Perineal body
Muscles-attaching-to-the-Pelvic-Body
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It represents the intersection of the EAS, superficial & deep transverse perinei, & bulbospongiosus/bulbocavernosus
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The transverse perinei & bulbospongiosus contribute significantly to anal continence
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Pelvic side wall includes the obturator internus & pyriformis muscle
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Anorectal spaces
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Perianal space
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Intersphincteric space
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Submucous space
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Ischiorectal space
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Medial boarder: levator ani, external anal sphincter
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Lateral boarder: obturator internus, obturator fascia
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Posterior boundary: lower border of the gluteus maximus & the sacrotuberous ligament
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Anterior boundary: superficial & deep transverse perineal muscles
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Contains adipose tissue, pudendal nerve branches and superficial branches of the internal pudendal vessels.
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Supralevator space
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Upper boundary: peritoneum
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Inferior boarder: levator ani
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Lateral boundary: pelvic wall
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Medial boundary: rectum
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Superficial & deep postanal spaces
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The postanal space is located posteriorly, between the levators (cranially) and the external sphincter (caudally)
This space may be solely involved, or infection may extend laterally to the ischiorectal fossa, forming the so-called horseshoe abscess
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Retrorectal space
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The right and left ischioanal space communicate posteriorly through the deep postanal space between the levator ani muscle and anococcygeal ligament.
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Inferior rectal artery < internal pudendal artery < internal iliac artery
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Venous drainage
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Upper canal: superior rectal vein → IMV → portal vein
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Inferior canal: inferior rectal vein → pudendal veins → internal iliac veins
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Lymphatic drainage
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Above the dentate line: mesorectal, lateral pelvic, & inferior mesenteric nodes
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Below the dentate line: superficial inguinal nodes
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Histology
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Above the dentate line: colorectal type glandular mucosa
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Immediately proximal to the dentate line (6-12mm) is the ‘anal transition zone’: histologically similar to uroepithelium
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Distal canal: nonkeratinzed squamous mucosa
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The whitish line called the pectinate line (Hilton's) indicates the junction between keratinized stratified squamous epithelium and unkeratinized stratified squamous epithelium.
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Presacral space
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It is a potential space
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The sacral nerve rootlets are located in this retrorectal space, and thus injury to and sacrifice of these structures can have substantial implications on rectoanal and sexual function
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Boundaries
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Anteriorly: mesorectum
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Posteriorly: presacral fascia and sacrum
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Laterally: lateral rectal stalks, ureters, & iliac vessels
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Superior extension: peritoneal reflection
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Inferior extension: levator ani complex & coccygeal muscle
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MRI Anatomy
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Pyriformis muscle
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Obturator internus, sciatic spine, & greater trochanter
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Physiology
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Under normal circumstances, fecal and plasma osmolality are similar.
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Function of the colon
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Bacterial homeostasis
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Bacteria contribute to approximately 50% of fecal mass
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Microflora contributes several important functions to the host including metabolic support of the colonocyte and gut-associated lymphoid tissue, which contributes significantly to both innate and adaptive immunity.
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Bacteroides species compose the predominant bacterial type throughout the colon. The other predominant species are facultative aerobes and comprise Escherichia, Klebsiella, Proteus, lactobacillus, and enterococci.
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Undigested dietary fiber is metabolized by colonic bacteria through the process of fermentation. Cellulose is a partially fermented starch, which leaves behind bulk, whereas fruit pectins are completely metabolized. The primary end products of this process include short chain fatty acids (SCFA), including butyrate, and gas
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Protein fermentation, or putrefaction, may result in the formation of potentially toxic metabolites including phenols, indoles, and amines. These toxic end products of bacterial metabolism can lead to mucosal injury, reactive hyperproliferation, and possible promotion of carcinogenesis. Increased stool bulk is felt to provide enhanced colonic transit resulting in decreased time of exposure of the colonic lumen to these toxins
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Absorption of
The ileal effluent is still rich in water, electrolytes, and nutrients that resist digestion. The colon has the functional ability to recover these substances and avoid unnecessary losses of fluids, electrolytes, nitrogen, and energy. To accomplish this, the colon depends highly on its bacterial flora. Because mammalian cells do not produce n-butyrate, the colonic epithelium relies on luminal bacteria to produce it through the fermentation of dietary fiber. The lack of n-butyrate, such as that resulting from the inhibition of fermentation by broad-spectrum antibiotics, leads to less sodium and water absorption and thus diarrhea
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Water is passively absorbed
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Na & Cl
A majority of sodium chloride absorption occurs in the proximal colon and is driven primarily through electroneutral absorption by tightly coupled luminal Na/H and Cl/HCO3 exchange.
Chloride is absorbed through luminal cystic fibrosis conductance regulator (CFTR) and other chloride channels
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Short chain fatty acids (SCFA)
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SCFAs are produced by microbial breakdown and fermentation of dietary starches
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The most common SCFA include acetate, proprionate, and butyrate
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Butyrate also plays a major role in the stimulation of NaCl absorption and inhibition of chloride secretion. It has been proposed that Abx-associated diarrhea is secondary to decreased butyrate production resulting in net secretion of fluid
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Butyrate has a trophic effect and stimulates cell proliferation in the crypts. It also reduces the number and size of aberrant crypt foci. This is important as aberrant crypt foci are the earliest precursors of colonic neoplasms.
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Butyrate also has an anti-inflammatory role primarily by inhibition of nuclear factor kB (NF-kB) in colonic epithelial cells
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Unlike most of the mucosal lining of the proximal GI tract, colonic mucosa does not receive its primary nutrition from the bloodstream. Instead, nutrient requirements are fulfilled from the colonic luminal contents. The primary energy source for the colonocyte is butyrate.
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Commercially available butyrate available for oral administration is limited by its short half-life, poor palatability, and side effects such as nausea and anorexia. Rectal formulations are most commonly utilized at this time.
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Secretion of
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HCO3
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K
Potassium is secreted on the luminal side and is driven by the electrogenic uptake of sodium
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Chloride
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Mucus
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Secreted mucus in the colon forms two distinct layers.
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The outer loose layer contains bacteria and lubricates feces and protects epithelial cells from abrasion and chemical insult.
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An inner layer is essentially sterile and is a dense gel that contains antimicrobial peptides, enzymes, and secretory immunoglobulin A (IgA) amongst other substances.
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Mucus is secreted from goblet cells as well as crypt epithelial cells.
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Propulsion of luminal content
Short chain fatty acids influence GI motility via the ileocolonic brake mechanism, which is defined as the inhibition of gastric emptying and nutrients reaching the ileocolonic junction
Camron: The ability to preserve the right colon in a patient with short small intestine can make the difference between the requirement for intravenous supplementation of fluid and the ability to rely on oral intake to maintain homeostasis. Following an ileocecal resection, 150cm of small bowel is the lower limit of adequate bowel length to avoid Short Gut Syndrome. When the ileocecum is present, just about 100cm may be adequate
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Colonic motility
At least seven different patterns of human colonic phasic pressure activity have been identified
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The ICC generates electrical pacemaker activity that provides the smooth muscle with the mechanism to produce propulsive rhythmic activity
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Phasic activity also increases within a few minutes after a meal and continues for up to 2.5h depending on the nutrient composition and caloric content of the meal. High fat meals elicit more of a response than carbohydrate rich meals.
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Segmental contractions
Non-propagating pressure waves occur randomly for at least 30s
The function of these nonpropagating waves is not well delineated, but they may serve as a means for local mixing of luminal contents and may allow for adequate mucosal sampling
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Propagated contractions
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Low-amplitude
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High-amplitude
High amplitude propagated contractions (HAPC) of pressures ≥75 mmHg and that migrate abroad ≥15 cm. HAPCs occur approximately 6 times a day and serve to move stool en masse across the colon.
Colonic instillation of bisacodyl or intravenous neostigmine induces HAPCs
Patients with slow transit constipation have a reduced frequency of HAPC
Colonic bisacodyl administration also produces a blunted HAPC response in patients with slow transit constipation
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Function of the rectum & anus
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The rectum has capacity & compliance allowing it to function as a reservoir
A stiff nondistensible rectum, such as in radiation proctitis, may produce incontinence, even when the sphincter muscles are competent
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Continence & defecation
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Fecal continence implies:
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1. Deferment of stool elimination
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2. Discrimination among gas, liquid, and solid stool
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3. Selective elimination of gas without stool
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The puborectalis is in a state of continual contraction, a factor vital to the maintenance of continence
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Elements in continence
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Rectoanal sensation & sampling
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The rectum does not itself have receptors for proprioception. The conscious sensation of the need to defecate lives in the levators and the anal canal, hence the preserved sensation in patients who have had complete proctectomies and anal anastomoses
Sensory innervation within the rectum is sensitive only to stretch, resulting in vague sensation to visceral pelvic pain. Distal rectal stretch or distention can result in significant parasympathetic stimulation of the vagus nerve, thereby resulting in bradycardia and hypotension
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The rectoanal inhibitory reflex (RAIR) is thought to allow the highly innervated sensitive epithelial lining of the upper anal canal to sample the contents of the distal rectum to determine its quality and consistency
Distension of the rectal wall causes an initial contraction of the EAS followed by a relaxation of the IAS. This was first noted by Gowers in 1877 and is felt to aid in the sampling mechanism of the anal canal
The upper anal canal discriminates between flatus and feces, and that rectal dilation relaxes the IAS via nitric oxide pathways
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Impaired sensation has been associated with: childbirth, perineal descent, and mucosectomy
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Hemorrhoids have the ability to expand to create a seal above the anus creating the fine tuning of continence
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Sensation & innervation
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Somatic sensory innervation begins in the anal transitional zone proximal to the dentate line for a short variable distance 0.3–1.5 cm. Within this zone, there is a dense collection of nerve endings for pain, touch, pressure, and temperature. These fibers are derived from the pudendal branches
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The therapeutic effects of SNS are due not only to peripheral motor stimulation of the anal sphincter complex in patients with fecal incontinence as was initially proposed, but instead due to changes in the motor and/or sensory function of the combined functional anorectal unit. Such a hypothesis would explain the “paradox” of SNS effectiveness in both fecal incontinence and chronic constipation
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Intermittent stimulation of the posterior tibial nerve has a beneficial effect on fecal incontinence through a mechanism that is not fully understood
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Normal defecation process
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1. The process starts with stool arriving into the rectum and sampling
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2. Anal sphincter will contract and rectum will start to distend without a person’s full awareness
Patients are often unaware that they have stool in the vault during rectal exam
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3. As the rectum continues to expand, a person becomes aware. There is an urge defecate that usually lasts for a few seconds and can be controlled by further contraction of external anal sphincter
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4. When it becomes socially appropriate to proceed, the process starts with contraction of abdominal musculature (Valsalva)
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5. Pelvic floor musculature relaxes
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6. The rectum itself starts to contract and both internal and external sphincters relax. Even if the sphincters are not completely relaxed, at this point pressure in the rectum exceeds pressure in the anal canal and defecation will occur
Once begun a number of patterns can occur. There may be a single evacuation of the rectal contents accompanied by mass peristalsis of the left and sigmoid colon clearing the bowel in one continuous movement, or the passage of smaller volumes of stool individually over a short time requiring recurrent efforts and straining
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Disturbance resulting in incontinence occurs through any of the following
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Reduced anal tone
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Excess rectal contraction
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Reduced sensation
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Inability to differentiate the consistency of the rectal contents
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Obstructed defecation
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Dysfunction may be associated with conscious/subconscious inhibition of the need to defecate during childhood. According to this theory, repeated delays in defecation result in altered sensation that eventually leads to dyscoordination between the anorectal and pelvic floor musculature. The relaxing effects of the upper parts of the nervous system are insufficient to overpower the abnormal stimulation. Once this occurs, and pelvic floor musculature such as puborectalis and sphincter complex fail to relax appropriately, increasingly higher intra-abdominal pressure is needed to overpower the rectal/anal pressure to evacuate
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Independent of what part of normal defecation was affected first, over time there is probably significant damage to the sensory pathways including receptors, efferent nerves and muscles. With time, this process will also start affecting the structural integrity of the pelvic floor
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Obstructed defecation disorders include
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Intussusception
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Rectocele
It is defined as > 2 cm of rectal wall out pouching or bowing anteriorly while straining
When a patient attempts to evacuate, generated pressure delivers stool anteriorly towards the weakened portion of the wall that is not contracting appropriately. This generates a sensation of bulge and incomplete evacuation and can be at least in part relieved in women by pushing on the vagina in the initial stages of the disease
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Non-relaxing puborectalis/levator muscle spasm
As a result, when a patient tries to evacuate the anorectal angle may not increase or may even become sharper. A patient’s natural response is to generate higher pressures in which only further worsens the symptoms. Over time, these changes likely cause more damage to the musculature and nerves.
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Dyssnergic puborectalis
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Enterocele
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Rectal prolapse
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Sensory input for feeling the urge to defecate is also present in the pelvic sidewall (large tumors give a constant feeling of wanting to empty the rectum)
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Pathophysiology of obstetric-related problems
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Fecal incontinence can develop as a result of direct disruption of:
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Anal sphincter
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Muscle
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Connective tissue
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Pudendal nerve injury
The pudendal nerve can be affected during pregnancy by stretching as well as traction injury during delivery
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Progesterone
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Leads to ↓ gut motility + ↓ tonic contraction of anal sphincters
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Leads to ligamentous laxity
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Labor can be associated with muscle stretching or even evulsion & pudendal nerve injury
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Additional risk factors for fecal incontinence
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Use of devices to aid labor (forceps and vacuum)
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Tearing and episiotomy
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Presence of symptoms after delivery is an additional risk factor for developing significant incontinence in the future when age further weakens already damages muscles and nerves
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Although many women experience immediate mild problems with incontinence to flatus or stool, most have enough reserves to compensate
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Ileal conduit considerations
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Patients have urine routed through a 10-15cm segment of intestine
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The left ureter is tunnelled under the sigmoid
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Testing
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DRE
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ASCRS: Relative contraindications DRE
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Anal fissure
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Thrombosed external hemorrhoids
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Grade IV internal hemorrhoids
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Neutropenic patient
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The patient should be asked to perform a Valsalva maneuver to potentially bring any lesions of the upper rectum or the rectosigmoid into the examiners reach
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The levator ani/puborectalis muscles can also be assessed on DRE with evaluation of both the strength and function of these muscles, along with any tenderness on direct palpation, indicating a possible pelvic pain disorder. When a patient with good sphincter function is asked to squeeze these muscles, the examiner’s finger will feel the muscle tighten and will have his finger pulled up into the rectum. Additionally, when the examiner pulls posteriorly on these muscles, the anal opening should gape and then return to normal, representing an intact reflex pathway to the thoracolumbar spinal cord
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Endoscopy
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Anoscopy
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For most instances, cleansing of the anorectum with an enema is not warranted.
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During the examination, the patient is asked to strain while the anoscope is withdrawn to visualize any prolapsing anorectal mucosa or hemorrhoidal tissue
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Rigid proctoscopy
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The main difference between an anoscope is that a proctoscope needs to hold air so the rectum can be distended
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Ideally, the patient should receive an enema preparation within 2h of the procedure in order to clear any stool
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Proctoscopes are available in three sizes, all 25 cm in length. Different luminal diameters include 11, 15, and 19 mm. In most patients, the 15 mm × 25 cm scope is ideal for a general inspection. Very rarely can the scope be inserted to its full length
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The distal extent reached on proctoscopic examinations averages approximately 17–20 cm
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Technique
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Adequate lubrication is applied; the obturator is held in place with the right thumb
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Insert and advance ~4–5 cm in the general direction of the umbilicus
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Then aimed toward the sacrum and advanced for an additional 4–5 cm
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The obturator is then removed and the viewing lens is placed
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Flexible sigmoidoscopy
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In general, the channel size ranges between 2.6 and 3.8 mm, the diameter of the scope ranges between 12 and 14 mm and the length varies from 60 to 71 cm
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Patients are typically given 1-2 enemas prior to the procedure and generally do not require oral laxatives or dietary restrictions
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Small polyps can be removed with cold or hot biopsy forceps. Larger polyp removal may be best suited during a subsequent colonoscopy when a full bowel preparation has been achieved
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Electrocoagulation should be avoided or used very judiciously in biopsies or snare techniques unless the patient has received a full mechanical bowel preparation to reduce the risk of explosion due to the presence of hydrogen and methane gas present within the bowel lumen
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Colonoscopy
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Scope lengths typically vary from 130 to 168 cm in length. There are also pediatric colonoscopes that are smaller in diameter than the typical adult endoscope: 11.3 mm versus 12.8 mm
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Chromocolonoscopy involves the use of dye with spray catheters to spray coat the colonic mucosa in an attempt to increase the visualization of the mucosa
There has been some demonstrated benefit with this technology in high-risk populations such as those with IBD or those with known genetic disorders, due to the difficulty in differentiating abnormal from normal mucosa in some of these patients.
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High definition endoscopy has not proven superior in the ability to detect additional colon neoplasms
Narrow Bandwidth Imaging (NBI) uses a filter to narrow the blue and green wave light and eliminates the red wavelength from standard white light. This leads to an accentuation of the microvasculature and improved visualization of pathology. The endoscopist is able to rapidly switch between white light and NBI views with the use of a foot pedal
Due to this ability to better predict histology, NBI technology may play a role in the future resection and discarding of diminutive polyps, but it has not received widespread acceptance.
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How to use NBI to detect dysplasia
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Learn to recognize subtle color differences between the polyp & surrounding mucosa
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Learn to recognize microvessel patterns characteristic for hyperplastic & adenomatous polyps
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Learn to recognize mucosal patterns characteristic for hyperplastic & adenomatous polyps
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Contraindications to anoscopy and proctoscopy
*
Painful anorectal conditions
*
Anorectal surgery within 1 month
*
Anal stenosis
*
Only FOBT and flexible sigmoidoscopy have Level I evidence supporting use in average-risk colorectal cancer screening
>
Endoscopic Ultrasound
V
>
EndoRectal US
Provides T & N staging comparable to MRI
Best in distinguishing T0, T1, & T2
Predicts LN involvement
Pasted_Graphic1_copy
>
Indications
V
*
Staging cancers
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*
Surveillance of cancer
*
It is impossible to distinguish blood vessels from LN on a static US image
>
EndoAnal US is the diagnostic test of choice for anal sphincter defects & to define occult collections
>
Indications
*
Assess sphincters
*
PreOp planning
*
Assess fistulas (often also used in the OR; aided with injection of hydrogen peroxide)
V
The anal canal is divided into three levels on EUS
V
*
The upper anal canal: defined by the U-shaped puborectalis muscle
Screen Shot 2020-08-03 at 13.55.02
*
The middle canal: has both EAS and IAS muscles visible (this is also where the IAS is at maximum width)
*
The lower anal canal: only the most distal external sphincter fibers are visualized (IAS is not visualized)
*
Collagen and fat, which can be mixed into the striated fibers of the puborectalis muscle and external anal sphincter, tend to have higher reflectivity and will appear hyperechoic
*
Muscle with its high water content, such as the smooth muscle of the internal anal sphincter, tends to be hypoechoic (black on EUS)
*
It’s useful to measure the size of the perineal body (visualization is aided by inserting a finger into the vagina)
*
Using 2D probes, a false positive anterior sphincter defect may be identified in 5–25 % of normal patients
*
The 3D probes allows automatic volumetric acquisition of images over a 6 cm axis without movement of the probe
*
Echodefecography uses a 3D 360-degree probe
>
Dynamic US
>
Indications for dynamic US
*
Urinary incontinence
*
Symptoms of voiding dysfunction
*
Recurrent urinary tract infection
*
Fecal incontinence
>
Pelvic floor dysfunction
*
Pelvic organ prolapse: cystocele, enterocele, rectocele, uterine prolapse
*
Symptoms of obstructed defecation: straining at stool, chronic constipation, vaginal or perineal digitation, and sensation of incomplete bowel emptying
*
Suspected pelvic floor dyssynergy
*
Pelvic, vaginal, or anal pain
*
Follow-up after pelvic floor surgery
V
3 probes are used to perform US in 4 separate steps
V
Images are acquired during rest and during cough, with squeeze, and with push
*
Transperineal scanning using linear transducer
*
Transvaginal US using biplane probe
*
Transvaginal US using 360-degree rotational probe
*
Endoanal US
>
Equipment & technique
*
Lateral decubitus patient position
*
Fleet enema X2
*
Critical to remove bubbles/air in the balloon and only use water to allow proper transmission of waves through water. Air and stool result in artifacts on the US also
*
Tip: insert the probe above the tumor and then visualize on withdrawal
>
Probes
*
7 Hz: deeper penetration 2-5 cm; lower resolution
*
10 Hz: less penetration 1-4 cm; higher resolution
>
Breath testing
*
13C-labeled substances are ingested and metabolized after passing the pylorus. Ultimately, there is conversion to CO2, which is exhaled
*
The results can be affected by pulmonary conditions resulting in CO 2retention
>
Used to evaluate for
*
Carbohydrate malabsorption
*
Intolerance
*
Bacterial overgrowth
>
Can provide estimation of
*
Gastric emptying
*
Orocecal transit time: normal range (30m to 3h)
>
Pelvic floor testing: mainly aims to differentiate anatomic from functional pathologies
*
For anal US, see Endoscopic Ultrasound
>
Defecography
>
Accomplished fluoroscopically (cinedefecography) or with MRI
*
Advantage of MRI: ability to evaluate all three pelvic compartments simultaneously and the lack of radiation exposure
>
Advantage of fluoroscopy:
*
Cheaper
*
Done in standard defecography position as opposed to lateral decubitus position needed for MR defecography
*
MRI underestimates prolapses that are not rectoceles
*
In addition to the rectum, opacification of the vagina, bladder & small bowel has been shown to improve diagnostic accuracy when only rectal opacification is not diagnostic
>
Technique:
*
Patient takes an enema
*
The rectum is infused with 50cc of thin barium & air insufflation
*
A caulking gun injector is used to inject 250-500g of thick barium paste into the rectum
*
Barium, water soluble contrast, or gel is inserted into the vagina for opacification
*
For opacification of the small bowel: 400-600ml of barium is administered PO 45-60m before the study
V
>
Results
Black line = pubococcygeal line (fixed landmark)
Green dot = anorectal junction
Angle = anorectal angle
Screen Shot 2021-04-11 at 10.04.09
V
>
Landmarks and normal values
Screen Shot 2021-04-11 at 12.04.03 2
V
>
Anorectal angle
Screen Shot 2021-04-11 at 10.06.18IMG_0292
*
It is the angle created by a line drawn through the central axis of the anal canal and a line drawn through either the central axis of the distal rectum or a line drawn parallel to the posterior wall of the distal rectum
*
At rest average value is 90 degrees (range 65-100 degrees)
*
Value at squeeze is ~75 degrees
*
Value at straining is 110-180 degrees
>
Anorectal junction
*
It is the uppermost point of the anal canal
*
During squeezing, the ARJ elevates
*
Movement against bony landmarks is used to determine descent of the pelvic floor
*
With straining, the junction descends into the perineum (but not more than 3.5 cm)
*
Excessive descent results in perineal descent syndrome
V
>
Pubococcygeal line is the line extending from the lowest point of the pubic bone and coccyx
Pubococcygeal-line-PCL-Sagittal-midline-T2-TSE-image-with-the-PCL-represented-red
*
In a normal patient, ≤ ⅓ of the rectum will lie below this line
*
The ischiococcygeal line is a line extending from the inferior border of the ischium to the last coccygeal joint.
>
During straining
*
The anorectal angle increases to > 110 degrees
*
Anorectal junction descends below the pubococcygeal line
V
>
During squeezing
Screen Shot 2021-04-11 at 10.08.55
*
The anorectal angle decreases to ~75 degrees
*
Anorectal junction migrates superiorly
*
The puborectalis impression is seen on the posterior rectum
>
In pelvic floor dyssynergia (paradoxical contraction)
*
During straining, there is lack of pelvic floor descent (anorectal junction), and paradoxical contraction of the puborectalis
*
Evacuation time is > 30s
>
Internal intussusception
V
*
Infold of the rectal wall > 3mm in thickness; usually most prominent at the anterior rectal wall
Screen Shot 2021-04-11 at 10.14.01
D1 and D2 represent infolding of the anterior and posterior rectal walls, respectively
*
Infold of rectal wall < 3mm indicates mucosal prolapse
*
Rectorectal intussusception is often asymptomatic
*
Rectoanal intussusception may cause incontinence, obstructive defecation, and rectal pain
V
*
Wisps of contrast indicate contrast along the mucosal fold
Screen Shot 2021-06-27 at 19.30.46
V
Rectocele
*
Usually occurs at the ventral wall, but lateral and posterior rectoceles have been described
*
May be seen in up to 93% of asymptomatic females, regardless of parity
>
Grading
*
Grade I: < 2cm (clinically insignificant)
*
Grade II: 2-4cm
*
Grade III: > 4cm
V
*
Rectocele are especially considered non-symptomatic if they empty adequately during defecography without requiring vaginal splinting. These rectoceles require no management
Screen Shot 2021-04-14 at 14.18.58
RI = rectal intussusception
PC = posterior compartment
SB= small bowel
V
*
Cystocele (demonstrated as anterior inward indentation in the vaginal wall on defecogram)
Screen Shot 2021-06-27 at 19.37.10
V
Enterocele and sigmoidocele: present on imaging between the rectum and the vagina
*
First degree: eneterocele above the pubococcygeal line
*
Second degree: enterocele between the pubococcygeal line and the ischiococcygeal line
*
Third degree: enterocele below the ischiococcygeal line
>
Descending perineum syndrome
*
Caudal migration of the anorectal junction > 3.5cm
*
Anorectal angle > 130 degrees at rest and rises to 150 during straining
*
The full evacuation process typically takes < 1m in physiologic conditions
>
Manometry measures with a transanal probe, under various conditions, within the anus & rectum:
*
A rectal manometry is the test of choice to evaluate for sphincter dysfunction
>
Used in the evaluation of
*
Fecal incontinence
*
Constipation (balloon expulsion test may suggest Dx dyssynergia)
*
Anal pain (to suggest chronic anal spasm)
*
Fissure (hyper vs hypotonic)
*
Hirschsprung’s disease (provisional Dx with impair RAIR)
*
Rectal hyposensitivity
*
High-resolution anorectal manometry and balloon expulsion can be used to differentiate outlet obstruction for patients with constipation.
>
Pressure measurements
*
After initial probe placement, a period of equilibration is necessary in order to allow the anal sphincter to return to baseline activity. This typically takes about 5 min
>
High-pressure zone
*
It is the length of the anal canal with resting pressures ≥30% higher than rectal pressure
*
It estimates the length of the anal canal, normally 2-4 cm
>
Normal resting pressure
*
Defined as the difference between the intra-rectal pressure and the anal canal pressure.
*
It is the pressure in the high-pressure zone at rest after a period of stabilization
*
Normal resting pressure: 40-80 mmHg
*
The internal anal sphincter tone is the primary determinant of the resting pressure. It is recognized, however, that up to 30 % of the resting pressure can come from the external anal sphincter tone and 15 % from the anal cushions themselves
*
Maximum resting pressure is the highest resting pressure recorded (as opposed to mean resting pressure)
*
Maximum voluntary pressure is the highest pressure recorded above the baseline (0) at any level of the anal canal during maximum squeeze effort by the patient
>
Squeeze pressure = maximum voluntary pressure — resting pressure
*
Normal squeeze pressure: 40-80 mmHg (above resting pressure)
*
This measurement will assess the contribution of the external anal sphincter and puborectalis only
>
Cough pressure = maximum pressure during cough — resting pressure
*
Cough reflex: a rapid rise in intra-abdominal pressure, such as with cough, causes a reflex contraction of the external anal sphincter.
V
Valsalva pressure
*
Non-relaxation or paradoxical contraction with feigned defecation can aid in the diagnosis of dyssynergic defecation.
*
It has been demonstrated that paradoxical sphincter contraction is also a common finding in healthy patients as well at the time of manometric evaluation, presumably a result of patient’s unease during the procedure itself
>
Dyssynergic defecation has 4 types
*
Type 1: ↑ intra-rectal pressure + ↑ intra-anal pressure
*
Type 2: stable intra-rectal pressure + ↑ intra-anal pressure
*
Type 3: ↑ intra-rectal pressure + stable/minimal change in intra-anal pressure
*
Type 4: stable intra-rectal pressure + stable/minimal change in intra-anal pressure
*
Sphincter endurance is the length of time that the patient can maintain a squeeze pressure above the resting pressure.
>
Rectoanal inhibitory reflex (RAIR) is tested by inflating a 50cc balloon at the distal tip of the probe, thereby distending the rectum
*
Distension of the rectal wall causes an initial contraction of the EAS followed by a relaxation of the IAS. This was first noted by Gowers in 1877 and is felt to aid in the sampling mechanism of the anal canal
*
It is characterized by a drop in IAS pressure by 10 mm Hg for ≥ 5 seconds from the naturally tonic state
*
Presence of the reflex = functioning myenteric plexus = absence of Hirschsprung’s disease.
V
Absence of RAIR should raise suspicion for certain pathologic conditions
*
Hirschsprung’s disease
*
Chaga’s disease
*
Dermatomyositis
*
Scleroderma
*
It can also be impaired in rectal prolapse, and after rectal resection
*
In the event of a negative reflex, testing at several levels within the canal and at a larger balloon volume may elicit the response
>
Rectal Sensation: measured by increasing the balloon volume inside the rectum (above anorectal ring)
*
Sensory threshold/ first sensation: is the minimum rectal volume perceived by the patient. Normal value: 10-30cc
*
Urge sensation / to defecate: is the volume associated with the initial urge to defecate
*
Maximum tolerated volume is the volume at which the patient experiences discomfort and an intense desire to defecate
*
Anal sensation: reflects the somatic sensory component of the pudendal nerve
*
Compliance
V
*
Balloon expulsion testing assesses the ability of the patient to expel a 50-cc balloon during defecation. The utility of the test has come into question. This test is, at best, complementary to other test
Normal electromyographic results or the ability to expel a 60-mL balloon does not exclude the presence of pelvic floor dyssynergia on defecography
>
High-Resolution Anorectal Manometry (HRAM)
>
Probe types:
*
Solid-state 4.2mm diameter probe with 12 sensors
*
3D 10.75mm diameter probe with 256 sensors
*
In comparison with conventional manometry, HRAM is capable of measuring a “topographic” pressure map over the entire length and circumference of the anal canal
>
EMG
*
Records electrical activity of the external anal sphincter and puborectalis muscles during rest, squeeze, and attempted defecation
*
Can be used for biofeedback training
*
Results can be affected by patient embarrassment
V
*
Normal results: a decrease in electrical activity to attempted defecation
Screen Shot 2021-04-14 at 14.09.10
V
*
EMG can be useful to identify patients with paradoxic contraction of the puborectalis
Screen Shot 2021-04-14 at 14.09.16
*
Given ultrasonography had similar accuracy and improved patient tolerance, endoanal ultrasound has replaced needle EMG in the anatomic assessment of patient with bowel incontinence
*
EMG still remains a useful tool in the detection of sphincter defects when the ultrasound is inconclusive as can be the case in areas of dense scarring
*
Normal electromyographic results or the ability to expel a 60-mL balloon does not exclude the presence of pelvic floor dyssynergia on defecography
>
Pudendal nerve terminal motor latency detects nerve damage; but has limited utility
*
Stimulation of the nerve is done intrarectally; measurement of response is done at the level of the anal sphincter
*
Normal value: 2.0±0.2 ms
V
Potential uses of PNTML
*
Fecal incontinence
*
Rectal prolapse
*
Constipation
*
ASCRS 2015 CPG:
Pudendal nerve terminal motor latency may be performed, but has limited impact in the diagnosis and management of patients with fecal incontinence, and is not routinely recommended.
Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.
>
Transit studies
V
Normal transit times:
*
Mouth to cecum: 30min to 3h
*
Mouth to anus: 20h to 4 days
*
Requires cessation of all laxatives X48h prior and during testing
>
Radio-opaque testing
*
24 radio-opaque markers within a single capsule are ingested
*
Average normal transit time through the colon: 31h in ♂; 39h in ♀
*
X-rays are obtained on days 1, 3, & 5
>
Slow transit is defined by retention of ≥ 20% opaque markers (five markers) in the colon at day 5
*
Colonic inertia is suggested by the markers being scattered throughout the entire colon
*
Pelvic outlet dysfunction is suggested by the markers aggravated in the sigmoid or proximal rectum
*
The X-ray on day 1 will document grossly normal gastric and small bowel transit if all of the markers are located in the colon at this point
*
Scintigraphy / Radionuclear marker study
*
SmartPill determines colonic transit based on the drop of pH detected when it crosses the ICV
>
Breath testing
*
Can provide estimates of both gastric emptying and orocecal transit time
*
Results are affected by pulmonary diseases resulting in CO2 retention
V
CTE requirements:
*
1L PEG followed by 1L H2O given 1h before scanning
*
IV contrast is used
*
Anti-spasmodics are often given to reduce bowel motion artifact
*
Rectal MRI and US — see Colorectal Cancer
>
FOBT/FIT, Polyps & colonoscopy
*
Non-invasive screening modalities are not appropriate for patients with personal Hx of polyps
V
>
ASGE Recommendations 2017
Screen Shot 2021-03-18 at 14.03.24
*
With 1-time application, FIT tests are approximately 80% sensitive for cancer detection and approximately 20%–30% sensitive for advanced neoplasia detection. To enhance advanced adenoma detection, repeated applications of FIT are required. Therefore, we recommend repeated testing to maximize the effectiveness of cancer detection and prevention with this modality. Strong recommendation; moderate-quality evidence.
*
Given the high positive predictive value of FIT for cancer detection, colonoscopy is recommended when the test is positive, not repeat FIT. Strong recommendation; moderate-quality evidence.
*
When comparing FIT with gFOBT, FIT has improved sensitivity for CRC and advanced colorectal neoplasia detection at similar levels of specificity. There is RCT-level evidence that adherence is superior for single-sample FIT compared with traditional 3-card gFOBT. Given these advantages, we recommend the use of FIT over gFOBT. Strong recommendation; high-quality evidence.
*
There is limited information examining the test characteristics of FIT when applied to a stool specimen obtained by DRE. Available data suggest that test characteristics may suffer. The Task Force suggests that FIT screening programs rely on spontaneously passed stool specimens and not an in-office DRE sample. Weak recommendation; very low quality evidence.
V
*
Based on currently available evidence, including the systematic reviews discussed earlier, the Task Force suggests a 1-sample annual FIT screening approach. Weak recommendation; low-quality evidence.
A meta-analysis also showed that the pooled performance characteristics of FIT for CRC were similar regardless of the number of FIT samples tested
*
There is no strong evidence that delays in FIT kit return of up to 10 days after sample deposit affects FIT performance. Nonetheless, the Task Force suggests that participants in FIT-based programs should be informed about the importance of rapid return of the kit (ie, preferably mailing it or returning it to the laboratory within 24 hours) once the sample has been deposited. Furthermore, programs should establish quality-assurance practices to monitor return times of the FIT kits and solicit repeat samples when kits fall outside the predetermined range of acceptability based on the device used (as established by the manufacturer). Weak recommendation; very low quality evidence.
>
Stool tests
V
Guaiac FOBT
*
Optimal use depends on following strict dietary (avoid red meats and plant oxidizers) adjustments prior to collecting the stool sample
*
This test requires at least 2 mL of blood loss a day to become positive
*
Screening requires annual testing
>
FIT
>
Utilizes specific antibodies to detect globin
*
Immunochemical methods may fail to recognize OB from the upper GI tract because the globin is digested by the time it gets in the stool.
*
Does not required following any dietary restrictions prior to testing
*
FIT can pick up as little as 0.3 mL of blood in the stool
*
Has higher sensitivity and specificity over gFOBT (13–25 % vs. 81 %)
>
Accuracy:
*
Sensitivity in detecting adenomas: 28%
*
Sensitivity in detecting CRC: 79%
*
Specificity in detecting CRC: 94%
*
Screening requires annual testing
V
*
FIT testing is only appropriate for average risk screening
CRCscreensenstvtyspecfct
>
Stool DNA testing
*
The test detects shed cells that contain abnormal DNA
*
Testing for screening can is done Q3Y
V
In context of asymptomatic patients, and compared to FIT testing, DNA testing is associated with:
*
Higher detection rate for CRC
*
Higher false positives
>
General
*
Polyp = mass projecting into the lumen of the bowel
*
Presence of a polypoid lesion is an indication for endoscopic polypectomy
>
Colonoscopic adenoma detection rate (ADR) = 25% in ♂; 15% in ♀
>
Adenoma detection rate is associated with:
*
Withdrawal time (minimum recommended time is 6-8m)
*
Withdrawal technique
>
Polyp miss rate = 22% pooled miss rate for polyps of any size
*
2% if > 10mm
*
13% if 5-10mm
*
26% if 1-5mm
V
>
Classification of polyps
Screen Shot 2020-07-27 at 16.24.44
>
Non-neoplastic
>
Mucosal
*
Usually < 5mm
*
Resemble adjacent flat mucosa
*
Have no clinical significance
>
Hamartomatous
*
Are non-neoplastic growths that are compromised of abnormal mixture of tissue that is normally found at that site
*
Occasional presentation: bleeding; intussusception; mucus discharge
>
Juvenile polyps
*
Are common in childhood, but may be found at any age
*
Consist of overgrowths of the lamina propria & dilated cystic glands rather than hyperplasic epithelial cells
*
They are usually removed because of the high risk of bleeding
>
Juvenile Polyposis Coli
*
⅓ of JPC have similar Family Hx in a FDR
*
Associated with increased risk for colorectal cancer and gastric cancer
>
Peutz-Jeghers polyps
*
Represent overgrowths of the muscularis mucosa
V
They are almost always associated with Peutz-Jeghers Syndrome:
*
Dx criteria: ≥ 2 hamartomatous polyps + melanin spots on the buccal mucosa & lips
*
50% have GI or breast/testicular cancer by 60Y
*
Surveillance with scope Q2-3Y
*
Polyps are usually benign but may produce symptoms, and they have malignant potential
*
Surgery is reserved for symptomatic polyps
>
Inflammatory pseudopolyps
*
They are irregularly shaped colonic mucosa
*
Result from ulceration & regeneration in IBD. May also occur after amebic, ischemic, or schistosomal colitis
*
They are usually multiple, and may mimic FAP
*
If occurring in clusters, they may be associated with dysplasia
>
Neoplastic: adenomatous polyps
>
General
*
Differ from hyperplastic polyps in that they have cellular atypia
*
Some degree of dysplasia exists in all adenomas i.e: an adenoma represents, at least, low grade dysplasia
*
Adenomatous polyps are the most common neoplastic polyps — they develop in 25% of the population > 50Y in the US
*
⅔ of all colonic polyps are adenomatous
*
♂ > ♀
*
Adenoma to carcinoma progression requires ~7-10Y. Cancers that develop in shorter periods may be called interval cancers and raise the suspicion for syndromes associated with colorectal cancer
*
Patients who develop adenomas have ↑ lifetime risk for colorectal cancer
V
*
Removal of polyps decreases the incidence of colorectal cancer
In 1993, the National Polyp Study Workgroup published a landmark study documenting a 76% to 90% reduction in colorectal cancer incidence compared with reference populations when adenomatous colon polyps are removed endoscopically. A year before this, Selby and Newcomb independently showed a 60% to 70% rectal cancer mortality reduction following sigmoidoscopy and polypectomy
V
V
Morpholoic classification
Screen_Shot_2019-08-25_at_12.06.31_PM_11_copy
*
Pedunculated = have a stalk
*
Sessile = base is attached to the colon wall
*
Flat = height < ½ of the diameter of the lesion
*
Depressed = likely to harbor high-grade dysplasia
V
>
Haggitt’s classification
Pasted_Graphic_15
*
By definition, all sessile polyps with invasive cancers are level 4 Haggitt’s
*
Memory cue: MNOPQRS
I: Muscularis Mucosa
II: Neck
III: Stalk
IV: SubMucosa
*
Haggitt levels 1-3 are equivalent to SM1 on Kikuchi classification. Haggitt 4 can be SM1, SM2, or SM3
>
Histologic classification
>
Tubular
*
Account for ≥ 80% of adenomas
*
Tubular component of the polyp accounts for ≥ 75%
*
Associated with malignancy in 5% of cases
*
Tubular adenoma > 2cm = 35% harbor malignancy
>
Villous
*
Account for 5-15% of adenomas
*
The villous component must be ≥ 75%
*
Are most often sessile
*
40% harbor cancer
*
Villous adenoma > 2 cm = 50% harbor malignancy
>
Tubulovillous
*
Have 26-75% villous component
*
Risk of malignancy is 22%
V
>
Size & histology are independent risk factors for malignancy
B9781416061892001220_t00251
*
Every 1cm in size increases the risk of the polyp harboring malignancy by 10%
>
Management
*
Non-carcinoma: polypectomy is sufficient
>
Invasive carcinoma:
*
Defined as cells invading the muscular mucosa (regardless of polyp morphology)
V
Polypectomy is sufficient if (criteria):
*
Only T1 lesions
*
≥ 2 mm resection margin
*
Lesion is well- or moderately-differentiated
*
⊖ LVI
*
⊖ Tumor budding
V
Indications for segmental resection:
*
Polyp not meeting polypectomy criteria
*
Extremely large polyps
*
Polyps not resectable endoscopically
>
Sessile serrated lesions
>
General
*
Classically have saw-toothed or serrated appearance of the crypts
*
Results from failure of normal apoptosis
>
Hyperplastic polyps
*
NCCN glossary for HP: Hyperplastic polyps are serrated polyps with normal crypt architecture and proliferative characteristics
*
A hyperplastic polyp is a serrated polyp with no pathological features of a serrated sessile lesion
*
Composed of normal cellular components; exhibit no dysplasia
*
They do not appear to increase the risk of colorectal cancer
*
They are usually found in the rectosigmoid and are ≤ 5mm
*
They are typically sessile
*
They are the most common non-neoplastic polyps
*
Large polyps are precursors to sessile serrated adenomas that can progress to colorectal cancer
>
Management
*
Consider full colonoscopy if they are detected on flexible sigmoidoscopy: a systematic review that included 18 studies estimated that 21-25% of patients found to have a distal hyperplastic polyp had a proximal neoplasm
*
In patients with hyperplastic polyps ≥10 mm, a repeat colonoscopy is suggested in 3-5Y
*
In patients with <20 hyperplastic polyps that are <10 mm, surveillance colonoscopy is recommended in 10Y
>
Sessile serrated polyps & traditional serrated adenomas
*
Often have a ‘cloud-like’ appearance and may be covered with mucus
*
Contain significant architectural, proliferative, and maturation abnormalities and may acquire morphologic evidence of dysplasia
*
Those with foci of dysplasia are considered the likely precursor lesions to sporadic MSI-H colon cancer through the CIMP pathway. The defect may result in hypermethylation of the promoter region of the MMR MLH1 and silencing of gene expression
*
There is molecular and clinical evidence that these lesions, either through being missed, incompletely removed, or through a more rapid progression from adenoma to cancer, disproportionally contribute to interval CRCs
>
Clinical management: like adenomatous polyps (complete excision)
*
Due to their sessile nature and indistinct borders, special care is needed to ensure their complete removal endoscopically
*
1-2 SSPs <10mm + ⊖dysplasia: colonoscopy in 5-10Y
*
3-4 SSPs: colonoscopy in 3Y
*
≥ 10mm SSP, SSP with dysplasia, or TSA: managed as advanced adenoma
>
Traditional serrated adenomas
*
NCCN glossary for TSA: Polyps with complex villous growth pattern; ectopic crypt formation is a unique feature that leads to mucosal protrusions; are associated with high-risk polyp recurrence
*
They are more prevalent in the rectosigmoid
*
Have diffuse cytologic dysplasia
>
Sessile serrated polyps/adenomas
*
NCCN glossary for SSP: Synonymous with sessile serrated adenoma; SSPs are a type of serrated polyp that is not dysplastic or does not contain foci of dysplasia; sessile lesions are attached to the mucosa without a stalk
*
They are more prevalent in the proximal colon
*
May have a foci of cytogenic dysplasia
*
The potential to develop colorectal cancer is higher than that in adenomatous polyps
*
Large polyps are associated with synchronous colorectal cancer
>
Submucosal lesions
*
Lipoma (is the most common): Dx by its yellow color & softness (pillow sign) — doesn’t require Bx
*
Fibroblastic polyps
*
Leiomyomas
*
Hemangiomas
*
Carcinoids
*
Metastatic lesions
>
Dysplasia
*
All adenomas by definition have dysplasia
*
High-grade dysplasia refers to the distribution of nuclei within the cells (nuclei stratified haphazardly between the basal and apical halves of the cells)
*
Tis refers to intramucosal carcinoma (involvement of lamina proprio with no extension through the muscularis mucosa)
>
Chemoprevention
*
ASA may be associated with 21% decrease in adenoma recurrence in patients with Hx of adenoma or CRC
*
Celecoxib 400mg/d may be associated with 34% reduction in adenoma recurrence in patients with Hx of adenoma
*
Calcium intake 1200-2000 mg/d may be associated with 18% reduction in adenoma recurrence in patients with Hx of adenoma
>
Colonoscopy / sigmoidoscopy and polypectomy
V
>
Abx prophylaxis
ASCRS
Screen Shot 2020-06-10 at 2.42.06 PM
*
While there are case reports of endocarditis following colonoscopy, the need for antibiotic prophylaxis for patients undergoing elective endoscopy is rare
*
ASCRS: Based upon current guidelines antibiotic prophylaxis is reserved for individuals with cardiac valvular disease at high risk of infective endocarditis
V
*
ASGE 2015 guidelines: even high-risk patients are not required to have antimicrobial prophylaxis prior to endoscopic procedures. In patients who fall into the high-risk category, a frank discussion with the patient’s cardiologist or infectious disease specialist is warranted.
All cardiac conditions: Antibiotic prophylaxis is not indicated solely to prevent IE ⊕⊕⊕⊖
Cardiac conditions associated with the highest risk of an adverse outcome from IE: For patients with these conditions who have established infections of the GI tract (such as cholangitis) and for those who receive antibiotic therapy to prevent wound infection or sepsis associated with a GI tract procedure, it is recommended that the antibiotic regimen include an antimicrobial agent active against enterococci, such as penicillin, ampicillin, piperacillin, or vancomycin. ⊕⊕⊖⊖
*
Patients with peritoneal dialysis should receive prophylactic Abx coverage
*
If needed: Amoxicillin 1 gram, 1 hr before the procedure is appropriate
If allergic to penicillins: azithromycin 500mg X1 is used
*
Colonoscopy is considered the gold standard for screening. It is the test of choice for patients with greater than average risk. However, it is the most morbid (& expensive) screening method. It is the screening test recommended for average-risk individuals; indeed, it may be the most cost-effective test if administered once every 10 years, as recommended. In the National Polyp Study Workgroup trial, colonoscopic examination revealed a 20% overall polyp miss rate. Clearly, the gold standard could be improved on, particularly for polyps smaller than 1.0 cm in diameter.
>
Chromoendoscopy
*
Involves topical spray application of dye (0.4% indigo carmine) via the colonoscope
*
Its use may result in improved overall adenoma detection rate, especially flat adenoma detection
>
NBI
*
Filters behind the light source remove red light → enhanced mucosal surface vascularity & polyp visualization
*
Meta-analysis suggests no improvement in adenoma detection when compared to standard colonoscopy
*
High-definition NBI may have an advantage over standard colonoscopy with respect to minimizing polyp & adenoma miss rate
>
Flexible sigmoidoscopy
>
Qualifications of flexible sigmoidoscopy
*
At least 40cm, preferably advancement to splenic flexure
*
Withdrawal time of ≥ 3.25 minutes
*
The major problem with sigmoidoscopy lies in its inability to evaluate the more proximal colon. Despite this, metaanalyses have demonstrated a beneficial reduction in the incidence of colorectal cancer and long-term mortality when compared with no screening
>
For average-risk individuals, combining FOBT with flexible sigmoidoscopy at 5-year intervals is deemed acceptable as a screening option
*
In randomized studies, annual use of FOBT alone with three consecutive stools produced a colorectal cancer-specific mortality reduction rate of 33%. Unfortunately, the false-negative rate using FOBT alone is unacceptably high
>
Colonoscopy in the elderly
*
Screening in ages 76-85 should be a decision unique to each individual taking into account overall health and prior screening
*
Those who have never been screened have more benefit from colonoscopy
*
There is higher complication rate and higher incomplete colonoscopy rates in the elderly
>
Colonoscopic adenoma detection rate (ADR) = 25% in ♂; 15% in ♀
>
Adenoma detection rate is associated with:
*
Withdrawal time (minimum recommended time is 6-8m)
*
Withdrawal technique
>
Polyp miss rate = 22% pooled miss rate for polyps of any size
*
2% if > 10mm
*
13% if 5-10mm
*
26% if 1-5mm
*
Study: the percentages of adenomas with advanced pathologic features were 3.4%, 13.5% and 38.5% for adenomas <0.5 cm, 0.5–1.0 cm and >1 cm respectively
*
Villous histology, left sided location and age ≥60 are often associated with advanced pathologic features
>
Bx, polypectomy, and tattooing
*
Polypectomy is best performed with the polyp in the 5–7 o’clock position. One may consider repositioning the patient so the base of the polyp is not in a dependent position to make postpolypectomy bleeding easier to control
>
Forceps polypectomy & Bx
V
*
Cold forceps biopsy is appropriate for polyp 1-3 mm
This technique requires minimal manipulation, uses no electrocautery, and has an insignificant risk of perforation
>
Hot forceps (no longer recommended) during removal is associated with
*
Impaired histologic evaluation of the specimen
*
Increased risk of delayed bleeding and perforation in the right colon
*
Unreliable in completely removing all adenomatous tissue with 17% of polypectomy sites revealing persistent viable polyp remnants
*
National societies recommend avoidance of hot biopsy forceps for polyps >5 mm and those in the right colon
>
Snare polypectomy
*
Cold snaring is the preferred technique for all small (<10 mm) and most diminutive polyps but this has not been well studied. The technique of cold snaring allows for a resection of a 1–2 mm margin of normal tissue around the polyp.
*
The application of electrocautery with snare polypectomy is more common for larger polyps (>7–8 mm) and pedunculated polyps
*
CRESCENT study (2017): Cold snare is as effective as a hot snare at complete resection for 5-10mm polyps
*
For pedunculated polyps, the snare should be closed at a third or halfway from the base of the polyp to ensure a sufficient stump to re-grasp if there is immediate bleeding
>
Main indications for hot-snare:
*
Pedunculated polyp with stalk ≥ 0.5 cm
*
Flat polyp ≥ 20-25mm
>
Management of stalling (snare closes and does not cut through the mucosa)
>
Step 1: Straighten
*
While holding the snare tightly closed for 10-15 seconds perform the following:
*
Maintain full insufflation and avoid suction.
*
Straighten and stretch the length of the catheter external to the instrument.
*
Gently move the snare catheter forward and backward within the instrument channel
>
Step 2: Drop
*
Partially reopen the snare (to about 1/3 of the snare handle; avoid fully opening the snare).
*
Slowly lift the lesion away from the colon wall.
*
Lower the lesion (to prevent fly-away).
*
Re-close the snare fully to cut the lesion.
>
Advanced techniques is appropriate for polyps > 2 cm
*
‘Non-lifting’ signs indicates a deeper lesions and unsuitability for EMR/ESD
>
EMR is effective and practical with good outcomes. When performed by experts, anywhere from 3-7% of patients are referred for surgical resection because of inability to remove the polyp endoscopically. Approximately 44% of lesions are removed en bloc and the remaining are removed piecemeal
*
Intraprocedural bleeding occurs in about 8% of patients, post-procedural bleeding in 0–1%, and perforation 1–2%. Local recurrence after EMR is variable and reported in up to 27% of cases (more than ESD)
*
Japan data: bleeding rate 4.4%; perforation 0.2%
>
ESD has the advantage of definitively permitting an en bloc and therefore histologically complete resection. These advantages come at the cost of an increased risk of perforation, bleeding, and a longer procedure time as compared with EMR
*
This technique is indicated when an en bloc resection cannot be done with EMR. It is also indicated for polyps with intramucosal to shallow submucosal invasion as well as lesions with submucosal fibrosis that cannot be lifted with submucosal injection during conventional EMR
*
Successful en-bloc resection may be as low as 60% in initial cases but increases up to 88–97% with experience
*
Bleeding risk: 1.5-7.9%
*
Perforation risk: 10%
*
Frequently, complications are successfully treated with endoscopic clipping
*
Patient positioning: position the patient with the polyp against gravity dependent location. As the dissection is started, gravity will help retract the mobilized part of the polyp
>
Tattooing
V
Tattooing solutions
*
Indigo carmine
*
Methylene blue
*
Ink spot (India Ink, Spot)
>
Findings
*
Polyps detected by flexible sigmoidoscopy should prompt full colonoscopic examination
*
Lipomas are distinguished by their shape, color, & consistency — they do not require Bx
>
Angiodysplasia
*
Is more prominent in the right colon
*
If no Hx of bleeding, no therapy is indicated
>
Tattooing technique for suspicious lesion
*
3-4 circumferential submucosal injections
*
Use 1ml just distal to the lesion
>
Complications
>
0.05% general compilation rate for diagnostic colonoscopy
*
Serious complications, defined as those resulting in hospital admission within 30 days of the procedure occur with a rate of 1-5 per 1000 exams
>
Cardiopulmonary complications are the most frequent complication related to procedural sedation
*
Scoping may cause a vagal response (↓HR & ↓BP) → stop maneuvering the scope & Rx IV fluids
*
The administration of sedative medications, particularly midazolam does cause transient hypotension in 20% of patients, with ST-segment depression in 7% of them. The clinical significance of these changes is unclear, however.
*
Colonoscopy in patients with a recent myocardial infarction is associated with a higher rate of minor, transient, and primarily cardiovascular complications compared with control patients but is infrequently associated with major complications
>
Bleeding is the most frequent serious complication (0.5-2%)
*
ASCRS: bleeding requiring a patient to seek medical care occurs in over 3% of all colonoscopic polypectomies
*
According to the 2005 ASGE guidelines, a diagnostic colonoscopy or a colonoscopy with biopsy is considered a low-risk procedure for causing hemorrhage. A polypectomy however is considered to be a high-risk procedure and any anticoagulant medications should be adjusted according to the medication that is being taken. These decisions will often need to be coordinated with the physician monitoring the anticoagulant, as it is often not within the purview of the endoscopist to evaluate the thrombotic risk.
>
ASCRS: Patients at higher risk for bleeding
*
Difficult colonoscopy with procedural bleeding
*
HTN has also been noted to be not only a risk for bleeding, but for increasing the interval between the polypectomy and hemorrhage
*
Anticoagulation medications; surprisingly, this risk is not seen with aspirin, NSAIDS, or other antiplatelet medications
>
The size of the polyps excised is the most consistent predictor of delayed hemorrhage after a polypectomy
*
Polyp > 2 cm: 3.8% bleeding rate
*
Polyp < 2 cm: 0.3% bleeding rate
*
The type of polyp either sessile or pedunculated has not been demonstrated to be a risk factor
*
Polyps located in the right colon more susceptible to bleeding
*
Immediate bleed is managed with clips or epinephrine injection
*
ASCRS: The incidence of post-polypectomy hemorrhage peaks at 4–6 days and this risk extends to at least 14 days. In general, the morbidity of a thromboembolic event is greater than that of hemorrhage (in context of the anticoagulated patient)
*
Almost all will stop spontaneously. Colonoscopy may be helpful to identify the source and for local control when necessary
*
Angioembolization has been shown to be effective in management
>
UTD: Techniques to prevent bleeding
*
Polyps <1 cm — We use cold snare polypectomy for polyps ranging in size from 4-9 mm because this approach is effective and reduces the risk
*
Hemoclips – Hemostatic metal clips (endoclips) may be used to prevent postpolypectomy bleeding after removal of large polyps, but data regarding their efficacy are mixed
*
Electrocautery settings — We generally use a blended setting
>
Postpolypectomy syndrome (0.3%)
*
It is believed to be the result of an electrocoagulation injury to the colonic wall, thereby creating a transmural burn with localized peritoneal inflammation, but without evidence of perforation.
*
Typically patients present several days following a colonoscopy with fever, localized abdominal pain, and leukocytosis and may have localized peritoneal signs
*
Typically present 0-3 days after colonoscopy
*
In one series, all patients were successfully managed medically without the need for surgery, with a median hospitalization of 5 days
*
Managed with: Abx, bowel rest, & serial examinations
>
Perforation (0.1%)
>
Mechanisms of perforation
*
Mechanical trauma from the pressure of the scope on the wall of the colon (often in the rectosigmoid region). These tend are typically large
*
Barotrauma (typically in the cecum)
*
Therapeutic procedure. These are typically small
>
Perforation rates:
*
Screening colonoscopy = 0.01-0.1%
*
Stricture dilation = 0-18%
*
EMR = 1-5%
*
ESR = ~10%
*
ASRCS: much less than 1/1000 procedures, with rates of 0.012% to 0.016% reported in large studies
*
ASRCS: a large study of IBD patients showed a low perforation rate of 0.16%
*
ASCRS: In most series attempting to examine the etiology of the complication, the incidence is as common when a biopsy is performed as from a diagnostic endoscopy alone
*
Mortality from perforation = 0-0.6%
*
Perforations from a diagnostic colonoscopy are likely larger and are less successfully managed with nonoperative treatment
*
A minority of patients can be managed nonsurgically. Such patients have a clean colon with no signs of peritonitis and improve symptomatically over 24 hours
*
Successful endoscopic clip closure of perforations has been reported and may be attempted if the perforation is visualized (double target sign) at the time of the colonoscopy and is accessible
*
If perforation is recognized early (no significant contamination) and occurs in a fully bowel-prepared colon, surgical primary repair may be sufficient
*
Diverticulitis
*
The mortality rate related to colonoscopy is 0.007%
>
Quality indicators for colonoscopy
V
>
1. ADR should be ≥ 25% overall (≥ 30% for ♂; ≥ 20% for ♀)
The American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG) recommends a minimum target for overall ADR of at least 25% based on the observation that higher ADRs were associated with a reduced risk of both proximal and distal cancer
V
How to improve ADR:
*
Look cleaner (better bowel preparations)
*
Look closer (image recognition training / freeze frame to examine suspected lesions)
*
Look slower (increase withdrawal time)
*
Look sharper (use high-definition/NBI, chromoendoscopy)
*
Look more completely
*
2. Cecal intubation rate should be ≥ 95% for screening colonoscopies & ≥ 90% overall
V
3. Ensure using a split-dosing bowel preparation for effective bowel preparation
*
Preferred timing of the second dose of split-dose preparation:
– Start 4–6 hours before colonoscopy
– End at least 2 hours before colonoscopy
*
4. Include photographs in the scope report (appendices orifice & ICV)
>
5. Ensure to document the quality of the preparation
>
Boston Bowel Preparation Score
V
*
0 = Unprepared colon segment with mucosa not seen due to solid stool that cannot be cleared.
nihms-148874-f0001
V
*
1 = Portion of mucosa of the colon segment seen, but other areas of the colon segment not well seen due to staining, residual stool and/or opaque liquid.
nihms-148874-f0002
V
*
2 = Minor amount of residual staining, small fragments of stool and/or opaque liquid, but mucosa of colon segment seen well.
nihms-148874-f0003
V
*
3 = Entire mucosa of colon segment seen well with no residual staining, small fragments of stool or opaque liquid. The wording of the scale was finalized after incorporating feedback from three colleagues experienced in colonoscopy.
nihms-148874-f0004
*
NCCN: In cases where colonoscopy is complete to the cecum but the preparation is ultimately considered inadequate, colonoscopy should be repeated within 1 year.
*
6. Colonoscopy withdrawal time
*
7. Complication rate
*
8. Interval between endoscopies
>
CT colonography (CTC)
>
Technique
V
There is variation in bowel preparation (full, partial, or none) and overall technique
*
Dry preparation agents are most commonly used (Na phosphate, Mg citrate, or bisacodyl)
*
Wet preparation (PEG) can leave liquid in the colon that can potentially obscure lesions
>
Fecal tagging is often employed
*
Oral ingestion of high-density contrast agent so that residual colonic contents can be differentiated from soft-tissue density polyps
*
Appears to decrease the need for cathartic preparation
*
Barium or iodine-based contrast agents may be used
*
Requires a small caliber flexible rectal catheter insertion for colonic distention (usually with CO2 utilizing an automated insufflator)
*
The procedure may require frequent repositioning, depending on the adequacy of colonic distention
V
*
Detection rate after ⊕FOBT are lower for CTC than colonoscopy
Screen Shot 2020-08-03 at 13.07.01
Plumb, Andrew A., et al. "Use of CT colonography in the English bowel cancer screening programme." Gut 63.6 (2014): 964-973.
V
*
Asymptomatic screening population sensitivity for adenomas varies by size. CTC sensitivity is adequate for adenoma > 10 mm
Screen Shot 2020-08-03 at 13.02.37
V
*
Sensitivity for cancer detection is equivalent to optical colonoscopy. Most cancers missed are usually in the rectosigmoid region (therefore: consider supplementing CTC with flexible sigmoidoscopy)
Screen Shot 2020-08-03 at 13.00.06
*
CTC perforation rate is 0.04% and usually can be managed non-operatively
>
Advantages of CTC
*
Certain software may allow omitting bowel preparation with fecal tagging
*
Detection of extra-colonic lesions
>
Disadvantage of CTC
*
Adenomas > 10 mm require colonoscopy
*
Radiation exposure
*
Sensitivity depends on radiologists experience
>
Clear indications for colonoscopy after CTC
*
≥ 1 polyp ≥10mm
*
≥ 3 polyps ≥ 6mm
V
*
Overview of colon polyp surveillance
Screen Shot 2020-04-18 at 12.55.26 PM
*
For advanced rectal polyp: re-scope in 3-6 months in clinic
V
*
Melanosis coli and laxative misuse syndromes
Long-term consumption of stimulant laxatives leads to accumulation of lipofuscin pigment in macrophages in the lamina propria. This imparts a brown discoloration to the colonic mucosa, often described as resembling ‘tiger skin’. The condition is benign and resolves when the laxatives are stopped. Prolonged laxative use may rarely result in megacolon or ‘cathartic colon’, in which barium enema demonstrates a featureless mucosa, loss of haustra and shortening of the bowel. Surreptitious laxative misuse is a psychiatric condition seen in young women, some of whom have a history of bulimia or anorexia nervosa. They complain of refractory watery diarrhoea. Laxative use is usually denied and may continue, even when patients are undergoing investigation. Screening of urine for laxatives may reveal the diagnosis
>
Functional bowel disorders
V
IBS
*
Affects 3-22% of the population
*
In patients who develop symptoms after GI infections, their symptoms resolve after only 5Y
V
Rome III criteria
*
1. Recurrent abdominal pain or discomfort ≥ 3d/month X 3m
*
2. Symptoms onset > 6m before Dx
V
Associated with 2 additional criteria:
*
a. Improvement with defecation
*
b. Onset associated with a change in infrequency of stool
*
c. Onset associated with a change in stool form/appearance
>
Work up / rule out
>
Celiac sprue
*
It is an enteropathy resulting from an immune-mediated response to deamidated gliadin
>
Dx by (either)
*
Small intestinal biopsy demonstrating villous atrophy, crypt hyperplasia, and inflammation of the lamina propria
V
Serum test for specific elevated antibodies
*
(IgA) anti-tissue transglutaminase antibody is the most diagnostic, followed by elevation of IgA endomysial and anti-tissue transglutaminase antibodies, and to a lesser degree, antigliadin antibody levels
*
 
*
Colonoscopy
*
Microscopic colitis
*
Lactose maldigestion
*
IBD
*
Thyroid dysfunction
*
Chronic constipation
*
Small intestinal bacterial overgrowth
>
Classification of disease
*
IBS-D (diarrhea-predominant)
*
IBS-C (constipation-predominant)
*
IBS-M (mixed)
V
>
Treatment
Untitled
V
General measures
*
Minimize foods high in carbohydrates or fat
*
Gluten restriction may improve IBS symptoms, especially IBS-D
V
>
↓ FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols)
These are short-chain carbohydrates that are poorly absorbed
*
Fructose (fruits, honey, high fructose corn syrup)
*
Lactose (dairy)
*
Fructans (wheat, garlic, onion)
*
Galactans (legumes)
*
Polyols (sweeteners)
>
↑ Fiber, especially for IBS-C (although results have been disappointing)
*
Soluble fiber may be more beneficial than insoluble in IBS patients
*
Use of insoluble fiber should be discouraged
*
Rifaximin may improve symptoms in non-constipation IBS
*
Consider probiotics
*
Exercise
*
Psychological therapy
*
Acupuncture
>
IBS-D
*
Antispasmodics may be used for postprandial cramping and loose stools
*
Peppermint oil
*
TCA
*
SSRI
*
Ondansetron may significantly improve stool consistency, nausea, stool urgency and frequency, bloating, and global IBS symptoms
V
IBS-C
*
Tegaserod (withdrawn for cardiovascular AE)
>
Laxatives
*
PEG
*
Non-stimulant laxatives
*
SSRI
>
Prosecretory agents
*
Lubiprostone
*
Linaclotide
>
Chronic functional pelvic pain
*
Affects 7% of the population
V
DDx
*
Cryptitis
*
Fissure
*
Abscess
*
Hemorrhoids
*
SRUS
*
IBD
*
Rectal ischemia
*
Prostatitis
*
Endometriosis
V
Classification
>
Chronic proctalgia
>
Rome III criteria
*
Chronic/recurrent rectal pain/aching ≥ 20m
*
Absence of structural or systemic disease
>
Subtypes
>
Levator ani sydnrome
*
It is termed such when traction on the pelvic floor produces tenderness
*
Tenderness on palpation is most commonly found on the left side where the muscle inserts into the pubic ramus of the pelvis.
*
Unspecified functional anorectal pain
*
Anorectal studies have little diagnostic or prognostic value
V
Treatment considerations
*
Biofeedback
>
Digital massage of the levator muscles
*
Performed firmly and repetitively
*
Often employed in conjunction with sitz bath or short course of diazepam
*
Trigger point injection with steroid or Botox
*
Electrogalvanic stimulation
>
Coccygodynia
>
Etiology & frequently associated Hx
*
Chronic spasm of the pelvic floor → tension on a stiff coccyx
*
Spicule (bone spur) or bursitis may cause pain
>
Trauma
*
Traumatic childbirth
*
Repetitive minor trauma such as horse-back riding
*
Lumbar disc degeneration
*
Hx of epidural injection
*
Previous spinal or rectal surgery
*
♀
*
Obesity
*
Workup may include MRI to exclude tumors, disc disease, and identify anatomic risk factors
*
Trigger point injection with steroid may be considered for transient relief
*
Coccyx manipulation is said to be beneficial
*
Failure of therapy may warrant coccygectomy
V
Pudendal neuralgia (Alcock’s canal syndrome)
*
The pudendal nerve travels through a musculo-osteo-aponeurotic tunnel between the sacrotuberal and sacrospinal ligaments
>
Etiology
>
Compression of the nerve
*
The two documented sites of pudendal nerve entrapment are between the sacrotuberous and sacrospinous ligament and in the pudendal (Alcock’s) canal
*
Herpetic neuropathy
*
Stretch neuropathy
*
Post-radiotherapy neuropathy
V
Dx criteria
*
Pain is limited to the innervation territory of the pudendal nerve (coccyx, pelvic, and gluteal areas only)
*
Pain is predominantly experienced when sitting
*
Pain rarely awakens patients at night
*
No objective sensory impairment can be found
*
Pain is relieved by anesthetic infiltration of the pudendal nerve
V
Treatment
*
SNS
*
Nerve ablation may be done by image-guided techniques
V
Surgical neurolysis (decompression of the canal)
*
Transperineal
*
Transgluteal
*
Transischiorectal
*
Laparoscopic
>
Perioperative care, bowel preparations, stomas, complications, & operative considerations
>
Bowel preparation
>
Inadequate cleaning reported in up to 27% of patients
V
*
It is recommend that patients undergo early repeat colonoscopy when the bowel preparation quality is deemed inadequate, defined as the inability to detect polyps smaller than 5mm
There are no prospective studies dealing with this patient population and the practices are individualized. Some practitioners either increase the amount of liquid diet by 1 day or add an osmotic or cathartic agent to the existing regimen
>
The goal:
*
Surgery: ↓ fecal load → ↓ infectious complications
*
Endoscopy: emptying luminal content and ↑visualization
V
*
Cochrane 2011: mechanical bowel preparation (and rectal enema) may be omitted safely without any statistically significant difference in postoperative complications
This was when MBP was compared to no-MBP (without the addition of PO Abx)
V
*
Cochrane 2014: combined PO & IV prophylaxis reduce the risk of SSI by 44% compared to IV Abx alone
Recent publications from statewide and nationwide data registries support this conclusion; combined preoperative oral antibiotic and mechanical bowel preparation is associated with reductions in:
- surgical site infections
- anastomotic leakage
- ileus
- health services utilization outcomes such as length of stay and readmission
- C-Diff infections (0.5% vs 1.8%)
V
>
Evidence of regimens
A Consensus Document on Bowel Preparation Before Colonoscopy: Prepared by a Task Force From The American Society of Colon and Rectal Surgeons (ASCRS), The American Society for Gastrointestinal Endoscopy (ASGE), and The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)
Dis Colon Rectum 2006; 49: 792–809 DOI: 10.1007/s10350-006-0536-z
The American Society of Colon and Rectal Surgeons
Published online: 02 May 2006
Special care must be taken to avoid altering the osmolarity of the preparation or adding substrates to the preparation, which can metabolize into explosive gases or alter the amount of water and salts absorbed.
Although beneficial, the addition of these carbohydrate-based solutions is associated with a theoretic risk of cautery-induced explosion if these carbohydrates are metabolized by colonic bacteria into explosive gases.
V
*
Dietary modifications, such as a clear liquid diet, alone are inadequate for colonoscopy. However, they have proven to be a beneficial adjunct to other mechanical cleansing methods (Grade IIB)
Two days prior to procedure:
High fibre foods which should be avoided
Breakfast cereals
Bacon, sausages, black pudding, red meat and pies
Fruit
Nuts and pulses including baked beans
Any vegetables, fruit or salad
Wholemeal or brown bread, puddings containing fruit or nuts, cakes and biscuits
Yoghurts
Potato skins or chips, wholemeal pasta, brown rice
Low fibre foods which are allowed
Eggs, white meat such as chicken (skinless), grilled or poached fish, cheese, tofu
White bread/toast/butter/margarine, croissants, pasta, rice, boiled or mashed potatoes
Water, fizzy drinks, fruit squash (NOT blackcurrant) Tea, coffee, clear soups
Ice cream, custard, boiled sweets
Shredless marmalade
>
Enemas
*
Rx: Tap water or NaP administered the evening before or the morning of the procedure
*
Before the development of PEG, enemas were an essential component of colonic preparation. However, conclusive evidence has demonstrated that enemas do not improve the quality of bowel cleansing, yet significantly increase patient discomfort. Enemas may still play a role in the patient who presents for colonoscopy with a poor preparation.
*
Recommendation: Use enemas in patients who present to endoscopy with a poor distal colon preparation and in patients with a defunctioned distal colon
V
*
High-volume gut lavage: Neither high-volume nor unbalanced solutions, such as mannitol, should be used for colonic preparation (Grade IA)
Mannitol was used in early formulations but abandoned secondary to bacterial fermentation into hydrogen and methane gas, which can cause explosion when electrocautery is used.
It can also result in dramatic fluid and electrolyte shifts
>
Rectal pulsed irrigation
*
Rx: 30-min infusion of short pulses of warm tap water via rectal tube immediately before colonoscopy (requires skilled nursing resources); used in combination with magnesium citrate the night before
*
Rectal pulsed irrigation administered immediately before the procedure combined with magnesium citrate given the evening before the procedure is a reasonable alternative to full-volume (4-liters) PEG in those individuals who cannot tolerate per oral administration of PEG (Grade IIB).
V
>
PEG
PEG is a nonabsorbable electrolyte solution that should pass through the bowel without net absorption or secretion
The number represents the average molecular weight (e.g. macrogol 3350, macrogol 4000 or macrogol 6000).
Screen Shot 2021-03-18 at 13.24.20
*
Rx: PO 240 ml (8 oz) Q10m until rectal output is clear or 4L are consumed
*
Rx: NGT 20-30 ml/m (1.2-1.8 L/h)
*
Consumption of the PEG solution less than 5h before the procedure resulted in better preparation than when given more than 19h before the procedure
*
PEG gut lavage has proven to be the preferred method for colonic cleansing in infants and children. PEG seems to be safe in pregnant women
*
PEG is safer than osmotic laxatives/NaP for patients with electrolyte or fluid imbalances, such as renal or liver insufficiency, congestive heart failure, or liver failure and is, therefore, preferable in these patient groups (Grade IA).
*
Divided-dose PEG regimens (2–3 liters given the night before the colonoscopy and 1–2 liters on the morning of procedure) are acceptable alternative regimens that enhance patient tolerance (Grade IIB)
*
Enemas, bisacodyl, and metaclopramide as adjuncts to the full volume of PEG have not been demonstrated to improve colonic cleansing or patient tolerance and are, therefore, unnecessary (Grade IIB).
*
Sulfate-Free-PEG is better tasting, but still requires the consumption of 4 liters in its standard regimen. SF-PEG is an acceptable alternative lavage solution when a PEG-based lavage solution is required (Grade IIB).
*
Two-liter PEG regimens combined with bisacodyl (i.e., HalfLytely®) or magnesium citrate are equally effective compared with standard 4-liter PEG regimens but appear to be better tolerated and therefore a more acceptable alternative to the 4 liter PEG regimens.
V
*
Two-liter PEG-3350 regimens combined with bisacodyl (i.e., Miralax®) are equally effective compared with standard 4-liter PEG (Grade IA).
Rx: Only clear liquids on the day of the preparation. Dosage is four bisacodyl delayedrelease tablets (5 mg) at noon. Wait for bowel movement or maximum of six hours; 240 ml (8 oz) every ten minutes until 2 liters are consumed
V
>
NaP
The NaP osmotically draws plasma water into the bowel lumen to promote colonic cleansing.
*
NaP must be diluted before drinking to prevent emesis
*
The mean onset of bowel activity was 1.7 hours after the first dose and 0.7 hours after the second dose
*
Bowel activity ceased within four hours in 83% of patients and within five hours in 87%
*
NaP preparations have been shown to alter both the macroscopic and microscopic features of intestinal mucosa, and induce aphthoid erosions similar to those seen in IBD
*
Although usually asymptomatic, hyperphosphatemia is seen in as many as 40% of healthy patients completing NaP preparations, and may be significant in patients with renal failure. As many as 20 percent of patients using NaP preparations develop hypokalemia;
*
Rx: Two doses of 30-45 ml (2-3 tbsp) oral solution (taken with 240 ml of water) at least 10-12h apart. The second dose must be taken at least 3h before the procedure.
*
Aqueous NaP colonic preparation is an equal alternative to PEG solutions except for pediatric and elderly patients, patients with bowel obstruction, and other structural intestinal disorders, gut dysmotility, renal or failure, congestive heart failure, or liver failure (Grade IA). Dosing of aqueous NaP should be 45 ml in divided doses, 10 to 12 hours apart with one of the doses taken on the morning of the procedure (Grade IIB)
>
Picolax ®
*
Saline laxatives that use sodium picosulfate and magnesium citrate as the active ingredients are available primarily in the United Kingdom. Bowel preparations with this regimen have been compared with both PEG and NaP. Picolax® was found to be equally effective as PEG in terms of quality of preparation but more tolerable (less nauseating and easier to finish). Conflicting data concerning NaP compared with Picolax® have been published.
*
Rx: Sodium picosulfate/magnesium oxide 300ml with 1000ml of water 10-18hr before the procedure; and 300ml with 750ml the 4-6h before the procedure
V
Regimens
>
MBP (either)
*
PEG 4 liters the night PreOp
*
PEG 2 liters + bisacodyl the night PreOp
*
Picolax (sodium picosulfate / magnesium citrate) 250 mL the night PreOp
*
Usually for surgery, a split bowel preparation is not feasible. Patients tend to get 2L of PEG the night before. Alternatively Pico-Salax sachets can be given in two doses on the day prior to surgery at 14:00h and 18:00h with a dose of bisacodyl prior to each sachet and 2 fleet enema (30 minutes apart) to be taken before showing with chlorhexidine 4% solution on the day of surgery
>
PO Abx (both)
*
Metronidazole 1g PO Q6-8h X 3 doses PreOp
*
Neomycin 1g PO at 19h, 18h, & 9h PreOp
V
>
For the sake of colonoscopy, split bowel preparation is definitely superior to non-split. The major difference will be in the presence of stool & in the coating of the right colon with bile that has not been washed off with the 2nd part of the split prep.
ASCRS: Multiple bowel preparation regimens exist, but regardless of which prep is chosen, splitting the timing into the half the day prior to and half the day of the procedure results in a better prep.
*
Preferred timing of the second dose of split-dose preparation:
– Start 4–6 hours before colonoscopy
– End at least 2 hours before colonoscopy
*
Always consent postmenopausal women for prohphylactic BSO with their CRC surgery
>
ERAS
*
It is a pathway aimed at attenuating the surgical stress response, reducing morbidity, and supporting early return of patient functioning
*
ERAS approach is associated with a reduction in the risk of complications by about 30% and reduces hospital stay by an average of 2 days
*
Postoperative day 3 is used as the target date for discharge after colon surgery
*
The discharge criteria are explicit for patients and caregivers
1) pain <4/10 with oral medications;
2) tolerating solid diet;
3) passing gas or stool;
4) normal vital signs;
5) and agreement with discharge
*
An emerging concept is the use of exercise to enhance functional capacity before surgery (prehabilitation). A 3- to 4-week multipronged program including moderate-intensity exercise and resistance training, nutritional counseling, and psychologic support increases functional capacity before and after surgery
*
Even mild perioperative hypothermia (34° to 36° C) is associated with adverse outcomes, including surgical site infection and blood loss.
V
*
Fluid overload of only 2.5 to 3 L, represented by weight gain exceeding 2.5 kg on postoperative day 1, is associated with worse outcomes, including ileus, impaired wound heaing, altered coagulation, and pulmonary edema
At induction of anesthesia, it is important to know whether the patient received a bowel preparation because the fluid losses will have to be replaced with an additional 1 L of fluid
*
Some observational data raise concerns about increased risk of anastomotic leak when NSAIDs are used in the first 48 hours, but this is not consistent in the literature
*
Oral intake is started as soon as the patient is awake as long as there is no nausea and vomiting
*
Patients are encouraged to drink more than 1 L fluid/day and the IV catheter is removed on POD1 if fluids are tolerated
V
*
Sample ERAS pathway
Preoperative Assessment and Optimization
Evaluation of medication compliance and control of risk factors: hypertension, diabetes, COPD, smoking, alcohol, asthma, CAD, malnutrition, anemia
Psychologic preparation for surgery and postoperative recovery: provide written information and e-module link including daily milestones in perioperative pathway (diet, ambulation, presence of drains, pain management, and expected hospital stay [3-4 days])
Physical preparation with exercises at home: aerobic 30 minutes/ day at moderate intensity (4-6 on Borg Scale) 3 days/week; resistance exercises; breathing exercises
Surgical considerations: operative approach (laparoscopic vs open)
Oral bowel preparation with antibiotics for rectal resections with planned ileostomy; fleet enemas for left sided resections
Stoma teaching as needed
Nutritional supplements if diminished oral intake, weight loss, low BMI
Day of surgery
Drink clear fluids with carbohydrates up to 2 hours before operation unless risk factors are present (e.g., gastroparesis, obstruction, dysphagia, previous difficult intubation, achalasia, pregnancy)
Preinduction
Short-acting sedative medication if needed for anxiety
Intraoperative Management
Anesthetic Management
Anesthesia protocol: Total intravenous anesthesia (TIVA)/desflurane/sevoflurane
Epidural catheter at appropriate level for postoperative analgesia for open surgery and infuse local anesthetics during surgery.
Bilateral transversus abdominis plane block for laparoscopic surgery
Intravenous lidocaine infusion 1.5 mg/kg bolus then 2 mg/kg/hr for duration of case if no epidural
Prevent PONV with dexamethasone and ondansetron plus others on the basis of baseline risk score
Avoid overhydration. IV Ringer’s lactate 1.5-2 mL/kg/ hr for laparoscopic surgery, 3-5 mL/kg/hr open surgery. Additional 1 L of Ringer’s lactate if bowel preparation used. Colloid 1:1 to replace blood loss
Maintain normothermia (>36° C)
Maintain glucose <10 mmol/L
Antibiotic and DVT prophylaxis
Neuromuscular blockade to allow lower pressure pneumoperitoneum (12 mm Hg)
Titrate depth of anesthesia with bispectral index
Surgical Care
Minimize incision size.
Laparoscopic surgery if feasible.
Maximize use of small trocars.
Infiltrate incisions with long acting local anesthetic at beginning and end of procedure.
Anastomotic leak test and endoscopy
Remove NG tube before extubation
Remove urinary catheter after right hemicolectomy
Postoperative Care
Postoperative Day 0
Discontinue IV fluid infusion (heparin-locking catheter) after discharge from recovery room
Gum chewing for 30 minutes TID (continue daily)
Full fluids with 1 can of nutritional supplement beverage if no PONV and no abdominal distension
Out of bed (sitting in chair) encouraged
Oral acetaminophen 650 mg every 4 hours and Celecoxib 200 mg BID for 72 hours routine
Glucose monitor and treatment if >10 mmol/L
Postoperative Day 1
Discontinue urinary drainage catheter
Gum chewing for 30 minutes TID
Full oral diet as tolerated including nutritional supplementation beverage with each meal
Mobilize out of bed for 4 to 6 hours. Walk length of hallway with assistance TID
Glucose monitor and treatment if >10 mmol/L
Postoperative Day 2
Gum chewing for 30 minutes TID
Mobilize out of bed for 8 hours
Transition from epidural to oral medication (oxycodone + acetaminophen + NSAIDs) if stop test successful
Discharge criteria assessed: passing gas or stool, no fever, pain <4/10 with oral analgesia, walking unattended, eating
Postoperative Day 3
Discharge before lunch if discharge criteria met
Instructions for home including eating normal diet with supplements as needed, daily exercise, avoid opioids, accessing psychologic support
Schedule follow-up appointment in clinic 2 weeks after surgery
>
ASCRS CPG 2017: Alvimopan is recommended to hasten recovery after open colorectal surgery, although its use in minimally invasive surgery remains less clear. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B.
*
Alvimopan is a drug which behaves as a peripherally acting μ-opioid receptor antagonist.
*
Dose 6-12mg
*
A Cochrane review of 9 studies affirmed that alvimopan was better than placebo in reversing opioid-induced increased GI transit time and constipation and that alvimopan was safe and efficacious in treating postoperative ileus, but the studies were in open laparotomy, and no ERP was noted in place
*
Additional studies have reported that alvimopan added no benefit in the rates of postoperative ileus or length of stay to laparoscopic colorectal surgery with an ERP, leading to the conclusion that the addition of alvimopan to an established ERP will lead to improvement in clinical outcomes in patients after open or hand-assisted colectomy but does not have a benefit after laparoscopic colorectal resection
*
ASCRS 2017 CPG: TAP block with a local anesthetic has been associated with decreased length of stay compared with systemic opioids in laparoscopic colorectal surgery. TAP blocks performed before surgery appear to provide better analgesia than TAP blocks performed at the end.
>
Stomas
*
The majority of small intestinal nutritional absorption occurs within the first 150 cm of intestine, as nearly 6 L of fluid is reabsorbed from the jejunum while only 2.5 L is reabsorbed in the ileum
*
Since fat-soluble nutrients are absorbed in the terminal ileum, proximal fecal diversion (greater than 100 cm proximal to the ileocecal valve) can render a patient with steatorrhea and vitamin B12 deficiency
V
*
Ileostomy output of electrolytes (i.e replacement with ½NS may be most suitable to avoid chloride overloading; but if the concern is Na, then iso-osmolar fluid appropriate)
Untitled
V
*
ASCRS Textbook: If a surgeon is forced to decide between making a poor stoma in a good location versus making a good stoma in a poor location, a general consensus amongst stoma care professionals is that a poor stoma in a good location is the lesser of two evils
A bad stoma in a good location can eventually be revised, but a badly located stoma eventually will require stoma re-siting
>
Stoma appliance considerations
*
Ileostomy typically requires emptying 5-6 X per day
*
The stoma appliance needs to be changed Q4-5d; otherwise afterwards appliances tend to smell or leak
*
Venting charcoal filter bags may be used to help patients with high gaseous outputs
>
Colostomy considerations
*
In some cases, the collateral communication via the marginal artery is not sufficient to sustain the sigmoid colon, so it is generally preferred to fashion a distal colostomy from the descending colon, which has a more reliable blood supply, than the sigmoid colon (especially if the IMA has been divided)
*
The motility characteristics of the colon are such that the more proximal the site of the colon selected to fashion a colostomy, the higher is the likelihood of prolapse through the stoma
*
With the passage of time and the natural maturation of the colostomy, the posterior wall of a transverse loop colostomy will retract and the stoma will no longer divert completely. The incidence of significant prolapse from a transverse loop colostomy is high and increases with time
>
Logistic considerations
*
Gaols of preOp stoma nurse consultation: education, counselling, & appropriate stoma site selection and marking.
*
2 PreOp visits (45 minutes each) results in improved QOL & ↓ length of hospital stay and stoma-related complications
>
PreOp education topics
*
GI anatomy & physiology
*
Planned surgical procedure
*
Demonstration of ostomy appliance
*
Description of lifestyle adjustment
*
Psychological preparation
>
PostOp education topics
*
Anatomy & function of the ostomy
*
Pouching procedural training
*
Nutrition
*
Clothing
*
Medications
*
Body image
*
Psychological issues
*
Social & recreational issues
*
Common complications (leaking, dermatitis)
*
Support groups & online resources
V
V
Choosing the site
Untitled
V
*
Default position
Stoma-marking_344x194.gif
*
Ideal position: a 2 inch ‘free’ spot
V
*
Examine the patient sitting, standing, and lying down
Screen Shot 2020-08-30 at 7.47.24 PM
>
Avoid:
*
Folds creases
*
Belt line
*
Scars
*
Bony prominences
*
Site of planned incision
*
Umbilicus
*
Identify edge of rectus muscle by having the patient contract the muscle
*
The stoma should be visible & accessible to the patient (not on the underside of a large panniculus)
*
In a normal-sized patient, the preferred site of stoma location is through the rectus muscle
V
*
The most common complication resulting from not putting a stoma through the rectus muscle is the development of parastomal hernia
“According to current wisdom, the stoma should be brought out of the abdomen through the rectus abdominis, so that the emerging stoma will be supported and the incidence of parastomal hernia reduced. The optimum site for a stoma should be selected without regard to its position in relation to the rectus abdominis but instead should be also dependent on body habitus and abdominal wall contour.”
*
Immediately after creation, the stoma will become edematous and swell to 2-3 times the original size. The stoma will shrink to normal size after approximately 4–6 weeks
*
If the stoma is not well “Brooked”, using a convex flange may be helpful in helping it pucker out in the immediate postoperative period
V
A stoma belt can be used for
*
Patients performing sports
*
Stomas that are not well “Brooked”
*
All stomas should be Brooked: preferably > 2cm for ileostomy and > 1cm for colostomy
V
*
Orientation of loop ileostomy: the preferred orientation is for the mucus fistula (or distal limb) to be at 12 o’clock
If the distal end is at 6 o’clock, the mucus produced will leak as the mucus fistula is flush with the skin usually
>
Ileostomy restrictions
*
Advised to continue on a low residue diet for 4-6w after stoma creation
*
Cooked food is all fine (even veggies)
*
Avoid: uncooked fiber if not cut small and not chewed greatly
*
Avoid popcorn
>
Peristomal (skin barrier) care
*
Zinc oxide
*
Aluminum paste ointment
*
Karaya powder
>
High output stomas
*
Approximately half of postoperative high output stomas will resolve spontaneously within 2 weeks
>
Dehydration and AKI is the most common indication for admission (17%) after diverting ileostomy creation
>
Predictors of dehydration/AKI
*
Age > 50Y associated with AKI
*
IPAA associated with dehydration
*
Use of diuretics
>
Factor not predictive of readmission for dehydration/AKI
*
Ostomy output at initial discharge
*
Length of stay on initial hospital admission
*
Discharge on antimotility agents
V
*
Ileostomy pathways are effective in reducing readmission rates for dehydration/AKI
Reference: Nagle et al. Dis Colon Rectum 2012; 55: 1266–1272
Documents to review with patient during first hospital stay
lleostomy Care Instructions
Taking Care of Your Ostomy booklet
I & O Measurement Chart
Documents and supplies to give to patient on discharge
lleostomy Care Instructions
Taking Care of Your Ostomy booklet
Ostomy supplies (4 pouch changes)
Prescriptions for ostomy supplies
I & O Measurement Chart
A hat and urinal
Items to complete before discharge
Give phone number to patient to make follow-up appointment with the ostomy RN (2-4 weeks postoperatively)
Make follow-up appointment with the surgeon
Resume and reconcile home medications
Pain controlled with oral pain medicine
Complete patient education regarding ostomy and/or wound care
Fax referral to VNA for ostomy and/or wound care
Give phone number to patient in the event they have
any questions or concerns
V
Management of high stoma output
*
Rule out partial bowel obstruction
V
Dietary adjustments
*
Avoid large bolus feeds: aim for 6 meals
*
Separate liquids from solids
>
Avoid following foods for high output
*
Soft drinks
*
Prune juice, prunes
*
Caffeine
*
Beer / alcohol
*
Spicy food and red pepper
*
Sweet foods: candy; cake; ice-cream; cookies; …etc
*
Avoid drinking fluids on an empty stomach
*
Increase intake of bananas; breads, crackers, peanut butter, apple sauce; pasta; oatmeal; oat bran; …etc
*
↓ motility: Loperamide, lomitil, codein/opioids,
*
↑ absorption: Bulking agent (H2O absorption), elemental diet
V
*
↓ secretion: PPI (stomach), octreotide (pancreatic), cholestyramine (bile)
Bile acids, metabolites of cholesterol, are normally efficiently reabsorbed in the jejunum and ileum. Excretion is increased up to tenfold when cholestyramine is given, resulting in the enhanced conversion of cholesterol to bile acids in the liver via 7a-hydroxylation, which is normally controlled by negative feedback by bile acids.
Cholestyramine can be used in patients with bile-acid diarrhea or choleretic enteropathy due to limited ileal disease or resection. Diarrhea develops in these patients because of the stimulation of active chloride secretion by bile acids in the colon. However, cholestyramine is not helpful in patients with extensive ileal disease and/or resection presenting with fatty acid diarrhea. In extensive ileal disease or resection, the body cannot produce sufficient quantities of bile acid to compensate for the increased loss due to extensive bowel loss, leading to impaired micelle formation and steatorrhea.
*
↑ viscosity: pectin, guar
*
Stoma ischemia typically begins with mucosal pallor and progresses to petechiae, cyanosis, and purple-black mucosal necrosis
>
Managing complaints of excessive gas
*
Avoid talking when eating
*
Avoid: using straws, smoking, and gum chewing
*
Simethicone (Gas-X) and α-galactosidase (Beano) can help reduce gas output
>
Peristomal wound complications
*
Allergic contact dermatitis
*
Folliculitis: usually caused by hair shaving — instruct patients to clip hairs instead
>
Fungal infection / candidiasis
*
Usually caused by excessive moisture
*
Has characteristic satellite lesions at periphery
*
Treat with anti-fungals as is with over-the-counter foot cream — use (Nystatin) powder rather than cream to avoid problems with adherence of stoma appliance
>
Pseudoverrous hyperplasia
*
usually at the mucocutaneous junction
*
Advise patient to decrease moisture
*
Silver nitrate may be used (or OR for chronic cases)
>
Pyoderma gangrenosum
*
Characterized by ↑↑↑ pain
*
Avoid pressure: avoid belts and convex pouches
*
The mainstay of treatment for peristomal PG associated with Crohn disease should be medical immunosuppression with systemic steroids and/or infliximab
>
Treatment
>
Wound care
*
Absorbant dressing
*
Ulcer debridement
*
Intra-lesional steroids
*
Topical tacrolimus
>
Systemic
>
Immunosuprresion:
*
Steroids
*
Cyclosporine
*
Mycophenolate
*
Methotrexate
*
Azathioprine
*
Dapsone
*
Tacrolimus
*
Infliximab
>
Varices
*
Avoid aggressive skin barriers to protect the skin above
*
Occasionally use silver nitrate
>
Initial treatment of hemorrhage:
*
Digital pressure
*
Application of epinephrine soaked gauze
*
Suture ligation (temporizing measure)
>
Definitive management:
*
Stoma reversal
*
Injection sclerotherapy
*
Octreotide
*
Percutaneous embolization
*
TIPS
*
Liver transplantation
*
Surgical mucocutaneous disconnection may be employed when local therapy fails and portal decompression is not possible. This local surgery involves a cylindrical incision around the mucocutaneous junction to the level of the anterior fascia with identification and ligation of varices and rematuration of the stoma. Preoperative peristomal infiltration of dilute epinephrine may assist with hemostasis during this potentially bloody procedure
>
Granulomas
*
Always occurs at mucocutaneous junction
*
Manage with: reduced friction ± barrier creams
>
Irritation dermatitis & moisture associated dermatitis
*
Most peristomal skin irritation arises from poorly fitted or improperly sized appliances
*
Irritated peristomal skin weeps exudative fluids that hinder stoma appliance adhesion
*
Rule out a high-out stoma as the cause
*
Manage with pouching systems
*
Mucocutaneous separation: can be managed by filling the separation site with ‘stoma powder’
*
Parastomal hernia
>
Prolapse
*
Supra-fascial revision tends to be successful
*
Intra-abdominal approach is favoured when prolapse is accompanied with parastomal hernia
>
Anastomotic complications of colorectal surgery
>
Bleeding
>
Minor (not requiring transfusion)
*
It is hypothesized that anastomotic bleeding occurs secondary to inadequate clearance of the mesentery prior to division and/or stapling of the bowel
*
Usually ceases spontaneously within 24h
*
50% progress to major bleeding
>
Major (requiring transfusion) occurs at a rate of 0.5-4.2%
V
Management:
*
Persistent bleeding from a low anastomosis → transanal evacuation of clot ± suture ligation
*
Persistent bleeding from a high anastomosis: endoscopic or angioembolization
*
HD instability → OR
>
Dehiscence & leak
>
2010 definition by the International Study Group of Rectal Cancer
*
It is defined as a defect in the intestinal wall integrity of a colorectal or coloanal anastomotic site (including suture and staple lines of neorectal reservoirs) leading to a communication between the intra- and extra-luminal compartments. A pelvic abscess close to the anastomosis is also considered as anastomotic leak
>
Grading of leaks
*
Grade A: asymptomatic leak
*
Grade B: requiring requiring intervention but not reoperation
*
Grade C: requiring reoperation
*
Anastomotic leak is associated with an increased risk for local recurrence for colorectal cancer
*
12% of leaks occur after POD30
>
Risk factors
>
For extraperitoneal leaks
*
Anastomosis ≤ 5cm from AV
*
Anastomotic ischemia
*
♂
*
Obesity (conflicting data)
>
For intraperitoneal leaks
*
ASA III-V
*
Emergency surgery
*
Operative time ≥ 4h
V
*
Hand-sewn ileocolic anastomosis
Hand-sewn ileocolic anastomosis – In a meta-analysis of six trials with 955 participants with benign and malignant disease, hand-sewn anastomoses were associated with a significantly higher rate of overall anastomotic leaks compared with stapled ileocolic anastomoses (6.0 versus 1.4 percent) [2]. For the subgroup of 825 patients with cancer, hand-sewn anastomoses were also associated with significant risk of an anastomotic leak (6.7 versus 1.3 percent).
>
Other & controversial factors:
V
*
Neoadjuvant radiation therapy
When an anastomosis is necessary, at least one limb of the anastomosis should utilize a non-radiated segment
*
Protective stoma: The controversy regarding a protective stoma involves whether or not the stoma prevents a leak and reduces the corresponding clinical consequences. Proximal fecal diversion by a protective stoma significantly reduces the overall risk of a reoperation following an anastomotic leak.
*
Mechanical bowel preparation
*
Nutrition: nutritional factors, including hypoalbuminemia, alcohol intake, and weight loss, have shown variable and conflicting results — as per UpToDate
*
ASCRS: One of the largest studies looking at anastomotic leak in colorectal patients included 250 left sided resections with anastomosis. The overall anastomotic leak rate was 7.5%. When patients were administered corticosteroids, either perioperatively or long term, the multivariate model concluded that corticosteroid use increased the risk for AL by more than seven times (OR, 7.52; standard error, 4.47; P = 0.001; 95% CI, 2.35–24.08). A meta-analysis evaluating the risk of corticosteroids on colorectal anastomotic integrity included 9564 patients from 12 studies demonstrated an overall leak rate of 6.77% (95% CI 5.48–9.06) compared to 3.26% (95% CI 2.94–3.58) in the non-corticosteroid group
*
Immunomodulators, including azathioprine and 6-mercaptopurine: A retrospective study of 417 operations involving bowel anastomoses for Crohn’s disease demonstrated no difference in the rate of anastomotic complications for patients on immunomodulators (10% vs. 14%; p = 0.263). Accordingly these medications are often continued until surgery.
*
Infliximab: Krane et al. performed a retrospective analysis of 518 patients with IBD undergoing elective laparoscopic bowel resection, of which 142 patients were on preoperative infliximab. There was no difference in the rate of anastomotic leak, which was overall low in both groups (2.1% with infliximab versus 1.3% without; p = 0.81). Overall the existing literature is limited and controversial but biologic agents are thought to impact wound healing and most surgeons prefer to hold these agents for 4–6 weeks if possible prior to major abdominal surgery
*
Bevacizumab is associated with increased incidence of postoperative complications, including impaired wound healing and anastomotic leak.
V
*
NSAIDs
Some data suggest that postoperative use of NSAIDs may increase the risk of anastomotic leak. Potential mechanisms include a reduction in prostaglandin-mediated collagen deposition, diminished collagen cross-linking, and increased anastomotic microthrombosis.
Intravenous ketorolac is a potent NSAID that is commonly used in enhanced recovery pathways for abdominal surgery. In one study of 398,752 patients, 5 percent of patients received ketorolac after colorectal (55 percent) or other gastrointestinal surgery (45 percent). Ketorolac use was associated with more readmissions for anastomotic complications (OR 1.20, 95% CI 1.06-1.36).
V
>
Air leak test
As per SAGES presentation by Dr. Elisabeth McLemore
>
Components
>
Assess for air leak
V
⊕ Air leak → 7.7% leak rate
*
If repaired → 12% leak rate
V
*
If diverted or anastomosis redone → 0% will leak rate. Therefore, suture repair with diversion is an acceptable option for a ⊕ leak test and is associated with 0% clinical leak afterwards (this is in context of a low anastomosis — for a high anastomosis, it’s best to just redo the anastomosis)
Also advised by Dr. Rocco Ricciardi in SAGES presentation 2019
*
⊖ Air leak → 3.8% leak rate
*
Not performing a leak test is associated with a high leak rate. Usually as high as a ⊕ leak test
>
Assess for hematomas and/or luminal ischemia
>
UC Irvine Anastomotic Endoscopic grading and management:
*
Grade 1: normal mucosa circumferentially
>
Grade 2: mucosal congestion/ischemia or hematoma involving < 30% circumference of one side of the staple line
*
UCI Grade 2 anastomosis has up to 25-50% leak rate
>
Grade 3: mucosal congestion/ischemia on both sides of staple line or > 30% on one side
*
All require redo-anastomosis
V
>
When to consider redoing the anastomosis (intraOp decision making)
When the anastomosis is not very low, the appropriate decision is likely to redo the anastomosis rather than to salvage it and protect it proximally
*
Incomplete donuts
*
Stapler malfunction
*
Air leak⊕
*
Inadequate perfusion
V
>
PREDICT Study
Stephensen, B. D., Reid, F., Shaikh, S., Carroll, R., Smith, S. R., Pockney, P., & PREDICT Study Group collaborators. (2020). C‐reactive protein trajectory to predict colorectal anastomotic leak: PREDICT Study. British Journal of Surgery.
*
A change in CRP level exceeding 50 mg/l between any two postoperative days had a sensitivity of 0.85 for detecting a leak, and a high negative predictive value of 0.99 for ruling it out. A change in CRP concentration of more than 50 mg/l between either days 3 and 4 or days 4 and 5 after surgery had a high specificity of 0.96–0.97, with positive likelihood ratios of 4⋅99–6.44 for a leak requiring intervention.
*
Screen Shot 2020-09-12 at 11.53.42 AM-squashed
*
Screen Shot 2020-09-12 at 11.54.18 AM-squashed
>
2014 meta analysis showed that CRP > 148 on POD3 had sensitivity & specificity of 95%. The cut off for the following days was 10 less for each additional day:
*
POD4: 123
*
POD5: 115
*
POD6: 105
*
POD7: 96
V
*
Summary of management
Screen Shot 2021-11-24 at 23.34.23
>
Management
>
Intraperitoneal leak
*
Subclinical leak → managed expectantly
V
Symptomatic leak
*
Stable patients + small contained abscess (< 3cm) → bowel rest + IV Abx
*
Large (> 3cm) or multiple collections → percutaneous drainage
V
Free intraperitoneal leak or HD instability→ operative management (everyone gets a stoma)
*
Minor anastomotic defect + adequate tissue quality → may consider primary repair + drain placement + proximal diversion
>
Major anastomotic defect (> 1cm or ≥ ⅓ circumference of anastomosis):
*
Resection of anastomosis + re-anastomosis + proximal diversion
*
Resection of anastomosis + end-ostomy ± mucus fistula
*
Rarely: exteriorization of both ends of the stoma
*
Intraoperative inoperable phlegmon → place para-anastomotic drains + proximal diversion
>
Extraperitoneal leak
*
Diversion if not done already
*
Additional option for extraperitoneal leak: for very low pelvic abscesses that are in continuity with the anastomotic leak and that are inaccessible by image-guided techniques → examination under anesthesia + transrectal or trans-anastomotic drainage. This approach is facilitated by making a wide opening in the anastomosis and/or inserting a mushroom-tipped catheter into the abscess cavity.
V
>
Leak management according to site (Dr. Bemelman, SAGES presentation)
Use a laparoscopic approach if the index procedure was laparoscopic.
Use the previous laparoscopic ports
*
Leak post right hemicolectomy: takedown anastomosis + end ileostomy + suture colon to sub-fascia for easy reversal later
>
Leak post left-sided colectomy
V
*
< ⅓ circumference: ileostomy + on-table lavage + repair + drain
Screen Shot 2020-12-02 at 16.43.40
*
> ⅓ circumference: Hartmann’s procedure
>
Leak post low rectal or coloanal anastomosis (silent, extraperitoneal leak)
*
Diversion if not done already
*
Drainage is the cornerstone of management
*
Consider endoluminal vacuum therapy
>
Strictures
V
*
Fasth et al. defined a colorectal anastomotic (CRA) stricture as the inability to pass a 12-mm sigmoidoscope through a rectal anastomosis
Olympus Standard scope width: 12.8mm
Olympus Pediatric scope width: 11.3mm
Olympus Ultra-thin scope: 9.5mm
*
Need to rule out recurrence in malignant index cases
>
Stenosis/stricture occurs in 0-30%
*
If a stricture is defined as inability to pass a 12mm scope or rigid proctoscope, the incidence is < 10%
*
The lower the anastomosis the higher the stricture rate, with IPAA and coloanal anastomoses having the highest stricture rates
>
Etiology
*
Anastomotic leak/inflammation
*
Ischemia
*
Anastomosis under tension
*
Recurrence of malignancy
V
Stapled colorectal anastomosis (but not ileocolic) anastomosis is associated with an increased risk of stricture formation compared to hand-sewn
*
This may be due to the high rate of diverting ileostomy creation that deprive the anastomosis of the ‘required’ dilatation effect from the passage of stool
*
2012 Cochrane meta-analysis: stapled and hand-sewn anastomosis were equivalent in all categories except stricture formation
*
Radiation
>
Presentation
*
Typically present within 2-12m postOp
*
A stricture that is not responsive to repeated dilation requires repeat biopsy and a high level of clinical suspicion
*
Patients with a diverting stoma created at the initial resection may develop a soft stricture or even heal the lumen closed.
*
Bx may not reveal a recurrence, but recurrent stenosis after endoscopic dilation should trigger repeat Bx that may show recurrence
V
Management
>
Malignant stricture
*
In the absence of metastatic disease → resection of stricture
*
In the presence of metastasis → consider palliative fecal diversion
>
Soft strictures after colorectal or coloanal anastomosis with fecal diversion
*
DRE at 4-6w postOp tends to relieve these strictures
*
If a tight, firm stricture is present, intraOp dilation with Hegar dilators may be performed in conjunction with ileostomy reversal
>
Early stricture: dilation
*
DRE
*
Flexible bougies
*
Metal dilators
*
Long cotton-tipped sigmoidoscopy swab passed through the rigid proctoscope. Up to 3 swabs are passed through the stricture. The swabs are then pulled through the stricture as a group. This usually allows 23mm diameter scope to pass through the stricture and fully fracture the scar
>
Endoscopic balloon dilation
V
*
Indication: Narrow lumen (< 10 mm) & short segment (< 4 cm)
Stenoses that are long or appear late and are caused by ischemia will develop surrounding nonexpandable fibrotic tissue and a rigid colon and are unlikely to respond to balloon dilation
*
Immediate efficacy: up to 80%
*
Often require sequential dilation with larger balloons over 2-3 sessions
>
Recurrence: 30-88%
*
At 1Y: 11%
*
At 3Y: 22%
*
At 5Y: 25%
*
Even in the 25% who eventually recurred most were successfully managed with repeat dilation and only a small number require surgical intervention
>
Alternative treatments for contraindicated/failed dilation
>
Endoscopic electrocautery incision
*
Several radial incisions are placed through the fibrotic mucosa along the most resistant portion of the stricture in order to relieve the tension on the stricture
*
Laser stricturoplasty
*
Urethroscope resection
*
ERCP papillotomy knife
*
Using a circular stapler to resect and re-staple
>
Stent (SEMS)
*
Have high migration rate
>
Reoperative surgery
>
Redo-anastomosis
*
30% of symptomatic strictures require surgical correction
*
Anastomotic strictures have been reported to be the most frequent indication for reoperative colorectal surgery and represent 40–50% of reoperations. This exceeds the rate of reoperation for anastomotic leak, fistula, chronic pelvic sepsis, and cancer recurrence
*
Most series report an average time between the initial surgery and reoperation of 14–41 months
*
The key to a successful anastomosis is to get below the area of fibrosis to soft, pliable colon or rectum
*
Given the high-risk nature of these anastomoses, proximal diversion is generally the rule
*
Successful revisions have been noted in 57–100%
*
If the stricture is less than 11 cm from the verge a handsewn coloanal anastomosis is almost universally constructed
*
Overall operative morbidity: 26-55 %
*
Permanent fecal diversion
*
Benign strictures are treated effectively with repeated dilatation using an examining finger or rubber dilators
>
Fistulas
V
Occur in 1-10%
*
5% of patients actually develop a symptomatic anastomotic vaginal fistula
>
Risk factors:
*
PreOp radiation
*
Anastomosis ≤ 5 cm from AV
*
Cancer resection
*
Inadvertent inclusion of the vaginal wall in a stapled anastomosis
*
Pelvic abscess
*
Recurrent cancer
*
Anastomotic vaginal fistula present later than a conventional leak
*
Rectovaginal & colovaginal fistulas: spontaneous closure is unlikely. The optimal time for surgical excision & repair is controversial.
>
Colocutaneous fistula
*
Initial management is with conservative & supportive care
*
50% of low-output fistulas will close spontaneously
*
High-output fistulas and fistulas that persist > 6w are unlikely to close spontaneously
*
Definitive intervention should be delayed for ~3-6m to allow for resolution of sepsis &/or to restore nutritional status
*
Ileorectal syndrome: anal tone simulates SBO and its physiology → prolonged ileus
>
Low Anterior Resection Syndrome (LARS)
*
It is a constellation of symptoms that occur after sphincter-sparing proctectomy (fecal urgency; frequent BMs; emptying difficulties; ↑ intestinal gas)
*
25-80% of patients develop ≥ 1 symptoms of LARS following a sphincter-sparing rectal surgery. ~50% > 10 years after surgery
>
Risk factors for LARS
*
Radiation (neoadjuvant or adjuvant)
*
Adjuvant chemotherapy
*
Low anastomosis
*
TME
*
Anastomotic complications
>
Dx & work up
*
Dx is made when symptoms persist > 1m after surgery & evaluation fails to elucidate an alternative etiology
*
Exclude sepsis/peritonitis with CT scan
*
Rule out IBD, toxic colitis, or chemo-induced colitis with colonoscopy
*
Rule out pelvic floor disorders with defecography
*
Sphincter injury is ruled out with endoscopic US
*
Consider Small Intestinal Bacterial Overgrowth in patients with excessive gas/flatulence/bloating
V
>
Evaluation of severity is done with the LARS Score
Screen Shot 2020-04-27 at 2.51.53 PM
V
>
It is formed of 5 question items
Pasted_Graphic_25
*
Incontinence for flatus
*
Incontinence for liquid stool
*
Fecal frequency
*
Clustering of BM (<1h apart)
*
Urgency
*
Score < 30 → mild LARS with preserved QoL
*
Score ≥ 30 → major LARS usually requiring invasive treatment
*
Normative study showed that up to 10% of ♂ and 15% ♀ from the general population may have major-LARS
V
*
Chen et al. found considerable discrepancy between the specialists’ perspective of what mattered to the patient and the patient’s actual views
Chen TY, Emmertsen KJ, Lauberg S. Bowel dysfunction after rectal resection cancer treatment: a study comparing the specialist’s versus patient’s perspective. BMJ Open. 2014; 4:e003374.
>
Pathophysiology:
*
Colonic dysmotility (increased proximal colonic motility)
*
Neorectal reservoir dysfunction (denervation by surgery or radiation)
*
Anal sphincter dysfunction (as complicated by surgery or radiation)
>
Management
>
Preventative measures
*
Kegel exercises for all patients
*
Patients with diverting stomas should receive QD enemas or anterograde colonic irrigation via the stoma
>
Mild LARS
*
Diarrhea is managed with loperamide ± cholestyramine
*
Postprandial urgency/incontinence is managed with 5HT antagonists (ramosetron 5mcg QD)
*
Gas/bloating is managed with rifaximin or neomycin
*
Fecal soilage is managed with bulking agents
>
Severe LARS
V
*
Fecal incontinence/frequency → transanal irrigation QD
Low-volume TAI simply achieves the effect of a mechanical washout. High-volume (>250 mL) irrigation generates functional colonic responses, such as colonic mass movements, which improves colonic transit time and fecal continence when administered regularly.
*
Persistence of major LARS after 1Y → sacral nerve stimulation
*
Intermittent stimulation of the posterior tibial nerve has a beneficial effect on fecal incontinence through a mechanism that is not fully understood
*
Surgery is a last resort and has poor outcomes. Options include anal sphincter substitution by electrostimulated graciloplasty, and fecal diversion
>
Presacral bleeding
*
IntraOp bleeding occurs in 4-7% of proctectomies
V
V
Source of bleeding is either: presacral venous plexus or the basivertebral veins.
Screen Shot 2021-10-20 at 12.56.53
V
Presacral venous plexus
*
Formed by: middle sacral, lateral sacral, and communicating veins
*
If the bleeding point can be controlled by compressing the surrounding veins, there has been an injury to the presacral veins
V
*
Managed by suture ligation
Injury to the presacral venous plexus can often be successfully managed with suture ligation ensuring that it is performed over intact presacral fascia and the bites are deep enough to contain presacral veins but also surrounding deep connective tissue so that the stitches hold traction
>
Basivertebral veins
*
Penetrate sacral foramina from S3 to S5, and penetrate through the spongiosa of the sacral bone via a venous sinus
*
If the bleeding is abated only by direct compression, it is from an injury to a fine or large-calibre basivertebral vein
*
Managed by thumbtacks, hemostatic agents, APC, or sealing with ‘welding’ tissue (epiploica or momentum)
*
The two are linked and provide a connection between the inferior vena cava and the vertebral venous system
>
Initial management:
*
Obtain exposure; consider removal of the specimen
*
Apply direct pressure for 15-20 minutes (not any less)
*
Ask for headlamp, if not already available
*
Allow anesthesia to ‘catch up’ ± massive transfusion protocol
*
Consider tranexamic acid administration
*
Most senior nurse to take over as scrub nurse; have multiple available unscrubbed nurses
*
Ask for help from a colleague
>
Definitive management options for ongoing bleeding
*
Spray diathermy
*
Apply hemostatic agents: FloSeal ± Surgicel Fibrillar
>
Definitive management of severe bleeding
*
Application of sterile thumbtacks or occluder pins at right angles into the sacrum, directly over the site of bleeding
*
Hemostatic matrix
*
Bone wax or bone cement
*
Teflon pledgets
*
Rectus abdominis muscle flap rotation into the pelvis (with intact inferior epigastric pedicle). The flap is secured to the sacrum with heavy sutures that compress the flap against the sacral wall
*
If all fails: temporary balloon tamponade (using a saline bag or breast implant) or tight pelvic packing with laparotomy pads & ICU transfer, with return to OR for hemostasis in 24-48h
>
Perineal complications following APR
*
Risk of complications: 14-80%
>
Risk factors for complications
*
Patient characteristics
*
Indication for surgery: complications more common for IBD indications than rectal cancer
*
PreOp radiation treatment
>
Prevention
*
Intersphincteric dissection for benign disease
V
*
Primary closure of the perineum in multiple layers is the optimal approach for the uncontaminated perineal wound
In the setting of inadequate hemostasis or gross contamination, primary closure with drainage is associated with expedited healing but increased morbidity
*
Closed suction drainage
V
*
Pelvic floor reconstruction by tissue transposition
The reconstructive procedures are complex and provide minimal benefit. Therefore, the authors do not advocate pelvic floor reconstruction for uncomplicated perineal resections.
V
*
Utility of perineal flaps
A systematic review of prospective studies and retrospective reviews indicates that overall wound healing and complication rates may be improved with the use of flap closure in patients who have received radiotherapy; however, the evidence is limited
*
Negative pressure wound therapy
>
Complications and management
*
For patients with draining wounds in the absence of overt pelvic sepsis (eg, fever, pain), the management includes local wound opening and drainage, debridement of ischemic tissues, removal of foreign bodies, and packing with wet-to-dry dressings or the application of a vacuum-assisted closure (VAC) device.
*
Abscess: IR drainage + broad spectrum Abx
V
Persistent perineal sinus
*
A persistent perineal sinus is a perineal wound that remains unhealed for longer than 6 months after surgery
*
Incidence: 14-40%
>
Work up
*
Bacterial swabs to identify a possible secondary infection
*
Bx of the tract to rule out recurrence
*
CT + MRI
>
Management
>
Initial (rarely results in complete healing)
*
Topical analgesics
*
Antiseptics
*
Local wound care
>
Early intervention is recommended
*
Curettage & primary closure
*
Sinus excision with partial coccygectomy & either pirmary closure or reconstruction with a flap or skin graft
*
Cleft closure
*
Reconstruction with split-thickness skin grafting, omentoplasty, gracilis muscle transposition, rectus abdominis myocutaneous flap, or gluteus maximus VY-advancement flap
*
Vacuum-assisted closure
V
*
Dehiscence
For patients who develop a perineal wound dehiscence, there is an increased risk of mortality
>
Perineal hernia
*
Asymptomatic perineal hernia: surgical repair is not indicated
*
In the acute setting with evisceration of the abdominal contents, immediate operative reduction and packing is performed
V
*
In the elective setting for symptomatic patients, several options for repair are available, including primary repair via the perineal approach, abdominal approach, or a combined approach, insertion of prosthetic or biologic mesh material, omentoplasty, closure with myocutaneous flaps (eg, gracilis flap, rectus abdominis flap), and/or retroflexion of the uterus
The abdominal approach is preferred because of superior visualization of the hernia sac and contents and therefore a lower risk of injury to major blood vessels and the bowel
>
Empty Pelvis syndrome
*
Potentially occur after pelvic exenteration
>
Manifestations may include:
*
Accumulation of fluid
*
Migration of small bowel loops into the pelvis
*
Pelvic abscesses
*
Perineal fluid discharge
*
Perineal wound dehiscence
*
Entero-perineal and entero-cutaneous fistulas
>
Prevention options (done at the time of pelvic exenteration)
*
Johnson et al (Colorectal Disease 2021) Mesh reconstruction and placement of breast prosthesis into the pelvis were associated with some of the lowest rates of SBO, fistula, and abscess formation without any reported additional morbidity
V
Myocutaneous flaps
*
Mainly address the skin defect while providing some muscle bulk in the perineum
*
It is associated with high rates of flap complications
V
Options
*
VRAM
*
Modified RAM
*
Gracilis flap
V
Synthetic & biologic meshes
*
Absorbable meshes are often used
V
Omental flaps
*
BioPEX RCT: use of biological mesh in ELAPE was not found to reduce the rates of surgical & nonsurgical complications compared to primary closure
V
Pelvic fillers
*
Breast prosthesis
*
Silicone expanders
>
Colorectal Cancer
>
General
>
CRC is the most common malignancy of the GIT
*
The 3rd most lethal cancer in the US
*
Canadian Cancer Society: Colorectal cancer is expected to be the third most commonly diagnosed cancer in Canada in 2020 (excluding non-melanoma skin cancers). It is the second leading cause of death from cancer in men and the third leading cause of death from cancer in women in Canada.
*
Lifetime risk in the US = 5-6%
*
In the United States, CRC incidence rates have been declining by approximately 2% per year
*
Over the past 40Y: incidence of cancer ↑ more in Rt colon than in Lt & rectum (flexible sigmoidoscopy is missing more cancers)
*
~30% of all cancers are diagnosed by endoscopy in the absence of symptoms
V
>
⅓ of CRC occur in the rectum
Pasted_Graphic_5
*
Anatomical rectum: extends from the point at which the three taenia coli fuse into a single longitudinal smooth muscle layer (rectosigmoid junction) to the anal canal
*
Oncologic rectum: it is the distal 12 cm (withstanding individual variation) in the extraperitoneal pelvis that constitutes the rectum
*
Metachronous cancer = detected after 6 months in a different colon part (as to not include recurrence)
>
Synchronous cancer
*
Defined as >1 primary cancer detected: preoperatively, intraoperatively, or within 6 months of resection
*
Lesions must be ≥ 4 cm apart
*
Synchronous cancer is found in ~5% of patients: managed with two segmental resections or TAC/subtotal colectomy
*
The presence of a synchronous ‘polyp’ with CRC is 15-50%
*
Average risk = no F.Hx of CRC + no personal Hx of IBD + asymptomatic
>
Risk factors
*
Aging is the dominant risk factor (incidence ↑ after 50Y)
V
>
Family Hx: 1 FDR with CRC < 60Y → 2-3 fold increase in lifetime risk of CRC
Screen Shot 2020-04-14 at 3.53.03 PM
>
Average risk population:
*
No family or personal history of CRC
*
No worrisome symptoms
>
High risk population:
*
Inherited polyposis syndromes
*
Personal Hx of CRC or advanced adenoma
*
CRC or advanced adenoma in FDR
>
Diet
*
↑Risk: ↑ Animal fat (saturated or polyunsaturated); EtOH
*
Does not alter risk: ↑ Oleic acid (olive oil, fish oil)
*
↓Risk: Vitamins A, C, E, & carotenoids
*
Obesity & sedentary lifestyle
*
IBD with pancolitis: 2% at 10Y, 8% at 20Y, 30-50% at 30Y
*
Cigarette smoking
*
Ureterosigmoidostomy
*
Pelvic irradiation
>
Cost effectiveness of life-saving interventions (cost per year of life saved)
*
Motorcycle helmet: $ 2,000
*
CRC screening: $ 20,000
*
Breast cancer screening: $ 35,000
*
Dual airbags: $ 120,000
*
Smoke detectors: $ 210,000
*
Seat belts in school buses: $ 2,800,000
V
Genetics of colon cancer
>
Quick revision of causes of abnormal gene expression
>
Mutation
*
Somatic (environment)
*
Germline (inherited)
*
DNA repair failure
>
Decreased expression
*
Methylation
*
Histones
*
miRNA
>
Loss of heterozygosity
*
Deletion
*
Recombination
*
Translocation
>
Genetic pathways
V
>
Chromosomal instability & Loss of Heterozygosity (LOH)
These processes affect the whole chromosome, and so it results in the so called chromosomal instability as opposed to the focal instability in MSH-H tumors
*
Chromosomal instability refers to an alteration in the chromosomal copy number or structure.
*
As one allele is lost, only 1 functional copy of the gene exists → loss of redundancy. Loss of the 2nd allele → complete loss of that gene function
*
Responsible for 80% of colorectal cancers
>
Developing tumors tend to be
*
Located in the left colon
*
♂ Predominant
*
Develop later in life
*
Microsatellite stable
V
>
Fearon-Vogelstein adenoma-carcinoma multistep model
ol-16-01-0009-g00
*
An adenoma, by definition, has elements of atypia (i.e: it has at least low grade dysplasia)
*
Colorectal cancer develops from adenomatous polyps by accumulation of genetic defects
*
The earliest mutations in the adenoma-Ca sequence occur in the APC gene
*
p53 mutation occurs late in the adenoma-carcinoma sequence
V
Genetic defects:
V
Activation of proto-oncogenes
>
KRAS mutation on chromosome 12
*
Results in inability to inactivate G-protein → uncontrolled cell division
*
50% of sporadic colorectal cancer have RAS mutation
*
Cetuximab & panitumumab are not effective in tumors that have KRAS mutations
V
Inactivation of tumor-suppressor genes (APC, DCC, p53)
*
Mutations in both alleles are necessary to initiate polyp formation
V
The genes:
V
APC gene on 5q21
*
It was first described in FAP
*
The site of mutation correlates with the severity of the disease
*
Is known to be present in 80% of sporadic cases
*
LOH is the main mechanism by which APC becomes inactivated
*
Inactivation of APC alone does not result in carcinoma, but it allows the accumulation of genetic damage that results in malignancy
*
Participates in cell cycle control by regulating β-catenin
*
DCC (Deleted in Colorectal Cancer)
>
p53 “guardian of the genome” / inducer of apoptosis
*
It’s the most frequently mutated tumor-suppressor gene in human neoplasia
*
Located on chromosome 17p13
*
Under normal conditions, p53 acts by inducing apoptosis in response to cellular damage or by causing G1 cell cycle arrest, allowing DNA repair mechanisms to occur
*
Mutations are present in 75% of colorectal cancer
*
Mutation → loses ability to induce apoptosis
>
MicroSatellite Instability (MSI) / Replication ERror (RER) pathway
*
Specific sites along the DNA strand are prone to errors during routine DNA replication. These sites are areas of repetitive DNA sequences are called microsatellites
>
MSI = mutations in a mismatch repair gene producing variable lengths of repetitive sequences (C:G)
*
MSI is detected by PCR
*
Loss of MMR gene → errors in MMR during DNA replication (MSI)→ accumulation of mutations → adenoma/cancer
*
Responsible for 20% of colorectal cancers
V
>
Determining MSS vs MSI-L vs MSI-H
A tumor is considered MSI-H if ≥ 30% of the markers tested show instability and microsatellite stable (MSS) if none of the markers are unstable.
*
5 Microsatellites (i.e 5 locations on the gene) are usually assessed during testing
V
*
If only 1 unstable marker is detected, it is termed MSI-L
MSI-L is infrequently encountered and its clinical significance is regarded similar to MSS tumors
*
If ≥ 2 unstable markers are detected, it is termed MSI-H
>
Mismatch Repair Gene (MMR) mutations
*
IHC detects loss of MMR protein expression
*
MMR mutations accelerate tumor progression by creating MSI
>
Involved mutations:
*
hMLH1, hMLH2, hMLH3
*
hPMS1, hPMS2
*
hMSH6
*
MLH1 & MSH2 are involved in 85% of cases
>
Tumors with MSI are:
*
More likely right sided
*
Associated with better prognosis
>
15% of MSI are sporadic & not part of an inherited disease
*
Sporadic BRAF mutations → hypermethylation → loss of MLH1
>
CpG Island Methylator Phenotype (CIMP) (AKA serrated pathway)
*
Epigenetic mechanisms affect gene expression & protein translation without changing the inherent DNA sequence
*
Hypermethylation in the promoter region silences transcription of a gene, and thus no functional protein is made
*
CIMP pathway results in serrated polyps (rather than adenomatous polyps as seen in the chromosomal instability pathway)
V
*
The most common initial mutation occurs in the BRAF oncogene → mucosal changes → hyperplastic/serrated polyp → increasing methylation gives rise to CIMP → methylation of MLH1 → silences transcription → MMR deficiency → MSI-H CRC
This is termed the serrated pathway
Screen Shot 2021-03-25 at 15.51.01
>
Tumors resulting from CIMP pathway tend to
*
Develop in the right colon
*
Occur at advanced age
*
Occur in ♀>♂
*
Sporadic (~80%) vs known family Hx of CRC (~20%); ~5% are associated with identifiable inherited CRC syndromes
>
Polyposis syndromes should typically be considered in patients with > 20 lifetime adenomas
*
There are few data to define the cumulative number of polyps that should prompt testing.
>
A cross-sectional study of 8903 individuals who had samples submitted for APC and MYH mutations to Myriad Genetics Laboratories was published in 2012.
>
Mutations were found in
*
82% of individuals with >1000 polyps
*
63% of individuals with 100 to 999 polyps
*
17% of individuals with 20 to 99 polyps
*
9% of individuals with 10 to 19 polyps
*
“These data show that reliance on genetic testing alone to define these syndromes is not adequate; clinical criteria for the diagnosis of polyposis are required for those in whom no known mutation is detected”
V
V
Familial and polyposis syndromes associated with colorectal cancer:
Autosomal dominance results in 50% expression in offsprings
IMG_0228
>
Polyposis syndromes
V
Adenomas
>
Polymerase Proofreading Associated Polyposis (PPAP)
*
Associated with mutations in POLE or POLD1
*
Dominant penetrance
*
Microsatellite stable tumors
>
Clinical phenotype
*
Oligo-adenomatous polyposis
*
Early-age CRC
*
Endometrial cancer
V
Surveillance
*
Colonoscopy starting 20-25Y; repeat Q1-2Y
*
EGD Q3Y
*
For POLD1 mutation: transvaginal US starting age 40Y
>
FAP-related
>
Familial Adenomatous Polyposis
>
Autosomal dominant truncation mutation in the APC tumor-suppressor gene on chromosome 5q21
V
*
The most significant mutations occur at codons 1061 & 1309
The site of APC mutation correlates with the severity of the disease
*
25-30% have no family history of FAP & develop it de novo
*
FAP is defined as: > 100 synchronous adenomas or < 100 with ⊕ F. Hx
>
Behavior
*
The rectum is almost always affected in classic FAP
*
There is no clear evidence that progression from polyp to cancer is accelerated
>
Polyps are found predominantly in the rectum & Lt colon
*
Present in 15% of patients by 10Y of age
*
Present in 75% of patients by 20Y of age
*
CRC before the 20Y is extremely rare and is usually accompanied by symptoms
*
Untreated risk of malignancy is 0.2% before the age of 15Y
*
Untreated risk of malignancy is 1.3% before the age of 20Y
*
Untreated risk of malignancy is ~100% by 35-40Y of age
*
The most common presenting symptoms are: bleeding, diarrhea, abdominal pain, & mucus discharge
>
Extracolonic disease
>
Intestinal
*
~90% develop hyperplastic gastric fundus polyps with very low malignant potential (they do not require removal as per Sabiston)
>
Duodenal adenomas are found in > 95% of FAP patients — they develop ~15Y later than colonic polyps
*
Duodenal cancer occurs in 5-10% of patients & is the 2nd leading cause of death
*
High-risk adenomas, severe duodenal polyposis, or high-grade dysplasia → pancreas-preserving duodenectomy
*
Cancer requires Whipple’s procedure
*
Chemoprevention with NSAID (sulindac, celecoxib) can result in polyp regression in those with lesser polyp burden — the effect is minimal at best
>
Extraintestinal
*
Osteomas in the mandible, skull, & tibia occur in > 80%
*
CHRPE: congenital hypertrophy of the retinal pigment epithelium can be detected by ophthalmoscopy in 75% of patients
*
Epidermoid cyst
*
Dermoids
*
Cancers: liver, biliary tree, pancreas, adrenal glands, & thyroid (PTC)
*
Desmoid tumors
*
Although most probands with >100 adenomas will have a detectable mutation or deletion in APC, there is a small proportion of cases where no mutation can be found
>
Attenuated FAP (aFAP)— differs from FAP in regards to:
*
Occurs at a later age (30-40s)
*
>10-20 but < 100 adenomas
*
Predominantly on the Rt colon; the rectum tends to be spared
*
Untreated risk of colorectal cancer is 100% by 60Y
*
Extracolonic & intestinal manifestations are typically not seen
*
Screening starts at late teens, Q1-2Y
*
Colectomy and ileorectal anastomosis is usually done after the age of 21Y (as long as suspicious adenomas can be managed endoscopically)
>
Mutation Y-homolog (MYH)–associated polyposis (MAP)
V
*
An autosomal recessive form of FAP resulting from biallelic mutation in MYH gene on chromosome 1p34
It is not clear whether individuals with monoallelic mutations have a higher risk of colorectal neoplasia.
*
Is thought to occur in 0.7-1% of the population
*
Number of polyps 10-100 (may be 100s to 1000)
*
More than 60% of cancers occur proximal to the splenic flexure; rectal cancer is uncommon
*
Occur at a median age of 48Y
>
Untreated risk of CRC
*
19% by age 50Y
*
43% by age 60Y
*
80% by age 80Y
>
Extra-colonic risks
*
Risk of duodenal adenoma and carcinoma is much lower than in FAP but higher greater than the general population
*
Bladder cancer
*
Ovarian cancer
*
Skin cancer cancer
>
Genetic testing for MYH is done when:
*
Patients have > 20 lifetime adenomas
*
No APC mutation is detected
*
There are <100 adenomatous polyps
*
F. Hx is irrelevant or doesn’t reveal dominant mode of inheritance
>
Screening
V
ASCRS CPG 2017: Patients with biallelic MYH mutations need yearly colonoscopy and polypectomy, as long as the adenomas can be controlled endoscopically. Siblings or children of an affected individual need to be screened for the family mutations in MYH. Those who have not been tested should undergo colonoscopy every 2 years, starting at age 20. Grade of Recommendation: Weak recommendation based on moderate-quality evidence, 2B
*
ASCRS CPG: Because of an accelerated adenomato-carcinoma progression in patients with MAP, patients with proven biallelic MYH mutations and siblings who have not been tested should have colonoscopy every year starting at age 20.
*
EGD starting at age 30-35Y; repeated Q3-5Y
*
Colectomy with ileorectal anastomosis (or consider proctocolectomy with IPAA) when endoscopic surveillance is not feasible
>
Gardner syndrome
>
FAP with extraintestinal growths:
*
Osteomas
*
CHRPE
*
Dental abnormalities
*
Cutaneous lesions
*
Desmoid tumors
*
Adrenal adenomas
*
Nasal angiofibromas
>
Patients are increased risk for extracolonic malignancies:
*
CNS cancers
*
Thryoid cancer
*
Stomach cancer
*
Duodenal cancer
*
Liver cancer
*
Pancreas cancer
*
Biliary cancer
*
Turcot’s syndrome = colonic polyps, brain tumors
>
Indications for APC gene testing
*
≥ 100 colorectal adenomas
*
FDR of FAP⊕ patients
*
FDR of aFAP⊕ patients
*
≥ 20 cumulative colorectal adenomas (suspected aFAP)
*
Personal Hx of desmoid tumor
*
Personal Hx of bilateral CHRPE
>
Management
>
Screening for FAP
>
Colonoscopy Q1Y, starting at age 10-15Y
*
If patient had TAC + ileorectal anastomosis, then endoscopic evaluation of the rectum every 6–12 mo depending on polyp burden
*
If patient had IPAA, then endoscopic evaluations of the ileal pouch every 1–3 y depending on polyp burden
*
EGD starting at age 20-25Y; following Spigelman stage (varies from Q3-6m to Q3-5Y)
*
Thyroid examination with US: annually
*
CNS: annual physical examination
*
Desmoid: annual abdominal palpation
>
Chemoprevention
*
Sulindac or celecoxib: can reduce number & size of polyps in the colon & rectum, but does not reduce cancer
V
*
An international RCT showed the addition of DiFluoroMethylOrnithine (DMFO) was required to achieve a benefit in reduction of adenoma count when compared with placebo
nihms-336997-f0002
>
Appropriate for:
*
Duodenal adenomas
>
At-risk rectal mucosa (FAP, aFAP, or MAP)
V
*
IPAA polyps
Etiology of pouch polyposis is not completely understood but may be related to fecal stasis in the pouch
*
Delayed surgery
*
Unwillingness or inability to tolerate polypectomy or completion proctectomy
*
High family risk of desmoid tumors
>
Surgery
>
Indications
*
Severe polyposis ( >1000 colonic or 20 rectal polyps)
*
APC mutations between codons 1250 & 1464 (carry high risk of cancer)
>
Timing of surgery
*
As early as possible
*
For patients with classic FAP, surgery typically occurs around 16-20Y of age
*
For those with a high risk of desmoid disease (family history, mutation in the 3′ end of the APC gene, female gender, extracolonic manifestations), surgery should be delayed as long as possible to decrease the chance of desmoid tumors developing
*
Young patients should have surgery delayed, if possible, to allow for adequate physical, social, and intellectual maturity
>
Surgical options
>
Total proctocolectomy with IPAA
V
Procedure is performed either:
*
With mucosectomy and hand-sewn IPAA. Benefit: ↓ATZ adenomas
*
Without mucosectomy and stapled IPAA. Benefit: ↑function, easier, ↓complications
*
ASCRS 2017 CPG: The evidence available, however, does not support routine mucosectomy if the residual rectal cuff is free of polyps and can be surveyed
>
Annual endoscopic surveillance of the remaining rectal and ATZ mucosa and IPAA must be performed.
*
A small percentage of patients may develop cancer in the anal transition zone or in the ileal pouch
>
Risk of adenoma at IPAA at 10Y
*
22% in mucosectomy group
*
51% in stapled IPAA group
*
There is a very small risk of adenocarcinoma after an IPAA, with only about 2 dozen reported cases in the literature
>
TAC with ileorectal anastomosis
*
Carries the advantage of eliminating risk for nerve injury, impotence & lower risk for leak
V
This procedure is considered only in cases of:
*
aFAP or mild polyposis amenable for endoscopic surveillance
*
FAP with rectal polyps < 20 in number and < 3 cm in size; & can be endoscopically managed
*
No colorectal cancer
*
A distensible & compliant rectum
*
Intact sphincter mechanism
*
It has been observed that the risk for rectal cancer is almost 3X higher in FAP patients with a mutation after codon 1250 than in patients with mutations before this codon
>
Risk for rectal cancer is up to 5% at 10Y, & 40% by 30Y
*
Requires strict (Q6-12m) proctoscopic surveillance
*
⅓ of patients will develop florid polyposis of the rectum & require proctectomy within 20Y
>
TAC with APR
*
Indications are as with low rectal cancer
V
PostOp surveillance:
*
Following IRA: proctoscopy Q6-12m
V
Following IPAA: anoscopy/pouchoscopy Q1-5Y
>
After 20Y, only ~22% of patients will be free of pouch adenomas, representing a highly relevant risk after pouch surgery
>
Risk factors for IPAA adenomas:
*
♂ sex
*
Gastric adenomas
*
Young age at the time of IPAA
*
IPAA loss 2ry to cancer development is likely: 0.5-1.0%
*
Pregnant patients with IPAA may in theory have a normal vaginal delivery, but they risk catastrophic injury requiring a complex pouch reconstruction in the even of a full thickness episiotomy (pouch-vaginal fistula that require quite proximal ileostomy for diversion)
>
Hamartomas (typically cherry red with long stalk on endoscopy)
>
Juvenile Polyposis Syndrome (JPS)
V
Autosomal dominant mutation in SMAD4 & BMPR1A genes on 18q21 & 10q22, respectively
*
SMAD4 is associated with: hereditary hemorrhagic telangiectasia & bleeding AVMs in the GI tract, pulmonary tract, brain, & mediastinum
*
Juvenile polyps are characterized by a round, reddish appearance and histologically appear cystic with mucin-filled glands in an abundance/overgrowth of lamina propria
>
Polyposis involves the whole GI tract. The colon is affected 100% of the time
*
Juvenile polyps are hamartomas
*
JPS are at risk for other types of polyps (ie, inflammatory, hyperplastic, adenomatous). Up to 75% of JPS patients have polyp diagnoses other than juvenile polyps, with some having up to 5-6 different polyp types diagnosed throughout the years
*
Colorectal cancer is the most common associated malignancy — lifetime risk 40-50%
>
15% develop extra intestinal manifestations:
*
Cleft lip & palate
*
Polydactyly
*
GU anomalies
*
Intestinal malrotation
*
Hydrocephalus
*
Congenital heart disease
V
Clinical Dx is made by (any):
*
Finding ≥ 5 juvenile polyps (hamartomas) in the colon
*
Finding multiple polyps in throughout the GI tract
*
Identifying juvenile polyps with a ⊕ Family Hx of JPS
V
Screening
V
Colonoscopy starting at age 12-15Y or earlier
*
Repeat Q2-3Y if no polyps are found
*
Repeat Q1Y if polyps are found
*
EGD starting at age 15-25Y
>
Treatment
V
Indications for surgery
*
Symptomatic disease: bleeding, intussusception, anemia, obstruction
*
HGD or cancer
*
Polyp burden cannot be effectively managed endoscopically
*
TAC + IRA is likely adequate unless there is rectal disease/cancer
>
Peutz-Jeghers Syndrome (PJS)
*
Autosomal dominant mutation in LKB1 (STK11) tumor-suppressor gene on chromosome 19p13
*
30-40% develop de novo
*
Peutz Jeghers polyps differ histologically from juvenile polyps in that they arise due to an overgrowth of the muscularis mucosa, rather than the lamina propria.
>
Hamartomatous polyps are found throughout the GIT (most commonly small intestines) and tend to cause bleeding or intussusception
*
Most common site of hamartomous polyps are small bowel > colon > stomach > rectum
>
Dx criteria (requires ≥2):
*
≥2 hamartomatous polyps of the gastrointestinal tract
*
Mucocutaneous hyperpigmentation of the mouth, lips, nose, eyes, genitalia, or fingers
*
Family history of PJS
V
Extraintestinal manifestations:
V
*
Hyperpigmentation: perineal, buccal, eye, nostrils, perianal, toes, hands, & feet
Hyperpigmentation dissipates as one ages
*
Malignancies: breast, ovary, cervix, fallopian tubes, thyroid, gallbladder, bile ducts, pancreas, & testicles
V
*
The risk for malignancy is 13X higher than the general population, but the risk for colorectal cancer is lower than that with other polyposis syndromes
Screen Shot 2020-02-25 at 7.56.33 PM
>
Screening / surveillance recommendation:
*
Colonoscopy starting late adolescence Q2-3Y
*
EGD Q2-3Y
*
Small bowel interrogation (CTE) Q2-3Y, starting from age 8-10Y
*
Testicular/pelvic examination starting age of 10Y; repeat Q1Y
*
Yearly MMG & breast MRI starting age 25Y
*
MRCP & CA19-9 Q1-2Y starting age 25-30Y
*
Asymptomatic gastric or colonic polyps larger than 1 cm should be removed endoscopically
*
Small bowel polyps larger than 1–1.5 cm or those that are have grown rapidly from prior exam should be removed to decrease future complications such as bleeding and intussusception
*
Surgery is reserved for symptomatic polyps, cancer, or inability to perform adequate surveillance
>
PTEN-Hamartoma tumor syndrome
*
90-95% have GI polyps (hamartomas, lipomas, ganglioneuromas, hyperplastic polyps, adenomas, or inflammatory polyps)
*
CRC lifetime risk: 10-15%
*
Screening colonoscopy Q1-2Y starting at 35Y
>
Hereditary Mixed Polyposis Syndrome (HMPS)
*
Autosomal dominant
*
Involves different colon & rectal polyps (hamartomatous, adenomatous, hyperplastic)
*
The risk for colorectal cancer is thought to be higher than the general population
*
Treatment is based on symptoms
>
Serrated Polyposis Syndrome (SPS)
*
It is the most common inherited polyposis syndrome currently known (2022)
*
>90% of SPS patients are of white European descent
*
Characterized by multiple polyps (hyperplastic, sessile serrated polyps or serrated adenomas (AKA traditional serrated adenoma)) throughout the colon
*
No heritable pattern & genetic cause is identified
V
WHO criteria for Dx (cumulative lifetime polyp findings)
*
≥ 5 Serrated polyps proximal to the rectum, all ≥ 5 mm, ≥ 2 of which are > 10 mm
*
> 20 Serrated polyps (any size) throughout the colon; ≥ 5 being proximal to the rectum
*
Risk of developing colorectal cancer is 30-50%
*
Treatment is based on polyp burden, dysplastic, or neoplastic changes
*
Genetic testing is not routinely recommended as the genetic basis of SPS is largely unknown
V
NCCN recommendation:
*
Colonoscopy with polypectomy until all polyps ≥5 mm are removed, then colonoscopy every 1 to 3 years depending on number and size of polyps.
*
Clearing of all polyps is preferable but not always possible
*
Consider surgical referral if colonoscopic treatment and/or surveillance is inadequate or if high-grade dysplasia occurs
*
Surgical procedure is usually: TAC with ileorectal anastomosis
V
>
Syndromes with no increased risk for colorectal cancer:
All associated with PTEN mutation and result in hamartoma formation for the most part
>
Cowden’s Syndrome
*
Autosomal dominant mutation in the PTEN tumor suppressor gene on 10q23
*
Polyps occur in the colon and stomach. Colonic polyps can include hamartomas, fibromas, adenomas, lipomas, & neurofibromas
V
Extraintestinal manifestations
*
Hamartomas in the breast, thyroid, & uterus
*
Macrocephaly
V
*
Trichilemmomas are pathognomonic
In 1962, Headington and French first described trichilemmoma as a benign neoplasm with differentiation toward pilosebaceous follicular epithelium, or outer root sheath. Although unusual, at times, a central zone of desmoplasia may develop and thus be termed desmoplasia trichilemmoma. While benign in nature, the significance of trichilemmoma resides in the association with Cowden disease (ie, multiple hamartoma syndrome), nevus sebaceous, and the need to differentiate trichilemmomas from other more aggressive cutaneous tumors, such as trichilemmal carcinoma.
*
The risk for colon cancer is no greater than the general population
*
The risk for thyroid cancer is ~ 50%
*
The risk for breast cancer is ~ 10%
*
Treatment is based on symptoms
>
Bannayan-Riley-Ruvalcaba Syndrome (BRRS)
*
Autosomal dominant mutation in the PTEN tumor suppressor gene on 10q23
>
Associated findings:
*
Penile macules
*
Macrocephaly
*
Hamartomas
*
Hemangiomas
*
Mental retardation
*
The risk for colon cancer is no greater than the general population
>
Cronkite-Canada Syndrome (CCS)
*
Noninherited mutation of the PTEN tumor suppressor gene on 10q23
>
Associated findings:
*
Hamartomatous GI polyps
*
Alopecia
*
Macrocephaly
*
Onycholysis
*
Cutaneous pigmentation
*
Diffuse gastrointestinal inflammation resulting in malabsorption, diarrhea, and protein-losing enteropathy can occur.
*
Risk for colorectal cancer is no greater than the general population
V
V
HNPCC / Lynch Syndrome
HNPCC and cancer risk by age 70
Colorectal Cancer
• Lifetime risk of cancer in HNPCC: 80%
• Risk in general population: 2-6%
Endometrial (uterine) Cancer
• Lifetime risk of cancer in HNPCC: 60%
• Risk in general population: 1.5%
Ovarian Cancer 
• Lifetime risk of cancer in HNPCC: 12%
• Risk in general population: 1%
Stomach Cancer
• Lifetime risk of cancer in HNPCC: 13%
• Risk in general population: Less than 1%
Other cancers
• Lifetime risk of cancer in HNPCC: 1-4%
• Risk in general population: Less than 1%
*
For details on MSI, see “Genetic pathways” above
>
Terminologies
*
“Lynch syndrome” = individuals with HNPCC phenotype + confirmed MMR gene mutation (inherited mutation is present in one allelic copy of an MMR gene; cancer develops when the second allele is ‘hit’)
*
“HNPCC” = individuals with the HNPCC phenotype + no gene defect is confirmed. i.e HNPCC is a clinical diagnosis, while Lynch Syndrome is a histopathologic diagnosis
*
“Lynch-like syndrome” AKA “suspected LS” AKA “mutation-negative LS” = MSI-H tumors but germline testing fails to detect a pathogenic mutation in any of the major MMR genes
*
“Constitutional MMR deficiency syndrome (CMMRD)” = individuals with biallelic mutations in one of MMR genes (requires both parents to have Lynch Syndrome)
*
“Familial CRC Type X” = individuals meeting Amsterdam criteria (strong family history but only for CRC, not HNPCC-related cancers) but have intact MMR genes
*
Muir-Torre Syndrome: Lynch Syndrome + skin sebaceous gland neoplasms (sebaceous adenomas and carcinomas) + hair follicle neoplasms (keratoacanthomas)
>
General
*
It is the most frequently occurring hereditary colorectal cancer syndrome in the US & Western Europe
V
*
Accounts for 3% of all colorectal cancer
Of newly diagnosed individuals with rectal cancer almost 1/35 will have HNPCC
Of patients diagnosed with CRC at age ≤ 35Y: 44% will demonstrate MMR deficiency (Aronson DCR 2015; 58: 645–652)
>
Autosomal dominant transmission
*
20% of newly Dx HNPCC are caused by spontaneous gremlin mutations
>
Colorectal cancer occurs in absence of a multitude of polyps
V
>
Polyp burden in Lynch Syndrome
Kalady Dis Colon Rectum 2015; 58: 388–392
*
23% have 1 polyp
*
11% have 2-5 polyps
*
2% have 6-9 polyps
*
4% have 10+ polyps
*
70% of cancers occur on the right colon
*
The cancers are predominantly poorly differentiated or mucinous
V
*
Lifetime risk for colorectal cancer = 55-80% (highest in MLH1/MSH2 mutation carriers)
The risk of CRC (and other cancers), is influenced by which mutation is present
Screen Shot 2021-03-23 at 21.25.22
V
>
Associated cancers:
After being diagnosed with CRC, Lynch patients have 35% risk of a 2nd cancer in 10 years, and 65% risk of a 2nd cancer in 15 years
Screen_Shot_2021-03-23_at_21.07.23
*
Endometrial & ovarian cancer (> 50%) — highest in MSH6 mutation carriers
*
Gastric cancer (13%)
*
Ureter/renal pelvis cancer (7%)
*
Bladder cancer
*
Small bowel cancer (4%)
*
Biliary & pancreatic cancer (2%)
*
Brain cancer (4%)
*
Skin cancer
V
V
Testing for HNPCC :
MMR defects are detected by IHC
MSI is detected by PCR
V
*
(Revised) Amsterdam II Criteria (1998) has low sensitivity in detecting HNPCC
≥ 3 relatives with CRC or HNPCC-associated Cancer, and:
1. One should be a FDR of the other two
2. ≥2 successive generations
3. Dx < 50Y
4. FAP excluded
5. Pathologically confirmed cancer
Memorization tip: <50Y, 3 relatives, 2 generations, 1 is FDR
V
*
Revised Bethesda Guidelines (2004) increases the sensitivity of detecting HNPCC
Just 1 of these criteria needs to be met:
1 Colorectal cancer diagnosed in a patient who is less than 50 years of age.
2 Presence of synchronous, metachronous colorectal, or other HNPCC-associated tumors, regardless of age.
3 Colorectal cancer with the MSI-H histology diagnosed in a patient who is less than 60 years of age (see below)
4 Colorectal cancer diagnosed in one or more first-degree relatives with an HNPCC-related tumor, with one of the cancers being diagnosed under age 50 years.
5 Colorectal cancer diagnosed with two or more first- or second-degree relatives with HNPCC-related tumors, regardless of age.
Memorization tip: MSI-H <60Y; <50Y; synch/metach; CRC in 2≥ FDR/SDR with HNPCC-related; CRC in 1≥ FDR with HNPCC-related Dx <50Y
Histologic features associated with MSI:
- Tumor-infiltrating lymphocytes
- Crohn's-like lymphocytic reaction
- Mucinous/signet-ring differentiation
- Medullary growth pattern
*
Following the Amesterdam or Bethesda criteria alone to decide on testing for MSI/MMR status is not efficient, they are rather used when resources are limited. Instead, universal screening with IHC is recommended for all CRC
V
V
Testing for Lynch and interpretation of results:
⊕ MSI is seen in 15% of sporadic CRC, but need to rule out Lynch → refer for IHC or gremlin mutation testing
Sporadic tumors with MSI-H have characteristic clinicopathologic features: they tend to occur in the proximal colon, have a greater mucinous component, contain lymphocytic infiltration, and are more often poorly differentiated
Screen Shot 2021-03-30 at 19.51.19
Screen Shot 2021-03-30 at 19.53.10
Screen Shot 2021-03-30 at 18.54.34
Screen Shot 2021-03-30 at 19.52.07
>
Determining MSS vs MSI-L vs MSI-H
*
5 Microsatellites (i.e 5 locations on the gene) are usually assessed during testing
*
If only 1 unstable marker is detected, it is termed MSI-L
*
If ≥ 2 unstable markers are detected, it is termed MSI-H
V
>
Frequency of gene mutations:
EGAPP Genetics in Medicine Jan 2009 Peltomaki Fam Cancer 2016:15:385-393
*
MLH1: 40%
*
MSH2: 34%
*
MSH6: 18%
*
PMS2: 8%
V
*
⊖ MSI (i.e MSI-L or MSS) + intact MMR proteins (all four: MLH1, PMS2, MSH2, MSH6) = Lynch syndrome ruled out
MSS: microsatellite stable
MSI-L: low microsatellite instability (< 30% of markers are unstable)
MSI-H: high microsatellite instability (≥ 30% of markers are unstable)
V
V
⊕ MSI-H:
High_MSI_or_expression_of_MMR:
>
Loss of expression of MLH1 & PMS2, MLH1 alone, or PMS2 alone = sporadic Vs inherited → Further analysis for BRAF V600E mutation ± MLH1 promoter
V
*
The majority of patients with loss of expression MLH1/PMS2 do not have Lynch Syndrome. BRAF v600E mutation (hypermethylation) is evidence against Lynch Syndrome
Non-inherited loss of MLH1 expression:
— Sporadic hypermethylation of MLH1
— BRAF mutations → hypermethylation → loss of MLH1
*
Should MLH1 promoter methylation be encountered in young patients with a family history suggestive of LS, the clinicians should be aware of two rare exceptions:
(1) the patient may have LS with an inherited MLH1 mutation and MLH1 promoter methylation may have developed as the “second hit,” leading to cancer development;
(2) germline MLH1 hypermethylation has been reported in rare families which exhibit characteristic cancers associated with LS
>
Loss of expression of MSH2 alone, (MSH2 & MSH6), or MSH6 alone → highly specific for gremlin defect (Lynch syndrome)→ genetic testing for EpCAM & MSH6 gene (blood)
*
MSH2 gene mutation suggests Lynch Syndrome. If negative, test EpCAM: if mutated, suggests Lynch Syndrome
V
MSH2/EPCAM and MLH1 are thought of as ‘upstream’ mutations
>
Mutations in either MSH2 or EPCAM genes typically result in loss of staining in both MSH2 and MSH6 proteins
*
Mutations in the gene EPCAM (or TACSTD1) upstream of MSH2 can silence or disrupt MSH2 expression
*
Mutations in MLH1 result in the loss of staining for both MLH1 and PMS2 proteins.
*
Mutations in MSH6 and PMS2 genes typically result only in the loss of the respective single gene product
V
*
Failure to identify a causative MMR gene mutation in a patient with a suggestive history does not exclude the diagnosis of HNPCC. In as many as 25-50% of patients with a family history that clearly demonstrates HNPCC-type transmission of cancer susceptibility, DNA testing will fail to identify the causative mutation
Only 79-89% of Lynch Syndrome patients will have a positive test for MSI
Only 83% of Lynch Syndrome patients will have 1-2 absent MMR gene
*
Neoadjuvant treatment of rectal cancer has been noted to sometimes result in MSH-6 gene mutation. Therefore, in patients who had received NART/NACRT, it’s always best to use the pretreatment sample to screen for HNPCC
>
Recommendations for Lynch Syndrome patients
V
>
Screening
Guidelines on Genetic Evaluation and Management of Lynch Syndrome: A Consensus Statement by the US Multi-Society Task Force on Colorectal Cancer:
Screen_Shot_2018-11-25_at_13.52.26
Memory cue:
- 20-25Y start colonoscopy Q1-2Y (or younger)
- 30-35Y start annual (TV US, pelvic exam, & UA), and Q2-3Y EGD
*
There have been well-documented cases of invasive colon cancers occurring 1Y after a negative colonoscopy. It is obvious that the slow evolution from benign polyp to invasive cancer is not a feature of the pathogenesis in HNPCC patients, and this phenomenon of accelerated carcinogenesis mandates frequent (annual) colonoscopic examinations
V
*
Colonoscopic surveillance
Screen Shot 2020-07-30 at 3.31.30 PM
V
V
Management
Guidelines on Genetic Evaluation and Management of Lynch Syndrome: A Consensus Statement by the US Multi-Society Task Force on Colorectal Cancer:
Resistant starch and aspirin 600 mg/day have been assessed as chemopreventive agents in patients with LS
Screen_Shot_2018-11-25_at_13.54.14
V
>
When colon cancer is detected in a patient with HNPCC, an abdominal colectomy–ileorectal anastomosis is the procedure of choice (segmental colectomy may be discussed with the patient, especially if young). Prophylactic colectomy is not recommended unless there is a strong familial pattern that influences decision making.
Screen Shot 2021-03-24 at 08.35.29
Screen Shot 2021-03-24 at 10.25.50
Memory queue: risk is almost 2X the follow up years
*
Natarajan et al (2010): Even though no survival benefit was identified between the cases and controls the increased incidence of metachronous colorectal cancer and increased abdominal surgeries among controls warrant the recommendation of subtotal colectomy in patients with Lynch syndrome
*
Despite higher metachronous cancer risk after segmental colectomy, a meta-analysis by Heneghan et al. found that 10Y overall survival is the same between segmental resection and total colectomy — but it’s possible that the effect is more pronounced after more than 10Y
*
Haanstra et al. (2012) showed no difference in QOL between segmental resection and TAC in Lynch Syndrome (despite worse function outcomes in the TAC group)
*
Mathematical models estimate that a 3-year survival benefit may be found in comparing segmental colectomy with TAC in patients aged 25Y. The older the patient, the less likely a survival benefit is seen. i.e it’s reasonable to consider less extensive surgery as patients get older patients
*
In multivariate analysis, MMR deficiency was associated with a HR of 3.65 (95%CI,1.44–9.21; p=0.006) for metachronous colorectal neoplasia, whereas extended resection with ileorectal or ileosigmoid anastomosis significantly decreased the risk of metachronous colorectal neoplasia (HR, 0.21; 95%CI, 0.05–0.90; p = 0.036). (Aronson DCR 2015; 58: 645–652)
*
Point of emphasis: electing for segmental resection requires stringent patient compliance with colon screening schedule
V
>
2017 ASCRS Clinical Practice Guidelines: For patients with Lynch syndrome and rectal cancer, the rectal cancer should be treated based on standard oncologic principles, as in sporadic rectal cancer. The decision for concomitant colectomy may be considered on a selective basis. Weak recommendation based on poor-quality evidence. 2C
Risk of metachronous colon cancer is 51%
*
Patients with LS and rectal cancer may be a group who are best served with segmental resection. The alternative of TPC ± IPAA presents a pronounced functional difference from the patient perspective versus restorative proctectomy. However, the risk of developing a second colorectal malignancy following proctectomy varies between 15% and 27% within the first decade postoperatively, even with regular endoscopic surveillance
*
In general there is no discussion of whether mucosectomy should be done for LS with rectal cancers. The rectal cancer is treated like a sporadic one, and the discussion of a TPC is based on the expected function and risk of metachronous colon cancer which is up to 50%
*
The rectum remains at risk for the development of cancer and annual proctoscopic examinations are mandatory after TAC
*
Hysterectomy has not been shown to reduce endometrial cancer mortality, but can reduce the incidence of endometrial cancer. Therefore, hysterectomy is a risk-reducing option that can be considered, especially in patients undergoing surgery for CRC
*
BSO may reduce the incidence of ovarian cancer. Timing of BSO should be individualized based on whether childbearing is complete
*
ASCRS CPG 2017: Patients with clinical polyposis, but without an identified mutation, should be treated and followed based on their phenotype. Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C.
V
Summary of genetic testing for polyposis
>
Adenomatous polyps
*
APC → FAP
*
MMR → Lynch
*
MYH mutations
*
POLE or POLD1 mutations → Polymerase Proofreading Associated Polyposis (PPAP)
>
Hamartomas
*
STK11/LKB1 → PJS
*
SMAD4 or BMPR1A → JPS
*
PTEN
>
Summary of who should be referred to consider genetic testing
*
Patients who meet Amsterdam or Bethesda criteria
*
Individuals with abnormal tumor screening (MMR/MSI) & hypermethylation has been ruled out
*
Known family history of Lynch Syndrome
*
Individuals with > 10 adenomatous polyps
*
Individuals with > 5 juvenile polyps or > 2 PJS polyps
V
>
Histopathologic influence
MMR defects are detected by IHC
MSI is detected by PCR
*
Neoadjuvant treatment of rectal cancer has been noted to sometimes result in MSH-6 gene mutation. Therefore, in patients who had received NART/NACRT, it’s always best to use the pretreatment sample to screen for HNPCC
>
Defining some features associated with worse prognosis
*
Mucinous adenocarcinomas (characterized by extracellular mucin in ≥ 50 % of the tumor volume)
*
Signet ring adenocarcinomas (characterized histologically by greater than 50% tumor cells with signet ring features—prominent intracytoplasmic mucin vacuole that pushes the nucleus to the periphery)
*
Tumor budding (refers to small clusters of undifferentiated cancer cells ahead of the invasive front of the lesion)
*
Poorly differentiated clusters (PDC) are aggregates of at least five neoplastic cells lacking evidence of glandular differentiation. By definition, they can be present at the invasive front (peripheral PDC or pPDC) and within the tumor stroma (central PDC or cPDC)
>
Testing that will influene chemotherapy
>
K-RAS testing in metastatic patients will determine who will benefit (KRAS wild-type and BRAF wild-type) from anti-EGFR (Cetuximab or Panitumumab)
*
Anti-EGFR therapy is not recommended for right-sided tumors
>
KRAS mutation is associated with
*
Lack of benefit from anti-EGFR therapy
*
Worse OS after resection
*
KRAS WT but PIK3CA mutated tumors don’t derive the same benefit as PIK3CA WT
>
BRAF V600E mutation makes response to panitumumab or cetuximab highly unlikely unless given with a BRAF inhibitor
*
Mutation → poor prognostic indictor for OS
*
Mutation is found in < 10% of all CRC
*
Best results from anti-EGFR is in patients who are: (KRAS WT + BRAF WT + PIK3CA WT)
V
*
EXPERT-C trial (2012): in high-risk operable rectal cancer, the addition of weekly Cetuximab has improved radiologic response (71% vs 51%) and overall survival at 3Y follow up (HR 0.27) in KRAS/BRAF wild-type patients. The primary endpoint of complete response was not affected
Treatment regimen was: CAPOX 4cycles → Capecitabine chemradiation → surgery → CAPOX 4cycles
>
MSI-H or dMMR
>
Stage II tumors with MSI-H or dMMR status have been shown to be associated with lower recurrence rate (11% vs 26%) after surgical resection alone
*
Adjuvant chemotherapy is not beneficial for stage II dMMR colon cancer
*
MSH-H tumors have resistance to 5-fluorouracil (5-FU)–based chemotherapy when given alone; however, they do derive benefit from oxaliplatin based chemotherapy
V
NACT is not beneficial for dMMR for both colon and rectal cancer
*
FOxTROT trial showed that dMMR tumors do not derive benefit from NACT for colon cancer
*
NACRT is still effective for dMMR rectal cancer
*
Neoadjuvant immunotherapy can lead to deep response in dMMR CRC
*
For patients with advanced or metastatic disease (with MMR deficient / MSI-H), offer Nivolumab or pembrolizumab (either alone or with combination of systemic chemotherapy)
>
HER-2 amplification
*
HER2 Amplification (in RAS & BRAF wild-type) → may indicate EGFR resistance
*
Metastatic disease may be candidates for Trastuzumab or Tucatinib
*
NTRK fusions (very rare): larotrectinib or entrectinib is offered after 1st line therapy
*
PIK3CA: can still respond to anti-EGFR and anti-HER2 therapies; consider trials
*
Signet ring cell tumors and BRAF⊕ tumors are poor candidates (or contraindicated) for HIPEC
>
Testing may alter surgical plan
V
>
FAP
*
Total proctocolectomy ± IPAA
*
Consider total colectomy with ileorectal anastomosis in patients with minimal rectal involvement (< 20 rectal polyps; ideally < 5) and no malignancy (colon or rectum)
V
>
Lynch Syndrome
Herzig et al. Dis Colon Rectum 2017
*
For individuals with Lynch syndrome who develop a colon cancer, a total colectomy is preferred for cancer risk reduction. Strong recommendation based on moderate-quality evidence. 1B
*
Patients with Lynch Syndrome who develop a colon cancer may consider segmental colectomy despite the inferior cancer risk reduction because of differences in bowel function between segmental and total colectomy. Weak recommendation based on low-quality evidence. 2C
*
For patients with Lynch Syndrome and rectal cancer, the rectal cancer should be treated based on standard oncologic principles, as in sporadic rectal cancer. The decision for concomitant colectomy may be considered on a selective basis. Weak recommendation based on poor-quality evidence. 2C
*
Hysterectomy and BSO should be offered to women with Lynch syndrome undergoing colectomy, particularly if they have finished childbearing. Strong recommendation based on moderate-quality evidence. 1B
V
>
Cumulative 25Y risk of metachronous colorectal cancer:
Renkonen et al. Dis Colon Rectum 2017
V
*
46.6% after segmental resection
Parry et al. Gut 2011: Risk of metachronous CRC after segmental
•10yrs: 16%
•20yrs: 41%
•30yrs: 62%
*
9.6% after extended resection
V
>
Risk for colonic neoplasia after proctectomy for rectal cancer in HNPCC
Kalady et al.  Ann Surg 2012
*
50 patients with Lynch Syndrome undergoing proctectomy for rectal cancer
*
13 patients (40%) had 48 high-risk adenomas on surveillance c-scopes (81% left-sided adenomas)
*
5 patients (15%) developed metachronous colon cancer (80% right-sided). Mean time to cancer: 72 months
>
Prognosis
*
MSI-H stage II disease is better than MSI-S or MSI-L (but worse for stage IV)
*
Presence of tumor-infiltrating lymphocytes is a favorable prognostic factor. Lymphocytic infiltration is also associated with mutations in MMR genes and MSI-H
*
CRC with mutated BRAF tend to have worse prognosis: liver metastasectomy is not offered
>
Spread
>
LN
>
Likelihood of LN metastasis increases with
V
*
Depth of invasion (T-stage) — the most significant predictor of LN spread
T1-2 = 5-20% LN spread
T3-4 = ≥50% LN spread
*
Tumor size
*
Poorly differentiated histology
*
LVI
V
*
Number of metastases correlates with 1) presence of M⊕ disease, and 2) survival
Minimum adequate LN harvest = 12
↑ Number of LN harvest → improved long-term outcome
≥ 4 ⊕ LN (pN2) = poor prognosis
>
Distant
>
Liver the most common site
*
Increased risk with tumor size & tumor grade
*
15-20% of patients present with ⊕ liver metastasis
*
60% of CRC will eventually develop liver metastasis
*
Lung
*
Carcinomatosis
>
Workup / preoperative
>
Colon preoperative workup
*
Consider polyposis syndromes or Lynch syndrome, as appropriate
*
DRE
>
CEA
*
It is produced by the columnar and goblet cells of the colon, as well as colonic cancer cells, and has a half-life of 3 to 11 days.
>
Utility of CEA:
>
Prognostic value
*
PreOp CEA ≥ 5 ng/mL is associated with worse prognosis, stage for stage, than patients with CEA < 5 ng/mL
>
Surveillance
*
Normalization of CEA in patients with an elevated serum CEA who are undergoing neoadjuvant therapy is a strong predictor of complete pathologic response
*
Extremely elevated CEA in the absence of metastatic disease apparent on CT imaging should alert the clinician about the possibility of peritoneal carcinomatosis, thus warranting PET scan or even diagnostic laparoscopy
V
Conditions associated with ↑CEA
*
Cancer: GIT, breast, lung, pancreatic, hepatobiliary
*
Epithelial tumors
*
Inflammation: colitis, cholecystitis, pancreatitis, diverticulitis
*
Cirrhosis
*
Peptic ulcer disease
*
Crohn’s disease
*
Smoking
*
COPD
*
CEA measurements have only 60-70% sensitivity and 80% of specificity in the Dx of colorectal cancer
*
Normal CEA levels do not exclude tumor recurrence
*
If CEA is elevated in the postoperative period it should be confirmed by retesting. False-positive elevations are common especially when the level is between 5-10 ng/mL
>
Colonoscopy with tattooing distal to the tumor
*
Synchronous cancers are present in 4-5% of patients
*
Synchronous adenomas are present in 30-50% of patients
V
>
CT chest/abdomen/pelvis
PET CT is not routinely recommended
*
CT Chest: 9% of patients will have ‘indeterminate pulmonary nodules’ on preOp staging, but only 11% of these lesions (~1% of the total population) declare themselves to be CRC metastases during surveillance. Given the low incidence of malignancy in these indeterminate pulmonary nodules, further preoperative evaluation can be avoided, and these lesions can be followed during surveillance
>
Patients with iodine allergy can undergo either:
*
PET/CT
*
(Non-contrast CT chest) + (MRI abdomen/pelvic)
*
CT sensitivity in detecting malignant perirectal lymphadenopathy is only 49%
>
For obstructive symptoms, consider a water-soluble contrast study to assess:
*
Degree of obstruction
*
Level of bostruction
*
Involve enterostomal therapist
*
NCCN: The rectum lies below a virtual line from the sacral promontory to the upper edge of the symphysis as determined by MRI
>
Rectum preoperative work up adds:
*
Elicit Hx of incontinence
>
Rigid proctosigmoidoscopy is performed in conjunction with the DRE, and allows delineation of:
*
Tumor orientation (anterior, lateral, or posterior)
*
Circumferential involvement (evaluated as a percentage of the entire bowel wall circumference)
*
Extent of proximal involvement
>
Imaging
V
>
EndoRectal US
Provides T & N staging comparable to MRI
Best in distinguishing T0 & T1. Sensitivity to T2 lesions drops to 80%. T3 sensitivity is high.
Predicts LN involvement with sensitivity 63-85%
Pasted_Graphic1_copy
*
Because the probe needs to start above the tumor, its utility is limited in obstructing lesions
*
The distal most length of rectum at the anorectal junction is difficult to assess by ERUS
V
*
Assessing cancer stage
Screen Shot 2020-08-03 at 13.49.24
Screen Shot 2020-08-03 at 13.49.39
Screen Shot 2020-08-03 at 13.49.58
Screen Shot 2020-08-03 at 13.50.16
*
It is impossible to distinguish blood vessels from LN on a static US image
>
Overall concordance between clinical stage on ERUS and final pathologic staging is 65% (lower than earlier studies)
*
17% were overstaged
*
18% were understaged
*
The highest clinico-pathological concordance is for T1 tumors
>
ERUS is especially not reliable for:
*
Differentiating T2 from early T3 disease
*
Differentiating early T3 from advanced T3
*
Centers where ≤ 10 ERUS are done per year
*
Assessment of mesorectal fascia
V
*
Overall accuracy of T-staging: ~84%
The poorest correlation was found for T2 and T4 rectal cancers
*
The diagnostic accuracy of ERUS for nodal staging (75%) — lower than that in MRI
V
>
Pelvic MRI (Gold Standard):
Best in distinguishing T1/T2, from T3, and T4 (Not accurate in distinguishing T1 from T2) — but this is where it will matter, as T3 disease will be offered NACRT
WJCO-8-214-g003
>
Defining the rectum is a contentious point between surgeons, anatomists, and radiologists
>
Radiologists define the upper rectum in different ways:
*
The point corresponding to bony landmarks: S2, S3, or sacral promontory
*
15cm from the anal verge (thus the anal canal is considered part of the rectum in regards to rectal adenoCa)
*
The point at which the vascular supply changes
V
*
The anorectal junction is defined as the point at which the axis of the rectum changes from anterioinferior to posterioinferior
Screen Shot 2021-06-30 at 18.10.02-squashed
V
*
“The lower rectum” is defined as the portion below the imaginary horizontal line between the levator muscles on coronal images
Screen Shot 2021-06-30 at 18.13.23
>
Technique
*
Time required is up to 15-45m
*
Requires a 1.5- or 3-Tesla magnet system
*
Slice thickness ≤ 3mm
*
Performed in supine position, feet first
>
Diffusion Weighted Imaging (DWI)
*
The technique has very low anatomic resolution, but high contrast resolution i.e large differentiation between normal tissue and tumoral tissue
V
*
Signal in normal tissue is suppressed as a result of H2O molecules being able to move freely between cells
The normal bladder loses signal intensity on DWI
Screen Shot 2021-06-30 at 18.48.42
V
*
Signal in tumoral tissue is high as H2O is ‘trapped’ between the highly cellular tumor tissue
Rectal tumor tissue showing high intensity on DWI
Screen Shot 2021-06-30 at 18.49.44
>
Controversial aspects
*
Antispasmodic agent to improve visualization (e.g 1mg IM glucagon or buscopan)
*
Rectum is filled with contrast (~100ml) or air insufflation
*
IV contrast enhancement with gadolinium is not recommended
*
Cleansing enema
>
Avoid
*
Endorectal coil
>
Recommended sequences
V
*
The first series is the sagittal, T2-weighted, fast (turbo) spin-echo sequence from one pelvic sidewall to the other, which enables identification of the primary tumor.
It is essential that the referring surgeon has accurately indicated the tumor position (low, mid, or high rectal) for proper planning of the sequences
*
The second series consists of large-field-of view axial sections of the whole pelvis.
*
The third series consists of the high-resolution images that are T2-weighted thin-section axial images (3mm) through the rectal cancer and adjacent tissues
>
On T2-weighted images, there are 3 easily discernible layers:
*
1. an inner hyperintense layer = mucosa and submucosa
*
2. a hypointense middle layer = muscularis propria
*
3. a hyperintense outer layer = perirectal fat
*
4. Rectal tumors appear as intermediate intensity lesions
>
Features to look for
V
*
1. T Stage
On T2-weighted images, the muscularis mucosal layer is shown as a fine low-signal-intensity line with the thicker, high-signal submucosal layer seen beneath. The muscularis propria can often be depicted as two distinct layers, the inner circular layer and the outer longitudinal layer. The outer muscle layer has an irregular grooved appearance with interruptions due to vessels entering the rectal wall.
The perirectal fat appears as a high signal surrounding the low signal of the muscularis propria and contains signal void vessels
Screen Shot 2020-04-17 at 6.52.07 PM
V
>
2. N Stage
Nodal staging has traditionally relied on size of the nodes using MRI criteria; however, several studies have indicated the inaccuracy of using this technique alone. Criteria based on the outline of the node and features of signal intensity have been shown to be more reliable.
Uniform nodes having homogeneous signal intensity are not considered to be suspicious. The nodes are judged suspicious if they have irregular borders, mixed signal intensity, or both
Screen Shot 2020-04-17 at 6.56.48 PM
*
The diagnostic accuracy of TRUS for nodal staging (70–75%) is similar to that of CT (55–65%) and MRI (60–65%)
>
The size of the LN alters the criteria required to consider it suspicious/positive
*
< 5mm: needs 3 malignant characteristics
*
5-9mm: needs 2 malignant characteristics
*
> 9mm: always suspicious
>
Malignant characteristics of suspicious/positive LN
*
Indistinct borders
*
Heterogenous signal
*
Rounded shape
*
LN are evaluated in the mesorectum and along the external iliac, obturator, and femoral groups
V
>
3. CRM: Circumferential (resection) margin (mesorectal fascia)
Defined as: distance from edge of tumor to the mesorectal fascia
Determines who will get neoadjuvant therapy
The limit of the mesorectal fascia is seen as the thin line separating the perirectal tissue from the outer fat plane
V
*
CRM is the key piece of information relevant in MRI (sensitivity ~97%)
Endoscopic sonography cannot accurately assess the circumferential resection margin or identify other prognostic features such as extramural venous invasion
V
*
1mm is the safe cut-off for MRI prediction of surgical margin status in rectal cancer
MERCURY study showed that high-resolution MRI can accurately predict involvement of the surgical resection margin (≤ 1mm) and extramural tumor invasion
*
A potentially positive margin is defined as tumor lying within 1 mm (< 1 mm) of the mesorectal fascia
*
If mesorectum around a rectal Ca is involved or threatened (only 1-2 mm clearance) → ↑↑ local recurrence & poor prognosis
V
>
4. Sphincter involvement
At the level of the top of the anal sphincter, fibers from the puborectalis sling join those of the outer muscle coat; together these form the conjoint longitudinal coat, which forms a thin muscular layer between the internal and external sphincters
Screen Shot 2020-04-17 at 6.54.15 PM
V
Staging:
*
Stage 1: Tumor confined to submucosa; no definite involvement of the IAS
*
Stage 2: Tumor invades IAS but does not extend into the intersphincteric space
*
Stage 3: Tumor invades the intersphincteric space and/or extends to > 1mm from the levator muscles
*
Stage 4: Tumor invades EAS or levator muscles
>
5. Extramural vascular invasion & depth of invasion
>
Presence of EMVI is associated with
*
3.7 fold increased relative risk for metastatic disease at 1Y of follow up
*
Local recurrence
*
Poor response to adjuvant chemoradiotherapy
*
Poor survival rate
>
Determining EMVI on MRI is through
*
Presence of nodular or irregular vessels
*
Focal vessel enlargement
*
Tumor signal in vessel with replacement of flow void
*
Accuracy of MRI to detect EMVI: 62% sensitivity; 88% specificity (as compared with pathologic examination)
*
Extramural depth invasion > 5mm is a poor prognostic feature
>
Mucin
*
Have high signal intensity on T2 weighted images
*
Mucinous tumors are hypocellular and thus have low diffusion on “diffusion weighted images” and PET activity
V
Presence of mucin has different implications depending on the imaging time point:
*
At initial staging: it denotes worse prognosis
*
After adjuvant therapy: implies favorable tumor response (i.e mucin degeneration)
>
Post-treatment MRI
>
Residual tumor
*
Intermediate signal on T2
*
Restricted diffusion
>
Fibrosis
*
Low signal intensity on T2
*
No restricted diffusion
>
Nodes
*
Size (short axis) is the most reliable variable
*
Nodes < 5mm are likely sterile
*
Nodes ≥ 5mm are likely still malignant
>
Accuracy
*
T3/T4 stage: sensitivity 87%; specificity 75%
*
Nodal metastases: sensitivity 77%; specificity 71%
*
Involved CRM: sensitivity 77%; specificity 94%
>
Approach to MRI
*
Look for interruptions in the submucosa (hyperintesnse layer) (T1 disease)
*
Look for intermediate intensity tumor infiltrating the ring of hypointense muscularis propria (T2 disease)
*
T2 sagittal view: determine tumor height
*
T2 coronal view: determine involvement of sphincters
*
T2 axial view: assess perirectal tissue
*
T1 axial view: assess LNs
V
*
Oblique axial T2 (the plane is turned so that it is perpendicular to the epicenter of the tumor): assess mesorectum
Oblique axial images require calibration by a radiologist while the images are being taken
>
MRI is superior to ERUS in evaluating:
*
Mesorectal fascia (and CRM): This variable may be the most valuable in predicting prognosis
*
Pelvic LN that are remote from the rectum
*
T-stage and N-stage accuracy of MRI and ERUS after NACRT is poor. Routine restaging after completion of neoadjuvant therapy is not indicated. However, CRM assessment is accurate with MRI after neoadjuvant therapy
>
PET
*
Has not been shown to offer an advantage over MRI or ERUS with regard to locoregional staging
*
PET possibly changes the treatment plan in 10-27% of patients
*
At present, PET is not recommended in the routine evaluation of patients presenting with primary rectal adenocarcinoma but is utilized to evaluate equivocal findings on CT when finding distant metastatic disease would alter management
*
Mucinous tumors are hypocellular and thus have low diffusion on “diffusion weighted images” and PET activity
>
Role of DRE
>
Features to look for:
*
Height
*
Position within the rectum / relation to the anorectal ring
*
Morphology
*
Firmness
*
Fixation
*
Involvement of sphincters
V
>
Rullier classification
Screen Shot 2022-02-08 at 22.57.23
>
Anorectal ring defined:
*
Clinically as the top of the squeeze pressure during DRE with voluntary contraction
*
MRI/US: upper border of EAS and lowest end of levator muscles
*
CRM > 1mm from elevator ani + free intersphincteric plane = sphincter preservation
*
Acellular pools of mucin at the level of the CRM after NACT were considered as a negative CRM
*
The 2 groups of patients that conventionally required APR (those with juxta-anal and intra-anal tumors, types ii-iii) have been treated by ultra sphincter-preserving surgery with the same 5-year local recurrence rate (5%-9% vs 6%) and disease-free survival (70%-73% vs 68%) as the group treated by conventional sphincter-preserving surgery for supra-anal (type i) tumors
*
Type II & III are amenable for intersphincteric dissection surgery. Functional outcomes after complete intersphincteric dissection tends to be very bad and these patients are likely better managed with APR, unless highly motivated
*
It is recommended that most rectal cancer cases be reviewed by a multidisciplinary team at Dx
V
>
Role of PET: reserved for when CT/MRI are equivocal in patients with advanced disease
Limited evidence suggests that the addition of routine PET/CT may alter treatment in as many as 20% of patients, but guidelines do not recommend PET/CT in the initial staging of CRC
>
Assessment of extrahepatic disease:
*
Currently MRI is considered the gold standard of imaging when liver metastases are detected by CT
*
FDG-PET or FDG-PET/CT can improve staging accuracy for CRCLM, especially when extrahepatic disease is suspected, leading to improved survival of selected patients.
*
FDG-PET and FDG-PET/CT are well-established imaging modalities to assess Indeterminate Lung Lesions > 1 cm in diameter with a sensitivity of 97% and specificity of 78%.
V
>
Assessment of treatment response:
Treatment effect during chemotherapy is measured by the Response Evaluation Criteria in Solid Tumors (RECIST), which looks at changes in the size of the lesion. The limitation of RECIST is that decreasing in tumor size does not necessarily translate into an improvement in prognosis, and it may take several weeks before it becomes apparent. Patients often receive full course of therapy with the full range of toxicity before definite effects are detectable. Because FDG-PET/CT focuses on metabolic changes, it may be able to measure tumor response before anatomic changes occur, thus defining early response to treatment.
*
Colorectal cancer: Baseline parameters measured by FDG-PET/CT do not correlate with prognosis in patients with colorectal liver metastases; instead variations of these parameters before and after chemotherapy can measure metabolic response and can be used as prognostic indicators.
*
Rectal cancer NACRT: Post-treatment MRI, CT, or TRUS often cannot differentiate between fibrosis, necrosis, or inflammatory tissue and residual tumor foci. Studies have suggested that FDG-PET is more accurate in assessing treatment response than CT or MRI. The major limitation of these studies is the lack of standardization of timing of imaging evaluation.
>
Detection of recurrence:
*
Several studies have shown that FDG-PET is sensitive and specific in detecting recurrence in patients with colorectal carcinoma, thus affecting patients’ management, and this remains the main area of PET use to date
*
When compared with standard CT imaging FDG-PET/CT appears to be superior in detecting recurrent disease in patients with elevated CEA. Ozkan and colleagues confirmed these results in a retrospective study that included 69 patients, showing a sensitivity of 97% and a specificity of 61% for FDG-PET/CT, versus 51% and 61% for CT scan
*
More recently studies have been demonstrated that FDG-PET/CT also could be useful in detecting recurrence in patients with normal CEA levels and suggested that this imaging modality should be included routinely in the follow-up of CRC patients
V
*
May have a role in rectal cancer patients planned for W&W
PET has not been shown to be reliable for the indication of complete responders (AUC 0.57–0.73). Although comparing the change in baseline with 12-week posttreatment standardized 18-FDG uptake values may provide some improvement in test performance
*
EMVI ⊕ has a 4-fold increase in metastatic disease and maybe warrants PET scan
>
Work up for CRCLM
*
Restaging imaging (5 mm thin cuts)
*
Repeat colonoscopy
V
*
PET scan
In cases where patients are being considered for liver resection of metastatic tumor, there is some evidence that PET-CT can detect extrahepatic disease that is missed in up to one third of patients evaluated by CT scan alone. This changed management strategy in 8–21% of patients
V
*
Consider staging laparoscopy
Staging laparoscopy prior to definitive laparotomy identifies approximately 50% of all unresectable patients
*
Sensitivity of MRI at detecting response of liver lesions to neoadjuvant treatments may be better than PET
>
TNM Staging (AJCC 2017; 8th Edition) & prognostic factors
V
*
T (NCCN: pTis is not considered a “malignant polyp.”)
• T0: No evidence of Ca
• Tis: intraepithelial or invasion of lamina propria
• T1: invades submucosa
• T2: invades muscularis propria
• T3: invades pericolorectal fat/tissue
T3a: invasion < 1mm of extramural depth beyond the muscularis propria
T3b: 1-5mm invasion of extramural depth beyond the muscularis propria
T3c: 5-15mm invasion of extramural depth beyond the muscularis propria
T3d: > 15mm invasion of extramural depth beyond the muscularis propria
• T4: invades serosa
• T4a: penetrates visceral peritoneum
• T4b: invades or adherent to other organs/structures
If mesorectum around a rectal Ca is involved or threatened (only 1-2 mm clearance) → ↑↑ local recurrence & poor prognosis
T1 tumors, which are limited to the submucosa, are associated with a 10–15% incidence of occult lymph node metastases detected at the time of radical surgery. T2 tumors, which invade into but not through the muscularis propria, are associated with a 20–26% risk of lymph node metastasis. Tumors invading to the SM3 level were shown to have a similar risk of lymph node metastasis and local recurrence as T2 cancers.
Screen Shot 2020-08-04 at 16.14.44
V
>
N
• N0: ⊖
• N1: <4 ⊕ pericolic or perirectal LN
• N1a: 1 ⊕ regional LN
• N1b: 2-3 ⊕ regional LN
• N1c: tumor deposits in subserosa, mesentery, or nonperitonealized pericolic or perirectal tissues without regional LN
• N2: ≥ 4 ⊕ pericolic or perirectal LN
• N2a: 4-6 ⊕ LN
• N2b: ≥7 ⊕ LN
Rectal Ca: NACRT reduces the number of identifiable LN after TME, in this case < 12 LN harvested is still considered adequate
Hint: If LN harvest is not adequate on the first pathology report, as the pathologist to look at the sample again looking for more nodes
Positive LNs are defined as those containing ≥ 0.2mm deposits of cancer cells
ASCRS CPG: While not a component of the recently updated AJCC colon cancer staging system, the presence of micrometastatic lymph node disease detected by ultra staging has been associated with disease recurrence and decreased survival in patients with otherwise lymph node-negative cancer evaluated by standard methods.
*
The diagnostic accuracy of TRUS for nodal staging (70–75%) is similar to that of CT (55–65%) and MRI (60–65%)
*
LN > 7mm in the lateral compartment (internal iliac or obturator nodes) on MRI are predictors of lateral pelvic recurrence. Performing outright lateral pelvic LN dissection in this group reduces recurrence from 20% to 6%
*
Mathematical modeling for the INT0089 study was used to determine the number of lymph nodes needed to be truly predictive of lymph node negativity and predicted a <25% probability of node positivity if >18 nodes are examined for T1/T2 tumors or if >10 nodes are examined for T3/T4 tumors
V
*
M
• M1a: confined to one organ or site without peritoneal metastasis
• M1b: ≥ 2 sites without peritoneal metastasis
• M1c: peritoneal surface metastasis
V
*
Stage
cTNM = clinical staging
pTNM = pathologic staging
uTNM = US staging
ypTNM = pathologic stage that was affected; initially given a cTNM and received neoadjuvant therapScreen_Shot_2018-11-04_at_11.31.10_1
>
Prognostic factors
*
Tumor deposits: the number of satellite tumors deposits discontinuous from the edge of the cancer that are not associated with a residual LN
>
Tumor regression grade: assessment of pathologic response to NACRT in terms of circumferential resection margin
*
TRG 0: no regression
*
TRG 1: cancer > fibrosis
*
TRG 2: fibrosis > cancer
*
TRG 3: microscopic cancer
*
TRG 4: no residual cancer
*
MSI
*
KRAS mutation status
*
Perineural invasion
>
Management
>
History:
*
Dr. Heald introduced TME in 1982
>
Open Vs Lap
>
Trials showing non-inferiority of long-term outcomes in Lap Vs Open (and improved short-term outcomes)
*
Barcelona trial (Lancet 2002, Ann Surg 2008)
*
COST trial (NEJM 2004)
*
CLASICC trial (Lancet 2005, JCO 2007)
*
COLOR trial (Lancet Oncol 2005, 2009)
>
Rectal cancer
V
*
COLOR II trial (NEJM 2015)
2:1 Randomization of rectal cancer to: laparoscopy vs open
Similar 3Y locoregional recurrence: 5% in laparoscopy & open
Similar 3Y DFS: 74.8% in laparoscopy & 70.8% in open
Similar 3Y OS: 86.7% in laparoscopy & 83.6% in open
V
*
COREAN trial (2006-2009, 2014): comparison of open versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant therapy
cT3N0-2M0 ≤ 9cm from AV → neoadjuvant therapy → randomization
2014 published long-term outcomes: 3Y DFS 72.5% in open and 79.2 in laparoscopic groups → Conclusion: laparoscopic resection for locally advanced rectal cancer after preoperative chemoradiotherapy provides similar outcomes for DFS as open resection
>
Trials that did not establish non-inferiority of Lap Vs Open
V
*
ALaCaRT (2010-2014)
T1-T3 rectal cancer < 15cm from AV
Primary endpoint: adequate resection (intact TME, negative CRM (≥ 1mm), negative distal margin (≥ 1mm)
Criteria met in 82% of laparoscopic and 89% of open surgeries
V
*
ACOSOG Z6051 (2008-2013)
Stage II-III rectal cancer, excluding T4, S/P NACRT then randomized to lap vs open
Primary endpoint: TME completeness, distal margin > 2 cm, CRM > 1mm)
Criteria met in 81.7% in laparoscopic and 86.9% in open surgeries
V
>
Meta-analysis (1005 to 2016 studies: 14RCTs: 2,989 patients)
Martínez-Pérez A, Carra MC, Brunetti F, de’Angelis N. Pathologic Outcomes of Laparoscopic vs Open Mesorectal Excision for Rectal Cancer: A Systematic Review and Meta-analysis. JAMA Surg. 2017;152(4):e165665. doi:10.1001/jamasurg.2016.5665
*
⊕ CRM: 7.9% in lap group Vs 6.1% in open group (p-0.26)
*
Non-complete mesolectal excision: 13.2% in lap Vs 10.4% in open (p-0.02)
V
*
Nishikawa et al. 2019: Laparoscopic multi-visceral resection may be a safe, less invasive alternative… with less blood loss and shorter hospital stay, and was not inferior to open surgery based on long-term oncological endpoints
Dis Colon Rectum 2019; 62: 40–46 DOI: 10.1097/DCR.0000000000001255
V
>
Colon cancer management
The role of neoadjuvant chemotherapy/chemoradiotherapy for primary colon cancer is unclear. The FOxTROT trial will be able to shed light once completed
NCCN suggest adjuvant RT be "considered" for patients with T4 disease with penetration to a fixed structure
In tumors that are located between vascular pedicles (e.g., hepatic or splenic flexures), extended colectomy is performed to remove nodes along both associated vascular pedicles.
>
Stage 0
*
Carry no risk of LN spread
V
*
Endoscopic excision
Endoscopic resection is suitable for benign adenomas, those with severe dysplasia, or carcinoma in situ, as long as resection margins are free
V
>
Indications (some are relative) for segmental resection:
Not all indications here apply to Stage 0 disease
*
Polyp cannot be removed entirely, specimen is fragmented, or margin cannot be assessed
*
Tumor within 1mm of resection margin
*
⊕ LVI
*
Tumor budding
*
High grade or poorly differentiated histology (Grade 3-4)
*
Cancer extends to the lower ⅓ of submucosa (SM3)
*
Any T2 lesion
>
Complete Mesocolic Excision (CME)
*
In performing CME, the pathologist needs a fresh sample (similar to Quirke fixation technique)
*
Japanese studies show that tumor drainage area for colon cancer is within 10cm of the tumor and 5cm of the draining vessels
*
The main principle in CME is maintaining dissection in the mesocolic plane and preserving the peritoneum overlying the colonic mesentery, much in the same way as mesorectal excision preserves the fascia propria coating the mesorectum
*
Grading of mesocolic excision is made based on the presence of peritoneal defects in the tumor drainage area (i.e having defects in the transverse mesocolon doesn’t affect the grading of a complete mesocolic excision for cecal tumors)
*
The concept of CME is applicable to D1, D2, and D3 excision
>
Components of CME
*
Mesocolic plane: it’s found to impact survival (leeds, CLASSIC) & local recurrence (CLASSIC)
*
Central vascular ligation: improves outcomes
*
Length of colon resected: no difference in survival between Tokyo and Germany
V
>
Stage I
T1-2 = 5-20% risk for LN spread
>
Indications (some are relative) for segmental resection:
*
Polyp cannot be removed entirely, specimen is fragmented, or margin cannot be assessed
V
*
Tumor within 1mm of resection margin
Butte et al found that a positive polypectomy margin (<1 mm) was associated with residual disease in the colon wall in 16% of patients, whereas no residual disease was found in patients with a margin greater than 1 mm. The rate of lymph node metastases in this study was about 7%
*
⊕ LVI
*
Tumor budding
*
High grade (Tis) or poorly differentiated histology (Grade 3-4)
*
Cancer extends to the lower ⅓ of submucosa (SM3)
*
Any T2 lesion
*
Adjuvant chemotherapy does not improve survival
>
Stage II
V
*
Segmental resection
Proximal obstructing lesions → RHC
Distal obstructing lesions may be managed with segmental resection with on-table lavage (via appendicostomy or the terminal ileum), Hartmann’s procedure, or subtotal colectomy with ileosigmoid anastomosis
>
Adjuvant chemotherapy considerations
V
*
Unselected patients with resected stage II colon Ca should not be offered routinely adjuvant chemotherapy
The benefit derived from adjuvant chemotherapy in Stage II is < 5%, unlike the 25-30% improvement for Stage III
*
Oncotype Dx Colon (Coloprint) has not been shown in prospective trials to help select which patients benefit from adjuvant chemotherapy
>
Risk stratification: High risk features
*
⊕ PNI
*
⊕ LVI
*
Insufficient LN sampling
*
Perforating/obstructing tumor (T4)
*
Inadequate (close/intermediate/positive) resection margin
*
Poorly differentiated histology (except with microsatellite instability-high [MSI-H] or mismatch-repair deficiency [dMMR])
*
High preoperative CEA levels
V
NCCN recommendations
>
Low-intermediate risk — Options:
*
Observe
*
6 months of 5FU/LV
*
6 months of Capecitabine
>
High-risk
*
Clinical trial
V
*
Standard adjuvant regimen for Stage III
Options:
- FOLFOX
- CapeOx
- FLOX
- 5FU/LV or Capecitabine without oxaliplatin
V
*
NCCN 2018: T4b may be considered for NACT with FOLFOX or CapeOx, followed by colectomy
This basically applies to patients in whom you are concerned about getting an adequate margin or if you fear that the concomitant second organ resection carries too much morbidity. In this case, they are treated with FOLFOX
V
*
UTD and ASCRS CPG: If adjuvant chemotherapy is chosen, most patients receive a fluoropyrimidine alone, unless they have a tumor with deficient MMR status, in which case adjuvant fluoropyrimidines alone are ineffective. (This only applies for Stage II - you give FOLFOX if you really wanted to make an argument for a specific patient. This is because an MMR defect patient that is given only 5-FU will have worse prognosis than not getting 5-FU)
Flouropyrimidine examples are capecitabine, floxuridine, and fluorouracil (5-FU)
>
Stage III
>
Segmental resection followed by adjuvant chemotherapy
*
Stage III colon cancer 3Y survival after surgery alone: 55-62%
V
Benefit of chemotherapy:
V
Benefits of fluoropyrimidine-based therapy X6 months
*
30% ↓ in risk for recurrence
*
26% ↓ in risk for death
V
V
Addition of oxaliplatin to fluoropyrimidine
MOSAIC trial showed the benefit of adding oxaliplatin to 5-FU/LV
*
Oxaliplatin-based adjuvant chemotherapy regimens improve survival of stage III colon cancer patients by an absolute 20–25% at 5Y versus no chemotherapy
*
The addition of adjuvant chemotherapy to N⊕ colon Ca with FOLFOX-based therapies improved 5Y DFS from 65 to 78 %
V
Adjuvant oxaliplatin-containing regimen
V
*
FOLFOX
• Leucovorin (Folinic acid): a vit-B derivatives that increases cytotoxicity of 5-FU
• 5-FU: pyrimidine analog that incorporates into DNA to stop synthesis. Main side effect is mucusitis = diarrhea & discharge
• Oxaliplatin: inhibits DNA synthesis. Main side effect is peripheral neuropathy, that is sometimes permanent
V
*
XELOX = CapeOx = Oxaliplatin + oral Capecitabine (Xeloda)
Oral capecitabine has been proven to be at least equivalent to infusional 5-FU. The combination of capecitabine and oxaliplatin (XELOX or CapeOx) was compared directly with bolus 5-FU/LV; DFS was significantly superior with XELOX than with bolus 5-FU/LV
V
*
Duration: 4-6 Months is the standard approach
Studies examined the differences between bolus and short-term infusional 5-FU; a lack of superiority but more favorable side effect profile was demonstrated for continuous infusional 5-FU over bolus 5-FU in four trials
*
For patients with significant comorbidities, underlying peripheral neuropathy (potentially DM patients), and elderly patients older than 70 years of age, 6 months of infusional 5-FU/LV or capecitabine alone can be considered
*
MSI-H stage III patients derive no benefit from 5-FU based therapy, instead they are offered oxaliplatin based chemotherapy
*
There is no role for the addition of irinotecan in the adjuvant setting after curative resection of localized colon cancer
*
Bevacizumab (Avastin) and cetuximab in adjuvant resected stage III disease have shown no DFS or OS benefit despite improved outcomes when added to chemotherapy regimens in the metastatic setting
*
For patients above 70Y, the addition of oxaliplatin is of unproven benefit. Consider 5-FU/leucovorin alone
*
Consider NACT for bulky tumors that may benefit from downsizing and for disease with extensive LN involvement
*
Retrospective data suggests that for patients with COX-2 over-expression, regular aspirin intake may decrease recurrence
V
>
Rectal cancer management
Screen Shot 2020-02-25 at 9.13.44 PM
V
>
Stage I
Untitled
>
T1N0 surgical options
V
>
Local excision always risks understaging & under-treating. Apply strict selection criteria in picking local excision candidates (see notes)
Even when criteria is applied, local recurrence rate range is 10-30% with longterm follow up (higher than for radical resection)
The risk for LN metastasis is likely 10-30% for all T1
Up to 3% of SM1 will have LN metastasis. For SM1, the morbidity of a radical resection is probably too high.
Up to 8% of SM2 will have LN metastasis
Up to 25-50% of SM3 will have LN metastasis. SM3 patients need radical resection
Screen Shot 2021-03-25 at 17.58.12
>
NCCN local excision criteria
*
<30% circumference of bowel
*
<3 cm in size
*
Margin clear (>3 mm)
*
Mobile, nonfixed
*
Within 8 cm of anal verge
V
*
T1 only
T2 disease may actually be candidates for a transanal excision.
V
*
No LVI or PNI
Lymphovascular invasion is found in 12–32% of T1 rectal cancers and is a strong predictor of lymph node metastasis with an odds ratio between 3.0 and 11.5 reported on multivariate analysis
*
Well to moderately differentiated
V
*
No or low budding
Defined as small nests of five or more, usually poorly differentiated, cancer cells along the invasive front
Tumor budding is present in 16–25% [27, 33] of T1 cancers and multivariate analysis has demonstrated an odds ratio of 5.1–5.8 in predicting lymph node metastasis.
*
No lymphadenopathy on pretreatment imaging
*
Full-thickness excision must be feasible
>
Local excision (compared to proctectomy) for T1N0 tumors is associated (at 3.7Y follow up) with
*
Higher local recurrence (12.5% vs 6.9%)
*
Lower 5Y disease-specific survival (93.2% vs 97.2%)
*
Similar 5Y overall survival (77.4% vs 81.7% —p-NS)
V
Radical resections:
V
Indications:
V
1. Final pathology revealing:
*
A) More locally invasive disease than suggested PreOp (i.e higher Stage)
V
B) High-risk pathologic features
*
⊕ Margin
*
Poorly differentiated histology
*
⊕ LVI or PNI
*
Inadequate resection margin
*
SM3 depth invasion
*
> 1000um of depth
*
Tumor budding
*
2. Cases of local recurrence after local excision i.e Salvage procedure
*
Timing: 4-6w after local excision to allow the bowel to heal
>
T2N0
*
Radical resection + TME
*
Adjuvant chemotherapy if LN ⊕ (upstaged postOp to Stage III)
V
*
In very select patients: consider NACRT if a tumor’s proximity to anorectal sphincter precludes a sphincter preserving procedure
CapeOx followed by local excision is associated with ↓ DFS & ↑ Chemotherapy adverse reactions. Therefore it generally is advised that NACRT followed by local excision be considered only for carefully selected patients with T2N0 tumors who refuse or are not candidates for radical resection
>
Local excision combined with supplemental radiation therapy has been considered for T2N0 disease
*
There isn’t adequate evidence to suggest adequacy of local excision following NACRT for uT2N0 rectal cancer. At present, this combination therapy should be reserved for patients unfit or unwilling to undergo the accepted standard therapy of proctectomy.
>
Stage II & III
V
>
Indications for NART ± Chemotherapy
A growing body of evidence suggests that radiotherapy could be safely avoided in patients with intermediate-risk rectal cancer (middle rectal Ca with ⊖ MRF on MRI)
>
T3-4 within 10cm of anal verge
*
Several retrospective analyses suggest that a subset of patients with low-risk disease (T3N0M0, extramural spread < 5mm, clear CRM by ≥ 2 mm) may not derive a significant benefit from RT.
*
N1-2
V
*
Threatened CRM (within 1-2 mm) or involved mesorectal fascia
These patients are not candidates for short-course radiation followed by surgery
*
Tumor invasion into sphincter complex
*
Lower ⅓ of tumors in which sphincter-preservation may not be possible without tumor regression
*
In general, tumors above the peritoneal reflection (~10cm from AV) derive little to no benefit from radiation and may be treated similar to colon cancers
>
NACT/NACRT
>
Benefit of neoadjuvant therapy
*
↓ recurrence (~50%)
*
↑ oncologic outcomes (no impact on DFS or OS)
*
↑ radiation completion rate
*
↓ dose compared to adjuvant radiation
*
↑ sphincter preservation
*
↓ chronic enteritis (compared to adjuvant radiation)
*
NACRT (compared to adjuvant) is associated with ↓ acute & chronic toxicities & improved 10Y local recurrence rate
*
NACRT does not greatly affect perioperative morbidity or mortality. Some report higher higher perineal wound complications with short-course radiation
V
V
Regimens
Long-course chemoradiation has become the preferred treatment regimen within the United States, largely because of increased local toxicity of the more concentrated doses of radiation that are administered with short-course therapy
>
5-FU must be present after radiation exposure to establish the radiosensitive state, and for this reason, bolus 5-FU quickly fell out of favor and continuous venous infusion (CVI) 5-FU 225 mg/ m 2daily became the standard
*
Compared to boluses during radiation, CVI is associated with ↓ local and distant recurrence
*
Some studies showed that CVI was associated with lower hematologic toxicity compared to bolus 5-FU
*
Addition of oxaliplatin (as radiosensitizing agent) results in ↑ toxicity but no improvement in therapy
>
Short-Course RT
V
*
Radiation: 5Gy/day X5d within 1w of surgery then adjuvant FOLFOX or CapeOx
Fluoropyrimidine-based chemotherapy should be delivered concurrently with radiation therapy
This regimen is not used for involved CRM or locally unresectable disease
*
SCRT followed by 12-16w of chemotherapy (FOLFOX, CapeOx, 5-FU/LV, or capecitabine) can be used even for involved CRM or locally unresectable disease
V
*
NCCN: Short-course RT is not recommended for low-lying tumors, <5 cm from anal verge
Short course may be best indicated for mid rectal cancer with CRM ⊖
>
Side effects:
>
Early:
*
Substantial proctitis occurs in the week following RTx: tenesmus, diarrhea, & pressure
*
Cramping abdominal pain
*
Less likely: dysuria; frequency
*
Typically no radiation-specific skin reaction
>
Late
*
Bowel dysfunction
*
Urinary dysfunction
*
Vaginal stenosis
*
Infertility in ♀
>
Long-course
*
45Gy to pelvis + 5.4 Gy boost (28 fractions of 1.8Gy/day) over 5-6w
>
Infusional 5-FU or oral capecitabine chemotherapy
>
LC + oxaliplatin (vs 5-FU based) is associated with
V
*
↑pCR
German study (17% versus 13%, p = 0.03)
FOWARC trial (27.5% versus 14%, p = 0.005)
*
↑ toxicity
*
ASCRS 2020 CPG: “Taken together, the toxicities associated with adding oxaliplatin to 5-FU-based LCCRT outweigh the oncologic benefits”
*
Surgery is done 8-12w later
V
Total Neoadjuvant Therapy (TNT)
*
Commonly refers to: induction systemic chemotherapy followed by LCCRT (or LCCRT followed by consolidation systemic chemotherapy)
*
The total duration of TNT treatment should not, in general, exceed 6 months
*
8 cycles FOLFOX or CAPOX
*
pCR: 24% in EXPERT trial & 29% in CONTRE trial
V
*
RAPIDO Trial
Screen Shot 2020-11-06 at 10.48.01 AM
>
It is reasonable to perform repeat DRE, CEA, endoscopy, & MRI to assess tumor response between 4-6w after completion of NACRT
*
When the indication for neoadjuvant therapy is a threatened CRM, reassess CRM status 6w post-completion of radiation therapy. If CRM is now adequate, resect. Otherwise continue with chemotherapy
>
Timing of surgery after adjuvant therapy
*
SCRT followed by long wait (8-12w) is reasonable to give better chance for downsizing or complete response
*
Pooled results of 13 observational studies including 3,584 patients show that delaying surgery beyond 8 weeks increased the incidence of pCR by 6% without increasing complications, but with no difference in R0 resections, disease-free or overall survival
*
GRECCAR-6 trial compared 7 vs 11 week wait after LCRT. Longer wait did not increase pathologic complete response and had higher postOp morbidity & medical complications. Quality of mesolectal excision was also worse in the 11-week arm
*
Because the pelvis is an active site of bone marrow function, patients who undergo pelvic irradiation can suffer from diminished hematopoiesis
>
Endorectal brachytherapy is administers via an endorectal probe over 4 consecutive days
*
Candidates: Mid-distal rectal cancers not involving the anal sphincters & lymphadenopathy confined to the mesorectum
V
>
Adjuvant chemotherapy
Although the benefit of addition of adjuvant chemotherapy after neoadjuvant chemoradiation followed by surgical resection remains controversial, the majority of patients do receive adjuvant chemotherapy similar to adjuvant therapy for resected colon cancer (such as 6 months postoperative FOLFOX, 5-FU/capecitabine, FLOX)
*
In patients with rectal cancer who were already treated with preoperative LCCRT, an 8-cycle (4 month) course of adjuvant FOLFOX is generally accepted
>
Regimen options (uses same agents as for colon cancer: FOLFOX, CapeOx)
*
Chemotherapy X2m, then Chemoradiotherapy X6w, then chemotherapy X2m
*
Chemotherapy X4m, then chemoradiotherapy X6w
V
General considerations
*
< 50% of patients receive the complete course of chemotherapy without interruptions
*
Each 4w delay in treatment may ↓ OS by 14%
V
*
O’Connell MJ et al NEJM 1994: For stage II-III, continuous infusion of 5-FU is superior to bolus during postOp RT
Untitled
*
If chemoradiation is planned, it is usually administered in a sandwich technique
*
Considered for high-risk Stage II
*
Recommended for Stage III (FOLFOX or CapeOx)
>
Watch & Wait
>
W&W strategy may have the greatest appeal for
*
1. Low tumors that will require APR
*
2. Early tumors (usually T2) that may obviate need for surgery
*
The interval from completion of chemoradiotherapy to clinical or pathologic assessment can impact the rate of complete response as ongoing regression can be observed well beyond the traditional 6-8w interval to assessment
>
Pathologic complete response (pCR) is seen in ¼ of patients following TNT (lower in conventional neoadjuvant therapy)
*
Rate is up to 25% in CAO/ARO/AIO-12 study
*
Rate: 28% in RAPIDO trial & PRODIGE 23 trial
V
*
mFOLFOX6 may ↑ pCR (up to 38%) after NACRT for locally advanced rectal cancer
This however was not a randomized trial
Screen Shot 2020-04-27 at 3.06.14 PM
*
Extramural depth of invasion < 0.5cm(T3a-b) at MRI is a predictor of pCR
V
Identifying cCR
>
Patients are said to have a cCR when (all the below)
*
DRE shows no palpable tumor (± nodularity)
>
Endoscopic findings support cCR
*
Regular & smooth mucosa
*
Changes such as whitening or telangiectasias
V
*
MRI shows TRG2 / TRG1 + absence of suspicious LN ± no restricted diffusion on DWI
Currently, the most objective method for identifying potential candidates for a W&W approach seems to be comparison of pre- and posttreatment high-resolution MRI imaging to assess response
*
CT demonstrates no disease
*
PET/CT has not been shown to be reliable for the idetification of complete responders (AUC 0.57–0.73). Although comparing the change in baseline with 12-week posttreatment standardized 18-FDG uptake values may provide some improvement in test performance
V
*
Combining clinical assessment (±Bx) with MRI has 98% accuracy in predicting complete response
Maas et al 2015
*
15% of patients will have mucosal abnormality and after surgery are found to have pCR
V
Following completion of chemoradiotherapy, 50% will experience complete Clinical Response (cCR)
*
In patients whom a cCR is desired to avoid surgery, endoscopy Q2m is performed
>
Concordance between clinical an pathologic evaluation has been poor in terms of sensitivity (~25%) for detecting pCR, and specificity (~60-90%) for excluding residual disease
>
While local excision of the scar may provide pathologic assessment of the bowel wall, it cannot provide information on the LN staging. N⊕ disease tends to be present in
*
9% of ypT0
*
17% of ypT2
V
W&W Surveillance protocols vary, but patients need assessments done at least Q3m (clinical, DRE, CEA, endoscopy)
V
*
MUHC W&W surveillance schedule
IMG_3242
*
If Bx is done at the scar site and shows LGD or HGD, many would argue that this is evidence of recurrence (with sampling error, and actual malignancy deeper than the Bx site)
>
OPRA trial showed that 3Y DFS in W&W was similar to a historical cohort (76%)
*
cCR and near-completeCR underwent W&W; incomplete response had TME
*
3Y TME-free survival was 41-53%
*
DFS after TME vs after TME-for-regrowth was similar
>
International W&W Database study:
*
97% of recurrences were either endoluminal or endoluminal-and-LN
V
Salvage therapy was possible in ≥ 90%
*
22% had local excision only
V
5Y OS was 85%
*
For sustained cCR: 88%
*
For local regrowth after W&W: 75%
V
>
⅓ of patients with cCR will develop tumor regrowth
This suggests that a number of patients initially thought to have a pCR based on clinical assessment of complete response actually have undetected viable tumor, highlighting one of the major challenges and pitfalls of the watch and wait approach
*
The majority of tumor regrowth will be detected within the first 12-24m
*
Some argue that delays in identification of regrowth may be associated with > 50% decrease in the ability to perform sphincter preserving salvage surgery
*
Patients with cCR but not pCR have a ↑ potential risk for distant metastasis
>
Local excision following NACRT is associated with
*
↑pain and
*
Poor wound healing (dehiscence in 26-70%)
*
Anorectal dysfunction
*
Sexual dysfunction
>
Cleveland Clinic Foundation (2020) indications for neoadjuvant therapy regimens:
>
Long course radiation with total neoadjuvant therapy
>
T3/T4 &/or N⊕ tumors
*
“cT4 tumors are at high risk of local recurrence and distant metastasis up to 20 and 60%, respectively. 145 Therefore, these patients should undergo long-course chemoradiation to improve local control and minimize distant recurrence”
>
If downstaging is necessary to help achieve
*
Sphincter preservation
*
Negative CRM
*
Possible watch & wait candidacy
>
Short course radiation
*
Symptomatic rectal cancer with metastatic disease: short course then chemotherapy
*
Locally advanced tumors in patients with oligometastasis who could be surgical candidates: short course + total neoadjuvant therapy
*
T3N0 with non-threatened mesorectal fascia margin: short course + immediate surgery
*
Non-chemotherapy candidates who require down-staging: short course + delayed surgery
>
Surgical options & considerations
V
>
Local procedures
Rectal wall is incised full-thickness down to the perirectal fat
Maintain a 1-cm resection margin
The defect is closed with absorbable sutures
>
NCCN local excision criteria
*
<30% circumference of bowel
*
<3 cm in size
*
Margin clear (>3 mm)
*
Mobile, nonfixed
*
Within 8 cm of anal verge
V
*
T1 only
T2 disease may actually be candidates for a transanal excision.
*
No LVI or PNI
*
Well to moderately differentiated
*
No lymphadenopathy on pretreatment imaging
*
Full-thickness excision must be feasible
V
*
Low lesions → TransAnal Excision (TAE):
Requirements: 6-8cm from AV + below peritoneal reflection
>
Mid- to upper lesions → Transanal Endoscopic Microsurgery (TEM) & TransAnal Minimally Invasive Surgery (TAMIS)
*
TEM and TAMIS have been shown to be more likely to result in a negative margin and have decreased local recurrence compared with TAE, likely because of improved visualization during the procedure
*
Tumors as high as 10cm anteriorly, 15 cm laterally, & 18cm posteriorly can be excised with TEM
V
*
A limitation of TEM and TAMIS is that very distal lesions (<5 cm from the anal verge) are often not amenable to either approach because of difficulty maintaining an adequate seal required for pneumorectum
In addition, inadvertent entry into the abdominal cavity may occur during resection of lesions that are located above the peritoneal reflection, which may lead to peritonitis and sepsis if not identified and repaired promptly. This may be repaired transanally but sometimes may require conversion to laparotomy.
V
Radical resection
>
Sphincter preserving: LAR
*
With proper training and experience, it usually can be performed safely when cancers are located more than 1 cm from the upper portion of the anorectal ring, as long as the patient has a favorable body habitus and pelvic anatomy.
>
Contraindications to LAR:
>
Absolute contraindications include tumor invasion into:
*
Anal sphincter
*
Levator muscles
*
Relative contraindication includes impaired anorectal function (because it often leads to poor postOp bowel function)
V
>
Reconstruction
It is generally thought to be preferable to avoid using the sigmoid colon as the proximal component of a colorectal anastomosis, because the blood supply to the sigmoid from the IMA may be tenuous, and the presence of diverticular disease, common in the sigmoid colon, is often considered to be a risk factor for anastomotic leak
>
Straight coloanal anastomosis
*
End-end
*
Side-end
V
>
Colonic reservoir
Improve short-term functional outcomes but evidence of benefit beyond 1-2Y are lacking in terms of continence and QOL
>
Colonic J-pouch
*
If the anastomosis is created above 9 cm from the anal verge, there is little benefit of a J pouch
>
Transverse coloplasty pouch
*
This technique provides a rectal reservoir by making an 8- to 10-cm colotomy 4 to 6 cm from the divided end of the colon. The colotomy is closed transversely to provide increased rectal space and capacitance
>
Diversion
*
Decreases the rate of symptomatic leak from 28% to 10%
*
When diversion is done only after a leak, the likelihood of stoma reversal is low
>
Risk factors for leak
*
♂
*
Low anastomosis (<6cm from AV)
V
*
PreOp radiation
Larry Lee: always divert LAR patients who had pelvic radiation
*
Occurrence of intraOp complications
>
Planning reversal:
>
PreOp evaluation:
*
Enema study to assess: leak or stenosis
*
DRE & flexible sigmoidoscopy: rule out recurrence
>
Timing:
*
Several studies show that reversal within 2-4w postOp is safe (even in patients who are planned for chemotherapy)
*
If no chemotherapy is planned: 3m postOp
*
If chemotherapy is planned: after completion of chemotherapy
*
Consider TaTME for rectal tumors < 8 cm from AV, especially in obese and male patients
V
Sphincter sacrificing: APR
V
*
Extralevator abdominoperineal excision (ELAPE) with tissue-flap reconstruction may result in a more cylindric specimen & decrease the rate of tumor perforation and positive CRM and improves outcomes.
Screen Shot 2020-04-27 at 2.50.06 PM
*
For ELAPE, to minimize would complications, be sure to only take the necessary levator muscles on the side involved by the tumor. Preserve the muscles in the unaffected side
>
Oncologic considerations
V
>
TME is the standard of care
TME entails sharp dissection done under direct vision in the avascular areolar plane between the visceral fascia that envelops the rectum and mesorectum and the parietal fascia overlying the sacrum and pelvic sidewall structures with pelvic nerve preservation (up to the level of the levators)
The potential space between the fasciae is referred to as the ‘holy plane’
TME was introduced by Heald & Ryall during the 1980s
*
Total mesorectal excision is required for middle and low lesions. If lesion >10 cm from AV → tumor specific excision + divide mesorectum at a right angle to the bowel 5cm distal to the mucosal edge of the tumor (also known as a Tumor-specific Mesorectal Excision (TsME)). You don’t need 5cm of margin on the mural margin, but lymphatic spread is seen beyond that of the mural extension.
*
Mesorectum = fatty connective tissue layer (2-3 cm thick) with associated vessels, lymphatics and LNs surrounding the rectum and enveloped by fascia
V
*
Tumor-specific Mesorectal Excision (TsME) is appropriate for tumors in the upper rectum
The mesorectum & rectum are divided at a right angle to the luminal axis at a level 5 cm distal to the tumor
>
Considerations:
*
Dissection medial to fascia → local recurrence
V
>
Dissection lateral to fascia → autonomic nerve injury
Pasted_Graphic_6
V
*
Superior hypogastric plexus (sympathetic)
• Arise from T12-L3
• Injury:
• Highest risk at time of:
• Ligation of IMV
• Posterior mesorectal dissection at the level of the sacral promontory
• Lateral mesorectal dissection
• Consequence:
• ↑ Bladder tone (female urgency and stress incontinence)
• ↓ Bladder capacity
• ♂ Retrograde ejaculation
V
*
Nervi erigentes (parasympathetic)
• Arise from S2-S4
• Join the sympathetic hypogastric nerves on the pelvic sidewall to form the inferior hypogastric plexus
• Injury:
• Highest risk at time of:
• Distal anterolateral mesorectal dissection
• Consequence:
• ↑ Voiding difficulties (atonic bladder)
• ♂ Erectile dysfunction
• ♀ Impaired vaginal lubrication
*
Local recurrence rates were reduced with TME (from 30-40% to < 5-10%)
V
*
Circumferential Resection Margin (CRM) (target: > 2mm)
CRM status refers to the adequacy of the surgical resection margin relative to the 360-degree radial extension of the primary tumor, which may include extension into the mesorectum and adjacent extrarectal soft tissue.
NCCN: A positive CRM is defined as tumor ≤1 mm from the margin
Local recurrence rate:
• 16% in margin <2 mm Vs 6% if >2 mm
• 78% in margin <1 mm Vs 13 if >1 mm
DFS & OS are affected when CRM <2 mm
V
*
Distal resection margin (DSM) (2-5 cm*)
Traditionally: 2-5 cm, but EBM shows that following NACRT, intramural extension beyond gross mucosal edge occurs in <2% & is found within 1cm
Strive from ≥ 2 cm, but 1cm is likely adequate in cases of:
• NACRT
• ⊖ Adverse histologic features
Obtain intraoperative frozen section if the distal resection margin status is uncertain
Results from the Dutch TME trial showed that while in nearly 40% of cases the distance between the tumour and the distal margin was, 2 cm, there was no statistical difference in recurrence between patients with a distal margin < 2 cm compared to those with a distal margin > 5 cm.
V
>
The specimen
NCCN: The pathologist should evaluate the quality (completeness) of the mesorectum (only for low rectal cancer - distal 2/3).
>
Judging the adequacy of resection is done by evaluating:
>
CRM (positive; negative)
*
A specific term that applies only to rectal tumours
V
*
This margin refers to the non-peritonealised bare area of the rectum located both anteriorly and posteriorly
Screen Shot 2020-04-17 at 6.35.32 PM
Screen Shot 2020-04-17 at 6.38.20 PM
*
This is the single most important factor for predicting the risk of local recurrence in patients with rectal cancer
>
⊕ CRM is defined as (either):
>
Direct tumour extension (either continuous or discontinuous)
*
A radial margin of ≤ 1 mm is regarded as positive and there is adequate evidence that tumour within 1 mm of the CRM is associated with an increased risk of local recurrence
*
There is now evidence that tumour extension to within even 2 mm of the radial margin is predictive of a worse outcome
*
The presence of a positive LN within 1 mm of the radial, nonperitonealised soft tissue edge
*
Nagtegaal et al showed that patients with a ⊕ CRM due to direct tumour extension developed local recurrence more frequently than those with a ⊕ CRM due to ⊕ LN (22.1% vs 12.4%, p = 0.06); in fact, in their study there was no difference in the rate of local recurrence between patients with a ⊕ CRM due to ⊕ LN compared to those with a ⊖ CRM
>
TME quality (bulk; coning; surface defects; CRM irregularities)
*
Coning refers to the tendency for the surgeon to cut towards the tubular rectum during distal dissection and is an indication of suboptimal surgical quality
V
*
DRM (positive; negative)
“One final issue to keep in mind, when measuring the distal margin, is shrinkage artefact. Goldstein et al have shown that a 5 cm length of colorectum in vivo is equivalent to 3 cm after resection and 2.2 cm after fixation. Pinning of the specimen under tension on a corkboard helps to avoid shrinkage.”
V
*
Grading the quality of the TME
Screen Shot 2020-04-17 at 6.21.22 PM
>
Handling of the specimen
*
The mesorectal fat is inked about its CRM, including all non-peritonealised bare areas anteriorly and posteriorly
V
*
The rectum may then be opened anteriorly, apart from the segment 2 cm above to 2 cm below the tumour, where the specimen is left intact
Screen Shot 2020-04-17 at 6.30.10 PM
*
Pinning the specimen on a corkboard is helpful to prevent shrinkage artefact, and placement of a gauze wick within the lumen of the intact segment is necessary to optimise fixation
*
The duration of specimen fixation should be at least 48 hours - this is an important step, which facilitates serial cross-sectional slicing of the specimen.
*
The unopened portion of the fixed specimen is then sliced into thin transverse sections (3–5 mm in thickness)
*
The orientation of grossly suspicious nodes that are closely related to the CRM should be preserved in sections, while the remainder of the lymph nodes can be harvested in the usual manner
>
The adequacy of the resection correlates with outcomes
V
Local recurrence
*
Complete vs incomplete: 36% vs 20%
*
Complete vs nearly complete: no prognostic difference
V
For ⊖ CRM patients: overall recurrence is affected by the quality of the excision
*
Complete vs incomplete: 28.6% vs 14.9%
*
For ⊕ CRM patients: there is no added value to the assessment of surgical quality in predicting prognosis
*
Stents (see Large bowel obstruction)
*
Nd:YAG laser therapy may be the palliative treatment of choice in patients with rectal carcinoma unsuitable for surgery
>
NCCN summary for adjuvant therapy considerations in colon cancer
*
Bolus 5FU is better tolerated than capecitabine or infusional 5FU
*
For stage II colon cancer: A survival benefit has not been demonstrated for the addition of oxaliplatin to 5-FU/LV. FOLFOX is reasonable for stage II patients with multiple high-risk factors and is not indicated for good- or average-risk patients with stage II colon cancer.
>
For stage III colon cancer
*
FOLFOX is superior to 5-FU/LV
*
Capecitabine/oxaliplatin is superior to bolus 5-FU/LV
>
For patients with advanced or metastatic disease that are not appropriate for intensive therapy (oxaliplatin or irinotecan), chemotherapy options include:
*
5FU/LV ± Avastin
*
Capecetabine ± Avastin
*
Cetuximab or panitumumab (KRAS wild-type)
*
Nivolumab or pembrolizumab (for MMR deficient / MSI-H patients only)
*
Previous therapy with oxaliplatin (without irinotecan) precludes further treatment with it. Irinotecan can be given alone or as part of FOLFIRI
*
Previous therapy with irinotecan (without oxaliplatin) precludes further treatment with it. Oxaliplatin can be given alone or as part of FOLFOX/CapeOx
V
*
Previous therapy with FOLFOXIRI are managed with irinotecan with biologics
Screen Shot 2020-07-30 at 4.27.54 PM
>
Management of metastatic disease
*
With chemotherapy, median survival has improved from ~12m to ≥ 24-36m
V
Assessment of the nature of metastasis
>
Isolated metastases (liver or lung) may benefit from metastasectomy
V
*
Neoadjuvant therapy is considered for colon cancer, and preferred for rectal cancer
Screen Shot 2020-07-30 at 5.32.50 PM
*
Resection of extrahepatic metastasis that present at the same time have been associated with long-term survival, especially when it’s to lungs
>
Colorectal cancer liver metastasis (CRCLM)
V
Benefits of NACT
*
Assists in identifying patients who are better candidates for surgery
*
Avoids delay in starting chemotherapy as a result of postoperative complications
*
Contraindication to resection is the inability to resect all the hepatic disease
*
For survivorship with/without resection of metastasis, see Prognosis section
*
“A liver-first strategy should be adopted as cancer survival is related to burden of systemic disease rather than the primary tumor”
>
Fong clinical risk score
>
1 point for each:
*
N⊕ primary disease
*
DFS < 12m
*
> 1 liver tumor
*
Tumor size > 5
*
CEA > 200 ng/ml
*
Score Survival
2Y 5Y
0 79% 60%
1-2 74% 42%
3 67% 20%
4 45% 25%
5 45% 14%
*
20% of CRCLM are resectable upfront
*
Upfront resectable CRCLM not necessarily require NACT in the setting of a colon primary (for rectal primary, start with chemoradiation). Patients may undergo a single stage or two-stage resection with chemotherapy 2-3 months in between. “Consider disease burden: start with resection if the extent of metastatic disease if very limited. Otherwise: NACT → restaging → combined/staged resection”
V
>
Resection approach: combined Vs liver first Vs colon first
Perioperative mortality in experienced centers is consistently less than 2-5%
V
*
Patients have 30-50% morbidity
Complications are most commonly bleeding, bile leak, abscess, and other generalized cardiorespiratory complications
V
>
Only 20-30% remain free of recurrence long term and may be cured
Cameron: Almost 50% of patients undergoing a liver resection for metastatic colorectal cancer will survive 3 years and 20% will survive 10 years
*
Only 5% of those who have second recurrence with isolated liver involvement are candidates for second liver resection
>
Ovarian metastasis
*
Primary en bloc resection of CRC with direct extension to the ovary (T4) or resection of macroscopic metastatic disease to the ovary with prophylactic bilateral resection has been suggested to offer survival benefit and should be performed with curative intent in the absence of other significant metastatic disease.
*
Ovarian metastases are frequently resistant to systemic chemotherapy even when other sites of metastatic disease are responding, and therefore, resection of these synchronous metastases including bilateral oophorectomy and resection of gross disease should be performed at the index operation. i.e If 1 ovary is involved with metastatic disease, bilateral oophorectomy should be performed
>
Prophylactic oophorectomy should be considered when there are other risk factors for ovarian pathology:
*
HNPCC
*
BRCA
*
Postmenopausal women
>
Unresectable synchronous (liver/lung) metastases only:
*
Chemotherapy is the mainstay of treatment
V
*
For rectal cancer: radiation therapy is reserved until reassessment of response to determine resectability. Resectable disease is candidate for short-course radiation.
Screen Shot 2020-07-30 at 5.39.07 PM
*
Consider colon resection only if imminent risk of obstruction, significant bleeding, or tumor-related symptoms
*
Re-evaluate Q2m to assess for resectability
>
Synchronous abdominal/peritoneal metastasis
V
If colorectal peritoneal metastasis is diagnosed during a surgical procedure, it is recommended that surgical intervention and disruption of anatomical planes are kept to a minimum. In this context, in a case of impending intestinal obstruction, defunctioning stoma formation is preferred over resection — ASRCS
>
Role of surgeon:
*
Consider limited resection or stoma for impending obstruction
*
Biopsies
*
Explore the extent of the disease (PCI score)
*
Refer for peritoneal malignancy center
*
Nonobstructing → manage with chemotherapy
*
Indications to proceed with a planned colectomy in the event of intraOp discovery of peritoneal metastases: perforation, obstruction, or bleeding
*
Obstructing or imminent obstruction → manage with colon resection vs diversion vs bypass vs stenting
*
For patients with isolated peritoneal carcinomatosis from colorectal cancer, radical surgery to achieve an R0 resection (if it can be accomplished) remains the mainstay of treatment
>
Chemotherapy regimens
*
FOLFOX
*
CAPEOX
*
FOLFIRI (for unresectable metastatic disease)
*
FOLFOXIRI (for unresectable metastatic disease)
V
>
Everyone receives chemotherapy & is considered for new complementing agents (in addition to 5FU regimens)
Cameron: Combination chemotherapy, including 5-FU with irinotecan or oxaliplatin combined with targeted antiangiogenic antibodies such as bevacizumab (anti-VEGF antibody) or cetuximab (Erbitux; antiepidermal growth factor antibody) have now resulted in response rates of over 50% and median survivals of 20 months and longer for patients with advanced disease
Avastin, Panitumumab, and Cetuximab are given Q2w
Cetuximab can also be given Q1w
>
Cetuximab and panitumumab:
*
Effective only on tumors that do not have a mutation of the KRAS gene (i.e KRAS wild-type gene)
*
Given in conjunction with FOLFIRI or FOLFOX
>
Bevacizumab (Avastin®) is indicated for unresectable metastatic disease
*
It is associated with wound and anastomotic complications. Surgery should be delayed 6-8w from the last dose. Avastin may be resumed no sooner than 28d postOp
*
Multi-kinase inhibitor (Regorafenib) may be used for metastatic disease but not for non-metastatic
>
Left untreated, patients receiving multiagency palliative chemotherapy:
*
~7-30% of primary lesions progressed to require emergency surgery (obstruction or perforation)
*
~4% required a nonoperative intervention (e.g., stent or radiotherapy)
*
NCCN: “The panel cautions that the use of bevacizumab (Avastin®) in patients with colon or rectal stents is associated with a possible increased risk of bowel perforation”
>
Surveillance
*
NCCN: pTis is not considered a “malignant polyp.”
>
Stage I
*
Colonoscopy at 1Y postOp
*
Colon cancer stage I: imaging is not routinely indicated and should only be based on symptoms and clinical concern for recurrent/metastatic disease.
*
For rectal cancer after local excision, add proctoscopy (with EUS or MRI with contrast) every 3–6 mo for the first 2Y, then Q6m for a total of 5Y
>
Stage II-III
*
Hx + physical exam + CEA: Q3m X 2Y, then Q6m X3Y
*
CT chest/abdomen/pelvis: Q12m X5Y
V
>
Colonoscopy: at 12m postOp (or within 3-6m if not done completely preOp)
Canadian practice: Flexible sigmoidoscopy can be done in clinic Q3m to assess anastomosis for recurrence
*
If ⊕ adenoma → Q12m colonoscopy
*
If ⊖ adenoma → Q3Y colonoscopy
*
Unresectable disease: reassess/re-stage Q2m to assess for resectability when appropriate
>
Recurrent disease
V
16-66% of patients with CRC are symptomatic at the time of their Dx with recurrence
*
< 7% with symptomatic CRC recurrence have resectable disease
>
Most common pattern of recurrence after colon cancer
*
Peri-anastomotic: 36%
V
Peritoneal: 16%
>
Most frequent symptoms are
*
Ascites (29.7%)
*
Bowel obstruction (19.5%)
>
Sensitivity of CT to detect lesions:
*
< 5mm: 28%
*
> 2cm: 70%
*
Thus, indirect signs such as bulky primary tumor, ascites, or bowel obstruction are important clues
*
Mesenteric: 15%
*
Retroperitoneal: 12%
*
Following proctectomy, the 5Y local recurrence rate is 5-10%
>
Locally recurrent rectal cancer
>
Incidence of local recurrence: 4-8%
*
Recurrence of high rectal cancer: 5%
*
Recurrence of mid rectal cancer: 10%
*
Recurrence of low rectal cancer: 15%
>
Approach / Questions that need to be answered
*
1. What if we don't resect/is there value to surgery?
*
2. Determine resectability
*
3. Is there a roles Neoadjuvant therapy??
*
4. What's the role of IORT
V
*
5. Assess potential long-term complications
Mortality: 0-3%
Double stomas
Pelvic & limb instability
Sacral resection at S3-S5 is acceptable
Sacral resection at S1-S2 is controversial
Nerve injury
>
Principles for treatment
*
Approach must be multimodal
V
*
MUST obtain negative margins any means necessary — the surgeon must be very aggressive
5Y-survival of locally recurrent rectal cancer: 9%
Surgery 57% (median survival 21 months)
Radiation and/or chemotherapy 0% (12 months)
Palliative 0% (3 months)
*
Most important prognostic indicator is negative margins
*
Preserve uninvolved organs
*
Maintain quality of life
V
*
Indications for surgery: achievable R0 resection with acceptable resultant morbidity
The required plane of dissection is one plane deeper to the level of the tumor involvement
>
Contraindications to radical surgery
*
1. Proximal tumor invasion with extension into sacral promontory or sacral involvement above S2
*
2. Tumor encasement of iliac vessels
*
3. Extension of tumor into greater sciatic notch / Sciatic nerve involvement
*
4. Unresectable extra-pelvic disease
*
5. Bilateral ureteric obstruction (disease is resectable, but they have poor outcomes)
*
6. Circumferential involvement of pelvic sidewall
*
7. Medically unfit patients (ASA IV-V)
*
± Lower extremity edema
*
Perform extensive restaging with confirmed tissue Bx and PET/CT, & MRI
V
>
Classification of recurrence:
R0 is easier for central/anterior than posterior than lateral
Screen Shot 2021-03-07 at 19.24.40
*
Axial (anastomotic, perineal, luminal)
*
Anterior (urologic, gynecologic)
*
Posterior (sacrum, coccyx)
V
*
Lateral (pelvic sidewall structures: ureters, iliacs, nerves, bone)
Obtaining R0 resection is notoriously challenging in lateral pelvic sidewall involvement (one study suggests the rate of R0 resection in these cases is only 19%)
EBM: Iliac vessel involvement may not affect the ability to achieve R0 resection
*
Surgery is a multidisciplinary team contribution
*
Always try to place clips at the lateral margin because it tends to be positive on final resection and so (it helps guide adjuvant radiation)
>
Radiation therapy
>
Almost everyone should get NART, even if they received it with the primary rectal cancer treatment
*
Previously treated RT patients can get: 20-30 Gy
*
Chemotherapy may be added to radiation therapy but chemotherapy alone does not affect outcomes
*
IntraOp radiation is of greatest benefit for patients with R1 & R2
>
Recurrent peritoneal disease
*
NCCN: If an R0 resection can be achieved, surgical resection of isolated peritoneal disease may be considered at experienced centers
*
NCCN: The panel currently believes that complete cytoreductive surgery and/or intraperitoneal chemotherapy can be considered in experienced centers for selected patients with limited peritoneal metastases for whom R0 resection can be achieved
V
*
Recurrent metachronous metastases: is considered for PET scan then resected (preferred) if resectable
Screen Shot 2020-07-30 at 4.07.17 PM
*
Re-resection can be considered in selected patients
V
*
Rectal cancer: resectable metachronous metastases are preferred to go for upfront resection (but metastatic disease at presentation should undergo NACRT)
Screen Shot 2020-07-30 at 5.43.31 PM
>
Prognosis
*
Lymphocytic infiltration has been repeatedly shown to be a positive prognostic feature. Associated with MSI-H biology, and reflects activation from T-cells directed against tumor-specific carboxy-terminal frameshifts associated with MSI. MSI-H is also a positive prognostic feature, and seems to mitigate the poor differentiation (which is also usually seen in MSI-H tumors).
V
>
5Y survival:
Screen Shot 2021-03-21 at 19.34.14Screen Shot 2021-03-21 at 19.33.34
*
Stage I = 90%
*
Stage II = 75%
*
Stage III = 50%
V
>
Stage IV = 5%
Screen Shot 2020-10-11 at 7.16.42 PM
V
*
Survival of CRCLM on chemotherapy: ~2Y
For Stage-IV being treated with chemotherapy, median survival has improved from ~12m to ≥ 24-36m
V
Survival of CRCLM after resection of CRCLM:
*
⅓ of resections are curative
*
5Y survival increases to 43%
>
Left untreated, patients receiving multiagency palliative chemotherapy:
*
~7-30% of primary lesions progressed to require emergency surgery (obstruction or perforation)
*
~4% required a nonoperative intervention (e.g., stent or radiotherapy)
*
In CRCLM, it is the metastatic disease in the liver (particularly if >3 cm in size) that is the primary determinant of overall survival
*
PostOp local & systemic recurrence occurs in 30% of patients within 2Y
>
85% of recurrence is within 2Y of the time of resection
*
Isolated hepatic or pulmonary metastases are amenable to resection, with a 5-year survival rate of 20%
V
>
Risk factors for metacharonous CRC peritoneal metastases
Honoré C. Ann Surg Oncol 2013 Jan;20(1): 183-92
*
Synchronous resected primary tumor: ~ 70%
*
Synchronous ovarian metastasis: ~60%
*
Perforated primary tumor: ~50%
*
Mucinous adenocarcinoma: ~30%
*
T4 primary tumor: ~20%
*
Colon cancer: high LN yield is correlated positively with survival
*
Rectal cancer: Rates of distal recurrence after TME are as high as 18% in stage II disease and 37% in stage III disease
V
Consider additional surveillance beyond what is advised in patients with prognosis affected by:
*
Poor differentiation
*
Mucinous or signet-ring cell histology
*
LVI / PNI
*
EMVI
*
Tumor budding
*
DNA aneuploidy
*
BRAF mutation
*
↑CEA (especially postOp levels ≥ 5.0 ng/mL)
>
Being operated by a high-volume surgeon is associated with:
*
Lower mortality rate
*
↓ 30% in reoperation rates
*
↓ 25% in complication rates
V
>
Neuroendocrine tumors of the rectum
Screen Shot 2020-08-09 at 17.56.12
*
Overproduction of serotonin can consume up tryptophan and cause deficiency in niacin (B7) and nicotinamide (B3)
V
Workup
>
If diagnosed preOp:
V
MRI or Endorectal US
V
If T2-4:
*
Colonoscopy
*
Abdomen/pelvic CT
*
± SSR-PET/CT or SSR-PET/MRI
*
± Chest CT
V
>
Staging
Screen Shot 2021-06-10 at 12.15.45
V
T
*
T1: ≤ 2cm
V
*
T2: > 2cm or invades muscularis propria
T2 disease is associated with N⊕ disease in 47%
*
T3: invades subserosal tissue
*
T4: invades visceral peritoneum
V
N
*
N0
*
N1
*
< 1cm incidental lesions: complete endoscopic resection
*
If not incidentally noticed: require MRI or EUS
*
≤ 2 cm + minimally invasive T1 (not involving muscularis propria): endoscopic or transanal excision is sufficient
V
Indications for radical resection:
*
≥ T2 (involvement of muscularis propria or size > 2cm)
*
N⊕
*
Ki67 > 20%
>
Resection for all rectal NET
*
< 1 cm + incidental + completely excised = surveillance
*
< 1 cm + incidental + positive margin or intermediate grade = as below
*
PreOp stage T1 = TAE
*
PreOp stage T2-4 = LAR/APR
>
Symptomatic management for metastatic disease
*
Octreotide / lanreotide
*
Interferon-alpha
V
Surveillance
*
3-12 months: CT and chromogranin A (as clinically indicated)
*
From 1Y to 10Y: Q12-24 months: CT and chromogranin A (as clinically indicated)
*
No recommendation for colonoscopy
>
Atypical tumors
>
Carcinoids (See Appendix for details)
>
General
*
Carcinoid tumors are associated with an increased risk of synchronous colorectal and small bowel tumors, as well as metachronous lung, prostate, and urinary tract neoplasms
*
May arise throughout the colon; most commonly found in cecum
*
Malignancy is frequently associated with carcinoids > 2 cm with invasion through the muscularis propria.
*
Metastatic disease tends to occur less frequently in carcinoid tumors of the hindgut (rectum 18%) when compared with midgut carcinoids and foregut tumors
*
Hindgut carcinoids rarely produce serotonin
>
Workup
*
Colonoscopy
*
Endoscopic US
V
24h urine 5HIAA
*
Normal range: 2-8 mg/24h
*
Sensitivity: 73%
*
Specificity: 100%
V
Levels of 5HIAA may be influenced by Rx:
*
Bananas
*
Pineapples
*
Nuts
*
Avocadoes
*
CT chest/abdomen/pelvis
V
SRS
*
10% of tumors do not express somatostatin receptors
*
18F-Dopa PET/CT detects more true positives and is better tolerated by patients than SRS
>
Management
>
Small bowel
V
Carcinoids are frequently multi centric and have a propensity for developing symptoms/complications
*
Obstruction/intussusception
*
Mesenteric fibrosis
*
Kinking of the bowel
*
Size of the tumor is a poor predictor of distant metastases
V
Treatment:
*
1. Surgical resection with lymphadenectomy even in the presence of metastatic disease
*
2. ‘Run the bowel’ to ensure no multicentric disease is present
>
Colon
*
Often asymptomatic until they develop into large tumors
*
Treatment: colonic resection similar to that performed for adenoCa
*
Rectum (see NET of the rectum)
>
GIST (see gastric GISTs for details)
*
Tumors located in the colon/rectum account for 10-20% of GISTs (rectum > colon)
*
Resection is done either by radical resection or local excision, as long as the pseudocapsule can be removed with adequate margin
*
Local recurrence after complete resection: 50%
>
Lymphoma
*
70% of lymphomas occur proximal to the hepatic flexure
>
Risk factors
*
Family Hx of lymphoma
*
Hx radiation or chemotherapy
V
Immunosuppression
*
Prolonged steroid use
*
Azathioprine & mercaptopurine
*
Autoimmune disorders
*
IBD
V
Viral infections
*
HIV
*
EBV
*
HBV
>
GIT is the most common site of extra-nodal lymphoma
*
Stomach (75%)> small bowel & colon
*
Account for 0.4% of all colonic malignacies
>
Most frequent histologic types seen in the colon
*
NHL DLBCL is the most common
*
Follicular lymphoma
V
MALT-associated low-grade b-cell lymphoma
*
As opposed to the stomach, colon MALT lyhmphoma does not appear to be associated with H. pylori
*
Mantle cell lymphoma
V
T-cell lymphoma
*
More commonly associated with ulcerative lesions & perforation than B-cell lymphoma
*
There are only few case reports of primary GI Hodgkin Lymphoma
*
Determining the histologic type aids in guiding treatment options & expected outcomes
*
Begin in the submucosal lymphoid tissue and spread either by direct extension or through lymphatic channels
V
Most common presenting symptom: weight loss & abdominal pain
*
T cell lymphomas are more commonly associated with ulcerative lesions and perforation than B cell lymphomas
>
Endoscopic findings
*
Mucosal nodularity
*
Mucosal induration
*
Mucosal ulceration
*
Mass ± ulceration
V
Dx is made on histologic, flow cytometric, and molecular evaluation of adequate tissue specimen
*
FNA is usually inadequate to determine specific lymphoma subtype
V
Criteria to Dx of primary GI lymphoma:
*
Absence of enlarged superficial LN or mediastinal LN
*
Normal total & differential WBC
*
At laparotomy: a dominant bowel lesion ± only regional LN disease
*
Liver and spleen are unaffected
V
CT scan and double-contrast barium enema are complementary modalities to assess extraluminal as well as subtle mucosal changes
*
Radiologic findings may mimic IBD
*
Lymphoma is more likely than adenocarcinoma to show extension into the terminal ileum, have well-defined margins, preservation of fat planes, an absence of invasion into adjacent structures, and perforation with no desmoplastic reaction
>
Lymphoma is more likely than adenocarcinoma to show:
*
Extension into the terminal ileum
*
Well-defined margins
*
Preservation of fat planes
*
Absence of invasion into adjacent structures
*
Perforation with no desmoplastic reaction
V
Modified TNM staging
*
T stage is similar to adenoCa, but T1 is divided into T1mucosa (T1m) & T1submucosa(T1sm)
>
N
*
N1: ⊕ regional LN
*
N2: ⊕ intra-abdominal non-regional LN
*
N3: ⊕ extra-abdmoinal LN
V
M
*
M1: noncontinuous involvement of separate site in GI tract
*
M2: noncontinuous involvement of other tissues or organs
V
B
*
B0: no bone marrow involvement
*
B1: ⊕ bone marrow involvement
V
Management
*
One unique consideration: high risk of radiation to the bowel in contrast to nodal beds elsewhere in the body
*
Patients with existing symptoms are best treated with surgery prior to chemotherapy
*
In general, if the disease is not advanced (stage III/IV) and is resectable, treatment starts with surgery and likely adds chemoradiation afterwards
V
Rationale for surgery when the Dx is made preOp:
*
Possibly therapeutic surgery if the disease has not spread
*
Avoid risks of obstruction, perforation, & bleeding
*
May provide a chance to decrease chemotherapy administration → ↓ toxicity
V
DLBCL and Burkitt’s lymphoma are usually quite sensitive to multiagent immunochemotherapy, which can be curative, even in advanced-stage disease.
V
*
For stage I/II DLBCL, surgery followed by chemotherapy is associated with lower recurrences & improve 3Y OS
Untitled
V
Rationale for & against upfront chemotherapy:
*
Possibility of avoiding surgery
*
One potential risk is perforation of the bowel if chemotherapy causes tumor necrosis
*
Disease control may be inferior to surgery and adjuvant chemotherapy
V
MALT lymphoma
*
Small, shallow lesions: ESD if amenable
*
Deeper and larger lesions: surgery ± radiation
*
Chemotherapy is considered in the setting of positive margins not amenable to radiation
*
Disseminated disease: chemotherapy
>
Leiomyosarcoma
*
Is very rare
*
Reports advocate for surgical treatment as soon as Dx is established
*
The decision between wide local excision Vs more aggressive (APR) surgery remains controversial
>
Diverticular disease
>
General
V
*
> 60% of affected individuals are older than 80Y
Although there is some evidence that young patients present with a more virulent form of the disease, it is not clear that these patients will go on to have a recurrence. — ASCRS Textbook
*
10-25% of diverticulosis patients will have acute diverticulitis
V
*
The incidence of diverticulosis/diverticulitis is increasing
Diverticulosis is a common condition of Western society and seems to be an unfortunate product of the Industrial Revolution. It is interesting that there seem to be no specimens of colonic diverticulosis in anatomic or medical museums in Europe that were archived before the Industrial Revolution
*
Sites of diverticulae are on the mesenteric side of the antimesenteric taeniae
*
Some estimate that in Asia, 70% of the diverticula is isolated to the right side
V
>
Histopathology
It is likely that a number of processes including impaired motility, low fiber intake, inflammation, and elastin deposition contribute to the pathogenesis of diverticular disease.
*
Fiber deficiency is related to diverticular disease
*
Colonic wall thickening is secondary to elastin deposition & not muscular hypertrophy or hyperplasia
*
The incidence of bleeding diverticular disease is < 20%
>
Risk factors
*
Recent data suggest that younger and older patients have similar severity of disease
*
♂:♀ ratio between 2:3 and 3:1
*
⊕ Family Hx of sibling with diverticular disease = 3X greater risk than the general population
*
Physical activity is protective against diverticular disease
*
Obesity
V
*
NSAID/ASA
“Evidence suggests that chronic NSAID use is almost twice as common in patients with diverticular disease as healthy controls with no known colonic disease.
While the health professionals follow-up study showed an increased incidence of uncomplicated diverticular disease in patients who used NSAIDs compared with their asymptomatic counterparts, additional studies have noted an increased risk of complicated diverticulitis with NSAID use. One retrospective study showed a 23% higher risk of perforating diverticulitis in patients who took NSAIDs regularly compared with patients with diverticular disease who did not take NSAIDs.” ASCRS Textbook
V
*
Smoking is associated with ↑ risk of diverticular disease in women
“The potential association between diverticular disease and smoking is contradictory” ASCRS Textbook
V
>
Factors not associated with ↑ risk of diverticulitis:
Reference - JAMA 2008 Aug 27;300(8):907
*
Nuts
*
Corn
*
Popcorn
*
Berries
V
*
15% of diverticular disease includes involvement of the ascending colon
Left-sided diverticular disease associated with higher rate of surgery than right-sided disease
Reference - Dis Colon Rectum 1995 Jul;38(7):755
>
Workup & classification (diverticulitis)
V
*
CT is the gold-standard, but US has a diagnostic accuracy of 97%, and MRI a sensitivity of 94% & specificity of 92%
The selection among CT, MRI, and ultrasound examinations varies considerably among institutions, but all three techniques have been shown to be useful in establishing the diagnosis of diverticulitis
*
US is highly sensitive and specific if done by an experienced operator
V
*
Hinchey / Modified Hinchey correlates with postoperative morbidity & mortality
Hinchey Classification
I: Pericolic abscess or phlegmon
II: Pelvic, intra-abdominal, or retroperitoneal abscess
III: Generalized purulent peritonitis
IV: Generalized fecal peritonitis
Modified Hinchey Classification
0: Mild clinical diverticulitis
Ia: Confined pericolic inflammation, phlegmon
Ib: Confined pericolic abscess
II: Pelvic, distant intra-abdominal, or retroperitoneal abscess
III: Generalized purulent peritonitis
IV: Generalized fecal peritonitis
V
*
Colonoscopy is usually delayed for 6w to avoid converting a sealed perforation into a free one
“This position has been questioned by other groups who have demonstrated that colonoscopy during an acute episode of diverticulitis can be safe” ASCRS Textbook
V
*
CRP level of ≥ 150-175 mg/L are indicators of complicated disease with higher chance of surgical intervention
Predictors of acute diverticulitis severity: A systematic review
James P.L. Tan a, b , Ahmed W.H. Barazanchi c, * , Primal P. Singh a , Andrew G. Hill a, b , Andrew D. Maccormick
V
*
CRP level may distinguish between complicated and uncomplicated disease among left-sided diverticulitis patients including those taking aspirin, but not among those on corticosteroid treatment
C-reactive protein as a marker of complicated diverticulitis in patients on anti-inflammatory medications
E. Nizri • S. Spring • A. Ben-Yehuda • M. Khatib • J. Klausner • R. Greenberg
>
Presentation & variants
>
Symptomatic Uncomplicated Diverticular Disease (SUDD)
*
Patients present with classical symptoms but lack confirmatory blood tests or imaging
*
Sabiston: Diverticular-Associated Colitis: In severe cases, mucin depletion, chronic architectural distortion, cryptitis, and crypt abscesses may be detected
*
They tend to have cyclic episodes of LLQ pain
*
⅓ of patients with an acute uncomplicated attack develop chronic symptoms
V
Management:
*
Increase fiber (30g/d) & water intake
*
Avoid foods high in fats
*
Consider surgery if symptoms impair quality of life
>
Acute Uncomplicated Diverticulitis
*
Medical therapy is successful 75-90% of the times
*
High fiber diet or dietary fiber supplement may reduce symptoms
*
Recent evidence now suggests that omitting Abx is safe
V
>
Indications for admission:
IV antibiotics for only 1 to 2 days may have similar outcomes as IV antibiotics for 7 days in treatment of acute uncomplicated diverticulitis (level 2 [mid-level] evidence) — Reference - Int J Colorectal Dis 2010 Nov;25(11):1363
*
Peritonitis
*
Inability to tolerate PO diet
*
Suspected complicated diverticulitis
V
>
Outpatient management entails:
Outpatient treatment often successful in patient with mild-to-moderate acute colonic diverticulitis (level 2 [mid-level] evidence) — (mild-to-moderate acute colonic diverticulitis (defined by ultrasound findings ranging from limited inflammation within diverticulum to abscess < 2 cm)) — Reference - Aliment Pharmacol Ther 2005 Apr 1;21(7):889
*
Clear liquid diet X 2-3 days
*
± Antibiotics
*
Follow up in 2-3 days
V
Antibiotic regimen
V
*
Single-agent regimen exhibit similar efficacy to two-agent regimen
ASCRS Textbook
V
*
Usual antibiotic regimens
For mild symptoms in outpatient setting, consider one of
trimethoprim-sulfamethoxazole DS 160/800 mg orally every 12 hours
ciprofloxacin 750 mg orally every 12 hours plus metronidazole 500 mg orally every 6 hours
levofloxacin 750 mg orally every 24 hours plus metronidazole 500 mg orally every 6 hours
consider one of suggested second-line regimens:
amoxicillin-clavulanate extended release (ER) 2,000/125 mg orally every 12 hours
moxifloxacin 400 mg orally every 24 hours
For mild-to-moderate symptoms in inpatient setting, consider one of
piperacillin-tazobactam 3.375 g IV every 6 hours or 4.5 g IV every 8 hours
ticarcillin-clavulanate 3.1 g IV every 6 hours
ertapenem 1 g IV every 24 hours
moxifloxacin 400 mg IV every 24 hours
For severe symptoms and inpatient management, consider one of
imipenem-cilastatin 500 mg IV every 6 hours
meropenem 1 g IV every 8 hours
doripenem 500 mg IV every 8 hours
V
*
Intermittent use of rifaximin may decrease likelihood of symptoms at 6-12m in acute uncomplicated disease
Rifaximin (Xifaxan) is an antibiotic structurally similar to rifampin and is not absorbed systemically.
addition of rifaximin to fiber supplementation associated with lower likelihood of symptoms at 6-12 months in patients with symptomatic uncomplicated diverticular disease (level 2 [mid-level] evidence)
Reference - Aliment Pharmacol Ther 2011 Apr;33(8):902 EBSCOhost Full Text
DynaMed commentary -- concept of symptomatic diverticular disease may be irritable bowel syndrome (IBS) in patient with diverticula; rifaximin reduces symptoms in patients with IBS
V
*
Optimal daily fiber recommendation ~ 20-30g (after acute attack)
Fiber found in fruits and vegetables conferred the most protective effect (compared with fiber from cereal), and a high intake of total fat and red meat increased the incidence of diverticular disease
V
V
5-Aminosalicylic Acid drugs:
“In a systematic review which included six randomized trials of 5-ASA products in the treatment of diverticulitis, patients treated with 5-ASA products had better outcomes than those not treated with 5-ASA. They also concluded, however, that larger trials which had objective confirmation of diagnosis by endoscopy are needed for confirmation of the initial data on this type of treatment” ASCRS Textbook
*
5-aminosalicylic acid medications may reduce recurrence and persistent symptoms in patients with uncomplicated diverticular disease (level 2 [mid-level] evidence)
*
Daily mesalazine therapy may be more effective than intermittent therapy to prevent recurrence and other complications following an attack of acute diverticulitis (level 2 [mid-level] evidence)
*
For diverticulitis patients: rifaximin/mesalamine (vs. rifaximin only) had significantly improved bowel habits, less recurrent episodes and lower symptom severity
*
Probiotics may be associated with longer remission
>
Recurrent Diverticulitis / Risk of recurrence
>
Start with ruling out other etiologies:
*
IBD
*
Ischemic colitis
*
Colorectal cancer
*
Gynecologic pathologies
*
IBS
>
Recurrences after acute uncomplicated diverticulitis
*
Overall recurrence rate: 13-33%
*
Rate of complicated recurrence: 5%
*
Rate of recurrence requiring emergency surgery: 1%
*
The risk of recurrence (and developing a complicated recurrence) increases if the first attack was complicated by an abscess (larger risk for bigger abscesses)
>
Risk of recurrence tends to increase with every subsequent episode
*
~20% recurrence after 1 attack
*
~30% recurrence after 2nd attack
*
~80% recurrence after 3rd attack
>
Recurrence after colectomy
*
Following resection, the most established risk factor for recurrent diverticulitis is the level of anastomosis
>
(Albany, 2020) & (Cleveland Clinic, 2003):
*
4.2-5% recurrence rate
*
0.3-0.4% reoperation rate
*
Mean time to recurrence: 55-78 months
V
Sparing of the sigmoid increases recurrence rate by 4 folds
>
Mayo Clinic recurrence:
*
22.7% in colocolic anastomosis
*
6.2% in colorectal anastomosis
>
Cleveland Clinic recurrence:
*
12.2% in colocolic anastomosis
*
2.8% in colorectal anastomosis
>
Smoldering Diverticulitis
*
This presentation only partially improves on antibiotics and medical therapy
*
Patients have recurrent symptoms which can manifest with ongoing low-grade fever
*
These patients often require resection to treat ongoing symptoms
>
Complicated
>
Bleeding diverticulosis
*
Typically experienced as abrupt onset of passage of red blood. Melena can happen
*
Stops spontaneously with bowel rest in 70-80%
*
After nonoperative management, the lifetime risk of rebreeding is 35%
>
Indications for surgery:
*
Requirement of more than 4-6 PRBC within 24h
*
Continued bleeding after 72h
*
Rebleeding within 1 week of the initial episode
V
>
Phlegmon/Abscess
The mortality rate with medical treatment of diverticular disease in patients with significant comorbidities is high (up to 60% in some trials), and the threshold for surgical intervention should be low
*
Occur in 15-20% of patients with diverticulitis
*
Abscesses less than 4 cm in size often resolve with intravenous antibiotics alone without the need for further procedures — ASCRS Textbook
V
*
28% symptomatic recurrence rate in patients having nonoperative management of diverticular abscess (level 2 [mid-level] evidence)
Reference - Dis Colon Rectum 2014 Dec;57(12):1430
*
The decision for surgery following successful drainage of a diverticular abscess should be approached on a case-by-case basis — ASCRS Textbook
>
Fistula
V
*
Fistulas occur in 2% of patients with diverticular disease
Diverticulitis is a more common cause of a fistula between the colon and bladder than Crohn’s disease or cancer
V
V
Colovesical is the most common form (65%)
Coloappendiceal; Colocolonic; Colocutaneous; Coloenteric; Colouterine; Colovenous; Cologastric; Coloperineal;Coloperianal; Coloureteral; Colovaginal; Colovesical; Colovesicovaginal
*
Cystoscopy & colonoscopy is indicated to exclude malignancy, when it is suspected
V
*
The fistula is generally small ± may be suture repaired
The bladder defect is usually so small that no closure is necessary, and healing will occur if the bladder is drained with a Foley catheter or suprapubic cystostomy for 7 days after the operation — Sabiston
*
Often, pinching off the fistula tract may be sufficient
*
Omentum is used to interpose tissue between the colonic anastomosis & the bladder
*
Prior to proceeding with surgery, ensure that the fistula site is not to the trigone of the bladder as that will require urology to assist in
>
Perforation
V
*
1% of patients with diverticulitis develop free perforation
Free perforation almost exclusively develops on the first attack of diverticulitis and is generally not seen in patients who have had multiple attacks of diverticulitis. — ASCRS Textbook
*
Reported mortality rates are 6% for purulent and 35% for fecal peritonitis
V
>
Surgical options
Risk factor for mortality in emergency surgery:
- Corticosteroid therapy or immunosuppression
- ASA > 3
- Hinchey IV
- Malnutrition
- Recent radiation
- Ascites
- Loss of autonomy
- Dyspnoea
- CKD
V
Resection vs lavage
V
>
Surgical considerations:
Although diverticulitis may only involve a portion of the sigmoid colon, the entire sigmoid should be resected and anastomosis performed to the proximal rectum.
V
*
The proximal resection margin = healthy descending colon with absence of thickened & inflamed tissue
It is not necessary to resect all proximal diverticula
*
Distal resection margin = proximal rectum
*
When inflammatory changes involve the upper rectum, the primary anastomosis potentially to the mid-rectum with proximal fecal diversion may be performed
*
Avoid incorporating diverticula in the proximal side of the anastomosis
>
Laparoscopic Peritoneal Lavage (LPL)
V
*
Laparoscopic Peritoneal Lavage is a conservative alternative to urgent resection in Hinchey III diverticulitis, as well as Hinchey I and II diverticulitis, after failure of medical treatment to avoid stoma creation or even elective sigmoid colectomy, which is performed in 38% to 51% of cases after Laparoscopic Peritoneal Lavage
Emergency Surgery in Acute Diverticulitis: A Systematic Review Dis Colon Rectum 2019; 62: 00–00
V
*
SCANDIV trial showed no difference in mortality between Hartmann’s vs laparoscopic lavage, but had 4X higher reoperation rates following lavage
Reference - SCANDIV trial (JAMA 2015 Oct 6;314(13):1364)
*
LADIES trial (LOLA group) compared LPL with urgent sigmoid colectomy (HP or primary resection with anastomosis (with or without diversion)) for Hinchey III: The trial was prematurely terminated because of increased morbidity in the LPL group. The 30-day mortality was comparable
*
DILALA trial compared LPL with HP for Hinchey III. Reoperation rate was significantly higher in the LPL group. Short-term morbidity was comparable between groups
>
Predictors of failure of LPL:
*
↑ CRP
*
Age > 65Y
*
ASA > 2
*
Presence of chronic rheumatologic disease or CKD
V
*
“In conclusion, LPL is not a good option for the surgical management of Hinchey III/IV diverticulitis.”
Emergency Surgery in Acute Diverticulitis: A Systematic Review Dis Colon Rectum 2019; 62: 00–00
V
>
Primary Resection & Anastomosis ± diversion Ileostomy (PRA±I)
Pasted_Graphic_48
V
6 systematic reviews concluded that PRA±I was superior to HP for Hinchey III and IV diverticulitis.
*
For guidelines, most concluded that the type of procedure depended on septic parameters (especially septic shock), whereas in the Danish guidelines the choice between PRA±I and HP was not settled in Hinchey IV diverticulitis.
V
*
A meta-analysis by Constantinides et al: Mortality was similar in PRA±I has similar morality rate to HP but with fewer wound & deep sepsis events
A meta-analysis by Constantinides et al included 15 studies composed of 963 patients. Mortality was similar in PRA±I and HP in the case of Hinchey III/IV diverticulitis (14.1% vs 14.4%; OR = 0.85 (95% CI, 0.36–2.01); p = 0.71), as well as operative time and LOS. However, there were fewer wounds and deep sepsis in the case of PRA±I
V
*
A meta-analysis by showed PRA±I to be significantly associated with reduced mortality & LOS (whereas morbidity was similar between groups)
V
*
PRA may be associated with lower mortality than HP in patients with Hinchey III or IV colon diverticulitis (level 2 [mid-level] evidence)
Reference - Int J Colorectal Dis 2013 Apr;28(4):447
*
PRA+I improves stoma reversal rate compared to HP in patients with perforated colon and peritonitis (level 1 [likely reliable] evidence)
V
*
“In total, the results of recent meta-analyses and RCTs on Hinchey III/IV diverticulitis indicated in the short term similar morbidity and mortality and reduced LOS with HP. In the long term, more definite stoma, along with a worse QoL with HP and finally a higher morbidity with Continuity Restoration after HP, was indicated.”
Dis Colon Rectum 2019; 62: 00–00
Emergency Surgery in Acute Diverticulitis: A Systematic Review
>
Hartmann’s Procedure (HP)
*
Biondo et al specified that HP was restricted to patients with a bad prognosis — see “risk factors for morality in emergency surgery”
>
Indications to perform HP rather than PRA+I:
*
Diffuse peritonitis
*
Hemodynamic instability
*
ASA > 3
*
Immunosuppression / malnutrition / severe anemia
*
Edema of the bowel at the proposed site of anastomosis
*
Pooled rates:
Procedure Morbidity Mortality
Resection + PA 31.7% 3.8%
Resection + PA + Diversion 23.7% 7.2%
Hartmann’s 49.5% 17.4%
V
*
Laparoscopic vs open: “In summary, patients who fail nonoperative treatment of Hinchey I/II diverticulitis are candidates for either laparoscopic or open colonic resection, but there are insufficient data to fully support the use of laparoscopy for colonic resection in Hinchey III/IV diverticulitis. Moreover, as explained above, LPL is not a good option for the surgical management of Hinchey III/IV diverticulitis.”
Dis Colon Rectum 2019; 62: 00–00
Emergency Surgery in Acute Diverticulitis: A Systematic Review
V
>
Perforated diverticulitis associated with 24.3% mortality — significant risk factors for death:
Reference - Br J Surg 2008 Jul;95(7):876
*
Preexisting renal disease
*
Increased age (especially if > 65Y)
*
Preexisting NSAID use
>
Obstruction / colonic stricture
V
*
Classic procedure for obstruction is Hartmann’s procedure.
Alternatives (in select patients) include a sigmoid resection with primary anastomosis & diverting ileostomy; resection, on-table lavage with primary anastomosis; or colonic stenting followed by semi-elective sigmoid resection
In the past, persistence of obstruction after treatment with antibiotics typically required sigmoid resection, end colostomy, and Hartmann closure of the rectum because of the concern about the increased risk of anastomotic leakage in patients who had dilated and edematous bowel or who were not able to undergo preoperative mechanical bowel preparation. While the Hartmann resection is still an excellent option in selected patients, other options include sigmoid resection with primary anastomosis and diverting proximal stoma (usually a loop ileostomy), on-table lavage and primary anastomosis, or colonic stenting placement followed by semi-elective sigmoid resection.
V
*
On-table lavage may be performed through the appendix, cecostomy, or ileostomy
Screen Shot 2020-12-02 at 16.43.40
*
Colonic stenting followed by semi-elective sigmoid resection is associated with high rate of stent migration as well as other delayed complications
*
Many patients with atypical presentations of diverticulitis may have irritable bowel syndrome
>
Following non-operative management
V
*
Prevention recommendations lack strong evidence
Limited evidence for efficacy of measures to prevent recurrent diverticulitis episodes, but consider:
supplemental or increased dietary fiber
rifaximin
antispasmodics
mesalamine: Mesalazine 800 mg twice daily for 10 days every month may reduce symptoms more than rifaximin in uncomplicated diverticular disease (level 2 [mid-level] evidence)
probiotics (such as Lactobacillus casei): length of remission was significantly longer when a probiotic was administered (14 months vs. 2.4 months). Although the initial results are promising, there is only a small amount of data supporting the use of probiotics.
exercise
weight loss if body mass index ≥ 30 kg/m
smoking cessation
V
Follow up
*
Failure of uncomplicated diverticulitis to improve within 2-3 days should trigger additional imaging to rule out complication
V
Colonoscopy in 4-8w to evaluate luminal disease (rule out malignancy & IBD)
*
Risk for colon cancer is higher with complicated diverticulitis compared to uncomplicated (11% vs 0.7%)
*
Routine colonoscopy for CT-proven uncomplicated diverticulitis may be unnecessary
*
Early (in-hospital) colonoscopy may be safe but may not be more useful than delayed colonoscopy in patients with CT results (level 2 [mid-level] evidence)
V
Elective surgery
*
See “Perforation” for surgical considerations
V
*
ASCRS practice parameters do not consider the number of episodes as a definite indication for elective surgery
Salem and associates have determined that performing colectomy after the fourth episode of diverticulitis, rather than after the second episode, in patients older than 50 years results in 0.5% fewer deaths, 0.7% fewer colostomies, and a reduction in cost per patient — Sabiston
*
“The risk of needing a colostomy following a successfully managed episode of diverticulitis is small (1/2000). Therefore, the practice of recommending elective surgery to avoid future stoma formation should be avoided” — ASCRS Textbook
*
The decision to perform elective surgery after uncomplicated diverticulitis is on a case-by-case basis and individualized to each patient
*
Immunocompromised patients have greater risk for recurrent complicated diverticulitis. Operative treatment during the first hospitalization may be required. The decision to offer sigmoid colectomy after recovery from uncomplicated acute diverticulitis in immunosuppressed patients should be individualized.
*
Elective resection in anticipation of transplantation remains controversial
>
Colitis, proctitis, IBD & IBS
V
*
Traveller’s diarrhea usually has no colitis or blood/pus in the stool. ETEC is treated with azithromycin
The symptoms of travellers' diarrhea depend upon the microbial etiology. The classic "turista" due to enterotoxigenic Escherichia coli (ETEC) generally produces malaise, anorexia, and abdominal cramps followed by the sudden onset of watery diarrhea. Very frequent stools are uncommon. Nausea and vomiting also may occur. Typically there are no symptoms of colitis such as blood or pus in the stool. Patients may develop a low grade fever
In general, we use azithromycin or a fluoroquinolone. In particular, azithromycin is the preferred option for patients with fever or dysentery (bloody or mucoid diarrhea), pregnant women, children, and for travelers to locations (such as Southeast Asia) where fluoroquinolone-resistant pathogens are prevalent. Fluoroquinolones had long been the first choice for treatment of travelers' diarrhea, but the emergence of resistance to this drug class and increased awareness of adverse events make the risk-benefit assessment less clear
V
>
Microscopic colitis
Screen Shot 2021-02-17 at 14.46.21
>
Collagenous colitis
*
Generally occurs in ♀ >50Y
*
Typically presents with profuse watery, non-bloody, diarrhea
*
Characterized histologically by marked thickening of the colonic subepithelial basement membrane
*
On endoscopic evaluation, the mucosa appears normal in most patients and the diagnosis is made by (random) endoscopic biopsy (2 Bx per segment)
>
Management is medical
*
Cessation of NSAIDS
*
Antidiarrheals may be used alone in patients with mild diarrhea
*
For active disease, start with budesonide 9mg QD± cholestyramine
>
2nd line medical therapy:
*
Bismuth subsalicylate
*
Prednisone
*
Mesalamine
*
Lymphocytic colitis
>
Behcet’s colitis
*
Behcet’s disease is a chronic, multisystem, vasculitic disease
*
HLA-B51 gene has been associated with the disease
>
Presentation
*
Typical onset: 3rd decade of life
*
Prevalence is high along the Silk Road, with Turkey having the highest prevalence
>
Clinical manifestations of Behçet syndrome are believed to be due to vasculitis
>
Intestinal Behcet’s
*
Ulceration (typically in the ileocecal area; involvement of the anus and rectum is exceptionally rare)
*
Anorexia
*
Vomiting
*
Dyspepsia
*
Diarrhea
*
Gl bleeding
>
Extraintestinal Behcet's
*
Recurrent oral ulcers
*
Arthritis
*
Uveitis
*
Thrombophlebitis
>
Dx
*
Primary Dx is by clinical findings
*
Nonspecific findings: ↑CRP; ↑IgD & IgA; ⊖ ANA antibodies; ⊖ Rheumatoid factors
*
Pathergy test is not specific
V
Diagnostic criteria:
>
Recurrent oral ulceration plus 2 of the following
*
Recurrent genital ulcers
*
Eye lesions (retinitis; uveitis)
*
Skin lesions (erythema nodosum; papulopustular lesions)
*
Positive pathergy reaction
*
Endoscopy: colonic ulcerations can take any shape and are usually large, deep, and “volcano-like”, and they are prone to progression and complication
V
*
Intestinal manifestation can be confused with IBD
Screen Shot 2021-03-16 at 19.36.41
>
Management
>
Medical management
*
First line: Sulfasalazine/mesalamine; corticosteroids
*
Second line: Azathioprine and thalidomide
>
Biologics
*
Infliximab
*
Adalimumab
>
Surgical management
*
Indications for surgery are similar to IBD
V
*
Early surgery may result in lower postoperative clinical recurrence & reoperation than late surgery
Dis Colon Rectum 2012; 55: 65–71 DOI: 10.1097/DCR.0b013e318238b57e
Early surgery was defined as:
“The early-surgery group included those patients who were first diagnosed with intestinal Behcet’s Disease at surgery”
“In some patients, intestinal BD is first diagnosed at surgery with an acute or complicated presentation. These patients undergo surgical intestinal resection at the time of diagnosis without receiving any specific medical treatment for intestinal BD. This surgical diagnosis group could be considered a surrogate model of “early surgery.””
Screen Shot 2021-03-16 at 19.55.21
V
*
Limited resection is more favorable than an extended one (as extended resections may not affect recurrence)
Choi IJ, KJm JS, Cha SD, Jung HC, Park J-G, Song IS, Kim CY. Long-term clinical course and prognostic factors in intestinal Behget's Disease. Dis Colon Rectum 2000;43:692-700.
V
>
Recurrence of intestinal lesions maybe be higher than with IBD
Choi IJ, KJm JS, Cha SD, Jung HC, Park J-G, Song IS, Kim CY. Long-term clinical course and prognostic factors in intestinal Behget's Disease. Dis Colon Rectum 2000;43:692-700.
*
25% at 2Y
*
50% at 5Y
>
Neutropenic enterocolitis (typhlitis)
*
Occurs most commonly in individuals with hematologic malignancies
*
The cecum is usually affected — with extension into ascending colon & terminal ileum
>
Pathogenesis
*
Mucosal injury by cytotoxic drugs
*
Impaired host defences
*
Rare reports have described it in otherwise healthy non-neutropenic adults following ingestion of food contaminated with C. perfringens type A
>
Presentation
*
It is considered in any severely neutropenic (ANC < 500 cell/microL) patients with fever & abdominal pain
*
Frequently occurs during the 3rd week after receiving cytotoxic chemotherapy
>
Evaluation
*
CT with IV & PO contrast should be given, when feasible
*
Rule out C-Diff & CMV colitis
*
Consider graft-versus-host disease — usually occurs after engraftment, while typhlitis occurs before engraftment
>
Management
>
Non-complicated disease
*
Bowel rest, IV fluids, NGT suction
*
Anticholinergic, antidiarrheal, and opioid agents should be avoided since they may aggravate ileus
*
Nutritional support (TPN)
*
Blood product support (PRBC, FFP)
>
Broad-spectrum Abx: tazocin, cefepime + flagyl, or imipenem-cilastatin
*
Abx (IV or PO) are continued for 14d following recovery from neutropenia
*
Antifungals (voriconazole) are started for protracted fever (>72h) despite Abx
*
The use of G-CSF in patients with neutropenic enterocolitis remains controversial
>
Surgical resection & stoma formation is reserved for complicated disease
*
A surgeon may be tempted not to resect edematous bowel without apparent severe inflammation or gangrene. The caveat is that diffuse mucosal necrosis may be present underneath unimpressive serosal inflammation; incomplete removal of all necrotic tissue uniformly results in death.
V
>
Infectious colitis
Ciprofloxacin is appropriate for all bacterial infections except for:
- Campylobacter infections for whom azithromycin 500mg TID X 3-5d is used
- EHEC or EAEC (see below)
- TB
IMG_0287
IMG_0291
*
Infectious colitides that mimic ulcerative colitis must be evaluated via stool culture.
Shigella, Salmonella, Yersinia, C-Diff, and CMV must be specifically queried
*
Campylobacter jejuni is a leading cause of infectious colitis worldwide and has become one of the major causes of infectious diarrhea in the United States. Only severe disease requires treatment ciprofloxacin or azithromycin
*
Patients infected with Yersinia enterocolitica typically present with bloody diarrhea and abdominal pain. Enteritis will resolve with supportive care alone. Severe cases may require aminoglycosides or trimethoprim-sulfamethoxazole
*
Salmonella typhi may rarely cause massive LGIB. Gangrenous cholecystitis has been reported with typhoid fever. Treatment is with Ciprofloxacin or Ceftriaxone
>
CMV colitis
*
Positive CMV antibody titers merely signal current or previous CMV infection (worldwide prevalence of CMV is in the order of 50%), but negative IgM titers means that the patient is highly unlikely to carry CMV and sigmoid biopsies are not required
*
Endoscopy shows patchy erythema: replication in the host cell typically manifests pathologically with large intranuclear inclusion bodies and smaller cytoplasmic inclusions, and is accompanied by the presence of CMV viral particles in the plasma
*
It is rare in immunocompetent patients
*
May present with bloody diarrhea
*
Treatment is with ganciclovir (foscarnet reserved for resistant cases)
>
Amebiasis
*
Incidence: worldwide with high rates in India, Africa, Mexico, & parts of Central and South America
V
Presentation
*
Subacute onset over 1-3w
*
Cecum and colon are the most common sites of involvement
V
Symptoms range from mild diarrhea to severe dysentery
*
Abdominal pain
*
Diarrhea (in 94-100%)
*
Bloody stools (94-100%)
*
Fulminant amebic colitis
*
Fever (in 38%)
V
Management
*
All E. histolytica infections should be treated, even in the absence of symptoms, given the potential risk of developing invasive disease and the risk of spread to family members
V
*
Invasive colitis: Flagyl followed by paromomycin (to eliminate intraluminal cysts)
Invasive colitis is generally managed with metronidazole (alternative therapies include tinidazole, ornidazole, and nitazoxanide), followed by a luminal agent (such as paromomycin, diiodohydroxyquin, or diloxanide furoate) to eliminate intraluminal cysts
*
A 10-day course of metronidazole eliminates intraluminal infection in many cases, but a second agent is still warranted
V
>
C.Diff Infection (CDI)
Most antibiotic-associated diarrhea is not attributable to C. difficile infection (but rather to osmotic mechanisms), whereas antibiotic-associated diarrhea associated with colitis is nearly always C. difficile–associated diarrhea
>
Microbiologic considerations
>
Pathogenicity Locus Genes
V
PaLoc encodes for toxins A (tcdA) and B (tcdB)
>
The most commonly discussed regulatory genes within PaLoc are:
*
tcdR
>
tcdC
*
Recognized as a risk factor for severe forms of disease
*
Associated with C.Diff outbreaks
*
tcdD
>
Binary toxin (CDT)
*
The binary toxin (CDT) is not as prevalent as toxins A and B.
*
Presence of binary toxin and a tcdC truncation is associated with higher incidence of recurrent infections with OR=5.3
V
Toxins A & B are considered part of the Large Clostridial Toxin (LCT) family
*
Studies using isogenic strains producing either toxin A or B were shown to be capable of causing life-threateningly severe CDI in rodents
*
The most frequently identified hypervirulent strain is known as B1, NAP-1/O27, toxigenotype III, or PCR-ribotype 027
*
Ribotype 078 harbors CDT in addition to tcdA and tcdB, and it has been associated with greater severity of disease than other non-027 ribotypes
*
Patients who maintain a carriage state without symptoms of CDI are those who have the ability to develop an antibody to toxins A and B
*
> 30% of Abx-associated diarrhea is 2ry to CDI
*
Colitis typically begins within 4-9d after the initiation of Abx, although some may have delayed symptoms up to 2-3 months
V
>
Characteristics of C. Diff diarrhea:
Patients who do not exhibit these kinds of bowel symptoms should not be tested for CDI
*
Watery stools
*
≥ 3 times / day
*
Without intervening constipation or formed BM
>
Additional risk factors
*
Age > 65Y
*
Recent hospitalization
*
Use of PPI
*
Immunocompromise
*
IBD is a significant risk factor for developing CDI and for requiring surgery
V
*
Diarrhea may be associated with mucus or occult blood. Occasionally, infection presents acutely with ileum with little or no diarrhea
For patients with ileus and suspected C. difficile infection, laboratory diagnosis via perirectal swab for toxin assay or anaerobic culture may be performed; the sensitivity of rectal swab for C. difficile culture in the setting of ileus is high (although takes time)
*
Fulminant infections occurs in 1-8% of cases and is associated with mortality rates in the range of 30-90%
*
Toxin B is the clinically important toxin
>
Workup
V
*
Testing
Screen_Shot_2019-07-22_at_10.36.06_PM
Cell culture cytotoxicity assay – The cell culture cytotoxicity assay was developed contemporaneously with the discovery of C. difficile and has been used as a gold standard test for diagnosis of C. difficile; it is more sensitive than enzyme immunoassay, although it is limited by lack of standardization and slow turnaround time (approximately two days)
>
2-step testing is preferred because no single test has a high enough sensitivity & specificity to reliably distinguish between asymptomatic carriers and symptomatic CDI
>
Initial screening (high sensitivity)
*
GDH: ↑sensitivity; ↓specificity
>
Nucleic acid amplification testing (NAAT) uses PCR to detect for toxin A or B genes
*
C. difficile DNA may linger within stool for as long as 30 days after resolution of infection, leading to a false-positive test
V
Institution of PCR testing, although more expensive, is associated with:
*
↓ days of patient isolation
*
↓ tests ordered
*
↓ empiric Abx treatment
*
Stool cultures are impractical for clinical use & do not differentiate between active infection and the presence of Clostridium spp. bacteria)
*
Confirmatory antigen recognition (high specificity for toxins)
*
In places where 2-step testing or toxin-based testing is not available, NAAT alone may be used, but the results should be interpreted in the context of risk factors and symptoms suggestive of CDI
*
Fecal leukocyte testing is not helpful for diagnosis of C. difficile infection
>
Endoscopy has a limited role in distinguishing C.Diff from other colitides (CMV, graft-vs-host disease, IBD, & ischemic colitis). This is further limited by the development of PCR-based stool assays that are rapid and have high sensitivity & specificity
*
It may be helpful for patients with ileus or fulminant colitis in the absence of diarrhea since it may allow visualization of pseudomembranes
*
The finding of luminal disease is unlikely to provide useful information to guide patient care decisions or direct the timing & extent of colectomy.
*
Endoscopy also lacks a validated predictive value in guiding medical or surgical therapy or providing prognostic information
>
Radiology
*
Fulminant colitis will frequently show ascites
*
Older data suggests that CT findings correlate poorly with the clinical severity of disease
*
~40% of patients will no radiologic evidence of colitis
*
The "accordion sign" is highly suggestive of pseudomembranous colitis; it consists of mucosal edema and inflammation involving the large bowel and is seen when orally administered contrast material becomes trapped between thickened haustral folds, giving the appearance of alternating bands of high attenuation (contrast material) and low attenuation (edematous haustra)
V
Management
*
The length of time from onset of symptoms to initation of treatment directly correlates with mortality
>
ASCRS CPG 2021: Probiotics may be useful in preventing CDI, but not in treating CDI. Grade of recommendation: Weak recommendation based on high-quality evidence, 2A.
*
A meta-analysis of 20 trials with almost 4000 patients demonstrated a reduced incidence of CDI associated with the use of probiotics (RR, 0.34; 95% CI, 0.24–0.49)
*
Despite extensive analyses regarding probiotics, questions regarding efficacy, the optimal agent(s), length of therapy, and dosing remain unanswered
>
Medical
*
Stop inciting Abx as soon as possible
V
ASCRS CPG 2021: Oral vancomycin or fidaxomicin is considered first-line treatment for an initial CDI, whereas metronidazole alone is no longer considered appropriate first-line treatment.
Grade of recommendation: Strong recommendation based on high-quality evidence, 1A
*
Fidaxomicin is associated with fewer CDI recurrences and higher rates of treating CDI than vancomycin, but higher costs prevent widespread use as 1st line agent
*
There has been a rise in resistance to metronidazole over the past 20Y
*
Combination therapy (vancomycin + metronidazole) is associated with ↑AE & is not typically recommended unless patients have severe-complicated or fulminant CDI
V
Duration of therapy
*
Not otherwise on Abx: 10-14 days
*
On Abx: continue therapy until cessation of offending Abx & extend an additional week after completion
*
Vancomycin enemas (for patients in ileum) or irrigations through a colonic tube may be used. The typical dose is 500 mg in 100 mL of NS given as a retention enema or irrigation administered Q6h
*
Tigecycline is a useful antibiotic in patients who need a broad-spectrum antibiotic that is also active against C. difficile
*
Fecal Microbiota Transplantation can be administered via NG, upper endoscopy, enema and colonoscopy (see recurrent disease for details)
V
Indications for Fecal Microbiota Transplantation currently include:
*
At least three episodes of CDI unresponsive to standard treatment
*
CDI not responding to therapy after a week
*
There is no role for repeat laboratory testing or testing for cure
>
Surgical
*
Surgery is required for complicated or progressive disease
V
Consider early surgery for patients with the following indications
*
Underlying IBD
*
Recent surgery
*
Prior treatment with IVIG
*
Vasopressor treatment
*
Signs of impending perforation
*
The mortality after colectomy for CDI has been reported to be 34-57%; although the cause of postoperative mortality is often related to the patient’s chronic comorbidities, and not to surgery
V
When the decision to resect has been made, the surgeon must proceed with a total colectomy with end ileostomy. A segmental colonic resection should not be performed for CDI regardless of the perceived extent of disease
*
Because C difficile colitis is a mucosal-based disease, a reliable assessment of the extent and severity of disease cannot typically be made by assessing the serosal surface of the bowel.
*
Retrospective studies comparing the extent of resection demonstrated, in general, lower mortality with total colectomy than with segmental resection (11%–56% total colectomy vs 14%–100% partial colectomy).
*
Partial colectomies were associated with ~16 % need for reoperation to resect additional colon
>
Alternative surgery for C-Diff: loop ileostomy with colonic lavage
V
Who to consider it for:
*
Patients who will not fare well with an end colostomy that is likely to be permanent
*
Patients with high mortality risk for colectomy
>
Technique
*
1. Visual assessment for colonic viability
*
2. Creation of loop ileostomy
*
3. Lavage: 8L of warmed PEG drained via a rectal tube
*
4. Postoperative antegrade enema: Vancomycin 500mg in 500ml of RL Q8h X 10days
>
Outcomes
*
93% do not require colectomy
*
79% have ileostomy reversal in 6 months
*
These results however have not been replicated, and so no clear evidence exists to suggest which patients benefit from this approach
V
Recurrent/nonresponding disease
*
Defined as recurrence of symptoms with ⊕ stool test within 8w after completion of therapy with resolution of symptoms
*
12-64% of treated patients will experience recurrence; 65% of those will develop additional recurrences
>
Risk factors for CDI recurrence
*
Age
*
Abx use after completing treatment for CDI
*
PPI use
*
Neutropenia
*
Infection with certain C. Diff strains
>
Bezlotoxumab, a monoclonal antibody that binds exotoxin B, administered concurrently with treatment of CDI, can decrease the risk of recurrence in patients at higher risk due to advanced age, immunosuppression, IBD, or other comorbidities
>
A single dose of 10mg/kg infused during Abx course is associated with:
*
40% relative risk reduction in recurrent CDI
*
↓ Length of hospital stay
*
Cost of bezlotoxumab may be prohibitive
*
Most recurrences present within 1-3 months after discontinuing antibiotic therapy
*
In general, patients are not treated by simply repeating the same regimen.
V
Strategies for subsequent recurrences:
*
Tapering & pulsed Abx strategies over 4-6w
*
In general, conventional antibiotic treatment should be used for at least 2 recurrences (ie, 3 CDI episodes) before offering fecal microbiota transplantation
>
Fecal Microbiota Transplantation
V
*
Most common delivery method is through colonoscopy; alternatively through NGT or oral capsules
Given active disease in the colon, consider NGT administration if possible
*
Most protocols require the patient to be off of Abx for ≥ 36h before the transplant
*
Overall success rates for fecal transplantation, regardless of the delivery mode, are reported to be between 60-90% after a single treatment
V
Predictors of failure of FMT after a single infusion by colonoscpy:
*
Severe CDI
*
Inadequate bowel preparation
V
*
The anion-binding resins colestipol and cholestyramine are not effective as primary therapy for C. difficile colitis, although they may be beneficial as adjunctive therapy for relapsing infection
Anion-exchange resins bind vancomycin as well as toxins; thus, the resin must be taken at least 2-3h apart from the vancomycin
ASCRS CPG: Toxin-binding agents such as cholestyramine and colestipol are also used as adjuncts for recurrent CDI with variable success.
V
*
Rifaximin may be used to treat recurrent CDI and has a moderate success rate (53%–67%) in this setting.
However, because of the propensity of C difficile to develop resistance to rifaximin, this drug should typically be used in combination with other recommended agents
*
Tigecycline can successfully treat otherwise multidrug-resistant strains of C difficile
*
Giardia lambda is a common cause of colitis in patients with history of hiking/camping
*
Cryptosporidium is more commonly seen in immunocompromised patients
>
Actinomycosis
*
Caused by Actinomyces israelii, an anaerobic gram-positive bacterium; a normal part of GI flora
V
Active infection results after
*
Break in mucosal defences
*
Presence of necrotic tissue
*
Infection results in formation of draining sinuses, fistulas, & abscesses [may be confused with IBD]
V
Manifestations
V
Systemic
*
Fever / chills
*
Night sweats
*
Weight loss
*
Thoracic
V
Abdominal
*
Usually involves the appendix/cecum
*
Manifests as slow growing mass with obstructive symptoms and localized peritonitis
*
May form fistulas to the abdominal wall
*
Dermal
V
Dx is by either
*
Culturing A. israelii
*
Microscopic identification of characteristic yellow (sulfur) granules
V
Treatment
*
Penicillin IV X 4-6w then oral penicillin X 6-12m to avoid relapse
*
Surgery is reserved for complications or when Dx is not definitive
>
IBD
>
Disease prevalence is higher in:
*
Higher socioeconomic populations
*
Urban areas
*
Geographic regions rather from the equator
>
Pathogenesis
*
The current theory on the etiology of inflammatory bowel disease is an exposure to an environmental factor of host or foreign origin in the individual with a genetic predisposition to dysregulated immunity
V
*
The NOD2/CARD15 gene, (involved in bacterial recognition and response), is the most commonly associated gene in IBD
NOD2: nucleotide-binding oligomerization domain-containing protein 2; AKA caspase recruitment domain-containing protein 15 (CARD15)Screen Shot 2022-01-11 at 18.17.39
V
*
Biological characteristics of CD & UC
Memory queues:
— Paneth cells are only present in the small bowel (i.e associated with CD but not UC)
— Th2 are highly associated with UC, whereas other T-cells are associated with CD
Screen Shot 2022-01-11 at 17.33.19
>
The presence of a family member with IBD is the number one risk factor for developing the disease
*
~ 40% of IBD patients have ≥ 1 affected family member
*
Affected family members from “IBD families” are generally concordant for age of onset, localization, and disease behaviour
*
Genetics play a stronger role in CD than UC
*
> 300 SNPs over 150 genetic loci/genes have been associated with IBD. No single gene appears to be causative of either CD or UC. Inheritance is not the simple Mendelian pattern seen in some disease.
*
Anti-inflammatory prostaglandins are involved in epithelial mucosal repair. Prostaglandin E receptor 4 (PTGER4) SNPs have been associated with the development of CD. A similar association has not been found in UC
*
Although the majority of such IBD alleles are associated with both CD and UC, others are exclusive to one or the other disease
*
Despite intense early interest, no role for Mycobacterium avium subspecies paratuberculosis (MAP) in IBD has been proven to date, and these “familial” cases were likely due to a shared genetic predisposition
V
*
Pathogens associated with IBD (highlighted in green seem to be protective)
Screen Shot 2022-01-11 at 17.43.21
*
Of all environmental factors studied, tobacco smoking has the most replicated association with IBD. The association appears to be “dose dependent”
*
Despite lack of clarity, avoidance of NSAIDs (except aspirin) is currently recommended in most IBD patients.
*
An increased likelihood of being diagnosed with CD is found in the first year following appendectomy by meta-analysis. However, this rate falls to that of the general population within 5 years
V
Immunity in CD
V
Innate immunity in CD
V
Epithelial barrier function & pathogen recognition
*
Tight junction abnormalities in IBD patients facilitate the uptake of antigens leading to inflammation and the release of cytokines such as interleukins, TNFα, and IFNɣ which in turn further propagate tight junction permeability
*
The NOD2/CARD15 pathway plays a role in recognition of MDP on the bacterial wall ultimately leading to NFkB activation that then results in changes in nuclear transcription of relevant inflammatory genes
*
Dendritic cells are the Antigen Presenting Cells most implicated in the pathobiology of IBD. “Leaky” epithelial barrier may allow increased DC-antigen contact and an overstimulation of the systemic immune system
>
Autophagy
*
TLR2 and TLR4 have been demonstrated to play the most prominent roles in IBD
*
The main site of autophagy is the small intestinal Paneth cell; thus autophagy plays a stronger role in the pathobiology of CD than UC
>
Adaptive immunity in CD
*
T cell-mediated adaptive immune responses are better characterized in the pathobiology of IBD than the B cell response
*
The secretion of the key immunological defense molecule, IgA, is the main function for B cells in IBD elucidated to date
V
Immunity in UC
V
Innate immunity in UC
>
Epithelial barrier function & pathogen recognition
*
The epithelial barrier plays a greater role in the pathobiology of UC as opposed to CD since the inflammation of UC is limited to the mucosa of the colon and rectum
*
Paneth cells are only found in the small intestine; thus they do not play a role in the pathobiology of UC
*
Two genes POU5F1 and LAMB1 are exclusively associated with UC, suggesting a greater role in epithelial barrier function in UC vs. CD
>
Autophagy
*
As granulomas are not found in UC, the role of macrophages in UC is likely limited to the production of proinflammatory cytokines and the activation of NK and dendritic cells
V
Adaptive immunity in UC
V
*
During differentiation, a Th2 cell bias leading to increased production of IL-4, IL-5, and IL-13 has been associated with UC
Screen Shot 2022-01-11 at 18.24.14
V
The most commonly studied autophagy-associated genes in IBD are:
*
NOD2 / CARD 15
*
ATG16L1
*
IRGM
V
>
Neoplasia in IBD
Screen Shot 2022-01-11 at 19.01.12
*
APC mutations are involved in the first step of progression from normal tissue to sporadic cancer. However, APC mutations are involved relatively late in the progression from inflammation to IBD-associated cancer
V
Surgical genetics
*
Three loci (IL-23R, IL-12B, & chromosome 11 open reading frame 30) are associated with increased need for surgery within 5Y of Dx of IBD
*
SNPs in the PTGER, NOD2, and TNFSF15 have also been associated with Crohn’s-like pouch complications (i.e., fistula, abscesses) and severe pouchitis after IPAA
>
Markers for disease
*
Inflammatory markers allow for excluding IBD Dx in patients with functional bowel disorders without invasive studies
>
Calprotectin
*
The presence of calprotectin in stool implies mucosal inflammation, which is nonspecific, and can also occur with mucosal bleeding
>
It has been used in:
*
Dx
*
Prediction of clinical course
*
Monitoring response to therapy
>
PostOp surveillance
*
In post-resection CD, fecal calprotectin >200 μg/g has been shown to be predictive of endoscopic recurrence after 12 months
*
Calprotectin was superior to CRP and a clinical disease index (CDAI) for detection of recurrence and monitoring response to treatment
*
A meta-analysis showed good sensitivity (93%) and specificity (96%) of fecal calprotectin to diagnose IBD in adult patients, although specificity (76%) was much lower for pediatric patients
>
CRP
*
Tends to be elevated in CD > UC
*
CRP tends to be a less reliable predictor of endoscopic disease in the postoperative CD patient
>
Endoscopy
*
Flexible endoscopy remains a gold standard technique in the initial diagnosis and follow-up management of suspected/established IBD
*
There are no specific guidelines for routine colonoscopy during medical therapy for IBD
*
Colonoscopy is recommended 6–12 months after surgery for CD, as anastomotic recurrence is common (60–90% at 1 year)
*
Meta-analysis has shown Video Capsule Endoscopy to have higher diagnostic yield than colonoscopy, push enteroscopy, conventional enterography, and CT enterography. VCE was found to be similar to MR enterography in those same reviews. Capsule retention is a rare, but feared, complication of VCE. Reported rates of capsule retention in CD patients are around 13%
V
>
Medical management
pyramid-1405x812-squashed
V
*
Crohn’s disease agent selection
Screen Shot 2021-10-27 at 16.19.47
>
UC Management
V
>
Mild-moderate distal colitis/proctitis = “bottom-up” approach
1
*
Suppositories are appropriate for proctitis without proximal involvement
*
Foams reach the sigmoid
*
Enemas may reach the splenic flexure
*
In moderately severe disease: PO + topical therapy is more effective than topical mesalamine alone in both achieving and maintaining remission
*
In either distal or extensive colitis not responding to 4w of aminosalicylate therapy, a course of oral steroids is indicated. This is usually started at 40–60 mg of prednisone per day.
>
Remission can be maintained by either: aminosalicylates, thiopurines, or infliximab
*
The choice of maintenance therapy is chiefly determined by the method by which remission was induced
*
Alternately, patients with a single episode of mild disease may opt for clinical observation alone.
V
>
Severe colitis
For toxic colitis and fulminant colitis, see Indications for Surgery
*
Hydrocortisone 300mg QD X 3-5d given under observation
V
20-40% with severe UC will fail to improve on IV steroids
*
Some 25–36% of patients with steroid-refractory UC have CMV disease in colonic biopsies
*
Continued PO diet is encouraged in most patients; but bowel rest may be indicated if BMs are excessive
*
Use of cyclosporine or infliximab is highly effective in steroid-resistant severe UC, with response rates of up to 82–83%. On the other hand, it has proven difficult to maintain remission in responders, with up to 54% of patients subsequently requiring colectomy
>
General guidelines for treatment of UC
*
Mild-moderate chronic UC is typically treated in a bottom-up manner with PO aminosalicylates, and if steroids are required for flares, then the patient is transitioned to AZA/6MP or a biologic agent to wean the steroids
*
Moderate-severe disease is typically treated in a top-down manner with combination therapy with a biologic agent and immunomodulator, often under the cover of temporary steroid treatment
>
Perianal Crohn’s disease
*
Corticosteroids are ineffective and should be avoided
*
There is no evidence that aminosalicylates play any role in the treatment of perianal Crohn’s disease
*
Infliximab (Remicade®), adalimumab (Humira®), and certolizumab (Climzia®) have been shown to be effective for perianal Crohn’s disease
*
Probiotics are ineffective for both induction and maintenance of remission in CD
>
Abx
*
Metronidazole is effective for active colonic and ileocolonic CD but not upper GI inflammation
>
Aminosalicylates (sulfasalazine; mesalamine)
*
Clinical effects of PO aminosalicylates are apparent in 2-4h
*
Patients who take sulfasalazine must also take folic acid (1 mg daily) because the medication depletes folic acid stores.
*
Topical steroids have similar efficacy to topical mesalamine in achieving remission in active disease
>
Three release mechanisms of the drug (mechanism dictates target area of bowel)
*
pH: Asacol®, Lialda®
*
Time-release: Pentasa®
V
Bacterial cleavage release: Azulfadine®
V
*
5-ASA is released in the colon when bacterial azo-reductases cleave the diazo bond
Newer sulfasalazine-like drugs (e.g., mesalamine) provide for a slow release of 5-aminosalicylic acid during their passage through the small bowel and colon
>
It’s the most common treatment (induction & maintenance) for mild-moderate UC
*
Salicylates can be used in the treatment of active disease at higher doses and also play a role in maintaining remission at lower doses
*
High doses are associated with ↑AE but are not more effective at induction of remission than moderate dose
*
“Bidirectional therapy” (PO + PR) is well known to be more effective than either alone. However, patients are often resistant to the daily use of suppositories or enemas
>
In context of CD
*
Given its reasonable side effect profile, mesalamine remains 1st-line therapy for CD
*
The effectiveness of sulfasalazine alone in the treatment of Crohn’s disease limited to the small bowel is controversial
*
In contrast to its use in UC, sulfasalazine has not been conclusively proven to maintain remission in Crohn’s disease or to prevent recurrence after surgery
>
AE
*
GI
>
Dermatologic
*
Sun exposure can lead to severe sunburn
>
Corticosteroids
*
Topical steroids have similar efficacy to topical mesalamine in achieving remission in active disease
*
Highly effective in the treatment of active UC & Crohn’s disease but are ineffective in maintaining remission in Crohn’s disease
>
Should not be used for maintenance therapy because of their AE profile
*
Long-term therapy (>1Y) is contraindicated
*
Inability to wean off chronic steroids represents an indication for surgery
>
Prednisone is generally prescribed in dosages of 40–60 mg daily for 2–6 weeks to induce remission
*
Maximum-effective dose is 300 mg hydrocortisone per day (equivalent to methylprednisone 60mg)
>
Duration of therapy & tapering
*
Prednisone 40-60mg QD X 2w
*
Taper 5mg Qweek
*
Steroids act to block phospholipase A2, thereby decreasing prostaglandins and leukotrienes
*
Patients weaning from steroids should anticipate symptoms of physical and emotional withdrawal from the steroids such as decreased energy and mood
>
Budesonide has a high first-pass hepatic metabolism, which allows for targeted delivery to the intestine while mitigating the systemic effects of steroid therapy
*
Budesonide is effective for chronic UC
*
Budesonide at any dose to maintain remission is no more effective than placebo, but significantly more toxic
*
Hydrocortisone enemas delivered BID-TID are often effective in the treatment of disease limited to the rectum and left side of the colon, these have the benefit of less absorption and therefore fewer systemic side effects
*
½ of patients treated for active symptoms with a glucocorticoid will be “steroid resistant” or “steroid dependent”
*
PreOp ‘high dose’ steroids is defined as > 20mg prednisone / day and is associated with ↑ postOp infectious complications
>
Immunomodulatory agents mostly applies to Crohn’s Disease
>
In context of Crohn’s disease
*
Immunomodulators are of limited use for induction of remission, but successfully maintain remission in many patients
>
Indications
V
*
Inducing remission
They are useful in inducing remission in patients who are refractory to 5-ASA
*
Allow steroid tapering in patients with “steroid-resistant” or “steroid-dependent” disease
*
Maintain remission in patients with quiescent disease
*
Clinical benefit may not be evident until 6–12w after initiation of therapy, but tends to be durable
*
The relapse rate following immunomodulator cessation in patients receiving immunomodulator monotherapy for maintenance of remission is nearly 20% at 1 year
*
Immunomodulatory therapy is associated with a marginally increased risk of lymphoma, but the absolute risk is small
*
Use of immunomodulators has not been associated with increased postOp complications
>
Thiopurines (AZA (Imuran®) & 6-MP)
*
Azathioprine is effective in inducing and maintaining remission, but its effects are slow with the time of onset measured in months, requiring overlap with an extended course of oral prednisone.
*
6-Mercaptopurine is a purine analogue, and azathioprine is its precursor
>
Exert a glucocorticoid-sparing effect for patients who cannot maintain remission when glucocorticoids are tapered and withdrawn
*
They are seldom used by themselves and are often started upfront with steroids (top-down or step-up therapy) to induce remission in a top-down manner. The steroids are then weaned, and the TP used as a maintenance drug
*
Since thiopurines are immunosuppressive, any active infections must be treated prior to initiating therapy
V
In TMPT-deficient patients, active metabolites are not efficiently degraded resulting in supra-therapeutic AZA concentrations → myelosuppression
*
Prior to starting therapy, TPMT enzyme activity or genotype should usually be assessed
*
Monitor CBC Q1–2w initially and subsequent to a dose change, then at least Q3m thereafter to detect evidence of acute or delayed bone marrow suppression
V
*
Relative risk of failure to prevent disease relapse on withdrawal of azathioprine: 0.39
This translates into 201 fewer disease relapses per 1000 patients for those continuing azathioprine compared with azathioprine withdrawal
>
Methotrexate
*
Antimetabolite, specifically inhibiting folic acid metabolism by competitive inhibition of DHFR
*
Dose: 25 mg SC/IM Q1w
*
Folic acid (1 mg daily) should be concomitantly prescribed
V
*
After remission has been achieved, a dose of 15 mg Q1w may be effective
Moderate quality evidence indicates that methotrexate at a dose of 15 mg weekly is superior to placebo for maintenance of remission in Crohn’s disease and appears to be safe [48]. Conversely, low-dose oral methotrexate (12.5–15 mg/week) does not appear to be effective for maintenance of remission
*
Although MTX may be used in the treatment of CD, at present there is no evidence supporting the use of MTX for induction or maintenance of remission in chronic UC
>
Cyclosporine and tacrolimus
*
Because of their AE profile, it is typically reserved for use in acute severe UC and refractory CD (rescue agent)
V
>
Biologics
Screen Shot 2022-01-13 at 07.33.45
>
Pretreatment assessment (because of risk of reactivation)
*
HBsAg, HBsAb, HBcAb
*
Tuberculin skin test
*
± HCV
*
± HIV
*
UTD: For most patients with fistulizing moderate to severe Crohn disease (eg, perianal or intestinal fistula), we use combination therapy consisting of TNF-inhibitor and an immunomodulator (eg, azathioprine [AZA], 6-mercaptopurine [6-MP], or methotrexate)
V
>
Anti-TNF
Screen Shot 2021-10-27 at 15.42.24
*
Active infection is an absolute contraindication to treatment with any TNF inhibitor
*
The best outcomes of anti-TNF therapy are seen in combination with other medications such as thiopurines
V
>
Infliximab (Remicade ® — 5 mg/Kg IV Q8w) is a first line agent, shows a clinical response in 70% & can induce remission.
Randomized trials have confirmed that infliximab maintenance therapy is superior to episodic delivery based on exacerbations and potentiates the benefit of azathioprine maintenance therapy
*
Loss of responsiveness can be managed with ↑dose to 10mg/Kg Q4-8w
>
Adalimumab (Humira® — 40 mg SC Q2w) is indicated for use in patients with moderate-to-severe CD and those with moderate-to-severe UC
*
Similar to infliximab albeit less powerful
*
Humira may be more convenient for patients since they self-administer, but some patients may be less compliant because patients may not be self-medicating
*
Although highly effective in the initial treatment stages, some patients lose response over time and the medication may need to be administered Q1w
*
Certolizumab Pegol (Cimzia®)
*
Golimumab (Simponi®)
>
Potential AE:
*
Susceptibility to infections (invasive fungal and other opportunistic infections)
*
Lymphoma
*
Tuberculosis reactivation
*
Demyelinating CNS lesions
*
Activation of latent multiple sclerosis
*
CHF exacerbation
>
Integrin receptor antagonist:
>
Should not be used in combination with immunomodulators or anti-TNF medications due to the risk of developing Progressive Multifocal Leukoencephalopathy
*
PML is caused by JC virus, although an immunocompetent immune system will prevent disease development
>
Natalizumab (Tysabri®)
*
Indication: inducing and maintaining remission in patients with moderate-severe CD who have inadequate response to or are unable to tolerate conventional therapies & anti-TNF agents
>
Vedolizumab (Entyvio®)
*
Monoclonal Ab to intern α4β7 (AKA Payer’s patch adhesion molecule (LPAM-1). Blocking this receptor results in upregulation of anti-inflammatory pathways
V
*
Anti-IL12/23 Ab: Ustekinumab (Stelara®) is approved by the FDA for use in adult patients with moderate to severely active Crohn disease who had failed standard therapy
UTD: We use ustekinumab as second line therapy after anti-TNF agents have been tried
*
Cessation of the anti-TNF agent in combination therapy (anti-TNF with immunomodulators) is associated with a 50% recurrence rate after 2 years. These findings suggest that a deescalating treatment strategy should be largely limited to patients with a high risk for severe adverse events and patients in deep remission
*
Anti-TNF therapy in the setting of an inflammatory mass (ie, phlegmon) with a concomitant abscess typically carries a low risk when initiated after intravenous antibiotics and PD of the abscess, as needed
*
Tofacitinib and methotrexate are not safe during pregnancy, however the remaining medications probably are.
*
There is mounting evidence that mucosal healing is a better target in IBD treatment than clinical symptom control, as it can alter the course of disease, reducing hospitalizations and rates of future surgery
>
Ulcerative Colitis
>
General
*
The goal for treating UC is to resolve symptoms and achieve mucosal healing, defined as the resolution of inflammatory changes on endoscopic evaluation
*
There appears to be seasonal variation in the activity of the disease: onset & relapse more often between August-January
V
*
75% have pANCA⊕
The presence of pANCA has been used as a diagnostic test to help differentiate ulcerative colitis from Crohn’s disease
*
Pain is uncommon except in severe active disease
*
After long-term medical therapy, patients tend to experience constipation
V
*
Backwash ileitis = severe inflammation of the cecum causing an inflamed terminal ileum
Dr. Hyman — Determining Crohn’s vs backwash ileitis: it’s backwash ileitis if colonoscopy was normal and then the pathologist calls inflammation post-resection. If it was evident grossly, then it is likely Crohn’s Disease
*
10% of patients will require surgery within the 1st year of Dx
>
Ultimately, 20-40% of patients with UC will require surgery
*
50% of those who do not undergo surgery will have active disease
*
50% of the who do not undergo surgery will be in remission
>
Disease behaviour
*
The disease location remains stable for the majority of patients. 5-15% develop proximal progression over 5Y
*
In distal disease (proctitis only): up to 20% will have spontaneous resolution
>
10Y colectomy rate is 9-21%
*
Pouchitis: 50% within 5Y
*
Pouch failure
*
♀ infertility
*
Nocturnal incontinence
>
Risk factors
*
Family Hx of IBD is the most prominent risk factor
*
It is more common in whites, Jews, and persons of northern European ancestry.
*
OCP
>
Environmental stimuli:
*
↑ sugar consumption
*
Low-fiber diet
*
Food allergies
*
Food additives
*
Infectious agents
*
Shortened breastfeeding time
*
Cigarette smoking is protective in UC, whereas it is a risk factor for developing (& for more severe) Crohn’s Disease
>
Pathologic findings:
*
Inflammation of the mucosa & submucosa, sparing the muscularis
V
Clinicians should be aware of certain instances where macroscopic inflammation in UC may not be in a continuous pattern. These situations are often confused with Crohn’s disease
*
Among medically treated UC patients, both oral and per rectum, 33–44% have been shown to have some patchy distribution of inflammation
V
Grossly: Pseudopolyps (more common in UC than CD), or inflammatory polyps, represent regeneration of inflamed mucosa and are composed of a variable mixture of non-neoplastic colonic mucosa and inflamed lamina propria
*
Significant pseudopolyposis may make surveillance unreliable by obscuring the mucosa or being too numerable to sample
*
Grossly: colonic strictures occur in up ate 12% of chronic UC
*
The most characteristic lesion is the crypt abscess, in which collections of neutrophils fill and expand the lumina of individual crypts of Lieberkühn (less likely seen in CD; may be seen in infectious colitis). Crypt branching may be seen in chronic ulcerative colitis and is an important characteristic
*
The number of goblet cells in the crypts is diminished, as is mucus production (not seen in Crohn’s disease)
*
Basal plasmacytosis is an early feature of UC and can be used to help differentiate it from infectious colitis
>
Dx: The combination of clinical disease activity, endoscopic findings, and histology generates accurate diagnosis
*
ASCA⊖ + pANCA⊕ = 98% specificity for UC
*
Other than in hospitalized patients, CRP tends not to be elevated in UC. It’s elevation may signal a Dx of Crohn’s Disease, super-infection, or severe acute colitis.
>
Classification of severity
V
*
Truelove-Witts classification of severity
Truelove-and-Witts-classification-of-severity-of-ulcerative-colitis-on-admission
V
>
Recently, the Montreal classification is the preferred way to specify disease activity for clinical use and for research
Screen Shot 2022-01-13 at 07.09.03
V
Severity
*
S0 = clinical remission
*
S1 = mild disease: <4 BM/d, no serologic or systemic signs of inflammation
*
S2 = moderate: >4 BM/d, some signs of inflammation
*
S3 = severe: ≥ 6 bloody BM/d, HR >90, T >37.5 °C, Hgb <10.5 g, and ESR >30 mm/h
V
Extent
*
E1: ulcerative proctitis
*
E2: Lt-sided colitis
*
E3: pan colitis
>
Endoscopic grading system: Mayo UC severity score
>
Mayo score 0 = normal/inactive disease
*
No friability or granularity
*
Intact vascular pattern
>
Mayo score 1 = mild disease (erythema; ↓ vascular pattern, mild friability)
*
Erythema
*
↓ Vascular pattern
*
Mild friability
>
Mayo score 2 = moderate disease (marked erythema; absent vascular pattern; friability; erosions)
*
Marked erythema
*
Absent vasular pattern
*
Friability & erosions
>
Mayo score 3 = severe disease (spontaneous bleeding; ulcers)
*
Spontaneous bleeding
*
Ulceration
*
Infectious colitides that mimic ulcerative colitis must be evaluated via stool culture. Shigella, Salmonella, Yersinia, C-Diff, and CMV must be specifically queried
V
>
Extrainstestinal manifestations
Screen Shot 2022-01-11 at 19.05.18
Screen Shot 2022-01-13 at 06.53.15
*
Arthritis: commonly the knees, ankles, hips, & shoulders
*
Eye disease (episcleritis, uveitis, iritis, conjunctivitis)
*
Ankylosing spondylitis most prevalent in HLA-B27⊕ patients
V
*
Erythema nodosum, pyoderma gangrenosum
ENlegs
Screen Shot 2020-03-02 at 1.58.29 PM
V
*
PSC: 10X more likely in patients with HLA-B8 and HLA-DR3 haplotypes
Patients with PSC and ulcerative colitis typically have a more quiescent disease course; however, the risk for colon cancer in these patients is up to five times greater than in patients with ulcerative colitis alone
>
Indications for surgery
V
V
Medically refractory disease is the most common indication for surgery
Screen Shot 2022-02-09 at 11.05.24
*
Defined by poorly controlled symptoms, poor QoL, growth failure, or long-term AE
>
Complications of long-term steroid therapy that warrant evaluation for surgical management:
*
DM
*
Avascular necrosis of the femoral head
*
Cataracts
*
Psychiatric problems
*
Osteoporosis
*
Weight gain
V
V
Acute severe colitis & toxic megacolon [are surgical emergencies as they indicate impending perforation]
Screen Shot 2022-07-23 at 13.11.47
>
Workup includes
*
Rule out C-Diff
*
Baseline AXR
*
Rule out CMV: FFS with Bx on admission; with consideration of repeat FFS with Bx if there is no response to steroids
V
*
Tuberculin test + CXR on admission in order to avoid delays in initiating Anti-TNF therapy when needed
Caution that false-negative TB test results may occur in patients with severe UC who have impaired immune function while receiving immunosuppressants such as high-dose corticosteroids or thiopurines.
>
General care
*
PO nutrition is recommended as long as there is no increase in abdominal pain or bloody diarrhea
V
*
Patients should be placed on VTE prophylaxis even if they are bleeding.
A meta-analysis of eight RCTs assessing the efficacy and safety of fractionated and unfractionated heparin in the treatment of active UC revealed no significant increase in bleeding in patients treated with heparin in addition to conventional therapy (aminosalicylates, steroids, and/or azathioprine) compared with patients receiving conventional therapy and no heparin. However, it also showed no added therapeutic benefit of heparin over conventional therapy.
*
Ask for stoma marking early on, in case it is needed
V
*
Fulminant colitis / severe acute colitis = colitis + ≥ 6-10 BM/d + one element of SIRS
The preferred nomenclature is acute severe colitis rather than fulminant colitis
*
Toxic colitis = end-organ damage colitis = fever + ↑HR + ↑WBC
V
*
Toxic megacolon = toxic colitis + ≥ 6-8 cm transverse colon on X-ray
Once the transverse colon is dilated past 8 cm, there should be great concern for impending perforation.
*
Surgical consultation is warranted on admission to the hospital with acute severe colitis
V
>
Stool frequency and CRP level are simple validated objective measures to assess response.
Other factors evaluated on day 1 or 3 of hospitalization that have been reported to predict steroid failure include erythrocyte sedimentation rate, albumin, and fecal calprotectin levels, and abdominal radiographs showing mucosal islands. However, these factors are of limited use until they have been validated.
>
Oxford Criteria / Oxford Index to define non-response correlates with the need of colectomy during the same admission (in 85% of population)
*
CRP level 45 mg/L & stool frequency 3-8/day
*
Stool frequency ≥ 8/day on day 3
>
Patients with acute severe UC who fail to improve within 3d of IV steroids are given either infliximab or cyclosporine as second-line medical therapy, or they undergo colectomy.
*
Corticosteroid therapy is maintained concurrently with second-line medical therapy.
>
Cyclosporine
*
Mean time to response: 5-7d
*
Prior use of azathioprine may predict failure of intravenous cyclosporine
*
Initial response rates with cyclosporine range from 64 to 90% when defined as the avoidance of colectomy
V
Subsequent colectomy rates in initial responders to cyclosporine range from
*
20% at 1 year
*
69% at 5 years
>
Infliximab
>
Patients who fail to respond to the initial infliximab infusion within 5d are usually given a second infliximab infusion at a dose of 10 mg/kg.
*
“For patients who respond to the second infliximab infusion, we give the third induction infusion of infliximab in four weeks following the second induction dose.”
*
Patients who do not respond to the 2nd infliximab infusion within 5d are evaluated for colectomy
>
Response
*
~50% patients responded to infliximab with significant improvement by day 7
V
*
For fulminant colitis index ≥ 8: 3-month colectomy rates between patients randomized to receive infliximab or placebo may be similar
“Finally, the Swedish index, also known as the fulminant colitis index, uses a formula including stool frequency and CRP (stool frequency/day + 0.14 × CRP (mg/L)); this index has a positive predictive value of 72% for colectomy at a cut-off score of >8 on the third day of corticosteroid therapy”
*
For severe or moderately severe UC activity, infliximab is associated with better outcomes at 3 months
*
Long-term colectomy-free survival:
*
71% at 3m
*
64% at 12m
*
59% at 36m
*
53% at 60 months
*
Statement 17: Sequential rescue therapy with cyclosporine and infliximab should be avoided. Vote: A + = 85%, A = 10%, A − = 5%; Grade of recommendation:1B
*
If perforation ensues, the mortality rate after surgical intervention may be as high as 57%
*
Postoperatively, steroid may be abruptly discontinued as long as the axis is not suppressed. The rectal stump inflammation will invariable settle down even without steroid
>
Bleeding
*
Incidence of massive hemorrhage = 0-5%
*
Bleeding accounts for 10% of all urgent colectomies performed for UC
*
Subtotal colectomy is the procedure of choice and will usually suffice. However, if bleeding continues from the remaining rectal mucosa, emergency proctectomy may be required
V
>
Dysplasia or cancer
Screen Shot 2022-02-09 at 11.03.38
*
Higher risk for cancer is seen in patients with early onset, severe, pancolitis
>
Historic analysis suggested a cumulative risk of CRC:
*
2.1% at 10Y
*
10% at 20Y
*
50% at 30Y
*
75% at 40Y
*
More recent meta-analysis report a cumulative risk of half of that reported in the historic analysis
*
A rule of thumb is the risk of developing CRC in chronic UC is 0.5–1% per year after the first 10Y of disease. Recent series show annual incidence of 0.06-0.2%
*
Carcinomas arising in UC tend to be poorly differentiated and highly aggressive tumors
V
>
If screening Bx specimens are positive for HGD or cancer, a patient should undergo proctocolectomy. The risk of having an undetected cancer that is found after colectomy for high-grade dysplasia is 42%
In the setting of low-grade dysplasia, patients are encouraged to undergo elective prophylactic proctocolectomy.
ASCRS: The recommended procedure for UC patients with colorectal cancer or HGD is therefore proctocolectomy with end ileostomy or IPAA
*
Kiran et al. reported a 14 % synchronous cancer and 55 % synchronous dysplasia rate in 176 UC patients with colorectal cancer
>
Managing LGD
*
When detected on non-targeted Bx: high-definition colonoscopy with chromoendoscopy is indicated
*
Patients with repeated unifocal, invisible LGD on non-targeted Bx: multidisciplinary discussion is warranted (there is limited evidence to guide practice in this scenario)
*
Repeat non-targeted Bx showing multifocal LGD: total proctocolectomy is recommended
>
ASCRS CPG 2021: Patients with visible polypoid or nonpolypoid dysplasia that is completely excised endoscopically should undergo endoscopic surveillance. Patients with visible dysplasia not amenable to endoscopic excision, invisible dysplasia in the flat mucosa surrounding a visible dysplastic lesion, or colorectal adenocarcinoma should typically undergo total proctocolectomy with or without IPAA. Grade of recommendation: Strong recommendation based on moderate-quality evidence, 1B.
*
After polypectomy, repeat endoscopic surveillance is warranted within 6m and then at 12m after removal of the index lesion
*
ASCRS CPG 2021: Patients with invisible dysplasia should typically be referred to an experienced endoscopist for repeat endoscopy using high-definition colonoscopy with chromoendoscopy with targeted and repeat random biopsies within 3 to 6 months. Patients confirmed to have invisible multifocal, low-grade dysplasia or any invisible high-grade dysplasia should typically be considered for total proctocolectomy. Grade of recommendation: Strong recommendation based on moderate-quality evidence, 1B
>
Sabiston: Strictures form in 5-12% of patients, 25% of which are malignant. The development of strictures is an indication for resection.
*
A colonic stricture in a patient with ulcerative colitis must be presumed carcinoma until proved otherwise
*
7% asymptomatic colonic strictures harbor occult carcinoma
>
Extracolonic manifestations
>
OLTx for PSC
*
If colectomy is required, permanent ileostomy is contraindicated because of the complications associated with peri-ileostomy varices from portal HTN
>
Proctocolectomy for UC is beneficial for:
*
Erythema nodosum (most responsive)
*
Arthritis
*
Eye disease (episcleritis, uveitis, iritis, conjunctivitis)
>
Proctocolectomy for UC is not beneficial for:
*
PSC
*
Ankylosing spondylitis
*
Sacroilitis
*
Growth failure in children/adolescence
V
>
Surgical options
Screen Shot 2021-01-12 at 15.42.53
>
Segmental colectomy
*
Selected patients with an increased operative risk or poor functional status may benefit from a segmental colectomy depending on the degree and extent of colitis
*
Two retrospective studies found patients who had a segmental resection done for colitis developed no CRC over a follow up duration of 7 & 9Y. However up to 20% of patients still required TPC for refractory disease
>
Staging surgeries:
*
The modified 2-stage IPAA (total abdominal colectomy and end ileostomy followed by completion proctectomy and IPAA without a diverting loop ileostomy), is not associated with increased rates of anastomotic leak, pelvic sepsis, or pouch failure compared with the conventional 2-stage IPAA (total proctocolectomy with IPAA and diverting ileostomy followed by ileostomy closure),
*
Although the preferred staged approach remains controversial, with the ever-expanding armamentarium of immunomodulatory agents used to treat these patients, a 3-stage IPAA should typically be considered to minimize postoperative morbidity
V
>
Turnbull-Blowhole colostomy for toxic colitis in extreme scenarios where the patient is not stable enough to carry out a complete total abdominal colectomy
Untitled
*
Small upper midline incision is made
*
Transverse colon are identified
*
The transverse colon is brought up through the midline
*
Water-tight closure of fascia to the transverse colon is done
*
The colon is incised and fashioned to skin
*
This may be done in conjunction to a RLQ loop ileostomy
>
Subtotal colectomy, end ileostomy
*
It’s the least morbid procedure
>
It’s the procedure of choice for
*
Emergency
*
First of a 3-stage pouch procedure
*
Patients on high-dose steroids / immunosuppression
*
Malnourished patients
*
The rectosigmoid is stapled above the sacral promontory
*
Remaining rectum has 10% risk of developing cancer
>
Total proctocoelctomy & end ileostomy
V
Is an acceptable option for patients with high risk of pouch failure:
*
Impaired anal sphincter
*
Previous anoperineal disease
*
Hx of pelvic radiation
*
Multiple comorbidities
*
Jimmo et al (DCR 2018) showed that permanent ileostomy may have similar QoL to IPAA
*
Intersphincteric proctectomy decreases the risk of perineal wound complications
>
Total proctocolectomy & ileal pouch-anal anastomosis (TPC + IPAA)
>
Relative contraindications to IPAA
>
Obesity is associated with high risk of pouch failure
*
In fact, it may be reasonable to perform an initial abdominal colectomy to allow control of disease and achieve weight loss prior to proctectomy and IPAA
*
A staged procedure would allow for weight loss when the weight is expected to be 2ry to steroid use
*
A goal BMI of ≤ 28 should be the target prior to IPAA
*
PreOp defecation problems including incontinence, diabetic neuropathy, & neurogenic disorders
>
NACRT
*
Adjuvant radiation therapy after pouch construction should be avoided at all costs
*
If needed, adjuvant radiation should be performed before pouch creation because postoperative radiotherapy is associated with radiation enteritis, poor pouch function, & consequent failure. That said, patients who had or will have radiation therapy may be better candidates for total proctocolectomy & end ileostomy
*
Age alone is not a contraindication
>
It’s the second of a 3-stage pouch procedure (or the 1st of a 2-stage procedure)
*
It may be done as a single procedure if performed by an experienced surgeon in young, healthy patients with no obesity or immunosuppression
*
It may be done as a two-stage procedure in which TPA + IPAA + DLI is done and then ileostomy reversal is done. A loop ileostomy is performed 40cm from the ileal pouch.
>
Criteria for a single stage TPC + IPAA:
>
Patient factors
*
Young
*
Healthy
*
“Less” obese
*
No anemia
*
No hypoalbuminemia
*
Low-steroid dose (prednisone < 20 mg/d)
*
ASCRS CPG 2021: The decision to perform a proctocolectomy and IPAA in a staged fashion should not typically be influenced by immunomodulator exposure
>
Operative technical factors
*
Elective surgery
*
Minimal blood loss
*
No tension on the anastomosis
*
Good blood supply
*
Visibly intact anastomosis
*
Experienced surgeon
>
Associated with:
*
< 0.5% mortality rate
*
20-27% morbidity rate
*
Good QoL
*
In women, studies report worse sexual function after IPAA with increased vaginal dryness and dyspareunia, but affected QoL scores improve within 12 months of IPAA, suggesting that these findings are transient.
*
The use of intramesorectal proctectomy, in an effort to avoid pelvic nerve injury, and laparoscopy does not confer an advantage regarding postoperative sexual function
>
Mucosectomy
*
For mucosectomy IPAA: need to make sure the pouch reaches 6cm below symphysis pubis
*
The entire mucosa from the anal canal and distal rectum are removed transanally with the specimen (using a self-retaining retractor such as a Lone Star)
V
>
Indications for mucosectomy:
Slide presentation by Dr. Feza RemziScreen Shot 2021-10-17 at 19.29.28
*
High grade dysplasia
*
Cancer
*
Pediatric population
*
Patients with PSC (known to have higher risk of dysplasia/cancer
*
FAP patients with polyps down to the low rectum
*
See advantages and disadvantages of mucosectomy vs stapled anastomosis in “Pouch construction & considerations”
V
>
Pouch construction & considerations
pouch-procedure-2
*
↑ pANCA (> 100 EU/ml) levels in UC patients undergoing IPAA have been shown to predict the incidence of chronic pouchitis (occurs in >50% of patients)
*
Main limiting factor in creating a pouch in cancer patients is the concern that they might get radiation after creation fo the pouch. If this happens, they will invariably lose the pouch
*
Some propose an intramesorectal dissection for the rectum (such as pediatric surgeons). Dr. Feza Remzi suggests that this is not great and the mesorectum left behind impairs the compliance of the pouch
>
Configuration
V
J-pouch limb is usually 15-18 cm
*
Adequate reach for the pouch is confirmed when the distal aspect of the pouch reaches 6 cm below the pubic symphysis, without tension
*
If the J-pouch does not reach, the procedure can be aborted and a loop ileostomy created. Often the pouch mesentery will stretch over time and in 6 months the patient can be reoperated to completed the IPAA
V
V
S-pouch provides extra 2-4 cm length & is reserved for cases where the J-pouch doesn’t reach
The distal part of the S-pouch should not be more than 2 cm to avoid Efferent Syndrome occurring
Screen Shot 2020-04-18 at 2.55.43 PM
*
Each limb is 12cm long
*
Maintain distal efferent end no longer than 2 cm in length
*
Isoperistaltic H-pouch
*
W-pouch (4-Loop reservoir) has increased capacity but studies have shown there is no difference in reservoir function in terms of incontinence, urgency, & soiling, compared to J-pouch
>
Maneuvers to improve reach of small bowel down to the pelvis:
*
1. Mobilize the small bowel mesentery from the retroperitoneum up to the duodenum
*
2. Mobilize SMA/SMV to the pancreas
*
3. Releasing incisions across the mesentery perpendicular to the small bowel mesenteric vessels supplying the pouch. This can be done anteriorly and posteriorly
>
4. Decide on dividing the ileocolic pedicle or distal SMA
*
ASCRS: ileocolic vessel ligation close to their origin from the superior mesenteric pedicle
*
Test-clamp (with bulldog clamps) some ileocolic branches and sacrifice them to enhance reach
V
*
“Although ligation of some of the branches of the SMA (or the main trunk of the SMA) has also been described, we rarely employ this maneuver due to the risk for compromise of blood supply to the entire small intestine”
2-Figure1-1
*
5. Consider s-pouch
*
6. If the pouch is formed and then it doesn’t reach. Consider stapling off the aperture and then creating a diverting ileostomy. Return to OR in a later date (6-12m later)
>
Anastomosis
*
Several comparative long-term studied have reported better functional results for the stapled IPAA
>
Stapled IPAA
>
Advantages:
*
Technical ease and faster
*
Less tension on the anastomosis
*
Improved functional outcomes
*
Preservation of specialized nerves in the ATZ (preservation of the highly specialized anoderm, therefore better function)
*
Improved visualization of the ATZ
*
Potential for fewer anastomotic complications
>
Disadvantages:
>
Cuffitis: inflammation of the retained mucosa
*
ASCRS Textbook: When we looked at our stapled IPAA patients with chronic inflammatory changes, we found that their function was still superior to their mucosectomy counterparts
>
Handsewn IPAA with mucosectomy
V
Advantages
*
Decrease the risk of dysplasia/cancer in retained rectal mucosa
>
Disadvantages
V
*
Mucosectomy does not reliably remove the entire rectal mucosa
Small islets of residual rectal mucosa have been identified in up to 14 % of patients and in 7 % it was located at the actual ileoanal anastomosis
*
Poorer functional outcomes
>
Tips from Dr. Feza Remzi
*
When one can live happily & with good QOL with a stoma. Trying to convince them for a re-do pouch surgery, is a great disservice
*
All IPAAs should be protected with an ileostomy
*
C-section is recommended rather than NVD after an IPAA
V
*
A ‘thoughtful ileostomy’ takes into account the possibility of future pouch failure. In its construction, the length of small bowel proximal to the current pouch approximates the length required to create a new pouch while still using the previous ileostomy. This may be a diverting ileostomy that is formed after a leak is noted in an IPAA
Screen Shot 2021-10-17 at 19.41.47
>
PostOp outcomes:
>
Normal pouch function
>
Short-term (adaptation phase: 0-12 months)
*
↑ Stool frequency & urgency
*
Difficulty differentiating gas and stool
*
Leakage
>
Long-term (after 12 months)
*
4-8 BM/day
*
1-2 Nocturnal stools, sometimes requiring pad
*
Semi-liquid or liquid stool consistency
*
Good daytime fecal continence
*
No urgency
>
Very long-term (>20-30Y)
*
Consistent stool frequency
*
± Fecal incontinence
*
Patients > 50Y of age at the time of IPAA have higher rates of postoperative incontinence and this dysfunction can become more pronounced with longer post-IPAA follow-up
>
Cuff complications
>
Cuffitis: persistent inflammation/proctitis involving the cuff of rectal mucosa between the dentate line and the IPAA
*
Occurs in up to 15% after stapled IPAA
V
Management
*
Topical steroids or 5-ASA
*
Failure of medical management may require transanal mucosectomy with ileal pouch advancement (with excellent results)
*
Excision of the pouch is a last resort
>
Dysplasia/cancer
>
Cleveland Clinic data:
*
Risk is 3.3% with a median of 11 months postOp
*
Preservation of ATZ did not lead to the development of cancer after 5-10Y of follow up
*
Author recommend long-term surveillance, and if repeat biopsy confirms persistent dysplasia, mucosectomy with pouch advancement is advised
>
Pouch complications
>
Anatomic
>
Bleeding
*
In patients with generalized oozing, instilling ice-cold saline with dilute epinephrine into the pouch facilitates hemostasis
V
>
Pouch leak
>
Leak from the tip of the “J”
*
ASCRS: “Over-sewing of the staple line is also prudent”
*
These leaks may be difficult to discover on routine pre-stoma reversal evaluation and may not become symptomatic until after stoma takedown
>
Salvage surgery:
*
Suture repair of the pouch
*
Excision of the tip of the “J”
*
UC patients receiving infliximab, are at particular risk for developing post-IPAA septic complications; a planned three-stage approach needs to be considered in this situation
V
*
Hand-sewn anastomosis is associated with higher leak than stapled anastomosis (9.2% vs 6.1%)
Fazio et al. 2013
V
*
Presacral leak is best managed with transanal drainage (not trans-gluteal)
Screen Shot 2021-04-14 at 18.06.32
V
*
Sometimes, the pouch may be opened onto the cavity to create a common channel. This can be done with a stapler or energy device
Screen Shot 2021-04-14 at 18.11.11
*
In the even of a leak, perform a triple contrast scan. If there is no extravasation, opt for percutaneous drainage. If there is extravasation, a better option is placing a catheter through the anastomotic defect
V
*
A ‘thoughtful ileostomy’ takes into account the possibility of future pouch failure. In its construction, the length of small bowel proximal to the current pouch approximates the length required to create a new pouch while still using the previous ileostomy. This may be a diverting ileostomy that is formed after a leak is noted in an IPAA
Screen Shot 2021-10-17 at 19.41.47
>
Pouch sinus
*
Occurs in 2-8%
*
Observation is recommended over intervention, when permitted by clinical circumstances, as these sinuses can resolve spontaneously.
*
Sinuses detected incidentally in patients without an ostomy are usually best left alone
V
Symptomatic sinus or a non-resolving tract may be managed by
*
Trans-anal debridement with drainage
*
Unroofing of the sinus
*
Glue injection
*
Diversion
*
Pouch revision
*
Redo-pouch surgery
>
Pouch-vagina fistula occurs in 3-16% & requires operative repair
*
Advancement flap repair
*
Transvaginal repair is considered when access to the pouch is limited (such as stenosis)
V
*
Perineal pouch advancement
The anterior half of the IPAA is disconnected from the anal canal and the pouch is mobilized down from the vagina and is reapproximated to the anal canal after freshening and repairing the tissue surrounding the defect in the rectovaginal septum.
V
>
Ileoanal anastomotic stricture occurs in 5-40%
Management includes finger dilation or repeated dilations under anesthesia and rarely a transanal approach with excision of the stricture and pouch advancement
>
Management options:
>
Endoscopic management is the first-line therapy
*
Endoscopic balloon dilation
*
Endoscopic stricturotomy for refractory, long, fibrotic strictures
*
Endoscopic strituroplasty
*
Surgical
*
Internal hernia & volvulus
>
Inflammatory
>
Pouchitis
>
Risk factors for pouchitis
*
Extent of UC disease: Extensive colitis has been associated with an increased risk of pouchitis
*
Extra-GI manifestations: patients with a PSC often have diffuse pouchitis and enteritis of a long segment of the afferent limb
*
Age at diagnosis or surgery: ↓ age associated with an ↑ risk
*
Coexisting autoimmune disorders
*
Obesity
*
Smoking status
V
*
Dietary factors
In a cohort study including 172 patients with ileal pouches, lower fruit consumption was correlated with higher rates of pouchitis compared with higher fruit intake (31 versus 4 percent). In a cross-sectional study including 80 patients with ileal pouches, patients with pouches consumed more bakery products, oils, fats, nuts, and seeds compared with healthy controls
*
NSAID use
*
Pouch configuration: J-pouch having higher rate of pouchitis than S-pouch in some studies
*
Hematologic disorders including DVT
*
Fecal stasis
*
Endoscopic findings of confluent, erythematous, friable mucosa of the pouch body and histology demonstrating inflammation with a normal afferent limb and ATZ are consistent with a diagnosis of pouchitis.
*
40% develop one episode; 20% develop recurrent episodes
*
Pouchitis / nonspecific inflammation is the most frequent long-term complication
>
Classification
*
Acute: < 4w
*
Chronic: > 4w
V
Management:
*
1. Acute pouchitis: Ciprofloxacin (preferred) or Flagyl: 500mg BID X 2w
V
2. If persists: Cipro + [Flagyl | tinidazole | rifaximin] X 4w
*
Small focal areas of cuff inflammation may be addressed with ablation.
V
3. Chronic Abx Dependent Pouchitis:
*
3.1 ± Probiotics
*
3.2 Ciprofloxacin 250mg QOD (up to 1g/d)
V
4. Chronic Abx-Refractory Pouchitis:
*
4.0 Rule out IgG4, ischemic pouch, surgical complications, Crohn’s disease
*
4.1 Anti-inflammatory: mesalamine; NSAIDs
*
4.2 Immunosuppressive: budesonide, corticosteroid enema
V
4.3 Biologics: Anti-TNF
*
Use of an agent that was not previously used is more likely to succeed than an agent used prior to IPAA
*
5. Consider: DLI; redo-pouch; pouch excision with end ileostomy
>
Assessing ‘pouchitis’ vs Crohn’s disease of the pouch
*
Pouch inflammation may be due to ischemia rather than pouchitis
*
Stricture formation may be due to technical complications or ischemia
*
Fistula in the pouch maybe due to anastomotic complications
>
Functional
>
Outlet obstruction
*
Manage with : pelvic floor biofeedback
*
Enemas and intermittent self-intubation to vent or to irrigate the pouch may be useful for patients with obstruction from either anatomic or functional causes
V
*
Afferent limb syndrome
Screen Shot 2020-04-18 at 3.10.33 PM
>
Pouch prolapse
*
Occurs < 1%
V
Initial managment
*
Dietary changes
*
Bulking agents
*
Avoidance of straining
*
Biofeedback
>
Definitive treatment
*
Mucosal prolapse: excision of redundant mucosa
*
Full-thickness prolapse: abdominal approach with fixation of the pouch to the sacrum
>
Neoplastic
>
Dysplasia / cancer
*
Extremely rare
V
Routine surveillance of the pouch
*
Not warranted for UC patients
*
FAP patients are at risk for developing future polyps or cancer and should undergo annual surveillance with pouchoscopy and biopsies
*
UC patients (stapled or hand-sewn after mucosectomy) are counseled about the risk of malignant degeneration in or near the anal transition zone and can be offered periodic surveillance
>
Pouch failure occurs in 5-10% when done at high-volume colorectal centers
V
Reasons for pouch failure
>
Technical
*
IPAA leak
*
Efferent limb syndrome (relevant in S-pouch)
*
Leak from the tip of the J-pouch
*
Change in Dx to Crohn’s disease
V
Functional
*
Pouch prolapse
V
*
Afferent limb syndrome
Screen Shot 2020-04-18 at 3.10.33 PM
>
5-20% develop pelvic sepsis after IPAA resulting from anastomotic dehiscence
V
*
Management should focus on prolonged sepsis control with closed suction drainage (6-12months) with serial EUA and gastrografin studies
Screen Shot 2020-04-18 at 3.02.13 PM
V
*
Defunctioning ileostomy may be key in salvaging the J-pouch after the occurrence of an leak. The stoma loop itself can be used to redo the J-pouch later on
Screen Shot 2020-04-18 at 3.06.57 PM
*
At the time of redo-pouch, you will need to excise the pelvic phlegmon
*
The decision to go for a redo-pouch surgery should be patient driven
>
Alternatives for when pouches fail
*
Continent ileostomy
*
S-pouch
>
Redo-IPAA
*
Dr. Hyman: Only offer the patient a redo-IPAA if you believe that it was a technical issue — this may be evident by inflammation only after stoma takedown by pouchogram showing some pathology that was missed before stoma takedown
*
For redo-IPAA, best to refer to an expert centre
*
~27% develop small bowel obstruction. It tends to be severe and 50% require surgery
>
Sexual dysfunction
*
Performing close rectal dissection rather than total mesorectal excision has been studied and does not appear to improve preservation of sexual function
>
Infertility
*
3 fold increased risk of infertility
*
Pouch dysfunction has been reported during the third trimester of pregnancy, this appears to be transient
>
Colectomy with ileorectal anastomosis
*
It is used in selective patients and requires a relatively spared, healthy, and compliant rectum
*
Segmental colectomy for ulcerative colitis, in contrast to Crohn’s disease, has been shown to be an inadequate procedure for controlling disease. For example, in the case of colitis confined to the left side, a proctosigmoidectomy with an end-descending colostomy or coloanal anastomosis invariably results in the recurrence of disease in the remaining colon within a short time and is contraindicated
*
It is contraindicated in Crohn’s disease patients who have moderate-severe inflammation of the rectum, dysplasia or cancer of the rectum, perianal disease, and known anal incontinence
*
It may be considered in young females who want to preserve fertility and avoid an ostomy, but it is rare to have patients with UC who require surgery but have minimal rectal inflammation
*
Rectal biopsies every 6–12 months are advised following IRA
*
The risk of malignancy of the rectum after IRA is approximately 10% at 10Y, and 25% at 20Y
>
The cumulative probability of having a functioning IRA:
*
At 5Y: 84%
*
At 10Y: 69%
*
At 20Y: 46-69%
>
Indications for completion proctectomy
>
Proctitis
*
¼ of patients require a proctectomy resulting from severe proctitis
V
Rates of requiring completion proctectomy for refractory disease:
*
10% at 5Y
*
24% at 10Y
*
40% at 20Y
>
Dysplasia & malignancy
>
Rate of dysplasia & adenoCa in the retained rectum:
*
Dysplasia: 24% at 25Y
*
AdenoCa: 9% at 25Y
*
Crohn’s disease
V
>
Total proctocolectomy with continent ileostomy (Kock’s pouch)
kockpouch1
*
Developed so patients are not required to wear stoma appliance
*
A nipple valve is created by intussusception of a portion of ileum into the planned reservoir
>
Two main complications associated with Kock’s pouch:
V
Malfunction of the nipple
*
When the continence mechanism fails, the stoma does not simply become conventional ileostomy, it rather causes mechanical obstruction requiring surgery for the “slipped valve”
*
Difficult intubation of the pouch occurs in 10-20% of patients
*
Pouchitis
*
The procedure has been abandoned in the management of UC because of the excellent outcomes with the ileal J-pouch and the large complication rate associated with the Kock pouch
>
Surveillance
*
Ideally, colonoscopy should be performed while in remission to minimize confusion in the recognition of carcinoma because of inflammation
*
A typical endoscopic biopsy samples 0.05% of the mucosal surface; accordingly multiple samples must be taken for adequate sampling. A minimum of 33 random biopsies has been shown to result in 80–90% sensitivity for detecting dysplasia, with 64 required for 95%
>
Endoscopic grading system: Mayo UC severity score
>
Mayo score 0 = normal/inactive disease
*
No friability or granularity
*
Intact vascular pattern
>
Mayo score 1 = mild disease (erythema; ↓ vascular pattern, mild friability)
*
Erythema
*
↓ Vascular pattern
*
Mild friability
>
Mayo score 2 = moderate disease (marked erythema; absent vascular pattern; friability; erosions)
*
Marked erythema
*
Absent vasular pattern
*
Friability & erosions
>
Mayo score 3 = severe disease (spontaneous bleeding; ulcers)
*
Spontaneous bleeding
*
Ulceration
>
8 years after Dx: endoscopy Q1-2Y
*
4-quadrant Bx Q10cm for a total of at least 32 Bx
*
Bx suspicious lesions + surrounding mucosa
*
If a patient also has primary sclerosing cholangitis or has a positive family history of colorectal cancer, surveillance intervals should shorten to annually.
V
*
Findings of HGD should prompt proctocolectomy. Low-grade dysplasia should be considered for proctocolectomy or strict endoscopic surveillance
Sabiston: When high-grade dysplasia is found and has been confirmed by a second independent pathologist, proctocolectomy should be recommended. This is also true for patients who have DALM. If low-grade dysplasia is confirmed, strong consideration should also be given to proctocolectomy.
Screen Shot 2020-03-02 at 2.30.19 PM
*
Rectal biopsies every 6–12 months are advised following IRA
>
ASCRS CPG postOp surveillance
*
Routine surveillance of ileal pouches for dysplasia in the ileal mucosa is not warranted.
>
Pouchoscopy is typically done at 1Y postOp then
*
Q1-3Y if there was evidence of neoplasia in the proctocolectomy
*
Q3-5Y if there was no evidence of neoplasia
V
>
Surveillance of the residual rectal cuff or the anal transition zone following restorative proctocolectomy may detect malignant degeneration.
Although the optimal surveillance interval remains largely anecdotal, patients should be counseled about the risk of malignant degeneration in or near the anal transition zone, and can be offered periodic surveillance by endoscopic or anoscopic means every few years, or when symptomatic
*
ASCRS Textbook recommends surveillance of ATZ Q1-3Y
>
Indeterminate colitis now called IBD-unspecified: accounts for 10-15% of IBD patients
*
The Montreal Working Party recommended that the term indeterminate colitis should be reserved only for those cases where colectomy has been performed and pathologists are unable to make a definitive diagnosis of either CD or UC after full examination
*
Ultimately, most patients with an initial IC diagnosis will be found to have UC.
*
In the absence of current or historical clinical features of CD, most IC patients could be considered for IPAA, with expectations of functional outcome and pouch retention rates similar to that of UC patients
*
Often clinicians are confronted with IBD patients who are difficult to diagnose with IBD or who do not fit nicely into the category of CD or CUC. In these patients, Prometheus® antigen testing panel has been used as a diagnostic aid. Now in its fourth generation the panel assesses nine antigens, Prometheus testing is reserved for helping to diagnose cases that are difficult to classify based on traditional testing. Prometheus testing is most helpful in ruling out IBD, but may also have a role in differentiating between CUC vs. indeterminate colitis vs. CD, although it may not have adequate specificity for that indication
>
Crohn's Disease
*
Surgeon’s note: Don’t operate on Crohn’s Disease operate on its complications
>
Prognosis
*
In patients with more than 20Y of disease, the cumulative probability of surgery is ~78%
>
Probability of surgery:
*
14-16% in 1Y of Dx
*
27-33% in 5Y of Dx
*
38-47% in 10Y of Dx
*
Before the era of anti-TNF therapy, 27-61% within 5Y of Dx
*
Risk of 2nd surgery: 28-45%
*
If defined exclusively by the need for reoperation, recurrence rates are only 25-30% at 5 years and 40-50% at 20 years. To put this in perspective, after a first resection for Crohn’s disease, about 45% of patients will ultimately require a second operation, of whom only 25% will require a third operation
*
Gastrointestinal cancer remains the leading cause of disease-related death in patients with Crohn’s disease; other causes of disease-related deaths include sepsis, thromboembolic complications, and electrolyte disorders
*
The small bowel is the part most commonly involved
*
15% have disease limited to the colon
V
*
Cigarette smoking is protective in UC, whereas it is a risk factor for developing (& for more severe) Crohn’s Disease
In regards to Crohn’s disease, smoking is associated with an increase in the incidence of relapse and failure of maintenance therapy
*
There is a strong familial association, with the risk for developing Crohn’s disease increased about 30-fold in siblings and 15-fold for all FDRs
V
>
Describe the disease
Regardless of the distribution and behavior of the intestinal component of the process, many patients have anal manifestations of the disease
*
Activity: acute/severe, acute fulminant, active/chronic, chronic, dormant
V
*
Behaviour: inflammatory, stricturizing, fistulizing/penetrating, neither
Strictures are not amenable to medical therapy once fibrosis sets in
V
*
Distribution: ileal, ileocolic, colic, isolated upper GI
Small bowel disease is the most common
General Surgery Review Course: Biologics are less effective for small bowel fistulas
For duodenal disease: resection is rarely need; plasty or bypass are best options
V
*
CD Activity Index
Screen Shot 2021-08-29 at 19.07.40
>
Extraintestinal manifestations:
*
Ankylosing spondylitis most prevalent in HLA-B27⊕ patients
V
*
Erythema nodosum, pyoderma gangrenosum
ENlegs
Screen Shot 2020-03-02 at 1.58.29 PM
*
Sclerosing cholangitis
*
Uveitis, iritis
*
Aphthous stomatitis
*
Hepatitis
*
Pericholangitis
>
Diagnosis
*
The combination of clinical disease activity, endoscopic findings, and histology generates accurate diagnosis
*
Labs: ↑ CRP/ESR; IDA; ↓Albumin; ⊕ ASCA; ⊖ p-ANCA
>
Pathologic findings:
V
Grossly: creeping fat of the mesentery ± strictures of the small/large intestines
*
“Creeping fat” is nonspecific and is found in other inflammatory conditions, including diverticular disease
>
Endoscopically: Linear ulcerations with cobblestone appearance
*
Coalescence and spread of the ulcers leads to the classic cobblestoned mucosal appearance
*
Pseudopolyps (resulting from inflammation & reactive hyperplasia) are more commonly seen in UC than CD
*
Crypt abscesses are less frequent than in UC (seen also in infectious colitis)
*
Transmural inflammation (predominantly submucosal) & lymphoid aggregation (not seen in UC)
*
Ulceration & deep fissures to the serosa (not seen in UC)
V
*
20-25% demonstrate noncaseating granulomas (Pathognomonic for Crohn’s)
Sabiston: Characteristic histologic lesions of Crohn’s disease are noncaseating granulomas with Langerhans’ giant cells
Screen Shot 2020-06-10 at 1.43.01 PM
>
Surgical indications
*
Traditional therapy for patients with terminal ileitis found at the time of surgery for appendicitis has been to perform an appendectomy when the cecum is normal, leave the ileum in place, and treat with medical therapy after surgery. A contradictory experience, however, has reported that 92% of patients found to have terminal ileitis at the time of surgery and who did not undergo resection require ileocolic resection for complications of Crohn’s disease within 12 years.
*
Early resection rather than the initiation of anit-TNF therapy may be appropriate in patients with limited, nonstricturing ileocecal CD as supported by an RCT that compared early laparoscopic ileocecal resection (n = 73) and infliximab initiation (n = 70) and demonstrated ↑ QoL scores and ↓ overall cost in the operative group
V
>
Intractability is the most common indication for operative treatment
Screen Shot 2022-02-09 at 11.05.24
*
For immunomodulators, a plateau in improvement of clinical symptoms is demonstrated within 12-16w
*
Inability to wean off corticosteroids within 3–6 months is also considered failure of medical management
*
ASCRS CPG 2015: If a patient cannot tolerate medical therapy other than steroids, or if their disease is limited in extent (e.g short segment ileocolic disease), surgery should be strongly considered
*
When in doubt of whether to keep the rectum or not in a Crohn’s colitis, evaluate distensibility of the rectum with endoscopy. If stiff, it needs to be resected
>
Massive LGIB: most commonly from the terminal ileum
*
LGIB in general is more common with UC, but massive bleeding is more likely Crohn’s disease related
*
Endoscopic clipping may be difficult in the presence of inflamed and friable mucosa and rebleeding in patients successfully managed with nonoperative measures may be reduced with anti-TNF therapy
*
Recurrence of bleeding after non-operative and even operative management is not uncommon and undermines the importance of accurate localization studies prior to intervention. This can be aided with highly selective methylene blue injection to localize occult bleeding sites
V
*
Severe/fulminant colitis, toxic megacolon
See Ulcerative Colitis for details
>
Stricture/obstruction
*
Strictures are classified as either inflammatory or fibrotic; the chronicity of symptoms and CRP levels can aid in differentiating between the two
*
Stricturoplasty is not indicated for disease of the terminal ileum. In most series, the recurrence rate of Crohn’s disease requiring reresection in patients who have undergone ileocolic resection, is approximately 50% in 10 years.
*
7% of asymptomatic colonic strictures will harbor malignancy; there’s a high rate of false negative Bx
>
Symptomatic strictures typically require surgery or endoscopic dilation
V
Outcomes of endoscopic dilation
*
Very high success rate (90%); only a single dilation is required in ⅔ of patients
*
Low complication rate (3%)
*
Rate of surgery after endoscopic dilation: 13%
*
20–25 % of surgeries for Crohn’s disease are secondary to obstruction
*
Stenting of anastomotic strictures tends to be successful but has high migration rates
>
Perforation, fistula, abscess
>
Abscesses is the indication for 7-25% of surgeries performed on Crohn’s
*
The majority of patients managed non-operatively will require surgery
*
Percutaneous drainage used as a bridge to bowel resection compared with bowel resection without prior PD results:
*
↓ overall complications,
*
↓ need for diverting stoma
*
↓ overall cost
*
No difference in rates of postoperative enterocutaneous fistula and anastomotic leak
*
Anti-TNF therapy in the setting of an inflammatory mass (ie, phlegmon) with a concomitant abscess typically carries a low risk when initiated after intravenous antibiotics and PD of the abscess, as needed
>
Fistulas
*
75-85% occur in the postOp period and are secondary to anastomotic leaks or inadvertent injury to the bowel
*
Spontaneous enterocutaneous fistulas are unlikely to heal without surgical intervention
*
Enterocutaneous fistulas are managed with drainage of abscesses if present & nutritional support and medical management. 50% of patients will be able to resolve the acute episode, and some of those will not require surgery.
*
Penetrating disease is particularly sensitive to anticytokine therapy, and a conservative approach to Crohn’s related fistula is most appropriate. However, many of these patients will require eventual resection as the disease progresses
V
Surgical management (consider interposition of omentum after resection)
*
Active disease only in fistulizing segment → resect active disease segment + repair the ‘fistulized-to’ organ
*
Active disease in both segments → resect both
*
The mere presence of a fistula does not necessarily mandate surgery, especially in the absence of malabsorption, intractable diarrhea, or recurrent infection
>
Free perforation:
*
Except for the rare situation of a free perforation with diffuse peritonitis, surgical intervention should be undertaken only in an optimally prepared patient by a surgeon prepared for a complex, multiorgan procedure
*
Perforation of small bowel secondary to stricture is best managed with resection + anastomosis ± proximal diversion
*
Resection is guided by the extent of disease activity. Frequently requiring a total colectomy + ileostomy
*
Site of perforation is at the atonic, thickened, transmurally inflamed, obstructed segment
V
>
Neoplasia/dysplasia
Screen Shot 2022-02-09 at 11.03.38
*
Patients with Crohn’s disease have 2-3X increased risk of CRC compared to the general population (this occurs also at a younger age of 49-56Y)
*
Literature supports that there is a higher risk of developing cancer in bypassed bowel and that it comes with a poor prognosis. It is for this reason that bypass surgery should be avoided and that defunctionalized rectal stumps should be removed if there is no plan for the patient to be placed back in continuity.
*
ASCRS CPG: Postinflammatory pseudopolyps are thought to increase the risk of CRC, and inflammation is believed to be risk factor for progression to colorectal neoplasia
V
Finding of dysplasia is an indication for resection because of the high risk of associated cancer (40%)
*
The predictive value of HGD for a final HGD or cancer diagnosis was 73 %
*
A good approach is to offer segmental resection if only one segment of the colon is involved. Total colectomy is offered if ≥ 2 segments are involved
*
When assessing whether the rectum should be resected or not (when not involved by cancer), evaluate its distensibility with endoscopy. Fibrotic rectums require resection
*
Polyps should be biopsied, as routine, in addition to the surrounding mucosa in four quadrants to sample for dysplasia or cancer
*
Although colonic strictureplasty has been reported, this is generally discouraged due to a lack of proven benefit as well as concerns about potential carcinoma being left in situ
>
Extracolonic manifestations — With resection of active disease:
*
Erythema nodosum & pyoderma gangrenosum are likely to improve
*
Ankylosing spondylitis & PSC are not likely to improve
>
Enteric findings suggestive of active disease rather than chronic fibrostenotic disease:
*
Mural hyperenhancement — is the most sensitive for active disease
*
Bowel wall thickening
*
Mural stratification
*
Extraenteric engorged vasa recta (comb sign)
*
Fat stranding
>
Surgical considerations & options
V
>
Surgery for early ileocecal disease
Screen Shot 2022-08-05 at 09.03.46
>
LIRIC trial
*
Symptomatic relapsing ileocecal disease without obstructive symptoms randomized to IFX or Lap ileocecal resection
*
20% of patients in IFX arm finally required surgery
*
Improved cost-savings and improved QoL with surgery
>
Long term analysis:
*
48% of IFX arm required resection and 58% still required biologics
*
50% of surgery arm did not require any further medical treatment
*
Salvage surgery (after failing IFX) was associated with higher stoma rates
>
Identify the extent of the disease preOp
>
CT or MR Enterography
*
MRE is better at demonstrating endo-luminal abnormalities and ulcerations
*
Endoscopy
>
Endoscopic balloon dilatation tends to have similar outcomes to surgery for structuring disease
V
Outcomes of endoscopic dilation
*
Very high success rate (90%); only a single dilation is required in ⅔ of patients
*
Low complication rate (3%)
*
Rate of surgery after endoscopic dilation: 13%
>
Surgical considerations:
*
When surgery is done for complications, the resection should be limited to the site involved with the complications. Diseased bowel that is not causing the complication should not be resected
>
Intestine should be resected with the aim of obtaining margins free of disease by gross inspection
*
Frozen sections of the margins of resection are unnecessary because positive microscopic margins are not predictive of postoperative recurrence
V
*
Stapled side-to-side anastomosis has fewer anastomotic leaks, shorter OR time, as well as lower rate of reoperation for recurrence compared to hand-sewn end-to-end
McLeod et al. performed a multicenter, randomized controlled trial comparing stapled sideto-side (ST) and hand-sewn end-to-end (HS) ileocolic anastomoses in Crohn’s disease patients. They did not find a difference with regard to overall complication rate. They concluded that the type of anastomosis did not affect recurrence of the disease [
*
ASCRS CPG: when possible, if a patient is on an every 8 weeks dosing regimen, the optimal time to perform surgery may be approximately 4 weeks after the last monoclonal antibody dose to allow for a washout period of about one half-life, with the plan to resume the monoclonal antibody about 4 weeks after surgery, if necessary, for postoperative treatment or prophylaxis
*
Ileocolectomy with primary anastomosis usually has acceptable anastomotic leak rates. For patients with multiple risk factors (smoking, steroid use, weight loss), temporary diversion should typically be considered
*
There remains controversy as to whether extended mesenteric resection helps control the disease and decreases recurrence and re-operation rates
>
Diversion only
*
A temporizing measure for colonic or anal disease, it allows inflammation to settle
*
Considered when resection is hazardous or as a first step for severely symptomatic disease
>
Colectomy
*
If 1 segment is involved → segmental resection
*
If multiple segments are involved → total colectomy ± proctectomy
V
*
Patients may develop ileorectal syndrome
Ileorectal syndrome: anal tone simulates SBO and its physiology → prolonged ileus
*
After ileocolic resection, patients may have impairment of bile-salt absorption that results in diarrhea. Management options include cholestyramine
>
Proctectomy
*
Intersphincteric proctectomy decreases the risk of perineal wound complications
V
*
There is no rush for proctectomy for less symptomatic patients, but the stump has ↑ risk of cancer
The presence of rectal stricturing that precludes endoscopic evaluation is especially worrisome. In the absence of known or suspected malignancy, completion proctectomy with intersphincteric anal dissection is recommended
*
Requires evaluation (±scope) in the event of: cancer, diversion proctitis, or recurrent disease
>
Healing may be impaired by anal fistulas — Management:
*
Fistulectomy ± wide excision
*
Consider: VAC or Myocutaneous flaps
>
IPAA
*
Usually not recommended 2ry to risk of recurrent disease at the pouch or perianally
*
Patient selection is paramount: ⊖ small bowel disease + ⊖ anal involvement + normal sphincter + long disease free interval post-colectomy
*
With appropriate patient selection, 5Y pouch survival rate is ≥ 85% (still lower than that of UC patients)
>
PostOp considerations & recurrences
*
Recurrence tends to occur at site of previous resection
*
Endoscopy is warranted at 6m postOp to assess for recurrence
V
>
Rutgeerts score was developed to predict post-surgical recurrence via endoscopy in patients after having ileocolonic resection
Chongthammakun et al. Gastroenterol Rep 2017 Nov: Median duration from EI to the first ileoscopy was 28 months (interquartile range: 11-93 months)
rutgeerts-1536x1152
*
Rutgeerts score ≥ i2 is usually managed with anti-TNF ± thiopurine
>
Recurrence rate varies by the definition used
V
*
Endoscopic recurrence at 1Y = 60-80%
Olaison et al. found even higher rates. They found 73 % of patients had endoscopic recurrence at 3 months, with 33 % being symptomatic. At 1 year, the endoscopic rate had increased to 93 % with a correlating symptomatic rate of 37 %
*
Clinical recurrence at 1Y = 10-20%
*
Clinical recurrence at 5Y = 28-45%
*
Surgical recurrence at 1Y = 5%
>
Risk factors for postOp recurrence (reoperation rate is 5% per year)
*
Shorter preoperative disease duration is associated with increased recurrence
*
Age < 30Y
V
*
Smoking
Smokers have higher rates of both postoperative clinical recurrence (OR 2.2, 95% CI 1.4-3.3) and surgical recurrence (OR 2.6, 95%CI 1.8-3.8) at 10 year follow-up
*
Penetrating or fistulizing disease
*
Presence of granuloma in the specimen
*
End-end anastomosis of ileocolic resection has higher recurrence rate than side-side
>
Low risk patients:
*
Metronidazole X 3m postOp has been shown to decrease recurrence
>
High risk patients are started on therapy 8w following resection
*
Treatment-naive patients: start azathioprine or 6MP
*
Treatment non-naive patients: start anti-TNF
>
Surveillance
*
Start colonoscopy 8Y after Dx, continuing Q1-2Y
V
>
Simple Endoscopy Score - Crohn’s Disease (SES-CD)
Screen Shot 2020-08-02 at 4.59.58 PM
Aphthous ulcers have a very characteristic appearance. The ulcers are discrete and usually 3 to 5 mm in diameter (picture 1A-C). They have an erythematous halo at the margin and a yellowish exudate centrally.
Simpleaphthosis
*
Score < 2 → remission
*
Score 3-6 → mild
*
Score 7-15 → moderate
*
Score > 16 → severe
*
Remember that strictured segments may not be accessible and may harbor malignancy
*
Patients with PSC, a family Hx of CRC, inflammatory pseudopolyps, strictures, or ongoing inflammation may warrant more frequent evaluation
*
Polyps should be biopsied, as routine, in addition to surrounding the surrounding mucosa in four quadrants to sample for dysplasia or cancer
>
Toxic colitis
>
Etiology
*
Inflammatory: IBD, chemotherapy
>
Infectious:
*
Bacterial: C-Diff, Salmonella, Shigella, Campylobacter, or Entamoeba
V
*
Viral: CMV
In patients with HIV infection or AIDS, CMV colitis is the leading cause of toxic megacolon and emergency laparotomy; this usually occurs in the setting of disseminated CMV infection
*
Vascular: ischemic colitis
*
The acute severe mucosal inflammation becomes transmural and extends into the smooth muscle layer, resulting in loss of motor tone and paralysis. The severely inflamed smooth muscle produces nitric oxide, which is released into the colonic wall and further inhibits smooth muscle tone and causes dysmotility and atony. The toxic systemic response results from bacterial translocation and subsequent bacteremia
*
Toxic colitis = fever + ↑HR + ↑WBC
*
Deterioration or lack of improvement within 48 to 72 hours of the initiation of medical treatment warrants an urgent procedure
V
*
Toxic megacolon = toxic colitis + ≥ 6-8 cm transverse colon on X-ray
Once the transverse colon is dilated past 8 cm, there should be great concern for pending perforation.
V
UTD ‘most widely used criteria’ for toxic megacolon (all need to be met):
*
Radiologic evidence of colonic dilation > 6 cm
V
At least 3 of the following:
*
Fever > 38 ℃
*
HR > 120
*
WBC > 10.5
*
Anemia
V
At least 1 of the following:
*
Dehydration
*
Altered sensorium
*
Electrolyte imbalance
*
Hypotension
*
Bacteremia occurs in up to 25% of patients with toxic megacolon
>
Management
>
Medical
*
No evidence to support NGT decompression without small bowel dilatation
*
Frequent patient repositioning is simple & may be attempted, but is not supported by strong evidence
*
Stop Rx affecting colonic motility: opioids, antimotility agents, & anticholinergics
*
DVT & gastric ulcer prophylaxis
*
Broad spectrum Abx
*
Serial examinations, labs, & X-rays
>
Establish etiology
V
*
Limited endoscopy may be considered to determine the cause of toxic megacolon in patients who are not known to have IBD
It should be performed with extreme caution, without bowel preparation, and with minimal air insufflation
V
*
For IBD: hydrocortison 100mg Q6-8h
There is no evidence that steroid therapy increases the risk for perforation
Aminosalicylic acid products are useful for mild-moderate cases, but no data supports their use in toxic megacolon
*
C-Diff: vancomycin PO/PT/enema or Flagyl
>
Surgery
*
Perforation & abdominal compartment syndrome increase the mortality rate from 9% to 40%
*
Ask for stoma marking early on, in case it is needed
>
Indications for surgery
*
Lack of improvement within 48-72h
*
Uncontrolled hemorrhage
*
Progressive colonic dilatation
*
Development of complications or perforation
*
Patients with CMV colitis or C. difficile infection respond poorly to medical therapy and often require emergent laparotomy with subtotal colectomy and ileostomy
V
*
Procedure of choice: total colectomy + end ileostomy
The rectum should not be resected at the time of this emergent operation, despite how inflamed it may appear.
*
If the rectosigmoid junction appears too inflamed to hold staples or sutures, then the surgeon should leave a short segment of sigmoid colon to form a mucous fistula to decompress the remaining colon and rectum. If a rectal stump is left in the peritoneal cavity, it should be decompressed in the operating room with a rectal tube that is left in place to allow for further postoperative decompression and possible vancomycin enemas
V
>
Alternative surgery for C-Diff:
May be associated with improved survival, but indicators for patient selection is still unclear
*
1. Visual assessment for colonic viability
*
2. Creation of loop ileostomy
*
3. Lavage: 8L of warmed PEG drained via a rectal tube
*
4. Postoperative antegrade enema: Vancomycin 500mg in 500ml of RL Q8h X 10days
V
>
Ischemic colitis
Pasted_Graphic_12
*
If the ischemia is limited to the most vulnerable layer of the intestine, the mucosa, the disease may be transient and recovery may be complete
*
Ischemia involving the muscularis → scarring and chronic stricture
*
Ischemia affecting the full thickness → gangrene, perforation and fecal peritonitis
*
The combination of abdominal pain, tenesmus, hematochezia/bloody diarrhea is present in about half of the patients
*
It tends to be segmental, based on the affected blood supply. The left colon (including the splenic flexure) is the most commonly affected segment, followed by the sigmoid colon. About 25% of patients demonstrate isolated right-sided IC. Patients with right-sided IC are more likely to have atrial fibrillation
*
After resolution, about 10% of patients will have a recurrence
*
A small proportion will continue to have chronic colitis lasting more than 3 months with continued symptoms
V
*
“Thumb printing,” which is indicative of submucosal edema, is the most common radiographic finding in patients with ischemic colitis
Pasted_Graphic_8
*
Flexible endoscopy is the gold standard for the diagnosis. The finding of hemorrhagic dusky mucosa is typical. Patches of inflammation may be interspersed with healthy-appearing mucosa
V
*
Mainstay of medical management is bowel rest, resuscitation & minimizing use of vasopressors, maximize cardiac output, & broad spectrum Abx. OCP is also stopped as it has been associated with ischemic colitis
Because loss of integrity of the mucosa may result in bacterial translocation, broad-spectrum antibiotics are generally advocated
*
Multiphasic CTA should be performed to exclude acute mesenteric ischemia in cases of pain of sudden onset that is out of proportion to physical and laboratory findings. Multiphasic CTA also is recommended after an endoscopically or CT-diagnosed isolated right colon IC because this may be an indicator of SMA occlusive disease
V
*
The mortality rate approaches 50% in patients who require acute surgical intervention for ischemic colitis
Indications for Surgical Intervention in Patients With Ischemic Colitis:
Acute
Peritonitis
Bowel perforation
Bowel necrosis
Fulminant colitis
Massive hemorrhage
Sepsis
Chronic
Intractable symptoms lasting >2 weeks
Recurrent sepsis
Chronic colitis
Ischemic stricture
Malnutrition from protein-losing enteropathy
>
Diversion colitis
*
Thought to develop as a result of butyrate deficiency
>
Endoscopic findings
*
Tissue palor
*
Mucus plugs
*
Contact irritations
*
Erythema
*
Ulceration
*
Bx are likely to demonstrate acute on chronic inflammation ± crypt architectural abnormalities
*
Presence of lymphoid follicular hyperplasia is pathognomonic
>
Treatment
*
Short-chain fatty acid enemas BID (up to 6w)
*
5-ASA enemas
*
Steroid enemas
>
Disinfectant and corrosive colitis
V
Etiology (often associated with cleaning solutions for endoscopes)
*
Hydrogen peroxide bases
*
Glutaraldhyde formulations
*
Formalin
*
Finding of plaques on withdrawal of an endoscope that were not seen on introduction raises suspicion for this type of injury
*
No treatment is necessary
*
Prevention is with thorough rinsing of endoscopes
>
NSAID & salicylate-induced colitis
V
NSAIDs may cause
*
Colonic mucosal injury and ulceration
*
Colonic stricture formation
*
Perforation
*
Hemorrhage
*
Presentation may be with diarrhea, rectal bleeding, or abdominal pain
*
Treatment is discontinuation of offending agents ± (5-ASA or steroid enemas)
>
Toxic Epidermal Necrolysis associated colitis
*
Endoscopic findings often show diffuse ulceration ± necrosis
*
Pathologic examination often demonstrates intact muscular layer with no crypt abscesses on pathology
>
STI
>
Screening
>
Asymptomatic high-risk patients:
>
Populations at risk:
*
Current ulcerative STIs
*
HIV seropositivity
*
Men who have sex with men (MSM) engaging in unprotected receptive anal intercourse
*
Method: regular universal testing for STIs
>
Symptomatic patients with:
>
Painful/painless perianal/genital lesions
*
Genital lesions in young sexually active patients are most likely to be genital herpes or syphilis
*
Suggested screening: syphilis, HSV, and HIV
*
Rectal/vaginal/urethral discharge
>
Proctitis
*
Swabs should be taken before doing a rectal exam with lubricant given its bacteriostatic properties.
*
Presence of both proctitis symptoms + anal ulceration = very likely to have HSV (83 %) or gonorrhea
>
Empiric treatment for proctitis should be given at the time of evaluation rather than waiting for test results and should consist of treatment for (all three):
*
Gonorrhea (ceftriaxone 250 mg intramuscular × 1 day)
*
Chlamydia/LGV (doxycycline 100 mg bid × 21 days)
*
HSV (valacyclovir 1 g bid × 10 days)
V
V
Infections
9123EE5A-648A-4C0C-A9D2-487AADCB4F2E_1_105_c
>
Bacterial
>
Gonorrhea and Chlamydia
>
Testing and diagnosis
>
NAAT has sensitivity of 86% and specificity of 97%
*
Men: first catch urine
*
Women: vaginal swab; endocervical swab if suspecting PID
V
NAAT is recommended for all situations except:
*
Prepubescent patients
*
Potential treatment failures
>
N. Gonorrhea
V
*
Neisseria gonorrhoea: intracellular Gram⊖ diplococci
Screen Shot 2021-12-20 at 22.56.45
*
The 2nd most common notifiable communicable disease in the USA
>
Most infection in men manifests with:
V
*
Urethritis
Screen Shot 2021-12-20 at 22.56.48
*
Epididymitis
*
Disseminated infection
>
Infections tend to be asymptomatic in women, although they can cause:
*
Cervicitis
*
Urethritis
*
Proctitis
*
Pelvic inflammatory disease
>
Screening & testing
*
CDC recommends routine screening of oropharyngeal, anorectal, and urogenital sites for all MSM who are sexually active and at risk for STI.
*
CDC recommends that NAATs be used in all circumstances to detect chlamydia and gonorrhea
*
Men: first catch urine or urethral swab
*
Women: vaginal swabs (self- or clinician-collected) or endocervical swab if a pelvic examination is also indicated
*
Culture testing indicated to evaluate for Abx susceptibility if treatment failure is clinically expected or if NAAT positivity persists
V
>
Treatment
Screen Shot 2021-12-20 at 21.12.04
*
Ceftriaxone 250mg IM X1 + azithromycin 1g PO X1
*
Alternative: Doxycycline 100mg PO BID X 7d
*
Sexual partners of infected patients in the preceding 2 months should also undergo treatment the same regimen
V
>
Chlamydia trachomatis
Screen Shot 2021-12-20 at 23.00.28
*
The most common notifiable disease in the USA
V
Presentations / manifestations
*
Most patients are asymptomatic or have mild nonspecific symptoms
*
Men most commonly have symptoms of urethritis, less frequently epididymitis or infertility
*
Some develop proctocolitis
*
Ocular infection and reactivation arthritis can also occur
>
Screening & testing
*
CDC and the US Preventive Services Task Force recommend screening sexually active women aged 24 and younger for chlamydia, as well as older women at increased risk for infection
*
Routine universal screening for men is not recommended
*
For all MSM reporting receptive anorectal intercourse, rectal chlamydia screening is recommended
*
Recommended testing method is with NAAT
*
Men: 1st catch urine or urethral swab
*
Women: vaginal swab
>
Treatment
*
Azithromycin 1g PO X1
*
Alternative: Doxycycline 100mg PO BID X 7d
*
Sexual partners of infected patients in the preceding 2 months should undergo testing and treatment
*
Routine test-of-cure several weeks after treatment is not recommended by the CDC if the patient has undergone appropriate treatment and is asymptomatic with no suspicion of re-infection. However, recurrent chlamydia infections are common in both men and women. When indicated, repeat testing should be performed three months after treatment
>
Lymphogranuloma venereum (C. Trachomatis)
*
Caused by C. Trachomatis serovars L1, L2, and L3 → result in severe inflammation and invasive infection
*
Inguinal syndrome (genital inoculation): painful inguinal/femoral lymphadenopathy (buboes) ± genital ulcers
*
Anorectal syndrome: ulcerative proctitis/proctocolitis (mucopurulent discharge + tenesmus + constitutional symptoms)
>
Untreated LGV can result in severe complications:
*
Colorectal fistulas
*
Strictures
*
Elephentiasis
*
Infertility
*
Pelvic fibrosis
V
Diagnosis
*
There is no routine diagnostic test for LGV serovars
*
It can be mistaken for IBD even on pathologic examination (may even cause granulomas)
V
Treatment
*
Doxycycline 100mg PO BID X 3w
*
Buboes require aspiration or I&D to prevent ulcerations
*
Sexual partners for the prior 60d should be treated
>
Syphilis
>
Stages of infection
V
>
Primary syphilis
HIV⊕ patients have higher rate of asymptomatic primary syphilis
*
Solitary non-tender genital chancre
*
± Proctitis: bleeding, pain, tenesmus
*
Regional lymphadenopathy
*
Secondary syphilis: rash, fever, malaise, pharyngitis, hepatitis, mucous patches, condyloma lata, alopecia
>
Tertiary syphilis
*
Cardiovascular system or gummatous disease (granulomatous disease of the skin and subcutaneous tissues, bones, or viscera)
*
Neurosyphilis (meningitis & stroke)
>
Testing
*
Screening with non-treponemal tests: VDRL and RPR (they become positive within 3w of the primary chancre)
*
Dark field examination to detect T. Palladium in lesion exudate or tissue may be successful in diagnosing early syphilis
V
Confirmatory treponemal tests (usually remain reactive for life in patients who have had a reactive test at one point):
*
Fluorescent treponemal absorption tests
*
T. pallidum passive particle agglutination assay
*
All sexually active MSM should be screened at least annually for syphilis, more frequently if they engage in high-risk sexual practices
*
Repeat testing with non-treponemal tests should be performed at 6 and 12 months after treatment
V
Treatment
*
Penicillin G 2.4 million units IM X1 for primary, secondary, and early latent syphilis
*
Patients coinfected with HIV should be treated with the regimen recommended for the treatment of neurosyphilis
*
Pregnant women with syphilis and a penicillin allergy should undergo desensitization and treated with penicillin
*
Repeat testing with non-treponemal tests should be performed at 6 and 12 months after treatment
>
Chancroid
*
Caused by Haemophilus ducreyi
V
*
Usually presents with multiple painful purulent genital ulcers that progress through pustular and ulcerative stages
Screen Shot 2021-12-20 at 23.07.02Screen Shot 2021-12-20 at 23.07.06
*
There are no FDA-approved tests for it in the USA. Thus, diagnosis of chancroid is made based on symptoms of painful genital ulceration and regional lymphadenopathy in the absence of syphilis and HSV
*
First-line treatment of chancroid includes azithromycin, erythromycin, ceftriaxone, and ciprofloxacin
*
Inguinal bubo formation requires at least a two-week course of antibiotic therapy and may also require aspiration or incision and drainage to prevent spontaneous rupture
>
Donovanosis (Granuloma Inguinale)
*
Caused by Klebsiella granulomatis
*
Donovanosis + HIV = ↑ aggressiveness and can result in malignant transformation
*
Transmission is via sexual contact, fecal contamination, and autoinoculation
*
Clinical presentation includes papules or nodules that progress into a painless ulcer, usually in the genital area
*
Testing is performed using tissue smears from the lesions and microscopic identification of characteristic intracytoplasmic inclusion bodies (Donovan bodies) or with PCR
*
Treatment regimens include 3w course of doxycycline, ciprofloxacin, erythromycin base, or trimethoprim/sulfamethoxazole
V
Viral
V
Herpes
>
HSV-1 and HSV-2 may cause anogenital herpes infection
*
Most cases are caused by HSV-2
*
HSV-2 infection is more likely to cause recurrences than HSV-1 infection
*
Present with multiple painful vesicular ulcers
*
HSV is the most common cause of proctitis among HIV-positive men
>
Testing
*
Cell culture or PCR (although a negative result may be attributed to intermittent viral shedding)
*
Serologic assays are useful for symptomatics but with negative cultures
*
Routine screening of the general population is not recommended
V
Treatment
*
The first clinical episode of genital herpes can cause severe ulcerations as well as systemic symptoms. Therefore, treatment with antiviral therapy—acyclovir, famciclovir, or valacyclovir—is recommended to shorten the course of the episode.
*
Suppressive antiviral therapy can decrease the number of recurrences in patients with frequent recurrences (at least four per year)
*
HPV (see ‘The Anus: HPV’)
V
HIV
*
HIV screening is recommended for all patients who present for STI testing
*
If patient is suspected of having acute HIV infection, then a nucleic acid test should be performed in addition to the antibody test, and the patient should be referred immediately to an infectious disease specialist
>
Molluscum contagiosum
*
Caused by Molluscipoxvirus
*
Causes small, waxy, dome-shaped umbilicate papules
*
Risk factors include shaving
*
Transmission: skin-skin & autoinoculation to other sites
*
Dx is made with visual inspection. Dermatoscopy may aid in Dx
*
Treatment is similar to that of genital warts (cryotherapy, curette) or Podophyllotoxin
>
Treatment
*
Immunocompetent patients will self-resolve the lesions over months to years. Therefore, treatment is offered to speed up the healing process
*
Immunocompromised patients are treated to prevent non-healing wounds and superinfections
>
Pubic lice: Phthirus pubis
*
Dx: by finding lice on pubic hair
*
Transmission is by direct contact, therefore: Dx of pubic lice should prompt testing for other STIs
*
Treatment: permethrin 1% cream or pyrethrins 0.3%/piperonyl but oxide 4%
*
Alternative treatment: ivermectin PO
*
Permethrin should be used on the day of Dx and again 7-10d later to completely eradicate the infestations as the treatment does not kill the eggs
*
Laundering clothes and feedings in hot water should be done to prevent reinfection
>
Scabies
*
Caused by Sacroptes scabiei
*
Trasmission: skin-to-skin contact
*
The mites burrow into the skin, creating wavy scaly lines on the skin surface, usually located on the hands and feet, typically in finger webs
*
Causes intense pruritic rash
*
Infants, children, and immunosuppressed patients may develop more severe vesicular and pustule rash
*
Skin scrapings is done by applying mineral oil to the skin and scraping laterally across the lesion then examining microscopically for mites, eggs, and fecal pellets
*
1st line treatment: permethrin 5% cream applied from the neck down (all the body), then washed off 8-14h later. Reapplication of the cream is performed 7d later to ensure eradication. Pruritic may press for up to 2w after treatment
*
Laundering clothes and feedings in hot water should be done to prevent reinfection
>
Large bowel obstruction
>
Etiology
*
1. Colorectal cancer (account for >50% in the USA)
>
2. Volvulus
V
*
Unlike many other conditions of the colon, the Western hemisphere actually has a lower incidence of colonic volvulus than other regions worldwide. In the region known as the volvulus belt, an area extending along South America, Africa, the Middle East, India, and Russia, colonic volvulus is more common, and accounts for approximately 50% of all cases of colonic obstruction.
The ‘volvulus belt’
Pasted_Graphic_9
*
Presentation may be urgent/emergent or as a relapsing chronic form of recurrent obstructions
*
Sigmoid volvulus is the most common cause of intestinal obstruction in pregnancy worldwide occurring at rates of 3.1–12.5%
*
Sigmoid volvulus patients are more likely older, male, and institutionalized
*
For ileosigmoid knotting: Imaging may suggest the diagnosis by a distended sigmoid colon on the right and distended small bowel loops on the left
>
Pathophysiology
*
Bowel almost exclusively twists in counterclockwise direction around mesocolic axis
*
Volvulus < 180 degrees is physiologic
*
Volvulus > 180 degrees results in mechanical luminal obstruction
*
Volvulus > 360 degrees results in vascular compromise
>
Management
>
Sigmoid volvulus (75%)
>
1. Endoscopic or operative detorsion
*
Successful in 75-95%
V
Endoscopic decompression alone has an extremely high recurrence (50-70%) and still carries a mortality of 6%.
*
May be performed with rigid proctoscopy or flexible sigmoidoscopy
*
A long flexible tube, such as a small-caliber chest tube or nasogastric tube, may be left in place to allow for continued decompression and to prevent retorsion.
*
Confirm successful reduction and absence of air under diaphragm by abdominal x-ray following detorsion procedure
*
Failure of endoscopic decompression is an indication for surgery
V
>
2. Operative
Resection of the sigmoid colon generally is accepted as the best method to address acute and chronic sigmoid volvulus.
V
Successful decompression is usually followed by semi-elective resection (usually < 5-7 days — during the same admission). Colonoscopy should be performed before elective surgery to exclude an associated neoplasm
*
In 2 retrospective reviews, emergency surgery at the time of recurrent sigmoid volvulus had much higher mortality (13% and 62%) than patients who had elective surgery following their initial volvulus episode (3.3% and 32%)
*
All fixation techniques carry a recurrence risk of ≥ 25%
*
The amount of bowel resected is determined by areas of ischemia and/or redundancy
V
Resection + (Hartmann’s pouch Vs anastomosis) is dependent on patient factors
*
Sigmoid resection with primary anastomosis has been associated with the greatest success in patients who have not developed gangrene
*
In patients with a history of volvulus in other segments of the colon or concurrent megacolon, subtotal colectomy should be considered because it may be more effective in preventing future volvulus than sigmoid colectomy alone
*
Resection can be done through a LLQ incision alone
*
ASCRS CPG 2021: Endoscopic fixation of the sigmoid colon may be considered in selected patients in whom operative intervention presents a prohibitive risk. Grade of recommendation: Weak recommendation based on low-quality evidence, 2C.
>
In pregnancy
*
Endoscopic detorsion should be undertaken in the first trimester with elective resection delayed until the second trimester, when the risk to the fetus is diminished
*
During the third trimester, endoscopic detorsion should be followed by close observation allowing for completion of fetal maturity, followed by delivery, and then elective resection
>
Cecal bascule & volvulus
V
*
Cecal bascule: the cecum turns anteriorly over a fixed ascending colon
The cecal bascule commonly causes intermittent bouts of abdominal pain because the mobile cecum permits intermittent episodes of isolated cecal obstruction that are spontaneously relieved as the cecum falls back into its normal position.
*
Cecal volvulus: the cecum turns along it’s mesenteric axis
*
Nonviable or gangrenous cecum is present in 18-44% of patients with cecal volvulus and is associated with a significant mortality rate
>
Operative fixation has ≥ 26% recurrence and a mortality of 5-10% (similar to resection)
*
Cecopexy: The colon is sutured into position using the surgeon’s suture of choice in either a running or interrupted fashion
V
*
Cecostomy tube: has a mortality double that of resection
A cecostomy is created by placing a purse-string suture (usually two layers) on the anterior surface of the cecum, then creating an enterotomy in the middle and placing a drainage tube (typically a Malecot tube [28F to 32F]) into the lumen of the cecum. This is tied into position and the tube then is drained externally providing a fixation point and relieving distension.
V
Resection
*
The amount of bowel resected is determined by areas of ischemia and or redundancy
*
Surgical resection: < 1% recurrence and a mortality of 5-10%
*
Anastomotic complications (to include leak/abscess/fistula) are as high as 15%
>
Transverse & splenic flexure volvulus
*
Surgical intervention is recommended because of the belief of high recurrence rate with endoscopic treatment alone
>
Ileosigmoid knotting
*
If ileosigmoid knotting is suspected, these patients should be resuscitated and emergently explored
*
3. Diverticular disease
>
4. Other:
>
Mechanical
*
Intussusception
*
IBD
*
Extrinsic tumor
*
Fecal impaction
*
Foreign body
*
Infection
*
Adhesion-related
V
Hirschsprung’s disease
>
General
*
It is caused by interruption of the normal migration of the neuroenteric cells (Meissner’s & Auerbach’s) from the neural crest before they reach the rectum.
*
Aganglionic area lacks nitric oxide synthase → lack of the muscle relaxant nitric oxide → constriction
*
Transition zone is usually (80%) the rectosigmoid colon
*
Incidence: 1 in 5,000 live births
*
♂ 4:1 ♀ (except in total colonic aganglionosis in which ♀>♂)
*
RET proto-oncogene mutations compromise nearly ½ of all familial cases & a smaller fraction of sporadic cases
>
Presentation
*
Delayed passage of meconium (> 48h)
*
Poor feeding, poor weight gain, progressive abdominal distension
V
Evaluation & Dx
V
Imaging
*
Xray: dilated bowel loops (the dilated part is the normal segment of bowel)
V
*
Barium enema with a rectum/sigmoid ratio of <1 is diagnostic
Barium enema is the primary diagnostic radiologic study and should be done before a rectal examination or washout enema is administered as that might decompress the characteristic transition zone
>
Rule out congenital abnormalities
*
Cardiac
*
Pulmonary
*
Urinary
*
GI
*
Evaluate for the presence of Hirschsprung’s associated eneterocolitis
>
Gold standard Dx is with Bx
*
Avoid Bx in the distal most rectum (0.5-1cm from dentate line) as that segment may normally be aganglionic
*
Infants: bedside suction rectal Bx of mucosa and submucosa is appropriate
*
Older children & adults: full thickness distal rectal Bx
>
Bx results
*
Absence of ganglion cells in submucosa
*
Hypertrophic parasympathetic nerve trunks
*
↑ acetylcholinesterase staining
*
Absence of calretinin positive nerves
>
Anorectal manometry is useful in adults but not paediatrics
*
Absence of RAIR should raise suspicion for certain pathologic conditions, including Hirschsprung’s disease, Chagas disease, dermatomyositis, and scleroderma
>
Management
>
Pediatric population
*
PreOp: bedside decompression with rectal irrigation 20-30ml/kg Q6h
*
If the transition zone is higher than can be reached by the washouts, the decompression is going to be unsuccessful and the patient will require a formal levelling colostomy. If the washouts are successful in decompressing the obstruction, an elective repair is contemplated
V
Stage 1: Colostomy creation / Levelling procedure
*
Levelling procedure = intraoperative biopsies are serially obtained to determine the level of ganglionosis
*
Identify transition zone
*
Transect bowel proximal to the transition zone
V
>
Stage 2: Pull through ± proximal diversion
40746_2020_195_Fig2_HTML
*
Throughout the procedure, full-thickness Bx are obtained at various levels to determine the level of ganglionosis on frozen sections
>
Swenson procedure
*
Resection of the entire aganglionic segment down to the dentate line
*
Perineal coloanal anastomosis
>
Duhamel procedure (rectorectal pull-through)
*
Posterior rectal dissection
*
The bowel is divided proximal to the transition zone (in the normally innervated colon)
*
From a transanal approach, an incision is made in the posterior rectal wall 1cm proximal to the dentate line
*
An anastomosis is made
*
Optional step: linear stapler is used to divide the common wall between the native rectal vault and the ganglionic colon to create a side-to-side anastomosis
*
This can be used as a salvage procedure for failed Swenson procedure
>
Soave-Boley procedure (submucosal endorectal pull-through)
*
Main advantage: minimizes risk to pelvic structures during dissection
*
The aganglionic intestine is resected to the level of the rectum below the peritoneal reflection
*
A submucosal dissection from both the pelvic side and the anal side removes the rectal mucosa and creates a muscular cuff
*
The ganglionic intestine is then pulled through the cuff
*
Anastomosis 1 cm above the dentate line
*
Most children do well regardless of the type of procedure
*
Stage 3: Reversal of diversion
>
Adult population
>
Posterior anorectal strip myectomy: diagnostic ± therapeutic. In short-segment disease, this procedure may be curative
*
Incision is made in the rectal mucosa proximal to the dentate line to expose the underlying muscularis.
*
A portion of internal sphincter muscle is excised and ideally contains ganglion cells at the proximal surgical margin.
V
Laparoscopic rectosigmoid resection with a trans-anal colonic pull-through followed by delayed coloanal anastomosis
V
Stage 1
*
Abdominal phase: in contrast to procedures for rectal cancer, the dissection plane stays between the rectal muscular layer and the mesorectum
>
Perineal phase:
*
Gradual anal dilatation
*
Installation of a LoneStar retractor
*
Circumferential incision of the mucosa is made at the level of the dentate line and a short mucosectomy is performed
*
Rectum is then transected at the upper border of the anal sphincter until the level of the abdominal dissection is reached (usually at the level of the levator ani)
*
The rectum and sigmoid colon are pulled through the anal canal. Once the colon is pulled through, it is cut above the megacolon, therefore leaving an 8-10 cm colonic segment outside the anal canal.
*
This exteriorized colonic segment is tied by means of 2 stitches to the right thigh and left open to allow clearance of gas and stool
*
The exteriorized segment is wrapped in absorbent, paraffin-impregnated gauze
>
Stage 2: 5-7 days after the first stage
*
No retractors are needed and the adhesions between the anal canal and colon must be left intact
*
After the mesocolon is tied off at the level of the anal verge, the pulled-through colonic segment is excised at the same level, and a handsewn coloanal anastomosis is created at the level of the dentate line
*
No preventive diverting stoma is constructed
*
Duhamel procedure: Only small numbers of Swenson and Soave operations have been reported in adults. Although functional results in the long term were reported to be satisfactory, the incidence of septic complications was higher with these operations. Neither of these two operations offers a compliant reservoir, which is usually considered a necessity for acceptable defecatory function. However, compared with the Swenson and Soave operations, the Duhamel and modified Duhamel operations are superior for preventing postoperative impotence and anastomotic dehiscence, and creating a reservoir to minimize soiling.
V
>
PostOp concerns
These more uncommon conditions may require reoperation, including a posterior myomectomy (in the case of recurrent enterocolitis), or redo-pull-through for strictures or aganglionic segments
>
Chronic obstruction; etiology:
*
Mechanical obstruction 2ry to strictures (most common) requiring dilatation
*
Recurrence / residual aganglionosis (second most common)
*
Motility disorder
*
Anal sphincter achalasia
>
Constipation
>
Etiology of constipation in Hirschsprung’s disease
*
Enterocolitis
*
Anastomotic issues (strictures)
*
Sphincter dysfunction
*
Retained/acquired aganglionic segment
*
Soiling/incontinence
>
Recurrent enterocolitis
*
Affects up to 40% of pull-through patients
V
>
Functional Ogilvie’s syndrome
Screen_Shot_2019-07-23_at_15.57.37
*
May be acute or chronic
V
*
It is most frequently associated with infection, cardiac disease, and operative & non-operative trauma
Cesarean section and hip surgery were the most common surgical procedures associated with acute colonic pseudo-obstruction
*
Usually involves the cecum and right hemicolon
*
Average onset is 4d after surgery
*
Ischemia or perforation at presentation is reported in 3-15% of cases (associated mortality: <50%)
V
Assessment & Dx
*
Colonoscopy should not be used to make the diagnosis of acute intestinal pseudo-obstruction, as insufflation of air may increase the colonic dilatation
*
The most useful investigation is a water-soluble contrast enema, which should be performed in all patients in whom the diagnosis is suspected, provided their condition is stable enough to warrant the procedure — Sabiston
*
Although larger cecal diameter is associated with a higher risk of perforation, the duration of distension and the rate of distension are important factors that contribute to perforation even in cases with less extreme degrees of dilation
>
Management
V
Cecal diameter < 12cm
*
Discontinue gut-slowing agents: opioids, antidiarrheals, anticholinergics, antipsychotics, & CCB
V
NPO / Bowel rest
*
In general, oral laxatives are contraindicated under these circumstances as these can increase intraluminal pressure
*
Ambulation
*
Knee-chest or prone positioning to promote flatus
*
Insertion or rectal tube ± NGT
*
Serial examinations and radiographs
*
Success rate of conservative therapy is 70-90%
>
Cecal diameter > 12cm (or failed conservative management)
*
There are reports of immediate resolution of Ogilvie’s Syndrome after the administration of an epidural anesthetic that provides sympathetic blockade
*
Variable success rates have been reported using hourly position changes, including prone, left, and right lateral decubitus
*
Medical complications and mortality were significantly less in the group managed medically (complications 44%, mortality 7.3%) than in those eventually requiring colonoscopy (complications 64%, mortality 9%), surgery (complications 60%, mortality 12.3%) or in those who required both colonoscopy and surgery (complications 74.6%, mortality 14.8%)
>
1. Neostigmine
*
Reversibly inhibits the acetylcholinesterase
*
It is obviously imperative that mechanical obstruction be excluded by water-soluble contrast enema or colonoscopy before the administration of neostigmine — Sabiston
>
Regimen
*
Neostigmine 2mg IV X1 over 3 minutes (repeat X1 in 24h, PRN)
*
Doses typically are reduced by 50% for a creatinine clearance of 10 to 50 mL/min
*
Simultaneous administration of intravenous glycopyrrolate at a dose of 0.4 mg has been shown to attenuate some of these side effects
V
>
Adverse effects of neostigmine
AE can include: : bradycardia, hypotension, asystole, seizures, restlessness, tremor, bronchoconstriction, nausea, vomiting, salivation, diarrhea, sweating, and abdominal cramps
*
Abdominal pain (50%–73%)
*
Sialorrhea (23%38%)
*
Vomiting (10%–20%)
*
Bradycardia (5%–9%)
V
V
Contraindications:
ASCRS clinical practice guideline: it may be used with caution in patients with bradycardia, asthma, chronic obstructive pulmonary disease, renal insufficiency, or recent myocardial infarction
*
Mechanical bowel obstruction
*
Presence of any baseline arrhythmia
*
SBP < 90
*
HR < 60
*
Severe active bronchospasm
*
Recent MI
*
Cardiac arrhythmia
*
Concommitant β-blocker use (relative contraindication)
*
Pregnancy
*
Efficacy: 60-100%
*
Administration is done in a monitored setting with glycopyrrolate or atropine readily available for rapid use in cases of bronchospasm or bradycardia
*
Effect is demonstrated usually in ≤ 30m
*
It induces bradyarrhythmias; atropine should be available at bedside
>
The recurrence rates (0-30%) following the administration of neostigmine appear to be far lower than those associated with colonoscopic decompression
*
Recurrences may be prevented by administration of polyethylene glycol (PEG) following decompression
V
2. Colonoscopic decompression
>
In general, the risks of colonoscopy and its high recurrence rates outweigh its benefits as a first-line treatment in the setting of ACPO. In summary, colonoscopy should be considered rescue therapy in those patients that have failed all supportive and pharmacologic measures
*
Perforation rate is 2-3%
*
Performed without bowel preparation
*
Use benzodiazepines alone for procedural sedation (narcotics will affect bowel motility)
*
Decompression at the level of the hepatic flexur is usually sufficient to achieve decompression
>
Success rate:
*
Decompression alone = 50%
*
Decompression + placement of decompression tube in ascending colon = 80-90%
*
Most patients require repeat colonoscopic decompression for it to be successful
*
Advancement to the cecum may be attempted, but if it cannot be safely reached, decompression up to the hepatic flexure is often sufficient for clinical benefit
>
Decompression tube care:
*
Applied to low intermittent suction
*
Flushed Q4-6h with small volume of saline to prevent clogging
*
The tube is removed after 72h
V
*
The ascending/transverse colon should decompress 2cm 4h after endoscopic decompression
Pham TN, Cosman BC, Chu P, Savides TJ. Radiographic changes after colonoscopic decompression for acute pseudo-obstruction. Dis Colon Rectum 1999;42:1586-1591.
PURPOSE: Colonoscopy has been the principal tool for decompression in acute colonic pseudo-obstruction, known as Ogilvie's syndrome. The objectives of this study were to determine the immediate effect of colonoscopy on the cecal diameter (measured on supine radiographs) and to delineate possible correlations in the diameters of dilated segments of the colon.
METHODS: The charts and radiographs of 24 patients who had colonoscopic decompression for acute colonic pseudo-obstruction between 1992 and 1997 at the San Diego Veterans Affairs Medical Center and the University of California, San Diego Hospitals were reviewed. We measured cecal, transverse, descending, and sigmoid colon dianleters on serial radiographs up to the point of clinical resolution.
RESULTS: Mean + standard deviation cecal diameter change (between initial and postdecompression films) was -2 + 3.4 cm at four hours and -2.2 + 3.3 cm one day after decompression. On the daily radiographs between colonoscopic decompression and clinical resolution, there was a close correlation between the diameter of the cecum and that of the transverse colon (P < 0.05). There was no correlation between the cecal diameter and that of the descending or sigmoid colon.
CONCLUSIONS: Colonoscopic decompression only causes a small decrease in cecal size in the patient with acute colonic pseudo-obstruction. Dilation patterns of the cecum and transverse colon are significantly correlated in acute colonic pseudo-obstruction. This correlation provides additional support to the contention that the same pathophysiology affects these two segments of the colon.
*
3.1 After decompression, administration of daily low-dose polyethylene glycol is advised to prevent recurrence
*
3.2 Percutaneous cecostomy may be placed endoscopically or with radiologic guidance
>
3.3 Surgery
*
Mortality rate: 30-60% in those who undergo surgery of any kind
V
Indicated for complications or if obstruction persists ≥ 6 days
*
UTD: The risk of colonic perforation increases when cecal diameter exceeds 10 to 12 cm and when the distention has been present for greater than six days. The duration of dilation is probably more important than the absolute diameter of the colon
*
In practice, patients without a firm indication for operation may undergo continued medical therapy with repeated attempts of pharmacotherapy and/or endoscopic decompression before ultimately moving to a surgical intervention.
V
Surgery: stoma creation ± resection
*
ASCRS textbook: Patients with viable colon without perforation most commonly undergo exploration to confirm there is no compromised colon and are then decompressed and vented through a colostomy. The role of colectomy under these circumstances is questionable.
*
Viable colon: tube cecostomy or cecostomy is successful in 95-100% of patients with no comparative data available to guide the preferred type of ostomy creation.
*
Ischemic/perforated colon: resection + (fecal diversion vs anastomosis)
*
Contrast enema is the gold standard imaging modality, and is occasionally therapeutic
V
*
Cecal dilation of ≥ 12cm is associated with increased risk for ischemia & perforation
However, there is no direct correlation between cecal diameter and risk of perforation. Perforation can occur at smaller cecal diameters.
*
Mortality rate of 14.9% for emergency surgery versus 5.8% for elective surgery
>
Enteral stents
>
Benefits of stenting
*
Palliation in advanced disease
*
Preoperative decompression as a bridge to surgery (conversion of an emergency operation to an elective one is associated with reduced morbidity and mortality)
*
Allows preOp colonoscopy to assess for synchronous lesions
*
Avoids the need for a colostomy
>
Contraindications
>
Absolute
*
Signs of systemic toxicity
*
Intraabdominal abscess or perforation
*
Receiving Avastin (bevacizumab)
>
Relative
*
Distal rectal lesion (within 5cm from AV)
V
*
Right sided lesions (stenting does not alter surgical procedure (single stage procedure, not requiring bowel preparation); but may be beneficial for palliative patients)
Clinical success in relieving obstruction with self-expanding metal stents is similar to left-sided obstructions (Dronamraju et al. DCR 2009)
*
Benign colon obstruction
>
Deployment systems
>
Through The Scope (TTS) stents
V
*
WallFlex Colonic Stent (Boston Scientific)
Uncovered nitinol
Mid-body diameter 22 or 25 mm
Proximal flange 27 or 30 mm
6,9,12 cm lengths
30-40% foreshortening
Screen Shot 2021-03-21 at 17.56.33
V
*
Evolution Colonic Controlled-Release Stent (Cook Medical)
Uncovered nitinol
Diameter 25 mm
Flanges 30 mm
6,8,10 cm lengths
Also has foreshortening
Screen Shot 2021-03-21 at 17.56.25
>
Non-TTS stents
V
*
Ultraflex Precision Colonic Stent (Boston Scientific)
Too large to pass through the endoscope
channel
Uncovered nitinol
Body diameter 25 mm, flange 30 mm
Lengths 5.7, 8.7, 11.7 cm
Less foreshortening
Cannot be re-constrained during deployment
>
Technique
*
Minimize insufflation (use water immersion instead)
*
Pass a guide-wire through the obstruction site, then confirm passage on fluoroscopy
*
Dilation of the lesion is no longer performed because of the ↑ risk of perforation
*
Deployment is done in 1-2 cm increments, under intermittent fluoroscopic guidance & endoscopic vision
*
The stent should sit ≥ 2 cm both proximal & distal to the lesion
*
To prevent re-obstruction, the diameter should be 24 mm at the mid-stent position
*
If stent placement is not satisfactory after deployment, a 2nd stent can be placed overlapping the first
*
Full expansion of the stent may take up to 72h & can be assessed by X-ray
*
After full stent expansion, the patient may be prepped for colonoscopic inspection of the entire colon
>
Outcomes
*
Technical & clinical success ~97%
*
Success rate is lower for distal tumors and tumors at flexures
*
Mean patency rate > 6 months
V
>
The Efficacy of Self-Expanding Metal Stents for Malignant Colorectal Obstruction by Noncolonic Malignancy with Peritoneal Carcinomatosis (Kim et al. 2013 DCR)
Screen Shot 2021-03-21 at 18.35.40
*
Technical success: 90%
*
50% did not need further intervention
*
Mean event-free survival: 119 days
*
Mean overall survival: 156 days
V
>
Predictors of clinical failure (on multivariate analysis)
Lee, Hyun Jung, et al. "Clinical outcomes of self-expandable metal stents for malignant rectal obstruction." Diseases of the Colon & Rectum 61.1 (2018): 43-50.
V
*
Extracolonic malignancy etiology (vs CRC)
Rectal obstructions are more likely to be due to non-CRC malignancy than left sided colonic obstructions
*
Use of covered stent (vs uncovered)
*
There are some concerns about worsening of oncologic outcomes for obstructed but curable average risk cancer patients who undergo stenting initially. “On the contrary, in high-risk surgical patients, initial stenting followed by optimization for interval colectomy is recommended by these societies and should be considered on an individualized basis” — ASCRS CPG
>
Post-stent care
*
Avoid: vegetables, fruits, & whole grains
*
Maintain a low-residue diet
*
Laxatives sufficient to maintain soft-to-loose stool consistency
>
Complications
*
Several studies have noted silent perforations at the time of surgery as well. In the setting of potentially curable cancer, these perforations could negatively impact cancer control
V
Perforation: ≤ 5%
>
Perforation timing
*
Immediate — caused by the scope, stent, or guidewire
V
*
Delayed — erosion/pressure necrosis caused by the flared end of the stent
This occurs more frequently in colonic segments with sharp angulation, in which the stent ends abut and abrade the colonic wall
V
*
Stented patients receiving chemotherapy with bevacizumab (Avastin) appear to be at a significantly increased risk for perforation
Prior therapy with bevacizumab does not appear to increase the risk of colonic perforation.
>
Stent migration:
*
Occurs in 20% for covered, 2% for uncovered
*
25% of migrations occur within 3d of placement
*
Occurs more frequently in benign lesions or lesions extrinsic to the colon
*
Stent occlusion: 4% for covered, 15% for uncovered
*
Minor bleeding may occur because of tumor friability
*
Abdominal pain after stent placement is usually mild and resolves within hours to days
>
On-table lavage Vs subtotal colectomy
*
Subtotal colectomy usually associated with worse functional outcomes
*
On-table lavage is associated with higher infectious complications
*
Leak rate is similar between the two
*
Subtotal colectomy may be preferred when part of the sigmoid colon can be preserved
>
On-table lavage may be preferred in the setting of:
*
Distal sigmoid / rectosigmoid obstruction
*
Existing anal incontinence
*
The major disadvantages of on-table lavage include the additional time to perform, which can be as much as 60 min, and the additional dissection it often requires
>
Endometriosis
>
15% of ♀ of reproductive age & ⅓ of infertile ♀ have endometriosis
*
Japanese women have double the incidence than Caucasian women
*
Studies indicate a possible genetic aspect to endometriosis
>
Affected sites
*
Ovaries: 60-75%
*
Uterosacral ligaments: 30-65%
*
Cul-de-sac: 20-30%
*
Uterus: 4-20%
*
Rectosigmoid colon: 3-10%
*
Appendix and terminal ileum: ≤ 2%
>
Presentation
*
Symptoms are related to the depth of penetration of lesions, and last for the duration of menstruation
*
Pain is the most common symptom, present in 80%
*
Dysmenorrhea occurs in most women
*
Presence of dyspareunia is often indicative of the degree of fixation of the pelvic organs (especially in cul-de-sac and rectovaginal septum)
>
Infertility
*
Pelvic endometriosis and the resulting inflammatory response can produce dense, fibrotic adhesions that may significantly interfere with both the oocyte release from the ovary and the ability of the fallopian tube to pick up and transmit the oocyte to the uterus.
*
Blockage of the tube may produce a hydrosalpinx
*
Endometrial implants of the appendix and cecum may serve as lead points for an intussusception
*
Endometriosis is associated with ↑ risk of ovarian cancer
>
Workup & Dx
*
There is no non-invasive screening test for endometriosis (Dx depends on visual or pathologic identification)
*
Confusion between small bowel endometriosis and Crohn’s disease is common, as both can produce similar laparoscopic, endoscopic, and even histologic findings
*
CA-125 is elevated in moderate-severe disease, but concentration does not correlate with the severity of disease
>
Colonoscopy for changes in bowel habits
*
Bx of mucosa in areas of endometriosis can resemble SRUS
*
Rarely is the Dx of endometriosis confirmed by endoscopy/Bx
>
Imaging studies
>
Transvaginal US
*
High accuracy in detecting ovarian endometriosis
*
Not very sensitive in detecting non-ovarian implants
>
CT
*
Has better evaluation of pelvic sidewall compared to US, but has low specificity
*
CT is most useful for patients with pelvic pain + ⊖US
>
MRI
*
The best non-invasive modality for suspected endometriosis
*
Identification of endometrial implants is dependent on the hemorrhage that occurs in these lesions
V
Detection of colorectal involvement:
*
Sensitivity: 78%
*
Specificity: 98%
>
Diagnostic laparoscopy
*
There is no uniform type of endometrial lesion. The classic implant is nodular with a variable degree of fibrosis and pigmentation
*
The color may be black, white, brown, blue, or even red. The appearance of the lesion may be vesicular, papular, or hemorrhagic
V
The timing of laparoscopy in relation to the menstrual cycle is unimportant except in patients being evaluated for infertility.
V
*
In these patients, the procedure is performed in the luteal phase to provide additional valuable information concerning ovarian function
ENG_inside_art_3.png
>
Management:
>
Prevention
*
As endometrioid and clear cell ovarian cancers carry a poor prognosis, the long-term use of OCP is recommended by some to decrease the risk of malignant degeneration
>
Medical management
>
Aimed at treating symptoms
*
In limited disease, medical therapy is comparable with surgery in terms of relief of symptoms, recurrence of disease, and subsequent pregnancy rates.
*
Advanced lesions, especially those with a nodular, proliferative histology, will often only partially regress
>
No current hormonal regimen can completely eradicate these lesions, and upon cessation of therapy, the lesions may again become symptomatic
>
Oral contraception
>
Pseudopregnancy with hyperhormonal amenorrhea
*
Estrogen/progestrone: daily administration X 6-9m
*
Progestogens alone
>
Danazol
*
Action: ↓ Peripheral estrogen/progesterone levels
*
Poorly tolerated for long-term suppresssion
*
Danazol raises free testosterone and produces a hyperandrogenic state, especially at lower doses
>
GnRH agonists
V
Administration suppresses pituitary release of FSH & LH
*
Administered at the wrong point in the menstrual cycle → hypersecretion of FSH and LH → precipitate an acute exacerbation in endometriotic symptoms →occasionally necessitating emergency surgical intervention
*
Recommended length of treatment: 6m
*
The degree of bone mineral density loss that can occur with the typical 6-month treatment regimen is 5–6%. This limits the use of GnRH-a to 6 months
*
Pain relief is complete in > 50% and significantly decreased in > 90%
*
Efficacy of danazol & GnRH agonist seem similar
>
Surgical management
*
Patients likely benefit from GnRH-a therapy for 3-6m preoperatively
*
Patients should have full mechanical & Abx bowel preparation
*
Ureteral stents are liberally used
>
Surgery improves pregnancy rate for moderate-severe, but not mild disease
*
In moderate or severe endometriosis, the pregnancy rates following surgery are 50% and 40%, respectively, compared to only 7% when expectant management is practiced
*
A study by Inoue on 2000 infertile women with mild endometriosis did not reveal any improvement in fertility with either medical or surgical therapy when compared to expectant management
>
Rectovaginal involvement
*
Surgical treatment of rectovaginal endometriosis involves dissection of the rectovaginal space and removal of the endometriotic nodules
*
If infiltration of the rectal or vaginal walls is present, resection and repair of these structures may be required
*
Some surgeons perform a LAR with repair for endometrial lesions
V
Bowel involvement other than rectosigmoid
*
For those patients with asymptomatic intestinal endometriosis, the natural history appears to be benign
*
Shaving or superficial excision – This may be performed only for lesions that do not invade beyond the serosa
*
Discoid full thickness bowel involvement: excision and repair
>
Segmental bowel resection and anastomosis indications:
*
Symptomatic implants
*
Stenosis
*
Multifocal lesions
*
Sigmoid involvement
*
Lesions > 3 cm or involving > 50% of the bowel wall circumference
V
PostOp outcomes
*
86% achieve complete or near-complete relief of pelvic pain
*
Recurrence after surgery: 19%
*
If the Dx is encountered intraoperatively: We would be reluctant to perform a total abdominal hysterectomy and bilateral salpingo-oophorectomy without the patient’s knowledge. — Dr. P. Gordon
>
Presacral tumors
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Anatomy of the presacral space
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It is a potential space
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The sacral nerve rootlets are located in this retrorectal space, and thus injury to and sacrifice of these structures can have substantial implications on rectoanal and sexual function
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Boundaries
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Anteriorly: mesorectum
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Posteriorly: presacral fascia and sacrum
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Laterally: lateral rectal stalks, ureters, & iliac vessels
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Superior extension: peritoneal reflection
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Inferior extension: levator ani complex & coccygeal muscle
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Classification of pathology
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Congenital (most common type: 55-70%; ♀ > ♂)
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Developmental cysts (most common congenital type: 60%)
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Ectodermal origin
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Epidermoid cysts: a closure defect of the ectodermal tube (have squamous epithelial lining)
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Dermoid cysts: similar to epidermoid cyst but with more mature elements (dermal appendages: hair follicles and sweat glands)
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Endodermal origin
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Enterogenous duplication cysts can undergo malignant degeneration
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Tailgut cysts / cystic hamartomas: derived from tailgut remnants (contain glandular, mucous-secreting columnar epithelium)
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Teratomas:
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10% contain cancer
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More common in children than adults
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Incomplete resection and resection where the coccyx is not removed are associated with malignant degeneration &/or recurrence
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Chordomas (the 2nd most common congenital type; the most common malignant type)
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Arise from vestiges of the fetal notochord, usually from within the vertebral bodies
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♂ > ♀
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Frequently present with pain and complaints related to nerve impingement (incontinence or impotence)
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Invade and destroy adjacent body structures, often requiring radical resection to prevent recurrence
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Anterior sacral meningocele: a herniation of the dural sac through a defect in the sacrum
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Present with headaches associated with defecation/Valsalva
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Pathognomonic scimitar sign
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Avoid biopsy to avoid meningitis
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Management: ligation of thecal sac
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Adrenal rest tumors: differentiated by radiology studies; treated as ectopic pheochromocytoma
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Inflammatory
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Foreign body granulomas: may be a result of barium leaks or postOp suture reaction
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Perineal abscesses: supralevator space abscess
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Chronic inflammation from fistulas
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Tuberculosis
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Neurogenic (10%)
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Ependymomas (malignant) is the most common of these tumors
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Neurofibromas
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Neurofibrosarcoma
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Neurilemomas (Schwannoma)
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Sporadic Schwannomas affect all ages, peak between 20-50Y
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Made entirely of benign neoplastic Schwann cells
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They are the most common tumor of peripheral nerves
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They grow from peripheral nerves or nerve roots in an eccentric fashion with the nerve itself usually incorporated into the capsule
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They do not transform to malignancy, with the exception of atypical types
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Ganglioneuromas
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Osseous (5-10%) may be the most aggressive of all presacral tumors
Although surgical excision of benign lesions often requires extensive resection and reconstruction, all osseous masses should be completely excised because of the high rate of recurrence
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Osteoma
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Osteogenic sarcoma
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Sacral bone cyst
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Ewing’s sarcoma
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Giant cell tumor
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Chondromyxosarcoma
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Miscellaneous (10-25%)
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Metastatic disease: commonly from the rectum
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Lymphangioma
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Desmoid tumor
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Leiomyoma
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Fibrosarcoma
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Endothelioma
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Presentation
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Most common presentation: asymptomatic mass noted on routine DRE
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Pain is the most common presenting symptom for malignant masses or for those of infectious etiology
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Many patients will have lower back pain or pelvic pain
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Small, midline dimples just posterior to the anus and immediately below the dentate line have been documented in 35-100% of patients with retrorectal developmental cysts
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Any patient with a midline posterior “fistula” exiting just distal to the dentate line should be evaluated closely for the possibility of a retrorectal mass
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Some lesions can cause vaginal canal obstruction that can lead to life-threatening dystocia during childbirth. This is one of the reasons that all retrorectal masses, even benign, asymptomatic masses, should be resected in females during childbearing years
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Examination & workup
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Most lesions are soft, compressible, and easily missed on DRE
V
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DRE: evaluate the proximal extent of tumor & fixation
S3-S4 is usually the extent of the examiner’s finger during DRE. i.e if you are able ‘to get above it’, then it’s below S4
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Sigmoidoscopy to assess extent of the tumor & mucosal integrity
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CT and MRI (with gadolinium) are complementary
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Evaluate if a lesion is cystic vs solid
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Assess for bony destruction & nerve involvement
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Assess pelvic sidewall involvement
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Define the upper extent of the lesion
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Bx is avoided for the following concerns
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Seeding of malignant tumors
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Infecting a sterile cystic lesion (as Bx is usually transvaginal or transrectal)
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Risk of meningitis in the case of anterior sacral meningocele
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Reserve Bx for unresectable lesions requiring tissue Dx to guide chemotherapy
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Select centers prefer to Bx solid lesions and report no increase in recurrence
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Treatment
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The cornerstone in the management of retrorectal tumor is surgical resection
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Unless there is evidence of metastasis, presacral tumors should be resected
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Rationale:
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Potential for malignant transformation
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Risk for infection making later attempts at resection more morbid with higher recurrence
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Symptoms or potential symptoms (e.g vaginal canal obstruction that can lead to life-threatening dystocia during childbirth)
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Radiation
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For locally advanced tumors: NART may ↓ size & ↑ resectability
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Pelvic sidewall involvement may necessitate intraoperative radiotherapy and vascular or ureteric reconstruction
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Surgical approach
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Abdominal approach for: tumors with their lowest extent above S4
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Frequently, the tumor is supplied by the middle sacral artery (branches from the aorta), which must be ligated
Gray539
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Posterior approach for:
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Small, benign tumors not extending above S4
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Presence of nerve involvement (nerves are better visualized from a posterior approach)
V
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A combined approach may be necessary to complete dissection from the abdomen and dissect the ureters and iliac vessels away from the tumor
There are several maneuvers that can aid with visualization and facilitate posterior dissection.
The lateral stalks can be taken down to the level of the levators, and the rectum can be mobilized anteriorly to the pelvic floor
The superior rectal artery can be divided at the level of the sacral promontory to take tension off the mesentery
The root of sigmoid and left colon mesentery can be detached from the retroperitoneum and aorta all the way to the root of the inferior mesenteric
These maneuvers, in combination, allow the rectum to be pulled up and out of the pelvis to allow easier visualization of the dissection planes and better retraction
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Surgical considerations & preOp planning
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If the involvement of the internal iliac vessels is identified preoperatively, catheter-based venous or arterial embolization can be considered in advance of surgery
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Proctectomy must be anticipated if there is invasion into the rectal wall
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Need to preserve one S3 nerve for continence
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Need to preserve half of S1 for pelvic stability (with the need for orthopaedic hardware)
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Consider ureteric stenting for bulky, high tumors
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The coccyx can harbor neoplastic cells
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Resection of the coccyx is recommended for malignant lesions or lesions of uncertain malignant potential, but not for benign lesions
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Risk for rectal injury
The fibers of the levator ani often can be difficult to differentiate from the rectal wall, particularly during the posterior approach
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The surgeon should be cognizant of dural injuries. Failure to close a dural tear can result in CSF leak, recurrence, and infection
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Wound closure
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Large defects may require TRAM flap
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Modest defects may be closed with V-Y fasciocutaneous flaps
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Outcomes
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Overall recurrence rate: 16%
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Recurrence of malignant lesions: 30% with intact en-bloc excision
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Radiation proctitis
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Current estimates: ~1-5% of patients develop chronic radiation proctitis after radiation for pelvic malignancy
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Assessment
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Symptoms
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Hematochezia
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Mucus discharge
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Tenesmus
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Fecal incontinence
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Rule out recurrence of the primary tumor that required radiation
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Assess anal tone
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Proctoscopy:
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Assess mucosa
V
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Assess extent of disease
Colonoscopy is indicated if proctoscopy cannot delineate the full extent of the disease
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Rule out malignancy
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Management
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ASCRS CPG 2018: Formalin application is an effective treatment for bleeding in patients with chronic radiation proctitis
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Application methods
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Irrigation method: in small aliquots (20–50 cc) up to a total volume of 400–500 cc
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Direct application of formalin soaked gauze onto mucosa
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4% Formalin solution is used followed by washout
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Treatment sessions are spaced 2w apart
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Avoid contact with the anoderm as formalin can be irritating to this area
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Many will have good response with one treatment, but it should also be noted that multiple applications may be required to achieve high efficacy rates of around 80%
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Possible complication
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Anal or pelvic pain
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Stricture
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Rectal wall necrosis
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Fistula formation
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ASCRS CPG 2018: Endoscopic APC is safe and effective
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A median of 2 sessions is typically required to control rectal hemorrhage
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Settings for APC
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Flow: 1-2 L/m
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Power: 40-60 watts
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Apply in pulses of 1-2 seconds
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ASCRS CPG 2018: Sucralfate enemas are moderately effective treatment for chronic radiation proctitis
“…10% sucralfate suspension in water administered twice daily, resulted in a significant decrease in rectal bleeding after 4 weeks of therapy, including negligible or complete cessation of bleeding in 23 patients (88%) after 16 weeks of therapy and no recurrent bleeding in 71% patients who were followed for a median of 45 months (range, 5–72 mo)”
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Short-chain fatty acid enema
Enemas with the SCFA butyrate may accelerate healing in patients with acute radiation proctitis.
ASCRS CPG 2018: Short chain fatty acids have been studied with reasonable clinical improvements in acute radiation proctitis, but have not been shown to decrease the incidence of chronic hemorrhagic radiation proctitis
ASCRS CPG 2018: Short chain fatty acid enemas given during radiation therapy were also studied in a randomized controlled trial and showed no benefit in preventing radiation proctitis
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Surgery is reserved for intractable symptoms & complications (stricture, pain, bleeding, perforation, or fistula)
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Other therapies
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Hyperbaric oxygen is effective but expensive, not readily available, and takes weeks to show improvement
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Antioxidants: Vitamin C & E
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5-ASA: No clear role for its use
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ASCRS CPG 2018: Nd-YAG laser, RFA, cryotherapy, and bipolar electrocautery are not recommended
Bipolar electrocautery may be as effective as APC, but carries high complication rates
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Pelvic floor disorders, RVF, constipation, & incontinence
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General
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16% of women have at least 1 pelvic floor disorder
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Prevalence of pelvic floor disorders in ♀ >80Y approaches 50%
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20% of ♀ ≥ 45Y have experienced accidental bowel leakage ≥ 1/year
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Posterior compartment prolapse and dyssynergic defection may be seen after hysterectomy or cystocele repair
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Vaginal delivery (especially with instrumentation) can cause sphincter injury, levator avulsion, and pudendal nerve injury
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Rectal prolapse
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General
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Rectal intussusception = rectum descends within itself but does not protrude from the anus
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Partial prolapse is identified by radial folds
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Complete prolapse is identified by circular folds
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Occur in ~0.5% of the general population
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90% of patients are females
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Often ≥ 50Y with Hx of vaginal childbirth
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An increased incidence is found in nursing home–bound and psychiatric patients
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♀ 6:1 ♂
Men with rectal prolapse tend to suffer from disordered defecation, dysmotility, psychiatric comorbidities, eating disorders, and autism or developmental delays
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30% of patients with rectal prolapse have vaginal prolapse
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Rectal prolapse eventually results in stretching of the anal sphincter and then leads to fecal incontinence
Screen Shot 2020-09-13 at 7.09.50 PM
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Risk factors / conditions associated with rectal prolapse
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Deep rectouterine pouch of Douglas
Pregnancy is thought to contribute to development of a deep pouch
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Levator ani diastasis: Laxity of muscles of the pelvic floor & anal canal
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Patulous anal sphincter (weakness of sphincter muscles)
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Pudendal neuropathy (present in 50% of patients with prolapse)
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Lack of rectal fixation with mobile, redundant rectosigmoid
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May be associated with pelvic disorders: rectal prolapse (enterocele, cystocele, rectocele) & urinary incontinence
Pasted_Graphic_11Screen Shot 2020-03-02 at 5.13.52 PMScreen Shot 2020-03-02 at 5.14.09 PM
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Presentation & evaluation
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Inquire about fecal incontinence and/or constipations
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Fecal incontinence is reported in 50-75%
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Constipation is reported in 25-50%, and may be associated with dysmotility or pelvic floor dyssynergia
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Inquire about urinary incontinence
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Inquire about uterine/vaginal prolapse
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1. Examination
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Options for position to examine: left lateral, lithotomy, on commode
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“The best method to diagnose the type and degree of prolapse is with the patient sitting on a commode and bearing down to simulate a bowel movement”
Indirect anoscopy
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Valsalva to help demonstrate prolapse
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Perineal examination
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Sensation of tissue outside of the anus
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Assess length and strength of perineal body
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Posterior compartment / anorectal examination
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Assessment of anal sphincter structure and function
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Rectal bleeding or mucus discharge after defecation
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Proctoscopy may show an anterior solitary rectal ulcer
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Anterior compartment / vaginal examination
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Examine for uterine or vaginal prolapse
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Examine for cystocele
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Presence of anterior compartment disorders warrant urogynecologic (speculum) examination or for suspicion of weak vaginal septum
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Pelvic Organ Prolapse - Quantitation system is used by OB/GYN to assess POP
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Patient is examined in lithotomy position and standing; while resting and performing valsalva
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Evaluation is performed for:
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Apical prolapse = prolapse of the cervix or vaginal vault
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Anterior vaginal wall prolapse
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Posterior vaginal wall prolapse
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The maximal point of prolapse of six points is recorded in relation to a fixed point of reference, the anterior-posterior plane of the hymen
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POP-Q Staging
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Stage 0: no prolapse
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Stage I: most distal portion of prolapse is “≤ -1”
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Stage II: most distal portion of prolapse is between ≥ -1cm to ≤ +1cm
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Stage III: most distal portion of prolapse is > +1 but < total vaginal length-2 cm
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Stage IV: eversion of the total length of the vagina
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2. Colonoscopy/flexible sigmoidoscopy to exclude colonic or rectal disease and rule out lead-point
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3. Consider:
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3.0. There is no role for routine imaging in the evaluation of pelvic organ prolapse, but it may be useful for diagnosis and management when rectal intussusception, occult rectal prolapse, sigmoidocele, or enterocele is suspected as the underlying cause of a patient’s defecatory symptoms
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3.1. Defecography (for incontinent or elusive examination)
V
Fecal incontinence is reported in 50-75% of patients
*
It develops secondary to impairment of anorectal sensation & laxity of the sphincters & pelvic floor
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Defecography may reveal the problem if clinical exam does not demonstrate the prolapse
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Contrast or MRI defecography may be used to assess occult prolapse or internal intussusception which has been described in up to 33% of patients with disordered defecation
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3.2. Colonic transit study (for constipated)
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Constipation is reported in 25-50% of patients
*
Prolapse may be associated with colonic dysmotility or pelvic floor dyssynergia
*
Patients with a Hx of chronic constipation may benefit from colonic transit evaluation, which may affect the procedure chosen (these patients benefit from a subtotal colectomy)
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Management
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Treatment is based on patient preference; repair of prolapse is a QoL issue. Always tailor therapy to address the patient’s symptoms
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Stool-bulking agents or stool softeners may provide some symptomatic relief
*
ASCRS Textbook: Reduction of incarcerated rectal prolapse can be performed by coating the prolapse with table sugar to reduce edema and gently push the prolapse above the sphincters
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Allowing prolapse to continue untreated beyond 4 years may lead to higher rates of subsequent rectal prolapse recurrence, presumably secondary to a secondarily weakened pelvic floor
*
Women who do not have symptoms of incontinence are at risk for de novo stress urinary incontinence when their prolapse is corrected because the previously obstructed urethrovesical junction is straightened by elevating the vaginal apex and anterior vaginal wall. Adding an anti-incontinence procedure at the time of prolapse repair significantly reduces the incidence of stress urinary incontinence
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Surgical goals:
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Narrowing of the anal orifice
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Obliteration of the pouch of Douglas
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Restoration of pelvic floor
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Decreased rectosigmoid redundancy with bowel resection
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Fixation of the rectum to the sacrum
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Choice of procedure is guided by:
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Patient’s comorbidities: abdominal vs perineal approach
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Abdominal surgeries are move invasive but are thought to be more effective, with lower rates of recurrence
*
ASCRS Textbook: The paradigm for treatment rectal prolapse in the elderly has changed from perineal to abdominal minimally invasive procedures in elderly and high risk patients
V
*
However, the data to support these lower recurrence rates in abdominal approaches have recently been called into question
A 2000 systematic Cochrane database review comparing 274 patients in 8 randomized or quazirandomized trials reported no significant differences in recurrent prolapse between abdominal and perineal approaches.
A 2008 update of the Cochrane review including 12 randomized controlled trials involving 380 participants reached a similar conclusion, 33,44 while lamenting the lack of large-scale, randomized controlled trials powered to measure these outcomes adequately.
A third 2015 review of 15 randomized controlled trials involving 1007 patients was also unable to demonstrate a difference in recurrence rates between the 2 approaches.
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Hx of constipation &/or incontinence
In general, because many patients with fecal incontinence secondary to rectal prolapse experience improvement in their symptoms once the prolapse is treated, rectal prolapse should be corrected as a first step in patients reporting of rectal prolapse and fecal incontinence.
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ASCRS Textbook: a sigmoid resection is thought to be unnecessary in individuals whose predominant complaint is fecal incontinence
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Resection tends to improve constipation ± incontinence
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Levatorplasty is considered to improve incontinence when Altemeier’s procedure is done
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Patients with constipation &/or pelvic dyssynergia may not be ideal candidates for certain surgical maneuvers known to exacerbate constipation after surgery (posterior rectal mobilization, transection of the lateral ligaments during suture rectopexy, or levatorplasty during a perineal proctectomy)
*
Patients with severe constipation are still candidates for resection suture rectopexy
*
For patients with confirmed slow colonic motility, sigmoid resection is an inadequate operation and a subtotal colectomy should be considered
V
Presence of pelvic floor defects
*
Rectocele or enterocele likely to benefit from rectopexy
*
Patients with pelvic dyssnergia are candidates for Altemeier’s procedure without levatorplasty
>
Consider simultaneous treatment of both rectal & genital prolapse
*
Abdominal sacrocolpopexy with rectopexy for combined middle and posterior compartment prolapse is a safe procedure with a low risk of recurrence and improves bowel function and quality of life
*
Presence of sphincter defect
*
Surgeon’s experience
V
*
Previous procedures that the patient has had (see section on recurrence)
Caution with resection procedures as that may result in a segment that is ischemic between the two anastomoses
*
Patient’s willingness to risk sexual dysfunction (associated with rectal dissection in abdominal procedures)
V
V
Surgical options
Screen_Shot_2019-07-29_at_11.45.36
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Perineal
V
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Mucosal sleeve resection (Delorme’s Procedure)
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*
The procedure of choice for mucosal and short-segment full-thickness prolapse
*
Dissection is started 1-2 cm above the dentate, and carried to separate the mucosa/submucosa from the muscular layer
*
50% report improvement in incontinence without associated constipation
V
PostOp morbidity (~25%)
*
Urinary retention
*
Anastomotic bleeding
*
Leak
*
Stricture
V
*
ASCRS Textbook: Overall recurrence rate 16-30%
Retrospective studies suggest that recurrence rates after Delorme in the range of 10% to 15% may be higher than recurrence rates after abdominal approaches, but a recent randomized controlled trial showed that recurrence rates and functional outcomes after Delorme procedures were comparable to perineal rectosigmoidectomy or abdominal procedures
*
Associated mortality rate 0-2.5%
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>
Perineal rectosigmoidectomy (Altemeier’s procedure)
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Surgical considerations
*
Patients with pelvic dyssnergia are candidates for Altemeier’s procedure without levatorplasty
V
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In patients with poor continence: Levator plication (levatorplasty: figure-of-eight 2-0 absorbable sutures - taking care to avoid incorporating the vaginal wall) can be performed before completion of the anastomosis
Levatorplasty is associated with improved postoperative continence, decreased recurrence rates, and increased length of recurrence-free intervals.
*
One study showed that levatorplasty reduces recurrence rates from 21% to 7%
*
Resecting too much puts tension on the anastomosis
*
Resecting too little leaves redundant sigmoid colon leading to recurrence
V
Outcomes:
*
Recurrence rate: 0-18% (may be as high as 30%) full-thickness prolapse; 6% mucosal prolapse
>
Morbidity rate up to 25%
*
PostOp bleeding
*
Anastomotic dehiscence
*
Mortality rate 0-6%
>
Stapled transanal rectal resection (STARR)
*
Used for internal intussusception or partial thickness prolapse
*
Some prefer STARR to Delorme’s procedure for full-thickness prolpase
V
Technique is similar to stapled hemorrhoidopexy
*
Sutures placed ~5cm proximal to dentate line
*
The anorectal junction is reinforced with the staple line
V
Outcomes
*
~30% develop recurrent internal intussusception or rectocele
*
Bleeding is the most common postOp complication (~10%)
*
Constipation with recurrence is reported by 50%
*
Incontinence is reported by 28%
V
*
Traditional anal encirclement (Thiersch procedure) options have been abandoned because of poor success rates (recurrence rate 33-44%). It is reserved for patients with high risk of anesthetic complications who could only tolerate local anesthesia
The Thiersch procedure involves reduction of prolapse and placement of a subcutaneous suture or mesh material to encircle the anus, thereby narrowing the anal canal. This procedure does not eradicate prolapse but prevents further descent by providing a mechanical barrier.
V
Abdominal procedures
>
Abdominal suture rectopexy & sigmoid resection
*
One of the most effective treatments for full-thickness prolapse
V
Technique:
*
Mobilize the rectum down to the levator complex while maintaining the lateral ligaments intact
*
Elevation of the rectum with permanent suture fixation to the presacral fascia i.e anterior spinous ligament (or the sacral bone) just below the sacral promontory
*
Optional step: obliteration of the cul-de-sac with suturing the endopelvic fascia anteriorly to the rectum
*
Resection of the redundant sigmoid colon with an end-to-end anastomosis
V
Outcomes:
*
Recurrence rate 0-9%
V
Morbidity rate 0-23%
*
Colonic & small bowel obstruction
*
Anastomotic leak
*
Presacral bleeding
*
Mortality rate 6.7%
*
Almost half of the patients will report improvement in constipation & incontinence
V
No-resection rectopexy
*
Recurrence rate 0-8%
>
Mesh rectopexy
V
>
Ripstein’s procedure (Anterior Sling Rectopexy) - partial anterior rectal encirclement
ASCRS Textbook: The Ripstein procedure (even the modified form) is being used less and less due to the morbidity and potential for new rectal outlet difficulties.
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V
Technique
*
Entails mobilizing the rectum down to the coccyx but preserving the lateral ligaments
*
5-cm mesh is wrapped anterior around the rectum at the level of the peritoneal reflection & sutured bilaterally to the presacral fascia (~5 cm below the sacral promontory)
*
The sling should allow 2 fingers between the rectum and the sling to avoid too tight of a wrap
*
The procedure is best suited for patients without preexisting constipation
>
Outcomes:
*
50% have improved incontinence
*
Patients have a mixed response to constipation after the procedure
>
Morbidity rate is high (17-33%)
*
Constipation with fecal impaction
*
Presacral hemorrhage
*
Stricture
*
Small bowel obsturction
*
Impotence
*
Fistula
*
Mesh complication: erosion into the bladder
*
Mortality rate 0-1.6%
V
>
Well’s procedure - partial posterior rectal encirclement
Screen_Shot_2019-07-29_at_12.28.57
*
Requires complete rectal mobilization
*
Typical description utilizes the Ivalon® sponge as the mesh material
*
The mesh is sutured to the rectum and anterior spinous ligament
*
Recurrence rate 3%
*
Morality rate 0-3%
V
>
D’Hoore ventral rectopexy - partial anterior rectal encirclement prior to attachment of the mesh to the sacrum.
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*
Laparoscopic VR is the current gold standard for treatment of rectal prolapse in European countries
*
It is the only technique for rectal prolapse repair that uses only a limited anterior rectal mobilization
>
Technique:
*
It can correct full-thickness rectal prolapse, rectoceles, and internal rectal prolapse and can be combined with vaginal prolapse procedures, such as sacrocolpopexy, in patients with multi-compartment pelvic floor defects.
*
It is based on correcting the descent in women of the posterior and middle compartment by mobilizing the rectovaginal septum down to the pelvic floor between the extraperitoneal rectum and the vagina
*
The rectovaginal septum is reinforced with (traditionally polypropylene) mesh and the mesh is suspended to the sacrum, thus elevating the pelvic floor
V
*
The mesh (synthetic or biologic) is secured on the anterior aspect of the distal rectum (+/- pelvic floor) & sacral promontory
Untitled
*
Minimal posterior dissection is is undertaken to expose the sacrum at the site of fixation
>
2014 Consensus Panel on Contraindications
V
Absolute
*
Pregnancy
*
Severe intraabdominal adhesions
*
Active proctitis
*
Severe psychological instability
V
Relative
*
High BMI
*
Hx of pelvic irradiation
*
Hx of sigmoid diverticulitis
*
♂ sex
>
Outcomes:
*
Recurrence rate: 3.4%
*
Complication rate 15-45%
*
Decreases fecal incontinence
*
Decreases constipation
>
Mesh complications
V
>
Mesh erosion rate is 2% by 23 months: vaginal erosion, rectal erosion, rectovaginal fistulas, or perineal erosion
Evans et al. DCR 2015; 58: 799–807
*
50% of mesh erosion patients will require minor surgery: local excision of exposed mesh/stitch
*
40% of mesh erosions will require major surgery: mesh removal, mesh removal plus colectomy, or anterior resection)
*
Pelvic pain, rectal bleeding, and mucus discharge may be concerning for mesh erosion
*
Sigmoid resection is not usually advocated in combination with repairs involving mesh
V
Suture rectopexy
*
Elevation of the rectum with permanent suture fixation to the presacral fascia i.e anterior spinous ligament (or the sacral bone) just below the sacral promontory
*
Frequently results in improved incontinence, and worsening constipation
*
Recurrence rates: 3-9% at 2Y; but may be up to 29% by 10Y
*
Permanent colostomy
V
*
Cochrane meta-analysis: division of the lateral rectal ligaments was associated with a decreased recurrence rate (0 vs 19%) but increased rates or worsening of constipation (67% vs 43%)
The lateral rectal stalks or ligaments are actually anterolateral structures containing the middle rectal artery
Preservation of the lateral stalks preserves nerves innervating the rectum. Division of the stalks may worsen or create new-onset constiptaiton
*
Emergency surgery for rectal prolapse is managed with Altemeier’s procedure ± proximal diversion
V
>
Recurrence
*
Mean time to (all procedure) recurrences: 33 months
*
ASCRS Textbook: Perineal procedures which have a higher incidence of recurrence after the primary procedure have an even greater chance at rerecurrence if utilized again for recurrent rectal prolapse.
V
*
The most important determinant of subsequent surgery is the remaining blood supply of the bowel
Patients who have previously undergone resection are at risk for development of ischemia to the segment of bowel between the two anastomoses should a second resection be attempted
Ding et al. reported that redo perineal rectosigmoidectomy is as safe and feasible after primary perineal rectosigmoidectomy as long as the prior anastomosis is included in resected specimen
V
>
Altemeier’s procedure patients are candidates for:
In this group of patients, addition of a sigmoid resection could cause ischemia in the remaining rectal segment
>
Altemeier’s procedure
*
Redo-Altemeier’s is safe and feasible, but has high recurrence rate (~40%)
*
Delorme’s procedure
*
Abdominal rectopexy without resection
*
Resection rectopexy following a Altemeier’s procedure should be performed with caution as the distal bowel requires an intact marginal artery for its blood supply. Aggressive mobilization could compromise the artery and lead to distal bowel ischemia.
>
Following ventral rectopexy
*
Small recurrence → Delorme procedure
*
Too big to address with Delorme → Reattachment of the mesh to the sacrum or reinforcement of the existing mesh
*
“We would not advise trying to excise the mesh that is attached to the rectal wall as this could lead to perforation” — ASCRS
*
Emergency rectal prolapse that presents with gangrene requires an Altemeier’s procedure preferably with proximal diversion
V
Rectovaginal fistula
V
Etiology
V
Obstetric injury is the most common cause
*
2% of vaginal deliveries are associated with 3rd-4th degree perineal tears
*
RVFs are reported to occur following 0.1-0.5% of all vaginal deliveries
*
Trauma after vaginal delivery is almost always the cause of low fistulas, which often are associated with an associated sphincter injury → incontinence
*
Prolonged labor resulting in compression of the rectovaginal septum by the infant’s head can lead to necrosis of the rectovaginal septum and cause a rectovaginal fistula that presents in a more delayed fashion
V
Grading of obstetric injury
*
1st degree: Injury to vagina/skin only
*
2nd degree: Injury to perineal muscles, not involving anal sphincters
V
3rd degree:
*
3a: < 50% injury to EAS
*
3b: > 50% injury to EAS
*
3c: Injury to EAS & IAS
*
4th degree: Injury involving EAS, IAS, and anal epithelium
>
Crohn’s disease is the 2nd most common cause
*
10% of Crohn’s disease patients develop rectovaginal fistulas
*
Have high recurrence rate
*
Repair should not be undertaken in the presence of active inflammation of the rectum as the repair is unlikely to heal. Those with significant Crohn’s-related pathology of the anorectum are unlikely to be good candidates for repair and should be managed either medically, with a seton, or with a proctectomy
*
Multiple reports have shown spontaneous healing of rectovaginal fistulas with infliximab — duration until healing may be longer than 14w
V
Iatrogenic injury
*
Post-fistulotomy
*
Post-transanal excision of lesions
*
Post vaginal surgery
*
10% of ♀ develop rectovaginal fistulas after LAR
*
Infectious: diverticulitis, cryptoglandular abscess, TB
*
Neoplasms: anal, rectal, vaginal, cervical
*
Radiation: external beam radiation, brachytherapy
V
*
Prevention and management of vaginal injury in colorectal surgery
RVF
V
Evaluation
*
If the fistula cannot be identified on examination, alternate etiologies to explain the patient’s symptoms should be considered, such as a colovaginal fistula rather than a rectovaginal fistula.
*
Tampon test: place a tampon in the vagina & an enema of diluted methylene blue dye is administered
>
Classification:
*
High Vs Low : in relation to the sphincter complex. Anything above the sphincter is high
*
Simple vs Complex: Simple fistulas being located in the middle or lower portion of the rectovaginal septum, are < 2.5 cm in diameter, & caused by trauma or cryptoglandular infection (does not include diverticulitis)
>
Assess:
*
Identify the fistula
*
Location of fistula relative to sphincter muscles
V
*
Quality & strength of sphincter muscles
Patients with RVFs from obstetric trauma should be evaluated for concomitant sphincter defects
*
Determine the cause & rule out malignancy
*
Rule out stricturing/scarring of anal canal
*
Identify surrounding injuries: assess condition of perineal body & rectovaginal septum
*
EUA is the initial step in patients with IBD and is the best option to identify an occult RVF
V
*
Endoanal US is valuable to assess for sphincter injury. If present patient likely will benefit from sphincteroplasty at the time of an advancement flap
It should be performed routinely in patients with an RVF secondary to obstetric trauma as they may have associated sphincter damage.
*
Supplementary testing may require: MRI, anorectal manometry, &/or pudendal nerve testing. Less useful tests include gastrograffin enema & vaginography
V
*
The first step in radiation-induced fistulas is to rule out malignancy: imaging + EUA with multiple Bx
No definitive repair should be undertaken for at least 6 months after the completion of radiation treatment
*
Colonoscopy to assess for disease activity, in Crohn’s Disease
V
>
Management
For many patients more than one attempt at repair is necessary
Screen Shot 2020-07-09 at 19.03.38
>
Preoperative
*
Phosphate enema is adequate for simple repairs & vaginal-based repairs
*
Full mechanical & oral bowel preparation is performed for extensive repairs or when fecal diversion is anticipated
V
Surgical management
*
Goals of treatment = preserve continence + achieve healing of the fistula
*
The presence of active sepsis is an absolute contraindication to any attempt at surgical repair
*
Seton insertion is done for inflamed/infected tissue. Usually when the etiology is cryptoglandular disease
*
If the local tissues are not adequate for repair, then transposition of healthy tissue should be considered. The most common tissues used for transposition are the Martius flap or gracilis muscle
*
Immediate (at the time of episiotomy) repair is warranted post-obstetric injury
V
*
Treatment of fistulas in the postpartum period is delayed for a period of 3-6m to allow acute inflammation to subside and fibrosis to develop
Symptomatic relief often is achieved with bulking agents and antidiarrheals
Spontaneous closure occurs in 50-75%
Management with stiz bath, stool bulking agent, local wound care
*
Always interpose healthy tissue (omental in abdominal approach; gracilus in perineal approach) whenever surgery is performed for recurrent disease
V
Surgical approaches:
V
Transanal
*
Fistulotomy: very rarely used today as it results in varying degrees of incontinence
>
Endorectal advancement flap (ERAF): the mainstay of treatment of low rectovaginal fistulas — it’s the most commonly performed procedure
*
The procedure may not be success in the presence of diseased rectal mucosa. It is not contraindicated in Crohn’s patients as long as the mucosa is healthy
*
ASCRS 2016 CPG: The link between ERAF and incontinence mandates a careful assessment of anal sphincter function and consideration of EUS before repair of RVF.
*
Flap retraction or necrosis is the most common cause of failure
*
The base of the flap should be at least twice as wide as the apex to ensure adequate blood supply
*
2 X 2 cm biological mesh may be placed and the flap sutured over it
>
Advantage:
*
Repair is performed from the high-pressure side of the fistula
*
Sphincter preservation
V
Short-term success rate 42-71%
V
The likelihood of a successful repair decreases if
*
Patients have undergone previous repairs
*
Crohn’s patients (29% success rate)
V
Disadvantage
V
*
The need for dissection of otherwise healthy rectal wall & sphincter
The flap is started 1 cm distal to the fistula and consists of the rectal mucosa, submucosa, and a portion of the underlying internal sphincter,
*
Risks for flap failure (6%) which may result in a larger opening
*
Fibrin glue
*
Bioprosthetic mesh used as an interposition graft
V
Transperineal
>
Episioproctotomy & layered closure
*
This repair converts the fistula into a fourth-degree perineal tear by dividing all the tissue between the rectum and vagina through the perineal body.
*
The greatest disadvantage of this procedure is the creation of a full-thickness defect in a previously uninjured part of the anal sphincter
*
This procedure should be attempted only by experienced surgeons and in patients with documented existing sphincter defects with fecal incontinence
*
In experienced hands, healing rates superior to ERAF closure
>
Transperineal LIFT procedure ± overlapping sphincteroplasty ± levatorplasty
*
The technique should achieve similar results of episioproctotomy and, if it should fail, will not result in worse than preoperative incontinence.
*
A transperineal repair with sphincteroplasty is the most appropriate type of repair in women who have a sphincter defect (most often from obstetric injury), as this is addressed simultaneously.
>
Interposition flaps
*
Patients that are appropriate candidates for transposition repairs are those who have failed less invasive techniques or who have inadequate native tissue
V
*
Options: gracilis flap & bulbocavernosus flap
An endorectal advancement flap can be added
*
Disadvantage: risks dyspareunia
*
Although not mandatory, fecal diversion typically is recommended
*
The success rate of the gracilis muscle flap has been reported to be as high as 75% to 80%.
>
Transvaginal: vaginal advancement flap
>
Advantages:
*
Healthy, pliable, well-vascularized flap
*
Relatively easy
*
Better exposure (compared to transanal approach)
*
Especially when fibrostenotic disease is present in the anus or a transanal approach has failed, a transvaginal advancement flap is a viable option
*
However, as the rectum is the higher-pressure side of the fistula, any repair is unlikely to be successful if the rectal side is not addressed. Therefore transvaginal repairs should involve closure of the rectum and not just of the vagina
>
Transabdominal
*
Generally reserved for fistulas that are located in the mid-rectum with an internal opening at the fornix of the vagina
V
Rectal resection/advancement with omental interposition
*
Indicated for: circumferential/stricturing disease or high & complex fistulas
*
Procedure entails mobilizing the rectum, resection of the diseased segment, anorectal anastomosis, & omental tissue interposition
*
ASCRS CPG 2016: Proctectomy with colon pull-through or coloanal anastomosis may be required to repair radiation-related and recurrent complex rectovaginal fistula.
V
>
Primary repair with omental interposition
Dr. Lee advises against this option as it is less likely to success. He suggests resection, diversion, and tissue interposition
*
Sometimes, a low rectovaginal fistula may require a transabdominal approach after multiple failed transanal, transvaginal, or transperineal approaches
V
Technique
*
If the rectal wall is healthy, the fistula tract can be débrided and closed primarily
*
The vaginal opening then is closed primarily
*
A pedicled omental flap is placed between the two closures and held in position with interrupted sutures
V
Other:
*
Fistula plug
*
Injection of fat into the tissue surrounding the fistula
*
TEMS approach for repair
>
Fecal diversion
*
After two failed attempts or the necessity of a pedicled flap closure, surgeons are more likely to proceed with diversion before or during the subsequent repair.
*
ASCRS: Patients undergoing major transabdominal resections, or muscle transposition procedures, should have fecal diversion
>
Crohn’s considerations
*
Treatment with anti-TNF agents should be considered preOp
*
Not all patients with Crohn’s disease and RVF will be candidates for repair
*
Repair should be considered for those who develop a mature isolated tract without branching, without other draining areas, and with healthy rectal mucosa. If this is not possible, non-cutting seton placement can be a long-term method of controlling symptoms
*
Proctectomy is considered for those with severe disease refractory to seton placement and maximized medical therapy.
*
Success rate of surgical interventions in Crohn’s: 30-70%
>
Decision making:
*
In patients with a sphincter defect, overlapping sphincteroplasty will address the fistula and incontinence and is first-line treatment
*
In those patients without sphincter defect, either a rectal or vaginal advancement flap can be undertaken as first-line options
*
If either the rectal or vaginal flap fails, the subsequent step is the opposite procedure
*
After failure of both a rectal and vaginal flap, the options are repeating a flap procedure or proceeding with an interposition pedicled flap, with the addition of fecal diversion
*
When low rates of success are anticipated (e.g., multiple prior repairs, poor tissue compliance), preoperative fecal diversion should be considered
*
Tobacco is identified as a risk factor for recurrence
>
Solitary rectal ulcer syndrome (SRUS)
*
The spectrum ranges from solitary ulceration to nodular lesions along the anterior rectum
*
SRUS is associated almost exclusively with disorders of defection & rectal prolapse (internal or external)
>
Pathogenesis
*
Associated with paradoxical puborectalis contraction & internal or external full-thickness rectal prolapse. Trauma from chronic straining may lead to ischemic injury
>
Other causative factors:
*
Ergotamine suppositories (potent vasoconstrictor)
*
Radiotherapy
*
Anal intercourse
*
Digitation
*
It is essential to exclude underlying malignancy leading to the formation of an ulcer
V
Presentation
*
Generally affects adults; mean age 49Y, ♀ predominance
V
The syndrome is characterized clinically by
*
Excessive rectal mucus
*
Bleeding
*
Anismus: failure of normal relaxation of pelvic floor muscles during attempted defecation
*
Tenesmus
*
Difficult evacuation
>
Dx criteria is based on the presence of:
*
1. Hx of straining / incomplete evacuation leaving the passage of blood & mucus per rectum
*
2. P/E demonstrating internal/external prolapse
>
3. Scope demonstrating typically anteriorly located solitary or multiple erythematous ulcerated or polypoid lesions. Located 5-12cm from AV
*
Ulcer is seen in 23% of cases; polyp/mass is seen in 74%
>
Ulcer features:
*
Single or multiple shallow ulcers
*
Have hyperemic margins and a pale base
V
4. Histologic evidence of: distorted muscularis mucosa, fibrous obliteration of lamina propria, extension of muscle fibers into lamina propria
V
*
On occasion, the glandular epithelium may be trapped in the submucosa during repeated healing episodes, resulting in the entity known as colitis cystica profunda. Biopsy of this may be confused easily with a cancer.
Screen Shot 2022-01-23 at 14.25.15
>
Workup/evaluation
*
Complete GI & sexual/social behavior history
*
All patients need colonoscopy (with a generous, deep Bx) to exclude malignancy or associated colitis
*
Work up for rectal prolapse ± defecating proctogram or dynamic pelvic MRI
*
Assess for weak pelvic floor disorders: uterine prolapse & urinary incontinence
*
Balloon expulsion EMG or anorectal manometry may detect abnormal or paradoxical puborectalis contraction with straining
*
EUS has been more recently used
>
Management is primarily symptomatic
*
Complete endoscopic histologic resolution is rarely achieved
>
Initial management
*
Elimination of harmful suppositories
*
High-fiber diet
*
Encourage ≥ 6 glasses of non-caffeinated fluids/day
V
>
Management algorithm
Screen_Shot_2019-07-29_at_13.52.14
*
Biofeedback is successful in the short-term
*
Botulinum toxin type A Botox is successful in > 50% patients with tenesmus
*
Surgical resection of the rectal wall abnormality has not been associated with favorable outcomes and is best avoided
*
Ultimately, proctectomy with permanent stoma may be required in the most difficult cases of severely symptomatic patients. Perineal approaches to rectal prolapse may be successful; however, the failure rate is higher compared with abdominal approaches.
>
Incontinence
*
“Loss of the ability to defer defecation until a socially acceptable time”
*
Defined as: uncontrolled passage of feces or gas over ≥ 1m duration, in an individual of ≥ 4Y of age, who had previously achieved control
*
Urgency is described as “the in-ability to defer defection 15 minutes”
>
The most common cause in women is obstetric injury
*
Injury is observed clinically in ~10 % of all vaginal deliveries, but occult sphincter damage may be identified in up to 21–35 % of vaginal deliveries
*
Injury may be sustained at a younger age but presentate late when pelvic floor muscles weaken
>
Prevalence
*
2.6% in 20-30Y age group
*
15% in ≥ 70Y
*
The puborectalis muscle is the most important muscle contributing to continence
>
Types of incontinence
>
Passive incontinence:
*
Leakage without notice
*
Usually related to low anal resting pressure & IAS deficiency
>
Urge incontinence:
*
Inability to withstand an urge to defecate
*
Usually related to insufficiency in EAS tone and activity
>
Evaluation
>
History
*
Illicit history of vaginal delivery, anal trauma, comorbidities, and Rx
*
Stool consistency and frequency
>
Physical examination
*
External inspection especially looking for perineal body size & scars (indicating episiotomy/tear scars)
*
With chronic diarrhea, consider candidiasis at the perineum. They usually have satellite inflammation in the area as opposed to a discrete edge marking the limit of inflammation. Treat with candesartan
*
DRE assessing: basal tone, anal sphincter squeeze, and use of accessory (gluteal) muscles
*
Assess for rectocele, rectal prolapse, rectal mass, stricture, and fistula
>
Assessment instruments
*
2-Week bowel diary is the simplest method
V
*
CCF-FIS: Cleveland Clinic Florida Fecal Incontinence Score
The-Jorge-Wexner-incontinence-score
*
SMIS: St. Marks Incontinence Score
*
FISI: Fecal Incontinence Severity Index
*
FIQL: Fecal Incontinence Quality of Life scale
V
>
Management & preOp testing
Screen Shot 2021-04-11 at 15.03.57
V
V
Nonoperative management
Screen Shot 2020-08-12 at 5.33.36 PM 2
Some surgeons will offer SNS to patients with sphincter defect first as that has already been shown to be effective in managing fecal incontinence. Dr. Wexner’s landmark paper on SNS included patients with sphincter defects < 60 degrees.
>
Medical
*
Goal: improve stool quality
*
20-50% improve after counselling regarding diet changes, fluid consumption, & medication management
*
Lactose, caffeine, & artificial sweeteners should be stopped if they are linked to symptoms
*
Fiber creates mores solid stools and prevents seepage. However, in patients with impaired sphincter function, the addition of fiber can possibly result in worsening incontinence due to increased volume and liquid consistency of stools
*
Constipating agents decrease transit time & firm stool consistency
*
Cholysteramine may be useful in patients post-cholecystectomy
*
Laxatives & stool softeners are helpful with overflow incontinence
V
*
Daily enemas may reduce incontinence by decreasing rectal stool load in select patients
This measure may be particularly helpful in patients with underlying primary constipation with overflow incontinence, or in patients secondarily constipated because of the use of antidiarrheal medication
>
Biofeedback = sphincter exercises
*
Ideal candidate: patient with some preserved voluntary sphincter contraction rather than extensive or exclusive use of accessory muscles when asked to squeeze
*
ASCRS 2015 CPG: Biofeedback should be considered as an initial treatment for patients with incontinence and some preserved voluntary sphincter contraction.
Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.
*
Constitutes sphincter exercises, rectal sensory training, & learning to coordinate voluntary external anal sphincter contraction with the onset of rectal distention
*
4-6 sessions are needed usually
*
At least some improvement is noted in 64-89% of patients
*
Cochrane review (2006) concluded that no study reported any major difference between the results of biofeedback or any other form of conservative management
>
Preoperative Testing
*
Anoscopy/proctoscopy: rule out proctitis
>
Endoanal US
*
Has excellent sensitivity and specificity in identifying sphincter defects
*
Sphincter defect may not correlate with degree of incontinence
*
Presence of sphincter defect does not correlate with outcomes after SNS
*
It is a critical element in the planning of a sphincteroplasty operation
>
Anorectal physiology testing / manometry
>
Manometry
*
Resting pressure
*
Squeeze pressure
*
Sphincter length
*
Anorectal sensation
*
Volume tolerance
*
Compliance
*
Measurement of RAIR
>
Pudendal nerve terminal motor latency
*
There appears to be no association of PNTML testing results with response to SNS
*
Testing is not recommended routinely
*
Defecography may demonstrate incomplete evacuation, overflow incontinence, intussusception, or rectal prolapse
*
Colonoscopy is indicated for patient with bleeding or change in bowel habits
V
V
Surgical management
Options:
Injectable bulking agents
Sacral nerve stimulation
Anterior sphincteroplasty
Magnetic sphincter
Artificial bowel sphincter
Graciloplasty
Tibial nerve stimulation
Radiofrequency energy application procedure
Anal cerclage
ACE procedure
Stoma
*
ASCRS 2015 CPG: Obvious anatomic defects such as rectovaginal fistula, rectal or hemorrhoidal prolapse, fistula in ano, or cloacalike deformity should be corrected as part of the treatment of fecal incontinence.
Grade of Recommendation: Strong recommendation based on low- or very low-quality evidence, 1C
>
Repair:
V
>
Overlapping anterior sphincteroplasty
Screen_Shot_2019-07-14_at_1.24.21_PM
V
*
It’s the gold-standard for treatment of incontinence in young women with obstetric sphincter injury
This may be a great option with the history of incontinence corresponds with the Hx of obstetric injury. It avoids all the limitations associated with SNS and its hardware including infections, external devices, recharging/replacing units…etc
*
It’s indicated also for older women with severe incontinence and an external sphincter defect < 120 degrees on US
*
It is most useful in the setting of an associated rectovaginal fistula
>
Technique
*
A curvilinear incision is made anterior to the anus in the perineal body
V
*
The two sides of the sphincter are mobilized
The associated scar should be preserved because this is important for the repair and allowing the sutures to hold.
*
Care is taken not to extend the dissection too far posteriorly (beyond 180 degrees) so as not to injure the pudendal nerves.
*
Once the dissection is completed, an anterior levatorplasty often is performed in conjunction with the sphincter repair to approximate the levator muscles.
*
The two sides of the sphincter-scar complex are reapproximated in an overlapping fashion with 2-0 monofilament mattress sutures.
*
The skin is closed loosely with deep dermal sutures to allow for drainage
>
Outcomes
*
80% develop reasonable function in the short-term (though not full continence)
>
After 5-10Y, ~10-14% have sustained improvement in most studies
V
*
Meta-analysis of 16 studies shows clear trend toward decay of functional outcomes over time
Screen Shot 2021-04-11 at 13.49.13
*
Unilateral or bilateral pudendal neuropathy was associated with poor outcome in some but not all studies
>
Recurrence
*
Management of recurrence (or even prophylaxis after surgical repair) with SNS has good results on the long-term
*
Repeat US can be considered to assess success of repair
*
Repeat sphincteroplasty has slim chances of success and patients may be better managed with SNS
V
*
ASCRS 2015 CPG: Repeat anal sphincter reconstruction after a failed overlapping sphincteroplasty should generally be avoided unless other treatment modalities are not possible or have failed.
Grade of Recommendation: Strong recommendation based on low- or very low-quality evidence, 1C.
In the absence of a rational identification of factors responsible for failure, like recurrent sphincter injury from additional vaginal delivery, repeat repairs are unlikely to be more successful.
*
ASCRS 2015 CPG: Plication of the external anal sphincter (Park postanal repair) is not recommended.
Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B.
>
Augmentation:
>
Injectable bulking agents
*
NASHA Dx (Solesta®) (stabilized hyaluronic acid dextranomer gel)
*
Office application with anoscopy: 1ml the bulking agent is injected into the submucosa just above the dentate line, typically in four areas evenly spaced around the anal canal. Needle is retained for 10s to avoid backward leakage through the injection channel
V
V
Outcomes in RCT:
Pasted_Graphic_6
Pasted_Graphic_7
*
Improvement (≥ 50% reduction in incontinence episodes) is seen in 53% (compared to 32% in the placebo group)
*
Improved outcomes likely require more than one injection
*
The improvement is sustained at 3Y
*
This procedure is low risk and easy to perform; however, it is probably most appropriate for patients with only mild fecal incontinence
>
Contraindications
*
Active IBD
*
Rectocele
*
Previous pelvic radiation
*
Full-thickness rectal prolapse
*
Anorectal malformation
>
Radiofrequency (SECCA®)
*
Contraindicated if the patient has previously had a biomaterial injection
*
Is done in the OR or endoscopy suite using a patented anoscope
*
Electrodes raise the temperature of the internal sphincter to 85 degrees → ↑ thickness of muscularis propria + change in collagen cell composition + ↓ interstitial cells of Cajal
>
Outcomes
*
Short- and long-term modest improvement in continence scores
*
Very few patients report full resolution of symptoms
>
Stimulation: Sacral nerve stimulation (SNS)
*
Involves stimulating the S3 nerve root by delivering mild electrical pulses
*
Stage-one of the procedure: Tined lead is placed under fluoroscopic guidance along the S3 nerve root utilizing a Seldinger technique
*
Stage-two of the procedure: Permanent battery is implanted in those who have good response to the initial procedure & there is not evidence of infection
V
>
Success (i.e ≥ 50% reduction in the number of incontinence episodes or incontinence days) rate:
Pasted_Graphic_5
Wexner et al 2010: SNS for fecal incontinence - Results of a 120-patient prospective multicenter study
The percentages in the graph demonstrate the degree of continence
*
70-83% success
*
35-40% achieve full continence
*
Only a minority of patient show absolutely no improvement on SNS after implantation of a permanent device after showing improvement in the initial 10-14d period
*
The majority of patients will develop AE in the form of pain & paresthesia
*
11% develop implant site infections, the majority of which require surgery and likely explantation of the device
*
The results persist beyond 5-6 years on follow up, possibly even up to 10Y
*
success has been reported in patients with sphincter defects of up to 120 degrees
>
Different studies showed SNS is effective for different etiologies causing fecal incontinence (with varying degrees of success: 60-100%):
*
Idiopathic incontinence
*
Traumatic/obstetric anal sphincter lesions
*
Anorectal surgery
*
Rectal resection
*
Rectal prolapse surgery
*
Pelvic floor injury
*
Radiation
*
Spinal cord injury
>
Risks and disadvantages
*
Infection rate: 11%
*
May require revisions/replacements for: lead migration, infection, or loss of battery power (battery usually lasts 7 years)
*
At 5 years, 24.4% of patients require at least 1 revision or replacement
*
Contraindication to body MRIs (though MRI of the head/neck are approved)
*
Stimulation: ASCRS 2015 CPG: Percutaneous tibial nerve stimulation may be considered because it provides short-term improvement in episodes of fecal incontinence.
Grade of Recommendation: Weak recommendation based on low- or very low-quality evidence, 2C.
V
Replacement:
>
Artificial bowel sphincter
>
Contraindications (conditions which impair healing):
*
Hx pelvic radiation
*
IBD
*
DM
*
Immunosuppression
>
Best indications for ABS
*
In whom all other treatments have failed
*
Extensive sphincter destruction (>180 degrees)
*
Congenital malformations
*
Neurogenic incontinence from spinal cord injury
*
Postsurgical significant bowel dysfunction with intact anal canal anatomy
>
Long-term outcomes
>
20% require revisions/removal of their device due to infection, erosion or device malfunction
*
Another common cause for revisions is scar creation around the balloon in the space of Retzius →poor anal cuff deflation → outlet obstruction
*
Only 58% of patients end up keeping a functional implant at 5Y
*
Normal continence is seen in 65%
*
Excellent solid stool continence (98%)
*
Dynamic graciloplasty
*
ASCRS 2015 CPG: Current data are insufficient to support the use of the magnetic sphincter for fecal incontinence.
Grade of Recommendation: Weak recommendation based on low- or very low-quality evidence, 2C.
V
Diversion & antegrade enemas
*
Colostomy creation
V
*
Malone antegrade continence enema (MACE)
ASCRS 2016 CPG: Antegrade colonic enema with appendicostomy or cecostomy may be an effective bowel management strategy in select highly motivated patients with refractory chronic constipation, although this is not a common alternative. Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C
3-Figure59.3-1-squashed
The appendix is imbricated. Openings on the mesentery of the appendix can be used for imbrication. The bowel is not opened throughout the procedure except when insertion the tube through the appendix. The tube is kept in place to allow the tract to fistulize.
*
Cecostomy tube placement
>
Leaker syndrome
*
Characterized by patients having normal bowel movements but then need to return many times to rewipe as the stool does not stop seeping out
>
Assessment often demonstrates:
*
Normal sphincter tone
*
Long anal canal
*
Soft stools
V
Management
*
Cleansing enemas after bowel movements (small volume, water only)
*
Harden stool with: dietary modification ± Imodium
>
Surgical management of constipation
*
Prevalence of constipation in general population = 28%; ♀> ♂
*
Patients complaining of constipation have 20-30% incidence of physical and sexual abuse
>
Assessment
>
History
*
Complaints of infrequent, hard stools may indicate colonic inertia
V
*
Complaints of incomplete evacuation may indicate pelvic floor dysfunction / obstructive defecation
Also associated with:
↑ Time spent on the toilet
↑ Number of attempts to defecate per day
*
Complaints of abdominal pain may indicate IBS
>
Physical examination to ilicit
*
Anal wink reflex
*
Hemorrhoids, fissures, skin tags
*
Rectal prolapse
>
DRE
*
Anal hypertonia
*
Paradoxical puborectalis contraction
*
Rectocele
*
Stricture
*
Rectal mass
*
Fecal impaction
*
Vaginal examination for rectocele and cystocele
>
Factors contributing to constipation
*
Psychiatric conditions
*
Neurologic conditions
*
Endocrine disorders
>
Lifestyle
*
Dehydration
*
Diet
*
Immobility
>
Rx
*
Opioids
*
Antidepressants
*
Anticholinergics
*
CCB
*
Calcium supplements
>
Diagnostic criteria: Rome IV (2016) Dx for constipation requires 3m duration of ≥ 2 of the following (in lack of IBS) that started > 6m ago:
*
(1) straining with ≥ 25% of defecations
*
(2) lumpy or hard stools in ≥ 25% of defecations
*
(3) sensation of incomplete evacuation for ≥ 25% of defecations
*
(4) sensation of anorectal obstruction/blockage for ≥ 25% of defecations
*
(5) manual maneuvers to facilitate ≥ 25% of defecations (digital evacuation, pelvic floor support)
*
(6) < 3 defecations per week
V
Rome IV criteria for IBS
*
Symptom onset ≥ 6m before Dx
>
Recurrent abdominal pain ≥ 1d/week in the last 3m associated with ≥ 2 of the following
*
Pain related to defecation
*
Change in frequency of stools
*
Change in the form/appearance of stool
*
ASCRS 2016 CPG: The routine use of blood tests, radiographic examinations, or endoscopy is not typically needed in patients with constipation in the absence of alarming symptoms, screening recommendations, or other significant comorbidities. Grade of Recommendation: Strong recommendation based on low- or very-low-quality evidence, 1C
>
Completion of the workup may require:
*
CBC
*
Chemistry panel with electrolyte levels
*
Thyroid function tests
>
Anorectal physiology and transit studies are warranted if patients do not respond to basic treatments (fiber + osmotic laxatives)
*
Anal manometry
*
EMG to assess puborectalis relaxation
*
Balloon expulsion test
*
RectoAnal Inhibitory Reflex testing (absent in Hirschsprung’s)
*
Colonic transit study
*
Defecography
>
Assessment scores
*
CCF-CS: Cleveland Clinic Florida Constipation Score
V
>
Classification of patients is based on presence/absence of abnormal transit &/or pelvic floor dysfunction
See section above in Colorectal Surgery > Testing
>
1. Slow transit constipation (STC) = colonic inertia
*
Defined by < 1 BM Q3D
*
STC may coexist with IBS (ASCRS Consensus Statement of Definitions for Anorectal Physiology Testing and Pelvic Floor Terminology)
V
V
2. Obstructive defecation syndrome (ODS) / Pelvic floor dysfunction (PFD)
The term pelvic floor dysfunction does not represent a particular pelvic floor disorder and should not be used in medical literature
>
Obstructed defecation syndrome is a well-defined symptom complex consisting of excessive straining at stool, need for perineal splinting, and incomplete rectal evacuation (± reduction in BM / weeks) — being present for ≥ 25% of the time
*
Patients tend to defecate frequently
*
Symptoms tend to be relatively refractory to cathartic therapy
V
Anatomic dysfunction
*
Overt rectal prolapse
V
*
Rectocele
It is defi as greater than 2 cm of rectal wall out pouching or bowing anteriorly while straining
*
Enterocele ± vaginal vault prolapse
*
Cystocele (demonstrated as anterior inward indentation in the vaginal wall on defecogram)
V
Non-anatomic dysfunction (dyssynergic defecation):
*
Occult rectal prolapse
V
Puborectalis
*
Non-relaxing puborectalis/levator muscle spasm
>
Paradoxical puborectalis
V
Dx is suspected with clinical examination
*
Having the patient strain during digital rectal examination, the puborectalis is felt to contract against the examining finger
*
Dx is confirmed with anorectal electromyography & defecography
*
On defecogram: usually patients develop infralevator ballooning of the anorectum
*
Conservative management (dietary + biofeedback) result in improvement in 40-60%
V
Rectal hyposensitivity ± mega-rectum
*
Seen frequently in patients with neurologic or psychiatric impairment.
*
Patient with megarectum could have short segment Hirschsprung’s disease or a non-relaxing pelvic floor and these types of problems must be actively ruled out
*
Dx is confirmed with defecography & anorectal manometry
V
Management
*
Dietary + behavioural + rectal stimulation suppository/enema
*
SNS
V
*
Abnormal perineal descent
Dx is confirmed with defecography (descent > 2-3.5cm past the static pelvic floor)
It is measured clinically by the position of the anal verge in relationship to the plane of the ischial tuberosities at rest and during maximal straining.
Normally, the anal verge lies just below an imaginary line drawn between the coccyx and the pubic symphysis. Perineal descent is diagnosed when the anus is observed to be several centimeters below this imaginary line at rest, with or without additional downward movement during straining.
Part of the pathology in abnormal perineal descent is that the pushing forces are no longer bound by the normal pelvis and thus pressure is directed not only along the axis of the anorectum, but it is also directed radially against the anterior and posterior rectal wall
*
3. Mixed disorder (STC + PFD)
*
4. Normal transit constipation (NTC) AKA constipation predominant-IBS
V
>
Management
Newer drugs including “secretagogues” (lubiprostone and linaclotide) and serotonin 5HT agonists are significantly more expensive with no proven advantage over traditional treatment and therefore generally are reserved as last-line medical agents.
Screen Shot 2020-03-02 at 8.26.39 PM
>
1.1 Fiber supplementation BID + increase liquid intake X several weeks
*
Recommended daily fiber intake is between 25 and 35 grams
*
Cathartic therapy, either stimulant or osmotic in nature, while important for certain etiologies of constipation is typically ineffective in management of obstructed defecation
*
1.2 Exercise
*
1.3 Dietary modifications
*
2. Add (PEG or lactulose) + PRN (glycerin or bisacodyl)
>
3. If > 6-month trial of maximal medical treatment has failed, further evaluation with physiologic testing is warranted
*
Anal manometry (balloon expulsion, followed by defecography) to assess for surgically correctable features (rectocele, sigmoidocele, enterocele, intussusception)
*
Colonic transit study is done only after assessment for pelvic dysfunction (as per American Gastroenterology Association)
V
*
If ⊕ STC, proceed with gastric emptying & small bowel transit studies
If positive, would indicate a more global motility problem that is not correctable with surgery
>
4. Management
>
Obstructive defecation caused by anatomic abnormality should be repaired surgically (not including occult rectal prolapse)
V
Suggested indications for repair:
*
Size > 2 cm
*
Significant contrast retention in defecography
*
Nonresolution of ODS symptoms
*
Surgery has more durable results and better outcomes when the primary complaint is related to symptoms of pelvic floor abnormality (e.g posterior vaginal wall prolapse in rectocele) rather than constipation
V
>
Approaches for management of rectocele
Rectocele operations performed via transrectal versus transvaginal approaches demonstrated equal complication rates in the 2 groups.
V
Conservative management
*
Weight loss
*
Smoking cessation
*
Optimize constipation
*
Kegel exercises: 5-10 seconds 100X per day
*
Pessary (may not be very effective for rectoceles): require cleaning Q3m
V
Native-tissue Transvaginal repair may allow for relatively better visualization and access to the endopelvic fascia and levator musculature, as well as maintenance of rectal mucosal integrity that may reduce infection and fistula complications
*
Literature (including Cochrane Review) supports that transvaginal repairs are more durable than transanal/transrectal repairs
*
Transvaginal repair is offerd to patients with isolated rectocele (no rectal intussusception or prolapse)
*
There is no benefit in adding mesh in a transvaginal repair
*
For patients without any desire to preserve sexual function, a vaginal obliterative procedure, colpocleisis, is an attractive approach for its relative ease and safety
V
Transrectal repair theoretically has the advantage of less sexual and defecatory dysfunction than repairs with the transvaginal approach
*
Transrectal anatomic repair is relatively contraindicated in patients with combined rectocele and fecal incontinence, because the rectocele is closed transversely, plicating the muscularis anteriorly, which may shorten the anal canal and worsen internal sphincter function.
V
*
Transperineal repair (usually performed with mesh) is appealing for patients with both a symptomatic rectocele and fecal incontinence as a result of a sphincter defect as concomitant sphincteroplasty or levatorplasty may be performed
The transperineal approach involves a transverse incision made across the bulbocavernosus and transverse perineal muscles followed by identification and development of the plane between the external anal sphincter and the vaginal mucosa superior to the cul-de-sac, often with placement of mesh along the length of dissection, with plication of the levator muscles and closure of the vaginal mucosa.
V
*
Patients with multiple compartment prolapse or with rectal intussusception are better managed with a laparoscopic ventral mesh rectopexy along with sacrocolpopexy
And so, the colorectal surgeon is likely to only operate on rectoceles when pelvic organ prolapse involves other compartments and this is done in an operative approach in conjunction with GYN
*
ASCRS 2016 CPG: Transrectal stapled repair of rectoceles and rectal intussusception are typically not recommended because of the high rate of complications. Grade of Recommendation: Weak recommendation based on moderate-quality evidence, 2B
*
Convincingly high-grade symptomatic rectal intussusception can be managed with ventral mesh rectopexy if they fail biofeedback
>
STC is better managed with TAC with IRA rather than with a subtotal or segmental colectomy
*
Postoperative symptoms include: diarrhea, abdominal pain, fecal incontinence, and constipation
*
Severe postoperative diarrhea is reported in a wide range, 0 to 46%.
*
90% of patients report that they would undergo TAC-IRA again to treat their constipation
*
Proctocolectomy with IPAA has been shown to have improvement for patients with STC with OOL scores higher than those with TAC-IRA, but these studies were in a highly-selected patient group. Before considering TAC-IRA, pelvic floor dysfunction must be ruled out
>
PFD / dyssynergic defecation :
*
Paradoxical puborectalis (PP) syndrome: managed nonoperatively with bowel training & biofeedback. Consider Botox under US guidance
*
Descending perineum syndrome (DPS): managed nonoperatively with bowel training & biofeedback
V
*
Mixed STC & PFD: surgery is of limited success. Manage each element separately (biofeedback first, then consider for TAC+IRA)
in general, patients with slow-transit constipation and pelvic floor dyssynergia should be treated with biofeedback before subtotal colectomy, because TAC-IRA in this population is associated with higher rates of recurrent constipation and lower rates of satisfaction
>
Adult Hirschsprung’s Disease
*
Clinical suspicion can be investigated with anal manometry, but the patient must undergo a full-thickness rectal biopsy to confirm the diagnosis pathologically
>
Posterior anorectal strip myectomy diagnostic ± therapeutic. In short-segment disease, this procedure may be curative
*
Incision is made in the rectal mucosa proximal to the dentate line to expose the underlying muscularis.
*
A portion of internal sphincter muscle is excised and ideally contains ganglion cells at the proximal surgical margin.
*
If myectomy is unsuccessful, AHD requires either bypass or resection of the dysfunctional rectum
V
Refractory disease may benefit from:
*
Diverting colostomies and ileostomies
V
*
Malone antegrade continence enema (MACE)
ASCRS 2016 CPG: Antegrade colonic enema with appendicostomy or cecostomy may be an effective bowel management strategy in select highly motivated patients with refractory chronic constipation, although this is not a common alternative. Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C
3-Figure59.3-1-squashed
The appendix is imbricated. Openings on the mesentery of the appendix can be used for imbrication. The bowel is not opened throughout the procedure except when insertion the tube through the appendix. The tube is kept in place to allow the tract to fistulize.
*
Sacral nerver stimulation
>
Levator ani syndrome
*
Described as constant and chronic pain felt in the rectum
*
Pain may be worsened or improved with bowel movement
*
Pathognomonic finding: ability to elicit tenderness on the left side during DRE (palpation of the levator muscle)
V
Management
>
Non-Pharmaceutical
*
Sitz Bath
*
Evaluation of seating and toilet habits
*
Acupuncture
*
Only biofeedback has been shown in an RCT have superior results in up to 87.1% at 1 month. These results have been sustained over time especially in patients who displayed tenderness of the levator ani on initial examination, with EGS and digital massage at 45% and 22% respectively.
>
Pharmaceutical can be tried for ~ 2m
>
Muscle relaxants
*
Methocarbamol
*
Cyclobenzaprine
>
Sedatives
*
Diazepam
*
Albuterol
V
Procedural
V
V
Botox injections (my be combined with pudendal nerve block)
IMG_0333
*
It must be highlighted that the posterior and lateral component of the pelvic sling are the target for therapy, as such there is minimal benefit from anterior injections
*
Steroid injections, electrogalvanic stimulation (EGS), and pudendal nerve block are recommended as second-line therapy options.
>
Dyschezia lusoria
V
Attempt to evacuate a body part
*
Small bowel
*
Bladder
*
Rectum
*
Peritoneal cavity
*
Greater strain gives greater sensation of a “mass”
*
It leads to a vicious cycle leading to nerve stretch and damage
>
The Anus
V
>
Overview of the approach and management of anal pain
IMG_0193
*
The prostate should be palpated since prostatitis may be the cause of anal pain
*
A cine-videodefecogram or dynamic MRI of the pelvis may help confirm the diagnosis of a patient with suspected proctalgia fugax or other pelvic floor disorders.
*
A pelvic radiograph can identify some foreign bodies
>
Proctalgia fugax
*
Duration does not exceed 30 minutes
*
Attacks are infrequent: 50% of patients have < 5 attacks per year
*
Completely asymptomatic between episodes
*
May have no obvious trigger for the pain
V
Treatment
*
Topical nitroglycerine or diltazem
*
Biofeedback
*
Botox injection
*
Pudendal nerve block
*
Inhaled β2-agonist albuterol may shorten the duration of symptoms
>
Chronic perineal pain
*
The ganglion impar is a solitary retroperitoneal structure at the level of the sacrococcygeal junction marking the termination of the paravertebral sympathetic chain.
*
The ganglion impar innervates the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina.
*
A ganglion impar block can be used to treat chronic perineal pain.
*
A diagnostic ganglion impar block with local anesthetic can be given to confirm the efficacy of the block.
*
The pain relief may be due to a blockade of nociceptive as well as sympathetic fibers.
*
If considerable pain relief is achieved, it can be long term in these patients by using a neurolytic or therapeutic block.
*
Different approaches to ganglion impar blocks have been described in the literature including injection via the anococcygeal ligament, transsacrococcygeal approach as well as a paramedian approach.
>
Pudendal neuralgia
V
*
The main symptom is pelvic pain; any area supplied by the pudendal nerve can be affected
FemalePudendalNerveWebMalePudendalNerveWEB
>
Characteristics of the pain
*
Burning / crushing / shooting / pricking
*
Develops gradually or suddenly
*
Usually is constant, but can be worse at times and better at others
*
May be worse when sitting down & improve on standing or lying down
V
Other symptoms
*
Numbness & pins/needles in the pelvic area
*
Increased sensitivity to pain & light-touch
*
Sensation of swelling or mass in the perineum
*
Urgency
*
Pain during sex; difficulty reaching orgasm; erectile dysfunction in men
>
Hemorrhoids
*
Hemorrhoids contribute ~15-20% of anal resting pressure & aid in continence
*
Hemorrhoidal cushions are situated at left lateral, right anterior, and right posterior positions
V
*
Internal hemorrhoids are above the dentate line and covered in anoderm
Internal hemorrhoids are fed by terminal branches of superior rectal artery
*
External hemorrhoids are below the dentate line and covered with skin
*
Prevalence of hemorrhoids: 4.4%, half of which are > 50Y
*
External hemorrhoids typically cause few symptoms, unless there is an acute thrombosis
>
Management
>
Fiber supplements
*
Recommended is: 25g (♀) to 38g (♂) per day
*
Meta-analysis has confired that fiber supplementation can alleviate hemorrhoidal bleeding but is not useful for pain, prolapse, and itching
*
It can take up to 6w for fiber therapy to show effect
*
Alternative to fiber = polyethylene glycol
*
Encourage ≥ 8 glasses of water/day
*
Counsel to reduce straining with defecation
*
Sitz bath for 20m TID helps with hygiene & provides symptomatic relief
V
>
Topical over-the-counter Rx have not been shown to reduce symptoms or address the underlying disease
ASCRS: The active ingredients can include vasoconstriction agents, local anesthetics, anti-inflammatory agents, and astringents. There is very little science to support the use of these agents; however, some patients do claim to get relief from these products, and there appears to be little or no harm in their use.
*
CCB and topical nitrates may be helpful in patient with high sphincter tone
V
>
Oral therapy (phlebotonics)
Phlebotonics are a heterogenous class of drugs consisting of plant extracts (i.e. flavonoids) and synthetic compounds (i.e. calcium dobesilate). Although their precise mechanism of action has not been fully established, they are known to improve venous tone, stabilize capillary permeability and increase lymphatic drainage.
>
Flavonoids (plant-based phlebotonic)
*
When used as oral therapy for hemorrhoids, a meta-analysis has shown decreased bleeding, pain, and itching with their use
>
Calcium dobesilate (synthetic phlebotonics)
*
Calcium dobesilate is one of many synthetic phlebotonics. It has also been shown to be effective in decreasing bleeding and inflammation in hemorrhoids
>
Procedures
>
Office procedures are indicated grade I-II ± III after failure of conservative management
>
Rubber band ligation (RBL)
*
Meta-analysis of multiple studies reveals that banding is the most effective non-excisional treatment available
V
*
Can be used for grades I-III internal hemorrhoids
A Cochrane review evaluated the efficacy of RBL with respect to grade of hemorrhoids and found that excisional hemorrhoidectomy was superior to RBL for grade III hemorrhoids
*
Does not require anesthetic
>
The largest hemorrhoids is addressed on the initial banding session — if this is tolerated well, the next session can address the two remaining hemorrhoids
*
1-3 hemorrhoids can be done at the same setting (but with increasing risk of pain, urinary retention, & vasovagal reaction)
*
By applying a rubber band at the apex of the internal hemorrhoid, the hemorrhoid is fixed high in the anal canal, correcting the prolapse, and by decreasing the blood flow caudally, the hemorrhoids shrink in size
>
Technique
*
Patient positioned in left lateral position or prone Jack-Knife position
>
Forceps ligature technique
*
Anoscope is introduced (and stabilized by an assistant)
*
The rubber ring ligating drum with two rubber rings is placed into the anal canal
*
The internal hemorrhoid is grasped with forceps, and the excess tissue is pulled toward the tip or drum of the handheld ligator gun apparatus while the trigger causes the release of the rubber band
>
Endoscopic suction ligator technique
*
Suction of the symptomatic hemorrhoid into the ligating drum, which is attached to an endoscope
*
The ring is deployed through a trigger passed through the biopsy channel of the endoscope
*
The band is placed 1-2 cm above the dentate line at the apex of the internal hemorrhoid plexus
*
Success rate > 90%
*
Recurrence rate 11% at 2Y
*
The band will slough in ~1w
*
Follow up is done in 2-4w to evaluate the success of the banding
>
Contraindications to rubber band ligation
*
Grade IV
>
Coagulopathy or anticoagulated patients
*
ASCRS CPG 2018: Although there is limited evidence regarding the safety of RBL in patients on anticoagulation, it is generally considered a contraindication.
>
Bleeding rate in a retrospective review of 805 patients undergoing 2114 RBLs:
*
25.0% in patients on warfarin bled postprocedure
*
7.5% in patients taking aspirin or NSAIDs
*
2.9% in patients not taking any of these products
*
Cirrhosis / portal HTN
*
Relatively contraindicated in immunocompromised patients
>
Complications
V
Pain
*
Severe pain immediately after placement indicated that placement was too low near the dentate line. Immediate removal is required
*
Minor bleeding
*
Vasovagal symptoms (can be mitigated by using local anesthetic prior to RBL)
*
Thrombosis of adjacent external hemorrhoids
>
Pelvic sepsis & urinary retention is rare and requires aggressive management with IV Abx & drainage/debridement of necrotic tissue
*
ASCRS: In more severe cases, laparotomy with diverting colostomy and pelvic drainage may be necessary.
>
Sclerotherapy
*
Appropriate for internal hemorrhoids, grade I-II
V
Sclerotherapy is reported to be highly successful but is still not quite as effective as RBL especially for grade III hemorrhoids
*
May only have 20% success at 1Y in the treatment of grade III hemorrhoids
V
Sclerosing agent used:
*
2-3ml of 5% phenol in almond or vegetable oil,
*
HTS
*
Etholamine
V
Technique
*
25-gauge needle inserted 1-cm above the dentate line into the submucosa at the apex of each hemorrhoid plexus
*
Can be applied to all hemorrhoids at the same session
*
Patients can be anticoagulated for the session
>
Risks are usually 2ry to inappropriate injection site
*
Pain
*
Ulceration
*
Sloughing of mucosa
*
8% experience transient bacteremia after sclerotherapy — Abx prophylaxis is considered for individuals at increased risk
*
Repetitive sclerotherapy can results in scarring/stricture but this is rare
>
Infrared coagulation (IRC)
*
Appropriate for grade I-II
*
Can be applied to all hemorrhoids at the same session
*
Technique: tip of the coagulator is placed at the apex of the internal hemorrhoid for 1-1.5 seconds X3-4 applications (different locations on each hemorrhoidal complex) per hemorrhoid
*
It is less painful than hemorrhoidal banding
*
Success rate: 81% for grade I-II hemorrhoids after 6m
*
28% of patients require a repeat procedure
>
Operative treatment
*
5-10% of patients with hemorrhoids will require surgical treatment
*
Excisional hemorrhoidectomy remains the gold standard for the long-term relief of hemorrhoidal symptoms
>
Indications for surgery
>
Grade III-IV hemorrhoids
*
In a metaanalysis of 18 RCTs comparing hemorrhoidectomy with office-based procedures, hemorrhoidectomy was the most effective treatment for patients with grade III hemorrhoids
*
Mixed (internal/external) hemorrhoids
*
Persistent symptoms despite medical and office-based treatments
*
Patients with substantial concomitant skin tags
>
Techniques
*
Prophylactic antibiotic therapy is not indicated for elective hemorrhoid surgery
*
PreOp fleet enema is used to clear the rectum
>
Hemrrhoidectomy
V
>
Ferguson “closed” hemorrhoidectomy
Pasted_Graphic_8
*
Involves removal of the hemorrhoid tissue with ligation of the pedicle ± closure of the defect
*
Lidocaine with epinephrine (1:200,000) is injected into the hemorrhoid
*
A V-shaped incision is made on the perianal skin toward the anal canal
*
The hemorrhoid is dissected off the external sphincter then off the internal sphincter
*
The apex of the hemorrhoid with the vascular pedicle is clamped and the hemorrhoid excised
*
The pedicle at the apex is suture ligated
*
The defect is closed in a running, locked, fashion in the anal canal and continued in a simple running fashion on the perianal skin
*
In regards to addressing multiple hemorrhoids in the same session: if one can still place a medium-sized Hill Ferguson retractor at the end of the procedure, then there is usually very minimal risk of anal stenosis.
*
Modified Ferguson: instead of tying off the vascular pedicle at the apex, ‘pinch-burn’ technique is used in the last part of the dissection. After approximating the anodermal junction, the suture is continued in a subcuticular fashion
>
Milligan-Morgan “open” hemorrhoidectomy
*
Similar to Ferguson “closed” hemorrhoidectomy with dissection of the hemorrhoid off the sphincters
*
The hemorrhoid is excised
*
The apex is suture ligated
*
The wound left open to heal by 2ry intention
>
Energy devices
*
The hemorrhoid tissue is grasped
*
The energy device is used to excise the hemorrhoid & seal the defect
*
Results in less pain on POD1 but similar pain at 2 weeks PostOp
*
Because the hemorrhoid tissue is not dissected off the sphincter, care must be taken to avoid damage to the sphincters
*
Excessive removal of anoderm can result in anal stenosis
V
>
Stapled hemorrhoidopexy
stapled-haemorrhoidectomy_e
*
Reserved for grade II-III circumferential internal hemorrhoids ± grade IV
V
*
Does not address external hemorrhoid disease
Removes a circumferential area of mucosa and submucosa proximal to the hemorrhoids. This does not remove hemorrhoidal tissue but rather disrupts the vascular supply and puts the hemorrhoids back into their proper position.
>
Technique
*
The dilator is placed into the anal canal
*
The clear plastic anoscope is sutured to the perianal skin to evert the dentate line
V
*
Place a purse-string in the submucosal plane 3-4 cm proximal to the dentate line
And so, this results in less PostOp pain compared to hemorrhoidectomy techniques
*
The purse-string is tied around the anvil of the stapler
V
*
The stapler is fired
In female patients the vagina should be inspected and palpated prior to firing the instrument to ensure that there is not a cuff of vaginal tissue included within the stapler.
*
The staple line should be inspected carefully for bleeding as this is a common occurrence and may require suture ligation.
>
Stapled (vs excisional hemorrhoidectomy) is associated with
*
↑ Recurrence
*
↓ QOL
*
↓ Pain
*
↑ Trend towards worse incontinence, tenesmus, & hemorrhoidal symptoms
*
Patients undergoing hemorrhoidopexy were also more likely to require an additional operative procedure compared with those who underwent excisional hemorrhoidectomy
>
Potential complications
*
Rectovaginal fistula
*
Rectal perforation
*
Stricture at staple line
>
Transanal Hemorrhoidal Deartirialization
*
May be used for gradeI-IV hemorrhoids
V
*
Technique: a specialized anoscope with a Doppler is introduced into the anal canal. The Doppler is used as the anoscope is rotated until one of the feeding arteries is identified and suture ligated. The Doppler can also be used to confirm that the artery was adequately ligated. The anoscope is rotated until all of the significant arteries are identified and ligated (generally 4–6 arteries, but this can be quite variable). Depending on the need to correct the prolapse, a suture mucopexy can be performed immediately following the ligation using the same stitch. Suture mucopexy entails placing a running suture at the apex of the hemorrhoid (as the suture is tightened, it pulls up the prolapsed hemorrhoid)
The arterial ligation and mucopexy are all done above the dentate line
V
Outcomes
*
Recurrence: 3.0-60%
*
Bleeding: 5-10%
*
Pain on defecation: 9%
>
Outcomes are superior to office procedures but results in more complications
>
Pain
*
Metronidazole (oral and topical) have had mixed results in regards to decreasing pain
*
Topical nitroglycerin & 2% Diltiazem ointment have also been shown to decrease post hemorrhoidectomy pain & earlier return to routine activity
*
Some advocate for a lateral internal sphincterotomy at the time of hemorrhoidectomy to decrease anal tone and decrease pain
V
*
“[A]dvantages of pudendal nerve block use… reduction in opioid consumption, postoperative pain, complications, and length of stay”
Mongelli et al. 2021 DCR: Pudendal Nerve Block in Hemorrhoid Surgery: A Systematic Review and Meta-analysis
>
Urinary retention is one of the most common complications (2-36%)
*
Incidence is higher after spinal anesthesia
V
*
Risk may be mitigated with decreasing volume of IV fluids and through judicious use of local anesthesia
ASCRS CPG 2018
>
Fecal incontinence (2-12%); etiology may include:
*
Sphincter stretch during OR
*
Direct injury to the sphincter complex
*
Loss of hemorrhoidal piles that have been contributing to 10-15% of continence
>
Hemorrhage
*
May be immediate: requires return to the operating room
*
May occur on POD 7-10: managed with packing of the anal canal or tamponade with a Foley. Uncontrolled bleeding requires return to the OR
>
Anal stenosis
*
Occurs if excessive anoderm is removed at the time of hemorrhoidectomy (most commonly in the emergency setting)
*
Treatment starts with bulk laxatives
*
May require dilatation or anoplasty
V
*
Infection/sepsis (<1%): may require operative drainage/debridement
Prophylactic antibiotic therapy is not indicated for elective hemorrhoid surgery
>
Complicated disease / special circumstances
>
Thrombosed external hemorrhoids
*
Present with an acutely painful purplish or blue mass in the perianal area
*
Pain usually peaks at 3-4 days
V
*
Aggressiveness of treatment is driven by the patient’s symptoms
ASCRS CPG 2018: Although most patients treated nonoperatively will experience eventual resolution of their symptoms, excision of thrombosed external hemorrhoids may result in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals.
*
Occasionally, a thrombosed hemorrhoid will evacuate spontaneously, leaving a small ulcer with residual clot at the anal opening
V
*
Once anesthetized, the skin should be excised overlying the thrombosis to allow as much of the clot to be removed
UTD: When indicated, external thrombosed hemorrhoids are best treated with hemorrhoid excision, rather than incision and simple evacuation of the clot, an approach that should generally be avoided. However, if timely evaluation by a surgeon is not available and the provider is not comfortable with excision of the thrombosed hemorrhoid, incision of the hemorrhoid can be performed to remove the clot, which should lessen symptoms.
The recurrence rate for a completely excised thrombosed hemorrhoid is 5-19%. By comparison, simple incision and evacuation of the clot is associated with a 30% risk of reaccumulation and thrombosis, which may disseminate to adjacent hemorrhoidal columns
When hemorrhoid incision, rather than excision, is used, there can be residual clot if the incision is too small, and reaccumulation of blood and thrombosis can occur.
*
The wound can be left open or closed with absorbable sutures, depending on surgeon’s preference
*
Bleeding usually can be managed with pressure, silver nitrate, & suture ligature
*
Consider prescribing Nifedipine/lidocaine ointment for faster resolution of symptoms
V
>
Strangulated, thrombosed prolapsed, hemorrhoids
IMG_0247
*
They present with pain ± urinary retention & referred pain
V
*
Urgent hemorrhoidectomy is required for non-reducible hemorrhoids as edema can lead to ischema, ulceration, and necrosis
The excisional hemorrhoidectomy can be performed in an open or closed technique, although some recommend an open technique in the face of necrosis.
*
Enucleation of the thrombus is inadequate treatment
>
Alternative management for patients who refuse surgery:
*
1. Local anesthesia
*
2. Apply pressure/massage to decrease edema
*
3. Rubber band ligation & thrombectomy
V
Portal HTN & rectal varices (not hemorrhoids)
V
It is important to determine if the bleeding is from hemorrhoids or rectal varices
*
Ganguly et al defined rectal varices as dilated veins that originate > 4 cm above the anal verge, clearly distinct from hemorrhoids, and not contiguous with the anal columns and/or pectinate line
V
EUS is better than endoscopy alone at detecting rectal varices
*
Color doppler US may be helpful in identifying high-risk group for rectal variceal rupture via the measurement of velocity
*
Anorectal varies are present in > 75% of patients with portal HTN; 38-56% of patients with cirrhosis
*
Rarely cause bleeding
V
Management of bleeding varices:
V
1. Medical management of portal pressures: β-blockers; target SBP 90-100 mmHg & HR < 100 bpm
*
All GI bleeds (including rectal bleeding) in cirrhosis patients benefit from prophylactic Abx
V
2. Endoscopic
V
Endoscopic injection sclerotherapy
*
The recurrence rate in one series was 24% over the 1­year follow­up period.
*
Endoscopic band ligation (less effective than sclerotherapy)
V
Surgical
*
Suture ligation / circumferential stapling
*
Surgical portosystemic shunts
V
Interventional radiology
*
TIPS
*
Embolization: results in high 1Y rebleed rates
>
Management of bleeding hemorrhoids
*
Conservative
*
Sclerotherapy
*
Suture ligation
*
Surgical hemorrhoidectomy
*
Avoid RBL
>
Pregnancy & hemorrhoids
*
Topical agents are to be used with caution after consultation with OB/GYN
*
Hemorrhoid symptoms are not uncommon during pregnancy
*
Symptoms tend to resolve after delivery & rarely need intervention
*
Surgical intervention is not warranted unless in case of emergency
>
Crohn’s disease & hemorrhoids
*
Surgical management has been reported to have a high rate of complications and can precipitate proctectomy for surgical complications not manageable with conservative means
V
Surgery may be considered for patients with:
*
Well-controlled disease
*
Not on steroids
*
No active anorectal involvement
*
Stapled hemorrhoidopexy is contraindicated
*
Hemorrhoidectomy is contraindicated in patients with anorectal Crohn’s disease or Crohn’s proctitis
*
The main complication associated with hemorrhoidectomy in Crohn’s disease is non-healing chronic wound
*
Surgical interventions such as RBL and excisional procedures should only be undertaken when conservative measures have failed and the anorectum is otherwise free of evidence of CD
>
Immunocompromised patients
*
Hemorrhoidectomy is safe in HIV-positive patients without AIDS
*
Poor wound healing and infectious complications are at the forefront of decision making
*
Surgical intervention is reserved for emergencies
*
Ulcerated hemorrhoids in context of immunosuppression is suspicious for malignancy. Consider hemorrhoidectomy & sending the specimen for pathologic examination
>
Abnormally looking hemorrhoids should be excised and send for pathology to rule out malignancy
V
SCC on final pathology
*
2 mm is adequate resection margin for anal canal SCC
*
1 cm is adequate resection margin for anal margin SCC
*
Patients requiring therapeutic anticoagulation are managed with sclerotherapy rather than rubber banding (when appropriate)
>
Anorectal abscesses & fistulas
>
Following drainage of an abscess, fistula formation rates are as high as 40% within 12 months
*
Systematic review 2018: Antibiotic therapy following incision and drainage of anorectal abscesses is associated with a 36% lower odds of fistula formation
V
>
Anorectal abscesses
*
♂ 2:1 ♀
*
50% of anorectal abscesses develop a fistula-in-ano requiring surgery
*
Always rule out a Hx of IBD or immunocompromise
>
Etiology
*
90% cryptoglandular
*
3% IBD
*
3% postoperative/traumatic
*
3% anal fissure
*
1% TB
*
Malignancy
*
Foreign body
*
Hidradenitis suppurativa
*
Invasive fungal infection
*
Iatrogenic
*
Osteomyelitis
>
Principles of management:
*
Control sepsis
*
Identify the involved anatomy
*
Attend to symptoms without compromising sphincter function
>
Principles of abscess drainage
*
The incision should be oriented over the side of the abscess closest to the anal verge without transgression into the sphincter complex
*
Bx should be obtained from recurrent abscesses or fistula tracts
*
Perianal abscess: bedside I&D
V
>
For postanal space abscess:
Screen_Shot_2019-07-14_at_10.02.16_AM
V
*
Horseshoe-type extensions of anorectal abscesses may occur in the intersphincteric plane, the ischioanal fossa, or the supralevator plane
Screen Shot 2022-08-08 at 15.17.52
*
Always consider an etiology of Crohn’s disease
*
Anesthesia is usually necessary
V
V
Technique
Cut at red; drain at greenScreen_Shot_2019-01-06_at_20.32.01
Screen Shot 2022-08-08 at 15.18.33
*
The first incision is made in the posterior midline outside of the sphincter mechanism and is carried down into the deep postanal space. This drains the pus and exposes the extent of the horseshoe bilaterally into the ischiorectal fossae.
*
Subcutaneous tissue is divided and the underlying fibers of the external sphincter are spread with a hemostat clamp
*
The anococcygeal ligament then is divided to access the postanal space
*
A digit is inserted to explore the extent of suppuration
*
If a horseshoe abscess is present, elliptical counter incisions over the involved ischiorectal fossa are created
*
Penrose drains can be looped between incisions to maintain patency
*
If an underlying fistula is noted, a noncutting seton is placed to prevent recurrent sepsis, otherwise division of IAS posteriorly to the level of the transsphincteric fistula is done
V
*
Intersphincteric abscesses are addressed transanally. Mucosa overlying the bulging anal canal is divided vertically with cautery
Treatment consists of laying open the abscess, with division of the fibers of the internal sphincter from its lower end up to the level of the dentate line, or to a higher level if the cavity extends higher
Simply draining the abscess is inadequate therapy
V
*
Ischiorectal abscess: bedside I&D ± counter-incision, occasionally under GA
If a very large abscess is present, liberal use of one or more counter incisions may be done to drain the cavity satisfactorily.
V
>
Supralevator abscess: treatment depends on the source:
There is no external evidence of disease
Its origin, if possible, should be determined before treatment is begun.
Screen_Shot_2019-01-06_at_20.07.49
*
If secondary to intersphincteric abscess: drain into the rectum by division of the internal sphincter
V
*
If secondary to ischioanal abscess: it should be drained through the ischioanal fossa
Attempts at draining this kind of abscess into the rectum will result in an extrasphincteric fistula and become a much more difficult problem to handle
>
Anorectal infections in immunocompromised patients:
*
Prolonged, broad-spectrum Abx are recommended
>
Patients with neutropenia suffer higher rates of morbidity following surgery, and mortality was upwards of 45 % in one study vs. 9 % in those treated only with antibiotics
*
Patients with absolute neutrophil counts > 1000/mm2 tend to mount a reaction that creates and abscess that requires surgical drainage
*
Patients with absolute neutrophil counts < 500/mm2 are not managed surgically because they don’t mount sufficient response
*
Due to the high risk of morbidity and mortality in patients with incomplete evacuation of purulent material, operative washout is preferred to bedside management.
>
Primary “prophylactic” fistulotomy
*
It is considered only in the most straightforward of superficial or low transsphincteric fistulas
>
Contraindications:
*
Women with anterior fistulas
*
Compromised fecal continence
*
Crohn’s disease
*
AIDS
*
High transsphincteric fistulas
>
Complications
V
Recurrence:
*
Incidence of recurrence after adequate abscess drainage: 30%
*
Recurrence rate is higher when management is delayed more than 7d after the onset of symptoms
*
Horseshoe abscess recurrence rate is higher: 18-50%
*
Fistula formation: incidence of fistula formation after adequate abscess drainage: 26-50%
*
Incontinence
V
Necrotizing perianal skin infection
*
Radical debridement of all nonviable tissue is necessary
*
The need for fecal diversion is debated but should only be considered in the subacute setting after hemodynamic stability is well established
*
Transfer to a tertiary center with hyperbaric oxygen capability should be considered
V
Fistula-in-ano
>
General
*
Prevalence: 1-5:10,000
*
♂2-5:1♀
>
Etiology
*
90% cryptoglandular
*
3% IBD
*
3% postoperative/traumatic
*
3% anal fissure
*
1% TB
*
Malignancy
*
Foreign body
*
Hidradenitis suppurativa
*
Invasive fungal infection
*
Iatrogenic
*
Osteomyelitis
*
Physical examination can be helpful in delineating the fistula anatomy and reaches a very good accuracy in identifying superficial (100%) and transsphincteric (100%) tracts, but it appears inadequate for supralevator (63.6%) and intersphincteric (33.3%) tracts
*
ASCRS recommends performing imaging (endoanal US, MRI or fistulogram) for an accurate preoperative classification of the primary tract and its extensions
>
MRI technique
*
T2-High resolution: 512 X 512
*
T2-FatSat: suppression of fat signal helps identify edema/inlfammation
*
IV contrast: helps identify vessels/inflammation
*
Done in 3 planes; ≤ 4mm thick slices
V
*
Classification is the one published by Park et al (1976)
Park-Classification-squashed
>
Features of complex fistulas (higher risk of recurrence and/or incontinence after intervention)
*
Multiple fistulas
*
High transsphincteric (>30% of anal sphincter length)
*
Suprasphincteric
*
Extrasphincteric
*
Associated high blind tract
>
Always rule out a Hx of IBD & fecal incontinence that is already present
*
It has been described that perianal CD fistulas reveal a characteristic aspect of hypoechogenic fistula tract surrounded by a well-defined hyperechogenic area with a thin hypoechogenic edge, defined as “Crohn’s Ultrasound Fistula Sign”.
*
Fistulas in Crohn’s often originate in the rectal mucosa creating high, complex fistulas
*
Fistulas in context of Crohn's tend to occur in a lateral position
*
Treatment strategies are uniformly conservative because of poor wound healing, high recurrence rates, vulnerability to incontinence related to frequent diarrhea, poor rectal compliance, & repeated insult to the sphincter complex with recurrent anal sepsis & need for intervention
*
The goal of treatment of perianal fistulas in Crohn’s disease is symptomatic control. Rubber seton placement are usually tolerated and satisfactory for long term (indefinite) management
V
Improved healing with metronidazole, fluoroquinolone, and immunomodulators have been reported
*
ACCENT II trial: infliximab shows significantly higher rate of fistula resolution compared to placebo (36% vs 19%)
*
CHOICE trial demonstrated adalimumab to be effective in inducing complete fistula healing in 39% after failing infliximab
V
Median duration of fistula closure during treatment with infliximab is 3m
*
Seton removal after at least 2 rounds (and better after at least 5 rounds) of infliximab ensure lower recurrence rate
*
Asymptomatic fistulas do not require surgical management
*
Endoanal ultrasound can also be used to determine the appropriate timing of seton removal in patients treated with infliximab therapy for perianal Crohn’s disease. If setons are not removed until the fistula tract is narrow and minimal hypoechoic inflammatory changes are seen on ultrasound, Schwartz et al. demonstrated long-term healing in 76 % of patients
*
Endorectal advancement flaps can be used in Crohn’s disease with fistulas when there’s no proctitis
>
Failure of local procedures warrants fecal diversion and then proctectomy if the disease is not controllable
*
When in doubt of whether to keep the rectum or not in a Crohn’s colitis, evaluate distensibility of the rectum with endoscopy. If stiff, it needs to be resected
*
For Crohn’s patients with extensive perianal disease, always assess for anal stenosis. If stenosis is present and an end colostomy is planned, the anus needs to be serially dilated to avoid having it scar down and causing perforated secondary to a closed loop obstruction. An alternative is to perform a mucus fistula with the distal colonic limb
*
As perineal disease can be extensive, a staged approach is often warranted. Abdominal proctectomy with rectal transection at the level of the levators will allow perineal disease to heal or improve and permit a subsequent, second-stage, perineal anoproctectomy of a more limited scale
>
Principles of management:
>
Define the fistula anatomy
*
Most often by EUA, aided by injecting hydrogen peroxide or blue dye
V
*
Goodsall’s rule: anterior external opening drain radially; posterior external openings (within 3 cm) drain to a posterior midline opening. The positive predictive value of Goodsall’s rule has been estimated to be 59 % and is more accurate for posteriorly located fistulas
Pasted_Graphic_14
>
If the tract cannot be cannulated fully:
*
External opening is enlarged toward the anal verge
*
The tract curetted, and the operation terminated
*
Adjunct imaging is done in 3-6w to allow inflammation to settle
*
Transanal US can predict the amount of sphincter that needs to be divided if primary fistulotomy is performed
*
MRI has been shown to alter surgical approach & decrease recurrence for complex & recurrent fistulas
>
Ensure resolution of sepsis
*
Always avoid fistulotomy with active proctitis
*
Always clear the tract and eliminate the source (gland) — usually done with fistulotomy of the internal sphincter portion
>
For complex fistulas or for patients with an obvious fistula at the time of treatment for anorectal sepsis: seton placement is most appropriate
*
For some Crohn’s or other high-risk patients, seton placement can be the definitive operation; it is left in place for prolonged periods to prevent recurrent sepsis without the intention to perform a second stage procedure because of the likelihood of failure or iatrogenic incontinence.
*
For patients initially treated with a seton, a second stage procedure is considered when the internal opening is < 5mm & the tract is simple, narrow, & without an associated cavity
*
Complex fistulas with persistent sepsis should be treated with débridement of the tract around the seton, widening of the external opening, and a search for a high blind or circular tract
>
Assess & preserve anal sphincter function
*
Division of the internal sphincter is well tolerated
*
Division of the distal ⅓ of the external sphincter is considered ‘safe’ in healthy male individuals
V
>
Sphincter preserving techniques are preferred in:
Pasted_Graphic_10
*
Women are vulnerable to incontinence because of their shorter sphincter complex, anatomic and neurologic injury to the pelvic floor sustained during childbirth, and to loss of elasticity and muscle attenuation associated with aging
*
IBD patients
*
Immunocompromised/immunodeficient patients
V
Management
*
Fit patients with symptomatic anal fistula should have some surgical intervention
*
Universal approach to fistulas: identify tract. Start with fistulotomy, consider dividing the internal sphincter fibers PRN. If need to divide the external sphincter, just place a seton and bail out. After inflammation settles, the seton around the external sphincter can likely be removed in clinic.
*
Be weary of dividing any sphincter muscle anteriorly in a woman
>
Chronic fistulas will have an increase risk for developing malignant transformation that is not adequately surveyed. This warrants, at minimum, long term follow up
V
Verrucous squamous carcinoma tends to develop in chronic fistulas and they are characterized by their large size, exophytic growth pattern, and lack of deep invasion.
*
These lesions may be radio-resistant, and there may be limited role for NART
V
Fistulotomy/seton placement
V
*
Intersphincteric fistula
In short: sacrifice as little of the internal sphincter as required (all of it, if needed), ensure the primary source is drained, drain perianally even if no tract present
Screen_Shot_2019-01-06_at_18.00.14
V
*
Transphicteric fistula
If low, divide internal & external muscle fibers.
If high (level of puborectalis), divide lower half of internal sphincter, ensure adequate drainage, divide only a small portion of external sphincter, & insert a seton
Dr. Lee: If high: just perform a LIFT
Screen_Shot_2019-01-06_at_18.09.32
V
*
Suprasphincteric fistula
Division of the lower half of the internal sphincter (to eradicate the anal gland of origin), creation of adequate drainage of the secondary limb, and division of variable amounts (approximately half) of the external sphincter. The use of a seton is encouraged
Screen_Shot_2019-01-06_at_18.20.05
V
*
Extrasphincteric fistula: If this tract is laid open, total incontinence will result.
An extrasphincteric fistula is most conveniently classified according to pathogenesis. When the cause is not ano-rectal disease, treatment consists of adequate drainage of the tract
When the disease is secondary to an Anal Fistula:
The primary tract in the anal canal must be eradicated by division of the lower half of the internal sphincter. The opening in the rectal wall is closed with two or three interrupted nonabsorbable sutures such as wire ones or with very slowly absorbable sutures such as polyglycolic acid ones. Adequate drainage of the fistulous tract must be achieved with special attention paid to the elimination of pocketing at the apex of the ischioanal fossa or supralevator extension. Preoperatively the patient is given a mechanical bowel preparation and postoperatively is fed an elemental diet, thus effectively creating a ‘‘medical colostomy’’
When the disease is secondary to specific Anorectal Disease:
These fistulas are not usually amenable to local treatment; thus, the disease itself must be treated, usually with a proctectomy
Screen_Shot_2019-01-06_at_18.27.18
*
Non-cutting seton: a period of 12 or more weeks is typically advisable during which the patient is assessed periodically to ensure adequate drainage
>
Cutting seton
*
Overlying skin and anoderm are divided
*
The seton is then secured tightly around the remaining sphincter complex and is further tightened in the office at varying intervals (days to weeks)
*
Typically reserve for patients with high complex fistulas who failed multiple prior interventions or in fistulas not amenable to other techniques such as high posterior-based fistulas in patients with deep buttock cleft
*
Women with prior vaginal deliveries experienced significant incontinence leading the authors to advice against the use of cutting seton in this subgroup of patients especially in the setting of an anterior fistula
>
Time to complete healing:
*
Range 1m to 12m
*
Mean: 9.3 weeks
>
Risks:
*
Incontinence (to liquid stool & flatus): 5-12% (up to 38%)
*
Recurrence: 3-5%
>
Fistulotomy with sphincter reconstruction is a suitable technique for complex or recurrent fistulas in incontinent patients or in patients who are at risk for incontinence
*
Prophylactic intravenous antibiotics are given at time of operation and are continued postoperatively for 1 week.
>
Technique
*
The fistula tract is completely divided using electrocautery
*
Curettage of the tract and any associated cavities is performed to ensure that all granulation tissue is debrided
*
Excision of the fibrous tract can be performed taking care not to excise any muscle or alternatively the fibrous tract is left in situ
*
An end-to-end primary sphincteroplasty is performed using a series of horizontal mattress sutures using 2.0 Vicryl or PDS sutures
*
The fistula bed of the divided fistulous tract is incorporated in the suturing to completely obliterate any potential space behind the muscle reconstruction
*
Overall healing rates range from 83.3 to 97.4 % and the incontinence rates between 3.7 and 21.4 %
>
Sphincter sparing
>
Ligation of Intersphincteric Fistula Tract (LIFT)
*
Performed most often as a second stage for transsphincteric fistula after a mature tract has developed
*
Very high fistula tracts are not good candidates for this approach
*
Success is higher than that with bioprosthetics & comparable to endorectal advancement flap
*
LIFT can be used for Crohn’s-related fistulas
V
>
Technique:
Pasted_Graphic_11
*
Fistula tract is cannulated
*
External opening is widened
*
1-2cm curvilinear incision is made over the palpated intersphincteric groove above the fistula tract
*
Lonestar retractor is deployed
*
The intersphincteric space is developed bluntly with a fine-tipped hemostat
*
The fistula tract is isolated circumferentially without disrupting it
*
The probe is removed
*
Either end of the intersphincteric tract is ligated with absorbable sutures
*
The tract is divided sharply with scissors
*
The external opening is injected with hydrogen peroxide. If there is persistent leak, the intersphincteric opening of the external sphincter is oversewn
*
The anoderm is reapproximated with a running absorbable suture
V
Modified techniques
*
BioLIFT: uses bio prosthetic porcine graft to reinforce the ligation and closure of the fistula tract
*
LIFT-PLUS: adds partial fistulectomy of the subcutaneous portion of the tract from the skin to the external sphincter
*
LIFT with endorectal advancement flap
>
Endorectal advancement flap (the gold standard sphincter-sparing procedure)
*
It’s appropriate for high risk fistulae (high transsphincteric, suprasphincteric, anterior fistula in women)
V
Reported success rate 70-90%; real world success < 50%
*
Success in Crohn’s disease: 64%
*
Repeat anorectal advancement flap after recurrence has been shown to be feasible with overall good outcomes
*
Preoperative bowel preparation is done to forestall PostOp bowel movement
V
V
Technique
304018_1_En_14_Fig1_HTML
*
The seton is removed & the internal opening serves to mark the apex of the flap
V
*
A flap is created by distal to proximal dissection with electrocautery, including mucosa, submucosa, and a few fibers of the internal sphincter (partial thickness).
To ensure adequate perfusion, it is crucial that the base (proximal end) of the flap is wide, at least two to three times the width of the apex.
The tongue-shaped flap is typically 2 to 4 cm long to allow for tension-free closure.
*
The fistula tract is débrided with a curette, and the external opening is widened to allow for drainage.
*
Absorbable suture is used to close the internal opening, and the integrity of the closure is tested with injection of hydrogen peroxide at the external opening.
*
The tip of the flap with the internal opening is excised
*
The flap gently is retracted distally over the internal opening to the dentate line, but not below it, to prevent ectropion formation.
*
Wound edges are reapproximated with interrupted absorbable suture.
*
Some surgeons place a small length of Penrose drain beneath the flap for drainage to decompress dead space and prevent seroma formation
*
Some authors describe maintaining the patient on antibiotics for 7 days postoperatively.
*
The location of the internal opening (posterior vs. anterior) has no impact on outcomes of advancement flap repairs in the published literature
>
Fibrin sealant & collagen plug
*
The principle of use it to obliterate the internal opening & fistula tract
*
Their primary benefit is a minimal risk profile
V
Fibrin sealant (Tisseel) is a combination of fibrinogen & thrombin: healing rate is low (10-67%)
*
Fibrin sealant: shorter fistula (<4 cm) tended to recur more frequently than longer fistula (>4 cm) with recurrence rate of 54% vs. 11%
V
Plug: bioabsorbable xenograft, made of lyophilized porcine intestinal submucosa (Surmises®): success rate 14-87%
*
For plug application: the tract is cannulated, a large silk suture is threaded through the tract, the suture is tied to the narrow end of the plug and then pulled through the tract until the plug exists the external opening
*
Success rate in Crohn’s disease: 29-86%; failure often attributed to plug extrusion
>
Stem cell therapy
*
There is limited evidence for the use of adipose-derived stem cells (ADSC) to treat complex anal fistula mostly in patients with Crohn’s disease. Autologous ADSC can be easily obtained with liposuction with minimal adverse effects on the patient.
V
Healing rate
*
71% initially
*
63% at 1Y
*
33% at 3Y
*
Rectal sleeve advancement flap
>
Rectourethral fistulas
>
Etiology
*
Congenital
>
Acquired
*
Surgery
*
Radiation
*
IBD
*
Neoplasms
*
Pelvic infeciton
*
Trauma
*
In the Western world, the most common mechanism of RUF is multimodality treatment for prostate cancer, including surgery, external radiation therapy (EBRT), or brachytherapy, with an incidence of 0.1–3 % in patients who received these therapies
*
Up to 50% of patients with RUF have a history of irradiation
*
The mean time from the last radiotherapy session and the diagnosis of RUF ranged from 14 months to as long as 14 years
V
>
Management
Untitled
*
Not all patients require definitive repair. A spontaneous closure rate of 14–46.5 % has been reported after fecal diversion, and some patients can heal small RUF with urethral catheter drainage alone
V
Small, minimally symptomatic, nonirradiated RUF can be managed initially with a urethral catheter and if needed suprapubic catheter drainage
*
If unhealed for 2 or more months, surgical intervention is usually warranted
*
Small distal fistulas and those not radiation-induced can be amenable to a local anal repair such as an endorectal advancement flap
*
If RUF remains unhealed following local flap repair, a diverting stoma followed by additional local flap repair or transperineal repair with gracilis interposition flap or dartos flap would be the next step
>
Patients with large RUF (>1 cm), prior radiation or cryotherapy, significant symptoms, severe urethral stricture, or prior failed repair require fecal diversion with suprapubic catheter drainage
V
*
After 3 months of fecal diversion, the RUF should be reassessed
It is important to reassess the patient with a minimum of two diagnostic studies (endoscopic or imaging) from the bladder and rectal side to confirm complete healing prior to closing the stoma
V
Unhealed:
>
Transabdominal (proctectomy with coloanal with or without omental flap, pelvic exenteration with or without sphincter preservation)
*
Patients with postoperative RUF following prostate or rectal surgery and positive oncologic margins can be offered a transabdominal approach
*
Additional indications include high RUF not accessible to a transanal or transperineal approach, patients with nonfunctioning irradiated bladder or severely stricture urethra which requires excision with urinary diversion, and patients with prior failed repairs
*
Transanal flap (endorectal advancement flap with or without biologic mesh)
V
Transperineal (gracilis flap interposition or dartos flap)
*
The gracilis muscle interposition is currently the most commonly used method for treating complex, large, recurrent, and/or irradiated RUF.
*
Transsphincteric (York-Mason technique)
*
Transsacral (Kraske approach)
>
Anal fissures
*
Constipation and diarrhea are frequent antecedent historical features
V
>
The Dx is made with an external physical examination
Screen Shot 2020-04-18 at 11.26.58 AM
*
Confirming the Dx: touching the site of defect with a cotton-tipped swab will reproduce the pain associated with defecation
*
DRE & office anoscopy are used to rule out other diagnoses if the Dx is unclear
*
If anal tone is high and there is twitching of the anal sphincter, even if there is no visible fissure, a diagnosis of anal fissure disease is likely
*
Failure to make a Dx warrants an EUA
V
Fissure location
*
75-90% of fissures are in the posterior midline; 10% are anterior midline (mostly in ♀). In 3% of patients, fissures can be located at posterior and anterior positions simultaneously
*
Anterior midline fissures are seen more commonly in women & are associated with an external sphincter defect
*
Younger women with anterior midline fissure: consider low-pressure fissure associated with obstetric trauma
V
Fissures not located in the midline should prompt work up for other disease:
*
Crohn’s disease
*
STDs (HIV; syphilis)
*
TB
*
Cancer
*
Non-healing ulcers should evaluated for a secondary cause of the fissure, most likely with an EUA and Bx
*
After 6-8w of developing the fissure & symptoms, the fissure takes on a chronic appearance: fibrosis, exposed internal sphincter muscle, skin tag at the distal end, and/or a hypertrophied papilla at the proximal end
*
The duration of symptoms guides management strategies
*
Anal manometry is indicated if the anal tone is suspected to be low or if fissure recurs after LIS
>
Management
*
↑ Dietary fiber, analgesia, sitz bath
*
Consider topical anesthetics or topical steroids
V
>
Medical management
Screen_Shot_2019-07-14_at_4.56.38_PM
*
Stepwise progression: Glycerine TriNitrate/CCB → botox → LIS
>
Most common AE with GTN & CCB is headaches (CCB better tolerated).
*
Dose escalation does not improve healing rates, but escalating doses are associated with an increased incidence of medication side effects
*
AEs are dose related and lead to the cessation of therapy in up to 20% of patients
>
CBD: 0.5% nifedipine ointment or 2% diltiazem cream is used QID
*
Healing rates: 65-95%
*
Data suggests that the cure rate associated with topical CCB is increased with increasing frequency of daily application
*
Anal fissures may also be treated with oral CCB. Direct comparison of oral and topical nifedipine found similar rates of healing and pain relief.
V
*
GTN: 1g of 0.2-0.4% applied BID/TID (commercially available only in 2% — dilute in soft paraffin e.g 10g of 2% in 100g)
Paraffin wax is a soft colorless solid derived from petroleum, coal or oil shale that consists of a mixture of hydrocarbon molecules containing between twenty and forty carbon atoms
>
Results from Botox injections are comparable to topical medications, less effective than surgery
*
Dr. Charlebois’s approach: 20-40u mixed in 1cc of NS: apply at either side of the fissure, proximally & distally, use 0.1-0.2 cc into each site
*
Injection of Botox is done into the internal sphincter or in the inter-sphincteric groove
*
ASCRS 2017: A Cochrane review from 2012 found no clear trend between dose, preparation, or injection site of botulinum toxin and associated healing rates
V
>
Surgical therapy
Screen_Shot_2019-07-14_at_4.56.49_PM
>
Lateral Internal Sphincterotomy
V
*
LIS is the gold standard for chronic anal fissures, but it associated with risk of incontinence
<10% of patients experienced difficulties with incontinence at more than 5 years of follow-up, and 3% experienced significant changes in lifestyle
*
Healing rate: 88-100% on 6Y follow up
V
*
LIS has a fecal incontinence rate of 8-30%, but is as low as 3% in some systematic reviews
Some of the surgeons at McGill suggest not performing LIS on young women as they will eventually develop incontinence as they age.
Some advocate a classical LIS for males and tailored LIS for women
*
Not appropriate for low-pressure fissures
*
LIS is not done posteriorly because it results in a keyhole deformity and results in soiling and seepage
*
Classical LIS is done up to the dentate line
*
Tailored LIS is done for a distance equal to that of the fissure
*
Some prefer a circum-anal incision to a radial incision as they see that circum-anal incisions heal better
V
>
Anocutaneous advancement flap is useful with patients with incontinence (or high risk of it) = cut a diamond (or house-flap) just distal to the fissure and use it to cover the fissure after ‘freshening the wound of the fissure’
Screen_Shot_2019-07-15_at_16.50.44
V-Y Flap:
393522_3_En_14_Fig5_HTML-squashed
*
Healing rate: 81-100%
*
Minor incontinence rate: 0-6%
*
ASCRS 2017 CPG: The addition of an anocutaneous flap to botulinum toxin injection or to lateral internal sphincterotomy decreases postoperative pain and allows for primary wound healing. Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C.
>
Fissurectomies may be offered as an alternative to anocutaneous advancement flap
*
Patients with prominent sentinel skin tag, hypertrophic anal papilla, and fibrotic wound base are the highest likely to benefit from fissurectomies
*
Fissurectomy can be combined with LIS
*
LIS has been compared with fissurectomy in 2 randomized trials including a total of 112 patients, with superior healing rates with LIS and with equivalent incontinence rates
V
>
Recurrent fissure
Screen_Shot_2019-07-14_at_5.00.47_PM
>
Repeat LIS (on contralateral side; or ipsilateral side if a tailored LIS was performed initially) if anal tone is hypertonic
*
Associated with 98% healing rate; 4% minor incontinence rate, at 12m follow up
*
Consider endoanal ultrasound to evaluate the integrity of the previously divided muscle after LIS. This helps guide whether a repeat LIS should be done on the ipsilateral or contralateral side
*
Fissurectomy with advancement flap if hypotonic sphincter or if there is a sphincter defect
>
Atypical fissures
>
Crohn’s Disease
*
It is reasonable to intervene only as complications dictate
*
Fissures in Crohn’s patients can be managed surgically (LIS or advancement flap) if it is a single, “characteristic” midline fissure, elevated resting sphincter tone, and a disease-free rectum.
*
Medical management of Crohn’s may lead to resolution of the anorectal disorders in ≥ 50%
*
Biologic therapy is the gold standard in the treatment of perianal Crohn’s disease
*
Topical metronidazole may be beneficial
*
STI-related fissure treatment: identify causative organism through Bx & tailor therapy
V
HIV
*
Poor sphincter tone and function is a more frequent finding than the hypertonicity that accompanies typical, non-HIV-related fissures
*
HIV-related anal ulceration: Bx, viral culture, debridement, & intralesional steroids
>
Pruritus ani
*
♂ 4:1 ♀
*
May be localized or diffuse
*
Often worse at night or in warm, moist climates
V
Etiology
>
Idiopathic
*
A Dx of exclusion
*
A result of fecal contamination leading to irritation
*
Purirotogenic foods include: coffee/tea, colas & energy drinks, citrus fruits, chocolate, & spicy foods
*
Overzealous hygiene may be implicated in the pathogenesis (excess soap & lotions destroy the natural skin barriers)
>
Secondary
V
*
Infectious
Bacterial infection (Staphylococcus, Streptococcus, erythrasma)
Sexually transmitted infection (Gonococcus, Chlamydia)
Fungal infection (Candida, dermatophytes)
Parasites (pinworms, scabies)
Viral infection (herpes virus, condylomata, Molluscum)
V
*
Anorectal disorder
Hemorrhoids (external, prolapsing internal)
Fistula-in-ano
Anal fissures
Hidradenitis suppurativa
Fecal incontinence
Perianal Crohn’s disease
Skin tags
Chronic diarrhea
Pilonidal disease
V
*
Dermatologic
Contact dermatitis
Atopic dermatitis
Perianal psoriasis
Lichen sclerosus
Seborrheic dermatitis
V
*
Malignant
Anal cancer
Rectal cancer
AIN-III
Extramammary Paget’s disease
V
*
Systemic disease
Diabetes mellitus
Leukemia
Lymphoma
Chronic renal failure
Iron-deficiency anemia
Hyperthyroidism
Hyperbilirubinemia
V
>
Evaluation is centred at assessing for secondary aetiologies to address them
IMG_0222
>
Detailed Hx and examination
*
A medication history of infliximab or etanercept may point to psoriasis as a cause for pruritus
*
If low resting anal tone is found on physical examination, stool seepage may be a cause for pruritus pain
*
For all patients: anoscopy & flexible sigmoidoscopy
>
For non-responders to topical agents:
*
Patch testing for allergy
*
Biochemical testing: LFT, renal panel, blood glucose, CBC, CRP
*
Biopsy (with an 11-blade or skin punch Bx) including an area of the lesion with adjacent normal skin: this is the single most valuable test in patients with primary pruritus
>
Washington severity staging
*
Stage 0: Normal-appearing perianal skin
*
Stage I: Erythematous and inflamed perianal skin
*
Stage II: White, lichenified (leathery) perianal skin
*
Stage III: Lichenified skin with coarse ridges and ulceration
>
Management
*
Address primary cause
*
Bowel augmentation with fiber
*
Clean & dry skin should be maintained throughout the day
*
Avoid perfumed cleansers, lotions, and tight-fitting garments
>
Non-responders are tried on 1% hydrocortisone cream may alleviate symptoms; not to be given for > 8w to avoid atrophic changes
*
Applied at night and in the morning after bathing
*
A tapering regimen should be set in place ending with substitution of a barrier cream such as Calmoseptine
*
Patients with many anal lesions are followed up to rule out dysplasia in these lesions
V
Second line therapy
V
*
1. Topical capsaicin TID X 4w
Capsaicin is a chili pepper extract with analgesic properties. Capsaicin is a neuropeptide releasing agent selective for primary sensory peripheral neurons. Used topically, capsaicin aids in controlling peripheral nerve pain
*
2. Topical tacrolimus
*
3. 1% mythelene blue injection into the perianal area up to the dentate line
>
Anal stricture
*
Is narrowing anywhere along the anal canal & is distinct from anal stenosis, (stenosis describes functional narrowing of the canal secondary to muscular hypertrophy or spasm)
*
The majority of strictures occur as a complication of previous anorectal surgery, most commonly hemorrhoidectomy with excessive anoderm excision
*
History should assess for anorectal surgery, radiation, Crohn’s disease, & perianal trauma
V
*
Classification
Pasted_Graphic_4
>
Crohn’s anorectal stricture
V
Management options
*
Fnger, coaxial balloon, or Hegar dilators
*
Effective management by rectal sleeve advancement has also been reported
*
50% of patients will eventually come to proctectomy
>
Conservative management should be started with everyone
*
Hydration, fiber supplementation (more formed stools help dilate the sphincter), stool softener
*
Patients with high risk for failure fo surgical management can undergo trial of manual dilation (start with Hegar size 5 and advance to size 18. Patient can do home dilations using size 14 dilators)
>
Surgical treatment
>
High risk of failure in surgical treatment is seen in
*
Immunocompromised patients
*
Crohn’s disease
*
Smokers
*
Radiation injury
*
DM
V
*
Anastomotic strictures and those associated with Crohn’s disease are best managed using incision with or without stricturoplasty
This can be performed in all four quadrants if needed. The wounds can be left to heal by secondary intention or closed transversely
V
V
The principle of anoplasty is release or excision of the fibrotic strictured tissue & replacement with normal pliable tissue with a tension-free, well vascularized flap
Screen_Shot_2019-07-15_at_16.50.06
V
Simple flaps (They derive their blood supply from the skin bridge)
V
*
Lateral mucosal advancement flap
Screen_Shot_2019-07-15_at_16.50.18
V
*
Y-V advancement flap
Screen_Shot_2019-07-15_at_16.50.28
V
*
S-flap
Screen_Shot_2019-07-15_at_16.50.52
V
Full-Thickness flaps (They derive their blood supply from the underlying subcutaneous tissue)
*
V-Y advancement flap
V
*
House flap
Screen_Shot_2019-07-15_at_16.50.44
>
HPV
V
HPV Serotypes 16 & 18 have been associated with cancer
*
79% of patients diagnosed with anal SCC are attributable to type 16 or 18
*
Those that are considered high risk include 16, 18, 31, 33, 35, and 45 and produce E6 and E7 proteins, which in turn inhibit two important tumor suppressor proteins, p53 and Rb
*
Most infections are transient and are cleared within 2Y
*
Transmission from mother to child during delivery can occur
*
HPV infects the basal keratinocytes of the epidermis
*
> 90% of anal SCCs are associated with HPV infection
*
HPV testing can be used to screen women for cervical cancer, but screening for HPV is not indicated for men
*
Liquid-based anorectal cytology specimens are the preferred specimen type to screen for high-grade anal dysplasia
V
Patient with positive findings should be referred to a specialist for high-resolution anoscopy or routine anoscopy and monitoring
V
3–5% acetic acid for 2–5 minutes, a magnifying anoscope is used to examine the anus and lower rectum (preferred)
*
Dysplastic epithelium will absorb acetic acid and appear as scaly white with greater disarray of vascular patterns and tissue friability as the grade of dysplasia increases
V
Iodine-based Lugol’s solution may also be added to further detect dysplastic tissue
*
The mechanism for Lugol’s utility is that only healthy epithelium absorbs this compound which causes normal tissue to appear wood-like, and dysplastic tissue does not absorb the solution giving these tissues a yellowish hue
>
Condyloma acuminatum (anal warts)
*
HSV types 6 & 11 are low-risk and are the most common etiologic agents for genital warts
*
They are regarded as premalignant lesions
*
Individuals with condyloma acuminatum are at increased risk for developing anogenital and head & neck cancers for 10 years or more after a diagnosis of anal warts
*
Presentation ranges from asymptomatic, to pruritus, bleed, discharge, pain, and interference with defecation or intercourse when large
*
Aids in Dx: Application of 5% acetic acid causes the lesions to turn white
*
Bx will confirm the Dx
V
Histologic features are:
*
Verrucous architecture composed of papillary excrescences (growths) & hyperkeratosis
V
>
The presence of koilocytic changes within a maturing squamous epithelium
A koilocyte is a squamous epithelial cell that has undergone a number of structural changes, which occur as a result of infection of the cell by human papillomavirus
*
Nuclear enlargement (2-3X the normal size)
*
Irregularity of the nuclear membrane
*
Darker than normal staining of the nucleus
*
Clear area around the nucleus (perinuclear halo or perinuclear cytoplasmic vacuolization)
V
>
Grading of the changes is based on the extent of basal layer expansion
The “LSILs and HSILs” terminology is based on histological findings such as mitotic activity, depth of dermal involvement, and abnormalities in squamous cell differentiation
Pasted_Graphic
*
The distinction between condylomas and LSILs is somewhat arbitrary; condylomas generally appear as bland exophytic, papillary proliferations with viral cytopathic changes, whereas LSILs tend to be flat lesions
*
ASCUS = atypical squamous cells of undetermined significance
*
AIN I (LSIL) = Nuclear abnormalities are confined 20-25% of the epithelium
*
AIN II (HSIL) = Limited to the lower ⅔ of the epithelium
*
AIN III (HSIL) = CIS = Full thickness involvement of the epithelium
*
The distinction between condylomas and LSILs is somewhat arbitrary; condylomas generally appear as bland exophytic, papillary proliferations with viral cytopathic changes, whereas LSILs tend to be flat lesions
>
Workup
V
Assess extent of involvement:
V
Physical exam (thorough genital examination)
*
Physical examination should include a head-to-toe evaluation for squamous cell lesions, considering all lymph node basins.
*
Proctoscopy
*
Colposcopy ± vaginal speculum exam
*
Cervical Pap smear for women diagnosed with condyloma
V
>
Management
Cameron: There is no evidence to suggest that one treatment is significantly superior to another, and patients should be counseled, in advance, that recurrence is common and generally occurs within the first few months after treatment.
Pasted_Graphic_2
*
The indication to treat anogenital warts is to relieve symptoms
*
The infection is self limited
*
Treatment is directly only to macroscopic (genital warts) or pathologic (precancerous) lesions
*
Spontaneous resolution has been reported, but most will require an intervention
>
Topical agents have moderate efficacy with response rate of ~50%
V
*
Podophyllotoxin (an antimitotic agent)
Associated with significant local toxicity & requires provider administration
*
Imiquimod cream (an inducer of local cytokines)
*
5-FU (an antimetabolite),
*
Trichloroacetic acid (TCA) (an inducer of protein coagulation)
*
Sinecatechins
*
IFN-α (local or systemic)
>
Surgical
V
*
Consider excision of larger condylomata and fulguration for small-moderate lesions
Dr. Charlebois suggests fulgration for even large lesions as long as they’re not pedunculated or have a stalk. Apply electrocautery to the lesion until the conduction of electricity ceases then wipe/scratch the lesion. The target of treatment is flat perianal skin
*
During any ablative or excision procedure, multiple Bx must be submitted to evaluate for dysplasia
>
Indications for surgical therapy
*
Large (≥ 1-2 cm at the base)
*
Intra-anal lesions
*
Failed medical management
V
Surgical options:
*
Cryotherapy requires multiple treatment sessions
V
*
Argon plasma beam
Cameron: Our practice eschews use of laser for fulguration because there can be viable virus in the smoke plumes with isolated case reports of transmission to healthcare providers
>
Excision
*
May be excised sharply or cauterized
*
When large lesions are excised, skin bridges must be left intact between wounds to minimize scarring & to avoid anal stenosis
*
Staged (3-4w apart) treatment is advised for ‘carpeting’ condyloma with minimal or no intervening normal skin to minimize scarring & stenosis
*
Fulgration
>
20-50% will develop recurrence regardless of treatment approach — recurrence is higher in immunocompromised patients
*
In patients with HIV, CD4 counts should be maximized to prevent or delay recurrence after treatment
*
Genital HPV types can be identified in plucked pubic and perianal hair, suggesting that an endogenous reservoir for HPV may play a role in recurrence.
V
>
Buschke-Lowenstein tumor AKA verrucous carcinoma AKA giant condyloma
The definition of Giant condyloma varies
*
Rare, slow growing
V
*
It’s an intermediate form between condyloma acuminatum & SCC
50% of giant condylomas harbor SCC
*
Excised specimens often demonstrate an endophytic component not present in ordinary condylomata
*
They tend to form abscesses & fistulae and to recur after excision
*
Treatment is wide local excision with 1 cm margin (often requires flap closure)
*
APR may be required with deep tissue involvement
>
HPV vaccine
*
Vaccination is effective in preventing HPV infection
*
For ♀: HPV9, HPV4, or HPV2 vaccines are recommended routinely at age 12Y up to 26Y
*
For ♂: HPV9 or HPV4 vaccines are recommended at age 11Y up to 21Y
>
Anal Intraepithelial Neoplasia (AIN)
*
It’s a necessary but not obligate precursor to SCC
*
Anal canal AIN without perianal involvement is very unusual
*
It is characterized by cellular & nuclear abnormalities limited to the epithelial cells without involving the basement membrane
*
It is strongly associated with HPV types 6, 11, 16, & 18
*
10% of AIN lesions are diagnosed as an incidental finding after excision of an “innocent” anal tag or condyloma-like lesion
>
Risk factors
*
HPV infection
*
Anal warts
*
Multiple sexual partners
*
Anoreceptrive intercorse
*
Hx of rectal discharge
*
IV drug use
*
Immunosuppression
*
Current cigarette smoking
*
Cervical or vulvar dysplasia or cancer in ♀
V
>
Grading is based on the extent of basal layer expansion
The “LSILs and HSILs” terminology is based on histological findings such as mitotic activity, depth of dermal involvement, and abnormalities in squamous cell differentiation.
Pasted_Graphic
*
The distinction between condylomas and LSILs is somewhat arbitrary; condylomas generally appear as bland exophytic, papillary proliferations with viral cytopathic changes, whereas LSILs tend to be flat lesions
*
ASCUS = atypical squamous cells of undetermined significance
*
AIN I (LSIL) = Nuclear abnormalities are confined 20-25% of the epithelium
*
AIN II (HSIL) = Limited to the lower ⅔ of the epithelium
*
AIN III (HSIL) = CIS = Full thickness involvement of the epithelium
V
>
The presence of koilocytic changes within a maturing squamous epithelium
A koilocyte is a squamous epithelial cell that has undergone a number of structural changes, which occur as a result of infection of the cell by human papillomavirus
*
Nuclear enlargement (2-3X the normal size)
*
Irregularity of the nuclear membrane
*
Darker than normal staining of the nucleus
*
Clear area around the nucleus (perinuclear halo or perinuclear cytoplasmic vacuolization)
*
AIN I & II may regress, but AIN III is less likely to do so — rate of progression to SCC is 10% at 5Y in immunocompetent patients & 50% in immunosuppressed patients
>
HSIL (graded as Tis by AJCC) encompasses the following terminologies:
*
Bowen disease
*
AIN II-III
*
Carcinoma in situ
V
>
Workup
Screen Shot 2021-06-01 at 09.10.52
*
Dysplastic tissues are most commonly found within the transition zone
*
The sensitivity of digital rectal examination in identifying anal neoplasia is fairly low as many AIN lesions are not palpable
V
*
ASCRS 2018: Biomarkers, including p16, should be used selectively to clarify equivocal high-grade lesions. Grade of Recommendation: Strong recommendation based on low- or very-low–quality evidence, 1C.
P16 is a tumor suppressor gene product that indicates HPV integration into the host genome.
The Lower Anogenital Squamous Terminology guidelines recommend the use of p16 in borderline HSIL/LSIL cases, with strong positive staining leading to an HSIL diagnosis and weak or absent staining supporting an LSIL diagnosis. The use of p16 staining, or any of the biomarkers, in a screening setting is less clear.
V
*
ASCRS 2018 : HPV testing may be used as an adjunct to screening for anal cancer. Grade of Recommendation: Weak recommendations based on moderate-quality evidence, 2B.
Biomarkers screen for the presence of high-risk HPV to estimate the risk of dysplasia.
The main limitation to this strategy is the high prevalence of HPV in the high-risk population
*
Lesions classified as atypical squamous cells of undetermined significance or higher are generally referred for HRA
>
High-Resolution Anoscopy (HRA)
V
Technique
*
Setting: office Vs OR
V
Topical agents are used to enhance detection of lesions not visible by conventional examination or anoscopy
*
3-5% acetic acid solution applied for 2-5m, this results in acetowhitening of dysplastic tissue
*
Lugol’s solution
*
It is superior to cytology or HPV testing in identifying HSIL
*
Cytology misses nearly ⅓ of high-risk lesions, suggesting that HRA would have the most clinical use for screening
V
*
Disadvantage: associated cost and required expertise
ASCRS 2018 CPG: Performing HRA requires specialized training and ongoing practice to perform good-quality examinations
V
V
Periodic Pap tests are offered to high-risk individuals with HPV (even before identifying AIN):
A swab or brush sample from the anal canal to include the ATZ can be evaluated for cytological evidence of dysplasia
The cytology must be performed before any instrumentation of the anus and before lubrication is used. The procedure is performed with a moist swab in the anal canal and without any preparation.
*
HIV⊕
*
Immunosuppressed patients
*
Men who have sex with men
*
Women with history of cervical dysplasia
V
Assess other HPV-related diseases
*
Physical examination should include a head-to-toe evaluation for squamous cell lesions, considering all lymph node basins.
*
GYN examination to assess for GYN-neoplasia
*
Dental examination to assess for oral cancer
*
Genital examination to rule out lesions
V
>
Management (no consensus) ranges from watchful waiting to aggressive surgery
Management is more aggressive for AIN III or immunocompromised patients
V
>
Periodic Pap tests are offered to high-risk individuals (even before identifying AIN):
A swab or brush sample from the anal canal to include the ATZ can be evaluated for cytological evidence of dysplasia
*
HIV⊕
*
Men who have sex with men
*
Women with history of cervical dysplasia
>
ASCRS 2018:
Vaccination against HPV in men and women under age 26 years for primary prevention is typically recommended.
Vaccination of individuals with anal dysplasia for secondary prevention of dysplasia and cancer is not recommended. Grade of Recommendation: Weak recommendation based on high-quality evidence, 2A.
*
Vaccines against HPV types 6, 11, 16, & 18 demonstrate decrease in AIN in men who sleep with men, as well as decrease in persistent HPV infection
*
A systematic review and meta-analysis of the efficacy of the vaccine in cervical dysplasia showed that it had no effect
*
Condom use has been associated with a reduction in the risk of acquiring HPV, clearance of infection, and higher rates of regression of cervical intraepithelial neoplasia in women and penile lesions in men
V
V
ASCRS 2018: Individuals with anal dysplasia should be followed at regular intervals with a history, physical examination, and a discussion of screening options. Grade of Recommendation: Weak recommendation based on moderate-quality evidence, 2B.
It is not clear that screening will prevent a cancer from occurring, but there is evidence that cancers detected during a screening program are identified at an early stage
*
AIN I & II: follow up Q12m
*
AIN III or immunocompromised: follow up Q4-6m + treatment of suspicious lesions
*
The risk of progression is fairly low in patients with low-grade dysplasia with evidence indicating that some proportion of patients will exhibit regression of disease without treatment
*
Observation may be the best option for patients with LSIL. In particular, this may be the least difficult technique for patients with no symptoms and with low likelihood of conversion to anal cancer
*
A conservative approach of observation is supported by the high recurrence rates seen after aggressive attempts at complete eradication. After HRA-targeted destruction of LSIL/HSIL, HSIL recurrence rate is up to 57% at an average of 19m
>
Topical agents have demonstrated effectiveness for both LSIL & HSIL:
>
Imiquimod
*
One of the most tested agents and is considered to be efficacious by those who use it regularly.
*
In one RCT: clearance of HSIL in HIV⊕ patients with imiquimod vs placebo: 43% vs 4%
>
5-FU
*
Evaluated against LSIL/HSIL in retrospective studies
*
Response rate 57%, with 39% having complete response
*
Trichloroacetic acid
*
Cidofovir
*
For immunocompetent patients with HSIL, the simplest method of treatment is ablation
V
V
Ablation options are burdened by high recurrence rates & significant morbidity.
ASCRS 2018 CPG: Ablative treatments with conventional anoscopy or HRA are appropriate therapies for HSILs. Grade of Recommendation: Weak recommendation based on moderate-quality evidence, 2B.
Lesions that make up ≥ 50% of the circumference of the anal canal may require staged treatment to avoid stenosis
*
Infrared coagulation
V
Electrocautery fulguration
*
Data reveal that electrocautery is highly effective in inducing complete response of AIN especially in immunocompetent individuals (72%) as compared to immunosuppressed individuals (51%), but recurrence rates are as high as 61%
*
The operating surgeon should remember that the disease is limited to the epidermis and does not require destruction of deeper dermal tissues
*
CO2 laser ablation
*
Cryotherapy
*
ASCRS 2018: Patients who have been treated for anal dysplasia may be observed without regular cytology, HPV testing, or HRA; however, treatment of visible or palpable disease should be offered. Grade of Recommendation: Weak recommendation based on low or very low-quality evidence, 2C.
>
Neoplasms
>
Bowen’s disease—use of this terminology is discouraged by ASCRS. Instead, they are grouped under AIN or SCC
*
It is a specific perianal manifestation of SCC in situ
*
Patients have minor symptoms: burning/pruritis, mass, &/or bleeding
*
Clinically characterized by erythematous, ± brown/red pigmented, scaly, or crusted plaques that have a moist or nodular surface
>
Management:
*
Sabiston: Bowen’s disease typically presented as a single confluent area of SCC in situ managed with wide excision
*
Sabiston: Confluent Bowen’s disease is usually managed with wide local excision or, as more recently reported, with 16 weeks of topical 5-FU
V
*
Cameron: Treatment is wide local excision ± skin flaps
Before excision, to ensure clear resection margins and to identify multifocal disease, biopsies are taken from four quadrants at the dentate line, the anal verge, and the perianal skin and are submitted for frozen section
*
Recurrence rate is 30%
>
Squamous cell carcinoma (SCC)
*
An anal canal cancer: any lesion that cannot be completely visualized with distraction of the gluteal cheeks
*
Perianal (which replaces the term anal margin) lesion can be completely visualized with distraction of the gluteal cheeks, and that is still within 5 cm of the anal orifice
*
Most patient have slow-growing, intra-anal or perianal mass
*
There is increasing frequency of SCC in US over the last 3 decades
>
Risk factors
*
Female sex (1.7 times more affected)
>
HPV related
V
HPV Serotypes 16 & 18 have been associated with cancer
*
Prevalence of HPV-16 in HIV⊕ men who have sex with men = 35%; incidence of cancer: 46/100,000
*
Prevalence of HPV-16 in HIV⊖ men who have sex with men = 12%; incidence of cancer: 5/100,000
*
Those that are considered high risk include 16, 18, 31, 33, 35, and 45 and produce E6 and E7 proteins, which in turn inhibit two important tumor suppressor proteins, p53 and Rb
*
Lifetime number of sexual partners
*
Previous STI
*
Hx of anogenital warts
*
Anoreceptive intercourse
*
Hx of cervical, vaginal, or vulvar cancer
>
Immunosuppression related
*
Autoimmune disorders: lupus, sarcoidosis
*
HIV
*
Men who have sex with men
*
Solid organ transplantation
*
Cigarette smoking
V
Presentation:
*
Bleeding (45%), pain (30%), asymptomatic (20%)
*
⅓ present with N⊕ disease
*
15% present with M⊕ disease
V
Workup & staging
*
Physical examination with DRE: assess fixation & invasion into local structures
*
Palpation of inguinal area for signs of lymphatic spread → FNA or core-needle Bx to confirm involvement
*
HIV testing if status is unknown
*
GYN exam for ♀ including screening for cervical cancer (cervical Pap test)
*
♂ require penile examination to exclude premalignant or malignant lesions
V
*
Anoscopy: determine size, location, & obtain Bx
SCC is defined, and differentiated from AIN, by invasion of tumor cells beyond the basement membrane.
V
*
Colonoscopy
ASCRS 2018 CPG: Although anal cancer is not a risk factor for the development of colon cancer, colorectal neoplasms have been demonstrated in <15% of patients with anal cancer; therefore, colonoscopy should be performed to rule out synchronous colorectal neoplasms.
>
Imaging
V
*
CT Chest/Abdomen/Pelvis
Most common metastasis is to liver and lungs
*
CT brain if symptoms/signs are present
*
MRI or endoanal US: determining primary tumor depth, sphincter involvement, and perirectal LN involvement as that enable optimal radiotherapy planning and allows for post-treatment comparisons
>
Consider PET for ≥ T2 or N⊕ disease
*
PET/CT has been shown to identify distant metastases that are not detected by physical examination or other imaging modalities in 17% to 25% of patients, resulting in a reported change in treatment (ie, radiotherapy) in <19% of cases
*
The main impact of PET/CT on therapy stems from its superiority in detecting involved pelvic or inguinal nodes
V
>
AJCC Staging
Screen Shot 2020-03-03 at 7.02.12 PM
V
*
T
Recall hint: remember T staging for the breast
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis HSIL (previously termed carcinoma in situ, Bowen disease, anal intraepithelial neoplasia II–III, high-grade anal intraepithelial neoplasia)
T1 Tumor ≤2 cm
T2 Tumor >2 cm but ≤5 cm
T3 Tumor >5 cm
T4 Tumor of any size invading adjacent organ(s), such as the vagina, urethra, or bladder
V
*
N
N1a Metastasis in inguinal, mesorectal, or internal iliac lymph nodes
N1b Metastasis in external iliac lymph nodes
N1c Metastasis in external iliac with any N1a nodes
V
*
M
M0 No distant metastasis
M1 Distant metastasis
>
Treatment
V
>
Indication for surgery
When to declare a patient a nonresponder is a matter of debate.
*
Upfront surgery is recommended for T1N0 well-differentiated perianal SCC that can be excised with 1cm margin
*
Persistent disease after chemoradiotherapy
*
Recurrent disease after chemoradiotherapy
V
*
Groin dissection for nodal disease but should not be done prophylactically
NCCN: Groin dissection can be done with or without APR depending on whether disease is isolated to the groin or is in conjunction with recurrence/persistence at the primary site
>
Chemoradiotherapy regimens
V
Radiation
V
Dose:
*
A minimum of 45G in 25 fractions, 1.8Gy each, over ~5w
*
For ≥T2 or N⊕ disease: a boost of 5.4-14.4Gy to the primary tumor & LN is recommended (total dose 50.4-59.4Gy)
>
Field:
*
Extend from the border of L5-S1 (involves rectosigmoid junction)
V
*
Spreading distally to incorporate the entire pelvis (including anus & inguinofemoral LN)
NCCN: The pelvic and inguinal nodes should be routinely treated in all patients
*
Terminating onto the perianal skin 2.5cm distal to the anus
>
AE
>
Short term
*
Dermatitis
*
Swelling and pain
*
Nausea
*
Vaginal discomfort & discharge
>
Long term
*
Anal stenosis
*
Pelvic fracture
*
Radiation proctitis
*
Vaginal stenosis ((female patients should be encouraged to use a vaginal dilator)
*
Fertility may be affected in both ♂& ♀
>
Chemotherapy
*
Addition of mitomycin (to radiation with 5-FU) improves colostomy rates, colostomy free-survival & DFS
>
Classically:
*
5-FU IV on days 1-4 & days 29-32 (i.e 4d Q28d)
*
Mitomycin bolus on days 1 & 29 (i.e 1d Q28d)
>
Alternatively
>
Option 1 (first-line):
*
Capecitabine PO BID
*
Mitomycin bolus on days 1 & 29
>
Option 2 (second-line):
*
5-FU
*
Cisplatin
>
Data evaluating cisplatin:
*
ACT II trial: radiation + 5-FU + (mitomycin vs cisplatin): similar in effectiveness and grade III-IV AE
>
Ajani et al (RCT): radiation + 5-FU + (mitomycin vs cisplatin): higher colostomy rate with cisplatin (10% vs 19%) but more hematologic toxicity with mitomycin
*
Follow up study: disease-free and overall survival were actually improved in the MMC-treated group compared with the cisplatin group
*
At this time, there is insufficient high-quality data to support the use of induction chemotherapy outside of a clinical trial
V
Regimen for M⊕ disease
*
Carboplatin + paclitaxel
*
FOLFOX
*
FOLFCIS
*
Subsequent therapy may include nivolumab or pembrolizumab
>
AE and considerations
*
Both men and women of child-producing ages should be counseled regarding sperm and ova banking before the onset of therapy
*
Female patients who are planning on sexual activity at any point after CRT should be counseled regarding the use of vaginal dilators to prevent vaginal stenosis resulting in the inability for coitus
*
With mitomycin-based chemoradiotherapy: incidence of grade III-IV nonhematologic toxicity is 74%; severe long-term toxicity effect seen in 11%
>
Mitomycin
*
Bone marrow suppression (↓WBC; ↓Plt)
*
Pulmonary toxicity
*
AKI
V
Previous radiation or inadequately controlled HIV may be limiting or contraindications to chemoradiation therapy or radical surgery
*
ASCRS 2018: Patients with HIV or AIDS who present with anal cancer as the first manifestation of their immunosuppression, and who are not medically deconditioned, can be safely treated according to the same regimens as immunocompetent patients. Grade of Recommendation: Strong recommendation based on medium-quality evidence, IC.
*
For HIV patients: CD4 count play a role in modifying the dose of RT; doses range from 32 to 63 Gy; chemotherapy may be delivered in conventional dose regimens
V
*
Treatment breaks and interruptions (of 2w or more) affect response rates from chemoradiotherapy
ASCRS: Treatment breaks and interruptions to CRT should be avoided if possible, although they occur as frequently as in 80% of patients with anal cancer
V
>
‘Anal margin cancer’ = “a perianal (which replaces the term anal margin) lesion can be completely visualized with distraction of the gluteal cheeks, and that is still within 5 cm of the anal orifice”
Pasted_Graphic
*
They behave like cutaneous malignancies (managed with local excision with 1cm margin)
*
They are classified as skin cancers rather than anal canal cancers
*
Tumors that extend into the anal canal are treated with definitive chemoradiation or APR
V
>
Anal canal cancer
An anal canal cancer would be any lesion that cannot be completely visualized with distraction of the gluteal cheeks
Pasted_Graphic_2
*
1. Chemoradiation can result in 92% 5Y-survival
V
2. Evaluate patients 8-12w after treatment ends to assess for complete remission
*
Clinical assessment should include DRE, anoscopy, and palpation of the inguinal LN
*
Because of slow tumor regression, biopsies for persistent disease are typically avoided at 8-12w and <6 months post-CRT
V
3. For those without complete remission:
*
If disease is progressing, redo Bx and staging and evaluate for APR if not metastatic
V
V
If disease is persistent, follow up in 4w with repeat imaging
Post-treatment imaging is most frequently undertaken 3 months from the completion of CRT, when treatment related fibrosis and residual tumor could be distinguished.
*
If disease is progressing, redo Bx and staging and evaluate for APR if not metastatic
*
If regressing or stable, re-evaluate Q3m
>
Recurrences
*
The majority of recurrences occur in 2-3Y
*
Patients who had complete response and then recurrence are managed with APR
>
Isolated inguinal LN recurrence
*
If hasn’t received RT before: RT ± chemotherapy
*
If has received RT before: LN dissection (not necessarily with APR)
V
>
Metastatic disease
Median survival is 12m
*
Combination chemotherapy: [CarboTaxol (preferred), Cisplatin/5-FU, or FOLFOX] ± radiation. Subsequently, nivolumab or pembrolizumab is given
*
Metastatectomy may improve long-term survival in select patients
*
Primary rectal SCC is rare and is treated with the same approach as anal SCC
>
Post-treatment surveillance
V
After complete response
*
DRE, anoscopy, & inguinal area examination Q3-6m X 5Y
*
CT annually X 3Y
>
Persistent disease (until remission): Q4w DRE, anoscopy, & inguinal area examination
*
EUA ± targeted Bx for persistent abnormalities 5-6 months after CRT, stenosis, pain, or scarring preventing adequate surveillance
>
Annual CT Chest/Abdomen/Pelvis X 3Y is indicated for:
*
T2-4 or N1 disease
*
Initially persistent disease that later regressed
*
Those who undergo APR for persistent or recurrent disease
>
Survival for M⊕ disease receiving chemotherapy
*
1Y: 60%
*
5Y: 32%
>
Adenocarcinoma
*
Adenocarcinoma of the anal canal accounts for 10% of all anal cancers
*
Most originate from the columnar epithelium of the upper anal canal or glandular cells of the ATZ zone
*
Have high risk of nodal disease along the inguinal and femoral nodal chains
>
Immunohistologically staining
*
CK20 ⊕
*
CDX2 ⊕
*
CK7 ⊖
*
Stage I: surgery alone is sufficient
*
Stage II & III are treated with NACRT (5-FU based) → surgery (APR) → 5-FU consolidation chemotherapy
V
>
Perianal Paget’s disease
Screen Shot 2021-06-23 at 19.36.00
*
It’s an intraepithelial adenocarcinoma
*
Often confused with eczema or dermatitis
*
It may represent a true primary lesion arising from apocrine glands or may represent synchronous or metachronous lesions in patients with internal malignancies
*
Bx shows large rounded cells with pale vacuolated cytoplasm and hyperchromatic eccentric nuclei
*
Staining positive for Periodic Acid–Schiff helps distinguish Paget’s disease from AIN
*
Disease typically extends microscopically beyond the visible lesion — it’s difficult to obtain negative margins without sacrificing large skin areas
>
Treatment
*
Localized disease: surgical wide local excision
*
Mohs micrographic surgery: surgery results in lower recurrence rates (8%) & less morbidity
V
Contraindications to surgery:
*
Multifocal disease
*
Widespread disease that precludes complete resection
*
Radiotherapy can be used as a primary treatment in these cases and also can be used in the adjuvant setting. Recurrence rates after primary radiotherapy vary widely in the literature (0 to 60%)
*
Chemotherapy (adjuvant & neoadjuvant) is used
V
Melanoma
*
It is the 3rd most common site of melanoma after skin & retina
*
Most common symptom: bleeding and pain
*
Early lesions may be mistaken for hemorrhoids
*
Up to 30% of anal melanomas are amelanotic (not pigmented) and do not have a macroscopically suspicious appearance
V
Workup should include
*
Pelvic MRI
*
PET-CT
*
Colonoscopy
*
Complete dermatologic examination
*
Ophthalmologic examination
>
Tumor cells express (histopathologic staining):
*
S-100
*
HMB-45
*
Melan A
*
Prognosis of anal melanoma is poor (Median survival after excision is only 2 years)
*
Surgery is the treatment of choice because anal melanoma does not respond to chemoradiation.
*
The extent of surgical resection (APR vs wide local excision) does not seem to significantly affect outcome because patients often die of distant metastases. There is, however, improved local control with APR compared to wide local excision in some studies, and the use of APR for larger lesions or for salvage and palliation can be considered in select cases
V
Mutations associated:
*
BRAF mutation: eligible for BRAF-inhibitors (Dabrafenib+trametinib)
*
C-KIT mutation: eligible for TKI (imatinib)
>
Neuroendocrine
*
They tend to be small and are managed with local excision
*
Definitive or neoadjuvant chemoradiation may be indicated for high-grade neuroendocrine neoplasms
>
Mesenchymal tumors
V
Types
*
GIST
*
Leiomyosarcoma
*
Rhabdomyosarcoma
*
Angiosarcoma protuberans
*
Shwannoma
*
Solitary fibrous tumor
*
The curative surgical approach is wide local excision — APR may be required to achieve a negative margin
>
Pediatric colorectal disorders
>
Anorectal malformations are associated with the VACTERL complex
V
Vertebral defects (e.g sacral anomalies; hemi-vertebra)
*
Rule out with plain radiographs of the vertebral column
*
Rule out tethered cord with spinal cord US
*
Anal atresia
V
Cardiac defects (e.g ASD and VSD)
*
Rule out with cardiac echocardiogram
V
Tracheo-Esophageal fistula
*
Ability to pass a NGT help rule out most types of TEF
>
Renal anomalies
*
Rule out with US
*
Limb dysplasias (e.g poorly formed radial bone ± absent thumb)
>
Cloacal anomalies
*
They are the most severe & complex form of anorectal malformation
*
Occur in 1:20,000 live-births
*
Embryologically, the cloaca is a transient organ that becomes divided to separate the gastrointestinal tract from the genitourinary tract
*
It is typically associated with hypoplastic malformation of the labial structure & a small perineal opening that may be too small to allow evacuation of secretions. May require urgent decompression via vaginostomy tube placement as well as colostomy
*
In one variant (urogenital sinus) only the urethra and vagina form a common channel; the rectum is separate and in the appropriate anatomic location
>
Management
V
Prenatal workup should determine the presence of hydrocolpos (distended vagina filled with fluid). Failure of its recognition can lead to vaginal rupture, hydronephrosis, and sepsis
*
Complications are prevented by early vaginal decompression
*
Managing complicated cases is complex and typically requires an open abdominal approach
>
Definitive management
>
Timing: once the anatomy has been mapped out using
*
Fluoroscopy or MRI
*
Cystoscopy & vaginoscopy
V
Length of the common channel is a major factor in choosing a definitive repair
>
Short common channels (< 3cm)
*
Repaired with perineal incision
*
Associated with ↓ morbidity
>
Long common channel (> 3cm)
*
Require abdominal and perineal approaches
>
Goal of repair:
*
Separation of the rectum from the cloacal channel
*
Implantation in the centre of the remaining sphincter complex
*
Introtial structures (vagina & urethra) are mobilized as a single unit and brought down to the perineal skin
>
Long term follow up is critical
*
Life-long urological & gynaecological problems
*
Incidence of fecal incontinence ≥ 50%
>
Cloacal exstrophy
*
A separate entity from anorectal malformations
*
Bladder & cecum open onto the external abdominal wall
>
Associated with:
*
Omphalocele
*
Imperforate anus
*
Ambiguous genitalia
>
Anorectal atresia / imperforate anus
*
Caused by abnormal hindgut development → ectopic positioning of the anal opening in the cloaca due to anatomical and/or genetic factors
*
Perineal fistulas are sometimes subepithelial in the midline raphe of the scrotum or perineal body and not always evident initially
*
Smaller defects have a more posterior phenotype, such as anocutaneous fistula
*
Extensive defects lead to more anterior abnormalities, such as recto-urethral fistula occurring above the levator muscles
>
Management
>
A post-24h prone lateral Xray (±US) allows visualization of the terminal location of the rectum to decide on primary repair or initial colostomy
*
Primary pull-through is feasible if the rectum has descended below the pubococcygeal muscle complex
>
Colostomy placement should be as proximal as possible on the descending colon (to allow for sufficient length to perform a pull-through later)
*
1. Contrast study through the colostomy help identify recto-urethral fistulas (often connecting through the prostate or sphincter complex of the urinary bladder)
>
2. The classical procedure is the posterior sagittal anorectoplasty (PSARP)
*
The rectum is identified above the levator complex
*
The rectum is opened to identify the recto-urethral fistula
*
Submucosal dissection then ligation of the fistula
*
Mobilization of the rectum to allow a pull-through
*
Using Pena muscle stimulator, the rectum is placed through the residual sphincter complex
*
3. Following surgery, anal dilations of the anal canal is required
*
4. A 12m old child will necessitate the easy passage of a #14 Hegar dilator before the colostomy is reversed
>
Long term considerations
*
Most will continue to have problems well into adulthood
>
Functional outcomes are dependent upon the height of the fistula
*
Lower lesions typically have constipation; PEG is commonly used
*
Higher fistulas have incontinence
>
Hirschsprung’s disease
>
General
*
It is caused by interruption of the normal migration of the neuroenteric cells (Meissner’s & Auerbach’s) from the neural crest before they reach the rectum.
*
Aganglionic area lacks nitric oxide synthase → lack of the muscle relaxant nitric oxide → constriction
*
Transition zone is usually (80%) the rectosigmoid colon
*
Incidence: 1 in 5,000 live births
*
♂ 4:1 ♀ (except in total colonic aganglionosis in which ♀>♂)
*
RET proto-oncogene mutations compromise nearly ½ of all familial cases & a smaller fraction of sporadic cases
>
Presentation
*
Delayed passage of meconium (> 48h)
*
Poor feeding, poor weight gain, progressive abdominal distension
>
Evaluation & Dx
V
Imaging
*
Xray: dilated bowel loops (the dilated part is the normal segment of bowel)
V
*
Barium enema with a rectum/sigmoid ratio of >1 is diagnostic
Barium enema is the primary diagnostic radiologic study and should be done before a rectal examination or washout enema is administered as that might decompress the characteristic transition zone
>
Rule out congenital abnormalities
*
Cardiac
*
Pulmonary
*
Urinary
*
GI
*
Evaluate for the presence of Hirschsprung’s associated eneterocolitis
>
Gold standard Dx is with Bx
*
Avoid Bx in the distal most rectum (0.5-1cm from dentate line) as that segment may normally be aganglionic
*
Infants: bedside suction rectal Bx of mucosa and submucosa is appropriate
*
Older children & adults: full thickness distal rectal Bx
V
Bx results
*
Absence of ganglion cells in submucosa
*
Hypertrophic parasympathetic nerve trunks
*
↑ acetylcholinesterase staining
*
Absence of calretinin positive nerves
>
Anorectal manometry is useful in adults but not paediatrics
*
Absence of RAIR should raise suspicion for certain pathologic conditions, including Hirschsprung’s disease, Chagas disease, dermatomyositis, and scleroderma
>
Management
>
Pediatric population
*
PreOp: bedside decompression with rectal irrigation 20-30ml/kg Q6h
*
If the transition zone is higher than can be reached by the washouts, the decompression is going to be unsuccessful and the patient will require a formal levelling colostomy. If the washouts are successful in decompressing the obstruction, an elective repair is contemplated
>
Stage 1: Colostomy creation / Levelling procedure
*
Levelling procedure = intraoperative biopsies are serially obtained to determine the level of ganglionosis
*
Identify transition zone
*
Transect bowel proximal to the transition zone
V
>
Stage 2: Pull through ± proximal diversion
40746_2020_195_Fig2_HTML
*
Throughout the procedure, full-thickness Bx are obtained at various levels to determine the level of ganglionosis on frozen sections
>
Swenson procedure
*
Resection of the entire aganglionic segment down to the dentate line
*
Perineal coloanal anastomosis
V
Duhamel procedure (rectorectal pull-through)
*
Posterior rectal dissection
*
The bowel is divided proximal to the transition zone (in the normally innervated colon)
*
From a transanal approach, an incision is made in the posterior rectal wall 1cm proximal to the dentate line
*
An anastomosis is made
*
Optional step: linear stapler is used to divide the common wall between the native rectal vault and the ganglionic colon to create a side-to-side anastomosis
*
This can be used as a salvage procedure for failed Swenson procedure
>
Soave-Boley procedure (submucosal endorectal pull-through)
*
Main advantage: minimizes risk to pelvic structures during dissection
*
The aganglionic intestine is resected to the level of the rectum below the peritoneal reflection
*
A submucosal dissection from both the pelvic side and the anal side removes the rectal mucosa and creates a muscular cuff
*
The ganglionic intestine is then pulled through the cuff
*
Anastomosis 1 cm above the dentate line
*
Most children do well regardless of the type of procedure
*
Stage 3: Reversal of diversion
V
Adult population
>
Posterior anorectal strip myectomy: diagnostic ± therapeutic. In short-segment disease, this procedure may be curative
*
Incision is made in the rectal mucosa proximal to the dentate line to expose the underlying muscularis.
*
A portion of internal sphincter muscle is excised and ideally contains ganglion cells at the proximal surgical margin.
>
Laparoscopic rectosigmoid resection with a trans-anal colonic pull-through followed by delayed coloanal anastomosis
>
Stage 1
*
Abdominal phase: in contrast to procedures for rectal cancer, the dissection plane stays between the rectal muscular layer and the mesorectum
>
Perineal phase:
*
Gradual anal dilatation
*
Installation of a LoneStar retractor
*
Circumferential incision of the mucosa is made at the level of the dentate line and a short mucosectomy is performed
*
Rectum is then transected at the upper border of the anal sphincter until the level of the abdominal dissection is reached (usually at the level of the levator ani)
*
The rectum and sigmoid colon are pulled through the anal canal. Once the colon is pulled through, it is cut above the megacolon, therefore leaving an 8-10 cm colonic segment outside the anal canal.
*
This exteriorized colonic segment is tied by means of 2 stitches to the right thigh and left open to allow clearance of gas and stool
*
The exteriorized segment is wrapped in absorbent, paraffin-impregnated gauze
>
Stage 2: 5-7 days after the first stage
*
No retractors are needed and the adhesions between the anal canal and colon must be left intact
*
After the mesocolon is tied off at the level of the anal verge, the pulled-through colonic segment is excised at the same level, and a handsewn coloanal anastomosis is created at the level of the dentate line
*
No preventive diverting stoma is constructed
*
Duhamel procedure: Only small numbers of Swenson and Soave operations have been reported in adults. Although functional results in the long term were reported to be satisfactory, the incidence of septic complications was higher with these operations. Neither of these two operations offers a compliant reservoir, which is usually considered a necessity for acceptable defecatory function. However, compared with the Swenson and Soave operations, the Duhamel and modified Duhamel operations are superior for preventing postoperative impotence and anastomotic dehiscence, and creating a reservoir to minimize soiling.
V
>
PostOp concerns
These more uncommon conditions may require reoperation, including a posterior myomectomy (in the case of recurrent enterocolitis), or redo-pull-through for strictures or aganglionic segments
>
Chronic obstruction; etiology:
*
Mechanical obstruction 2ry to strictures (most common) requiring dilatation
*
Recurrence / residual aganglionosis (second most common)
*
Motility disorder
*
Anal sphincter achalasia
>
Constipation
>
Etiology of constipation in Hirschsprung’s disease
*
Enterocolitis
*
Anastomotic issues (strictures)
*
Sphincter dysfunction
*
Retained/acquired aganglionic segment
*
Soiling/incontinence
>
Recurrent enterocolitis
*
Affects up to 40% of pull-through patients
>
Necrotizing enterocolitis
>
Highest risk with
*
Birthweight < 1,000 grams
*
Birth at < 28w GA
>
Pathogenesis
*
Disrupted or immature GIT immune modulation → ischemic cascade → loss of epithelial barrier function → mucosal then full-thickness injury
*
Breast milk protective, likely secondary to high concentrations of epidermal growth factor (EGF) and IgA
>
Indications for surgery
*
Clinical signs of perforation
*
Clinical deterioration despite maximum medical treatment
*
As many neonates may be hemodynamically unstable, and may not tolerate a full laparotomy, performing a percutaneous drainage of the abdomen via a small right lower quadrant incision is an option for very small premature infants an alternative to surgery. Outcomes between open laparotomy and drainage have been shown to have somewhat equivalent outcomes
*
50% of neonates undergoing surgery do not survive
>
Constipation
*
In the neonatal period, a child with “constipation” should be considered to have an organic cause of their constipation or a bowel obstruction until proven otherwise
*
In children outside of the neonatal time period, the vast majority of their constipation is functional
*
Rome III criteria is considered the best method to make the Dx
>
Etiology of constipation in Hirschsprung’s disease
*
Enterocolitis
*
Anastomotic issues (strictures)
*
Sphincter dysfunction
*
Retained/acquired aganglionic segment
>
Management
V
Medical
*
PEG is most commonly used
*
Senna is used with more resistant cases
*
Empty the colon of stool and begin a bowel management program
*
Those children that are refractory to initial treatment need further work-up to rule out an organic cause
>
Surgical
V
*
Malone antegrade continence enema (MACE)
ASCRS 2016 CPG: Antegrade colonic enema with appendicostomy or cecostomy may be an effective bowel management strategy in select highly motivated patients with refractory chronic constipation, although this is not a common alternative. Grade of Recommendation: Weak recommendation based on low-quality evidence, 2C
3-Figure59.3-1-squashed
The appendix is imbricated. Openings on the mesentery of the appendix can be used for imbrication. The bowel is not opened throughout the procedure except when insertion the tube through the appendix. The tube is kept in place to allow the tract to fistulize.
*
Cecostomy antegrade enema via Chait® tube
*
SNS
*
IBD
>
The appendix
>
Acute appendicitis
*
Lifetime risk: 7%
*
Highest incidence in ♂ 10-14Y
*
The appendix plays an active role in the secretion of immunoglobulins, especially IgA
>
Etiology: mechanical obstruction with
*
Fecalith
*
Lymphoid hyperplasia
*
Parasitic infection
*
Neoplasms
*
The most common isolated bacteria: E. coli, Bacteroides fragilis, Klebsiella pneumonia, Steptococcus, Enterococcus, Pseudomonas
*
More than 50% of older patients with appendicitis are found to have perforated appendices, compared with fewer than 20% of younger patients.
*
Patients above 40Y with perforated appendicitis have high incidence of malignancy - interval appendectomy is necessary
>
False negative US findings are seen with:
*
Retrocaecal position of the appendix
*
Overlying fat
*
Very large/distended → mistaken for bowel loop
*
If perforated → compressible
>
Differential Dx
>
Acute mesenteric adenitis
*
Always have Hx of URTI
*
Relative lymphocytosis may be seen
>
Other
>
Salmonella typhimurium
*
Mesenteric adenitis
*
Paralytic ileus
>
Campylobacter jejuni
*
Diarrhea
*
Pain
*
Dx Culture from stool
>
Yersinia enterocolitica or psudotuberculosis
>
Causes
*
Mesenteric adenitis
*
Ileitis
*
Colitis
>
Acute appendicitis
*
Will need appendectomy
*
Rx: tetracycline or ampicillin
*
When in doubt, immediate exploration is the safest option
>
PID
*
Sexual history
*
May be complicated by tuba-ovarian abscess
*
Look for vaginal discharge
>
Ruptured Graafian follicle
*
A result of ovulation → spillage of blood & follicular fluid
*
Pain at midpoint of menstrual cycle → AKA Mittelschmerz
>
Ovarian cyst
*
Serous cysts are common
>
Complicated cysts mimic appendicitis
*
Torsion: requires surgery
*
Leak of ovarian cyst. Resolves spontaneously
>
Mass palpable on exam?
*
Yes = easy Dx
*
No → transvaginal US or CT
>
Ruptured ovarian cyst:
*
Usual onset is with strenuous physical activity
*
± Vaginal bleeding
*
Most women with ovarian cyst rupture have an uncomplicated case and are candidates for observation. Complicated cases may require inpatient management and/or surgery
>
Ruptured ectopic pregnancy
*
↑ B-hCG
>
Acute ileitis (Yersinia; Campylobacter; Salmonella)
*
Self-limiting
*
Suspect when diarrhea is the prominent symptom
*
Findings at surgery: inflammation around the appendix & terminal ileum + mesenteric lymphadenitis
>
Mickel's diverticulitis
*
May be indistinguishable from Acute appendicitis
*
Occasionally accompanied with LGIB
>
Special population
>
Children
*
Appendicitis progression is rapid
*
↑Risk rupture
*
Appendectomy is routinely performed during Ladd’s procedure for malrotation because the diagnosis becomes difficult afterwards (caecum at LUQ)
>
Appendicitis in pregnancy
*
Appendicitis is the MC surgical emergency (incidence: 0.06%)
*
No relation between appendectomy & subsequent fertility
*
Dx: US, MRI
*
CT is not an absolute contraindication; CT delivers 29-43 mGy of radiation to the fetus. The best quantitative estimate of risk is ~1 cancer per 500 fetuses exposed to 30 mGy of radiation
*
Unruptured appendicitis is associated with 3-5% fetal loss
*
Ruptured appendicitis is associated with 20-25% fetal loss
*
In later stages of pregnancy, the ability to visualize the appendix is severely limited. In one study, the ultrasound was unable to detect the appendix in 71% of patients with surgically proven appendicitis
>
HIV
*
Appendicitis is more prevalent in HIV-infected population
*
Have similar presentation but without ↑WBC (relative leukocytosis may be seen)
*
Have ↑ risk of rupture
>
DDx (opportunistic)
*
TB
*
CMV
*
Lymphoma
*
Infectious colitis
*
Kaposi sarcoma
V
>
Management
d53434b22dd443cfaf4304faa0d140b8
>
Operative management
*
Mortality < 1%
*
Wound infection < 5%
*
Conversion from laparoscopic to open = 2%
*
Leave a closed suction drain in place only if a well-defined residual abscess cavity exists after reflection of the small bowel away from the appendiceal bed
>
If a normal appearing appendix is encountered:
*
± Remove the appendix
>
Perform a thorough search for patient’s symptoms:
*
Examine small bowel: Meckel’s, Crohn’s, mesenteric lymphadenopathy
*
Examine pelvis: ovarian torsion, hernias
V
*
If findings of Crohn’s are found and the base of the appendix is not involved → appendectomy prevents future confusion
If the base of the appendix is inflamed, best to avoid appendectomy to minimize the risk of fistula formation
Acute distal ileitis may be a manifestation of early Crohn’s disease, but it also may be unrelated, such as when it is caused by a bacteriologic agent (e.g., Campylobacter, Yersinia). Patients usually present in a similar fashion to those presenting with acute appendicitis with a sudden onset of right lower quadrant pain, nausea, vomiting, and fever. These entities normally resolve spontaneously and, when noted during surgery, no biopsy or resection should be performed
>
Nonoperative management of uncomplicated appendicitis
*
30-50% require appendectomy within 48h
*
5-15% develop complications
*
Rate of recurrence of appendicitis is 7-14% at 1Y
*
Recurrence is higher with the presence of a fecalith
*
In children, recurrent appendicitis is as high as 72%
*
Untreated appendicitis that resolve spontaneously have 38% recurrence rate
V
Tumors of the appendix
V
Primary neoplasms of the appendix are found in ~1% of appendectomy specimens
*
Even intraoperatively, < 50% of appendiceal neoplasms are recognized as such
*
The most frequent histology: mucinous adenocarcinoma (~38%) > intestinal-type adenocarcinoma (~26%) > NET/carcinoid (~17%)
V
Epithelial neoplasms
V
Mucinous neoplasms
V
V
Mucoceles are classified into:
Mucocele: any lesion that is characterized by a distended, mucus-filled appendix
*
The appendix is the most common source of mucoid fluid collections in the abdomen
*
In 50%: the appendiceal wall is fibrotic and—as a sign of chronicity—may sometimes contain calcifications
V
>
Non-neoplastic mucoceles
The non-neoplastic mucoceles (mucosal hyperplasia and simple retention cysts) have a higher prevalence as compared with neoplastic mucoceles (mucinous cystadenomas and cystadenocarcinomas) with prevalence rates
*
Mucosal hyperplasia
*
Simple (benign) or retention cysts caused by obstruction
V
Neoplastic mucoceles
V
V
Mucinous cystadenomas - Low-grade mucinous neoplasms (LAMNs)
For pseudomyxoma peritonei, see Management of psudomyxoma periteoni & intraoperative metastasis
*
LAMNs are characterized by well-differentiated adenomas that can proliferate outside the appendix in a malignant fashion. Acellular or cellular extra-appendiceal mucin may be associated with LAMNs, although this is not a requirement.
High-grade appendiceal neoplasms (HAMNs) share some histologic features with LAMNs but exhibit more aggressive cytologic atypia.
Rarely, a primary appendiceal mucinous neoplasm will harbor high-grade cytology yet lack infiltrative invasion associated with adenocarcinoma. These lesions are best classified as HAMNs.
*
They are often asymptomatic
*
May show ↑ESR, ↓Hgb, ↑CEA, ↑CA19-9
>
Imaging:
*
US: variable internal echogenicity depending upon the consistency of the mucocele. Nodular enhancing lesions in the wall of the mucocele are suggestive of an underlying malignancy
>
CT findings:
*
Low-attenuation, well-encapsulated round or tubular cystic mass.
*
Soft tissue thickening + wall irregularity = suggestive of a malignancy
>
Endoscopy:
*
As appendiceal mucoceles are extrinsic or submucosal, on colonoscopy they can produce a smooth indentation of the cecal lumen or have the appearance of a glossy, rounded, protruding mass arising from the appendiceal orifice
*
The appendiceal orifice may be seen in the center of a mound-like elevation of the cecal wall (volcano sign)
*
Dx: a presumptive diagnosis can be made based on abdominal CT scan findings of a well-encapsulated round or tubular cystic mass with calcification at the expected site of the appendix and colonoscopic findings of a smooth indentation of the cecal lumen or rounded protruding mass arising from the appendiceal orifice
>
Requirements for the pathologic Dx of LAMN
*
Extravasated mucin (extravasated mucin is commonly seen in interval appendectomies, and this makes the Dx of LAMN suspicious)
*
Dysplastic epithelium (not only at the site of the ruptured appendix)
>
Staging:
V
*
LAMNs have their own AJCC TNM staging
T category
T criteria
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ (intramucosal carcinoma; invasion of the lamina propria or extension into but not through the muscularis mucosae)
Tis(LAMN)
Low-grade appendiceal mucinous neoplasm confined by the muscularis propria. Acellular mucin or mucinous epithelium may invade into the muscularis propria.
T1 and T2 are not applicable to LAMN. Acellular mucin or mucinous epithelium that extends into the subserosa or serosa should be classified as T3 or T4a, respectively.
T1
Tumor invades the submucosa (through the muscularis mucosa but not into the muscularis propria)
T2
Tumor invades the muscularis propria
T3
Tumor invades through the muscularis propria into the subserosa or the mesoappendix
T4
Tumor invades the visceral peritoneum, including the acellular mucin or mucinous epithelium involving the serosa of the appendix or mesoappendix, and/or directly invades adjacent organs or structures
T4a
Tumor invades through the visceral peritoneum, including the acellular mucin or mucinous epithelium involving the serosa of the appendix or serosa of the mesoappendix
T4b
Tumor directly invades or adheres to adjacent organs or structures
*
HAMN AJCC TNM staging follows Colon Cancer staging
V
Management:
*
A concurrent colorectal adenocarcinoma can be found in approximately 20% of patients with appendiceal mucoceles. Colorectal cancer should therefore be ruled out intraoperatively, if a colonoscopy was not performed preoperatively
*
Mucosal hyperplasia, retention cysts, or cystadenoma → appendectomy
V
Mucoceles that have ruptured are more likely to be associated with the spread of epithelial cells within mucoid fluid throughout the peritoneal cavity, so-called pseudomyxoma peritonei, or mucinous carcinomatosis of appendiceal origin
*
Patients having LAMN or HAMN limited to the appendix without perforation do not require any additional surgical treatment beyond appendectomy, provided there are clear resection margins. It is also questionable whether a completion right hemicolectomy is necessary when the appendectomy margins are histologically positive or have mucin on the resection margin
*
In two separate, comparative studies, the peritoneal recurrence rates associated with acellular mucin outside of the appendix were 4% and 7% at follow-up, compared with 33% and 75% in cases of cellular mucin, respectively. In this context, there is no evidence that a right hemicolectomy is associated with a reduction of PMP risk.
*
Cystadenocarcinoma are best treated with right hemicolectomy
V
Surveillance:
*
Appendectomy without violating the tumor or spilling mucin → no follow up
>
If there was spillage of mucin → CT/MRI at 12m is performed — however, a diagnostic laparoscopy may be offered
*
The prognosis of a ruptured LAMN is dependent on the amount and cellularity of mucin deposits, and recurrence rates increase when epithelial cells are present in the mucin
V
Mucinous cystadenocarcinomas - High-grade mucinous neoplasms (HAMNs)
*
Signet-ring cell carcinoma is a rare but aggressive subentity of mucinous adenocarcinoma; typically associated with poor prognosis
*
Although appendectomy alone is typically sufficient for treating HAMNs, care should be taken to exclude the presence of associated invasive adenocarcinoma, including comprehensive histologic evaluation of the entire surgical specimen
*
5FU-based chemotherapy (similar to CRC) is recommended for HAMNs with N⊕ disease or peritoneal disease
*
Perforated HAMNs may be candidates for systemic chemotherapy (LAMNs are not)
*
Mucinous adenocarcinomas have a markedly worse outcome (reduced cancer-specific survival) than non-mucinous adenocarcinomas of the appendix
*
Mucinous tumors that penetrate the visceral peritoneum and cause mucin deposits confined to the right lower quadrant are still considered a T4a (stage II if N⊖); when mucin has dispersed beyond the right lower quadrant, it is designated M1a
>
Non-mucinous neoplasms
>
Invasive adenocarcinoma
>
Found in < 1% of appendectomy specimens
*
Signet ring cells consign the tumor to the poorly differentiated category and is associated with poor prognosis
*
Because they are usually incidental pathology findings, staging is usually done postoperatively: CT chest/abdomen/pelvis + colonoscopy
*
Right hemicolectomy is recommended for noncarcinoid cancers larger than 1 cm.
*
UTD: For most patients, we suggest right hemicolectomy rather than simple appendectomy alone, and we reserve simple appendectomy alone for unruptured, well-differentiated, completely resected adenocarcinomas that invade no deeper than the submucosa (ie, T1 tumors).
*
Recommendations for adjuvant chemotherapy parallel that for colon cancer
>
Goblet cell adenocarcinoma (GCAs)
*
May clinically cause appendicitis
*
Have features of both adenocarcinoma and NET
*
The histologic hallmark is the focal presence of mucin-containing goblet shaped epithelial cells, which may cluster in the lamina propria or submucosa of the appendix
*
All GCAs stain positive on periodic acid-Schiff (PAS) staining for mucin and, thus, can be differentiated from appendiceal NETs
*
UTD: Given the higher risk of metastases with an appendiceal GCA compared with an appendiceal NET, we suggest that most patients, even those with T1 or T2 favorable histology tumors, undergo complete right hemicolectomy within three months of initial appendectomy
*
Prognosis is somewhat worse than with a malignant NET, but overall, it is better than with appendiceal adenocarcinoma
V
Non-epithelial neoplasms
V
V
Neuroendocrine neoplasms (carcinoid)
Carcinoid is a general term for well-differentiated NET
*
Arise from enterochromaffin (Kulchitsky) cells at the base of the crypts of Lieberkuhn
*
Overproduction of serotonin can consume up tryptophan and cause deficiency in niacin (B7) and nicotinamide (B3)
*
The appendix accounts for 16-38% of all NET arising within the tubular intestinal tract; the majority arise in the small bowel
>
Predisposing conditions
*
MEN1
*
Neurofibromatosis
*
Presence of breast or colorectal cancer
V
For nonfunctional tumors, some tumor markers are helpful:
V
*
5HIAA
Elevated urinary levels of 5-HIAA are highly specific for serotonin-producing carcinoid tumors (ie, those arising in the midgut), but they are not particularly sensitive
If there is suspicion for liver metastases or carcinoid syndrome, measurement of the serotonin metabolite 5-hydroxyindoleacetic acid (5HIAA) in a 24-hour urine collection is indicated
V
*
Chromogranin-A
As a general rule, serum concentration of chromogranin A (CgA; a protein that is stored and released with peptides and amines in NETs) parallels 5-HIAA excretion. Because it does not rely on serotonin secretion, serum level of CgA is a more sensitive marker than urinary 5-HIAA for gastroenteropancreatic NETs, including those arising in the appendix; it is less specific
*
Pancreatic polypeptide
*
Neuron-specific enolase
*
The majority are well-differentiated
*
Midgut NETs (ie, those arising in the appendix and small bowel) are more commonly associated with classic carcinoid syndrome than those that arise in the foregut or hindgut. Carcinoid syndrome being characterized by episodic flushing, wheezing, diarrhea, and right-sided valvular heart disease. 90% of carcinoid syndromes have metastasis
*
They are usually found incidentally. Operative finding: firm, yellow-tan, bulbar mass; 75% are located at the tip
*
Most are submucosal & located in the distal ⅓ of the appendix
*
Metastasis mainly involves the liver. Extrahepatic metastasis is extremely uncommon
>
Staging
V
Staging workup is advised for:
*
NET > 2 cm
*
Incomplete resection (either lack of LN or positive margin)
*
Those with concern for distant metastasis based on symptoms
*
Somatostatin-receptor-based diagnostic imaging is reserved for patients with suspected metastatic disease
*
Colonoscopy is performed prior to completion right hemicolectomy to assess for synchronous cancers
*
The surgeon should perform a complete inspection of the bowel intraoperatively since up to 25% of midgut NETs (small bowel, proximal colon) may be multifocal and are sometimes associated with malignant gastrointestinal tumors of other histologic types
>
Tumors < 2 cm are unlikely to have metastasized. ⅓ of larger lesions are metastatic at Dx
V
The risk of N⊕ at Dx
*
0% for NETs < 1cm
*
7.5% for NETs 1-1.9cm
*
33% for NETs >2 cm
*
AJCC staging for carcinoids is based on tumor size as it correlates with the incidence of metastases and represents the most important prognostic parameter, whereas depth of invasion, lymphatic, perineural, or serosal invasion lack prognostic power
*
The best available evidence (which is limited) suggests that perforation has no influence on the prognosis of classical appendiceal NETs
>
Treatment
V
Indications for completion right hemicolectomy
*
Tumor > 2 cm
*
Tumor 1-2 cm with deep mesoappendieceal invasion (controversial)
*
Positive or unclear margin
*
High proliferative rate
*
Angioinvasion
*
Mixed histology (goblet cell adenocarcinoma)
V
Metastatic disease
*
Carcinoid symptoms are well controlled with long-acting somatostatin analogs
*
Somatostatin analogs prolong the time to disease progression and overall survival in asymptomatic patients
*
Liver resection for selected patients may be beneficial, particularly for symptom relief
*
Everolimus is an option for patients with progression following somatostatin analog therapy
*
The role of cytotoxic chemotherapy continues to be debated
V
Surveillance
V
Tumor < 2 cm treated with simple appendectomy: no surveillance
V
*
CT/MRI X1 for NET > 1-2cm is advised, but not supported by evidence
After complete resection of 10–20 mm lesions, a single CT or MRI to rule out lymph node and distant metastases is recommended, but without level I evidence
V
Tumor > 2 cm treated with right hemicolectomy:
*
Hx & physical examination Q3-12m, then Q6-12m with imaging as clinically indicated
*
Consider 5HIAA/cGA & SPECT/CT
V
*
Goblet cell adenoCa (see non-mucinous adenocarcinomas)
Have features of both adenocarcinoma and NET
*
Mixed neuroendocrine-non-neuroendocrine neoplasms (MiNEN)
*
Lymphoma
>
GI bleed
>
UGIB
>
Etiology
V
>
Ulcer disease
Forrest classification
Screen Shot 2020-04-17 at 2.18.36 PM
V
*
Peptic ulcer disease (the most common cause of UGI bleeding)
Repeat testing for H.Pylori if negative in the acute setting (as the false-negative rate in the acute bleeding setting is significant)
*
Curling ulcers are seen after burns to more than 30% of total body surface area
*
Cushing's ulcers develop following central nervous system injury
*
Cameron ulcer: linear erosion or ulceration of the mucosal folds lining the stomach where it is constricted by the thoracic diaphragm in persons with large hiatal hernias
*
Marginal ulcer: mucosal erosion at the gastrojejunal anastomosis
>
Isolated gastric varices
V
*
Tend to occur secondary to splenic vein thrombosis
6957717E-BE0B-4583-A8A9-8C9B87110778
V
>
Type
Sarine’s Classification
Gastroesophageal varix (GOV) type 1: Extension of esophageal varices along lesser curvature
Gastroesophageal varix type 2: Extension of esophageal varices along great curvature
Isolated gastric varix (IGV) type 1: isolated to the fundus
Isolated gastric varix type 2: Varices anywhere else in the stomach or duodenum
Sarin-classification-of-gastric-varices-GEV-gastric-epiploic-vein-GOV
*
Type 1: located in the fundus
*
Type 2: isolated ectopic varices located anywhere in the stomach
>
Management
*
Both esophageal varices and gastroesophageal varices types I (along the lesser curvature of the stomach) and II (along the greater curvature of the stomach) can be treated by sclerotherapy or band ligation. However, isolated gastric varices do not usually lend themselves to these modalities of treatment
*
Bleeding intragastric varices should be treated with octreotide and balloon tamponade followed by cyanoacrylate injection, TIPS placement, or surgery. Endoscopic variceal ligation is also an option for patients with gastroesophageal varices along the lesser curvature of the stomach (GOV1). Bleeding gastric varices can be technically difficult to treat and cyanoacrylate injection is the preferred initial approach, where available, for most gastric varices
*
Isolated gastric varices in the setting of splenic vein thrombosis are readily treated by splenectomy
>
Complications of portal hypertension:
V
>
Gastroesophageal varices
Both esophageal varices and gastroesophageal varices types I (along the lesser curvature of the stomach) and II (along the greater curvature of the stomach) can be treated by sclerotherapy or band ligation. However, isolated gastric varices do not usually lend themselves to these modalities of treatment
*
Type 1: extension of esophageal caries along the lesser curvature
*
Type 2: extension of esophageal varices along the greater curvature
V
>
Portal hypertensive gastropathy (treat as with variceal bleeds)
Varixmagfni2
*
Has snake-skin appearance, usually in the fundus
*
Treat with β-blocker & octreotide
*
TIPSS if severe
*
Erosive pathology: esophagitis, gastritis, duodenitis
V
>
Stress gastritis (see stomach for details)
Stress is considered present when hypoxia, sepsis, or organ failure occurs. When stress is present, mucosal ischemia is thought to be the main factor responsible for the breakdown of these normal defense mechanisms. There is little evidence to suggest that increased gastric acid secretion occurs in this situation. More than 50% of patients develop stress gastritis within 1 to 2 days after a traumatic event
*
Coagulopathy and prolonged ventilation (> 48 hours) put patients at greatest risk for stress ulcers
*
Lesions are almost always seen in the fundus of the stomach and only rarely in the distal stomach
*
There is little evidence to suggest that endoscopy with electrocautery or heater probe coagulation has any benefit in the therapy of bleeding from acute stress gastritis. However, some studies have suggested that acute bleeding can be effectively controlled by selective infusion of vasopressin into the splanchnic circulation through the left gastric artery. Vasopressin is administered by continuous infusion through the catheter at a rate of 0.2 to 0.4 IU/min for a maximum of 48 to 72 hours
*
In facilities with the requisite expertise, angiographic intervention may be used to treat bleeding stress ulcers as well
>
Vascular lesions
>
AVM / angiodysplasia
*
Angiodysplasia of the small bowel is most common cause of obscure GI bleeding particularly in elderly
*
Right colon is the most common site
*
Jejunum > ileum > duodenum
*
Associated with aortic stenosis & renal failure
V
*
Osler-Weber-Rendu or renal failure may cause diffuse AVMs
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler–Weber–Rendu disease and Osler–Weber–Rendu syndrome, is a rare autosomal dominant genetic disorder that leads to abnormal blood vessel formation in the skin, mucous membranes, and often in organs such as the lungs, liver, and brain
>
Dieulafoy lesion:
*
A dilated aberrant submucosal vessel that erodes the overlying epithelium in the absence of a primary ulcer
V
*
Sabiston: The lesions generally occur 6 to 10 cm from the GE junction, generally in the fundus, near the cardia
Usually located in the proximal stomach along the lesser curvature, near the esophagogastric junction (typically within 5 cm), although they have been found in all areas of the GI tract, including the esophagus, duodenum, and colon
*
The classic presentation of a patient with a Dieulafoy’s lesion is sudden onset of massive, painless, recurrent hematemesis with hypotension.
V
*
Endoscopic management is tried when the lesion is identified on EGD
Endoscopic hemostasis: epinephrine injection followed by bipolar probe coagulation ± hemoclip placement
*
Gelfoam angioembolization (usually a branch of the Lt gastric artery) may be successful
V
*
Surgical management consists of gastric wedge resection to include the offending vessel
The difficulty at the time of exploration is locating the lesion unless it is actively bleeding. The surgical procedure can be greatly facilitated by asking the endoscopist to tattoo the stomach when the lesion is identified.
>
GAVE: gastric antral vascular ectasia
V
*
Usually in antrum, showing a ‘water-melon’ appearance
F1.mediumWatermelon20Stomach-200
*
Argon-beam coagulation for hemostasis
*
TIPSS is not helpful
*
Neoplasm
>
Traumatic
>
Mallory-Weiss syndrome
>
General
*
Any bodily action that results in an abrupt increase in intra-abdominal pressure and gastric herniation may cause a Mallory-Weiss tear. 50% of patients may not have a history of vomiting preceding hematemesis
*
It is a linear mucosal or submucosal lacerations of the gastroesophageal junction. Most tears occur within 2 cm of the GEJ
*
It’s the 2nd most common cause of nonvariceal UGI bleeding
*
Hiatal hernia confers the greatest risk for developing Mallory-Weiss tear and can be found in 40-50% of cases
*
10% present with melena alone
>
Management
*
Superficial mucosal Mallory-Weiss tears can start healing within hours and can heal completely within 48h
*
PPI to accelerate mucosal healing by raising intragastric pH to improve coagulation
>
Endoscopic hemostasis is accomplished with various techniques, including injection therapy, multipolar electrocoagulation, band ligation, hemoclipping, or combination treatment
*
1 to 3 mL 1:10,000 epinephrine, prepared by mixing 1 mL 1:1000 epinephrine and 9 mL 0.9% saline solution, injecting into the area surrounding and close to the bleeding points with an injection needle
*
“Rebleeding has been reported to occur in 5.8% to 44% of cases. Given the relatively high rebleeding rate, we recommend that epinephrine injection be combined with a second endoscopic therapy”
*
Angioembolization is considered for recurrent bleeding that failed EGD
*
Operative: gastrotomy & oversewing the tear with absorbable sutures
*
Aortoenteric fistula
*
Hemobilia
*
Homosuccus pancreaticus
V
*
Approach
Pasted_Graphic_13
V
*
Abx prophylaxis in endoscopy (for details regarding colonoscopy, refer to section of colorectal surgery)
Screen Shot 2020-05-16 at 7.04.59 PM
>
Consider ETT to protect the airway for emergency EGD if:
*
Altered mental status
*
Respiratory insufficiency
*
Ongoing hematemesis
V
*
Restrictive blood transfusion protocols in patients with UGIB are associated with fewer re-bleeds, fewer emergency surgeries, & improved survival
Screen Shot 2020-04-17 at 2.07.46 PM
>
Clinical guidelines from “Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group” Barkun et al in AIM 2019
V
>
Resuscitation, risk assessment, and preendoscopy management
Screen Shot 2020-01-08 at 10.00.25 AM
V
*
Glasgow-Blatchford Score (GBS)
Screen Shot 2020-04-17 at 2.09.58 PM
V
>
Endoscopic management
Screen Shot 2020-01-08 at 10.00.33 AM
>
Indications for endoscopic intervention:
*
Forrest classification IA: spurting hemorrhage
*
Forrest classification IB: oozing
*
Forrest classification IIA: visible vessel within an ulcer
*
For adherent clot: vigorous irrigation and subsequent endoscopic intervention if Forrest IA,IB,IIA
*
Risk of rebelled after initial endoscopic control is ~15% (with double intervention technique)
V
*
Pharmacologic management
Screen Shot 2020-01-08 at 10.00.42 AM
V
*
Nonendoscopic and nonpharmacologic in-hospital management
Screen Shot 2020-01-08 at 10.00.48 AM
V
*
Secondary prophylaxis
Screen Shot 2020-01-08 at 10.00.54 AM
V
*
No recommendation statements
Screen Shot 2020-01-08 at 10.01.00 AM
>
Non-variceal bleeding
*
Testing for H. pylori has a high false negative rate during active bleeding. It’s warranted to repeat testing once the episode has resolved
>
High risk patients requiring intervention:
*
Forrest classification IA: spurting hemorrhage
*
Forrest classification IB: oozing
*
Forrest classification IIA: visible vessel within an ulcer
*
Double intervention is recommended for high risk patients = injection + (diathermy or clip)
*
Re-endoscopy is warranted for rebleeds (75% success rate)
*
Mortality is mostly secondary to underlying comorbidities rather than exsanguination
>
Indications for surgery
*
Hemodynamic instability with > 6 units PRBC
*
Failure of endoscopic control
*
Recurrent hemorrhage with hemodynamic instability
*
Recurrent hemorrhage after 2nd attempt at endoscopic control
*
Ongoing bleeding requiring > 3 units PRBC/day
V
>
Variceal bleeding:
Screen_Shot_2019-01-17_at_18.22.30
>
Nonbleeding
V
*
All cirrhotic patients should be screened endoscopically for varices
Variceal hemorrhage occurs at a yearly rate of 5% - 15%
V
*
Nonselective B-blocker
Significantly decreases the likelihood of recurrent hemorrhage and demonstrates a trend toward decreased mortality
V
*
Long acting nitrate (isosorbide 5-mononitrate)
The combination of a beta blocker and long-acting nitrate (e.g., isosorbide 5-mononitrate) has been shown to be more effective than variceal ligation
*
Avoid hepatotoxic therapies
>
Acute bleeding
>
Rx
V
*
Antibiotics: ceftriaxone or ciprofloxacin
This has been shown to decrease the infection rate by over 50%, decrease re-bleeding, and improve survival
“Antibiotic prophylaxis significantly increases survival at 14 days from acute variceal bleed”
V
*
Octreotide drip: 50 mcg bolus then 50 mcg/hr X 5 days
Better tolerated than vasopressin
*
PPI drip
*
Consider: vasopressin (+ nitroglycerine to manage AE of vasopressin)
>
Modalities
>
EGD
*
Banding/sclerotherapy: 90% successful
*
Banding is safer than sclerotherapy
>
AE
*
Esophageal ulceration
*
Esophageal perforation
*
Stricture
*
Fibrosis
V
>
Sengstaken-Blakemore tube = temporizing measure
Technique:
Insert to 50cm
Inflate gastric bag with 50ml
Check placement: with Xray or stethoscope
Inflate gastric bag up to 250ml
Tamponade — check for bleeding using the gastric aspiration port
Inflate esophageal bag to 50ml, if needed
Attach traction (250-500g of weight)
*
Have 90% success rate
*
50% will re-bleed on deflation (considered a bridge to more definitive therapy)
>
AE
*
Esophageal rupture
*
Esophageal necrosis
*
Aspiration
*
Needs to be removed within 24-36h
V
>
TIPS: Transjugular Intrahepatic Portosystemic Shunt
Portosystemic shunting is therefore the only definitive treatment for portal variceal bleeding.
The newly placed TIPS has air trapped within it, which limits ultrasound penetration and can simulate the sonographic appearance of an occluded TIPS. Waiting at least 2 weeks after TIPS for the air to be absorbed is generally adequate to avoid this problem.
V
*
Rate of rebleeding after TIPS = 4%/year
The rebleeding rate after TIPS placement is 4% per year, the lowest among all treatment options, including endoscopic management
>
Considered for:
*
Bleeding with failed EGD
*
Rebleeding
*
Procedure: Rt IJ access → Rt hepatic vein → through liver parenchyma → into a portal branch
>
AE
*
Stenosis & thrombosis (up to 50% of shunt stenosis or shunt thrombosis within the first year)
*
Encephalopathy
*
Bleeding
*
Sepsis
*
Liver infarction
*
Liver failure
*
Mortality at 6 weeks for patients who undergo TIPSS for uncontrolled or recurrent bleeding is high (30-40%)
V
>
Surgical shunts
Diversion of portal blood, which contains hepatotropic hormones, nutrients, and cerebral toxins is also responsible for the adverse consequences of shunt operations—namely, portosystemic encephalopathy and accelerated hepatic failure
Operative mortality rates exceed 25% in the emergency setting
V
>
Non-selective
Generally, a nonselective shunt is constructed only when a TIPS cannot be performed or when a TIPS fails.
*
Portal to caval
*
Divert all portal flow away from the liver
V
*
Risks hepatic encephalopathy & liver failure
The most common causes of death in medically treated and shunted patients were rebleeding and accelerated hepatic failure, respectively
*
Dissection of porta hepatis in liver transplant candidates is discouraged. Mesocaval ‘H’ shunts are used as a bridge to liver transplantation
V
>
Options
Screen_Shot_2019-01-21_at_12.23.37_PM
>
Side-End portocaval
*
Risks severe hepatic encephalopathy
*
No longer used
*
Side-Side portocaval shunt
*
Interposition portocaval shunt
V
*
Splenorenal shunt
The conventional splenorenal shunt consists of anastomosis of the proximal splenic vein to the renal vein. Splenectomy is also performed. Because the smaller proximal rather than the larger distal end of the splenic vein is used, shunt thrombosis is more common after this procedure than after the distal splenorenal shunt
>
Selective
*
Portal to azygos shunts
*
Preserve some portal inflow
>
Options
*
Lt gastric to IVC shunt
V
*
Distal splenorenal shunt
The distal splenorenal shunt tends to aggravate rather than relieve ascites
Another contraindication to a distal splenorenal shunt is prior splenectomy
Until improvements in TIPS technology are fully realized, the distal splenorenal shunt is likely to remain a more durable long-term solution and a reasonable alternative for TIPS failure
Screen_Shot_2019-01-17_at_18.33.24_1
*
After control of the acute episode, endoscopic band ligation is repeated Q1-2w until varices are completely obliterated. Nonselective β-blocker ± nitrates are initiated
V
>
Recurrent bleeding is defined as:
As per General Surgery Review Course
*
Hematemesis or bleeding NGT aspirate > 6h post-endoscopy
*
Melena or hematochezia after normalization of stool color
*
Hgb drop > 20 after two stable values
*
Hemodynamic instability in the absence of other causes
V
LGIB
>
Etiology
>
Anatomic
*
Anorectal (6-16%): fissure, hemorrhoids, rectal ulcer
>
Diverticulosis (4-40%)
*
MCC of painless hematochezia
*
Dx is confirmed only with ‘Stigmata of Recent Hemorrhage’:
• Visualized bleeding
• Exposed blood vessel
• Adherent clots
*
Resolves spontaneously in 80% overall & in 98% of those requiring ≤ 4PRBC
*
⅓ Rebleed within 6-12 months
V
Consider intervention if requires ≥6 PRBC
*
Endoscopic options:
• Epinephrine injection: help localization, but are often a temporary measure (1:20,000 in saline given in 1ml aliquots X4 around the base of the diverticulum)
• Bipolar: may risk perforation
• Endoclip: they are preferred over heater probe cautery when stigmata of recent hemorrhage is localized to the diverticular dome
*
Embolization
• Vasopressin risks colonic ischemia
• Coils are preferred
V
*
Meckel’s diverticulum
Bleeding is most common complication of Meckel’s in adults
V
*
Postpolypectomy hemorrhage (<15%)
See section on colonoscopy in Colorectal Surgery
*
Anastomotic ulcer
>
Vascular
>
AVM / angioectasia
*
The 2nd most common cause of LGIB in the Western world
*
Colonic lesions are usually right-sided
V
Most common sites of angioectasia
*
Jejunum (80%)
*
Duodenum (51%)
*
Stomach (23%)
*
Right colon (11%)
*
Ileum (5%)
*
In regards to recurrent bleeding, one must consider that angioectasias tend to be multiple and often involve proximal regions of the intestinal tract that require investigations in addition to colonoscopy
>
Have been associated with
*
AS
*
CHF
*
CKD
*
vWD
*
90% resolve spontaneously — 50% recur within 12m
>
Management:
*
Endoscopic APC is the treatment of choice for bleeding angioectasia. Alternatively: electrocautery or laser coagulation can be used
*
Non-bleeding AVMs do not require management
*
Thalidomide & octreotide are beneficial for chronic bleeds
*
Segmental resection is reserved for failed medical management
>
Dieulafoy’s lesions
*
Right colon most commonly affected
*
Radiation induced
*
Ischemic: thrombotic, embolic, low flow state
*
Ectopic varices
V
Infectious
*
C-Diff
>
Enterohemorrhagic E.Coli (EHEC)
*
Diarrhea is initially non-bloody, but in most patients, becomes visibly bloody 1-3d later
*
No fever
*
Dx is through stool cultures & Shiga toxin
V
*
HUS: AKI + ↓Plt + hemolytic anemia
Begins 5-10d after diarrhea
Fever & neurologic symptoms may develop
50% will require dialysis
*
Management is supportive
*
Abx are not recommended; may increase risk of HUS
*
Less frequent: Shigella, Salmonella, Campylobacter, enterovirus, Yersinia
>
In HIV⊕ patients, also consider:
*
HSV
*
CMV
*
HIV-related idiopathic pancolitis
*
Kaposi’s sarcoma
*
Chlamydia
*
Gonorrhoea
*
Inflammatory (2-4%)
>
Neoplasm
>
Kaposi sarcoma
*
If bleeding is not massive, treat with radiation/chemotherapy/HAART
*
If bleeding is massive and angiography is able to identify the lesion: leave the angiography catheter in place and localize the catheter intra-Op and perform a resection
>
Diagnostic & therapeutic modalities
V
>
Indications for EGD:
For low-index of suspicion, may start with GI lavage and perform EGD if positive.
*
Massive LGIB
*
HD instability
*
BUN:Cr > 20
*
Melena
>
Colonoscopy
*
‘Stigmata of Recent Hemorrhage’:
• Visualized bleeding
• Exposed blood vessel
• Adherent clots
*
Epinephrine 1:10,000: Up to 10cc of injection may be made in 0.5-1cc aliquots
>
Radionuclear scan (99mTC)
*
Tc-labelled RBCs study is superior to Tc-sulfur colloid study
*
Detects a bleeding rate of 0.1-0.5 ml/min
>
Obtaining images:
*
Tc colloid method: Quickly cleared from the vascular system
V
*
Tc-labeled RBC: Every few hours X 24h — Useful intermittent/low volume bleeds
An advantage is its ability to detect bleeding occurring up to 24h after tracer injection
*
Localizes the bleeding area, but not the site
*
May be false-positive in 25% leading to unwarranted surgery
*
Segmental resection guided by scintigraphy alone leads to unacceptably high rates of postoperative rebleeding
>
CTA
*
Detects a bleeding rate of 0.3-0.5 ml/min
>
Sensitivity
*
~97% when there is transfusion requirement or HD instability
*
~90% when active bleeding is present
*
~45% when bleeding is intermittent
*
Is the best tests with overt active bleeding
>
Angiography
*
Detects a bleeding rate of 0.5-1.0 ml/min
*
If no prior localization is available, start with SMA then IMA and Celiac trunk
*
Koh et al. also found that mesenteric angiography after a positive CTA was 8.56 times more likely to be positive when performed within 90 min of the CTA
*
Rate of success therapy: 70%
V
A point of controversy: prior radionuclear scanning will ↑ success of angiography
*
Pre-angiography CTA followed by therapeutic angiography typically results in administration of similar cumulative volumes of intravenous contrast when compared to angiography preceded by 99mTc-RBC
*
Due to its efficacy and low risk of complications, superselective embolization is now considered by most to be the first-line angiographic therapy for LGIB
*
Capsule endoscopy: Sensitivity 90% & specificity 95% with obscure bleeding
>
Double Balloon Endoscopy
*
Requires 60-90 mins and is labor intensive
*
The approach can evaluate the small bowel either from an oral or anal route
>
Surgery
>
Indications for surgery for diverticular bleeds:
*
Hemodynamic instability
*
Massive transfusion requirements
*
Persistent hemorrhage
>
Blind segmental resection is not appropriate
*
Mortality rate: 30-57%
*
Re-bleeding rate: 33-75%
*
The small bowel should be thoroughly examined to exclude a Meckel’s diverticulum or a palpable mass that could be a source of bleeding.
*
Transillumination of the small bowel may reveal small tumors or angiodysplasia.
*
If the patient is stable, an intraoperative colonoscopy can be performed with luminal lavage and irrigation of sequential segments with proximal compression of the colon. Intraoperative push enteroscopy can also be considered if a colonic source is not identified and there is bright red blood and/or clots in the terminal ileum, though this can be technically challenging and time-consuming.
>
When no localization is done preOp, a subtotal colectomy is done
*
If a clear source cannot be identified and there is no obvious source in the stomach or small bowel (and an anorectal source has been excluded), the bleeding source is presumed to be colonic. In this scenario, and in the face of ongoing hemodynamic instability or ongoing frank hemorrhage, a total abdominal colectomy should be performed
*
Total proctocolectomy in the urgent setting carries a prohibitively high mortality rate, and the leak rate from a primary anastomosis is unacceptably high
V
*
Approach
Pasted_Graphic_12
V
>
Obscure GI bleed
Eval_obscure_GI_bleeding
*
50% have recurrent bleeding
*
Angiodysplasia is the most common cause
V
*
Video capsule endoscopy is the recommended first-line investigation as long as no specific lesion is thought to be the cause of bleeding. Ideally done within 14d of bleeding episode
Capsule endoscopy does not require a bowel preparation, but most patients are instructed to remain either NPO or on a clear liquid diet for 10–12 h prior to the procedure.
>
Stomach/Bowel resection consequence
V
>
Functional outcomes
Screen Shot 2020-04-14 at 4.32.27 PM
>
Stomach — copied from Upper GI section
V
*
Types of reconstruction
Screen Shot 2019-12-02 at 21.30.25
V
For benign ulcer, Billroth-I is preferred over BII or R-en-Y
V
Advantage
*
No duodenal stump leak
*
No afferent loop obstruction
*
No retained antrum syndrome
V
Billroth-II
V
Advantage
*
If patient already had a vagotomy, Billroth-II is preferred over R-en-Y (to ↓ Roux stasis syndrome (gastric atony))
*
BII & R-en-Y are appropriate if extensive kocherization has not created sufficient mobilization
V
The duodenal stump
*
Leak rate 1-3%
*
Leak with BII usually occurs POD6-10
*
A drain is usually placed next to the stump with BII
*
Internal drainage is advised if the stump is questionable
*
Afferent limb ideally no longer than 20 cm to prevent afferent limb syndrome
V
R-en-Y
V
Advantage
*
↓ Bile reflux than BI or BII
*
Without previous vagotomy, R-en-Y may be preferred because of ↓ GERD/esophagitis & remnant gastritis
*
Roux limb of ≥ 40 cm helps prevent bile reflux
*
Ileo-Descending colon anastomosis: 2-3 BM/d (liquid vs formed)
>
Ileorectal anastomosis:
*
5-6 BM (liquid)
*
5% incidence of nighttime seepage
*
68% urgency mostly/sometimes
>
Nutritional consequences
>
Stomach
V
Loss of Intrinsic Factor
V
*
Megaloblastic anemia
The following findings on the blood smear and their associated conditions may be helpful, although none are pathognomonic for a specific condition:
Target cells are suggestive of liver disease.
Macro-ovalocytes are suggestive of a megaloblastic process such as B12, folate, or copper deficiency; or drug-induced megaloblastic anemia.
Neutrophils with more than five distinct lobes (referred to as multilobed or hypersegmented neutrophils) are suggestive of a megaloblastic process.
Neutrophils with fewer than three distinct lobes (referred to as hypolobulated neutrophils or pseudo-Pelger-Huet cells) and/or reduced number of cytoplasmic granules (hypogranular neutrophils) are associated with myelodysplasia
*
Antrectomy → removes G-cells → ↓ gastrin → ↓ parietal cell stimulation → ↓ HCl
V
Vagotomy →
*
↓ HCl secretion by 50%
V
Loss of antral pump function
*
↓ Emptying solids
*
↑ Emptying liquids
V
↓ Fe (stomach metabolizes iron prior to its absorption
*
IDA
V
Post Gastric surgery problems
V
Vitamin D deficiency
*
Occurs with truncal and selective, but not highly selective, vagotomies
>
Duodenum
V
↓Absorption of
*
Fe
*
Ca
*
Folate
*
Mg
>
Jejunum
V
↓Absorption of
*
Fat-soluble vitamins
*
Fatty acids
*
Ca
*
Lactose
>
Terminal Ileum
V
↓Absorption of
*
B12
V
Bile Salts
*
→ Malabsorption diarrhea
*
 
*
Ca
*
Zinc
*
Mg
>
Colon
V
↓Absorption of
*
Bile acids
*
Short chain fatty acids
*
If ↓ Intraluminal Ca (↓PO or by binding to intraluminal fat)→ oxalate is not bound to Ca → ↑absorption in colon → nephrolithiasis (Ca oxalate stones)
>
Leak rate after anastomosis
*
Small bowel - small bowel: 5%
*
Ileocolic: 5-8%
*
Colo-colic: 5-10%
*
Sigmoid: 10%
*
Rectum: 10-15%
*
Low rectum: 15-18%
*
Colo-anal: 18-20%