Oxford Medical Handbooks- Oxford Handbook of Clinical Surgery
Lecture notes about colorectal surgery based on Oxford Clinical Handbook of surgery. Contains information about clinical features of each condition, as well as relevant diagnostic tests and investigations, risk factors, causes and management guidelines.
Everything has been cross referenced with p...
Benign tumours – do not invade surrounding tissues
Malignant tumours – can directly invade adjacent tissues or enter blood and lymphatic channels. The
malignant genotype develops as a result of progressive acquisition of cancer mutations formation of
cancer stem cells.
Malignant tumours of the large intestine
Colorectal adenocarcinoma
Most common GI malignancy, lifetime risk ~5%
Pathological features
May occur as polypoid, ulcerating, stenosing, or infiltrative tumour mass
Majority are L side of colon and rectum (75%); rectum – 45%, descending sigmoid – 30%, transverse – 5%,
R-sided 20%
Algorithm for referral
Risk factors Urgent pathway (2WW)
- Male gender Patients > 40 w/ unexplained weight loss and
- Increasing age abdo pain or
- Family hx Patients > 50 w/ unexplained rectal bleeding or
- Westernised diet Patients > 60 w/
o High fibre = protective - IDA or
o High-energy, low-fibre, high-fat = risk - Change in bowel habit or
factors - Tests showing occult blood in faeces
- Aspirin thought to be protective
- Polyposis syndromes (FAP, Lynch syndrome, Consider suspected cancer referral in adults w/
Juvenile polyposis) rectal/abdo mass
- Previous hx of polyps or CRC
- Chronic UC or colonic CD Consider for adults < 50 w/ rectal bleeding and
any of the following unexplained symptoms
Clinical features - Abdo pain
Rectal location - Change in bowel habit
- PR bleeding (deep red, surface of stools) - Weight loss
- Change in bowel habit - IDA
- Difficulty with defecation
- Tenesmus
Descending-sigmoid location
- PR bleeding (typically dark red, mixed with stools)
- Change in bowel habit (often frequency, variable consistency, mucus PR, bloating, flatulence)
R sided location
- IDA may be only presentation
Emergency presentations
Up to 40% present as emergencies
- Large bowel perf. (colicky pain, bloating, bowels not opening)
- Perf with peritonitis
- Acute PR bleed
Population screening
, - Scotland – screening every 2 years for people aged 50-74 years
- Rest of UK – offered every 2 years for people aged 60-74 years
- Faecal immunochemical testing (FIT)
o Normal normal recall
Protocol for rectal bleeding outside 2WW
o Abnormal colonoscopy
Emergency admission for patients with profuse
rectal bleeding cause hypotension or Hb
Diagnosis and investigation
- Colonoscopy 1st line
Referral for patients with persistent unexplained
- CT colonography can be useful for
rectal bleeding and/or anorectal symptoms
investigation of altered bowel habit
resistant to local 1st line treatments
- Emergency presentations
o Commonly diagnosed by CT abdo
- Staging
o CT CAP, CT-PET
o Assessment of local extent Duke’s staging (5yr survival, %)
CT for colonic carcinoma A, confined to bowel wall only (75-90)
Pelvic MRI for rectal cancer B, through bowel wall (55-70)
o Colonoscopy or barium enema C, any with + lymph nodes (30-60)
o Tumour marker CEA no use for diagnosis D, any with metastases (5-10)
or staging but can be used to monitor
disease relapse if raised at diagnosis TNM
T 1-4 – stage of invasion through bowel
Management wall
Potentially curative – suitable for resectable tumours w/ N0/1/2 – No/ up to 4/ >4 lymph nodes
no evidence of metastases (or metastases potentially M0/M1
curable by liver/lung resection)
- Surgical resection (w/ lymphadenectomy) = only curative treatment
o R/transverse: R/extended R hemicolectomy
o L: L hemicolectomy
o Sigmoid/upper rectum: high anterior resection
o Lower rectum: low anterior resection/abdominoperineal resection (APER)
o Anorectal: APER w/ end colostomy. Some very superficial tumours can use trans-anal
endoscopic microsurgery (TEMS)
- Preoperative (neoadjuvant) chemoradiotherapy may be used to rectal cancer to chance of
curative resection
- Adjuvant chemo (5FU) offered for tumours with + lymph nodes or evidence of vascular invasion
- +/- hepatic/lung resection
May require de-functioning stoma –
where stoma is performed proximally to
anastomosis to allow anastomosis to rest
prior to use
Total/subtotal colectomy – may be used
for UC, polyposis (including FAP)
Total – end ileostomy
Subtotal – ileo-rectal anastomosis
*Involves excision of colonic mesentery,
ligation of arterial supply at origin, and
excision of all accompanying lymph
nodes*
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