Science topic

Colorectal Surgery - Science topic

A surgical specialty concerned with the diagnosis and treatment of disorders and abnormalities of the colon, rectum, and anal canal.
Questions related to Colorectal Surgery
  • asked a question related to Colorectal Surgery
Question
6 answers
After low or ultralow anterior resection, it is difficult to assess the future bowel function before reversing the ileostomy
Relevant answer
Answer
Schwandner F, Klimars U, Gock M, et al. The Water-Holding Procedure for Ensuring Postoperative Continence Prior Restoring Intestinal Continuity. J Gastrointest Surg. 2020;24(2):411-417. doi:10.1007/s11605-019-04171-7
A standardized water-holding test can function as an easy and reliable method before stoma reversal to predict sufficient postoperative fecal continence. In case of a sufficient water-holding test despite low manometric pressure levels, the risk for postoperative anal incontinence seems to be low. Preoperative manometric pressure levels do not appear to predict postoperative continence.
  • asked a question related to Colorectal Surgery
Question
27 answers
I asked this question more than a year ago in this forum and never got an answer.
I do not believe that cecal volvulus can anatomically exist. This empirical nomenclature misdirects the diagnosis of practitioners,  however,  a recent article was published about " Cecal Volvulus mimicking Ogilvie's Syndrome..." in Annals of Med and Surg., London, May 2016". The picture looks like Cecocolic Torsion with Psedocystic configuration previously described elsewhere.
Relevant answer
Answer
Thanks
  • asked a question related to Colorectal Surgery
Question
58 answers
There are many techniques for managing pilonidal sinus disease. I would be interested to know which you refer and how you decide which technique to perform if you use more than one.
Relevant answer
Answer
Could you possibly describe your technique to us Dr. Hofer?
  • asked a question related to Colorectal Surgery
Question
17 answers
After Pilonidal Surgery we always advise the Patient to shave/remove hair from natal cleft repeatedly to prevent recurrence. Usually many patients do not follow these instructions and in some cases recurrence takes place. We started advising permanent hair removal by laser or by other methods. Now we have observed no recurrence (4 yrs. follow up). Are we right ?
Relevant answer
Answer
It seems that Dr. Dwivedi has opened up a can of worms with his question ! I think this is a very relevant and pertinent question, with pilonidal sinus being a common problem, notorious for its recurrence.
I agree with Dr. Naqvi - there is a theory for recurrence in a hairless cleft. It's most likely due to the hairs that fall from the head down the back and eventually into the cleft.
  • asked a question related to Colorectal Surgery
Question
36 answers
Though Mesentery may be considered as a single entity all along the gut tube, but why is it called an organ? I don't see any reason for that. Neither is there any international body to come up with definitions of tissues and organs? Some anatomical society should come forward to address this issue.
Relevant answer
Answer
Thank you Dr. Castillo,
I feel the problem lies in the absence of any appellate body for the proper nomenclature of human body parts.
Chemistry recognized the problem very early and came up with a sophisticated system called IUPAC (International Union for Pure and Applied Chemistry) nomenclature.
I think it is the prime responsibility of the the Anatomists and Physiologists to come forward and establish a commission for the nomenclature of body parts and functions. It seems just simple right now, but as the fashion of naming every single entity as a separate organ grows, it will be a problem to tackle the issue then.
There was recently a new floating that human body consists of some 78 organs and Mesentery is the 79th in the list. I am afraid that I don't know who generated that list. This list was most probably a bogus list or the journalist's flaw.
Additionally, the Lancet paper published by Prof. Coffey does not seem to be sufficiently justifying the organ status of Mesentery. Because, in order to do that, it is important to place the definition of an organ in the introduction itself. The paper by Coffey and his colleagues is just a review trying to give an idea that based on the endoscopic experiences and other speculative approaches, Mesentery may be a continuous entity from Jejuno-ilial junction to rectum. I do agree to this statement because we have done a number of cadaveric dissections and found that Mesentery is a continuous entity. But that is no justification to refer to Mesentery as an organ.
  • asked a question related to Colorectal Surgery
Question
5 answers
63 yr old male.
Apr 2015 radical nephrectomy (left) . for CCRC grade 4. PT3a N0M0.
Aug 2016 local récurrence 1,5 cm 1yr after. Complete resection.
Feb 2017 2nd local récurrence with left colic angle obstruction. Complete resection.
MDRD: 32 ml/mn
do you propose targeted therapies? When? Which?
thanks
Relevant answer
Answer
But we don’t heal the proper mechanism of the microscopic disease , i.e , cell spreading....
  • asked a question related to Colorectal Surgery
Question
6 answers
78 year lady underwent upfront lap sigmoid colectomy for a bulky tumor. Distal resection margin below promontory with distal resection margin 6 cm. post operative course uneventful. Final histology t3n1 with 2/30 nodes positive. However distal resection margin showed acellular mucin. Would she require resurgent for this or close observation with adjuvant chemotherapy?
Relevant answer
Answer
Patient recieved adjuvant chemotherapy and is on surveillance more than 2 years, disease free. No rerescection required
she underwent flexible sigmoidoscopy every 6 months
  • asked a question related to Colorectal Surgery
Question
11 answers
I have a young female patient with a rectal mass 3cm from anal verge. Biopsy has been done twice and both times showed only high grade dysplasia. MRI shows it to be a T3 lesion. No lymph nodes. Should she be started on neoadj therapy?? 
Relevant answer
Answer
Discuss it in a multidisciplinary committee, it is a question that involves considering many details
  • asked a question related to Colorectal Surgery
Question
6 answers
The incidence of splenic abscesses is currently 0.14-0.7% with a reported mortality of 0-47%. The diagnosis of splenic abscess which has ruptured into the abdomen is often overlooked because of its rarity and its misleading clinical presentations. Percutaneous coronary interventions (PCIs) and coronary stenting procedures increased from 184,000 to 885,000 (from 335 to 1,550) and from 3,000 to 770,000 (from 5 to 1,350 per one million inhabitants), respectively. A 40-year-old Asian male presented to our emergency department with upper abdominal pain 5 days after a percutaneous transluminal coronary angioplasty. Clinical examination raised the possibilities of acute pancreatitis and intraabdominal sepsis. An initial ultrasound of the abdomen and blood tests were negative. A computed tomography scan of the abdomen revealed a splenic abscess that had ruptured into the abdomen. Pus culture revealed a multidrug-resistant strain of Klebsiella pneumoniae that was sensitive to meropenem. The patient recovered quickly after open surgical drainage and antibiotic therapy. As this is the second case of splenic abscess and the first case report of a ruptured splenic abscess following a PCI, it will be rational to administer a short course of antibiotic prophylaxis for high-risk immunocompromised patients who are undergoing percutaneous transluminal coronary intervention.
Relevant answer
It is of course true that cardiac catheterization carries a negligible risk of bacteremia but with PCI bacteremia occurs frequently (in approximately 30% of cases); however, clinical sequelae occur rarely in such cases. PCI has a greater bacteremic potential, probably because of the length of the procedure and the repeated insertion of interventional devices into the vascular system . Infective mycotic aneurysm presenting as transient acute coronary occlusion and infectious pericarditis [Badshah A, Younas F, Janjua MSouth Med J. 2009 Jun; 102(6):640-2.]
  • asked a question related to Colorectal Surgery
Question
3 answers
I am investigating the question of colonic diverticula formation. It was suggested by Mayers et al. that diverticula tend to form in the weak-spots of the muscular layer, where blood vessels passing along the taenias protrude the musculature in order to reach the submucosa. In my cryo-sections, I came across these samples (images bellow). It is 4% PFA fixed, full-thickness human sigmoid colon of a senior patient. It is not located next to a taenia as could be judged from the thickness of longitudinal muscle layer, although some vessels are clearly visible.
So is this to be considered a “weak-spot” or not? If so, should they be considered to be “normal” or pathological formation? And does circular muscle layer supposed to have these types of intrusions or should this be considered “non-normal/pathological”?
Relevant answer
Answer
Dear collegue,
I guess that the diverticula formation can have more than one mechanisme. In old patients it can be the weak muscle together with the death of the neuronal components , it leads to the hypokinetic constipation, bacterial hyper growth and toxic damage of the mucosa and sumucosal layer.  In other case the main reason can be the direct hypoxy of the muscular layer after the  enlargement of the colon. So it is necessary to study the case-records and the resulte of the R-study of the colon 
  • asked a question related to Colorectal Surgery
Question
12 answers
I have a patient with curious case of internal growth (double in size within a year, now 5 cm) . On MRI, no definitive diagnosis except heterogeneous T2 showing fluid like and connective loose fibrosis. Two CT core biopsies only showed fibrosis. Patient had previous chordoma resected 2 years ago with free margin and pre and post proton treatments. Not chordoma, sarcoma or granuloma.  Any suggestions? Hypertrophic scar internally? What is the management?
Relevant answer
Answer
I think most of us would surgically excise the abnormal tissue and get a pathology report.
  • asked a question related to Colorectal Surgery
Question
17 answers
43 yr old male with Rectal bleeding diagnosed to have a moderately differentiated adenocarcinoma muscularis mucosa was involved but no nodal or distant mets.CRM is clear.Pt does not want preop chemo radiation and wait for 6 to 12 weeks for surgery.Earlier APR with stoma used to be the standard procedure.Agree preop chemo radiation is the standard protocol.
Relevant answer
Answer
Dr Prasanna Kumar Reddy
Since this is cT1 N0, mod differentiated adenocarcinoma 1cm above dentate line, addition information on tumour size and persentage of circumference involvement may indicate the possibility of a Trans anal wide excision..
  • asked a question related to Colorectal Surgery
Question
8 answers
A 41 yrs old man with a mass(2*2 cm) from 4cm from anal verge. biopsy showed GIST.metastatic work up was negative. EUS confirmed sphincter involvement.
which option do you recommend?
Relevant answer
Answer
LAR
  • asked a question related to Colorectal Surgery
Question
19 answers
42 years-old female very slim ( BMI = 18 kgs-m2) patient with recurrent carcinoid gastric type 1 into fundus-body about 1,5 cm previously resected by means eco-endoscopy. She presented recurrence after 4 months after full endoscopic resection. The lesion is moderate grade lesion - expression of Ki-67 = 10 %. Octreoscan is negative to distance spreading. What is the best approach to this case? New endoscopic approach? Subtotal distal or total laparoscopic gastrectomy? If total gastrectomy is choosen , Is whorthwilhe an esophago-jejunal anastomosis with interposed jejunal-pouch to decrease lost of weight? 
Relevant answer
Answer
Look there was very early recurrence. This patient is young and high levels of gastin will remain everytime. So new carcinoid tumors will always return.
  • asked a question related to Colorectal Surgery
Question
9 answers
Well I have this 87 year old patient with rectal cancer on 12 cm. MRI says it is T3c (MRF+, EMVI+) N+. CT's of abdomen and thorax are OK. She is in good condition, no other diseases, but doesn't want to be operated on.
So I contacted our oncologists and they are not very happy with my idea of neoadjuvant therapy and perhaps wait and see aproach. They probably think the patient is to old and/or sick and propose 5 x 5 Gy short term treatment.
I searched the web but didn't find any such protocols after short term radioterapy only . Does any of You have any experiences or literature about this issue?
I think that the problem is in toxicity of neodjuvant therapy. At least our oncologists claim, that the patient who is not the good candidate for rectum resection because of adjacent diseases is even worst candidate for neaodjuvant treatment. Is it really like that?
I believe that exactly those patients, who doesnt want or can't be operated on should be candidates for nonoperative treatment.
What do You think?
asist prof Bojan Krebs, MD
Relevant answer
Answer
What would be your approach in a fit 50 yr old patient with these characteristics? Chemoradiotherapy with 25 fractions and capecitabine?
  • asked a question related to Colorectal Surgery
Question
20 answers
There are multiple definitions/landmarks for the beginning of the rectum.
Eg. sacral promontory, S3, peritoneal reflection, coalescence of taenia coli, or distance from the anal verge (eg 9, 12, 15, 16cm).
How does your country distinguish the rectum from the sigmoid? Is this based on any evidence? Definitions and references from your country welcome!
Relevant answer
Answer
Dear Nigel,
Based on the local recurrence rate of rectal tumors, the National Cancer Institute establish the length of the rectum to be 12 cm above the anal verge (> 12 cm, local recurrence same with colon cancer; < 12 cm local recurrence similar with middle rectum).
From a classical & surgical point of view, the upper limit of the rectum is at the third sacral vertebra, and the inferior limit is represented by the anal verge.
However, a universally accepted length is 15 cm from the anal verge, and may be divided into three segments:
  • Upper rectum: 11 – 15 cm from the anal verge, covered by peritoneum on its anterior and lateral sides.
  • Middle rectum 7 – 11 cm from the anal verge, covered by visceral peritoneum only on its anterior surface.
  • Lower rectum: 0-7 cm from the anal verge.
Other clinicians are considering 0-5 cm, 5-10 cm, 10-15 cm as boundaries for lower, middle and upper rectum, respectively. 
On the other hand, in Gray's anatomy there are two different anatomical structures: anal canal and rectum.
The anatomic anal canal is 2 cm long (anal verge-dentate line), while the surgical anal canal has a length of 4 cm from the anal verge (anal verge - puborectal muscle).
Measurement of rectal tumors from the anal verge should be done with a rigid proctosigmoidoscope and not with a flexible instrument which introduces an important degree of variability.
  • asked a question related to Colorectal Surgery
Question
8 answers
If the cancer comes back locally in the pelvic area in a year after the definitive surgery done what do you think to do first and then?
What type of diagnostic tools do you have  dealt with?
Systemic Chemotherapy or cytoreductive surgery with HIPEC what do you think?
Relevant answer
Answer
The management of recurrent rectal cancer depends on re-staging it the same way you would any primary tumour, with histology/CT/MRI/PET CT/Bone Scans. This provides staging of the local disease along with ascertaining the presence and extent of distant disease, if any. Of course, the specific treatment would depend on the stage and treatment given first time around, specifically the amount of radiotherapy that was used. A lot of oncologists do offer some radiotherapy for the recurrence, using more targeted techniques. Then, depending on the involvement of other pelvic organs, resection is possible, usually in the form of an appropriate pelvic excenteration. It is best to approach such a resection along with other specialists, commonly, a Urologist (for the construction of an illeal conduit in place of the bladder), an Orthopaedic or Spinal surgeon, for the sacrectomy; a plastic surgeon, particularly as it is likely radiotherapy has been used and a local flap reconstruction may be required for the perineal defect; a vascular surgeon, if the iliac vessels have been encased, and in women, a pan-hysterectomy with a partial vaginectomy might be needed. It is better to start out such ventures with a fully established team as it is a completely different ball-game compared to just converting an anterior resection into an APER. The results, however, are rewarding; and are similar to those obtained following an anatomically curative liver resection for colorectal liver metastases i.e. 30-40% 5 year survival. In the UK, there are only a handful of centres that offer the complete service, and this is with good reason! See data published by Prof Peter Sagar, Leeds, UK, amongst others.
HIPEC is not commonly required, as rectal recurrence is usually infraperitoneal, though locally advanced. Recurrence of an intraperitoneal colonic tumour is a different matter. Here, once again, it is imperative to obtain tissue diagnosis and complete staging, particularly looking for distant metastatic disease, with a CT/MRI/PET CT etc. The extent of involvement determines the resectability of disease. i.e. one would not simply debulk colorectal disease and perform HIPEC; the aim is to remove all visible macroscopic disease, via visceral peritonectomy, which is a procedure resulting in significant morbidity and mortality on; HIPEC is an adjuvant measure, not therapeutic on its own. For UK data, see that published by Brendan Moran, Bassingstoke.
The take-home message is that recurrent colorectal cancer includes a wide spectrum of disease; some easily manageable locally by all colorectal surgeons; the rest requiring not only highly detailed work-up and discussion, but then specialist teams used to dealing with such cases. Given the variable resources internationally, inevitably, there is a limit to what is available in different nations; and, vitally important, what patients and organisations are able to afford. A case that one would refer to a specialist centre in one nation would inevitably be deemed futile for surgical intervention in another. We all work within the local realms of possibility. Thus, while I would stretch to develop local expertise, I would ensure I did not provide my patients false hope or declare them unsuitable for any treatment. Though an inoperable rectal recurrence often remains limited to the pelvis till the patient succumbs, it is a miserable condition to suffer from, and requires a lot of specialist care to ensure the patient's last days are as comfortable as possible. Once inoperability is established and decided, I would plan to convert to an end-colostomy sooner after than later. Established ancient techniques for debulking including alcohol injections often come in handy towards the end.
  • asked a question related to Colorectal Surgery
Question
13 answers
Recent evidence has found a strong association between NSAID use and Anastomotic leaks. However, ERAS guidelines recommend using NSAIDs as part of the multimodal analgesia. In light of this new evidence linking NSAIDS with anastomotic leaks, what is the safest combination for managing post operative pain in colorectal surgeries?
Relevant answer
Answer
In the majority of the patients we remove epidural after 2-3 days   we also use  dipirone as a reliable pain killer drug with few side effects We also have a Pain group that manage most of these patients
  • asked a question related to Colorectal Surgery
Question
1 answer
Spread to the peritoneum not uncommonly occurs in cancers of the gastrointestinal tract, gynaecological cancers. I am aware that, in Singapore, peritonectomy or cytoreductive surgery to remove all visible tumour on the peritoneum followed by the instillation of hyperthermic intraperitoneal chemotherapy or HIPEC into the abdomen to eliminate microscopic disease is performed and, to date, the Peritoneal and Pelvic Malignancy Service at the National Cancer Centre Singapore has performed >100 Peritonectomies and HIPEC and has conducted research projects in this field; I just wonder who are actively doing these work in Hong Kong, thank you!
  • asked a question related to Colorectal Surgery
Question
10 answers
This can save rectum to be able to make anastomosis, instead of being forced to do ultra-low anterior resection.
Relevant answer
Answer
can it be possible to extract the stent trans anally?If this is possible we will get a higher anastamosis.I am not quite clear about the question.
  • asked a question related to Colorectal Surgery
Question
19 answers
9 months old boy is suffering from Fistula in Ano with a history of 5 months chronicity. Multiple external Fistulous openings with 1 int. opening are present. 3 openings are in Rt side and 2 in left. What will be the possible etiopathology and line of management ? BCG was given.Please guide.
Relevant answer
Answer
This is sensible as such features goes with tuberculosis and in developing countries, this should be the first possibility that should be looked for.
Remember, Common things are common. 
  • asked a question related to Colorectal Surgery
Question
16 answers
I`m very interestting in opiods free analgesia
Relevant answer
Answer
на операции эпидуральная и общая анестезия, в послеоперационном периоде-первые сутки-эпидуральный блок, далее трамал и кеторолак.
  • asked a question related to Colorectal Surgery
Question
9 answers
A 46 year-old patient, with performance status of 2, diagnosed with colorectal cancer underwent a partial colectomy ( R2 margin). The thoracic CT scan described infracentimetric secondary lesions in both lungs. The abdominal CT scan described multiple hepatic metastases (image attached).
My questions for you are (especially for the surgeons but also for medical oncologists):: 
1. do you think this patient could benefit from resection of liver metastases? Not even after chemotherapy+biological therapy?
2. what is your opinion about the surgical management of this patient?
Relevant answer
Answer
Dear Dr Afrasanie
Inorder to decide that patient can benefit from liver metastasectomy , we should have all liver plan and radiologist should say about future liver remnant (FLR) , it should be more than 20% in normal situation and at least 30% in patient who received chemotherapy.
Besides we should be sure about extra liver situation such as lung metastasis.if there are mets in lung it should be operable.
For better judgment about how many mets in liver or lung , new studies recommend PET CT scan.
However for yours patient , according one cut of liver , it seems to be at least borderline or inoperable . In optimist situation, neoadjuvant chemotherapy in orer to down size of tumor or left portal vein embolisation in order to hypertrophy of right liver lobe is an option to have a secure FLR.
Good Luck.
  • asked a question related to Colorectal Surgery
Question
3 answers
role of stoma therapy nurse preop ( before someone goes for colorectal surgery ) ?
Relevant answer
Answer
I agree with both the above. Consideration of forming stomas might be common-place for some health-care providers, but there is the overwhelming majority of patients, belonging to a large variety of cultural backgrounds where the very idea of having a GI stoma is scary, unsavoury, non-religious and unhygienic, to mention a few feelings. In such circumstances, a nurse who is both surgically educated and culturally sensitive forms the vital supportive common denominator to patients and surgeons alike. Despite the desire to do so, surgeons are unlikely to have the time to alleviate patient apprehensions regarding stomas; stoma nurses are able to do that. Further, there is a lot of practical information patients often seek, specifically in nations where public health services are either not available or are of highly variable standards. As far as colorectal surgery is concerned, particularly in the elective scenario, if I was fortunate to have the choice of one specialty nurse, it would be a stoma nurse. Over the years, stoma nurses I have worked with have easily extended their skills into covering colorectal cancer, IBD, anorectal physiology, urogynae and abdominal wound care nurses. The stoma nurse has become indispensable to our practice such that whenever a junior colleague asks me what to look for in a potential employment, stoma nurses hold an equal position on that list as other medical colleagues. Yes, get one - and if you're lucky enough to do so, cherish them!
  • asked a question related to Colorectal Surgery
Question
20 answers
a 55 yrs old woman with a past history of colon cancer that underwent left hemicolectomy ,T2N0 well diff adenocarcinoma, in follow up colonoscopy one year after operation shows a 1*1 cm cessile polyp that removed endoscopically . pathology showed hi grade dysplasia .
what is your recommendation?
Relevant answer
Answer
Dear Dr Negar
Thanks for your attention. according NCCN ver 2,2016 for sessile polyp ,two option was recommended but regard to patient history of cancer i am keen to surgery.
  • asked a question related to Colorectal Surgery
Question
21 answers
Relevant answer
Answer
Thanks. And though I think you're right, as we do learn of definite "proven" contributory factors,new have a duty to alter our practice accordingly. If I had a crystal ball I would say that in another 2-3 decades, at least in cancer, resections will go out of the window. We will be using individual patient-tumour targeted bio pharmacology for treatment,msuch that all that would be left is a small lesion, requiring a minimal local excision, if that! I guess the message is embrace developing wisdom - and, it appears in surgery that wisdom is heading towards a minimalistic approach, which will hopefully reduce leak rates to 0, even if that means no surgery. The more risk factors we understand, the more we take an individualistic approach in our recommendations hence, science provides us the justification for an intelligent, philosophical and ethical approach. For instance, if our risk stratification gives us a possible leak rate of 80% and individualised neo-adjuvant chemo-rad a pCR rate of, say 50%, would we ethically be able to recommend resection as the first course? Science is progressing rapidly; we cannot predict whether we will know all the answers to a particular issue - all we can do is be willing to change, intelligently, rather than change for the sake of change! There - a more philosophical approach!
  • asked a question related to Colorectal Surgery
Question
1 answer
Last year's ESCP pan-European audit recruited >3200 patients from 284 centres! There is still time to register your site for the 2016 audit, which will explore outcomes after stoma closure operations
Please visit http://www.escp.eu.com/research/cohort-studies/2016-audit      for the full protocol and sign-up instructions
Relevant answer
Answer
Royal Devon and Exeter Hospital will be taking part in the ESCP closure of intestinal stoma audit
  • asked a question related to Colorectal Surgery
Question
15 answers
I am doing video analysis of colonoscopy videos. We are now at a state where we developed a method and a whole system that could be used by a medical doctor. We also tested it on a public available dataset with very good results. The problem is that we need more data and also different diseases (at the moment we only have polyps). Therefore I look for medical experts that are interested in providing their knowledge and using/testing the system.
Relevant answer
Answer
Hello  Michael,
I have ZERO experience in the medical imaging field but have over 40 years of experience with digital image analyses of satellite, aerial, and shipborne imaging (remote sensing) of the Earth surface (including acoustic imaging of the ocean surface) .  I have an interest in the application of some of the capabilities developed over 4 decades in remote sensing to the medical field.  I think that my expertise related to radiometric and geometric calibration, change detection, and spatial variability analyses might be useful in the medical field.   I retired from the federal government (USGS) after 38 years and currently am an adjunch research professor.
If you think this might be of interest let me know.
Pat
  • asked a question related to Colorectal Surgery
Question
2 answers
It happens only in India. Even now a days folklore practices are exists. A female aged about 45 yrs herself (as she claimed) / her husband ligated a mass around anus by Strands of Horse tail, though it was excised and treated later by us. Do you have any comment ?
Relevant answer
Answer
Probably the same Idea as ruberband ligature for Hemoroids
  • asked a question related to Colorectal Surgery
Question
6 answers
There have been many trials and meta anlaysis on Goal Directed fluid therapy as monitored through esophageal dopplers that conclude that fluid restriction is associated with better outcomes.
For this reason Enhanced Recovery After Surgery (ERAS) also recommends the same, however, with regards to the type of fluid that should be used ERAS recommends "Balanced IV fluids" like Ringer's lactate against the 0.9% Saline solution. This recommendation is based on "British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP)". They base their recommendation on trials that are all on non colonic surgeries like renal transplant and Abdominal aortic aneurysm repair surgeries.
So the question is... has there been any trial that can compare the various types of crystalloids in colonic surgeries? and if so.. what is the recommendation?
Relevant answer
Answer
To my knowledge the best evidence we have so far is in the form of retrospective observational trials. See the two attached cohort studies. I believe there is a RCT currently underway addressing this question in major abdominal surgery however. 
  • asked a question related to Colorectal Surgery
Question
4 answers
I would like to look into the difference of CRC patients in selection for MIS or open surgery by comparing the odd ratio. In analyzing the MIS (minimally invasive surgery) data, I am wondering whether I should add converted cases to open surgery or to the MIS. As the intention to treatment for these cases was MIS initially but they converted intra-operatively to conventional open surgery. 
Relevant answer
Answer
Honestly speaking, there is no ideal answer to your question!!
The problem is the reason why intention to treat analysis is applied; is to avoid the attrition, crossover, and similar sources of bias that are related to non completion of the outcome data in a subset of individuals originally assigned to a particular arm.
Despite that this could be very useful in tremendously large number of situations, I think this could be applied with vigilance in many others.
An explicit example for that would be the initial cases of laparoscopic resection. Here the conversion is most likely due to in-appropriate application of the method (whether due to learning curve, difficult cases due to chasing opportunities ,,exct,,). If one conducts an intention to treat analysis, and simply retain the converted patients into their initial assignment, this would be in my opinion a mistake!!.
It is common in these case that the conversion is resorted to in a non smooth situation, which would at least deviate the multilevel factors (blood loss, time, anatomical breaching ....) form the norm. If in such a case one keep them attached to the initial arm, the results could be biased as well. 
The appropriate technique for analysis depends, in my opinion on couple of issues related to the sample size and the concious analysis of the converted cases. similarly on the outcome of interest. For example, if your analysis is concerned with surgical mortality, here it is obvious that you must retain group assignment.
Perhaps, it is appropriate to provide in the report a subset stratification of these data
Good luck 
  • asked a question related to Colorectal Surgery
Question
6 answers
Recently an approach of waiting after high dose radio-chemotherapy (RTx/CTx) in distal rectal cancer patients (0 to 6 cm ab ano) was reported. The authors discuss this as an option for patients with rectal cancer, please find below the abstract and citation for convenience:
key points:
-n=51 pts
-primary resectable T2-3, N0-1 distal rectal cancer (0-6cm ab ano)
-RTx primary tumor: 60 Gy (in 30 fractions)
-RTx lymph nodes 50 Gy in 30 fractions & 5Gy boost)
-CTx: oral tegafur-uracil 300 mg/m² every weekday for 6 weeks
-Median Follow-up 23.9 months
-local recurrence rate 15.5%
Background
Abdominoperineal resection is the standard treatment for patients with distal T2 or T3 rectal cancers; however, the procedure is extensive and mutilating, and alternative treatment strategies are being investigated. We did a prospective observational trial to assess whether high-dose radiotherapy with concomitant chemotherapy followed by observation (watchful waiting) was successful for non-surgical management of low rectal cancer.
Methods
Patients with primary, resectable, T2 or T3, N0–N1 adenocarcinoma in the lower 6 cm of the rectum were given chemoradiotherapy (60 Gy in 30 fractions to tumour, 50 Gy in 30 fractions to elective lymph node volumes, 5 Gy endorectal brachytherapy boost, and oral tegafur-uracil 300 mg/m2) every weekday for 6 weeks. Endoscopies and biopsies of the tumour were done at baseline, throughout the course of treatment (weeks 2, 4, and 6), and 6 weeks after the end of treatment. We allocated patients with complete clinical tumour regression, negative tumour site biopsies, and no nodal or distant metastases on CT and MRI 6 weeks after treatment to the observation group (watchful waiting). We referred all other patients to standard surgery. Patients under observation were followed up closely with endoscopies and selected-site biopsies, with surgical resection given for local recurrence. The primary endpoint was local tumour recurrence 1 year after allocation to the observation group. This study is registered with ClinicalTrials.gov, number NCT00952926. Enrolment is closed, but follow-up continues for secondary endpoints.
Findings
Between Oct 20, 2009, and Dec 23, 2013, we enrolled 55 patients. Patients were recruited from three surgical units throughout Denmark and treated in one tertiary cancer centre (Vejle Hospital, Vejle, Denmark). Of 51 patients who were eligible, 40 had clinical complete response and were allocated to observation. Median follow-up for local recurrence in the observation group was 23·9 months (IQR 15·3–31·0). Local recurrence in the observation group at 1 year was 15·5% (95% CI 3·3–26·3). The most common acute grade 3 adverse event during treatment was diarrhoea, which affected four (8%) of 51 patients. Sphincter function in the observation group was excellent, with 18 (72%) of 25 patients at 1 year and 11 (69%) of 16 patients at 2 years reporting no faecal incontinence at all and a median Jorge-Wexner score of 0 (IQR 0–0) at all timepoints. The most common late toxicity was bleeding from the rectal mucosa; grade 3 bleeding was reported in two (7%) in 30 patients at 1 year and one (6%) of 17 patients at 2 years. There were no unexpected serious adverse reactions or treatment-related deaths.
Interpretation
High-dose chemoradiotherapy and watchful waiting might be a safe alternative to abdominoperineal resection for patients with distal rectal cancer.
Appelt AL, Pløen J, Harling H, Jensen FS, Jensen LH, Jørgensen JC, Lindebjerg J, Rafaelsen SR, Jakobsen A: High-dose chemoradiotherapy and watchful waiting for distal rectal cancer: a prospective observational study. Lancet Oncol. 2015 Jul 3.
Relevant answer
Answer
The rational behind the wasteful watching principle in patients complete regression following neoadjuvant radiation and chemotherapy for mid and low rectal cancer is truly alluring. However, a series of issues still need to be addressed with regard with this treatment option.
First: 
  • asked a question related to Colorectal Surgery
Question
7 answers
Many times we come across the multiple external openings of Fistula in Ano ( may be a Horse shoe shaped FIA), in which many surgical procedures like Fistulectomy / Lift / VAAFT etc are difficult to perform. Is their any applied surgical anatomy of different Peri anal spaces in reference to these cases ? 
Relevant answer
Answer
Hello Dr. Dwivedi, I have seen some anterior fistulae that look like they open directly into the anal canal on clinical exam, and eventually turn out to be a complex posterior fistula with an anterior opening, i.e. a posterior fistula can fistulate all the way round and open out into the anterior half, and even into the vagina. Also, I suspect, but have no evidence for this, that there must be instances where multiple anal glands might become infected, extend outwards, and perhaps connect with other infected glands elsewhere in the anal canal. My advice would probably be that unless it is extremely obvious there is an anterior fistula with an obvious radial internal opening, always be suspicious there might be complex fistulation. MRI is very helpful, but I have found the usefulness of these depends a lot on the experience of the radiologist in interpretation. I hope that helps.
  • asked a question related to Colorectal Surgery
Question
4 answers
Where and when to tattoo colonic neoplasms prior to resection is a hotly debated topic. We are interested in experiences of colorectal surgeons globally to inform a potential prosepctive study into common problems and how to avoid them.
Relevant answer
Answer
No, no negative issues. May fade at different speed, depending on patient type and related perfusion. Clipping may be easier to find as you can xrays. or you combine both.
  • asked a question related to Colorectal Surgery
Question
4 answers
I found this case of Ano-vestibular Fistula in 30 year old female. The P/V examination reveals no extension and the patient has no previous H/O of any surgical treatment. What should be the course of treatment for this fistula? Should it be as for every fistula: follow/ drain through an anatomical structure?
Relevant answer
Answer
If it is a congenital ano-vestibular, it will have an epithelial lining. If it is, then does it cause enough symptoms to warrant excision? In infants I would normally excise with a covering colostomy, but I know that in places where there is a lot more experience (India & China) it is often done without.
  • asked a question related to Colorectal Surgery
Question
8 answers
A baby boy 2 and half years old was operated upon for his anterior ectopic anus. 5 days after the operation the perineal wound gaped. what is the best treatment option?
Relevant answer
Thank you so much Dr. Roy 
  • asked a question related to Colorectal Surgery
Question
3 answers
I work in an intestinal failure unit and perform approximately 40 ECF repairs per annum. I find it hard to believe that these plugs would work in any of our patients. NICE have recently published guidelines. The surgery is complex but with good success rates. Also what about the abdominal wall? We normally have to reconstruct this with Ramirez type techniques and biological mesh etc. A plug would obviously leave this unattended. Which type of fistulas would be suitable? The evidence seems extremely poor to say the least.
Relevant answer
Answer
collagene plugs can be used but the success rate is low. As it's without rusk why not trying to avoid a new intervention. To be successfull collagene plug neds to be inserted on a clean fistula ( no collected infection) so use irrigation before.
  • asked a question related to Colorectal Surgery
Question
22 answers
A male of 46 yrs is having this tumor since 6 months.O/E lumen of lower GIT is free, no any infiltration is noted. Anal orifice and anal sphincters are free from any growth.Pt. doesn't give any previous h/o treatment anywhere and even he didn't come back for further examination HPE etc. Only for academic point of view, Please discuss as this is important to me
Relevant answer
Answer
Take a Biopsy 
  • asked a question related to Colorectal Surgery
Question
6 answers
Provided that the initial surgery was cutting seton procedure.
Relevant answer
Answer
Video Assisted Anal Fistula Treatment (VAAFT) is a good option in recurrent high FIA. It allows visualization of the main and side tracks and possibly the internal opening as well. It can be both diagnostic and therapeutic.
  • asked a question related to Colorectal Surgery
Question
2 answers
There are various definitions for salvage surgery in head and neck cancer. To my knowledge there are no currently international or even nationally agreed definitions as to what constitutes a completion operation and a salvage procedure for recurrent rectal cancer following previous local excision.
Relevant answer
Answer
I agree with A Julianov that we use the term of " completion surgery" only for those cases requiring surgery  In case of unfavourable histology after TEM, or positive resection margins . Conversely, The "salvage surgery" is used for a surgical procedure performed  for recurrence after a full-thickness transanal excision for Stage I rectal cancer. In both cases a TME- proctectomy  is the surgical procedure of choice and the sphincter preservation is mostly possible. But  in both cases, the results aren't equivalent .
In fact , if  no difference was found in outcome between patients with rectal cancer undergoing  TME-proctectomy  after TEM and those undergoing primary TME , in case of  Salvage surgery for recurrence after local excision of rectal cancers  it may not provide results equivalent to those of initial radical treatment.
Tech Coloproctol. 2013 Aug;17(4):397-403.
The outcome of rectal cancer after early salvage TME following TEM compared with primary TME: a case-matched study.
Levic K1, Bulut O, Hesselfeldt P, Bülow S.
J Surg Educ. 2008 Jan-Feb;65(1):67-72. 
Early rectal cancer: local excision or radical surgery?
Chang AJ1, Nahas CS, Et al.
Dis Colon Rectum. 2002 Jul;45(7):875-9.
Salvage radical surgery after failed local excision for early rectal cancer.
Friel CM1, Cromwell JW, Marra C, Madoff RD, Rothenberger DA, Garcia-Aguílar J.
  • asked a question related to Colorectal Surgery
Question
19 answers
After colonic resection and anastomosis, Is it actually safe to begin oral intake in the first post operative day?
In my institusion, the patient is kept fast for 3 days, and then, oral fluids only allowed for 3 days, then, oral semisolids for 3 days?
Relevant answer
Answer
This reference is the best I can suggest to answer the question. In my experioece, I agree with the above regarding right hemicolectomies and chewing gum if patient isn't tolerating fluids particuarly well.
Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(®)) Society recommendations. World J Surg. 2013 Feb;37(2):259-84. doi: 10.1007/s00268-012-1772-0.
  • asked a question related to Colorectal Surgery
Question
3 answers
Surgical experience. Literature review.
Relevant answer
Answer
By local repair eventually using staple-fixation:
Ecker KW, Schmid Th, Xu HS, Feifel G: Improved Stabilization of Conventional (Brooke) Ileostomies with the Stapler Technique. World J Surg 1992; 16: 525 – 529
  • asked a question related to Colorectal Surgery
Question
6 answers
what education medication can cut down on ileostomy output
Relevant answer
Answer
The patient should measure ileostomy output for 2 days. If over 1200 ml per day, start taking loperamide  up to 16 mg (8 tablets) per day, taken in divided doses before meals and at bedtime.
Eat 6 small meals per day rather than 3 larger ones.
Try limiting fluid intake with meals. Still make sure you are drinking 8-10  cups of fluid per day.
Avoid high fiber foods.
Limit or avoid caffeine and high fat foods.
  • asked a question related to Colorectal Surgery
Question
4 answers
Added with thromboprophylaxis 
Relevant answer
Answer
thank you very much
  • asked a question related to Colorectal Surgery
Question
5 answers
Is it the mindset and experience or the Surgeon/institution, the patients perception of risk or national guidelines that are the most important in the decision process? Would the same patient recieve the same treatment when the initial staging is performed in a "non-TEM institution", as he/she would in a "TEM institution"?
Relevant answer
Answer
Jo
GB and I were discussing this very recently and are keen to explore this further. Have you seen these composite risk tables in a very well written open access article by Taylor and hosie:
The tables they present are very thought provoking NNT by completion TME after clear excision of a T1Sm2 to acheive one life saved at 5 yrs is 40!....This is in a young fit patient & ignoring morbidity of TME!
There are also some interesting articles on patients surprising willingness to gamble life expectancy to avoid morbidity.  A recent systematic review I'm sure you have already seen:  Colorectal Dis. 2014 Aug 23. doi: 10.1111/codi.12754. [Epub ahead of print]  A systematic review of patient preference elicitation methods in the treatment of colorectal cancer.  Currie A1, Askari A, Nachiappan S, Sevdalis N, Faiz O, Kennedy R.
  • asked a question related to Colorectal Surgery
Question
42 answers
I just started with laparoscopic abdominoperineal resections for low rectal cancer. There was a patient with rectal cancer on 1 cm, without neoadjuvant therapy. It was a thin man, and operation went smoothly. I put some sutures on peritoneum to close the pelvis, like in open procedure. But after operation patient went in ileus and I had to operate him again (laparoscopicaly) on day 8 and found cca 30cm of terminal ileum in pelvis, which slipped between sutures. Bowel was vital but affected, no perforation, no peritonitis. I closed the pelvis with dual mesh. After two days patient became more and more septic and our team decided to make laparotomy and we found diffuse peritonitis with fibrin and pus everywhere. The mesh was in situ, there was no bowel perforation. We performed only lavage and treated the abdomen with negative pressure. After two sessions we managed to close the abdomen, and the patient is now OK.
How do you act in APR? Do you close the peritoneum over pelvis or leave it open?
Relevant answer
Answer
Never, because the peritoneum generally doesn't meet easily and small gaps will be left (which are much more dangerous than big gaps for causing internal small bowel obstruction). Its the same reason I never close mesenteric defects after segmental resection.
  • asked a question related to Colorectal Surgery
Question
19 answers
There is an increasing trend in the number of elderly patients with colorectal pathologies.
Relevant answer
Answer
Of course, the aspects of anaesthesiology are important, and part of the preoperative preparations. Comprehensive geriatric assessment is, however, much more: The key is to determine the biological reserves - or biological age - of the individual elderly patient, which often differs from the chronological/calendar age. A 90 year old person may have the biological reserves/age of a 70 years old person, and vice versa. There are a number of publications from the above mentioned group of authors that describe CGA clearly, and which impact it has on outcomes in colorectal surgery in elderly patients. Frailty is one of the most important predictors of poor surgical outcome in elderly, and worthwhile to assess preoperatively. Knowledge about and implementation of these aspects would in my opinion define a geriatric colorectal surgical service.
  • asked a question related to Colorectal Surgery
Question
31 answers
What is the best way to excise the hemorrhoids- monopolar, bipolar, LigaSure or harmonic scalpel. Which method provides best patient comfort postop and low spincter damage?
Relevant answer
Answer
Let’s go for the Nobel prize! I prefer hemorroidectomy with ligasure. It is expensive but give less blood loss and pain with nice cosmetic results. I do this only if banding fails. I tried the pexy technique. Results were pain and recurrence. With the Milligan Morgan you resect less tissue than the ligasure. I am still a little skeptical about the laser.
  • asked a question related to Colorectal Surgery
Question
20 answers
Patient being stable with no pelvic collections.
Relevant answer
Answer
Suturing of pelvic peritoneum is life saving to avoid peritonitis in case of likage.
Usually we pu two drains. In case of leakage with stable patient, Iirrigation with betadine ghrough one drain and 
  • asked a question related to Colorectal Surgery
Question
5 answers
It seems very promising and quite simple procedure. I am interested if anybody tried it and what are the results?
Relevant answer
Answer
I combine a fistulectomy with  a rectal advancement flap  and a Cook fistula plug and have a succes rate of 75 %. The first 30 cases are in press, albeit in the Acta chirurgica belgica because " Colorectal disease turned it down. The OTSC was proposed to me but I am reluctant to use because  of 1° its cost and 2° it's  fate . What happens when this huge thing stays clinged in the anal canal.  As Dr. Benesch states I guess it can be  painful . How do you get rid of it  when it's not useful anymore ????
  • asked a question related to Colorectal Surgery
Question
3 answers
Alot of results are normal.
Relevant answer
Answer
Perianal Crohn's disease might first present this way.
  • asked a question related to Colorectal Surgery
Question
6 answers
I noticed that younger men have increased risk
Relevant answer
Answer
Dr. Alawad, A similar detailed discussion was initiated by Dr. Alfie on June 24, 2013
  • asked a question related to Colorectal Surgery
Question
8 answers
Staplers and hand sewn anastomosis work equally well.
Relevant answer
Answer
I think that surgery is an handcraft work. Despite a lot of reviews and EBM scientific paper an eclectic way of thinking is essential in surgery. Like " the only good knot is the right one" we can say that "the only good anastomosis is the right one". Often also a stapled anastomosis needs a tailored execution , adding , ad example , a running suture tu assure hemostasis of stapled line.
When you respect the three holy principles of good blood supply , tension free and impermeability , the technique of anastomosis is irrelevant.
  • asked a question related to Colorectal Surgery
Question
25 answers
Fast-track surgery has come in a big way to say that bowel prep is not required
Relevant answer
Answer
Regarding Bowel Prep we had published an article summing current evidence:
Deka P, Negi SS. Role of mechanical bowel preparation before colorectal surgery. National Medical Journal of India 2009;22(1):7-8.
  • asked a question related to Colorectal Surgery
Question
10 answers
I think the opening for organ extraction should be mede at the beginning in the umbilicus.
Relevant answer
Answer
I think I will. Thanks
  • asked a question related to Colorectal Surgery
Question
19 answers
The skin incision just above the organ or umbilicus in any organ?
Relevant answer
Answer
A photo of a patient who underwent laparoscopic sigmoidectomy by an umbilical zigzag skin incision technique 1 year ago. Can you see the scar? Almost invisible!
  • asked a question related to Colorectal Surgery
Question
17 answers
Any preventive measures?
Relevant answer
Answer
In my practice, I culture all cases of perineal abscess, and if E. coli is grown, I tell the patients that fistula is highly likely.
Reference: Elsevier Saunders Publisher; A Companion to Specialist Surgical Practice; Colorectal Surgery; 3rd Volume; Edited by Robin K. S. Phillips; Chapter 13; Page 244
  • asked a question related to Colorectal Surgery
Question
4 answers
Some surgeons prefer to fashion a colonic pouch after TME to improve the functional outcome. However, there are concerns that in the long-term the pouch dilates and results in poor function. What are your experiences/opinions in this regard?
Relevant answer
Answer
Straight coloanal anastomosis may be related to higher evacuation frequency and the occurrence of fragmented evacuations, while colonic pouch is related to better functional results and more predictable evacuations in early evaluations. although long term evaluations show almost no difference between straight or pouch anastomosis, it must be considered that some patients will not have "long term" evaluation, which makes this issue important. this is why i always use J-pouch when I have to do a ultra-low rectum or anal canal anastomosis.
  • asked a question related to Colorectal Surgery
Question
4 answers
Should we make a new incision for drainage or try to drain via the existing external opening?
Relevant answer
Answer
I also prefer MRI imaging followed by drainage via seton. In complex fistulas you can leave the seton for several months. The major aim is to avoid surgery near the sphincter, as many patients will undergo multiple operations and the preservation of sphincter function is crucial for their QoL.
  • asked a question related to Colorectal Surgery
Question
10 answers
Epiploic appendagitis is considered as a rare cause of left iliac fossa pain, usually diagnosed on CT scan and managed by NSAID as outpatient.
Relevant answer
Answer
The appendices epiploicae, are small pouches of the peritoneum filled with fat and situated along the colon and upper part of the rectum.
They are mainly the appended to the transverse and sigmoid colon, however, their function is unknown.
The appendages can become inflamed, a benign but painful process known as epiploic appendagitis which can mimic acute appendicitis and other conditions.
I published One case study seen in 1995 in UK as Registrar. We opened him due to signes of acute abdomen and CT findings were Internal Herniation. At laparotomy I found two appendices epiploicae, were joined at tips inflammed causing a Ring where the small bowel were herniated.
  • asked a question related to Colorectal Surgery
Question
1 answer
Primary indications of colon cancer growth in DMH induced Model.
Relevant answer
Answer
The primary morphological changes are the development of adenomatous polyps. However, the only method is to perform an endoscopic examination to animals with a dedicated instrument. “Coloview miniendoscopic system”, consists of a miniature endoscope (scope 1.9 mm outer diameter), a xenon light source and a triple chip camera (all from Karl Storz, Tuttlingen, Germany). his method is expansive, but allows to avoid the sacrifice of the animals.
  • asked a question related to Colorectal Surgery
Question
26 answers
...
Relevant answer
Answer
I have changed my practise over the years. While training in HPB, as a protocol were putting T tubes across all HJ's performed(Whipple's, biliary strictures etc). I did not see any complication related to the T tube( no leaks because of T tube, no infection etc). The advantages were to monitor the colour of the bile, output, could flush the tube if there was thick infected bile or sludge etc and we would perform cholangiogram always before removal of the T tube. Patients who had cholangitis preop or had thick sludge in the bile duct where the tissues were friable and thin, putting a stent gave a sense of relief even if there was leak(controlled fistula). However the disadvantage from patients perspective was a tube sticking out and the need for a visit to pull the tube out.
I changed and started putting T tubes selectively in patients with cholangitis and who had thick infected bile. The size of the duct was not a criteria to decide regarding T tube insertion. In living donor liver transplant, where the ducts are small, many times more than one duct, I never place a T tube(except in post transplant situation if there was a need for HJ - reason being while on steroids and other immunosuppressants tissue healing is compromised and here the stent would stay for a long period).
As far as transhepatic stents are concerned, if there were PTBD catheters placed preoperatively for any reason( hilar cholangio- biliary decompression etc), these catheters were placed across the anastomosis, otherwise I do not feel the need to place transhepatic catheters preoperatively.
  • asked a question related to Colorectal Surgery
Question
2 answers
In those cases, a contrast CT scan seems to be more effective to locate and diagnose the nature of the bleeding. What do you think?
Relevant answer
Answer
I do not think that diverticular disease is the only cause of lower gastrointestinal bleeding. In emergancy settings a CT scan may be indicated only after a proctologic examination does not find other source of bleeding (haemorroids, fissures, rectal or anal polyops, solitary ulcer syndrome). Anyway, a successive colonoscopy is mandatory expecially in old patients.
  • asked a question related to Colorectal Surgery
Question
9 answers
Many experts believe rectal washout to be a measure that reduces implantation of intraluminal shed tumor cells and thus results in decreased anastomotic recurrence. Do you think rectal washout is effective and how do you perform it, in particular:
- Timing, whether at beginning of surgery or just before resection.
- Whether performed after clamping distal to tumor or not.
- Washout agent used, betadine, chlorhexidine or water.
Relevant answer
Answer
We wash out for the simple reason to remove faeces from the rectum to ease the passage of the staple gun.......although I secretly believe it may affect luminal recurrence although it assumes you perform the Moran Triple Stapling Technique of a second transverse stapler below the first, if not any tumour cells or distal limit of the tumour are potentially already in the anastomosis!
  • asked a question related to Colorectal Surgery
Question
9 answers
Recently we managed a patient which involved removal of 8 foreign bodies from the rectum. I have been unable to find any case in the literature that reports removal of these many foreign bodies in a single patient so was thinking of writing a case report as I found it unusual. Should it be reported?
Relevant answer
Answer
Usual cases can be managed according to usual references but unusual cases are challenging!
  • asked a question related to Colorectal Surgery
Question
17 answers
Relevant answer
Answer
The identification of a definite point of obstruction, the ‘transition zone’, with dilated small bowel loops proximal to the site of obstruction and collapsed loops distally, is the most reliable CT criterion for diagnosing small bowel obstruction .
  • asked a question related to Colorectal Surgery
Question
18 answers
A male aged about 60 yrs, presented with multiple external openings in peri anal area, most of them are interconnected. Digital exam reveals an ulcer wide with regular edges but deep floor at just below anorectal ring.Posterior sling is indurated. This case was refereed to higher center by the surgeon who was treated previously with the provisional diagnosis of malignancy. But before I plan a BIOPSY(HPE), I kept him on Anti tubercular treatment for 15 days. Is it the right approach?
Relevant answer
Answer
Dr Dwivedi, my only reservation in empiric use of Antituberculous therapy is that we often keep in mind only two scenarios that either the patient has tuberculosis that will get better on ATT or it won't be tuberculosis in which case it won't be affected..
In real life, however, there are many more scenarios that can exist, which this simple assumption will fail to recognize.. the patient, for example, can have multidrug resistant TB (an entity not uncommon these days, especially in southeast asia) in which case he won't get better even on ATT.. or the patient has a complex fistula that goes in temporary remission following discharge and some drainage, and we might attribute the response to ATT, thus subjecting the patient to a full course of therapy..
maybe i am being overcautious, but in this day and age (of antimicrobial resistance and its global permutations) empiric treatment of tuberculosis with a premise that if it gets better, then it is TB might not be in overall benefit of the community..
attempts to diagnose TB can be made by sending the pus from fistulas for acid fast bacilli, and pathology from the fistula tract for routine histopathology as well as mycobacterial PCR since the culture yields are not very high..
regards, raza
  • asked a question related to Colorectal Surgery
Question
13 answers
A 19 year old female pt. had vomiting 6 times until 5 pm since this morning, had once defecation at noon with abdominal pain, came in our hospital and diagnosed with Acute Abdomen. plain abdominal x-ray showed gas in the transverse and sigmoid colon, routine blood test was negative except WBC was slightly higher. What is a good way to manage this case?
Relevant answer
Answer
In a young patient, previously fit and well, with foregut pain and vomiting with no physical signs surely biliary colic is high in the list of differentials.
I can see no indication for antibiotics, no mention of blood tests (WCC/CRP, amylase, LFTs) and no mention of the key and least invasive and most important investigation in this case: an abdominal ultrasound looking for gallstones.
Not to mention specifically mentioning the negative finding of no inguinal/femoral hernias - essential if you are considering even subacute/partial SBO in a patient with a virgin (not previously operated) abdomen.
This presentation is very common on our acute surgical take in the UK.
Gynae history is essential also (LMP, History of PID, Beta hcg etc).
To sum up: management depends on diagnosis (not clear here), which depends on history, examination and special investigations.
What are you treating with the antibiotics?
BW,
John.
  • asked a question related to Colorectal Surgery
Question
10 answers
How do you currently manage the primary tumor in these patients.
Relevant answer
Answer
The response is Yes, the radiotherapy has to be used if the satging is T3/4 or/and N+
one important data: the Sweden short course radiotherapy is effective to decrease the local recurrence risk.
In practice for
- rectal cancer T3/4 or/and N+ CRM>1mm with an important liver involvement. The treatment of liver met is the priority and a preoperative 5X5gy is a good choice to avoid 3 months wihtout effective chemotherapy
- rectal cancer T3/4 or/and N+ CRM<1mm with an important liver involvement. the treatment is difficult and depend of other additional factors
- rectal cancer T3/4 or/and N+ with a little liver involvement. A long course of radiochemotherapy has to be used. The residual question is the moment of this treatment. But this is antoher question
  • asked a question related to Colorectal Surgery
Question
2 answers
A male aged about 60 yrs having H/O Hemorrhoidectomy 4 yrs back, H/O excision of huge sinus 2 yrs back and with H/O Ch. Osteomylitis of Rt. Ischeal tuberosity; comes with 3 external fistulous opening viz.A B C and 1 Internal opening D at 7'O clock in anal canal below Ano rectal ring. Please refer images. All openings are interconnected. What should be the approach to manage ?
Relevant answer
Answer
In addition to my Question
  • asked a question related to Colorectal Surgery
Question
6 answers
We use porcine collagen to reconstruct the perineum following elAPE, and I am interested in other surgeons experience using materials in the pelvic floor.
Relevant answer
Answer
Perineal hernias after aper were seen in about 8% patients. Omentopexy and soft tissue closure alone do not prevent perineal hernias. No Patient with pelvic floor reconstruction (flaps/mesh) developed perineal hernia. However incidence of wound infection and dehiscence ( p=ns) seemed higher after biological mesh.
PPT attached
  • asked a question related to Colorectal Surgery
Question
3 answers
SILS™-port was originally designed for laparoscopic surgery. However some years ago our team, as did many others, found it very useful as a tool for transanal endoscopic microsurgery. Now we use it for almost all TEM procedures instead of the originally designed commercially available TEM-set. I would like to know whether SILS™-port changed your practice too?
Relevant answer
Answer
We have used the standard TEM the SILS port (covidien) and the TAMIS platform we like the TAMIS and SILS ports because we can use standard laparoscopic instruments and energy devices. The SILS limitations have be with keeping the port inside and keeping insufflation. The TAMIS works very well and has a kit that is available for practice and teaching of residents. The ability to move between platforms has worked best for our patients but the TAMIS port seems to be the easiest to use.
  • asked a question related to Colorectal Surgery
Question
5 answers
Placing the device like a "bridge to surgery" has lowered the incidence of colic stomas and eventually improved the results with respect to patients operated on in emergency settings without placing SEMS.
Relevant answer
Answer
The first Dutch study was aborted because of high rate of complications, but other three study are on going. The UK CReST Trial, a second Dutch trial and a swedish trial. I think that we have to wait these results for better understanding the value of the procedure.
  • asked a question related to Colorectal Surgery
Question
9 answers
Is there a precise number of lymph-nodes for considering a resection for colorectal cancer adequate?
Relevant answer
Answer
There are studies as Intergroup trial INT-0089 [EST-2288] demonstrating that the number of lymph nodes examined in CRC surgery may be associated with patient outcome.So the NCI and AJCC sponsored panel recommended that at least 12 lymph nodes should be examined in patients with CRC to evaluate the nodal involvement. At our center if the pN0 is based on evaluation of <12 nodes the N-staging is considered inaccurate and patients received adjuvant chemo.
  • asked a question related to Colorectal Surgery
Question
2 answers
What does the current literature say?
Relevant answer
Answer
This is just part of a package of measures to minimise the disturbance to physiology through either open or laparoscopic surgery and calorific nutrition may be given either as food or nutritional supplements that are absorbed in the upper small bowel.
  • asked a question related to Colorectal Surgery
Question
43 answers
Could be still performed only for the surgeon security?
Relevant answer
Answer
I always do protective defunctioning transversostomy after resection for mid- and lower third rectal cancer, irrespective of the type of anastomosis (double-stapled, hand-sewn coloanal). After resection for upper third rectal cancer I usually do not divert, excluding very high risk patients. Before 4-5 years there was different policy in my team – after reconstruction we put two tube drains transperineally on both sides of anastomosis and did meticulous peritonisation of the pelvis. If leak occurs we started irrigation-suction of the pelvic cavity through perineal drains, stopped oral feeding and started antibiotics and parenteral nutrition. In one our publication we concluded that this policy is able to prevent fatal complications of anastomotic leak after LAR with TME. And that is truth, but the patients with leaks had very long hospital stay if treated like that. On the other hand their quality of life is very poor because of the need to keep drains in place for a longer periods. And finally in a series of about 50 pts with leaks there were 2 pts who needed a diverting stoma because of high fecal output from the drains. So, we changed our policy.
  • asked a question related to Colorectal Surgery
Question
17 answers
I am interested to know your current approach – do you think that patient deemed unresectable by general/colorectal surgeon or medical oncologist needs an opinion from experienced liver surgeon?
Relevant answer
Answer
In our centre both oncology and HPB surgery see every patient, even the initially unresectable patients since some of these will become respectable in the future after chemotherapy. This is important since a portal vein embolization or a staged resection can render some of these patients operable but the opportunity may be missed if surgery is not also following these patients. After the initial visits the patients are presented at HPB Tumor Board. The oncologists, surgeons, interventional radiologists, and radiation oncologists are present, every one is trying to determine how many patients can be converted to a resectable state, i.e. everyone believes that a resected patients is better off. There is no question about the patients that is resectable at presentation, barring other medical conditions they will be offered surgery. it is important that every centre bring all the parties to the table and have a discussion driven by the literature and get buy in for an in-house protocol for these patients, this may need to be done every 2-3 years. The protocol should reflect the centres strengths and attempt to boost their weaknesses.
  • asked a question related to Colorectal Surgery
Question
25 answers
Usually emergency left large bowel surgery or difficult low rectal anastomosis need protective diversion stoma. Decision of ileostomy or colostomy is always dependent upon preference of the surgeon. A lot of debate is still going on which is better ileostomy or colostomy. So what should be the preferred technique for diversion? Personal experiences of surgeons, colorectal surgeons, surgical oncologists as well as commentary on available literature is invited to establish the mode of diversion.
Relevant answer
Answer
Defunctioining seems to work. I think it must be personal preference but still believe that ileostomy is supported by some kind of evidence. Bowel prep or not does not seem to make incidence of leak worse (see thread after other question on this site regarding that point). I can't see the logic in the arguments around ileostomy if prepped and colostomy or not. If the bowel is non prepped then there will be some stool above the anastamosis no matter where the proximal defunction is (and there is only 30-40cm or so difference between ileostomy an transverse defunctioning colostomy, leaving more than enough faeces distally to cause sepsis and death if moving through the leak). The bottom line here is that there is no need to prep the colon. if there is no need, we shouldn't do it (all interventions can cause complications).
  • asked a question related to Colorectal Surgery
Question
78 answers
Bowel preparation before elective bowel surgery is being practiced but in cases of emergency surgery, we perform procedures on unprepared bowel. In this context, in elective large bowel surgery, should every patient have prepared bowel, just a selective group of patients or no patients at all? So, what should be the protocol regarding bowel preparation?
Relevant answer
Answer
Just to clarify, this from the Cochrane Review on this topic:
"Despite the inclusion of more studies with a total of 5805 participants, there is no statistically significant evidence that patients benefit from mechanical bowel preparation, nor the use of rectal enemas. In colonic surgery the bowel cleansing can be safely omitted and induces no lower complication rate. The few studies focused in rectal surgery suggested that mechanical bowel preparation could be used selectively, even though no significant effect was found."
  • asked a question related to Colorectal Surgery