Questions related to Colorectal Surgery
After low or ultralow anterior resection, it is difficult to assess the future bowel function before reversing the ileostomy
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.
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.
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 ?
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.
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?
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?
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??
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.
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”?
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?
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.
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?
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
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!
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?
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?
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!
This can save rectum to be able to make anastomosis, instead of being forced to do ultra-low anterior resection.
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.
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?
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?
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
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.
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 ?
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.
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?
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:
-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%
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.
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.
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.
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.
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 ?
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.
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?
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?
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.
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
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.
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?
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"?
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?
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?
It seems very promising and quite simple procedure. I am interested if anybody tried it and what are the results?
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?
Should we make a new incision for drainage or try to drain via the existing external opening?
Epiploic appendagitis is considered as a rare cause of left iliac fossa pain, usually diagnosed on CT scan and managed by NSAID as outpatient.
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?
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.
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?
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?
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?
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 ?
We use porcine collagen to reconstruct the perineum following elAPE, and I am interested in other surgeons experience using materials in the pelvic floor.
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?
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.
Is there a precise number of lymph-nodes for considering a resection for colorectal cancer adequate?
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?
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.
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?