Colorectal-Surgery

Fistulas

 A fistula is defined as an abnormal connection between two epithelial surfaces.

 There are many types ranging from Branchial fistulae in the neck to entero-
cutaneous fistulae abdominally.
 In general surgical practice the abdominal cavity generates the majority and most
of these arise from diverticular disease and Crohn's.
 As a general rule all fistulae will resolve spontaneously as long as there is no
distal obstruction. This is particularly true of intestinal fistulae.

The four types of fistulae are:

Enterocutaneous
These link the intestine to the skin. They may be high (>500ml) or low output (<250ml)
depending upon source. Duodenal /jejunal fistulae will tend to produce high volume,
electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-
cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the
spontaneous rupture of an abscess cavity onto the skin (such as following perianal
abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even
be surgically desirable e.g. mucous fistula following sub total colectomy for colitis.

Suspect if there is excess fluid in the drain.

Enteroenteric or Enterocolic
This is a fistula that involves the large or small intestine. They may originate in a similar
manner to enterocutaneous fistulae. A particular problem with this fistula type is that
bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly
serious in inflammatory bowel disease.

Enterovaginal
Aetiology as above.

Enterovesical
This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract
infections, or the passage of gas from the urethra during urination.

Management
Some rules relating to fistula management:

 They will heal provided there is no underlying inflammatory bowel disease and
no distal obstruction, so conservative measures may be the best option
 Where there is skin involvement, protect the overlying skin, often using a well
fitted stoma bag- skin damage is difficult to treat
 A high output fistula may be rendered more easily managed by the use of
octreotide, this will tend to reduce the volume of pancreatic secretions.
 Nutritional complications are common especially with high fistula (e.g. high
jejunal or duodenal) these may necessitate the use of TPN to provide nutritional
support together with the concomitant use of octreotide to reduce volume and
protect skin.
 When managing perianal fistulae surgeons should avoid probing the fistula
where acute inflammation is present, this almost always worsens outcomes.
 When perianal fistulae occur secondary to Crohn's disease the best management
option is often to drain acute sepsis and maintain that drainage through the
judicious use of setons whilst medical management is implemented.
 Always attempt to delineate the fistula anatomy, for abscesses and fistulae that
have an intra abdominal source the use of barium and CT studies should show a
track. For perianal fistulae surgeons should recall Goodsall's rule in relation to
internal and external openings.

Rectal bleeding

Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In
the clinical history it is useful to try and localise the anatomical source of the blood.
Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more
suggestive of a proximally sited bleeding source. Blood which has entered the GI tract
from a gastro-duodenal source will typically resemble malaena due to the effects of the
digestive enzymes on the blood itself.

In the table below we give some typical bleeding scenarios together with physical
examination findings and causation.

Cause Type of Features in history Examination findings

bleeding
Fissure in Bright red Painful bleeding that occurs Muco-epithelial defect usually in
ano rectal post defecation in small the midline posteriorly (anterior
bleeding volumes. Usually antecedent fissures more likely to be due to
features of constipation underlying disease)
Haemorroids Bright red Post defecation bleeding noted Normal colon and rectum.
rectal both on toilet paper and drips Proctoscopy may show internal
bleeding into pan. May be alteration of haemorrhoids. Internal
bowel habit and history of haemorrhoids are usually
straining. No blood mixed with impalpable.
stool. No local pain.
Crohns Bright red or Bleeding that is accompanied Perineal inspection may show
disease mixed blood by other symptoms such as fissures or fistulae. Proctoscopy
altered bowel habit, malaise, may demonstrate indurated
history of fissures (especiallymucosa and possibly strictures.
anterior) and abscesses. Skip lesions may be noted at
colonoscopy.
Ulcerative Bright red Diarrhoea, weight loss, Proctitis is the most marked
colitis bleeding nocturnal incontinence, passage finding. Peri anal disease is
often mixed of mucous PR. usually absent. Colonoscopy will
with stool show continuous mucosal lesion.
Rectal cancer Bright red Alteration of bowel habit. Usually obvious mucosal
blood mixed Tenesmus may be present. abnormality. Lesion may be
volumes Symptoms of metastatic fixed or mobile depending upon
disease. disease extent. Surrounding
mucosa often normal, although
polyps may be present.

Image showing a fissure in ano. Typically these are located posteriorly and in the
midline. Fissures at other sites may be associated with underlying disease.
 Image sourced from Wikipedia

Colonoscopic image of internal haemorroids. Note these may often be impalpable.

Image sourced from Wikipedia

Investigation

 All patients presenting with rectal bleeding require digital rectal examination and
procto-sigmoidoscopy as a minimal baseline.
 Remember that haemorrhoids are typically impalpable and to attribute bleeding
to these in the absence of accurate internal inspection is unsatisfactory.
 In young patients with no other concerning features in the history a carefully
performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may
be sufficient. If clear views cannot be obtained then patients require bowel
preparation with an enema and a flexible sigmoidscopy performed.
 In those presenting with features of altered bowel habit or suspicion of
inflammatory bowel disease a colonoscopy is the best test.
 Patients with excessive pain who are suspected of having a fissure may require an
examination under general or local anaesthesia.
 In young patients with external stigmata of fissure and a compatible history it is
acceptable to treat medically and defer internal examination until the fissure is
 healed. If the fissure fails to heal then internal examination becomes necessary
along the lines suggested above to exclude internal disease.

Special tests

 In patients with a malignancy of the rectum the staging investigations comprise

an MRI of the rectum to identify circumferential resection margin compromise
and to identify mesorectal nodal disease. In addition to this CT scanning of the
chest abdomen and pelvis is necessary to stage for more distant disease. Some
centres will still stage the mesorectum with endo rectal ultrasound but this is
becoming far less common.

 Patients with fissure in ano who are being considered for surgical sphincterotomy
and are females who have an obstetric history should probably have ano rectal
manometry testing performed together with endo anal ultrasound. As this service
is not universally available it is not mandatory but in the absence of such
information there are continence issues that may arise following sphincterotomy.

Management

Disease Management
Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first
line treatment. Botulinum toxin for those who fail to respond. Internal
sphincterotomy for those who fail with botox, can be considered earlier in
males.
Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection
sclerotherapy or rubber band ligation. For external haemorrhoids consider
haemorrhoidectomy. Modern options include HALO procedure and stapled
haemorrhoidectomy.
Inflammatory Medical management- although surgery may be needed for fistulating
bowel disease Crohns (setons).
Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum.
Total mesorectal excision is now standard of care. Most resections below
the peritoneal reflection will require defunctioning ileostomy. Most patients
will require preoperative radiotherapy.
Lower Gastrointestinal bleeding

Colonic bleeding
This typically presents as bright red or dark red blood per rectum. Colonic bleeding
rarely presents as malaena type stool, this is because blood in the colon has a powerful
laxative effect and is rarely retained long enough for transformation to occur and
because the digestive enzymes present in the small bowel are not present in the colon.
Up to 15% of patients presenting with haemochezia will have an upper gastrointestinal
source of haemorrhage.

As a general rule right sided bleeds tend to present with darker coloured blood than left
sided bleeds. Haemorrhoidal bleeding typically presents as bright red rectal bleeding
that occurs post defecation either onto toilet paper or into the toilet pan. It is very
unusual for haemorrhoids alone to cause any degree of haemodynamic compromise.

Causes
Cause Presenting features
Colitis Bleeding may be brisk in advanced cases, diarrhoea is commonly present.
Abdominal x-ray may show featureless colon.
Diverticular Acute diverticulitis often is not complicated by major bleeding and
disease diverticular bleeds often occur sporadically. 75% all will cease
spontaneously within 24-48 hours. Bleeding is often dark and of large
volume.
Cancer Colonic cancers often bleed and for many patients this may be the first
sign of the disease. Major bleeding from early lesions is uncommon
Haemorrhoidal Typically bright red bleeding occurring post defecation. Although patients
bleeding may give graphic descriptions bleeding of sufficient volume to cause
haemodynamic compromise is rare.
Angiodysplasia Apart from bleeding, which may be massive, these arteriovenous lesions
cause little in the way of symptoms. The right side of the colon is more
commonly affected.

Management

 Prompt correction of any haemodynamic compromise is required. Unlike upper

gastrointestinal bleeding the first line management is usually supportive. This is
because in the acute setting endoscopy is rarely helpful.
 When haemorrhoidal bleeding is suspected a proctosigmoidoscopy is reasonable
as attempts at full colonoscopy are usually time consuming and often futile.
 In the unstable patient the usual procedure would be an angiogram (either CT or
percutaneous), when these are performed during a period of haemodynamic
 instability they may show a bleeding point and may be the only way of
identifying a patch of angiodysplasia.
 In others who are more stable the standard procedure would be a colonoscopy in
the elective setting. In patients undergoing angiography attempts can be made
to address the lesion in question such as coiling. Otherwise surgery will be
necessary.
 In patients with ulcerative colitis who have significant haemorrhage the standard
approach would be a sub total colectomy, particularly if medical management
has already been tried and is not effective.

Indications for surgery

Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension

Surgery
Selective mesenteric embolisation if life threatening bleeding. This is most helpful if
conducted during a period of relative haemodynamic instability. If all haemodynamic
parameters are normal then the bleeding is most likely to have stopped and any
angiography normal in appearance. In many units a CT angiogram will replace selective
angiography but the same caveats will apply.

If the source of colonic bleeding is unclear; perform a laparotomy, on table colonic

lavage and following this attempt a resection. A blind sub total colectomy is most
unwise, for example bleeding from an small bowel arterio-venous malformation will not
be treated by this manoeuvre.

Summary of Acute Lower GI bleeding recommendations

Consider admission if:
* Over 60 years
* Haemodynamically unstable/profuse PR bleeding
* On aspirin or NSAID
* Significant co morbidity

Management

 All patients should have a history and examination, PR and proctoscopy

  Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding

Colonic polyps

Colonic Polyps
May occur in isolation, or greater numbers as part of the polyposis syndromes. In FAP
greater than 100 polyps are typically present. The risk of malignancy in association with
adenomas is related to size, and is the order of 10% in a 1cm adenoma. Isolated
adenomas seldom give risk of symptoms (unless large and distal). Distally sited villous
lesions may produce mucous and if very large, electrolyte disturbances may occur.

Follow up of colonic polyps

Group
Colorectal cancer
Large non pedunculated colorectal polyps
(LNPCP), R0 resection
Large non pedunculated colorectal polyps
(LNPCP) R1 or non en bloc resection
High risk findings at baseline colonoscopy
No high risk findings at baseline
colonoscopy
Action
Colonoscopy 1 year post resection
One off scope at 3 years
Site check at 2-6 months and then a further
scope at 12 months
One off surveillance at 3 years
No colonoscopic surveillance and invite
participation in NHSBCSP programme when
due

High risk findings

 More than 2 premalignant polyps including 1 or more advanced colorectal polyps

OR

 More than 5 pre malignant polyps

Exceptions to guidelines
If patient more than 10 years younger than lower screening age and has polyps but no
high risk findings, consider colonoscopy at 5 or 10 years.

Segmental resection or complete colectomy should be considered when:

1. Incomplete excision of malignant polyp

2. Malignant sessile polyp
3. Malignant pedunculated polyp with submucosal invasion
4. Polyps with poorly differentiated carcinoma
5. Familial polyposis coli
-Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy
-Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy.

Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.

Colonic polyps

Colonic Polyps
May occur in isolation, or greater numbers as part of the polyposis syndromes. In FAP
greater than 100 polyps are typically present. The risk of malignancy in association with
adenomas is related to size, and is the order of 10% in a 1cm adenoma. Isolated
adenomas seldom give risk of symptoms (unless large and distal). Distally sited villous
lesions may produce mucous and if very large, electrolyte disturbances may occur.

Follow up of colonic polyps

Group
Colorectal cancer
Large non pedunculated colorectal polyps
(LNPCP), R0 resection
Large non pedunculated colorectal polyps
(LNPCP) R1 or non en bloc resection
High risk findings at baseline colonoscopy
No high risk findings at baseline
colonoscopy
Action
Colonoscopy 1 year post resection
One off scope at 3 years
Site check at 2-6 months and then a further
scope at 12 months
One off surveillance at 3 years
No colonoscopic surveillance and invite
participation in NHSBCSP programme when
due

High risk findings

 More than 2 premalignant polyps including 1 or more advanced colorectal polyps

OR

 More than 5 pre malignant polyps

Exceptions to guidelines
If patient more than 10 years younger than lower screening age and has polyps but no
high risk findings, consider colonoscopy at 5 or 10 years.

Segmental resection or complete colectomy should be considered when:

1. Incomplete excision of malignant polyp

2. Malignant sessile polyp
3. Malignant pedunculated polyp with submucosal invasion
4. Polyps with poorly differentiated carcinoma
5. Familial polyposis coli
-Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy
-Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy.

Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.

References
Rutter MD et al. British Society of Gastroenterology/Association of Coloproctology of
Great Britain and Ireland/Public Health England post- polypectomy and post- colorectal
cancer resection surveillance guidelines. Gut 2019;0:123.

Colorectal cancer treatment

Patients diagnosed as having colorectal cancer should be completely staged using CT of the
chest/ abdomen and pelvis. Their entire colon should have been evaluated with colonoscopy or
CT colonography. Patients whose tumours lie below the peritoneal reflection should have their
mesorectum evaluated with MRI.

Once their staging is complete patients should be discussed within a dedicated colorectal MDT
meeting and a treatment plan formulated.

Treatment of colonic cancer

Cancer of the colon is nearly always treated with surgery. Stents, surgical bypass and diversion
stomas may all be used as palliative adjuncts. Resectional surgery is the only option for cure in
patients with colon cancer. The procedure is tailored to the patient and the tumour location. The
lymphatic drainage of the colon follows the arterial supply and therefore most resections are
tailored around the resection of particular lymphatic chains (e.g. ileo-colic pedicle for right sided
tumours). Some patients may have confounding factors that will govern the choice of
procedure, for example a tumour in a patient from a HNPCC family may be better served with a
panproctocolectomy rather than segmental resection. Following resection the decision has to be
made regarding restoration of continuity. For an anastomosis to heal the key technical factors
include; adequate blood supply, mucosal apposition and no tissue tension. Surrounding sepsis,
unstable patients and inexperienced surgeons may compromise these key principles and in such
circumstances it may be safer to construct an end stoma rather than attempting an anastomosis.
When a colonic cancer presents with an obstructing lesion; the options are to either stent it or
resect. In modern practice it is unusual to simply defunction a colonic tumour with a proximal
loop stoma. This differs from the situation in the rectum (see below).
Following resection patients with risk factors for disease recurrence are usually offered
chemotherapy, a combination of 5FU and oxaliplatin is common.

Rectal cancer
The management of rectal cancer is slightly different to that of colonic cancer. This reflects the
rectum's anatomical location and the challenges posed as a result. Tumours located in the
rectum can be surgically resected with either an anterior resection or an abdomino - perineal
resection. The technical aspects governing the choice between these two procedures can be
complex to appreciate and the main point to appreciate for the MRCS is that involvement of the
sphincter complex or very low tumours require APER. In the rectum a 2cm distal clearance
margin is required and this may also impact on the procedure chosen. In addition to excision of
the rectal tube an integral part of the procedure is a meticulous dissection of the mesorectal fat
and lymph nodes (total mesorectal excision/ TME). In rectal cancer surgery invovlement of the
cirumferential resection margin carries a high risk of disease recurrence. Because the rectum is
an extraperitoneal structure (until you remove it that is!) it is possible to irradiate it, something
which cannot be offered for colonic tumours. This has a major impact in rectal cancer treatment
and many patients will be offered neoadjuvent radiotherapy (both long and short course) prior
to resectional surgery. Patients with T1, 2 and 3 /N0 disease on imaging do not require
irradiation and should proceed straight to surgery. Patients with T4 disease will typically have
long course chemo radiotherapy. Patients presenting with large bowel obstruction from rectal
cancer should not undergo resectional surgery without staging as primary treatment (very
different from colonic cancer). This is because rectal surgery is more technically demanding, the
anastomotic leak rate is higher and the danger of a positive resection margin in an unstaged
patient is high. Therefore patients with obstructing rectal cancer should have a defunctioning
loop colostomy.

Summary of procedures
The operations for cancer are segmental resections based on blood supply and lymphatic
drainage. These commonly performed procedures are core knowledge for the MRCS and should
be understood.

Risk of
Site of cancer Type of resection Anastomosis leak

Right colon Right hemicolectomy Ileo-colic Low <5%

Transverse Extended right hemicolectomy Ileo-colic Low <5%

Splenic Extended right hemicolectomy Ileo-colic Low <5%

flexure

Splenic Left hemicolectomy Colo-colon 2-5%

flexure

Left colon Left hemicolectomy Colo-colon 2-5%

Sigmoid colon High anterior resection Colo-rectal 5%

Upper rectum Anterior resection (TME) Colo-rectal 5%

Low rectum Anterior resection (Low TME) Colo-rectal 10%

(+/- Defunctioning
stoma)

Anal verge Abdomino-perineal excision of colon and None n/a

rectum

In the emergency setting, where the bowel has perforated, the risk of an anastomotic
breakdown is much greater, particularly when the anastomosis is colon-colon. In this situation,
an end colostomy is often safer and can be reversed later. When resection of the sigmoid colon
is performed and an end colostomy is fashioned the operation is referred to as a Hartmans
procedure. Whilst left sided resections are more risky, ileo-colic anastomoses are relatively safe
even in the emergency setting and do not need to be defunctioned.

Ano rectal disease

Location: 3, 7, 11 o'clock position

Haemorrhoids Internal or external
Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy
Fissure in ano Location: midline 6 (posterior midline 90%) and 12 o'clock position. Distal
to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae
Proctitis Causes: Crohn's, ulcerative colitis, Clostridium difficile
Ano rectal E.coli, staph aureus
abscess Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric
Anal fistula Usually due to previous ano-rectal abscess
Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric.
Goodsalls rule determines location
Rectal prolapse Associated with childbirth and rectal intussceception. May be internal or
external
Pruritus ani Systemic and local causes
Anal neoplasm Squamous cell carcinoma commonest unlike adenocarcinoma in rectum
Solitary rectal Associated with chronic straining and constipation. Histology shows
ulcer mucosal thickening, lamina propria replaced with collagen and smooth
muscle (fibromuscular obliteration)

Rectal prolapse

 Common especially in multiparous women.

 May be internal or external.
 Internal rectal prolapse can present insidiously.
 External prolapse can ulcerate and in long term impair continence.
 Diagnostic work up includes colonoscopy, defecating proctogram, ano rectal
manometry studies and if doubt exists an examination under anaesthesia.

Treatments for prolapse

 In the acute setting reduce it (covering it with sugar may reduce swelling.
 Delormes procedure which excises mucosa and plicates the rectum (high
recurrence rates) may be used for external prolapse.
 Altmeirs procedure which resects the colon via the perineal route has lower
recurrence rates but carries the risk of anastamotic leak.
 Rectopexy is an abdominal procedure in which the rectum is elevated and usually
supported at the level of the sacral promontory. Post operative constipation may
be reduced by limiting the dissection to the anterior plane (laparoscopic ventral
mesh rectopexy).
Pruritus ani

 Extremely common.
 Check not secondary to altered bowel habits (e.g. Diarrhoea)
 Associated with underlying diseases such as haemorrhoids.
 Examine to look for causes such as worms.
 Proctosigmoidoscopy to identify associated haemorrhoids and exclude cancer.
 Treatment is largely supportive and patients should avoid using perfumed
products around the area.

Fissure in ano

 Typically painful PR bleeding (bright red).

 Nearly always in the posterior midline.
 Usually solitary.

Treatment

 Stool softeners.
 Topical diltiazem (or GTN).
 If topical treatments fail then botulinum toxin should be injected.
 If botulinum toxin fails then males should probably undergo lateral internal
sphincterotomy.
 Females who do not respond to botulinum toxin should undergo ano rectal
manometry studies and endo anal USS prior to being offered surgery such as
sphincterotomy.

Appendicitis

History

 Peri umbilical abdominal pain (visceral stretching of appendix lumen and

appendix is mid gut structure) radiating to the right iliac fossa due to localised
parietal peritoneal inflammation.
 Vomit once or twice but marked and persistent vomiting is unusual.
  Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation
and some loose stools. A pelvic abscess may also cause diarrhoea.
 Mild pyrexia is common - temperature is usually 37.5 -38 oC. Higher temperatures
are more typical of conditions like mesenteric adenitis.
 Anorexia is very common. It is very unusual for patients with appendicitis to be
hungry.

Examination

 Generalised peritonitis if perforation has occurred or localised peritonism.

 Retrocaecal appendicitis may have relatively few signs.
 Digital rectal examination may reveal boggy sensation if pelvic abscess is present,
or even tenderness with a pelvic appendix.

Diagnosis

 Typically raised inflammatory markers coupled with compatible history and

examination findings should be enough to justify appendicectomy.
 Urine analysis may show mild leucocytosis but no nitrites.
 Ultrasound is useful in females where pelvic organ pathology is suspected.
Although it is not always possible to visualise the appendix on ultrasound, the
presence of free fluid (always pathological in males) should raise suspicion.

Ultrasound examination may show evidence of luminal obstruction and thickening of the
appendiceal wall as shown below
 Image sourced from Wikipedia

Treatment

 Appendicectomy which can be performed via either an open or laparoscopic

approach.
 Administration of metronidazole reduces wound infection rates.
 Patients with perforated appendicitis require copious abdominal lavage.
 Patients without peritonitis who have an appendix mass should receive broad
spectrum antibiotics and consideration given to performing an interval
appendicectomy.
 Be wary in the older patients who may have either an underlying caecal
malignancy or perforated sigmoid diverticular disease.

Laparoscopic appendicectomy is becoming increasing popular as demonstrated below

Image sourced
from Wikipedia

Diverticular disease
Diverticular disease is a common surgical problem. It consists of herniation of colonic
mucosa through the muscular wall of the colon. The usual site is between the taenia coli
where vessels pierce the muscle to supply the mucosa. For this reason, the rectum,
which lacks taenia, is often spared.

Symptoms

 Altered bowel habit

 Bleeding
 Abdominal pain

Complications

 Diverticulitis
 Haemorrhage
 Development of fistula
 Perforation and faecal peritonitis
 Perforation and development of abscess
 Development of diverticular phlegmon

Diagnosis
Patients presenting in clinic will typically undergo either a colonoscopy, CT cologram or
barium enema as part of their diagnostic work up. All tests can identify diverticular
disease. It can be far more difficult to confidently exclude cancer, particularly in
diverticular strictures.

Acutely unwell surgical patients should be investigated in a systematic way. Plain

abdominal films and an erect chest x-ray will identify perforation. An abdominal CT scan
(not a CT cologram) with oral and intravenous contrast will help to identify whether
acute inflammation is present but also the presence of local complications such as
abscess formation.

Severity Classification- Hinchey

I Para-colonic abscess
II Pelvic abscess
III Purulent peritonitis
IV Faecal peritonitis
Treatment

 Increase dietary fibre intake.

 Mild attacks of diverticulitis may be managed conservatively with antibiotics.
 Peri colonic abscesses should be drained either surgically or radiologically.
 Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative
indication for a segmental resection.
 Hinchey IV perforations (generalised faecal peritonitis) will require a resection
and usually a stoma. This group have a very high risk of post operative
complications and usually require HDU admission.

Colorectal cancer

 Annually, about 150,000 new cases are diagnosed and 50,000 deaths from the
disease
 About 75% will have sporadic disease and 25% will have a family history
 Colorectal tumours comprise a spectrum of disease ranging from adenomas
through to polyp cancers and frank malignancy.
 Polyps may be categorised into: neoplastic polyps, adenomatous polyps and non
neoplastic polyps.
 The majority of adenomas are polypoidal lesions, although flat lesions do occur
and may prove to be dysplastic.
 Non-neoplastic polyps include hyperplastic, juvenile, hamartomatous,
inflammatory, and lymphoid polyps, which have not generally been thought of as
precursors of cancer.
 Three characteristics of adenomas that correlate with malignant potential have
been characterised. These include increased size, villous architecture and
dysplasia. For this reason most polyps identified at colonoscopy should be
removed.
 The transformation from polyp to cancer is described by the adenoma -
carcinoma sequence and its principles should be appreciated. Essentially genetic
changes accompany the transition from adenoma to carcinoma; key changes
include APC, c-myc, K RAS mutations and p53 deletions.

Crohns disease
Crohns disease is a chronic transmural inflammation of a segment(s) of the
gastrointestinal tract and may be associated with extra intestinal manifestations.
Frequent disease patterns observed include ileal, ileocolic and colonic disease. Peri-anal
disease may occur in association with any of these. The disease is often discontinuous in
its distribution. Inflammation may cause ulceration, fissures, fistulas and fibrosis with
stricturing. Histology reveals a chronic inflammatory infiltrate that is usually patchy and
transmural.

Ulcerative colitis Vs Crohns

Crohn's disease Ulcerative colitis
Distribution Mouth to anus Rectum and colon
Macroscopic Cobblestone appearance, apthoid Contact bleeding
changes ulceration
Depth of disease Transmural inflammation Superficial inflammation
Distribution Patchy Continuous
pattern
Histological Granulomas (non caseating epithelioid cell Crypt abscesses, Inflammatory
features aggregates with Langhans' giant cells) cells in the lamina propria

Extraintestinal manifestations of Crohns

Related to disease extent
Aphthous ulcers (10%)
Erythema nodosum (5-10%)
Pyoderma gangrenosum (0.5%)
Acute arthropathy (6-12%)
Ocular complications (up to 10%)
Unrelated to disease extent
Sacroiliiitis (10-15%)
Ankylosing spondylitis (1-2%)
Primary sclerosing cholangitis (Rare)
Gallstones (up to 30%)
Renal calculi (up to 10%)

Diarrhoea in Crohns
Diarrhoea in Crohns may be multifactorial since actual inflammation of the colon is not
common. Causes therefore include the following:

 Bile salt diarrhoea secondary to terminal ileal disease

 Entero-colic fistula
 Short bowel due to multiple resections
 Bacterial overgrowth

Surgical interventions in Crohns disease

The commonest disease pattern in Crohns is stricturing terminal ileal disease and this
often culminates in an ileocaecal resection. Other procedures performed include
segmental small bowel resections and stricturoplasty. Colonic involvement in patients
with Crohns is not common and, where found, distribution is often segmental. However,
despite this distribution segmental resections of the colon in patients with Crohns
disease are generally not advocated because the recurrence rate in the remaining colon
is extremely high. As a result, the standard options of colonic surgery in Crohns patients
are generally; sub total colectomy, panproctocolectomy and staged sub total colectomy
and proctectomy. Restorative procedures such as ileoanal pouch have no role in
therapy.
Crohns disease is notorious for the developmental of intestinal fistulae; these may form
between the rectum and skin (peri anal) or the small bowel and skin. Fistulation between
loops of bowel may also occur and result in bacterial overgrowth and malabsorption.
Management of enterocutaneous fistulae involves controlling sepsis, optimising
nutrition, imaging the disease and planning definitive surgical management.

Large bowel obstruction

Colonic obstruction remains a common surgical problem. It is most commonly due to

malignancy (60%) and diverticular disease (20%). Volvulus affecting the colon accounts for 5% of
cases. Acute colonic pseudo-obstruction remains a potential differential diagnosis in all cases.
Intussusception affecting the colon (most often due to tumours in the adult population) remains
a rare but recognised cause.
The typical patient will present with gradual onset of progressive abdominal distension, colicky
abdominal pain and either obstipation or absolute constipation.
On examination abdominal distension is present, the presence of caecal tenderness (assuming
no overt evidence of peritonitis) is a useful sign to elicit. A digital rectal examination and rigid
sigmoidoscopy should be performed.
A plain abdominal x-ray is the usual first line test and; the caecal diameter and ileocaecal valve
competency should be assessed on this film.

Imaging modalities
Debate long surrounds the use of CT versus gastrograffin enemas. The latter investigation has
always been the traditional method of determining whether a structural lesion is indeed present.
However, in the UK the use of this technique has declined and in most units a CT scan will be
offered as the first line investigation by the majority of radiologists (and is advocated by the
ACPGBI). In most cases this will provide sufficient detail to allow operative planning, and since
malignancy accounts for most presentations may also stage the disease. In the event that the
radiologist cannot provide a clear statement of lesion site, the surgeon should have no
hesitation in requesting a contrast enema.
Surgical options
The decision as to when to operate or not is determined firstly by the patients physiological
status. Unstable patients require resuscitation prior to surgery and admission to a critical care
unit for invasive monitoring and potential inotropic support may be needed. In patients who are
otherwise stable the decision then rests on the radiological and clinical findings. As a general
rule the old adage that the sun should not rise and set on unrelieved large bowel obstruction
still holds true. A caecal diameter of 12cm or more in the presence of complete obstruction with
a competent ileocaecal valve and caecal tenderness is a sign of impending perforation and a
relative indication for prompt surgery.

Right sided and transverse lesions

Right sided lesions producing large bowel obstruction should generally be treated by right
hemicolectomy or its extended variant if the lesion lies in the distal transverse colon or splenic
flexure. In these cases an ileocolic anastomosis may be easily constructed and even in the
emergency setting has a low risk of anastomotic leak.

Left sided lesions

The options here lie between sub total colectomy and anastomosis, left hemicolectomy with on
table lavage and primary anastomosis, left hemicolectomy and end colostomy formation and
finally colonic stent insertion.
The usefulness of colonic stents was the subject of a Cochrane review in 2011. The authors
concluded that on the basis of the data that they reviewed, there was no benefit from the use of
colonic stents over conventional surgical resection with a tendency to better outcomes seen in
the surgical group (1). A more recently conducted meta analysis met with the same conclusion
(2). However, the recently concluded CREST trial has suggested that self expanding metallic
stents can improve outcomes and avoids a stoma.

Rectosigmoid lesions
Lesions below the peritoneal reflection that are causing obstruction should generally be treated
with a loop colostomy. Primary resection of unstaged rectal cancer would most likely carry a
high CRM positivity rate and cannot be condoned. Where the lesion occupies the distal sigmoid
colon the usual practice would be to perform a high anterior resection. The decision
surrounding restoration of intestinal continuity would lie with the operating surgeon.

Anal cancer
- Cancers arising from the squamous epithelium of the anal canal

 Arise inferior to the dentate line

 Strongly linked to HPV type 16 infection
 Other risk factors include ano-receptive intercourse, smoking and
immunosuppression
 Presenting symptoms include anal discomfort, discharge or pruritus
 Lymphatic spread typically occurs to the inguinal nodes
 Diagnosis is made by EUA and biopsies
 Staging is with CT scanning of the chest, abdomen and pelvis
 First line treatment is typically with chemoradiotherapy
 Second line treatment for non metastatic disease is with salvage radical
abdominoperineal excision of the anus and rectum

Anal fissure

Anal fissures are a common cause of painful, bright red, rectal bleeding.
Most fissures are idiopathic and present as a painful mucocutaneous defect in the
posterior midline (90% cases). Fissures are more likely to be anteriorly located in
females, particularly if they are multiparous. Multiple fissures and those which are
located at other sites are more likely to be due to an underlying cause.
Diseases associated with fissure in ano include:

 Crohns disease
 Tuberculosis
 Internal rectal prolapse

Diagnosis
In most cases the defect can be visualised as a posterior midline epithelial defect. Where
symptoms are highly suggestive of the condition and examination findings are unclear
an examination under anaesthesia may be helpful. Atypical disease presentation should
be investigated with colonoscopy and EUA with biopsies of the area.

Treatment
Stool softeners are important as the hard stools may tear the epithelium and result in
recurrent symptoms. The most effective first line agents are topically applied GTN (0.2%)
or Diltiazem (2%) paste. Side effects of diltiazem are better tolerated.
Resistant cases may benefit from injection of botulinum toxin or lateral internal
sphincterotomy (beware in females). Advancement flaps may be used to treat resistant
cases.
Sphincterotomy produces the best healing rates. It is associated with incontinence to
flatus in up to 10% of patients in the long term.
Anal fistula

Fistula in ano is the most common form of ano rectal sepsis. Fistulae will have both an internal
opening and external opening, these will be connected by tract(s). Complexity arises because of
the potential for multiple entry and exit sites, together with multiple tracts. Fistulae are classified
into four main groups according to anatomical location and the degree of sphincter
involvement. Simple uncomplicated fistulae are low and do not involve more than 30% of the
external sphincter. Complex fistulae involve the sphincter, have multiple branches or are non
cryptoglandular in origin[1]

Assessment
Examination of the perineum for signs of trauma, external openings or the stigmata of IBD is
important. Digital rectal examination may reveal the cord linking the internal and external
openings. At the same time the integrity of the sphincter mechanism can be assessed. Low,
uncomplicated fistulas may not require any further assessment, other groups will usually require
more detailed investigation. For the fistula, the use of endo-anal USS with instillation of
hydrogen peroxide into the fistula tract may be helpful. Ano-rectal MRI scanning is also a useful
tool, it is sensitive and specific for the identification of fistula anatomy, branching tracts and
identifying occult sphincter involvement[2].

Identification of the internal opening

Fistulas with an external opening less than 3cm from the anal verge will typically obey Goodsalls
rule (see below).
 Image sourced from Wikipedia

Therapies
Seton suture
A seton is a piece of material that is passed through the fistula between the internal and external
openings that allows the drainage of sepsis. This is important as undrained septic foci may drain
along the path of least resistance, which may result in the development of accessory tracts and
openings. Their main use is in treating complex fistula. Two types of seton are recognised,
simple and cutting. Simple setons lie within the fistula tract and encourage both drainage and
fibrosis. A cutting seton is inserted and the skin incised. The suture is tightened and re-tightened
at regular intervals. This may convert a high fistula to a low fistula. Since the tissue will scar
surrounding the fistula it is hoped that this technique will minimise incontinence[3].
Unfortunately, a large retrospective review of the literature related to the use of cutting setons
has found that they are associated with a 12% long term incontinence rate [4]

Fistulotomy
Low fistulas, that are simple should be treated by fistulotomy once the acute sepsis has been
controlled. Fistulotomy (where safe) provides the highest healing rates [5]. Because fistulotomy
is regarded as having a high cure rate, there are some who prefer to use this technique with
more extensive sphincter involvement. In these patients the fistulotomy is performed as for a
low fistula. However, the muscle that is encountered is then divided and reconstructed with an
overlapping sphincter repair. A price is paid in terms of incontinence with this technique and up
to 12.5% of patients who were continent pre-operatively will have issues relating to continence
post procedure[6]. The same group also randomised between fistulotomy and sphincter
reconstruction and ano-rectal advancement flaps for the treatment of complex cryptoglandular
fistulas and reported similar outcomes in terms of recurrence (>90%) and disturbances to
continence (20%)[7].
Other authors have found adverse outcomes following fistulotomy in patients who have
undergone previous surgery, are of female gender or who have high internal openings [8], in
these patients careful assessment of pre-operative sphincter function should be considered
mandatory prior to fistulotomy.

Anal fistula plugs and fibrin glue

The desire to avoid injury to the sphincter complex has led to surgeons using both fibrin glue
and plugs to try and improve fistula healing. Meticulous preparation of the tract and prior use of
a draining seton is likely to improve chances of success.
The use of anal fistula plugs in high transphincteric fistula of cryptoglandular origin is to be
discouraged because of the high incidence of non response in patients treated with such
devices [9]In most patients septic complications are the reasons for failure [10]. Fibrin glue is a
popular option for the treatment of fistula. There is variability of reported healing rates In some
cases initial success rates of up to 50% healing at six months are reported (in patients with
complex cryptogenic fistula). Of these successes 25% suffer a long term recurrence of fistula
[11]. There are, however, no obvious cases of damage to the sphincter complex and the use of
the devices does not appear to adversely impact on subsequent surgical options.

Ano-rectal advancement flaps

This procedure is primarily directed at high fistulae, and is considered attractive as a sphincter
saving operation. The procedure is performed either with the patient in the prone jack knife
position or in lithotomy (depending upon the site of the fistula). The dissection is commenced in
the sub mucosal plane (which may be infiltrated with dilute adrenaline solution to ease
dissection). The dissection is continued into healthy proximal tissue. This is brought down and
sutured over the defect.
Follow up of patients with cryptoglandular fistulas treated with advancement flaps shows a
success in up to 80% patients[12-14]. With most recurrences occurring in the first 6 months
following surgery[12]. Continence was affected in some patients, with up to 10% describing
major continence issues post operatively.

Ligation of the intersphincteric tract procedure

In this procedure an incision is made in the intersphincteric groove and the fistula tract
dissected out in this plane and divided. A greater than 90% cure rate within 4 weeks was initially
reported[15]. Others have subsequently performed similar studies on larger numbers of patients
with similar success rates.
Fistulotomy at the time of abscess drainage?
A Cochrane review conducted in 2010 suggests that primary fistulotomy for low, uncomplicated
fistula in ano may be safe and associated with better outcomes in relation to long term chronic
sepsis[16]. However, there is a danger that such surgery performed by non specialists may result
in a higher complication rate and therefore the traditional teaching is that primary treatment of
acute sepsis is incision and drainage only. All agree that high/ complex fistulae should never be
subject to primary fistulotomy in the acute setting.

Colonic obstruction

Cause Features Treatment

Cancer  Usually insidious onset
 History of progressive constipation
 Systemic features (e.g. anaemia)
 Abdominal distension
 Absence of bowel gas distal to site of
obstruction
Establish diagnosis (e.g.
contrast enema/ endoscopy)
Laparotomy and resection,
stenting, defunctioning
colostomy or bypass

Diverticular  Usually history of previous acute Once diagnosis established,

stricture diverticulitis usually surgical resection
 Long history of altered bowel habit Colonic stenting should not
 Evidence of diverticulosis on imaging be performed for benign
or endoscopy disease

Volvulus  Twisting of bowel around its mesentery Initial treatment is to

 Sigmoid colon affected in 76% cases untwist the loop, a flexible
 Patients usually present with abdominal sigmoidoscopy may be
pain, bloating and constipation needed
 Examination usually shows Those with clinical
asymmetrical distension evidence of ischaemia
 Plain X-rays usually show massively should undergo surgery
dilated sigmoid colon, loss of haustra Patient with recurrent
and U shape are typical, the loop may volvulus should undergo
contain fluid levels resection

Acute colonic  Symptoms and signs of large bowel Colonoscopic

pseudo- obstruction with no lesion decompression
obstruction  Usually associated with metabolic Correct metabolic disorders
disorders IV neostigmine
 Usually a cut off in the left colon (82% Surgery
cases)
 Although abdomen tense and distended,
it is usually not painful
 Cause Features Treatment
 All patients should undergo contrast
enema (may be therapeutic)

Ulcerative colitis

Ulcerative colitis is a form of inflammatory bowel disease. Inflammation always starts at

rectum, does not spread beyond ileocaecal valve (although backwash ileitis may occur)
and is continuous. The peak incidence of ulcerative colitis is in people aged 15-25 years
and in those aged 55-65 years. It is less common in smokers.

The initial presentation is usually following insidious and intermittent symptoms.

Features include:

 bloody diarrhoea
 urgency
 tenesmus
 abdominal pain, particularly in the left lower quadrant
 extra-intestinal features (see below)

Questions regarding the 'extra-intestinal' features of inflammatory bowel disease are

common. Extra-intestinal features include sclerosing cholangitis, iritis and ankylosing
spondylitis.

Common to both Crohn's disease Notes

(CD) and Ulcerative colitis (UC)
Related to Arthritis: pauciarticular, asymmetric Arthritis is the most common extra-
disease activity Erythema nodosum intestinal feature in both CD and
Episcleritis UC
Osteoporosis Episcleritis is more common in
Crohns disease
Unrelated to Arthritis: polyarticular, symmetric Primary sclerosing cholangitis is
disease activity Uveitis much more common in UC
Pyoderma gangrenosum Uveitis is more common in UC
Clubbing
Primary sclerosing cholangitis

Pathology
  Red, raw mucosa, bleeds easily
 No inflammation beyond submucosa (unless fulminant disease)
 Widespread superficial ulceration with preservation of adjacent mucosa which
has the appearance of polyps ('pseudopolyps')
 Inflammatory cell infiltrate in lamina propria
 Neutrophils migrate through the walls of glands to form crypt abscesses
 Depletion of goblet cells and mucin from gland epithelium
 Granulomas are infrequent

Barium enema

 Loss of haustrations
 Superficial ulceration, 'pseudopolyps'
 Long standing disease: colon is narrow and short -'drainpipe colon'

Endoscopy

 Superficial inflammation of the colonic and rectal mucosa

 Continuous disease from rectum proximally
 Superficial ulceration, mucosal islands, loss of vascular definition and continuous
ulceration pattern.

Management

 Patients with long term disease are at increased risk of development of

malignancy
 Acute exacerbations are generally managed with steroids, in chronic patients
agents such as azathioprine and infliximab may be used
 Individuals with medically unresponsive disease usually require surgery- in the
acute phase a sub total colectomy and end ileostomy. In the longer term a
proctectomy will be required. An ileoanal pouch is an option for selected patients

Benign proctology

Condition Features Treatment

Fissure in ano Painful, bright red rectal bleeding Stool softeners, topical diltiazem or GTN,
botulinum toxin, Sphincterotomy

Haemorroids Painless, bright red rectal bleeding Stool softeners, avoid straining, surgery (see
occurs following defecation and bleeds below)
onto the toilet paper and into the toilet
pan

Fistula in ano May initially present with an abscess Lay open if low, no sphincter involvement or
and then persisting discharge onto the IBD, if complex, high or IBD insert seton and
perineum, separate from the anus consider other options (see below)

Peri anal Peri anal swelling and surrounding Incision and drainage, leave the cavity open
abscess erythema to heal by secondary intention

Pruritus ani Peri anal itching, occasional mild Avoid scented products, use wet wipes
bleeding (if severe skin damage) rather than tissue, avoidance of scratching,
ensure no underlying faecal incontinence

Overview of surgical therapies

Haemorroidal disease
The treatment of haemorroids is usually conservative. Acutely thrombosed haemorroids may be
extremely painful. Treatment of this acute condition is usually conservative and consists of stool
softeners, ice compressions and topical GTN or diltiazem to reduce sphincter spasm. Most cases
managed with this approach will settle over the next 5-7 days. After this period there may be
residual skin tags that merit surgical excision or indeed residual haemorroidal disease that may
necessitate haemorroidectomy.
Patients with more chronic symptoms are managed according to the stage of their disease,
small mild internal haemorroids causing little symptoms are best managed conservatively. More
marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is
largely internal may benefit from stapled haemorroidopexy. This procedure excises rectal tissue
above the dentate line and disrupts the haemorroidal blood supply. At the same time the
excisional component of the procedure means that the haemorroids are less prone to prolapse.
Adverse effects of this procedure include urgency, which can affect up to 40% of patients (but
settles over 6-12 months) and recurrence. The procedure does not address skin tags and
therefore this procedure is unsuitable if this is the dominant symptom.
Large haemorroids with a substantial external component may be best managed with a Milligan
Morgan style conventional haemorroidectomy. In this procedure three haemorroidal cushions
are excised, together with their vascular pedicle. Excision of excessive volumes of tissue may
result in anal stenosis. The procedure is quite painful and most surgeons prescribe
metronidazole post operatively as it decreases post operative pain.

Fissure in ano
Probably the most efficient and definitive treatment for fissure in ano is lateral internal
sphincterotomy. The treatment is permanent and nearly all patients will recover. Up to 30% will
develop incontinence to flatus. There are justifiable concerns about using this procedure in
females as pregnancy and pelvic floor damage together with a sphincterotomy may result in
faecal incontinence. The usual first line therapy is relaxation of the internal sphincter with either
GTN or diltiazem (the latter being better tolerated) applied topically for 6 weeks. Treatment
failures with topical therapy will usually go on to have treatment with botulinum toxin. This leads
to more permanent changes in the sphincter and this may facilitate healing.
Typical fissures usually present in the posterior midline, multiple or unusually located fissures
should prompt a search for an underlying cause such as inflammatory bowel disease or internal
prolapse.
Refractory cases where the above treatments have failed may be considered for advancement
flaps.

Fistula in ano
The most effective treatment for fistula is laying it open (fistulotomy). When the fistula is below
the sphincter and uncomplicated, this is a reasonable option. Sphincter involvement and
complex underlying disease should be assessed both surgically and ideally with imaging (either
MRI or endoanal USS). Surgery is then usually staged, in the first instance a draining seton
suture may be inserted. This avoids the development of recurrent sepsis and may allow
resolution. In patients with Crohns disease the seton should be left in situ long term and the
patient managed medically, as in these cases attempts at complex surgical repair nearly always
fail. Fistulas not associated with IBD may be managed by advancement flaps, instillation of plugs
and glue is generally unsuccessful. A newer technique of ligation of intersphincteric tract (LIFT
procedure) is reported to have good results in selected centres.

IBD

Ulcerative colitis Vs Crohns

Crohn's disease Ulcerative colitis

Distribution Mouth to anus Rectum and colon

 Crohn's disease Ulcerative colitis

Macroscopic Cobblestone appearance, apthoid ulceration Contact bleeding

changes

Depth of disease Transmural inflammation Superficial inflammation

Distribution Patchy Continuous

pattern

Histological Granulomas (non caseating epithelioid cell Crypt abscesses, Inflammatory

features aggregates with Langerhans' giant cells) cells in the lamina propria

Surgical treatment

Ulcerative colitis
In UC the main place for surgery is when medical treatment has failed, in the emergency setting
this will be a sub total colectomy, end ileostomy and a mucous fistula. Electively it will be a pan
proctocolectomy, an ileoanal pouch may be a selected option for some. Remember that
longstanding UC increases colorectal cancer risk.
 Image sourced from Wikipedia

Crohn's disease
Unlike UC Crohn's patients need to avoid surgeons, minimal resections are the rule. They should
not have ileoanal pouches as they will do poorly with them. Management of Crohn's ano rectal
sepsis is with a minimal approach, simply drain sepsis and use setons to facilitate drainage.
Definitive fistula surgery should be avoided.

Image sourced
from Wikipedia

Pilonidal sinus

 Occur as a result of hair debris creating sinuses in the skin (Bascom theory).
 Usually in the natal cleft of male patients after puberty.
 It is more common in Caucasians related to their hair type and growth patterns.
 The opening of the sinus is lined by squamous epithelium, but most of its wall
consists of granulation tissue. Up to 50 cases of squamous cell carcinoma have
been described in patients with chronic pilonidal sinus disease.
 Hairs become trapped within the sinus.
 Clinically the sinus presents when acute inflammation occurs, leading to an
abscess. Patients may describe cycles of being asymptomatic and periods of pain
and discharge from the sinus.
 Treatment is difficult and opinions differ. Definitive treatment should never be
undertaken when acute infection or abscess is present as this will result in failure.
 Definitive treatments include the Bascom procedure with excision of the pits and
obliteration of the underlying cavity. The Karydakis procedure involves wide
excision of the natal cleft such that the surface is recontoured once the wound is
closed. This avoids the shearing forces that break off the hairs and has reasonable
results.

Surgery for inflammatory bowel disease

Patients with inflammatory bowel disease (UC and Crohns) frequently present in surgical
practice. Ulcerative colitis may be cured by surgical resection (Proctocolectomy), this is
not the case in Crohns disease which may recur and affect other areas of the
gastrointestinal tract.
Ulcerative colitis

 Elective indications for surgery include disease that is requiring maximal therapy,
or prolonged courses of steroids.
 Longstanding UC is associated with a risk of malignant transformation. Dysplastic
transformation of the colonic epithelium with associated mass lesions is an
absolute indication for a proctocolectomy.
 Emergency presentations of poorly controlled colitis that fails to respond to
medical therapy should usually be managed with a sub total colectomy. Excision
of the rectum is a procedure with a higher morbidity and is not generally
performed in the emergency setting. An end ileostomy is usually created and the
rectum either stapled off and left in situ, or, if the bowel is very oedematous, may
be brought to the surface as a mucous fistula.
 Patients with IBD have a high incidence of DVT and appropriate
thromboprophylaxis is mandatory.
 Restorative options in UC include an ileoanal pouch. This procedure can only be
performed whilst the rectum is in situ and cannot usually be undertaken as a
delayed procedure following proctectomy.
 Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and
poor physiological function with seepage and soiling.

Crohns disease

 Surgical resection of Crohns disease does not equate with cure, but may produce
substantial symptomatic improvement.
 Indications for surgery include complications such as fistulae, abscess formation
and strictures.
 Extensive small bowel resections may result in short bowel syndrome and
localised stricturoplasty may allow preservation of intestinal length.
 Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g.
MRI enteroclysis).
 Complex perianal fistulae are best managed with long term draining seton
sutures, complex attempts at fistula closure e.g. advancement flaps, may be
complicated by non healing and fistula recurrence.
 Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch
reconstruction in Crohns carries a high risk of fistula formation and pouch failure
and is not recommended.
  Terminal ileal Crohns remains the commonest disease site and these patients may
be treated with limited ileocaecal resections.
 Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the
risk of gallstones.

Colonic pseudo-obstruction

Colonic pseudo-obstruction is characterised by the progressive and painless dilation of the

colon. The abdomen may become grossly distended and tympanic. Unless a complication such
as impending bowel necrosis or perforation occurs, there is usually little pain.
Diagnosis involves excluding a mechanical bowel obstruction with a plain film and contrast
enema. The underlying cause is usually electrolyte imbalance and the condition will resolve with
correction of this and supportive care.
Patients who do not respond to supportive measures should be treated with attempted
colonoscopic decompression and/ or the drug neostigmine. In rare cases surgery may be
required.

Ileostomy

Ileostomies are generally fashioned in the right iliac fossa in a triangle between the anterior
superior iliac spine, symphysis pubis and umbilicus. They should lie one-third of the distance
between the umbilicus and anterior superior iliac spine. A 2cm skin incision is made and
dissection continued through the rectus muscle. A cruciate incision should be made, and
generally dilated to admit two fingers. The ileum is brought through the incisions and should
generally be spouted to a final length of 2.5cm. Ileostomies that are too short may cause
problems with appliance fixation and those which are too long may cause problems with tension
and subsequent ulceration or prolapse.

Complications following ileostomy construction include dermatitis (most common), bowel

obstruction (usually adhesional) and prolapse.

Ileostomy output is roughly in the range of 5-10ml/Kg/ 24 hours. Output in excess of

20ml/Kg/24 hours usually requires supplementary intravenous fluids. Excessive fluid losses are
generally managed by administration of oral loperamide (up to 4mg QDS) to try and slow the
output. Foods containing gelatine may also thicken output. Early high output is not uncommon
and most patients (50%) will respond to conservative management.

Laxatives

Bulk forming laxatives

Bran
Psyllium
Methylcellulose

Osmotic laxatives

Magnesium sulphate
Magnesium citrate
Sodium phosphate
Sodium sulphate
Potassium sodium tatrate
Polyethylene glycol
Docusate

Stimulant laxatives

Bisacodyl
Sodium picosulphate
Senna
Ricinoleic acid

Rectal prolapse

Rectal prolapse may be divided into internal and external prolapse. Patients with the
former condition may have internal intussceception of the rectum and present with
constipation, obstructed defecation and occasionally faecal incontinence. Patients with
external rectal prolapse have a full thickness external protrusion of the rectum. Risk
factors for the condition include multiparity, pelvic floor trauma and connective tissue
disorders.

Diagnosis
External prolapse is usually evident. Internal prolapse may be identified by defecating
proctography and examination under anaesthesia.
Sinister pathology should be excluded with endoscopy

Treatment
 Perineal approaches include the Delormes operation, this avoids resection and is
relatively safe but is associated with high recurrence rates. An Altmeirs operation
involves a perineal excision of the sigmoid colon and rectum, it may be a more
effective procedure than a Delormes but carries the risk of anastomotic leak.
 Rectopexy - this is an abdominal procedure. The rectum is mobilised and fixed
onto the sacral promontary. A prosthetic mesh may be inserted. The recurrence
rates are low and the procedure is well tolerated (particularly if performed
laparoscopically). Risks with ventral mesh rectopexy include chronic pain and
visceral mesh erosions.
 Thirsch tape- this is a largely historical procedure and involves encircling the
rectum with tape or wire. It may be of use in a palliative setting.