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 +

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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

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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

+

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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)

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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 +

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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

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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

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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

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-1

GS50 General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• asymptomatic or chronically itchy until acutely infected, then pain/tenderness, purulent discharge,

and increased moisture near the tailbone

Treatment

• acute abscess

• l&D (often performed by primary care physicians)

wound packed open

40% develop chronic pilonidal sinuses

• surgery

indication:failure of healing after l&D, recurrent disease, or complex disease

pilonidal cystotomy: excision ofsinus tract and cyst;wound closed by secondary intention (vac

dressing), primary closure with tissue flap,or marsupialization (cyst edge sewn to surrounding

tissue to leave sinus tract open)

Rectal Prolapse

Definition

• protrusion ofsome or all of rectal mucosa through external analsphincter

Epidemiology

• extremes of ages:<5 yr and >50 yr

• 85% women

Etiology

• lengthened attachment of rectum secondary to constantstraining

• 2 types

1. false/partial/mucosal: protrusion of mucosa only, radial furrows at junction with analskin;

most common type of rectal prolapse in childhood

2. true/complete (most common):full-thickness extrusion of rectal wall, concentric folds in:

- 1st degree: prolapse includes mucocutaneous junction

- 2nd degree: without involvement of mucocutaneous junction

- 3rd degree (internal intussusception): prolapse is internal, concealed, or occult

True rectal prolapse

Risk Factors

• gynaecological surgery

• chronic neurologic/psychiatric disorders affecting motility e.g. chronic constipation

• multiparity

• weak pelvic floor

Clinical Features

• extrusion of mass with increased intra-abdominal pressure

• difficulty in bowel regulation

tenesmus, constipation,fecal incontinence

• permanently extruded rectum with excoriation, ulceration, and constantsoiling

• may be associated with urinary incontinenceor uterine prolapse

• pain is not common

\

Ji Extornal hemorrhoids

Figure 23. Rectal prolapse (true vs.

false)

Treatment

• type I

conservative:gentle manual reduction of prolapsed area, especially in children

mucosectomy with excision of redundant mucosa, mostly in adults

• type 11

conservative: reduce if possible

« surgery:abdominal, perineal, and trans-sacral approaches

Anal Neoplasms

ANAL CANAL

Squamous Cell Carcinoma of Anal Canal (Distal to Dentate Line)

• most common tumour of anal canal (75%)

• anus prone to human papillomavirus (HPV) infection, therefore at risk for anal squamous intraepithelial lesions (ASIL)

high-grade squamous intra-epithelial lesion (HSIL) and low-grade squamous intra-epithelial

lesion (LSIL) terminology used

• clinical features: anal bleeding, pain, mass, ulceration, and pruritus; 25% asymptomatic

• treatment: chemotherapy ± radiation ± surgery

• prognosis:80% 5 yrsurvival

r *i

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GS5I General and Thoracic Surgery Toronto Notes 2023

Malignant Melanoma of Anal Canal

• 3rd most common site for primary malignant melanoma after skin, eyes

• aggressive, distant inetastases common at time of diagnosis

• occasionally an incidental finding in pathological evaluation of an anal specimen

• clinical features: bleeding, mass anorectal pain, change in bowel habits, pigmented in one third cases,

regional lymph node involvement

• treatment:wide excision or APR ± chemoradiation

• prognosis: <5% 5 vr survival

ANAL MARGIN

• clinical features and treatment as for skin tumours elsewhere

• squamous and basal cell carcinoma, Bowen'

s disease (SCC in situ), and Paget'

s disease

Liver

Inferior vena cava Inferior vena cava

Middle hepatic vein

/ Left hepatic vein Right hepatic Middle hepatic vein vein eft hepatic vein Right hepatic vein

Hepatic artery proper

Portal vein Portal vein

k. Bile duct Bile duct hepatic artery

proper

I

CN

O

I. Posterior (caudal)$egment IVa. Medialsegment (medialsuperior area) VI. Rightanterior lateralsegrnentlposterior inferior areal 5

II. LateralsegmentI lateralsuperior area) IVb. Medialsegment (medial inferior area) VII. Posterior lateralsegrnentlposteriorsuperior area) “

III.Left anterior lateralsegment V. Anterior medialsegment VIII. Posterior medialsegmentianteriorsuperior area)

(lateral inferior area) I anterior inferior area)

i

s

iz.

©

Figure 24. Anatomy of liver

Liver Cysts

Table 25. Characteristics of Liver Cysts

Simple Cysts Polycystic Liver Disease Choledochal Cysts Hydatid (Cystic

Echinococcosis)

Cystadenoma

(Premalignant)/

Cystadenocarcinoma

Description form from biliary ducts that

do not communicate with the

inlrahepatic biliary tree and

contain clear fluid

Most common

May have multiple cysts

Always benign

Eiamples include congenital

cysts.Catoli disease, biliary

hamartomas, and polycystic liver

disease IPCtO)

Clinical Features Usually asymptomatic

Mass died can cause: dull RUO

pain. N /V. bloabng, and/or early

satiety

Several (>20) cyststhat replace

much of the liver parenchyma

Autosomal dominant condition

More common in females

Congenital malformations ol the Infection with parasite

Echinococcus granulosus

Associated with exposure to

Cysladenomas ate rare cystic

neoplasms arising trom the

bile ducts

dogs,sheep,horses, pigs, goats. Cystadenoma is the most common

camels, and cattle in Southern premalignant liver lesion

Europe.Middle East, Australasia. Cystadenocarcinoma isan

South America

Ingested parasitic eggs hatch in

the small intestine, where larvae

enter blood and lymph

bile ducts

High-risk of malignancy

Majority present before age10

Todani classification based on

anatomical characteristics within

biliary tree invasive carcinoma

Minority present with acute

complications due to cyst

rupture, hemorrhage,infection,

and compression of adjacent

structures

Progressive

50% associated with polycystic

kidney disease (if ove r age GO)

U/S:cysts are well circumscribed

and nonenhancing

MRI:more sensitive and specific,

used for preoperative planning

Recurrent abdominal pain

Intermittent jaundice

RUO mass

Cholangitis

Symptomatic gallstones

Pancreatitis

Portal HIN

Upper abdominal mass

May have palpable RUO mass or Abdominal pain

Anorexia

Usually asymptomatic

hepatomegaly

Chronic RUO pain when

symptomatic

Nausea, lever, and dyspepsia are

non-specific symptoms

Labs:LfT abnormalities Labs: anti-Echinococcusab Labs:cystadenocarcinoma may

have elevated LFIs.CEA, or

CA 19-9

UIS:anccholc mass with internal

septations that are highly

cchogcnic

Investigations Labs:some have elevated GOT,

CEA.CA 19-9

U/S: Used for diagnosis and

followup

Cl:well demarcated lesion lhal

does notcnhancc with contrast

r t

U /S U/S

lJ

ct CT: calcified cystic walls

Iranshcpalic cholangiography Needle biopsy

ERCP

MRCP

Cl

MRI +

MRCP

ERCP

Need histology (or definite

diagnosis

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GS52 General and Thoracic Surgery Toronto Notes 2023

Table 25. Characteristics of Liver Cysts

Simple Cysts Polycystic Liver Disease Choledochal Cysts Hydatid (Cystic

Echinococcosis)

Cystadenoma

(Premalignant)/

Cystadenocarcinoma

Symptomatic patients: cyst

aspiration with sclerosis,cyst

fenestration, hepatic resection. if cystic dilatation involves

transarterial emboliiation. and

transplantation

Complete excision of cysts Systemic chemothera py:

Liver resection or transplantation Albendazole (anti-helminthic

drug) cure up to 30%

Surgical:radical (total

pcricystectomy, partial

hepatectomy, or lobectomy) vs.

conservative (drainage or open/

closed cystectomy)

Percutaneous: PAIR Ipuncture,

aspiration, injection, reaspiration)

Biliary cirrhosis, portal KIN.cyst IVC compression

rupture, or citolangiocarcinoma Cyst rupture which can cause

Increased risk of biliary fever, pruritis. eosinophilia.

malignancy biliary colic, jaundice.

cholangitis, pancreatitis,or

anaphylaxis

All complex,multiloculated cysls

(exceptechinococcal)should be

excised because of malignancy

Treatment Not required unless very large

and/or symptomatic

Monitor if >4 cm

laparoscopic or open cyst

wall removal (unroofing)is

established treatment and is

usually curative

Percutaneous aspiration and

ethanol sclerotherapy also an

option, butnot curative

inlrahepalic bile ducts(Caroli’s

disease)

lisk

Cystadenocarcinoma can invade

adjacent tissues and metastasize

Complications Hemorrhage, rupture,infection.

and biliary obstruction more

likely in larger cysts

Intracystic hemorrhage is

rare and presents with severe

abdominal pain

Liver Abscesses

Etiology

. types

pyogenic (bacterial):most common etiology; most often polymicrobial- Klebsiella, E. coli,

Proteus, Streptococcus, Staphylococcus,and anaerobes

parasitic (amoebic):Entamoeba histolytica,Hchinococcal cyst

fungal:Candida

sources: direct spread from biliary tract infection, portal spread from G1 infection,systemic

infection (e.g. endocarditis)

Clinical Features

• fever, malaise, chills, anorexia, weight loss, abdominal pain, and nausea

• RUQ tenderness, hepatomegaly, and jaundice

Investigations

• CBC (leukocytosis, anemia), Ll-Ts(elevated ALP and hypoalbuminemia common; elevated

transaminases and bilirubin variable), blood cultures, INR/PTT,stool cultures, and serology ( E.

histolytica and Echinococcus)

• CT or VIS are the imaging modalities used for diagnosis with abscess drainage for C&S to confirm

diagnosis; MRI can also be used.

Treatment

• treat underlying cause

• pyogenic abscesses generally treated with antibiotic therapy (e.g. ceftriaxone and metronidazole or

piperacillin-tazobactam) and VIS- or CT-guided percutaneous drainage orsurgical drainage

• consider potential source ofsepsis (e.g. biliary source, infected tumour)

Differential Diagnosis of Metastatic

Liver Mass

Some GU Cancers Produce Bumpy

Lumps

Stomach

Genitourinary cancers (kidney,ovary,

uterus)

Colon

Pancreas

Breast

Prognosis Lung

• overall mortality 15% - higher rate if delay in diagnosis, multiple abscesses, malnutrition, elderly, KiU

admissions, shock, cancer, cirrhosis, GKD, acute respiratory failure, and biliary origin of abscess

Neoplasms

BENIGN LIVER NEOPLASMS

Hemangioma (cavernous)

• pathogenesis: most common benign hepatic tumour; resultsfrom malformation and proliferation of

vascular endothelial cells

• risk factors: M:l

'

=3:1

• clinical features

• usually small and asymptomatic, those greater than 10 cm are considered giant and may cause

abdominal pain or discomfort

• consumptive coagulopathy if giant (in children)

• investigations

contrast CT (well-demarcated hypodense mass with peripheral enhancement on arterial phase

with centripetal filling on delayed phases),VIS (homogeneous hyperechoic mass),MR1

avoid biopsy: may result in hemorrhage

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GS53General and Thoracic Surgery Toronto Notes 2023

•treatment

none if asymptomatic

• in symptomatic patients or those with hemangiomas large enough causing mass effect,surgical

resection should be considered after other causes of pain are excluded

• surgical resection options: liver resection, hepatic artery ligation, enucleation, and in severe cases

liver transplantation.

non-surgical treatment: hepatic artery embolization and radiotherapy

Focal Nodular Hyperplasia

•pathogenesis: unclear, hyperplastic response to vascular anomaly leading to disorganized growth of

hepatocytes and bile ducts

•risk factors: female, reproductive age

•clinical features: usually asymptomatic, rarely grows or bleeds, and no malignant potential

•investigations: central stellate scar surrounded by homogenous lesion on CT scan; MRI,biopsy may be

required

•treatment: may be difficult to distinguish from adenoma/ffbrolamellar HCC (malignant potential)

• if confirmed to be l-

'

NH -> no treatment required

Liver Transplantation Criteria for

Hepatocellular Carcinoma

Milan Criteria* 1tumour <5an

Up to 3 tumours each

<3cm

UCSF Criteria* 1lumour <6.5 cm

Up 10 3 Innours each

s4.5cm,total diameter

s8cm

Toronto Criteria’ No tumoursireor number

restrictions

No systemk symptoms

Not poorly differentiated

Adenoma

•pathogenesis: benign abnormal growth of glandular epithelium

•risk factors: female, ages 20-50, estrogen (OCP, pregnancy), obesity, anabolic androgen use, and type 1

glycogen storage disease

•clinical features: asymptomatic, 25% present with RUQ pain or mass, may present with bleeding

•investigations: CT (well-demarcated masses, often heterogeneous enhancement on arterial phase,

isodense on venous phase without washout of contrast), U/S,MRI, biopsy can be considered, with

bleeding risk taken into account

•treatment

stop anabolic steroids or OCP

excise, especially if large (>5 cm), due to risk oftransformation to HCC and spontaneous rupture/

hemorrhage

'Euihctilerla auunanouMityjtkmino

nucravaMuldrlmeiofl

Child- Turcotte-Pugh Score (Prognosis

of Chronic Liver Disease/Cirrhosis,

including Postoperatively)

MALIGNANT LIVER NEOPLASMS

Primary

•most commonly HCC and cholangiocarcinoma

•others include angiosarcoma, hepatoblastoma, and hemangioendothelioma

•risk factors

chronic liver inflammation: cirrhosis from any cause, chronic hepatitis B (inherently oncogenic)

and hepatitis C, hemochromatosis, al -antitrypsin deficiency, and non-alcoholic steatohepatitis

medications: OCPs (3x increased risk),steroids

• smoking, alcohol, betel nuts chewing

chemical carcinogens: aflatoxin, microcvstin, and vinyl chloride (associated with angiosarcoma)

•clinical features

RUQ discomfort and rightshoulder pain

jaundice, weakness, weight loss, and ± fever (if central tumour necrosis)

hepatomegaly,bruit, and hepatic friction rub

• ascites with blood (sudden intra-abdominal hemorrhage)

paraneoplastic syndromes: hypoglycemia, hypercalcemia, erythrocytosis, and watery diarrhea

metastasis: lung, intra-abdominal lymph nodes, bone, adrenal gland, brain, and peritoneal

seeding

•investigations

• INR and LFTs: AST, ALT, ALP, bilirubin, and albumin

1Point 2Points 3PolnU

Albumin (g'L) »35 28-35 *2!

Absent Easily Poorty

cootrdM (or

*

olid

Biluutn <34 34-51 >51

(limolil)

Ascites

<2.0 20-3.0 >10

Coagulation <1.7 1J-23 >23

(mgfdll

in -1

Hepatic Hone Unriial

Encephalopathy

(Grade Ml) Mranced

(Grade III

Points Class OneYr IwoYr

Survival Survival

54 m isv

on 57%

45% 35%

A

7-9 1

elevated ALP, bilirubin, and a-fetoprotein (80% of patients)

U/S (poorly-defined margins with internal echoes), triphasic CT (enhancement on arterial phase

and washout on portal venous phase), and MRI

1015 C

•treatment

cirrhosis is a relative contraindication to tumour resection due to decreased hepatic reserve

surgical: resection (10% of patients have resectable tumours)

liver transplant; may use bridging therapy while awaiting transplant

absolute contraindications: extrahepatic disease and vascular invasion

relative contraindications: dependent on liver transplant protocol based on staging criteria

followed by transplant centre

non-surgical: radiofrequency ablation, percutaneous ethanol injection, transcatheter arterial

chemoembolization (TACE), chemotherapy (consider sorafenib for HCC; preoperative

chemotherapy for hepatoblastoma is standard of care),and radiotherapy

r t

L J

•prognosis

• 5 yr survival: 18% of all patients; 40-70% of patients undergoing complete resection

+

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GS5I General and Thoracic Surgery Toronto Notes 2023

Secondary

• metastases to the liver are the most common malignant tumoursfound in the liver

• etiology

G1 (colorectal most common),lung, breast, pancreas,GI NET,stomach, melanoma,ovary, uterus,

kidney,gallbladder, and prostate

Secondary liver metastases are common

inmany cancers,with some studies

showing a prevalence of 40-50%

amongst patients with oitrahepatic

cancers. They commonly arise from

colorectal,lung, and breast cancers.

For metastases secondary to colorectal

cancer,surgical resection offers the

greatest likelihood of cure

• treatment

depends on the primary cancer site and prognosis

often liver metastases are a manifestation of Stage IV disease and chemotherapy is indicated

metastasectomy may be appropriate for cancers either through surgical resection or local

treatment (i.e. embolization)

hepatic resection of metastatic colorectal liver metastases isstandard of care as part of multimodality treatment that includes chemotherapy if complete resection of the primary cancer

and metastases is possible

transplant also a new and emerging alternative for metastatic disease in the liver.

• prognosis

• following liver resection for colorectal metastases is an overall survival of 30-60% at 5 yr

Liver Transplantation

Table 26. Conditions Leading to Transplantation Living Liver Donors vs. Deceased Liver

Donors

The right lobe of a living donor liver is

transplanted into the recipient whereas

whole livers from deceased donors are

transplanted orthotopically into the

recipient

Parenchymal Disease Cholestatic Disease Inborn Errors Tumours

Chronic hepatitis B or C *

Alcoholic cirrhosis

Acute liver failure

Budd-Chiari syndrome

Congcnilal hepatic fibrosis

Biliary atresia"

Primary biliary cirrhosis

Sclerosing cholangitis

atantilrypsin deficiency

Wilson's disease

Hemochromatosis

Hepatocellular carcinoma

Hepatoblastoma

Metastatic NETs

Coloredal cancer

Li

Autoimmune hepatitis

Cryptogenic cirrhosis

Drug induced hepabtoxicity

Non-alcoholic sleatohepatitis

'leading cause in adults:"leading cause in children

Clinical Indications

• early referral for transplant should be considered for all patients with progressive liver disease not

responsive to medical therapy, especially:

decompensated cirrhosis (ascites, esophageal variceal hemorrhage,spontaneous hepatic

encephalopathy, coagulopathy, progressive jaundice,severe fatigue)

unresectable primary liver cancers

unresectable but localized liver metastasis of colorectal cancer - new emerging indication

• acute liver failure

liver-based metabolic conditions including a-l-antitrypsin deficiency

• end-stage liver disease with life expectancy <1 yr and if no other therapy is appropriate

• suitable HCC not amenable to liver resection

Criteria for Transplantation

• Model for End-Stage Liver Disease (MELD): prognostic model to estimate 3 mo survival following

transjugular intrahepatic portosystemic shunt (TIPS) procedure and to prioritize patients awaiting

liver transplant;based on creatinine, bilirubin, IN R,sodium (MELD-Na), female sex, and serum

albumin;MELD scores used to prioritize liver allocation

• Child-Turcotte-Pugh Score:classification system to assess the prognosis and the abdominalsurgery

perioperative mortality of chronic liver disease and cirrhosis; patient must have 7 points (Class B) for

transplant evaluation

Contraindications

• active alcohol/substance use

• extrahepatic malignancy within 5 yr

• advanced cardiopulmonary dis

• active uncontrolled infection

ease

Postoperative Complications

• primary non-function (graft failure): urgent re-transplantation is indicated

• acute and chronic rejection, ischemia-reperfusion injury

• vascular: hepatic artery or portal vein thrombosis, IVC obstruction

• biliary complications: fever, increasing bilirubin

• complications related to immunosuppression: HTN, renal disease, DM, obesity, hyperlipidemia,

osteoporosis,malignancy, neurologic complications, infection (leading cause of mortality following

transplant)

Prognosis

• patientsurvival at 1 yr:85%

• graft survival at 1 yr: >80%, at 5 yr:60-70%

rt

and ALF

+

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GS55 General and Thoracic Surgery Toronto Notes 2023

Biliary Tract

Cholelithiasis

<§

>

Definition

• the presence ofstones in the gallbladder

Risk Factorsfor Cholesterol Stones

Pathogenesis

• imbalance of cholesterol and itssolubilizing agents ( bile salts and lecithin)

• excess hepatic cholesterol secretion relative to bile salts and lecithin > supersaturated cholesterol

which precipitates as gallstones

• North America:cholesterol stones (80%), pigment stones(20%)

Risk Factors

• cholesterol stones

• obesity

• increasing age

prevalence higher in females (especially females <50 y r)

• estrogens:female, multiparity,OCPs

• impaired gallbladder emptying:starvation, T'

PN, DM

rapid weight loss:rapid cholesterol mobilization and biliary stasis

• pigmentstones(contain calcium bilirubinate)

cirrhosis

chronic hemolysis

biliary stasis (strictures, dilation, biliary infection)

terminal ileal resection or disease (e.g. Crohn'

s disease)

• protective factors

• statins, physical activity, vitamin C, poly- and monounsaturated fats and nuts, coffee

4Fs

Fat

Female

Fertile

Forties

Summary of Biliary Tract Conditions

Gallbladder Asympto- Pain Infection -

matk Only Pain

Cholelithiasis •

Nionlr)

Biliary Celle

Cholecystitis V

Common Bile Asympto- Pah Infection*

Duct matk Only Pain

Uioledoclmlilhiaiis (napAyl

Cholangitis

J

J

(majority)

Cholelilliiasis/Cholecvslitis

Common hepatic duct

Cystic duct

Gallbladder

LigamentolTreitz

Pancreas

Pancreatic duct Choledocholllhiasis/Cholangitis

Sphincter of Oddi

Ampulla of Veter Duodenum

Cliolecystoenleric fistula may

lead to gallstone ileus © Morry Shiyu Wang 2012

Figure 25. Gallstone disease

Clinical Features

• asymptomatic (80%):found incidentally

18% risk of progression to symptomatic gallstone disease within 20 yr

most do NOT require treatment

• consider cholecystectomy if: increased risk of malignancy (choledochal cysts,Caroli’s disease,

porcelain or calcified gallbladder),sickle cell disease, paediatric patient, bariatric surgery, and

immunosuppression

. biliary colic (10-25%)

Investigations

• normal Woodwork:CBC, electrolytes, Gr, LITs, bilirubin, lipase

• U/S:diagnostic procedure of choice

image for signs of inflammation, obstruction, and localization ofstones

• 95% specific for detecting stones

r I

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Biliary Colic

Pathogenesis

• gallstone transiently impacted in cystic duct, no infection

Clinical Features

• an episode of steady,severe dull pain in the epigastrium or RUQ lasting minutes to hours(<6 h),

crescendo-decrescendo pattern

• can present with chest pain, right shoulder tip pain,scapular pain

. N/V

• frequently occurs at night or after fatty meal, not after fasting

• no peritoneal findings, no systemic signs

Biliary colic is a pain that comes and

goes, but cholecystitis is a pain which is

constant and usually increasing

2 Most Important Lab Tests lor Biliary

1' II I!

• Lipase:to determine if element of

pancreatitis

• Bilirubin:to determine if bile duct

Investigations obstruction

• normal blood work:CBC, electrolytes,Cr,LFTs, bilirubin,lipase

* U/S shows cholelithiasis,may show stone in cystic duct

Treatment

o

• analgesia, rehydration during colic episode

• elective cholecystectomy (95% success)

complications:CBD injury (0.3-0.5%), hollow viscus injury, bile peritonitis, and vessel injury

leading to liver damage

laparoscopic cholecystectomy isthe standard of care, no benefit to delayingsurgery

Biliary colic istreated with analgesia and

elective cholecystectomy

Acute cholecystitis is treated with

antibiotics and early cholecystectomy if

surgical risk appropriate

Acute Cholecystitis Toronto Video Atlas of Surgery:

Standard Laparoscopic

Cholecystectomy

TV Asurg is an open accesslibrary of

animation enhanced surgical videos

created by surgeons in Toronto. For

a videosimulation of a standard

laparoscopic cholecystectomy,see

pie.med.utoronto.ca/TVASurqfproiect/

Pathogenesis

• inflammation of gallbladder resulting from sustained gallstone impaction in cystic duct or

Hartmanns pouch

• no cholelithiasisin 5-10% (see AcalculousCholecystitis,GS57)

Clinical Features

• often have history of biliary colic

• severe constant (>6 h ) epigastric or RUQ pain, anorexia, N/V, and low grade fever (<38.5"C)

• focal peritoneal findings: Murphy'

ssign, palpable, and tender gallbladder (in 33%)

• Boas'

sign:rightsubscapular pain

Investigations

• blood work: elevated WBC and left shift,mildly elevated bilirubin concerning for bile duct obstruction

(eitherstones or Mirizzisyndrome)

• U/S:98% sensitive, consider HI DA scan if U/S negative

• signs:gallbladder wall thickening >4 mm, edema (double-wall sign), gallbladder sludge,

cholelithiasis, pericholecystic fluid, and sonographic Murphy'

s sign

Mirizzi Syndrome

Extrinsic compression of the CHD

by a gallstone in the cystic duct

or Hartmann 's pouch. Impacted

gallstone may erode into the CHD or

CBD, creating a cholccystohepatic or

cholecystocholedochal fistula: Mirizzi

syndrome has an association with

gallbladder cancer

Complications

• gangrenous gallbladder (20%) most common complication

• perforation (10%):result in abscessformation or rarely local peritonitis

• Mirizzi syndrome:extra-luminal compression of CBD/CHD due to large stone in cystic duct

• empyema of gallbladder:suppurative cholecystitis (pus in gallbladder) and sick patient

• emphysematous cholecystitis: bacterial gas present in gallbladder lumen, wall, or pericholecystic space

(risk in diabetic patient); organisms involved in secondary infection:C. welchii, E.coll, Klebsiella,

anaerobic streptococci, Enterococcus

• cholecystoenteric fistula (from repeated attacks of cholecystitis) can lead to gallstone ileus

Rouviere's Sulcus

Fissure between right lobe and caudate

process (segment I) of liver; keeping

dissection anterior to this landmark can

minimize bile duct injury

Treatment

• admit, hydrate, NPO, NG tube (if persistent vomiting from associated ileus), analgesics

• antibiotics

• cefazolin if uncomplicated cholecystitis

• ERCP prior to surgery if CBD stones are present on US

MRCP ± ERCP if CBD is markedly dilated or CBD stonessuspected

• cholecystectomy

early (within 72 h) vs.delayed (after 6 wk)

equal morbidity and mortality

early cholecystectomy preferred:shorter hospitalization and recovery time, no benefit to

delaying surgery

emergent OR indicated if high-risk, e.g. emphysematous

• laparoscopic isstandard of care (convert to open for complications or difficult case)

reduced risk of wound infections,shorter hospital stay,reduced postoperative pain, and

increased risk of bile duct injury

• intraoperative cholangiography (IOC)

indications:clarify bile duct anatomy, history of biliary pancreatitis,small stonesin gallbladder

with a wide cystic duct (>15 mm), and jaundice

Critical View of Safety (CVS)

Decreases risk of injury to CBD during

laparoscopic cholecystectomy . 3criteria

are required to achieve the CVS:

1. The hepatocystic triangle (formed

by the cystic duct,CHD, and inferior

edge of the liver) is cleared of fat and

fibroustissue

2.The lower one third of the gallbladder

isseparated from the liver to expose

the cystic plate

3.Two and only two structuresshould be

seen entering the gallbladder (cystic

duct and artery)

r i

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GS57 General and Thoracic Surgery Toronto Notes 2023

has been mostly replaced by preoperative MRCP

• percutaneous cholecystostonty tube:critically ill or if general anesthetic contraindicated

• some centres can perform percutaneous stone extraction to avoid cholecystectomy

Acalculous Cholecystitis

Definition

• acute or chronic cholecystitis in the absence of stones

Pathogenesis

• typically due to gallbladder ischemia and stasis

Risk Factors

• ICU admission (most common), DM, immunosuppression, trauma patient,TPN, and sepsis

Clinical Features

• see AcuteCholecystitis,GS56

• occurs in 10% of cases of acute cholecystitis

Investigations

• Woodwork:CBC, electrolytes,Cr, LFl'

s,liver enzymes, bilirubin, and lipase

• U/S:showssludge in gallbladder, other U/S features of cholecystitis (see Acute Cholecystitis,GS56)

. CT or HIDA scan

Treatment

• NPO, IV fluids, and pain management

• IV broad-spectrum antibiotics, cholecystectomy

• if patient unstable -> percutaneous cholecystostomy

Choledocholithiasis

Definition

. stones in CBD

Clinical Features

• often have history of biliary colic

• tenderness in RUQ or epigastrium

• acholic stool, dark urine, and fluctuating jaundice

• primary vs.secondary stones

primary:formed in bile duct, indicates bile duct pathology (e.g. benign biliary stricture,

sclerosing cholangitis, choledochal cyst, and CP)

• secondary: formed in gallbladder (85% of cases in the U.S.)

Investigations

• CBC: usually normal; leukocytosissuggests cholangitis

• LI- Ts: increased AST, ALT early in disease, increased bilirubin (more sensitive), ALP, GGT later

• lipase: to rule out gallstone pancreatitis

• U/S:intra-/extra-hepatic duct dilatation;differential diagnosis is choledochal cyst

. MRCP (90% sensitive)

visualization of ampullar)'region, biliar)’,and pancreatic anatomy

non-invasive diagnostic test of choice

. ERCP

CBD stones in periampullary region

diagnostic and therapeutic; removal of stones and sphincterotomy possible

complications: retained stones, ERCP pancreatitis (1-2%),pancreatic or biliary sepsis

• Percutaneous Transhepatic Cholangiography

percutaneous approach to the proximal biliary tree (i.e. intrahepatic biliary system) via the

hepatic parenchyma

useful for proximal bile duct obstruction or when ERCP fails or not available

• contraindications:ascites, peri/intrahepatic sepsis, and disease of right lower lung or pleura

complications:bile peritonitis, chylothorax, pneumothorax,biliary sepsis, and hemobilia

• Intraoperative Cholangiography (IOC)

« intraoperative injection of radiographic contrast into the cystic duct to evaluate CBD during

laparoscopic cholecystectomy

useful for identifying CBD stones, clarifying biliary anatomy, and preventing CBD injury during

cholecystectomy

American Society of Gastrointestinal

Endoscopy 2019 Guideline on

Ible of Endoscopy in Evaluating

Choledocolithiasis

Proceed directly to ERCP

• CBD stone on U/S

• Clinical ascending cholangitis

. Bilirubin >4mg/dL (>347umol/L) &

dilated CBD on U/S

Perform U/S, MRCP, Laparoscopic IOC

or Intraoperative US

. Abnormal liver tests

• Age >55 yr

. Dilated CBD on U/S

r •»

u

+

Complications

• cholangitis, pancreatitis, biliary stricture, and biliary cirrhosis

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GS58 General and Thoracic Surgery Toronto Notes 2023

Treatment

• treat with ERCP for CBD stone extraction possibly followed by elective cholecystectomy in 25% of

patients

• biliary tree flushing with laparoscopic cholecystectomy:

during a laparoscopic cholecystectomy ± cholangiogram, the cystic duct can be flushed to the

CBD with the use of glucagon to relax the sphincter between the CBD and duodenum.Can also

use cholangiogram to confirm stones flushed into duodenum

Acute Cholangitis

Pathogenesis

• obstruction of CBD leading to biliary stasis, bacterial overgrowth,suppuration, and biliary sepsismay be life-threatening, especially in elderly

Etiology

• choledocholithiasis (60%),stricture, neoplasm ( pancreatic or biliary), extrinsic compression

(pancreatic pseudocyst or pancreatitis), instrumentation of bile ducts (PTC, ERCP), and biliary stent

• organisms: E. coli,Klebsiella, Enterobacter, Pseudomonas, Enterococcus, B.fragilis,and Proteus

Clinical Features

• Charcot’

s triad:fever, RUQ pain, and jaundice

• Reynold’s pentad:Charcot’striad,hypotension, and altered mentalstatus

• may have N/V,abdominal distention, ileus, acholic stools, and tea-coloured urine (elevated direct

bilirubin)

Charcot’sTriad

Fever.RUO pain, jaundice

Investigations

• GBC:elevated WBC i left shift

• may have positive blood cultures

• LITs:obstructive picture (elevated ALP, GGT, and conjugated bilirubin, possible mild increase in AST,

ALT )

• lipase: rule out pancreatitis

• U/S: intra-/extra-hepatic duct dilatation

• CT:bile duct dilatation and can identify biliary stenosis

• MRCP when diagnosisis unclear

Reynolds' Pentad

Fever.RUO pain, jaundice,shock, and

altered mentalstatus

Common Bacteria in Biliary Tract

KEEPS

Klebsiella

Enterococcus

F.coli, Enterobacter

Proteus. Pseudomonas

Serrotia

Treatment

• initial:NPO,fluid and electrolyte resuscitation,± NG tube, IV antibiotics (treats 80%)

. biliary decompression

ERCP t sphincterotomy:diagnostic and therapeutic

PTC with catheter drainage: if ERCP not available or unsuccessful

open or laparoscopic CBD exploration and I -tube placement if above fails

• in addition to biliary decompression, the underlying cause should be addressed. In the case of

patients with choledocholithiasis, elective cholecystectomy is recommended after resolution of acute

cholangitis to prevent re-occurrence

Prognosis

• suppurative cholangitis mortality rate:20-30%

Gallstone Ileus

Pathogenesis

• repeated inflammation causes a cholecystoenteric fistula (usually duodenal) -> large gallstone enters

the G1 tract (impacting near the ileocecal valve) causing a mechanical bowel obstruction (note:ileus is

a misnomer in this context)

Rigler's Triad of Gallstone Ileus

Pneumobllia

Small bowd obstruction

Gallstone

Clinical Features

• crantpy abdominal pain, N/V, constipation/obstipation (see Large Bowel Obstruction, ( IS37)

Investigations

• AXR: dilated small intestine, air fluid levels, may reveal radiopaque gallstone, and air in biliary tree

(pneumobilia) (40%)

• CT:biliary tract air,obstruction, and gallstone in intestine

• Rigler’s triad: pneumobilia,SBO (partial or complete),and gallstone (usually in right iliac fossa)

ft)

Bouveret'sSyndrome

Gastric outlet/duodenal obstruction

caused by a large gallstone passing

through a cholecystogastric or

cholecystoduodenal fistula

n

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