Activate Windows

Go to Settings to activate Windows.

GS10 General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• depend on severity of inflammation and whether or not complications are present; hence rangesfrom

asymptomatic to generalized peritonitis

• LLQ pain/tenderness (2/3 of patients) often for several days before admission

• constipation, diarrhea, N / V, and urinary symptoms (with adjacent inflammation)

• low-grade fever, mild leukocytosis, and occult or gross blood in stool rarely coexist with acute

diverticulitis

• complications (25% of cases)

• abscess: palpable, tender abdominal mass

fistula: colovesical (most common), coloenteric, colovaginal, and colocutaneous

colonic obstruction:due to scarring from repeated inflammation

perforation: generalized peritonitis(feculent vs. purulent)

• recurrent attacks rarely lead to peritonitis

Efficacy and Safety of Monantibiotic Outpatient

Treatment in M lid Acute Diverticulitis (DINAMO

study): A Multicentre, landomised, Open-label.

Noninferiority Trial

Ann Surg 2021;274(5):e435.

Background:In recent years,it hasshown no benefit

olantrkotntjAl!) in the treatrnentof uncomptcated

AD mhospitalited patients.

Methods:Prospective,nnlticentre. open-label,

noninferiority,randomized controlled trial.

Desalts: Differences in hospitaliiation rates,revisits,

and poor par n controlat 2 daysfollow- up were within

the non-inferiority margin.

Conclusions lit

of mild AD issafe and effectneand is not inferior to

current standard treatment

Investigations

• CT scan (test of choice)

very useful for assessment of severity and prognosis (97% sensitive, 99% specific)

• usually done with rectal contrast

increased soft tissue density within pericolic fatsecondary- to inflammation, diverticula

secondary to inflammation, bowel wall thickening,soft tissue mass (pericolic fluid, abscesses),

and fistula

10% of diverticulitis cannot be distinguished from carcinoma

. AXR, upright CXR

• localized diverticulitis(ileus,thickened wall, SBO, and partial colonic obstruction)

free air may be seen in 30% with perforation and generalized peritonitis

• colonoscopy or barium enema and flexible sigmoidoscopy (elective evaluation)

establish extent of disease and rule out other diagnoses (polyps and malignancy) AFTER

resolution of acute episode

Treatment

• uncomplicated: conservative management

• outpatient: clear fluids only until improvement. Avoid treatment with antibiotics for those with

uncomplicated acute diverticulitis

• hospitalize:ifsevere presentation, inability to tolerate oral intake,significant comorbidities,or fail to

improve with outpatient management

treat with NPO, IV fluids, and IV antibiotics (e.g. IV ceftriaxone + metronidazole)

• image-guided (CT) percutaneous drainage of abscesses reduces the urgency ofsurgical resection in

most patients

• surgery:

indications:

diverticulitis and

inflammation

Colostomy

unstable patient with peritonitis

Hinchey stage 3-4 (see Table 19)

after 1 attack if immunosuppressed

consider if recurrent episodes of diverticulitis(S3); recent trend is toward conservative

management of recurrent mild/moderate attacks

Resection of

diseasedarea

and closure

of distal

rectal stump

• procedures:

Hartmann resection (for unstable or complex cases)

• colon resection + colostomy and rectal stump > colostomy reversal in 3-6 mo

• for more stable patients with Hinchey stage 3 and 4 acute diverticulitis: colonic resection, primary

anastomosis + diverting loop ileostomy is becoming more common, with benefitsfor mortality

and morbidity

for Hinchey stage 3: laparoscopic peritoneal lavage with drain placement near the affected colon,

in addition to 4 antibiotics(NO resection), has been proposed

• complications:perforation,abscess,fistula, obstruction, hemorrhage,inability to rule out colon

cancer on endoscopy, or failure of medical management

Anastomosis -

in approximately s

:- 3mo

„

Figure 14.Hartmann procedure

Prognosis

• mortality rates:6% for purulent peritonitis,35% for feculent peritonitis

• recurrence rates:13-30% after first attack, 30-50% aftersecond attack

Table 20. Hinchey Staging and Treatment for Diverticulitis

Hinchey Stage Description Acute Treatment r i

1 L J

Phlegmonfsmall pericolic abscess

large abscess/fistula

Purulent peritonitis (ruptured abscess)

Feculent peritonitis

Medical

Medical, abscess drainage tresection with primary anastomosis

Resection or Hartmann procedure

Hartmann procedure

2

3

4

+

Activate Windows

Go to Settings to acti Window!

GS41 General and ThoracicSurgery Toronto Notes 2023

Colorectal Neoplasms

Colorectal Polyps

Definition

• polyp: protuberance into the lumen of normally Hat colonic mucosa

sessile (flat) or pedunculated (on a stalk)

Epidemiology

• 30% of the population have polyps by age 50,40% by age 60,50% by age 70;M>F

Clinical Features

• 50% in the rectosigmoid region, 50% are multiple

• usually asymptomatic, do not typically bleed, tenesmus, intestinal obstruction, and mucus

• usually detected during routine endoscopy or familial/high-risk screening

Bowel lumen

-Bowel wall

v

Pathology

• non-neoplastic/non-adenomatous

hyperplastic: most common non-neoplastic polyp

mucosal polyps:small <5 mm, no clinical significance

hamartomas:juvenile polyps(large bowel), Peutz|

- eghersyndrome (small bowel)

malignant risk due to associated adenomas (large bowel)

low malignant potential-> mostspontaneously regress or autoamputate

inflammatory pseudopolyps:associated with IBD, no malignant potential

• submucosal polyps: lymphoid aggregates, lipomas, leiomyomas, and carcinoids

• neoplastic/adenomatous

adenomas: premalignant, considered carcinoma in situ if high-grade dysplasia

may contain invasive carcinoma (“malignant polyp” - 3-9%): invasion into submucosa

malignant potential related to histological type:villous > tubulovillous > tubular

Table 21. Characteristics of Tubular vs. Villous Polyps

OJanlea Wong 2003 J

Figure 15. Sessile and pedunculated

polyps

Tubular Villous

Comraon (60-80%)

Small(<2cm)

Pedunculated

less common(10%)

Large (usually>2 cm)

Sessile

Higher

tell sided predominance

Incidence

Size

Attachment

Malignant Potential

Distribution

Lower

(ven

Investigations

• colonoscopy with biopsy/resection (gold standard)

• CT colonography:increasing in availability;patientsstill require bowel prep and will require

colonoscopy if polyps are identified

• other: flexible sigmoidoscopy (if polyps are detected, proceed to colonoscopy for examination of entire

bosvel and biopsy)

Treatment

• indications:symptoms, malignancy or risk of malignancy (i.e. adenomatous polyps)

• endoscopic removal of entire growth

• indications forsegmental resection for malignant polyps:1) lymphovascular invasion; 2) tumour

budding; 3) positive resection margin; 4) poorly differentiated cells; 5) evidence of regional or distant

metastases on staging

most of these cases are usually discussed at multi-disciplinary’tumour boards

• follow-up endoscopy:

• every 5 yr: if low-risk polyp (<10 mm tubular adenoma or <10 mm sessile serrated without

dysplasia)

every 3yr: if high-risk polyp (3-10 tubular adenomas, >10 mm tubular or serrated polyp,

adenoma with villous features or high grade dysplasia, or sessile serrated with dysplasia)

i. J

+

Activate Windows

Go to Settings to activate Windows.

GSI2 General and Thoracic Surgery Toronto Notes 2023

Familial Colon Cancer Syndromes

FAMILIAL ADENOMATOUS POLYPOSIS

Epidemiology

• accountsfor <1% of colorectal cancers, affects males and females equally Referral Criteria for Genetic Screening

for APC

• To confirm the diagnosis of FAP

(in patients with >100 colorectal

adenomas)

• To provide pre-symptomatic testing

for individuals at risk for FAP (1st

degree relatives who are >10 yr)

• To confirm the diagnosis of

attenuated FAP (in patients with >20

colorectal adenomas)

Pathogenesis

• autosomal dominant inheritance, mutation in adenomatous polyposis coli (APC) gene

Clinical Features

• hundreds to thousands of colorectal adenomas usually by age 20 (by 40’s in attenuated TAP)

• virtually 100% lifetime risk of colon cancer (due to number of polyps)

• extracolonic manifestations

bile duct, pancreas,stomach, thyroid (large benign multinodular goitre), adrenal glands, and

small bowel

congenital hypertrophy of retinal pigment epithelium presents early in life in 2/3 of patients;97%

sensitivity

• variants

Gardner’ssyndrome: FAP + extra-intestinal lesions (sebaceous cysts, osteomas, desmoid

tumours)

• Turcot syndrome: FAP f CNS tumours (childhood cerebellar medulloblastoma)

Revised Bethesda Criteria for HNPCC

and Microsatellite Instability (MSI)

T umours from individuals should be

tested for MSI in the following situations:

• Colorectal cancer diagnosed in a

patient who is <50 yr

• Presence of synchronous,

metachronous, colorectal,or

other HNPCC-associated tumours,

regardless of age

• Colorectal cancer with the MSI-H

histology diagnosed in a patient who

is <60 yr

• Colorectal cancer diagnosed in one

or more first-degree relatives with an

HNPCC-related tumour,with one of

the cancers being diagnosed <50 yr

• Colorectal cancer diagnosed in two

or more first- or second-degree

relatives with FIN PCC-related

tumours, regardless of age

Investigations

• genetic testing (80-95% sensitive, 99-100% specific)

• if no polyposis found: annual flexible sigmoidoscopy from puberty to age 50, then routine screening

• if polyposis or APC gene mutation found: annual colonoscopy, consider surgery, and consider upper

endoscopy to evaluate for periampullary tumours

Treatment

• surgery indicated by ages 17-20

• total proctocolectomy with ileostomy or total colectomy with ileorectal anastomosis

• doxorubicin-based chemotherapy

• NSAIDs for intra-abdominal desmoids

HEREDITARY NON-POLYPOSIS COLORECTAL CANCER - LYNCH SYNDROME

Epidemiology

• most common inherited colorectal cancer susceptibility syndrome and accounts for 3% of colorectal

cancer diagnoses

Pathogenesis

• autosomal dominant inheritance, mutation in a DNA mismatch repair gene (MSH2, MSH6, MLH 1,

PMS2) resulting in microsatellite genomic instability and subsequent mutations

• microsatellite instability account for approximately 15% of all CRCs

Elderly persons who present with

iron-deficiency anemia should be

investigated for colon cancer

Clinical Features

• early age of onset, right > left colon,synchronous and metachronous lesions

• mean age of cancer presentation is 44 yr, lifetime risk 70-80%; M>F

HNPGG 1: hereditary site-specific colon cancer

HNPGG II:cancer family syndrome > high rates of extracolonic tumours (endometrial, ovarian,

hepatobiliary,small bowel, adrenal)

Diagnosis

• Amsterdam Criteria (“3-2-1 rule")

• 3 or more relatives with verified Lynch syndrome associated cancers, and I must be 1 st degree

relative of the other 2

• 2 or more generations involved

• I case must be diagnosed before 50 yr

• FAP is excluded

• genetic testing (80% sensitive)

• refer individualsfor genetic screening if they fulfill either the Amsterdam Criteria or the revised

Bethesda Criteria

• colonoscopy (starting age 20) annually

• surveillance for extracolonic lesions

APR removes distal sigmoid colon,

rectum, and anus: permanent end

colostomy required

LAR removes distal sigmoid and rectum

with anastomosis of distal colon to distal

roctum/anus

j

Treatment

• total colectomy and ileorectal anastomosis with annual proctoscopy +

Activate Windows

Go tc :o c

GS-13 General and Thoracic Surgery Toronto Notes 2023

IRemoved Colorectal Carcinoma

Epidemiology

• 3rd most common cancer (lung>breast>colon), 2nd most common cause of cancer death

Risk Factors

• most patients have no specific risk factors

• ages >50 (dominant risk factor in sporadic cases), mean age is 70

• genetic: FAP, HNPCC, or family history of CRC

• colonic conditions

adenomatous polyps (especially if >1 cm, villous, multiple)

• IBD (especially UC: risk is 1-2%/yr if UC >10 yr)

previous colorectal, gonadal, or breast cancer

• diet (increased fat,red meat, decreased fibre) and smoking

• DM and acromegaly (insulin and IGF-1 are growth factors for colonic mucosal cells)

Pathogenesis

• adenoma-carcinoma sequence; rarely arise de novo

Clinical Features

• often asymptomatic

• hematochezia/melena, abdominal pain, and change in bowel habits

• others:weakness, anemia, weight loss, palpable mass, and obstruction

• 20% patients have distant metastatic disease at time of presentation

• spread

direct extension, lymphatic, and hematogenous (liver most common, lung, bone, and brain;

tumour of distal rectum -> IVC -> lungs)

• peritoneal seeding: ovary and Blumer’sshelf (pelvic cul-de-sac)

Figure 16. APR vs. LAR

Table 22. Clinical Features of CRC 5 Year Survival Rates for CRC

Stage 20-64 yr >65 yr

95.2% 89.1%

89.6% 84.4%

67.6% 55%

91.3% 851%

76.9%

61.8%

14.2%

Right Colon Left Colon Rectum

I

Frequency 25% 35% 30%

Pathology

IIA

Exophytic lesions with occult

bleeding

Weight loss,weakness,rarely

obstruction

Annular, invasive lesions Ulcerating IIB

IIIA

64.6%

45.5%

IIIB Symptoms Constipation ± overflow (alternatingbowel

patterns),abdominal pain,decreased stool

calibre,rectal bleeding

BRBPR. LBO

Obstruction,tenesmus,rectal

bleeding INC

IV 7.4%

Signs Fe-deficiency anemia,RLQ mass

(10%)

Palpable mass on ONE.BRBPR

Preoperative vs.Postoperative

Chemoradiotberapyior Locally Advanced Rectal

Cancer:Results of tbeCerman CAQ AR0 A10-

94RandamiiedPhaseIIITrial after a Median

Follow-Up of TIFr

J Clin OncDl 2012;30:1925-1933

Background: fhe CAO ARO AI0-94 trial

(pub listed2004) recommeriedpreoperative

chemoradiofieiapy (CR1) as standard treatment for

localcy advanced rectal cancer.Hnwever,no survival

benefit was shown after median follow-upoUEno.

and this study reports long-term effects.

Methods:Patients with stageIItoillrecal cancer

(n-799) were randomiy assigned tupreoperative

(r404|or postoperative CRI|n-395)with

ftuorouracil|FU|.rada’

Jon.and adjuvant FU

chemotherapy,in addition tototal mesorectel

excision surgery,follow-up was designed to assess

long-term overall sumalasthe primary andp omt

and emulative incidence of localand distant

relapses as well as disease-free survival assecondary

endpoints.

Results:‘0 yr incidence of localrelapse was

significantly lower inthe preoperativeCRI group

than inthe postoperative group (11% vs.10.1%.

R*

0.048).Overall survival at10 yr was similar a:

“

60% for patentstreated ruts preoperatve or

postoperative CRI(P*

0.85|.Disease-free sovival

rates at 10 yr was similar a:

-68% for patentineared

with preoperatve or postoperative CRT (P'0.54).No

significant difference was detected for10 yr incidence

of distant metastases (preoperatve CRI 29.8% is.

postoperative CRI 29.6%.R'0.9).

Conclusion laereis long-term reduction inlocal

recunence of stageI!to INrectal cancel wits

pieoperatve chemotherapy,hut no improvement in

overall survival or distant recunence of disease.

Investigations

• colonoscopy (gold standard):look forsynchronouslesions (3-5% of patients)

- if a patient is FOB!positive, has microcytic anemia, or has a change in bowel habits -»

colonoscopy

alternative:air contrast barium enema (“apple core" lesion) + sigmoidoscopy

• laboratory:CBC, U/A, LFTs,CEA (preoperative for baseline, >5 ng/mL have worse prognosis)

• staging:CT chest/abdomen/pelvis;bone scan and CT head only if lesions suspected

• rectal cancer: pelvic MRI or endorectal U/S to determine T and N stage

Table 23. TNM Classification System for Staging of Colorectal Carcinoma (AJCC/UICC 8th

edition)

Primary Tumour (T) Regional Lymph Nodes (N) Distant Metastasis (M)

Tx Primary tumour cannothe assessed Nx

TO No primary tumour found

Regional nodes cannot be assessed

No regional node metastasisand no tumour M1a

deposits

Metastasis In1regional node

M0 No distant metastasis

Distant metastasis to 1organ or

site and no peritoneal metastasis

Distant metastasis to >1(2

or more organs sites) and no

peritoneal metastasis

Metastasis to peritoneal surface

NO

Tis Carcinoma vns/fer,limited to

intraepitbelial or invasive lamina

propria

T1 Invasion inlosubmucosa

12 Invasion into muscularis propria

N1a M1b

Metastasis in 2-3 regional nodes

No regional node metastasis:tumour

deposits were submucosal,mesangial or

peritoneum-covered para-colorectal tissue

Metastasis in 4- 6 regional nodes

N1b Mic

H1c

r >

T3 Invasion through muscularis propria N2a

and intopericolorectal tissues

T4a Invasion through visceral peritoneum N2b

T4b Invasion or adhorenl to other organs

or structures

i.J

Metastasis in >7 regional nodes

+

Activate Windows

Go to Settinas to activate Windo

GS44 General and Thoracic Surgery Toronto Notes 2023

Treatment

• colon cancer

• wide surgical resection oflesion according to vascular distribution and regional lymphatic

drainage; usually colectomy with primary anastomosis

curative: wide resection of lesion (5 cm margins) with nodes (>12) and mesentery

care is taken to notspread tumour by unnecessary palpation

adjuvant chemotherapy (oxaliplatin-based) forstage 111 and is considered in select stage II

patients

palliative:if distantspread, local control for hemorrhage or obstruction

• metastatic lesions confined to the liver can be resected with curative intent

• rectal cancer

• choice of operation depends on individual case

LAR:curative procedure of choice if adequate distal margins (~2 cm);uses technique of total

mesorectal excision

- APR:if adequate distal margins cannot be obtained;involves the removal of distal

sigmoid colon, rectum, and anus permanent end colostomy required

transanal minimally invasive surgery (TAM1S)- local excision forselectT1lesions only

palliative proceduresinvolve proximal diversion with an ostomy for obstruction and radiation for

bleeding or pain

combined neoadjuvant chemoradiation therapy followed by postoperative adjuvant chemotherapy

for stages 11 and 111

Follow-Up

• stage 1: mixed recommendations; either routine colonoscopy orscreening like stage 11 & ill

• stage 11 & 111:regular follow-up q3-6 mo for 3yr,then q6 mo until 5 yr, with regular measurement of

serum (.

'

HA for at least 3yr;annual CT chest/abdo/pelvis for at least 3yr;colonoscopy at 1,3,and 5yr

• stage IV: no data on surveillance strategy

Other Conditions of the Large Intestine

Angiodysplasia

Definition

• vascular malformation:focalsubmucosal venous dilatation and tortuosity

Clinical Features

• most frequently in right colon of patients >60 yr

• predisposition in end-stage renal disease, and VWD,and aortic stenosis

• bleeding typically intermittent, rarely massive, and not usually hypotensive (melena, anemia, and

occult blood positive stools)

• >90% of cases cease bleeding spontaneously

Investigations

• colonoscopy:cherry red spots, branching pattern from central vessel

• angiography:early-filling vein, vascular tuft,and delayed emptying vein;rarely active bleeding

• RBC technetium-99 scan

• barium enema is contraindicated (obscures other x-rays,i.e. angiogram)

Treatment

• none if asymptomatic

• cautery, embolization,vasopressin infusion,sclerotherapy, band ligation,laser,octreotide, and rarely

segmental resection if other treatments fail

Volvulus

Definition

• rotation ofsegment of bowel about its mesenteric axis

• sigmoid (65%), cecum (30%),transverse colon (3%),and splenic flexure (2%)

elderly >70 yr (sigmoid), adult 40-60yr (cecal), and neonates and infants(midgut)

• 5-10% of large bowel obstructions; 25% of intestinal obstructions during pregnancy

Risk Factors

• age (50% of patients >70 yr:stretching/elongation of bowel with age)

• high fibre diet (can cause elongated/redundant colon),chronic constipation,laxative abuse,

pregnancy, bedridden, and institutionalization (lessfrequent evacuation of bowels)

• megacolon

• intestinal bands/adhesions

Cecal Volvulus

AXR:Central cleft of “coffee bean"

sign

points to RLO

r -<

L J

Sigmoid Volvulus

AXR:Central cleft of‘coffee bean "

sign

points to LLO

Barium enema:“ace of spades"

or

“bird's beak” sign

+

Activate Windows

Go to Settings to activate Windows.

GS45General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• symptoms due to bowel obstruction (see Large Bowel Obstruction, GS37) or intestinal ischemia (see

Intestinal Ischemia,GS31)

• colicky abdominal pain, persistence of pain between spasms, abdominal distention, and vomiting

Investigations

• AXR (classic findings): “omega,” “bent inner-tube," “coffee-bean" signs, multiple air-lluid levels

• barium/Gastrografin’enema:

"

ace of spades” (or “bird'

s beak") appearance due to funnel-like luminal

tapering of lower segment towards volvulus

• sigmoidoscopy or colonoscopy as appropriate

• CT:

“whirl pattern” of mesenteric vessels twisting about the volvulus axis

barium contrast and colonoscopy are contraindicated due to risk of perforation

Treatment

• initial supportive management same as initial management for bowel obstruction (see Large Bowel

Obstruction,GS37 )

• cecum

• colonoscopic detorsion and decompression;successful 15-20% of cases

surgical

right colectomy + ileotransverse colonic anastomosis

• sigmoid

decompression by flexible sigmoidoscopy and insertion of rectal tube past obstruction

subsequent elective surgery’recommended (50-70% recurrence)

surgical

surgical resection with or without primary anastomosis

» indicationsfor urgent surgical management:strangulation, perforation, or unsuccessful

endoscopic decompression

Toxic Megacolon

Pathogenesis

• extension of inflammation into smooth muscle layer causing paralysis and leading to non-obstructive

colonic dilatation

• damage to myenteric plexus and electrolyte abnormalities are not consistently found

Etiology

• IBD ( UC > Crohn’s disease)

• infectious colitis:bacterial (C. difficile, Salmonella, Shigella,and Campylobacter),viral

(cytomegalovirus), and parasitic (H.histolytica)

Clinical Features

• infectious colitis usually presents for >1 wk before colonic dilatation

• diarrhea ± blood (sudden improvement of diarrhea may signify onset of megacolon)

• abdominal distention, tenderness, ± local/general peritoneal signs (suggests perforation)

• triggers: hypokalemia, constipating agents (opioids, antidepressants, loperamide, and

anticholinergics), barium enema,and colonoscopy

Diagnostic Criteria

• must have both colitis and systemic manifestationsfor diagnosis

• radiologic evidence of dilated colon >6 cm, and

• three of:fever, HR >120, WBC >10.5, anemia and

. one of:dehydration, electrolyte disturbances, hypotension,or altered LOG

Investigations

• CBC (leukocytosis with left shift and anemia from bloody diarrhea), electrolytes, elevated GRP, and

HSR

metabolic alkalosis (volume contraction and hypokalemia) and hypoalbuminemia are late

findings

• AXR:dilated colon >6 cm (right > transverse > left), loss of haustra

• CT: useful to assess underlying disease severity and possible complications(i.e. abscess, perforation,

ascending pylephlebitis)

+

Activate Windows

Go to Settings to activate Windows.

GS46 General and Thoracic Surgery Toronto Notes 2023

Treatment

• NPO, NG tube,stop constipating agents, correct fluid and electrolyte abnormalities, and transfusion

• serial A XRs

• broad-spectrum antibiotics (reduce sepsis and anticipate perforation)

• aggressive treatment of underlying disease (e.g.steroids in 1BD and metronidazole for C.difficile)

• indicationsforsurgery (50% improve on medical management)

worsening or persisting toxicity or dilation after 48-72 h

severe hemorrhage,perforation

high lactate and WBC, especially for C. difficile

• procedure:subtotal colectomy + end ileostomy (possible re-anastomosislater)

Use

o

caution when giving antidiarrheal

agents, especially with bloody diarrhea

Prognosis

• 2540% mortality

Fistula

*

Definition

• abnormal communication between two epithelialized surfaces(e.g. enterocutaneous, colovesical,

aortoenteric, and entero-enteric)

Why Fistulae Stay Open

FRIENDO

Foreign body

Radiation

Infection

Epithelialization

Neoplasm

Distal obstruction (most common)

Others:increased flow;steroids(may

Inhibit closure, usually will not maintain

fistula)

Etiology

• foreign object erosion (e.g. drainage tube, gallstone, graft)

• inflammatory states(e.g. infection, IBD (Crohn’

s > UC), and diverticular disease)

• iatrogenic/surgery (e.g. postoperative anastomotic leak and radiation)

• congenital, trauma

• neoplastic

Investigations

• U/S, CT scan, fistulogram

• measure amount of drainage from ftstula

Treatment

• decrease secretion:octreotide/somatostatin/omeprazole

• surgical intervention:dependent upon etiology (for non-closing fistulas)

Colostomy/Ileostomy

. Connection of proximal limb of colon

or ileum to abdominal wall skin

• Mucous fistula

• Connection of distal limb of resection

margin to abdominal wall skin

• Ileal Conduit

• Connection of bowel to ureter

proximally and abdominal wall

distally to drain urine

Stomas

Definition

• an opening of the Cil tract onto the surface of the abdomen wall

end stomas: the proximal end of the Gl tract forms the stoma and the distal end of the G1 tract is

not part of the stoma

loop stomas: a loop of the Gl tract is brought up to the skin and the anti

-mesenteric surface of the

bowel is matured as a stoma

Ileostomy

• usually positioned in RLQ;ileum is brought through rectus abdominis muscles

• indications:after proctocolectomy for UC,some cases of Crohn’s disease or familial polyposis

• conventional ileostomy:dischargessmall quantities of liquid material continuously, appliance (plastic

bag attached to a sheet of protective material) required at all times

• continent ileostomy:reservoir is constructed from distal ileum (ileal pouch anal anastomosis)

Loop Colostomy

Colostomy

• indications:to decompress an obstructed colon, to protect a distal anastomosis after resection, or to

evacuate stool after distal colon or rectum is removed

• colostomies can be done by making an opening In a loop of colon (loop colostomy) or by dividing the

colon and bringing out one end (end colostomy)

• most common permanent colostomy is a sigmoid colostomy (expelsstool/digital removal of feces)

• chronic paracolostomy hernia is a common complication

(Proximal) (Distal)

End Colostomy Mucous Fistula

Complications (10%)

• obstruction:herniation,stenosis (skin and abdominal wall), adhesive bands, volvulus

• peri-Ueostomy abscess and fistula

• skin irritation

• prolapse or retraction

• diarrhea (excessive output), which may lead to fluid, electrolyte, and nutritional imbalances

r

L J

® JoaoYi'Chun Lin 2014>

Figure 17.End vs.loop colostomy +

Activate Windows

Go to Settings to activate Windows.

OS-17 General and Thoracic Surgery Toronto Notes 2023

Removed

UMMMM Colostomy End Colostomy &

I

>•

i

f

—-

!

1

Loop Ileostomy Loop Colostomy Loop Ostomy (Side View)

Figure 18. Ostomies

Anorectum

Hemorrhoids

Etiology

• vascular and connective tissue complexes form a plexus of dilated veins(cushion)

• internal:superior hemorrhoidal veins,above dentate line, portal circulation

• external:inferior hemorrhoidal veins, below dentate line,systemic circulation

Risk Factors

• increased intra-abdominal pressure: chronic constipation, pregnancy, obesity, portal Hl'

N, heavylifting

.

Internal

hemorrhoid

liddle l rectal

win

//

Inferior

rectal 1

lentate Ime

=-

-External ^ ,:is Clinical Features and Treatment — _

• internal hemorrhoids

• engorged vascular cushions usually at 3,7,11 o

'

clock positions(patient in lithotomy position)

• painless rectal bleeding, anemia, prolapse, mucus discharge, pruritus, burning pain, and rectal

fullness

1

Figure 19. Hemorrhoids

1st degree: bleed but do not prolapse through the anus

- treatment:high fibre/bulk diet,sitz baths,steroid cream (short course), pramoxine

(Annsol*),phlebotonics,rubber band ligation,sclerotherapy-,and photocoagulation

2nd degree:bleed,prolapse with straining,and spontaneousreduction

- treatment:rubber band ligation,and photocoagulation

3rd degree:bleed, prolapse, and require manual reduction

- treatment:same as 2nd degree,but may require closed hemorrhoidectomy

4th degree: bleed, permanently prolapsed,and cannot be manually reduced

- treatment:closed hemorrhoidectomy

Always rule out more serious causes

(e.g. colon cancer or anal canal cancer)

in a person with hemorrhoids and rectal

bleeding

• external hemorrhoids

• dilated venules usually* mildly- symptomatic

pain after bowel movement, associated with poor hygiene

medical treatment dietary fibre,stoolsofteners,steroid cream (short course), pramoxine

(AnusoP), phlebotonics, and avoid prolonged straining

• thrombosed hemorrhoids are very painful

resolve within 2 wk, may leave excessskin = perianalskin tag

treatment:considersurgical decompression within first 48 h of thrombosis, otherwise

medical treatment

• indications for referral for endoscopic evaluation:history of rnelena, postural vital sign abnormalities,

constitutionalsymptomssuggestive of malignancy,and family history of inherited colorectal

syndromes

Prevention

• high fibre diets, present constipation,stoolsofteners

Band ligation can be done as outpatient

External hemorrhoids wil often recur

L J

+

Activate Windows

Go lu Seltinys to dctivdte Windows.

GS-18 General and Thoracic Surgery Toronto Notes 2023

Table 24. Signs and Symptoms of Internal vs. External Hemorrhoids

Internal Hemorrhoids External Hemorrhoids

Painless BRBPR

Rectal fullness or discomfort

Mucus discharge

Sudden severe perianal pain

Perianal mass

Anal Fissures

Definition

• tear of anal canal below dentate line (very sensitive squamous epithelium)

• 90% posterior midline because posteromedial area is poorly perfused, 10% anterior midline

• if off midline: consider other possible causessuch as 1BD, ST Is, TB, leukemia, or anal carcinoma

• repetitive injury cycle after first tear

sphincter spasm occurs preventing edges from healing and leads to further tearing

• ischemia may ensue and contribute to chronicity

Etiology

• local trauma: constipation, irritation, diarrhea, vaginal delivery, anal intercourse

• secondary to:Crohn'

s disease, granulomatous diseases, malignancy, communicable diseases

• further tearing by internal analsphincterspasm and hypertonicity

Clinical Features

• acute fissure

very painful bright red bleeding especially after bowel movement,sphincterspasm on limited

DRE

treatment is conservative:stoolsofteners, bulking agents, and sitz baths (heals 90%)

• chronic fissure (anal ulcer)

• triad:fissure,sentinel skin tags, and hypertrophied papillae

treatment

* stool softeners, increased fibre intake, and sitz baths

topical nitroglycerin or calcium channel blocker (nifedipine or diltiazem): increaseslocal

blood flow, promotes healing, and relievessphincterspasm

lateral internal anal sphincterotomy (most effective): relieves sphincter spasm to increase

blood flow and promote healing:reserved for medically-refractory cases due to 5% chance of

fecal incontinence

* alternative treatment: botulinum toxin A; inhibits release of acetylcholine (ACh ), reducing

sphincter spasm

Prevention

• avoid diarrhea or constipation, avoid straining during defecation, high fibre diet, adequate fluids

Anorectal Abscess

Definition

• infection typically originating within an obstructed anal crypt which forms an abscess

• common bacterial:E. coli, Proteus, Streptococci, Staphylococci, Bacteroides,and anaerobes

Supralovator space

Supralovator abscess

Levator muscle

Column of Morgagni

Internalsphincter

Deep externalsphincter

incteric abscess

Ischiorectal abscess r T

L J

Externalsphincter

Perianal nbsccss I

+

o

I

Figure 20. Different types of perianal abscesses

Activate Windows

Go to Settings to activateWindows.

GS49 General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• throbbing pain that may worsen with straining and ambulation

• abscess can spread vertically downward (perianal), vertically upward (supralevator), or horizontally

(ischiorectal)

• tender perianal/rectal mass on exam

Recurrent perianal abscesses is

associated with Crohn's disease

Treatment ft

. I&L)

Antibiotics arc not typically helpful In the

treatment of perianal abscesses

curative in 50% of cases

• 50% develop anorectal fistulas

• may require antibiotics if patient has DM, a heart murmur, or cellulitis

Fistula-ln-Ano

Definition

• fistula from anal canal to perianal skin

• an inflammatory tract with internal os at dentate line, external os on skin

Anterior

Secondary

openingTransverse

/7 A

Etiology

• see Vistula,US-16

• same processes that lead to the formation of an anal abscess

• other causes: postoperative, trauma, anal fissure, malignancy, and radiation proctitis

Clinical Features

• intermittent or constant purulent discharge from perianal opening

• pain

• palpable cord-like tract

• inflamed or excoriated perianal skin

Posteiior

Figure 21. Goodsall’s rule

Treatment

• identification

• internal opening

Goodsall’

srule:fistulas originating anterior to a transverse line through the anus will have a

straight course and exit anteriorly,whereas those originating posterior to the transverse line

will begin in the midline and have a curved tract

fistulous tract

probing or fistulographv under anesthesia

Rectum

• surgery

primary fistulotomy: unroof tract from external to internal opening, allows drainage, heals by

secondary intention

best treatment for low lying fistula (does not involve externalsphincter)

staged fistulotomy with Seton (rubber band orsuture) placed through tract

used for high lying fistula (involves external sphincter)

promotes drainage, fibrosis, and decreases incidence of incontinence

delineates anatomy and usually done to spare muscle

ligation of intersphincteric fistula tract (Lll

-

'

T) procedure

access fistula between sphincter muscles,sparing them

• endoanal advancement flaps

Internal 1

sphincter

hstUa

External.

sphincter

Anus —

/ V Drainage

© Agnes Chan 2013

^

Figure 22. Fistulotomy with Seton

suture Postoperative

• sitz baths, irrigation, and packing to ensure healing proceeds from inside to outside

Complications

• recurrence

• rarely fecal incontinence

Pilonidal Disease

Definition

• pilo = hair, nidal = nest; cyst or abscess near or on the intergluteal cleft of the sacrococcygeal area

containing hair and skin debris

Epidemiology

• occurs most frequently in young men ages 15-35; rare in >50 yr

Etiology

• obstruction of the hair folliclesin this area -> formation of cysts,sinuses, or abscesses

• associated with occupations that require prolonged sitting, obesity,and high amounts of body hair

r T

L J

+

Activate Windows

Go to ScttinQS toactivateWindows:

-1