14. Large Bowel, Rectum and Anus.pdf management

Large bowel, rectum management

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5. Large Intestine, Intestinal
Obstruction, Rectum and Anus
Chapters 77,78,79,80
Bailey Update Series
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6. Chapter 77
Large Intestine
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7. Bailey update Question
•The large intestine though 150 cm in length can be concertinaed
over an endoscope , so the caecum can be reached within…. Cm of
colonoscope marking
a.50-60 cm
b.70-90 cm
c.90-100 cm
d.120 cm
Ans. B ( Ref Bailey 28
th
edition page 1354)
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8. Colonoscopy
•The large intestine is approximately 1.5 m long, but it can be concertinaed
over an endoscope so the caecum can be reached with 70–90 cm of a
colonoscope.
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9. Bailey Update Question
•Regarding the external appearance of Colon-False statement is
a.3 longitudinal muscles run on colon and named as taenia coli
b.Fat filled peritoneal tags known as appendices epiploicaeis
commonly seen in right colon
c.Incomplete transverse markings are seen in Colon
d.Haustrations are formed by taenia coli
Ans. B ( Ref Bailey 28
th
Edition page 1355)
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10. Colon External Anatomy
•The external appearance of the colon is distinguished from the small bowel by the presence
of taenia coli, three bands of longitudinal muscle that run from the appendix base to the
rectosigmoid junction and fat-filled peritoneal tags known as appendices epiploicaefound
principally on the left side of the colon.
•The taenia coli act to pull the colon into its sacculated state, producing a series of
haustrations that may be visible on abdominal radiograph and allowing distinction from
distended small intestine, which has complete transverse markings caused by the valvulae
conniventes
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11. Bailey Update question
•Metaplastic Polyps in Colon-False statement is
a.Also known as Hyperplastic polyp
b.> 10 mm Size are associated with KRAS/BRAF mutation
c.Serrated polyps are associated with malignancy
d.Follow up is not needed after removal
Ans. D ( Ref Bailey 28
th
Edition page 1355)
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12. Metaplastic Polyp
•Metaplastic or hyperplastic polyps are common and are generally considered
benign.
•Recently certain subtypes have been recognised to have malignant potential.
•Sessile serrated lesions and hyperplastic polyps ≥10 mm in diameter are
associated with KRAS/BRAF mutation that may lead to methylation of
tumour-suppressing genes, dysplasia and malignancy along what is termed
the ‘serrated pathway’.
•Such polyps should be removed and follow-up colonoscopy arranged
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13. High Risk findings in Polyp-recommended surveillance by
British Society of GASTROENTEROLOGY
Two or more premalignant polyps, including at least one advanced colorectal
polyp
(defined as a serrated polyp ≥10 mm in size or containing any grade of
dysplasia or as an adenoma ≥10 mm in size or containing high-grade
dysplasia); or
Five or more premalignant polyps.
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15. Bailey Update question
•In polypectomy-failure of submucosal injection to elevate the polyp –What is
the wrong statement ?
a.Such scenario is suggestive of malignancy
b.Complete EMR/ESD is needed
c.Site must be tattooed
d.Biopsy is must if referred for EMR
Ans. D ( Ref Bailey 28
th
Edition page 1355)
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16. Endoscopic polypectomy
•The risk of malignant change increases with size, almost one-third of large (>3 cm) colonic
adenomas will have an area of invasive malignancy.
•Size is easily assessed endoscopically, which, alongside pit pattern and morphological
classification, aids management.
•If felt appropriate and safe to resect endoscopically, various techniques are available,
including hot or cold snare polypectomy for the most common smaller pedunculated lesions.
•Larger or fatter polyps may require infiltration of a solution to ‘raise’ the polyp before snare
resection.
•The area of the polyp should be tattooed to facilitate later endoscopic or laparoscopic
localisation of the site of the polyp.
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17. •Failure of submucosal injection to elevate a polyp is suggestive of malignancy.
•In these circumstances, the site should be tattooed.
•A biopsy should not be taken if referral for endoscopic mucosal resection or
endoscopic submucosal dissection is being considered.
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18. Bailey Update Question
•False statement about FAP
a.80% cases have family History
b.Equal in Male and female
c.CHRPE is seen in 50% of Gardner syndrome
d.Mutations between 1286-1513 have good prognosis
e.Most severe disease is seen in 1309 mutation
Ans. D ( Ref Bailey 28
th
Edition page 1357)
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19. •FAP is defined clinically by the presence of more than 100 colorectal adenomas but is also
characterised by duodenal adenomas and multiple extraintestinal manifestations
•Over 80% of cases come from those with a positive family history.
•The remainder arise as a result of new mutations in the adenomatous polyposis coli (APC)
gene on the long arm of chromosome 5.
•FAP is inherited as an autosomal dominant condition and is consequently equally likely in
men and women.
•The lifetime risk of colorectal cancer is up to 100% in those with an APC gene mutation.
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20. •FAP can also be associated with benign mesodermal tumours such as desmoid tumours and
osteomas.
•Epidermoid cysts can also occur (Gardner’s syndrome); desmoid tumours in the abdomen
spread locally to involve the intestinal mesentery and, although non-metastasising, they may
become unresectable.
•Up to 50% of people with FAP have congenital hypertrophy of the retinal pigment epithelium
(CHRPE), which can be used to screen affected families if genetic testing is unavailable.
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21. •Polyps are usually visible on sigmoidoscopy by the age of 15 years and will almost always be
visible by the age of 30 years.
•Regular endoscopic surveillance in a suspected family member should therefore commence
at the age of 12–14 years, even if a genetic mutation has not been identified.
•Patients with mutations located between codons 1286 and 1513 of the APC gene
generally have a worse prognosis with earlier disease onset than those with mutations
outside this region.
•Germline mutations at codon 1309 are associated with the most severe disease.
•AFAP, also associated with APC gene mutation, is associated with fewer than 100 polyps and
may not present until the fourth decade
•If the diagnosis is made during adolescence, surgery is usually deferred to the age of 17 or 18
years unless symptoms develop.
•Malignant change is unusual before the age of 20 years.
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22. Bailey Update Question
•Following are the Ectodermal derivatives of Extra intestinal manifests
of FAP except
a.Pilomatrixoma
b.Osteoma
c.CHRPE
d.Brain Tumors
e.Epidermoid Cysts
Ans. B ( Ref Bailey 28
th
Page 1357)
Desmoids and Osteomas are Mesodermal derivatives
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24. Bailey Update Question
•Total Colectomy with Ileo-rectal anastomosis is a procedure opted for some
people-False statement regarding this
a.Rectal polyps < 20 numbers can undergo IRA
b.AFAP is opted for IRA as there is no risk of rectal cancer at all
c.Surgery is associated with lower risk of sexual dysfunction
d.Infertility rate is reduced in females
Ans. B ( Ref Bailey 28
th
Edition page 1357)
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25. IRA Indications
•For patients with relative rectal sparing (<20 polyps), total colectomy and IRA is an option to
be considered, particularly as it is associated with less risk of sexual dysfunction in males and
less infertility in females.
•However, the rectum requires regular endoscopic surveillance as up to 10% of patients will
develop invasive malignancy in the rectum.
•In AFAP, patients may consider rectal preservation surgery on the understanding that their
cancer risk is lower (around 2%) but still present.
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26. Other Autosomal Recessive mutations
MUTYH Associated polyposis
•Increased colorectal cancer-3-6 fold
•Colonoscopy performed every 2 years once
•Colectomy may be needed
•Duodenal adenomas are also seen, hence surveillance advised
NTHL 1 tumor syndrome
•Rare
•Polyps can be adenomatous, Hyperplastic and sessile serrated
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27. Bailey Update Question
False statement regarding HNPCC
a.MLH1, MSH2, MSH6, PMS2 mutation is associated with increased risk
b.Cancer develops after 50 years
c.Life time risk is 80% for CRC
d.MC in proximal colon
e.Females have 30-50% risk of Endometrial cancer
Ans. B ( Ref Bailey 28
th
Edition page 1359)
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28. HNPCC
•It is an autosomal dominant condition caused by a mutation in one of four DNA mismatch
repair genes (MLH1, MSH2, MSH6 and PMS2).
•These genes, when functioning normally, code for mismatch repair (MMR) proteins, which
repair sporadic mutations that occur in other genes.
•Thus individuals with an MMR gene mutation tend to develop colorectal polyps at an early
age (before the age of 50 years) that quickly become cancerous.
•Not everyone with a mutation develops cancer; the lifetime risk is 80%.
•Most cancers develop in the proximal colon.
•Females have a 30–50% lifetime risk of developing endometrial cancer.
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30. Bailey Update Question
•Which of the following mutations in HNPCC –5 yearly screening is enough
a.MLH1
b.MSH2
c.PMS2
d.MSH6
Ans. C ( Ref Bailey 28
th
Edition page 1358)
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31. Surveillance and Surgery
•Because of the accelerated pathway from adenoma to cancer in Lynch syndrome those with a
gene mutation should be offered 2-yearly endoscopic surveillance from age 25 years (MLH1
and MSH2 carriers) or 35 years (MSH6 carriers).
•PMS2 carriers should be offered 5-yearly screening beginning at age 35 years
•For patients with polyps that cannot be managed with endoscopic polypectomy or those who
develop a cancer, an extended colectomy (MLH1 and MSH2 carriers) should be considered.
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32. Colorectal Cancers
•Approximately one-third of these tumours are in the rectum and two-thirds in the colon.
•The burden of disease is greater in men than in women (56% versus 44%).
•Mutations of the APC gene occur in two-thirds of colonic adenomas and are thought to
develop early in the carcinogenesis pathway.
•K-rasmutations result in activation of cell signalling pathways and are more common in
larger lesions, suggesting that that they are later events in mutagenesis.
•The p53 gene is frequently mutated in carcinomas but not in adenomas and therefore thought
to be a marker of invasion
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33. Bailey Update Question
•Consensus molecular Subtypes-False statement is
a.CMS1 is associated with Lynch Syndrome
b.WNT and MYC is associated with CMS2
c.Metabolic dysregulation with with CMS3
d.Beta catenin with CMS4
Ans. D ( Ref Bailey 28
th
Edition Page 1359)
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34. CMS
•A recent international consortium has identified four consensus molecular subtypes (CMSs)
of colorectal cancer based on bioinformatic analysis of gene expression in more than 4000
patients.
•MSI, a feature of Lynch syndrome, may occur sporadically, particularly in right-sided tumours
(CMS1),
•While others show WNT and MYC signalling activation (CMS2),
•Metabolic dysregulation (CMS3) and
•Transforming growth factor beta activation (CMS4).
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35. Bailey update question
•Risk factors of CRC-False statement is
a.Cholecystectomy is associated with left colon cancer
b.Selenium has protective effective is unproven
c.High magnesium intake is protective
d.Intake of red meat has high risk
Ans. A ( Ref Bailey 28
th
Page 1359)
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36. •Worldwide, the prevalence of colorectal cancer is closely associated with
intake of red meat and particularly processed meat products (haem and N-
nitroso compounds).
•Increased risks for colorectal cancer have also been associated with smoking
and alcohol.
•Conversely, high magnesium and calcium intake may be protective.
•A protective potential for antioxidants such as vitamin E and selenium is as
yet unproven
•Cholecystectomy may marginally increase the risk of right-sided colon cancer.
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37. Spread to Liver
•Haematogenous spread is most commonly to the liver via the portal vein.
•One-third of patients will have liver metastases at the time of diagnosis and
50% will develop metastases at some point, accounting for the majority of
deaths.
•The lung is the next most common site of metastatic disease whereas spread
to the ovaries, brain, kidney and bone is less common.
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38. Bailey Update Question
•IN AJCC TNM staging, CRC-N1C stands for
a.4-6 nodes
b.Satellite deposits
c.2 or 3 nodes
d.Peritoneal mets
Ans. B ( Ref Bailey 28
th
Page 1360)
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40. Bailey Update Question
•In UK Screening for Colon cancer is done between 60-74 years, by means of
a.Sigmoidoscopy
b.Colonoscopy
c.Guaiac test
d.FIT
Ans. D ( Ref Bailey 28
th
Edition page 1360)
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41. Cancer screening
•In the UK screening is offered every 2 years to men and women aged 60–74 years, followed
by colonoscopy in those who test positive.
•Originally a guaiac-based test was used, which detects peroxidase-like activity of faecal
haematin.
•Studies suggested a 15–20% reduction in colorectal cancer-specific mortality in the screened
population.
•More recently the faecal immunochemical test (FIT) has been introduced.
•This test is more accurate and easier to complete than the old faecal occult blood test.
•A one-of flexible sigmoidoscopy for people aged 55 was offered as a screening tool in the UK.
•It was shown to reduce colorectal cancer-specific mortality but is now being replaced with
FIT screening.
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42. Bailey Update Question
•CT Colonography is sensitive in picking up polyps size < …. Mm
a.2
b.4
c.6
d.8
Ans. C ( Ref Bailey 28
th
Page 1361)
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43. Bailey Update Question
•Complete Mesocolicexcision in Right hemicolectomy means
a.Removal of mesocolon fully
b.Removal of transverse mesocolon
c.Removal of D3 nodes by ligating at the level of origin of Ileocolic and right
colic vessels at their origin from SMA
d.Removal of D1 and D2 nodes
Ans. C ( Ref Bailey 28
th
edition page 1362+ other sources)
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44. •The ileocolic artery is ligated close to its origin from the superior mesenteric
artery (‘high-tie’) and divided.
•Complete mesocolic excision with dissection along embryological planes and
removal of the lymphovascular supply of the resected colon with flush
ligation of the ileocolic and right colic vessels at their origin from the superior
mesenteric artery may improve survival in node-positive disease
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45. D2 Lymphadenectomy
•Conventional D2 involves removal -including pericolic nodes
(N1 region), intermediate nodes (N2 region),
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46. Complete MesocolicExcision with Central vascular
Ligation-D3
•The CME-CVL or D3 lymphadenectomy for right-sided colon cancer require ligation of the
ileocolic vein, right colic vein, Henle trunk, and middle colic vein on their appearance from
the SMV, and of the ileocolic artery, right colic artery, and middle colic artery on their
emergence from the SMA.
•Right hemicolectomy with CME and D3 lymph adenectomy involves complete resection
of regional lymph nodes, including pericolic nodes (N1 region), intermediate nodes (N2
region), and main nodes along superior mesenteric vessels (N3 region)
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47. Bailey update question
•For full mobilization of left colon for anastomosis-the following vein is
divided …
a.Left colic vein
b.Right colic vein
c.Ileocolic vein
d.Inferior mesenteric vein
Ans. D ( Ref Bailey 28
th
edition page 1363)
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48. Bailey update question
•Post operative care after Right/ Left hemicolectomy-False statement is
a.Anti thrombotic measures must be continued for 28 days
b.Abdominal drains are having no advantage
c.Anastomotic leaks occur in 4-8% of Ileocolic / Colo colic anastomosis
d.ERAS program has reduced the stay from 10-14 days to 3-5 days
e.In presence of peritonitis following a leak-urgent PCD is done
Ans. E ( Ref Bailey 28
th
Edition page 1363)
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49. Leaks
•Anastomotic leaks occur in 4–8% of ileocolic or colocolicanastomoses.
•The possibility should be borne in mind in any patient not progressing as expected or with
unexplained cardiac abnormalities, fever or worsening abdominal pain.
•Early investigation with contrast-enhanced CT scan is appropriate.
•In the presence of sepsis or peritonitis, early return to theatre and taking down the leaking
anastomosis with the formation of stomas is usually advised.
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50. Bailey Update question
•FOxTROTstudy in Colon cancer is dealing with
a.Postop chemo
b.Post op RT
c.Preop Chemo
d.Adjuvant Chemo+RT
Ans. C Preop Chemo ( Ref Bailey 28
th
Edition page 1363)
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51. •In most patients with colon cancer preoperative chemotherapy is not
required; however, a recent research study (FOxTROT) has shown that it is
safe and further work on case selection has been recommended.
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52. Bailey update Question
•Regarding the adjuvant therapy for colon cancer-False statement is
a.Stage III disease, adjuvant therapy increases survival from 20% to 67-70%
b.K ras+ vecases must receive Cetuximab
c.Pemrolizumabis useful in MSI tumors
d.BRAF mutation has Bad prognosis
Ans. B ( Ref Bailey 28
th
Page 1364)
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53. Adjuvant therapy in CRC
•In those with stage III disease adjuvant chemotherapy increases the chance of 5-year disease-
free survival by approximately 20% to 67–70%.
•Those presenting with unresectable metastatic disease at diagnosis have a 5-year survival of
approximately 10%.
•In metastatic disease chemotherapy based on 5-FU and folinicacid in combination with
irinotecan (FolFiri) is often used as first-line treatment.
•Second-line therapy may include introduction of a monoclonal antibody such as a vascular
endothelial growth factor (VEGF) inhibitor (bevacizumab) or an epidermal growth factor
receptor (EGFR) inhibitor in KRAS wild-type tumours (cetuximab, panitumumab).
•Recently immunotherapy (pembrolizumab) has been shown to have a role in MSI tumours.
•Tumours exhibiting the BRAF V660E mutation (approximately 10%) have a poor prognosis
but may respond to treatment with combined BRAF (Encorafenib) and MAP kinase
(Binimetinib) inhibitors.
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54. Bailey update Question
Carcinoid Tumors in Colon-False statement
a.<10% of colonic carcinoids presents with Carcinoid syndrome
b.Small <1cm hindgut tumors excised by Local excision
c.> 2cm tumors needs enblocresection
d.Midgut tumors <1cm excised by Local excision
Ans d ( Ref Bailey 28
th
Page 1365)
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55. •They constitute around 50% of all neuroendocrine tumours of the gut and about 5% of all
colonic tumours. Fewer than 10% of colonic carcinoid tumours present with carcinoid
syndrome (skin erythema, diarrhoea, cardiorespiratory symptoms) owing to release of
hormones.
•Surgery remains the only potentially curative treatment
•Tumours greater than 2 cm require enbloc resection of adjacent mesenteric lymph nodes.
•In the midgut (the area receiving its blood supply from the superior mesenteric artery) even
lesions less than 1 cm have been shown to metastasise and radical resection is also indicated.
•Small (<1 cm) hindgut tumours (the area receiving its blood supply from the inferior
mesenteric artery) can be safely locally excised
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56. Bailey update Question
•Most common Site of NHL in colon is
a.Ascending colon
b.Descending colon
c.Rectum
d.Caecum
Ans. D ( Ref Bailey 28
th
Page 1365)
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57. Bailey Update Question
•Regarding the infective colitides-False statement
a.Enteroinvasive E Coli causes-Hematochezia
b.C Jejuniis the most common form of gastroenteritis in Resource rich
countries
c.Clostridium difficleis usually diagnosed by Stool culture
d.Salmonella is diagnosed by Stool Culture
Ans C ( Ref Bailey 28
th
Edition page 1365-1367)
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58. Clostridium difficle
•Clinically, C. difficleinfection presents with diarrhoea, abdominal pain and fever.
•Infection may progress to pseudomembranous colitis, so called because on endoscopic
visualisation of the bowel plaques of inflammatory exudate between oedematous mucosa are
seen.
•Diagnosis is usually made by detection of the toxin in stool samples, rather than by culture.
Treatment is by metronidazole or vancomycin along-side supportive care.
•In refractory cases, faecal transplantation to restore a healthy microbiota may be tried.
•If toxic dilatation occurs, an emergency subtotal colectomy and ileostomy may be necessary.
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59. E Coli
•Entero-toxigenic E. coli –causing ‘traveller’s’ diarrhoea (diarrhoea, vomiting
and colicky pain). In adults, infection is usually brief and self-limiting.
•A more severe form –Enteroinvasive E. coli –causes a more systemic illness
and haematochezia.
•A very severe form –EnteroHaemorrhagicE. coli –results in colonic oedema,
ulceration and haemorrhage with the very ill requiring colectomy.
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60. Salmonella Typhi
They present with fever and abdominal pain after a 10-to 20-day incubation
period. Over the next week, the patient can develop distension, diarrhoea,
splenomegaly and characteristic ‘rose spots’ on the abdomen caused by a
vasculitis.
A number of surgical complications can result:
●Paralytic ileus;
●Intestinal haemorrhage;
●Perforation;
●Cholecystitis.
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61. Bailey Update Question
In AIDS patients –MC indication for Colectomy
a.Cancer right colon
b.Cancer left colon
c.Campylobacter jejuni
d.CMV
Ans. D ( Ref Bailey 28
th
Edition page 1367)
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62. CMV
•Cytomegalovirus (CMV) is present asymptomatically in 40–100% of adults.
•It usually remains latent within the host but can reactivate in
immunocompromised patients.
•Commonly affected are those with acquired immunodeficiency syndrome
(AIDS) (where it is the most common indication for colectomy) and patients
on immunosuppressive therapy for IBD.
•Symptoms include profuse bloody diarrhoea and colicky pain.
•Severe disease may lead to perforation.
•Treatment is with Ganciclovir with surgery necessary for severe disease or
complications.
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67. Bailey update Question
•Patients with DPYD gene mutation will develop colitis if given with …. Drug
a.Statins
b.5FU
c.Digoxin
d.Ergotamine
Ans. B ( Ref Bailey 28
th
Edition page 1367)
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68. •Patients with the DPYD (dihydro pyrimidine dehydrogenase) gene mutation
are particularly prone to colitis if treated with 5-FU during treatment for
colon cancer. Dose reduction should be employed.
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69. Bailey Update Question
•The bleeding from Colonic Diverticula is typically
a.Painful and mild
b.Painful and profuse
c.Painless and mild
d.Painless and profuse
Ans. D ( Ref Bailey 28th Edition page 1368)
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70. •Haemorrhage from colonic diverticula is typically painless and profuse.
•Bleeding from the sigmoid will be bright red with clots, whereas right-sided
bleeding will be darker.
•Torrential bleeding is fortunately rare and, in fact, more commonly due to
angiodysplasia, but diverticular bleeding may persist or recur, requiring
transfusion and resection.
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71. Bailey Update Question
•False statement regarding the management of Diverticulitis
a.Traditionally Hartmann’s done
b.Emergency laparoscopy can be done with lavage and drain in selected cases
is done
c.In colovesicalfistula –bladder is also resected with sigmoid colon
d.Recent guidelines is to treat even patients with recurrent attacks of
diverticulitis conservatively in absence of complications.
Ans. C ( Ref Bailey 28
th
Edition page 1370)
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72. Updates in Diverticulitis
•There may be a role for emergency laparoscopy in diverticular disease in expert hands.
•It allows assessment of the disease and in very selected cases a simple but thorough washout
and drainage.
•In a colovesicalfistula, once cancer has been excluded, the sigmoid can often be pinched of
the bladder, the sigmoid colon resected and the bladder drained with an indwelling catheter
for 7–10 days.
•If an anastomosis is performed, it is wise to place an omental pedicle between the bowel and
bladder to prevent recurrent fistulation
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73. •Cohort studies suggest that of patients under 50 years old admitted with diverticulitis, 25%
will have a further episode.
•The data may be used as an argument for offering elective resection but equally indicate that
75% will not get another severe attack.
•Many surgeons would discuss the pros and cons of elective surgery after two emergency
admissions, although comorbidities must be carefully considered.
•However, there is an increasing tendency to treat even patients with recurrent attacks of
diverticulitis conservatively in the absence of complications.
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74. Bailey Update Question
•Heyde'sSyndrome is
a.Aortic stenosis+ Angiodysplasia
b.Aortic Regurgitation + Angiodysplasia
c.VWD+ Mitral stenosis+ Angiodysplasia
d.Aortic Stenosis + Diverticulosis
Ans. A ( Ref Bailey and Love 28
th
Page 1371)
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75. Update Points Volvulus
•For sigmoid volvulus the initial management is non-operative decompression using either a
rigid sigmoidoscope or a colonoscope.
•Direct vision allows assessment of mucosal viability and de rotation.
•With successful de rotation a well-lubricated flatus tube should be inserted and left for 2–5
days.
•Bloody bowel contents or discoloured mucosa suggest ischaemia and the need for urgent
surgery.
•Attempted de rotation in this situation should be abandoned as it could lead to circulatory
collapse and death.
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76. •Such surgery should involve at least resection of the whole of the sigmoid colon and can be
carried out laparoscopically.
•Given that there is very little need for colonic mobilisation and a large utility incision is
required because of the bowel size, some of the benefits of a laparoscopic approach are
negated.
•It is therefore reasonable to carry out surgery through a mini laparotomy incision with the
same recovery outcomes.
•An alternative to surgical resection in the very unfit patient is a percutaneous endoscopic
colostomy, using a colonoscope to place a drainage tube through the abdominal wall into the
sigmoid to fix the bowel in an untwisted position.
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77. •In the emergency situation where there is evidence of necrosis it may be wise
to ligate the mesenteric vessels before untwisting the volvulus to theoretically
avoid the systemic release of ischaemic toxins.
•It may also be prudent to avoid anastomosis.
•Instead, a Hartmann’s-type approach or a Paul–Mikulicz double-barrelled
stoma should be considered.
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78. Bailey update Question
Prolapse is more common with
a.End ileostomy
b.End colostomy
c.Loop Ileostomy
d.Loop Transverse Colostomy
Ans D ( Ref Bailey Page 1373, 28
th
Edition)
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79. •Prolapse is more common in loop stomas, particularly transverse colon loop
stomas.
•If recurrent and causing problems with stoma care the most effective solution
is reversal.
•Other options include conversion to an end-stoma and/or resection of
redundant bowel
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80. Ischemic Stoma
•If the stoma looks ischaemic a proctoscope is useful to assess viability below
the fascia.
•Urgent surgery is required if the mucosa below the fascia is also ischaemic.
•Conversely if the mucosa of the bowel immediately proximal to the stoma is
viable, the patient can be managed expectantly in the hope that the non-
viable mucosa will slough and the worst late result is a stenosis that can be
managed with a more local procedure.
•This may be preferable to an immediate, difficult relaparotomy.
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81. Chapter 78
Intestinal Obstruction
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82. Bailey Update Question
Conservative treatment for Adhesive Obstruction must not be done for more
than … hours
a.24 hours
b.48 hours
c.72 hours
d.96 hours
Ans. C( Ref Bailey 28
th
Edition page 1387)
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83. RRM NEXT SS Coaching Institute

84. Chapter 79
Rectum
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85. Bailey Update Question
False about Solitary Rectal Ulcer Syndrome
a.Seen in anterior wall of rectum situated 6-8 cm from anal verge
b.May appear like Polypoidal also
c.STARR procedure provides excellent response for SRUS
d.It is associated manifestation of Obstructed Defecation syndrome
Ans C ( Ref Bailey 28
th
Edition page 1399)
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86. •Solitary rectal ulcer syndrome (SRUS) may also be another associated manifestation of
obstructed defecation syndrome.
•Classically, SRUS takes the form of an ulcer on the anterior wall of the rectum, situated 6–8 cm
from the anal verge.
•Proctographic studies may indicate accompanying rectal intussusception or anterior rectal
wall prolapse.
•Histology will confirm the diagnosis. The condition is difficult to treat. Symptomatic relief
from bleeding and discharge may sometimes be achieved by controlling any associated
straining with re­ coordination of defecation using biofeedback therapy.
•Transanalstapled resection of the intus­susception (STARR procedure) or resuspension of
the rectum by abdominal rectopexy may be beneficial, but the results are not as good as for
internal or external rectal prolapse. In rare cases, rectal excision may be required with or
without stoma.
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87. Bailey Update Question
False statement about the Laparoscopic Ventral Mesh repair is
a.Plane between rectum+ vagina( prostate) is dissected
b.Mesh placed between Anterior Rectum and posterior vaginal vault
c.Improvement happens in Constipation and incontinency also
d.As per 2020 publications from Cumberlegemesh can be used in Vaginal
surgery
Ans. D ( Ref Bailey 28
th
Page 1401)
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88. •As an abdominal rectopexy may lead to worsening constipation, some
surgeons recommend combining this procedure with resection of the sigmoid
colon, so­ called ‘resection rectopexy’, but this adds an additional risk because
of the anastomosis.
•An alternative is LVMR, which has become increasingly popular in western
practice (D’Hoore).
•In this procedure, the plane between the rectum and vagina (or prostate) is
dissected, and a strip of mesh sutured to the anterior rectum and posterior
vaginal vault.
•The upper end of the mesh is secured to the sacral promontory with sutures
or tacks, thus resuspending the rectum and preventing prolapse
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89. •The success of LVMR in treating external rectal prolapse and rectal intussusception has been
variously reported between 70% and 80%, with improvement in both constipation and
incontinence scores.
•It is a relatively safe procedure (overall complication rate 10%) with a quick recovery
because of the laparoscopic approach.
•Possible complications include pro­ lapse recurrence, bleeding, pelvic pain and dyspareunia.
•More recently, there has been concern regarding mesh complications when used more
generally for pelvic organ prolapse surgery, culminating in the 2020 publication of the
CumberlegeReport in the UK.
•As a result, the use of mesh for vaginal surgery has been restricted.
•When used for LVMR, mesh complications (infection and erosion) have been reported in 2–
4% of cases and are higher when a polyester mesh is used.
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90. Bailey Update Question
•Regarding the Endoscopic treatments for Rectal polyps –False
statement is
a.Resection plane for both EMR and ESD is superficial to
Submucosal layer
b.A non lift sign can be seen in previous fibrosis due to tattooing
c.EMR is used for < 20 mm lesions
d.ESD results in piecemeal resection
Ans. D ( Ref Bailey 28
th
Edition page 1404)
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91. •Polyps greater than 1 cm in size have a 10% chance of malignancy.
•The difficult polyp can be defined by a range of variables, including the number of polyps, a
size greater than 15 mm or a certain shape, whether with a large pedicle or a fat appearance
•Endo mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are techniques
to consider when use of biopsy forceps or a snare is not optimal.
•The resection plane for both EMR and ESD is the superficial submucosal layer.
•Both techniques utilise an injection into the submucosal layer
•Importantly, if the mucosa does not lift, this may indirectly indicate deeper invasion of the
lesion.
•A ‘non­lift’ sign may also occur because of fibrosis from previous resection attempts or
tattooing
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92. •EMR is typically used for lesions up to 20 mm in size, although the piecemeal resection for
lesions greater than 20 mm may obviate surgery at the risk of a higher recurrence rate.
•ESD was created to counter the shortcomings of EMR as enbloc resection allows assessment
of both horizontal and deep margins, which is not possible with a piecemeal resection
•The submucosal injection is performed at the proximal border of the lesion, after which
endoscopic knives are used to create an incision and dissect the submucosal layer free.
•ESD is informally indicated for lesions larger than 20 mm, when high ­grade dysplasia or
superficial submucosal invasion is suspected and when other endoscopic techniques have
failed.
•Larger polyps are more difficult to remove by EMR and may require a transanalprocedure,
such as transanalendoscopic microsurgery (TEMS).
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93. Bailey update Question
•M1c in Colorectal cancer stands for
a.Metastasis in more than 1 organ
b.More than 1 metastasis in 1 organ
c.Peritoneal metsassociated with Liver metsonly
d.Peritoneal metswith or without any organ mes
Ans. D ( Ref Bailey 28
th
Page 1407)
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94. Distant metsin Colorectal cancer
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95. Nodal Mets
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96. Bailey Update Question
•In cancer rectum-if the resection margins are not threatened but
cancer is at high risk of local recurrence-the procedure that can be
followed is
a.Neoadjuvant Long course Chemo Radiotherapy
b.Neoadjuvant Long Course Chemotherapy
c.Preop short course RT
d.Post op Short course RT
Ans. C ( Ref Bailey 28
th
edition page 1409)
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97. •When a tumour appears to be locally advanced (i.e. invading a neighbouring
structure or threatening to breach the circumferential resection margin), the
use of neoadjuvant (preoperative) radiotherapy or chemoradiotherapy is
usually considered.
•Long­ course chemoradiotherapy is given as five fractions of radiotherapy
combined with chemotherapy over a 6­week period.
•The aim is to downstage the cancer and increase the chances of a complete
resection with clear oncological margins.
•Alternatively, preoperative ‘short­ course’ (5 days) radiotherapy can be
used if the resection margins are not threatened but the cancer is still at
high risk for local recurrence (e.g. perirectal lymph node involvement).
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98. Bailey Update Question
•Regarding HabrGamma Approach-false statement is
a.20% rectal cancers has complete response on Neoadjuvant CRT
b.30% of them will recur in wait and watch policy
c.Those recurrence cases are difficult to remove by salvage
surgery
d.There is increasing trend towards this approach
Ans. C ( Ref Bailey update 28
th
Edition page 1409)
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99. HabrGama Approach
•Approximately 20% of rectal cancers treated by neo­ adjuvant
chemoradiotherapy show a complete clinical response with no evidence of
residual cancer on clinical examination, biopsy or radiological imaging.
•There is an increasing trend for such patients to be offered the option of
‘watch and wait’ (Habr­ Gama) in the hope that they may have been cured of
the disease and spared the morbidity of resectionalsurgery.
•Some 30% of cases will recur on a ‘watch­ and­ wait’ policy, but most can be
salvaged by surgical resection
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100. Bailey update Question
•The concerns of increased…….. Injuries has resulted in little
reduction in the Trans anal Total mesorectalexcision
a.Prostate
b.Vaginal
c.Urethra
d.Bladder
Ans. C ( Ref Bailey 28
th
Edition page 1413)
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101. Bailey Update
•taTMEbuilds on the principles of laparoscopic surgery, with an airtight anal
device used to provide transanalinsufflation and access for laparoscopic
instruments.
•The operation proceeds by placing a purse­ string suture below the distal
level of the tumour and incising the bowel wall to enter the mesorectalplane.
•Dissection then proceeds using a ‘bottom­ up’ approach to accomplish TME.
•It is usual for this procedure to be undertaken as a combined operation, with
synchronous ‘top­ down’ laparoscopic resection by an abdominal operator
who mobilises the left colon, takes down the splenic flexure and does some of
the upper rectal dissection.
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102. •Initial results have demonstrated that taTMEis safe, with short­ term oncological outcomes,
in terms of pathological quality of the resection specimen and circumferential resec­tion
margins, comparable to those of traditional laparoscopic and open techniques.
•However, concerns have been raised regarding the increased incidence of urethral injuries
and the development of multifocal local recurrences.
•These concerns highlight the critical importance of adequate taTMEtraining, proper case
selection, and proctorship with maintenance of high procedural volumes in an MDT setting to
help ensure optimal outcomes.
•Meanwhile, several multicentre randomised controlled trials such as COLOR III and TaLaRare
well under way to confirm the long ­term oncological safety of taTME.
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103. Chapter 80
Anus and Anal canal
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104. Bailey update Question
•Post anal dermoid-False statement is
a.It presents in adult life though it is congenital
b.Cyst is easily palpable on PR examination
c.Bottle neck cyst is seen on radiography on a contrast
examination
d.Coccyx is carefully preserved while excising the dermoid cyst
e.Currarino triad is associated
Ans. D ( Ref Bailey 28
th
Edition page 1423)
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105. Post anal Dermoid
•The space in front of the lower part of the sacrum and coccyx may be
occupied by a soft, cystic swelling –a postanal dermoid cyst.
•Hidden in the hollow of the sacrum it is unlikely to be discovered unless a
sinus communicating with the exterior is present or it develops as a result of
inflammation.
•Such a cyst usually remains asymptomatic until adult life, when it is prone to
becoming infected.
•Exceptionally, because of its size, it gives rise to difficulty in defecation.
•The cyst is easily palpable on rectal examination.
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106. •When a discharging sinus is present, a postanal dermoid will probably be
mistaken for a pilonidal sinus or even an anal fistula.
•Pressure over the sacrococcygeal region with a finger in the rectum may
cause a flow of sebaceous material, and injection of contrast medium
followed by radiography reveals a bottle-necked cyst in front of the coccyx
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107. •Treatment involves complete excision of the cyst and, if present, the sinus.
•In the case of large cysts, it is necessary to remove the coccyx to gain access.
•The coccyx should also be removed enbloc in any child with a presacral
dermoid because of the risk of sacrococcygeal teratoma.
•Care must be taken to exclude the Currarino triad, an autosomal dominant
hereditary condition characterised by sacral malformation, anorectal
malformation (often stenosis) and a presacral mass consisting of a dermoid
cyst/teratoma and/or anterior meningocele.
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108. Name the operation
Karydakis’soperation an off-midline incision is made
around the sinus complex, which is excised, and a
contralateral fap is mobilised to allow tension-free off-
midline closure
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109. Name the operation
The Limbergfap the sinus complex is excised using a
rhomboid incision and a measured fap is rotated (A) to (A')
to achieve tension-free closure
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110. Name the operation
Bascom’s technique for pilonidal sinus (a); lateral incision
and curetting cavity (b); excision midline pits
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111. Bailey update Question
•Sphinkeeperis used to for
a.Pilonidal sinus
b.Anal incontinency
c.Fistula
d.Constipation
Ans. B ( Ref Bailey 28
th
Edition page 1426)
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112. •Injectable biomaterials to add bulk to the anal
canal and thereby augment faecal continence
were first introduced by Shafik, who injected
poly tetra fluoroethylene paste into the anal
submucosa.
•The ideal agent should be biocompatible, easy to
deploy and should not migrate.
•Many materials have been investigated.
•Recently the SphinKeeper® (Ratto) has been
shown to restore sphincter function through
placement of self-expanding prostheses into the
inter sphincteric space, adding bulk to the
sphincter complex
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113. Bailey Update Question
•Regarding the procedure shown here-
False statement is
a.This is Sacral nerve stimulus
procedure
b.S1 and S2 nerve roots are stimulated
c.SNS is used for long term
improvement in Fecal incontinency
d.Infection may require device removal
Ans B ( Ref Bailey and Love 28
th
Edition
page 1426)
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114. SNS
•Sacral nerve stimulation (SNS) is a novel technique that uses low-voltage electrical
stimulation to the S3 or S4 nerve roots to augment continence thought to work primarily by
activation of autonomic sensory pathways in patients with pelvic neuropathy, which
principally occurs after childbirth.
•The technique consists of a screening phase of peripheral nerve evaluation, followed by a
therapeutic phase of permanent neurostimulator implantation (Matzel)
•SNS is sustainable with long-term improvement in symptoms. Postoperative complication
rates are low; however, infection or loss of efficacy may require device explantation.
•Percutaneous posterior tibial nerve stimulation (PTNS) is a less expensive
neuromodulation technique; however, results from prospective studies suggest only modest
improvement in outcome.
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120. Bailey update Question
•The HubBleTrial is one which compared HAL ( Transnal
Hemorrhoidal Ligation ) with….
a.Longo
b.Milligan morgan
c.Sclerotherapy
d.Rubber band ligation
Ans d ( Ref Bailey 28
th
edition page 1433)
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121. •The HubBLetrial, which compared HAL with rubber band ligation, found that
the recurrence rate following HAL was significantly lower, but HAL was less
cost-effective.
•The complication rate and postoperative pain scores are better after HAL
than with conventional surgery.
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122. Bailey Update question
•False about setons-in fistula in ano
a.Seton in non absorbable non degenerative and Comfortable
material
b.Loose setons are used before advanced techniques
c.Loose seton is used for 3 months
d.Cutting setons is used for Crohn disease
Ans. D (Ref Bailey 28
th
Edition page 1441)
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123. •Loose setons are most commonly used before ‘advanced’ techniques (fistulectomy,
advancement fap, cutting seton) while sepsis resolves and secondary extensions heal as part
of a staged fistulotomy.
•Such a staged approach is valuable in treating secondary (horseshoe) tracks in the
ischiorectal fossa, where the primary track crosses the external sphincter to reach the deep
postanal space (Hanley).
•The seton is left in place for 3 months and either simply removed or replaced by a cutting
seton to complete the fistulotomy.
•Loose setons are also used for long-term palliation to avoid septic and painful exacerbations
by establishing effective drainage, most often in Crohn’s disease and in those with
problematic fistulae not wishing to countenance the possibility of incontinence
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124. •LIFT involves disconnection of the internal opening from the fistula tract at the level of the
inter sphincteric plane and removal of the residual infected glands without dividing any part
of the sphincter complex.
•The tract is then ligated and divided, the internal part is removed and the external part of the
track is curetted and drained
•Hence it is a sphincter-preserving procedure, thereby maintaining continence.
•Systematic reviews report healing rates of 75% with little or no impairment of continence.
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125. Advancement flaps
•Ideally sepsis and secondary tracks have healed, leaving a direct track that can be cored.
•The internal opening is then closed with a broad-based, well-vascularised flap of anorectal
mucosa and the internal sphincter is sutured without tension to the anoderm below the
dentate line.
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126. Biological agents
•These include fibrin glue, cross-linked porcine dermal collagen and more recently
mesenchymal stem cells.
•Antibiotics, particularly metronidazole and ciprofloxacin, are of value in treating fistula-
associated sepsis and many have immune-modulating effects of value in Crohn’s disease.
•Patients must be warned of potential side effects of prolonged therapy, including peripheral
neuropathy (metronidazole) and tendinopathy (ciprofloxacin).
•Biological therapies, including the anti-tumour necrosis factor drug vedolizumab and
ciclosporin, are of value as part of multimodality treatment of perianal Crohn’s disease
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127. VAAFT
•Video-assisted anal fistula treatment (VAAFT) involves the introduction of a rigid fistuloscope
into the tract through the external opening.
•The scope has a channel to accommodate a forceps, brush or diathermy.
•The scope is passed into accessible tracks to allow lavage, curettage, cautery or the
introduction of setons.
•VAAFT represents a form of advanced track identification and preparation before a definitive
technique is performed.
•Fistula tract laser closure (FiLaC) uses radial emitting laser to obliterate the luminal aspect of
the fistula to a known depth, throughout its length.
•An over-the-scope clip (OTSC) involves closing the internal opening using a nitinol clip,
disconnecting the external tract.
•Clip migration and elective removal because of pain are the main complications.
•The FISCLOSE trial is currently recruiting.
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128. Bailey Update Question
•Anal intra epithelial neoplasia –False statement is
a.HPV 16 and 18 are associated with Anal cancers
b.10% of AIN III lesions will progress to Cancer in 5 years
c.AIN III involving > 30% anal margins are excised
d.AIN 1/II has indolent course and hence 12 month follow up is
enough
Ans. C( Ref Bailey 28
th
Edition page 1443)
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129. •Subtypes 6 and 11 are most often associated with warts and early AIN,
whereas subtypes 16 and 18 account for more than 75% of anal cancers.
•The prevalence is <1% of the population with a rising incidence, especially in
those areas where ano-receptive inter-course and HIV are prevalent
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130. •Patients’ symptoms include pruritus, pain, bleeding and discharge.
•AIN is present in 28–35% of excised anal warts.
•Approximately 10% of AIN III lesions will progress to anal carcinoma at 5
years.
•Regression of AIN III rarely occurs, but AIN I and AIN II may regress.
•The association between AIN III and carcinoma is strengthened by the
findings of AIN III in 80% of anal cancer biopsies.
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131. •Specialised centres may offer colposcopy of the anus (anoscopy), utilising 5% acetic acid with
Lugol’siodine to assess in vivo the dysplastic areas of the anus.
•The affected areas show up white and can be biopsied.
•Focal disease may be excised and local excision is effective for lesions <30% of the
circumference of the anus.
•More widespread disease can be dealt with surgically by wide local excision and closure of
the resultant defect by fap or skin graft, with or without covering colostomy (especially if
there is intra-anal disease).
•However, for a condition with uncertain malignant potential, this approach should be used
with caution as it carries with it significant morbidity.
•Anal mapping uses a 3-mm corneal punch biopsy, and a total of 8–12 biopsies allows for
adequate mapping of most disease.
•An operative map or photograph is helpful.
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132. •Localised or focal AIN is defined as <30% of the anal circumference, whereas extensive AIN
involves more than 30% of the circumference.
•Lesions involving <30% of the anal circumference can be simply excised with the resulting
wound left to granulate or closed as appropriate.
•AIN III lesions involving >30% of the anal margin or canal cannot be excised as the risk of
severe anal stenosis is significant.
•The remaining areas are regularly observed at 6-monthly intervals. AIN I/II and AIN III have
differing natural histories.
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133. •Topical imiquimod (5%) or oral retinoids have some effect on the progression of dysplasia
and can cause regression by at least two histological grades. Other newer options may
include anti-HPV treatment; vaccination may reduce the incidence in the long term
•AIN I/II has an indolent course except in immunocompetent patients, for whom 12-monthly
anoscopyis recommended.
•Patients with AIN III and multicentric intraepithelial neoplasia should be managed by
clinicians with an interest in this disease and require a multidisciplinary approach involving
gynaeco-logical specialists.
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134. Nigro regimen Update
•Historically anal cancer was treated by abdominoperineal resection; however, since the late
1970s chemoradiotherapy (Nigro) has become the primary treatment.
•The UK Coordinating Committee on Cancer Research (UKCCCR) Anal Cancer Trial (ACT I)
found that chemoradiation with radiotherapy (50.5 Gy) gave superior local control compared
with radiotherapy alone while the ACT II trial found similar outcomes when
chemoradiotherapy using cisplatin/5-fluorouracil (5-FU) was compared with mitomycin/5-
FU.
•The longer infusion time required to administer cisplatin/5-FU has led to the preferred use of
the mitomycin/5-FU combination.
•Current trials (ACT III, ACT IV and ACT V) are investigating more personalised treatment
protocols, including local excision only for small tumours and a combination of excision along
with varying radiotherapy regimes for other tumours.
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135. Thank you..
NEXT Update Transplant
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