Abdominal aorta aneurysm

- Abdominal aortic aneurysms are a common problem in vascular surgery.

 They may occur as either true or false aneurysm. With the former all 3 layers of the arterial wall
are involved, in the latter only a single layer of fibrous tissue forms the aneurysm wall.

 True abdominal aortic aneurysms have an approximate incidence of 0.06 per 1000 people. They
are commonest in elderly men and for this reason the UK is now introducing the aneurysm
screening program with the aim of performing an abdominal aortic ultrasound measurement in
all men aged 65 years.

Causes

 Several different groups of patients suffer from aneurysmal disease.

 The commonest group is those who suffer from standard arterial disease, i.e. Those who
are hypertensive and have been or are smokers.

 Other patients such as those suffering from connective tissue diseases such as Marfan's may
also develop aneurysms. In patients with abdominal aortic aneurysms the extracellular matrix
becomes disrupted with a change in the balance of collagen and elastic fibres.

Management

 Most abdominal aortic aneurysms are an incidental finding.

 Symptoms most often relate to rupture or impending rupture.

 20% rupture anteriorly into the peritoneal cavity. Very poor prognosis.

 80% rupture posteriorly into the retroperitoneal space

 The risk of rupture is related to aneurysm size, only 2% of aneurysms measuring less than 4cm in
diameter will rupture over a 5 year period. This contrasts with 75% of aneurysms measuring over
7cm in diameter.

 This is well explained by Laplaces' law which relates size to transmural pressure.

 For this reason most vascular surgeons will subject patients with an aneurysm size of 5cm or
greater to CT scanning of the chest, abdomen and pelvis with the aim of delineating anatomy
 and planning treatment. Depending upon co-morbidities, surgery is generally offered once the
aneurysm is between 5.5cm and 6cm.

A CT reconstruction showing an infrarenal abdominal aortic aneurysm. The walls of the sac are calcified
which may facilitate identification on plain x-rays
 Image sourced from Wikipedia

Indications for surgery

 Symptomatic aneurysms (80% annual mortality if untreated)

 Increasing size above 5.5cm if asymptomatic

 Rupture (100% mortality without surgery)

Surgical procedures
Abdominal aortic aneurysm repair

Procedure:

GA
Invasive monitoring (A-line, CVP, catheter)
Incision: Midline or transverse
Bowel and distal duodenum mobilised to access aorta.
Aneurysm neck and base dissected out and prepared for cross clamp
Systemic heparinisation
Cross clamp (proximal first)
Longitudinal aortotomy
Atherectomy
Deal with back bleeding from lumbar vessels and inferior mesenteric artery
Insert graft either tube or bifurcated depending upon anatomy
Suture using Prolene (3/0 for proximal , distal anastomosis suture varies according to site)
Clamps off: End tidal CO2 will rise owing to effects of reperfusion, at this point major risk of myocardial
events.
Haemostasis
Closure of aneurysm sac to minimise risk of aorto-enteric fistula
Closure: Loop 1 PDS or Prolene to abdominal wall
Skin- surgeons preference

Post operatively:

ITU (Almost all)

Greatest risk of complications following emergency repair
Complications: Embolic- gut and foot infarcts
Cardiac - owing to premorbid states, re-perfusion injury and effects of cross clamp
Wound problems
Later risks related to graft- infection and aorto-enteric fistula
Special groups

Supra renal AAA

These patients will require a supra renal clamp and this carries a far higher risk of complications and risk
of renal failure.

Ruptured AAA
Pre-operatively the management depends upon haemodynamic instability. In patients with symptoms of
rupture (typical pain, haemodynamic compromise and risk factors) then ideally prompt laparotomy. In
those with vague symptoms and haemodynamic stability the ideal test is CT scan to determine whether
rupture has occurred or not. Most common rupture site is retroperitoneal 80%. These patients will tend
to develop retroperitoneal haematoma. This can be disrupted if Bp is allowed to rise too high so aim for
Bp 100mmHg.
Operative details are similar to elective repair although surgery should be swift, blind rushing often
makes the situation worse. Plunging vascular clamps blindly into a pool of blood at the aneurysm neck
carries the risk of injury the vena cava that these patients do not withstand. Occasionally a supracoeliac
clamp is needed to effect temporary control, although leaving this applied for more than 20 minutes
tends to carry a dismal outcome.

EVAR
Increasingly patients are now being offered endovascular aortic aneurysm repair. This is undertaken by
surgeons and radiologists working jointly. The morphology of the aneurysm is important and not all are
suitable. Here is a typical list of those features favoring a suitable aneurysm:

 Long neck

 Straight iliac vessels

 Healthy groin vessels

Clearly few AAA patients possess the above and compromise has to be made. The use of fenestrated
grafts can allow supra renal AAA to be treated.

Procedure:

GA
Radiology or theatre
Bilateral groin incisions
Common femoral artery dissected out
Heparinisation
Arteriotomy and insertion of guide wire
Dilation of arteriotomy
Insertion of EVAR Device
Once in satisfactory position it is released
Arteriotomy closed once check angiogram shows good position and no endoleak

Complications:
Endoleaks depending upon site are either Type I or 2. These may necessitate re-intervention and all
EVAR patients require follow up . Details are not needed for MRCS.

……………..

Benign liver lesions

Benign liver lesions

 Most common benign tumours of mesenchymal origin

 Incidence in autopsy series is 8%

 Cavernous haemangiomas may be enormous

Haemangioma
 Clinically they are reddish purple hypervascular lesions

 Lesions are normally separated from normal liver by ring of fibrous tissue

 On ultrasound they are typically hyperechoic

 90% develop in women in their third to fifth decade

 Linked to use of oral contraceptive pill

 Lesions are usually solitary

 They are usually sharply demarcated from normal liver although they usually lack
Liver cell adenoma a fibrous capsule

 On ultrasound the appearances are of mixed echoity and heterogeneous texture.

On CT most lesions are hypodense when imaged prior to administration of IV
contrast agents

 In patients with haemorrhage or symptoms removal of the adenoma may be

required

Mesenchymal
Congential and benign, usually present in infants. May compress normal liver
hamartomas

Liver abscess  Biliary sepsis is a major predisposing factor

 Structures drained by the portal venous system form the second largest source
  Common symptoms include fever, right upper quadrant pain. Jaundice may be
seen in 50%

 Ultrasound will usually show a fluid filled cavity, hyperechoic walls may be seen in
chronic abscesses

 Liver abscess is the most common extra intestinal manifestation of amoebiasis

 Between 75 and 90% lesions occur in the right lobe

 Presenting complaints typically include fever and right upper quadrant pain
Amoebic abscess  Ultrasonography will usually show a fluid filled structure with poorly defined
boundaries

 Aspiration yield sterile odourless fluid which has an anchovy paste consistency

 Treatment is with metronidazole

 Seen in cases of Echinococcus infection

 Typically an intense fibrotic reaction occurs around sites of infection

 The cyst has no epithelial lining

 Cysts are commonly unilocular and may grow to 20cm in size. The cyst wall is
thick and has an external laminated hilar membrane and an internal enucleated
germinal layer

 Typically presents with malaise and right upper quadrant pain. Secondary
Hyatid cysts bacterial infection occurs in 10%.

 Liver function tests are usually abnormal and eosinophilia is present in 33% cases

 Ultrasound may show septa and hyatid sand or daughter cysts.

 Percutaneous aspiration was previously contra indicated, it is now incorporated

into some treatment regimens

 Treatment is by sterilisation of the cyst with mebendazole and may be followed

by surgical resection. Hypertonic swabs are packed around the cysts during
surgery

 Usually occurs in association with polycystic kidney disease

Polycystic liver
 Autosomal dominant disorder
disease
 Symptoms may occur as a result of capsular stretch

Cystadenoma  Rare lesions with malignant potential

  Usually solitary multiloculated lesions

 Liver function tests usually normal

 Ultrasonography typically shows a large anechoic, fluid filled area with irregular
margins. Internal echos may result from septa

 Surgical resection is indicated in all cases

…………….

Ulcerative colitis

Ulcerative colitis is a form of inflammatory bowel disease. Inflammation always starts at rectum, does
not spread beyond ileocaecal valve (although backwash ileitis may occur) and is continuous. The peak
incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years. It is less
common in smokers.

The initial presentation is usually following insidious and intermittent symptoms. Features include:

 bloody diarrhoea

 urgency

 tenesmus

 abdominal pain, particularly in the left lower quadrant

 extra-intestinal features (see below)

Questions regarding the 'extra-intestinal' features of inflammatory bowel disease are common. Extra-
intestinal features include sclerosing cholangitis, iritis and ankylosing spondylitis.

Common to both Crohn's disease (CD) and

Notes
Ulcerative colitis (UC)

Arthritis: pauciarticular, asymmetric

Arthritis is the most common extra-intestinal
Related to disease Erythema nodosum
feature in both CD and UC
activity Episcleritis
Episcleritis is more common in Crohns disease
Osteoporosis

Unrelated to disease Arthritis: polyarticular, symmetric Primary sclerosing cholangitis is much more
activity Uveitis common in UC
Pyoderma gangrenosum Uveitis is more common in UC
Clubbing
 Primary sclerosing cholangitis

Pathology

 Red, raw mucosa, bleeds easily

 No inflammation beyond submucosa (unless fulminant disease)

 Widespread superficial ulceration with preservation of adjacent mucosa which has the
appearance of polyps ('pseudopolyps')

 Inflammatory cell infiltrate in lamina propria

 Neutrophils migrate through the walls of glands to form crypt abscesses

 Depletion of goblet cells and mucin from gland epithelium

 Granulomas are infrequent

Barium enema

 Loss of haustrations

 Superficial ulceration, 'pseudopolyps'

 Long standing disease: colon is narrow and short -'drainpipe colon'

Endoscopy

 Superficial inflammation of the colonic and rectal mucosa

 Continuous disease from rectum proximally

 Superficial ulceration, mucosal islands, loss of vascular definition and continuous ulceration
pattern.

Management

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

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

Crohns disease

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

Ulcerative colitis Vs Crohns

Crohn's disease Ulcerative colitis

Distribution Mouth to anus Rectum and colon

Macroscopic
Cobblestone appearance, apthoid ulceration Contact bleeding
changes

Depth of disease Transmural inflammation Superficial inflammation

Distribution
Patchy Continuous
pattern

Histological Granulomas (non caseating epithelioid cell aggregates with Crypt abscesses, Inflammatory
features Langhans' giant cells) cells in the lamina propria

Extraintestinal manifestations of Crohns

Related to disease extent Unrelated to disease extent

Aphthous ulcers (10%) Sacroiliiitis (10-15%)

Erythema nodosum (5-10%) Ankylosing spondylitis (1-2%)

Pyoderma gangrenosum (0.5%) Primary sclerosing cholangitis (Rare)

Acute arthropathy (6-12%) Gallstones (up to 30%)

Ocular complications (up to 10%) Renal calculi (up to 10%)

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

 Bile salt diarrhoea secondary to terminal ileal disease

 Entero-colic fistula

 Short bowel due to multiple resections

 Bacterial overgrowth

Surgical interventions in Crohns disease

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

Mesenteric vessel disease

Mesenteric ischaemia accounts for 1 in 1000 acute surgical admissions. It is primarily caused by arterial
embolism resulting in infarction of the colon. It is more likely to occur in areas such as the splenic flexure
that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.

Types

Acute mesenteric  Sudden onset abdominal pain followed by profuse diarrhoea.

embolus (commonest
 May be associated with vomiting.
50%)
  Rapid clinical deterioration.

 Serological tests: WCC, lactate, amylase may all be abnormal particularly in established
disease. These can be normal in the early phases.

 Usually longer prodromal history.

 Post prandial abdominal discomfort and weight loss are dominant features. Patients wil
usually present with an acute on chronic event, but otherwise will tend not to present u
Acute on chronic
mesenteric flow is reduced by greater than 80%.
mesenteric ischaemia
 When acute thrombosis occurs presentation may be as above. In the chronic setting the
symptoms will often be those of ischaemic colitis (mucosa is the most sensitive area to
insult).

 Usually a history over weeks.

Mesenteric vein  Overt abdominal signs and symptoms will not occur until venous thrombosis has reache
thrombosis stage to compromise arterial inflow.

 Thrombophilia accounts for 60% of cases.

 This occurs in patients with multiple co morbidities in whom mesenteric perfusion is

significantly compromised by overuse of inotropes or background cardiovascular
Low flow mesenteric compromise.
infarction
 The end result is that the bowel is not adequately perfused and infarcts occur from the
mucosa outwards.

Diagnosis

 Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease).

 Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning
in the arterial phase with thin slices (<5mm). Venous phase contrast is not helpful.

 SMA duplex USS is useful in the evaluation of proximal SMA disease in patients with chronic
mesenteric ischaemia.

 MRI is of limited use due to gut peristalsis and movement artefact.

Management

 Overt signs of peritonism: Laparotomy

 Mesenteric vein thrombosis: If no peritonism: Medical management with IV heparin

  At operation limited resection of frankly necrotic bowel with view to relook laparotomy at 24-
48h. In the interim urgent bowel revascularisation via endovascular (preferred) or surgery.

Prognosis
Overall poor. Best outlook is from an acute ischaemia from an embolic event where surgery occurs
within 12h. Survival may be 50%. This falls to 30% with treatment delay. The other conditions carry
worse survival figures.

…..

Arterial blood gas interpretation

In advanced life support training, a 5 step approach to arterial blood gas interpretation is advocated.

1. How is the patient?

2. Is the patient hypoxaemic?

The Pa02 on air should be 10.0-13.0 kPa

3. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)

4. What has happened to the PaCO2?

If there is acidaemia, an elevated PaCO2 will account for this

5. What is the bicarbonate level or base excess?

A metabolic acidosis will have a low bicarbonate level and a low base excess (< -2 mmol)
A metabolic alkalosis will have a high bicarbonate and a high base excess (> +2 mmol)

……………………………..

Colorectal cancer

 Annually, about 150,000 new cases are diagnosed and 50,000 deaths from the disease

 About 75% will have sporadic disease and 25% will have a family history

 Colorectal tumours comprise a spectrum of disease ranging from adenomas through to polyp
cancers and frank malignancy.

 Polyps may be categorised into: neoplastic polyps, adenomatous polyps and non neoplastic
polyps.

 The majority of adenomas are polypoidal lesions, although flat lesions do occur and may prove
to be dysplastic.
  Non-neoplastic polyps include hyperplastic, juvenile, hamartomatous, inflammatory, and
lymphoid polyps, which have not generally been thought of as precursors of cancer.

 Three characteristics of adenomas that correlate with malignant potential have been
characterised. These include increased size, villous architecture and dysplasia. For this reason
most polyps identified at colonoscopy should be removed.

 The transformation from polyp to cancer is described by the adenoma - carcinoma sequence and
its principles should be appreciated. Essentially genetic changes accompany the transition from
adenoma to carcinoma; key changes include APC, c-myc, K RAS mutations and p53 deletions

……………………….

Colonic polyps

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

Follow up of colonic polyps

Group Action

Colorectal cancer Colonoscopy 1 year post resection

Large non pedunculated colorectal polyps

One off scope at 3 years
(LNPCP), R0 resection

Large non pedunculated colorectal polyps

Site check at 2-6 months and then a further scope at 12 months
(LNPCP) R1 or non en bloc resection

High risk findings at baseline colonoscopy One off surveillance at 3 years

No high risk findings at baseline No colonoscopic surveillance and invite participation in NHSBCSP
colonoscopy programme when due
High risk findings

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

OR

 More than 5 pre malignant polyps

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

Segmental resection or complete colectomy should be considered when:

1. Incomplete excision of malignant polyp

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

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

Colonic pseudo-obstruction

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

……………………….

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

Symptoms

 Altered bowel habit

 Bleeding

 Abdominal pain

Complications

 Diverticulitis

 Haemorrhage

 Development of fistula

 Perforation and faecal peritonitis

 Perforation and development of abscess

 Development of diverticular phlegmon

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

Acutely unwell surgical patients should be investigated in a systematic way. Plain abdominal films and an
erect chest x-ray will identify perforation. An abdominal CT scan (not a CT cologram) with oral and
intravenous contrast will help to identify whether acute inflammation is present but also the presence of
local complications such as abscess formation.
Severity Classification- Hinchey

I Para-colonic abscess

II Pelvic abscess

III Purulent peritonitis

IV Faecal peritonitis

Treatment

 Increase dietary fibre intake.

 Mild attacks of diverticulitis may be managed conservatively with antibiotics.

 Peri colonic abscesses should be drained either surgically or radiologically.

 Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a
segmental resection.

 Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a
stoma. This group have a very high risk of post operative complications and usually require HDU
admission.

………….

Lower Gastrointestinal bleeding

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

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

Cause Presenting features

Bleeding may be brisk in advanced cases, diarrhoea is commonly present. Abdominal x-ray may show
Colitis
featureless colon.

Acute diverticulitis often is not complicated by major bleeding and diverticular bleeds often occur
Diverticular
sporadically. 75% all will cease spontaneously within 24-48 hours. Bleeding is often dark and of large
disease
volume.

Colonic cancers often bleed and for many patients this may be the first sign of the disease. Major
Cancer
bleeding from early lesions is uncommon

Haemorrhoidal Typically bright red bleeding occurring post defecation. Although patients may give graphic descriptio
bleeding bleeding of sufficient volume to cause haemodynamic compromise is rare.

Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of
Angiodysplasia
symptoms. The right side of the colon is more commonly affected.

Management

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

bleeding the first line management is usually supportive. This is because in the acute setting
endoscopy is rarely helpful.

 When haemorrhoidal bleeding is suspected a proctosigmoidoscopy is reasonable as attempts at

full colonoscopy are usually time consuming and often futile.

 In the unstable patient the usual procedure would be an angiogram (either CT or percutaneous),
when these are performed during a period of haemodynamic instability they may show a
bleeding point and may be the only way of identifying a patch of angiodysplasia.

 In others who are more stable the standard procedure would be a colonoscopy in the elective
setting. In patients undergoing angiography attempts can be made to address the lesion in
question such as coiling. Otherwise surgery will be necessary.

 In patients with ulcerative colitis who have significant haemorrhage the standard approach
would be a sub total colectomy, particularly if medical management has already been tried and
is not effective.

Indications for surgery

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

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

If the source of colonic bleeding is unclear; perform a laparotomy, on table colonic lavage and following
this attempt a resection. A blind sub total colectomy is most unwise, for example bleeding from an small
bowel arterio-venous malformation will not be treated by this manoeuvre.

Summary of Acute Lower GI bleeding recommendations

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

Management

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

 Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding

……………………..

Ano rectal disease

Location: 3, 7, 11 o'clock position

Internal or external
Haemorrhoids
Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy

Location: midline 6 (posterior midline 90%) and 12 o'clock position. Distal to the dentate line
Fissure in ano
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae

Proctitis Causes: Crohn's, ulcerative colitis, Clostridium difficile

Ano rectal E.coli, staph aureus

abscess Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric

Anal fistula Usually due to previous ano-rectal abscess

 Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Goodsalls rule determines
location

Rectal prolapse Associated with childbirth and rectal intussceception. May be internal or external

Pruritus ani Systemic and local causes

Anal neoplasm Squamous cell carcinoma commonest unlike adenocarcinoma in rectum

Solitary rectal Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria
ulcer replaced with collagen and smooth muscle (fibromuscular obliteration)

Rectal prolapse

 Common especially in multiparous women.

 May be internal or external.

 Internal rectal prolapse can present insidiously.

 External prolapse can ulcerate and in long term impair continence.

 Diagnostic work up includes colonoscopy, defecating proctogram, ano rectal manometry studies
and if doubt exists an examination under anaesthesia.

Treatments for prolapse

 In the acute setting reduce it (covering it with sugar may reduce swelling.

 Delormes procedure which excises mucosa and plicates the rectum (high recurrence rates) may
be used for external prolapse.

 Altmeirs procedure which resects the colon via the perineal route has lower recurrence rates but
carries the risk of anastamotic leak.

 Rectopexy is an abdominal procedure in which the rectum is elevated and usually supported at
the level of the sacral promontory. Post operative constipation may be reduced by limiting the
dissection to the anterior plane (laparoscopic ventral mesh rectopexy).

Pruritus ani

 Extremely common.

 Check not secondary to altered bowel habits (e.g. Diarrhoea)

  Associated with underlying diseases such as haemorrhoids.

 Examine to look for causes such as worms.

 Proctosigmoidoscopy to identify associated haemorrhoids and exclude cancer.

 Treatment is largely supportive and patients should avoid using perfumed products around the
area.

Fissure in ano

 Typically painful PR bleeding (bright red).

 Nearly always in the posterior midline.

 Usually solitary.

Treatment

 Stool softeners.

 Topical diltiazem (or GTN).

 If topical treatments fail then botulinum toxin should be injected.

 If botulinum toxin fails then males should probably undergo lateral internal sphincterotomy.

 Females who do not respond to botulinum toxin should undergo ano rectal manometry studies
and endo anal USS prior to being offered surgery such as sphincterotomy

………….

Pilonidal sinus

 Occur as a result of hair debris creating sinuses in the skin (Bascom theory).

 Usually in the natal cleft of male patients after puberty.

 It is more common in Caucasians related to their hair type and growth patterns.

 The opening of the sinus is lined by squamous epithelium, but most of its wall consists of
granulation tissue. Up to 50 cases of squamous cell carcinoma have been described in patients
with chronic pilonidal sinus disease.

 Hairs become trapped within the sinus.

  Clinically the sinus presents when acute inflammation occurs, leading to an abscess. Patients
may describe cycles of being asymptomatic and periods of pain and discharge from the sinus.

 Treatment is difficult and opinions differ. Definitive treatment should never be undertaken when
acute infection or abscess is present as this will result in failure.

 Definitive treatments include the Bascom procedure with excision of the pits and obliteration of
the underlying cavity. The Karydakis procedure involves wide excision of the natal cleft such that
the surface is recontoured once the wound is closed. This avoids the shearing forces that break
off the hairs and has reasonable results.

Pilonidal sinuses are most commonly located in the midline of the natal cleft, as illustrated below

…………………..

Anal fistula

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

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

Identification of the internal opening

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

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

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

Anal fistula plugs and fibrin glue

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

Ano-rectal advancement flaps

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

Ligation of the intersphincteric tract procedure

In this procedure an incision is made in the intersphincteric groove and the fistula tract dissected out in
this plane and divided. A greater than 90% cure rate within 4 weeks was initially reported[15]. Others
have subsequently performed similar studies on larger numbers of patients with similar success rates.

Fistulotomy at the time of abscess drainage?

A Cochrane review conducted in 2010 suggests that primary fistulotomy for low, uncomplicated fistula in
ano may be safe and associated with better outcomes in relation to long term chronic sepsis[16].
However, there is a danger that such surgery performed by non specialists may result in a higher
complication rate and therefore the traditional teaching is that primary treatment of acute sepsis is
incision and drainage only. All agree that high/ complex fistulae should never be subject to primary
fistulotomy in the acute setting.

……………….

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

 There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae
abdominally.

 In general surgical practice the abdominal cavity generates the majority and most of these arise
from diverticular disease and Crohn's.

 As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction.
This is particularly true of intestinal fistulae.

The four types of fistulae are:

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

Suspect if there is excess fluid in the drain.

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

Enterovaginal
Aetiology as above.

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

Management
Some rules relating to fistula management:

 They will heal provided there is no underlying inflammatory bowel disease and no distal
obstruction, so conservative measures may be the best option

 Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag-
skin damage is difficult to treat
 A high output fistula may be rendered more easily managed by the use of octreotide, this will
tend to reduce the volume of pancreatic secretions.

 Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal)
these may necessitate the use of TPN to provide nutritional support together with the
concomitant use of octreotide to reduce volume and protect skin.

 When managing perianal fistulae surgeons should avoid probing the fistula where acute
inflammation is present, this almost always worsens outcomes.

 When perianal fistulae occur secondary to Crohn's disease the best management option is often
to drain acute sepsis and maintain that drainage through the judicious use of setons whilst
medical management is implemented.

 Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra
abdominal source the use of barium and CT studies should show a track. For perianal fistulae
surgeons should recall Goodsall's rule in relation to internal and external openings.

………………….

Anal cancer

- Cancers arising from the squamous epithelium of the anal canal

 Arise inferior to the dentate line

 Strongly linked to HPV type 16 infection

 Other risk factors include ano-receptive intercourse, smoking and immunosuppression

 Presenting symptoms include anal discomfort, discharge or pruritus

 Lymphatic spread typically occurs to the inguinal nodes

 Diagnosis is made by EUA and biopsies

 Staging is with CT scanning of the chest, abdomen and pelvis

 First line treatment is typically with chemoradiotherapy

 Second line treatment for non metastatic disease is with salvage radical abdominoperineal
excision of the anus and rectum

……….

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

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

Identification of the internal opening

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

Image sourced from Wikipedia

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

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

Anal fistula plugs and fibrin glue

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

Ano-rectal advancement flaps

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

Ligation of the intersphincteric tract procedure

In this procedure an incision is made in the intersphincteric groove and the fistula tract dissected
out in this plane and divided. A greater than 90% cure rate within 4 weeks was initially
reported[15]. Others have subsequently performed similar studies on larger numbers of patients
with similar success rates.

Fistulotomy at the time of abscess drainage?

A Cochrane review conducted in 2010 suggests that primary fistulotomy for low, uncomplicated
fistula in ano may be safe and associated with better outcomes in relation to long term chronic
sepsis[16]. However, there is a danger that such surgery performed by non specialists may result
in a higher complication rate and therefore the traditional teaching is that primary treatment of
acute sepsis is incision and drainage only. All agree that high/ complex fistulae should never be
subject to primary fistulotomy in the acute setting.

………….

Crohns disease

Crohns disease is a chronic transmural inflammation of a segment(s) of the gastrointestinal tract

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

Ulcerative colitis Vs Crohns

Crohn's disease Ulcerative colitis

Distribution Mouth to anus Rectum and colon

Macroscopic Cobblestone appearance,

Contact bleeding
changes apthoid ulceration
 Crohn's disease Ulcerative colitis

Depth of disease Transmural inflammation Superficial inflammation

Distribution
Patchy Continuous
pattern

Granulomas (non caseating Crypt abscesses,

Histological
epithelioid cell aggregates with Inflammatory cells in the
features
Langhans' giant cells) lamina propria

Extraintestinal manifestations of Crohns

Related to disease extent Unrelated to disease extent

Aphthous ulcers (10%) Sacroiliiitis (10-15%)

Erythema nodosum (5-10%) Ankylosing spondylitis (1-2%)

Pyoderma gangrenosum (0.5%) Primary sclerosing cholangitis (Rare)

Acute arthropathy (6-12%) Gallstones (up to 30%)

Ocular complications (up to 10%) Renal calculi (up to 10%)

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

 Bile salt diarrhoea secondary to terminal ileal disease

 Entero-colic fistula

 Short bowel due to multiple resections

 Bacterial overgrowth

Surgical interventions in Crohns disease

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

Diverticular disease

Diverticular disease is a common surgical problem. It consists of herniation of colonic mucosa

through the muscular wall of the colon. The usual site is between the taenia coli where vessels
pierce the muscle to supply the mucosa. For this reason, the rectum, which lacks taenia, is often
spared.

Symptoms

 Altered bowel habit

 Bleeding

 Abdominal pain

Complications

 Diverticulitis

 Haemorrhage

 Development of fistula

 Perforation and faecal peritonitis

 Perforation and development of abscess

 Development of diverticular phlegmon

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

Acutely unwell surgical patients should be investigated in a systematic way. Plain abdominal films
and an erect chest x-ray will identify perforation. An abdominal CT scan (not a CT cologram) with
oral and intravenous contrast will help to identify whether acute inflammation is present but
also the presence of local complications such as abscess formation.

Severity Classification-
Hinchey

I Para-colonic abscess

II Pelvic abscess

III Purulent peritonitis

IV Faecal peritonitis

Treatment

 Increase dietary fibre intake.

 Mild attacks of diverticulitis may be managed conservatively with antibiotics.

 Peri colonic abscesses should be drained either surgically or radiologically.

 Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a
segmental resection.

 Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a
stoma. This group have a very high risk of post operative complications and usually require HDU
admission.

………..

Colorectal cancer treatment

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

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

Treatment of colonic cancer

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

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

Risk of
Site of cancer Type of resection Anastomosis
leak

Right colon Right hemicolectomy Ileo-colic Low <5%

Transverse Extended right hemicolectomy Ileo-colic Low <5%

Splenic
Extended right hemicolectomy Ileo-colic Low <5%
flexure

Splenic
Left hemicolectomy Colo-colon 2-5%
flexure

Left colon Left hemicolectomy Colo-colon 2-5%

Sigmoid
High anterior resection Colo-rectal 5%
colon

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

Colo-rectal
Low rectum Anterior resection (Low TME) (+/- Defunctioning 10%
stoma)

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

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

…
 Lower Gastrointestinal bleeding

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

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

Causes

Cause Presenting features

Bleeding may be brisk in advanced cases, diarrhoea is commonly present. Abdominal

Colitis
ray may show featureless colon.

Acute diverticulitis often is not complicated by major bleeding and diverticular bleeds
Diverticular
often occur sporadically. 75% all will cease spontaneously within 24-48 hours. Bleedin
disease
often dark and of large volume.

Colonic cancers often bleed and for many patients this may be the first sign of the
Cancer
disease. Major bleeding from early lesions is uncommon

Typically bright red bleeding occurring post defecation. Although patients may give
Haemorrhoidal
graphic descriptions bleeding of sufficient volume to cause haemodynamic compromi
bleeding
is rare.

Apart from bleeding, which may be massive, these arteriovenous lesions cause little in
Angiodysplasia
the way of symptoms. The right side of the colon is more commonly affected.

Management

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

bleeding the first line management is usually supportive. This is because in the acute setting
endoscopy is rarely helpful.

 When haemorrhoidal bleeding is suspected a proctosigmoidoscopy is reasonable as attempts at

full colonoscopy are usually time consuming and often futile.
 In the unstable patient the usual procedure would be an angiogram (either CT or percutaneous),
when these are performed during a period of haemodynamic instability they may show a
bleeding point and may be the only way of identifying a patch of angiodysplasia.

 In others who are more stable the standard procedure would be a colonoscopy in the elective
setting. In patients undergoing angiography attempts can be made to address the lesion in
question such as coiling. Otherwise surgery will be necessary.

 In patients with ulcerative colitis who have significant haemorrhage the standard approach
would be a sub total colectomy, particularly if medical management has already been tried and
is not effective.

Indications for surgery

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

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

If the source of colonic bleeding is unclear; perform a laparotomy, on table colonic lavage and
following this attempt a resection. A blind sub total colectomy is most unwise, for example
bleeding from an small bowel arterio-venous malformation will not be treated by this
manoeuvre.

Summary of Acute Lower GI bleeding recommendations

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

Management

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

 Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding,.

 ………….
Fistulas

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

 There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae
abdominally.

 In general surgical practice the abdominal cavity generates the majority and most of these arise
from diverticular disease and Crohn's.

 As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction.
This is particularly true of intestinal fistulae.

The four types of fistulae are:

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

Suspect if there is excess fluid in the drain.

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

Enterovaginal
Aetiology as above.

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

Management
Some rules relating to fistula management:
 They will heal provided there is no underlying inflammatory bowel disease and no distal
obstruction, so conservative measures may be the best option

 Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag-
skin damage is difficult to treat

 A high output fistula may be rendered more easily managed by the use of octreotide, this will
tend to reduce the volume of pancreatic secretions.

 Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal)
these may necessitate the use of TPN to provide nutritional support together with the
concomitant use of octreotide to reduce volume and protect skin.

 When managing perianal fistulae surgeons should avoid probing the fistula where acute
inflammation is present, this almost always worsens outcomes.

 When perianal fistulae occur secondary to Crohn's disease the best management option is often
to drain acute sepsis and maintain that drainage through the judicious use of setons whilst
medical management is implemented.

 Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra
abdominal source the use of barium and CT studies should show a track. For perianal fistulae
surgeons should recall Goodsall's rule in relation to internal and external openings.