Lower GI Surgery for Finals

Alasdair Scott BSc MBBS MRCS PhD

Clinical Lecturer and Colorectal Surgical Trainee

as703@ic.ac.uk

28/11/2019
Contents
1. Malignant
a) Colorectal cancer
b) Anal cancer

2. Benign
a) Perianal disease
b) Inflammatory bowel disease

3. Emergency
a) Diverticular disease
b) Bowel obstruction
c) Bowel ischaemia
d) Lower GI bleeding
Malignant Conditions
Colorectal Ca - Epidemiology
All cancers Colorectal cancer

<10% >90%
Colorectal Ca - Pathophysiology

Adenoma Invasive carcinoma

Colorectal Ca - Risk Factors
Male sex, ↑ age Inflammatory bowel disease

Genetic syndromes
Family history
• FAP
• HNPCC
Colorectal Ca - Pathology
Metastases
• Liver
95% adenocarcinoma • Lung
• Peritoneal
Colorectal Ca - Presentation
Elective Emergency
Colorectal Ca - Investigation
Diagnosis Staging Surveillance
• Colonoscopy + biopsy • CT Chest, abdomen and pelvis • CEA
• CT Pneumocolon • MRI for rectal cancer • CT +/- PET
• Frail • Endoscopy
• Unable to tolerate bowel preparation
Colorectal Ca - Treatment: MDT

Radiology
Pathology

Cancer
nurse
specialist
Gastro-
Patient enterology

Stoma
nurse

Oncology
Surgeon
Colorectal Ca - Treatment: Resections
Right hemicolectomy / Sigmoid colectomy Anterior Resection / Total Abdominoperineal
extended right mesorectal excision (TME) resection
Anatomy

Tumour Caecum to splenic flexure Sigmoid colon Rectum Low rectum

Anastomosis Ileo-colic Colo-rectal Colo-rectal, or NA
Colo-anal
Incision (if Midline, or Midline Midline Midline and perineal
open) Right transverse (no anus)
Stoma No Temporary loop Temporary loop Permanent end
ileostomy (unusual) ileostomy (common) colostomy
Colorectal Ca - Treatment: Chemo / Radio / Biologics
Neo-Adjuvant Therapy Adjuvant Therapy
Radiotherapy
Chemotherapy Surgery Chemotherapy

• Chemo- / radio-therapy prior to surgery • Chemotherapy after surgery

• Aim is to down-stage the tumour prior to • Aim is to lower the risk of local recurrence and
surgery and lower risk of local recurrence distant disease and prolong overall survival.
• Only routinely used in locally advanced • Used for stage II/III colon or rectal cancer
rectal cancer
Palliative Therapy
Chemotherapy
• For unresectable / incurable disease (stage 4)
• Aim to prolong survival
Colorectal Cancer - Summary
1. Epidemiology 4. Pathology 6. Investigation
– 4th commonest cancer – 95% adenocarcinoma – Diagnosis
– Lifetime UK risk: 1 in 15 males and 1 in 18 – ~30% rectum • Colonoscopy + biopsy
females – ~30% sigmoid • CT pneumocolon
– Peak incidence 85-89 years – ~20% caecum / ascending – Staging
– >90% cases diagnosed in over 50s – Metastases • CT abdomen and chest
• Liver • MRI (rectum)
2. Pathophysiology • Lung – Surveillance
– Adenomas  carcinomas • Peritoneum • CEA
– Mounting genetic changes • CT +/- PET
5. Presentation
– Anorectal mass 7. Treatment
3. Risk Factors
– Anorectal bleeding – Within the LGI MDT
– Age
– Change in bowel habit – Surgery
– Male sex
– Weight loss • Resection
– IBD
– Anaemia • Diversion
– Family history
– Abdominal pain – Chemo- / radio-therapy
– Genetic syndromes: FAP, HNPCC
– Large bowel obstruction
– Obesity
– ↑ animal fat / protein and ↓ fibre
Anal Cancer
HPV: esp. 16, 18, 31 and 33

Anal mass

Squamous
cell cancer
Inguinal
lymph nodes

Chemoradiotherapy
Anal Cancer - Summary
1. Epidemiology 4. Pathology 6. Investigation
– Relatively rare: 2/100 000 incidence – Nearly all variants of – Diagnosis
squamous cell carcinomas • EUA + Biopsy
– Lymphatic drainage – Staging
2. Pathophysiology
• Above dentate  • CT abdomen and chest
– Squamous intraepithelial lesion (SIL)
internal iliac nodes • CT PET
• LSIL: low-grade
• Below dentate  • MRI
• HSIL high-grade inguinal nodes
– LSIL  HSIL  SCC
– But, most LSIL and HSIL will not progress 7. Treatment
to SCC 5. Presentation – Within the LGI MDT
– Anal mass – Chemoradiotherapy
– Pruritis anal – Surgery (APR)
3. Risk Factors – Anal bleeding • Rare
– HPV: esp. 16, 18, 31 and 33 – Incontinence • For recurrent or non-responsive
– HIV – Fistula-in-ano disease
– MSM
– Smoking
– Age
Benign Conditions
Haemorrhoids
Pain if prolapsed and
thrombosed

Painless PR bleeding
Perianal haematoma (or
external haemorrhoid)

Prolapsed haemorrhoids
Skin tags, not haemorrhoids!
Fissure-in-ano
Painful defaecation
associated with bright red
bleeding
 Seton
Fistula-in-ano
“Abnormal connection between
two epithelial surfaces.”

Park’s Classification

Perianal abscess
Pilonidal Disease

Pilonidal sinus
Pilonidal abscess
“Blind-ending tract that opens
onto an epithelial surface.”
Rectal Prolapse
Elderly females with weak pelvic
floor

Usually assoc. with incontinence

Perianal Conditions - Summary
Condition Presentation Key Facts Management
Haemorrhoids Painless, bright red PR bleeding Associated with constipation and Conservative
Prolapse from the anus straining Banding or injections
Painful thrombosis Surgical: excision or stitching

Fissure-in-ano Painful, bright red PR bleeding Associated with constipation Laxatives

May be associated with skin tag Usually posterior @ 6 o’clock GTN or diltiazem ointment
EUA + Botox injection
(Rare: sphincterotomy or flap)
Fistula-in-ano Perianal discharge Follow Goodsall’s Rule May investigate with MRI
Perianal abscess May be assoc. with Crohn’s disease EUA +/- fistulotomy +/- seton
I+D for abscesses

Pilonidal disease Discharge from natal cleft Presumed foreign body reaction from Surgical excision
Pilonidal infection or abscess hair working it’s way beneath the skin. I+D for abscesses

Rectal prolapse Full thickness, circumferential prolapse Usually elderly females with weak Conservative
of rectum pelvic floor.
Incontinence Surgery: abdominal and
Bright red PR bleeding Often associated with incontinence perineal approaches
Inflammatory bowel disease: presentation
• Typically young patient: usually 20-30s
• Males slightly more common than females

• Diarrhoea - may be bloody or contain mucous

• Abdominal pain
• Weight loss
• Perianal disease - Crohn’s
• Obstruction - Crohn’s
• Malignancy
• Extra-abdominal features: e.g. skin, eyes, joints
Inflammatory bowel disease: investigation
Diarrhoea and
Red flags:
abdominal pain • Age >=60
• Weight loss
• Anorectal bleeding
• Nocturnal symptoms
Faecal • Fever
calprotectin

FC Low FC High Colonoscopy

Persistent
Treat as IBS symptoms
Inflammatory bowel disease: medical management

Induce remission Maintain remission

• Steroids: e.g. prednisolone, budesonide

• 5-ASAs
• Biologics: e.g. infliximab, adalimumab
• Immune modulator
• UC: ciclosporine
• CD: methotrexate, azathioprine
Inflammatory bowel disease: surgical management
Emergency Elective
Indications Indications
UC • Failure of medical management • Failure of medical management
• Massive bleeding • Carcinoma or high-grade dysplasia
• Perforation
• Toxic megacolon Procedures
• Curative intent
Procedures • Proctocolectomy and either end ileostomy or pouch
• Subtotal colectomy • Total colectomy and ileorectal anastomosis

Indications Indications
CD • Failure of medical management • Failure of medical management
• Massive bleeding • Stricture
• Perforation • Perianal disease
• Stricture  obstruction • Carcinoma or high-grade dysplasia

Procedures Procedures
• Limited resection • Never curative
• Stricturoplasty • Limited resection or stricturoplasty
• Diverting ileostomy • Perianal procedures
Procedures for UC: subtotal colectomy

• Remove diseased colon

• Leave rectosigmoid stump
• End ileostomy
• +/- “mucus fistula” as end-colostomy
• Usually a temporizing procedure

• Follow by either:
• Completion proctectomy
• Proctectomy and formation of ileal pouch
• Ileo-rectal anastomosis
Procedures for UC: proctocolectomy

• Remove colon + rectum and either:

• Remove anus, leaving permanent end ileostomy
• Leave anus and create an ileal pouch
Procedures for UC: ileal pouch anal anastomosis

• Performed to restore continence after a proctectomy

• Typically a “J Pouch”
• Usually “covered” with a temporary defunctioning loop
ileostomy because of high risk of anastomotic leak
IBD: Summary Inflammato ry Bo we l Dis e as e : Patho lo g y and Pre s e ntatio n
1. Epidemiology
Epide mio lo g y 4.Patho
Pathology
lo g y 6. Investigation
– Typical
UC onset in 20-30s but can
Cro hn’s UC Cro hn’s – Faecal calprotectin
occur at any age
Prev 100-200 /100,000 50-100 /100,000 Mac ro s co pic – Ileocolonoscopy
– AgAffects
e 30s M and F equally
20s Location Rectum + colon Mouth to anus
Sex F>M (just) ± backwash ileitis esp. terminal ileum
Aet Concordance = 10% Concordance = 70% Distribution Contiguous Skip lesions
Smoking protective
TH2-mediated
Smoking ↑ risk
TH1/TH17-mediated
Strictures No Yes 7. Treatment
2. Pathophysiology Mic ro s c opic – Medical
Inflammation Mucosal Transmural

– Autoimmune-mediated
Ulceration Shallow, broad Deep, thin, serpiginous • Induce and maintain remission
→ c obbles tone muco s a

• UC: TH2
Fibrosis None Marked • Steroids
Granulomas None Present

• CD: TH1
Pseudoplyps Marked Minimal • 5-ASA
Fistulae No Yes

– PreInteraction • Biologics
s e ntatio n between microbial,
immune, genetic and • Immune modulators
UC Cro hn’s
5. Presentation
environmental factors – Surgical
S ympto ms – Diarrhoea +/- blood/mucus • Can be curative in UC but not CD
Systemic Fever, malaise, anorexia, wt. loss in active disease
Abdominal • Diarrhoea – Weight loss • Diarrhoea (not usually bloody)
• Blood ± mucus PR • Abdominal pain • Management of complications or
3. Risk Factors • Abdominal discomfort – Abdominal • Wt.pain
loss
Tenesmus, faecal urgency
failure of medical management
– Smoking •
– Perianal disease (CD)
S igns
• ↑ risk of CD
Abdominal • Fever – Obstruction (CD) ulcers, glossitis
• Aphthous
• Protective• inTender,
UC
distended abdomen
– Malignancy• Abdominal tenderness
• RIF mass
– Family history – • Perianal abscesses,
Extra-abdominal featuresfistulae, tags
• Anal / rectal strictures
Extra-abdominal S kin • Skin: pyoderma gangrenosum
Jo ints
• Clubbing • Arthritis (non-deforming, asymmetrical)
Diverticular disease: presentation
Diverticulosis: presence of diverticulae, usually asymptomatic
Diverticular disease: diverticulae with symptoms

Pain: usually LIF, relieved by defaecation, diarrhoea

Diverticulitis: LIF pain, fever, diarrhoea +/- blood, ↑ CRP/WCC
• Perforation: abscess or acutely unwell with peritonitis
Bleeding: usually painless, bright or dark red
Stricture: can cause large bowel obstruction
Fistulae: can fistulate into bladder or vagina

Outpouchings of mucosa through colonic

muscular wall - ”false diverticulum”
Diverticular disease: classification
Perforated diverticulitis classified by the Hinchey
Classification system
I. Localised, para-colic abscess
II. Pelvic abscess
III. Purulent peritonitis
IV. Faeculent peritonitis
Diverticular disease: management
Diverticulitis
• Typically managed with antibiotics (PO or IV) but no evidence for
benefit in uncomplicated diverticulitis.
• Occasionally resection is offered for debilitating symptoms
Diverticular abscess
• Antibiotics
• Drainage by interventional radiology
Perforation with peritonitis
• Laparoscopic washout may be suitable for mild purulent
contamination
• Hartmann’s procedure
Bleeding
• Usually managed conservatively
• Occasionally embolised
• Resection rare
Stricture or fistulae
• Sigmoid resection
Diverticular disease: Hartmann’s Procedure
“Emergency sigmoid colectomy in which the proximal colon is exteriorized as an end-
colostomy and the rectal stump is over-sewn and left in situ.”
Diverticular disease: summary
1. Epidemiology 4. Presentation 6. Treatment
– Common – Diverticulitis – Diverticulitis: Abx
– Incidence increases with age: 10% at • Abscess • Occasionally resection if recurrent attacks
40yrs and 80% at 80yrs • Peritonitis – Abscess: drainage
– LGI bleeding – Peritonitis: Hartmann’s
2. Pathophysiology – LBO – Bleed: conservative or IR embolisation
– Unclear – Fistula – LBO: resection
– ? High luminal pressures  herniation of – Fistula: resection
mucosa at sites of weakness where 5. Investigation
arteriole enters bowel wall. – CT abdomen
– Only 10% get symptoms – Endoscopy /

3. Risk Factors
– Age
– ? ↑ animal fat / protein and ↓ fibre
– Obesity  ↑ risk of inflammation or
bleeding
Bowel obstruction: presentation

1. Abdominal distension
2. Abdominal pain
3. Absolute constipation
4. Vomiting
Bowel obstruction: radiology
Bowel obstruction: radiology
Bowel obstruction: radiology
Bowel obstruction: radiology
Bowel obstruction: radiology
Bowel obstruction: management
1. Resuscitation: drip and suck
2. NBM
3. Imaging: CT abdomen and pelvis

Small bowel obstruction Large bowel obstruction

Conservative
• Adhesional obstruction without suspicion of bowel
ischaemia
• May try gastrograffin per NG
Surgical
• Suspected bowel compromise
• Causes other than adhesions: e.g. hernia
• Failure of medical management
No place for conservative management
Interventional
• May occasionally stent benign or malignant
strictures
• Flatus tube for sigmoid volvulus
Surgical
• Typically laparotomy + resection
• Occasionally diverting loop colostomy
• May occasionally stent benign or malignant
strictures
Bowel obstruction: summary
1. Classification 3. Other causes 5. Investigation
– Simple – Non-mechanical – AXR
– Closed loop: 2 obstructing points • Ileus – CT
• Band • Pseudo-obstruction – Lactate
• IC valve – Mechanical
– Strangulated • Extra-luminal 6. Management
• Mural – Drip and suck
• Luminal – NBM
2. Common causes
– SBO – Conservative
• Adhesions 4. Presentation • Adhesional SBO
• Hernia – Abdominal pain – Interventional
– LBO – Abdominal distension • E.g. stenting
• Diverticular stricture – Absolute constipation – Surgical
• Colorectal cancer – Vomiting
• Volvulus
Bowel ischaemia
Acute Mesenteric Ischaemia Ischaemic Colitis
• Nearly always small bowel • Large bowel, usually splenic flexure

Cause Cause
• Thrombo-embolic • Chronic thrombus
• Veno-occlusive
• Hypovolaemic Presentation
• Moderate left-sided abdominal pain
Presentation • Diarrhoea +/- blood
• Severe abdominal pain
• Shock Investigation
• WCC/CRP
Investigation • CT abdomen
• ↑ lactate and WCC/CRP
• Triple phase CT: pre-contrast, arterial and venous phases Management
• Conservative: Abx, IV fluid
Management
• Resuscitation
• Laparotomy + SB resection
Bowel ischaemia: radiology
Lower GI Bleeding
Causes
• Common and important
• Perianal: haemorrhoids, fissures
• Colorectal cancer
• Diverticular
• IBD
• Brisk upper GI
• Infection
• Ischaemia
• Angiodysplasia
• Trauma
Stomas
Classification
• Anatomy
• Ileostomy
• Colostomy
• Urostomy
• Jejunostomy
• Gastrostomy
• Nephrostomy

• Type
• End
• Loop
Stomas: complications
Complications
 
Early
• Haemorrhage
• Ischaemia
• High output (can → fluid and electrolyte
disturbance)
• Stoma retraction
• Parastomal abscess
 
Delayed
• Parastomal hernia
• Bowel obstruction: 2O to adhesions or hernia
• Dermatitis (esp. ileostomy)
• Stoma prolapse
• Stenosis or stricture
• Psychosexual dysfunction
Stomas: summary
“Artificial union between a hollow viscus and the skin”
1. Assessment 2. Indications 3. Complications
• Site  
Output  
• Stool type: solid, small bowel content,
 Diversion of bowel or ureters Early
urine
 Distal anastomosis: e.g. anterior • Haemorrhage
• Spout • Ischaemia
resection
• Stomas: how many openings?  Discontinuity • High output
• State - e.g. Hartmann’s or AP resection • Stoma retraction
– of surrounding skin - e.g. urinary diversion post • Parastomal abscess
– of intestinal mucosa cystectomy  
 Distal disease: e.g. severe Crohn’s Delayed
• Scars
disease • Parastomal hernia
 Decompression due to distal obstruction • Bowel obstruction
Ileostomy Colostomy   • Dermatitis (esp. ileostomy)
Watery stool Solid stool Input • Stoma prolapse
 Feeding: e.g. gastrostomy / jejunostomy • Stenosis or stricture
RIF LIF •
 Lavage: e.g. appendicostomy Psychosexual dysfunction
Spouted No spout
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