This document discusses various diseases of the colon, rectum, anus and provides treatment options. It covers: 1. Left sided colonic obstruction from colorectal cancer and options like stenting, colostomy, resection. 2. Colorectal liver metastases and various treatment sequences involving chemotherapy and surgery. 3. Left sided diverticulitis classified by Hinchey stages and treatments like resection or Hartmann's procedure. 4. Benign anorectal diseases including infections, hemorrhoids and rectal prolapse. Treatment may involve drainage, fistulotomy or abdominal procedures.

1. COLON, RECTUM, ANUS
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ORAL EXAM TUTORING AND SUMMARY

2. IMPORTANT!!!!
 Lt sided colonic obstruction
 Colorectal liver metastasis (CRLM)
 Lt sided diverticulitis
 Benign anorectal diseases: anorectal infection, hemorrhoid, rectal prolapse

3. Lt sided colonic obstruction from CRC:
choices
 (For right sided obstruction: Rt hemicolectomy)
 Endoscopic colonic stenting (self-expandable metallic stent (SEMS)
 Bridging to surgery (preoperative decompression)
 palliation
 Loop colostomy/ileostomy
 Segmental resection with end colostomy (Hartmann Procedure: 2 stages)
 Total/subtotal colectomy
 Segmental resection with primary anastomosis
 With on-table lavage
 With manual decompression
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4. SEMS
 Pallliation or bridging to surgery
 Advantages: only 1 stage surgery
 Complications:
 Stent obstruction
 Perforatioin
 migration
 Contraindication: colonic perforation, distal rectum < 5cm from AV (pain,
tenesmus, fecal incontinence)
 No role in proximal colonic obstruction
 Be careful in patients receiving bevacizumab

5. Loop colostomy/ileostomy
 Prefer in primary unresectable rectal cancer
 No!!! End colostomy
 Transverse colostomy in patients planned for LAR
 Sigmoid colostomy in patients planned for APR

6. Hartmann’s procedure
 Easy
 2-stage: some patients did not get to have a second operation

7. Total/subtotal colectomy
 Indications
 Cecal serosal tear
 Synchronous lesion
 Complications: diarrhea

8. Segmental resection with primary
anastomosis
 Only in experienced surgeons and be careful of anastomotic leakage
 On table lavage VS manual decompression
 OTL: more SSI
 Technique: don’t forget to fully mobilize colon

9. CRLM
 Synchronous: worst prognosis
 Metachronous
 Early < 12 month
 Late > 12 month : better prognosis

10. CRLM: METACHRONOUS
 Resection
 Neoadjuvant chemotherapy

11. CRLM: synchronous
 Chemotherapy-first
 Liver-first
 Colon-first
 simultaneous

12. CRLM: CMT-first
 CMT  liver resection  CMT  CRC resection
 Used in extensive liver metastasis
 High CEA
 +ve LN
 Tumor > 5

13. CRLM: liver-first
 Liver resection + ostomy  chemotherapy  colorectal resection
 Used in asymptomatic CRC but extensive liver metastasis

15. CRLM: colon-first
 Used in symptomatic CRC:
 Perforation
 obstruction

16. CRLM: simultaneous
 Low tumor burden both CRC and liver

17. Lt sided diverticulitis
 Hinchey Classification
 CT
 Techniques

18. Lt sided diverticulitis: Hinchey
 Described colonic perforation due to diverticulitis
 I: pericolic abscess
 II: pelvic , intraabdominal, retroperitoneal abscess
 IIA: amendable to PCD
 IIB: with fistula
 III: generalized purulent peritonitis
 IV: generalized fecal peritonitis

19. Lt sided diverticulitis: CT
1. Thickening of colonic wall > 4 mm
2. Pericolic fat stranding
3. Diverticula with contrast/air/fecal inside
4. Pericolic, extrapelvic abscess
5. Fistulous tract
6. Stricture/SBO/ureteric obstruction
7. Extravasation of contrast/extraluminal air  perforation

20. Lt sided diverticulitis: technical
consideration
 Extension:
 Proximal: just inflamed segment
 Distal: upper rectum
 No diverticula at anastomosis  leakage
 Always perform leak test
 If cancer is suspected  go on oncologic resection
 Ureteric stent (ureteric injury 1%)
 Elective surgery for Hinchey I-II: Resection with primary anastomosis with or
without ostomy
 Emergency surgery for Hinchey III-IV:
 Hartmann
 RPA with protective ileostomy

21. BENIGN ANORECTAL DISEASES
 Anal pain
 Hemorrhoid
 Anorectal infection
 Rectal prolapse

22. ANAL PAIN: DDx
 Anal fissure
 Thrombosed/strangulated hemorrhoid
 Anorectal abscess
 Fournier gangrene
 Obstructed CA rectum
 Retain foreign body
 Acute proctitis
 Proctalgia fugax: sphincter spasm

23. Technical Notes for Urgent
Hemorrhoidectomy from Lohsiriwat V.
 Preoperative antibiotics
 Adequate analgesia and anesthesia
 Manual reduction first to reduce edema
 Anoderm or mucosa-sparing
 > 1 cm mucosal bridge
 > 50% of good circumferential mucosa
 Vicryl 2. 3-0 for mucosal approximation
 Plication of hemorrhoid may be used for small lesions
 Oral metronidazole and flavonoid for 1 week

24. Anorectal infection
 Anorectal abscess
 FIA
 Fournier gangrene

25. summary of Anorectal infections
Definition in this summary = anorectal abscess and fistula-in-ano or anal fistula
Anorectal abscess = acute condition
Fistula-in-ano = chronic condition
Fistulous abscess = simultaneous
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Pathogenesis:
Anal gland (at crypt) obstruction  stasis  infection
For fistula-in-ano: infection  epithelialization to fistula
Predominant organisms: Mixed:
E.coli (22%),
Enterococcus spp. (16%),
Bacterioides fragilis (20%)
History taking: pain, swelling, diarrhea
Physical examination:
- Look around buttock and anus
- PR if not severe pain or no lesion
- Proctoscopy and sigmoidoscopy in fistula-in-ano
(anorectal abscess is painful so no proctoscope)
Investigations: mostly done in diificult FIA and recurrence
 fistulograpy, endoanal US, MRI, BE, colonoscope
Conditions that antibiotics have the role:
Extensive cellulitis
Systemic signs of infection (sepsis)
Immunocompromised host: DM, valvular heart
disease, HIV
Atypical microbes: TB, actinomycosis

26. summary of Anorectal infections
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Content Anorecal abscess Fistula-in-ano
History taking Pain with swelling, Predisposing diarrhea, Bleeding
per rectum
Discharge, Pain (34%), Swelling, Bleeding, Diarrhea
Physical exam Redness, Heat, Swelling (not in intersphincteric
abscess), pain, Loss of function, Mass when PR
(mostly impossible to PR), Pus exuding, Inguinal LN
enlargement
External opening: granulation
Purulent serosanguinous discharge when compression
Goodsall’s rule:
• Opening posterior to coronal plane: fistula
originates from dorsal midline
• Opening anterior: runs directly to nearest crypt
example

27. summary of Anorectal infections
Content Anorectal abscess Fistula-in-ano
classification
In supralevator abscess: determine to origin  ischioanal,
intersphincteric, or pelvic (diverticulitis, appendicitis, Crohn’s
disease
A – intersphincteric B – treansphincteric
C – suprasphicteric D – extrasphincteric
treatment Adequately drain: cruciate incision closed to anal verge
Incision via intersphincteric groove in interphincteric abscess
Supralevator: drainage via origin  rectal lumen, ischioanal
fossa, abdominal wall
Horseshoe abscess: Hanley’s or modified Hanley’s
Fistulotomy – used in simple interphincteric and low
transphincteric
Fistulectomy – higher incontinence than fistulotomy
LIFT – used in high transphincteric
Seton – complex fistula, high trans and suprasphincteric

28. Rectal Prolapse
 Signs & symptoms:
 Obstructive defecation syndrome
 Incontinence
 constipation
 Theory:
 Sliding hernia
 Rectal intussussceptioin

29. Rectal Prolapse
 Pathophysiology
 Deep CDS
 Redundant sigmoid
 Diastasis of levator ani  pelvic floor descent
 Patulous anal sphincter
 Loss of rectosacral attachment

30. Rectal Prolapse: Treatment
 Thiersch procedure: only temporary
 Perineal: used in high risk patient
 Altemeire = perineal rectosigmoidectomy with levator plication
 Delorme = sleeve rectal mucosal resection
 Abdominal: lower recurrence rate
 Frykman-Goldberg = sigmoidectomy with rectopexy