3 rd year Surgical Clerkship 546 Seminar

1. 3rd year Surgical Clerkship 546 Seminar Or Why All-Bran is the Panacea for (nearly all) Coloanal ills

2. Diverticular disease Haemorrhoids Colorectal cancer Fissures & Fistulae

3. Daily Recommended Fibre Intake Women25 grams per day, < 5021 grams per day, > 50 Men38 grams per day, < 5030 grams per day, > 50

4. Constipation Ideal Diarrhoea Lewis SJ, Heaton KW (1997). "Stool form scale as a useful guide to intestinal transit time". Scand. J. Gastroenterol.32 (9): 920–4.

5. So why constipation is bad and how it may produce disease • Haemorrhoids • Hard stool (+ straining) traumatises anal mucosal cushions -> oedematous & friable -> bleeding & prolapse • Fissures • Hard stool tears anal mucosa below dentate line -> exposes internal sphincter -> anal spasm (+ ischaemia) -> pain & poor healing -> opiate analgesia -> constipation…… • Diverticular disease • “rabbit pellet” stools -> hypersegmentation -> high pressure zones -> outpouching at sites of vessel penetration through serosa -> diverticula • Colorectal cancer (theoretical – evidence mixed) • Constipation -> slow colonic transit -> longer time potential carcinogens in contact with colonic mucosa (esp recto sigmoid) -> polyp formation….

7. Anatomy

9. History & Physical • Symptoms • Bleeding • bright/dark red on/on stool • Painful/painless • Discharge • colour • Itch • Bowel habit • Consistency • Shape • Family history • Anal surgery • Continence • Stool • Air • Urgency • History of IBD • Signs • “if you don’t put your finger in it – you’ll put your foot in it” • Inspect • Prolapse • Tags • Pruritis • patulousness • DRE • Anal canal 2-5cm • Note anal tone • Squeeze pressure • Prostate/cervix • Rectal mass • Tenderness vs discomfort • Proctosigmoidoscopy & anoscopy

11. Initial Management Algorithm of Bright Rectal Bleeding • If < 50 years and bright red rectal bleeding and no change in bowel habit • Rigid proctsigmoidoscopy • Likely anal cause • If < 50 years family history of CRC (esp if occurred young), change in bowel habit, pus or mucus • Colonoscopy & rigid proctsigmoidoscopy • r/o neoplasm or IBD • If > 50 years bright red rectal bleeding, no change in bowel habit • Barium enema & rigid proctsigmoidoscopy • Low suspicion for neoplasm • Likely anal cause • May identify diverticular diisease, IBS • If > 50 years and dark and bright blood, change in bowel habit or stool • Colonoscopy (with call to GI otherwise might wait 5 months!) • If –ve rigid proctsigmoidoscopy NB what ever GI tell you the anal canal can not be adequately be inspected by the colonoscope!

12. Rectal Bleeding: A Management Algorithm Alarm Symptoms: Change in bowel habits, blood on stool, mucus/puss, change in shape of stool, family history of CRC/polyps < 60 Note: Just because patient has a polyp/cancer, doesn’t mean they don’t have anal pathology!

13. Hemorrhoid (h m – roid) n.dictionary.com definition An itching or painful (only if thrombosed) mass of dilated veins (No – bright red rectal bleeding) in swollen anal tissue Also called piles Thrombosed external (veins) [from Middle English emoroides, hemorrhoids, from Old French emoroides, from Latin haemorrhoidae, from Greek haimorrhoides, pl. of haimorrhois, from haimorrhoos, flowing with blood: haimo, hemo- + rhein, to flow]

14. Hemorrhoids • St Fiacre’s Curse • Patron saint of gardeners • His prolapsed hemorrhoids cured by sitting on a stone and prayer • Aetiology myths • Prolonged driving • Cold benches • Spicy food • Manual labour • Definition • Dilated mucosal cushions • Assist in differentiating liquid, solid and air • Chronic straining leads to engorgement, overlying mucosa becomes friable, bleeding occurs from arterio-venous connections in the mucosal cushions

15. Hemorrhoids • Classification • 1st degree • Painless bleeding • 2nd degree • Prolapse on defecation • Spontaneous reduction • bleeding • 3rd degree • prolapse • Manual reduction • bleeding • 4th degree • Irreducible • bleeding

23. PPH Stapled HemorrhoidectomyEthicon J & J

24. Ligasure HemorrhoidectomyTyco Valleylab Harmonic Scalpel

25. Thrombosed Hemorrhoid (pile)

26. Active Ingredients: Mineral Oil 14% (Protectant), Petrolatum 71.9% (Protectant), Phenylephrine HCI 0.25% (Vasoconstrictor), Shark Liver Oil 3.0% (Protectant)Inactive Ingredients: Beeswax, Benzoic Acid, BHA, Corn Oil, Glycerin, Lanolin, Lanolin Alcohol, Methylparaben, Paraffin, Propylparaben, Thyme Oil, Tocopherol, Water Active Ingredients: contains: Pramoxine Hydrochloride (1%), Zinc Oxide (12.5%), Mineral OilInactive Ingredients: Benzyl Benzoate, Calcium Phosphate Dibasic, Cocoa Butter, Glyceryl Monooleate, Glyceryl Monostearate, Kaolin, Peruvian Balsam, Polyethylene Wax

28. Anal Fissure - Fissure-in-ano • Tear in anoderm • Usually posterior • Below dentate line • Acute • Severe anal spasm • Unable to sit • Chronic • Pain (85%) on or following defecation • Pruritis (15% – 40%) • Bright red blood on toilet paper (80%) • Small amount • cf hemorrhoids – drip into the toilet bowl • Anal spasm • Tends to heal over days to weeks, but recurs (30%) • Typical history 3 – 5 months • Associated with passage of constipated stool • But localised ischemia plays a part • Anal tag (sentinel pile) (30%) • & fibrous anal polyp

29. Fibrous anal polyp 25% Fissure Anal tag (sentinel tag/pile) 70% Associated findings: anal spasm 75%, hemorrhoids 35%

30. Anal fissure - non operative Rx • Traditional • Acute • Diet • Stool softeners • Sitz (salt baths) • 5% xylocaine gel • NSAIDS • Chronic • Diet • Stool softeners • Sitz (salt baths) • 50% heal 4-8 weeks • 75% recur • Newer Chemical sphincterotomy • Based on ischaemia and Nitric Oxide • Vasodilatation • Internal sphincter relaxation • Topical 0.2% GTN paste 6 weeks • 50% – 80% healing • 15% Headaches • Topical 2% diltiazem 9 weeks • 65% – 75% healing • Fewer side effects • Botulinum Toxin injections

31. Recurrence rate 5% Incontinence air 5 -10% usually temporary feces < 5% (beware the patient with poor tone pre-op Bleeding, hematoma, abscess

33. Abscess & Fistula in Ano • Fistula • “ an abnormal connection between to epithelial lined surfaces” • Abscess • A localized collection of pus • Pus • Fluid composed of bacteria and dead cells • If perianal will contain fecal organsim e.coli, strept fecalis etc cf “boil” staph

35. Rare – difficult to Rx, think IBD, Seton 2nd commonest – lots of pus esp. in diabetics, I&D in OR Commonest – can be I&D in ER Infrequent – often difficult to diagnose, lots of pain nothing to see, boggy on DRE, TRUS

36. True perianal sepsis is due to faecal organisms with over 50% recurrence rate with I&D alone

45. screening Examination of people with no symptoms, to detect unsuspected disease. surveillance Oversight; watch; inspection Origin: F, fr. Surveiller to watch over; sur over + veiller to watch, L. Vigilare. See Sur-, and Vigil.

46. Colorectal Cancer • Diagnosis • Colonoscopy • Routine wait time 5-6months! • Risk of perforation 1 in 2-4,000 • Failure to reach ceacum rate 5 -15% • Ba enema • Not that bad but ……….. • 10 - ?% false negative rate • Esp for polyps < 1cm • Easier and quicker to get • Polyp • 2cm > 50% chance invasive ca • Benign to malignant transformation 2-5yrs

47. Clinical Risk Factors for Colorectal Cancer • Polyposis syndromes • Familial polyposis coli • Gardner syndrome • Peutz-Jeghers syndrome (hamartomas) • HNPCC • 5% of CRC • 80% will get • 3 relatives with CRC • 2 successive generations • CRC in relative < 50 • Other cancers ovarian, endometrial, bladder • Pre-existing disease • Ulcerative colitis • Crohn’s disease • Prior colorectal cancer • Neoplastic polyps • Pelvic irradiation • Breast or genital tract cancer • General • Age > 40 years • Family history of CRC

48. Prognostic Risk Factors in Colorectal Cancer • Age • Patients < 40 years of age often present with more advanced stage disease • BUT stage for stage same prognosis • Symptoms • Symptomatic patients tend to have more advanced stage disease • Obstruction and perforation • Poorer prognosis when present • Location of primary • Rectosigmoid & rectal cancers lower cure rates compared with colon cancer • Tumor configuration • Exophytic tumors less advanced stage cancer compared with ulcerative tumors

49. Prognostic Risk Factors in Colorectal Cancer • Perioperative blood transfusions during resection of primary tumor • Poorer survival rates • Independent variable • Not just worse tumours – bigger surgery • anergy • Poorer Prognosis • Blood vessel invasion • Lymphatic vessel invasion • Perineural invasion • Lymphocytic infiltration • Carcinoembryonic antigen • when elevated pre op

50. History of Staging • 1932 Dr Cuthbert Dukes of St Marks Hospital City of London • Links prognosis of patients with rectal cancer to pathological stage • Stage A – confined to bowel wall 90% survival • Stage B – through bowel wall 60% survival • Stage C – metastases to (resected) lymph nodes 30% survival