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GASTROINTESTINAL
https://t.me/med1917
165
SURGERY
Perianal disease ....................................................................166
Colorectal cancer .................................................................168
ABBREVIATIONS
CEA – Carcinoembryonic antigen
CRC – Colorectal cancer
CT CAP – Computed tomography chest,
abdomen & pelvis
DM – Diabetes mellitus
DRE – Digital rectal examination
EUA – Examination under anaesthetic
FAP – Familial adenomatous polyposis
GA – General anaesthesia
GTN – Glyceryl trinitrate
HNPCC – Hereditary non-polyposis
colorectal cancer
HSV – Herpes simplex virus
IAP – Intra-abdominal pressure
IBD – Inflammatory bowel disease
IDA – Iron-deficiency anaemia
12
Anal cancer ............................................................................... 170
LN – Lymph node
PR – Per rectum
PV – Per vagina
SB – Small bowel
UC – Ulcerative colitis
UTI – Urinary tract infection
166 Chapter 12: Gastrointestinal surgery
https://t.me/med1917
Perianal disease
Fistulae
DDx perianal lump:
∙ Abscess
∙ Pilonidal sinus
∙ Fistula-in-ano
∙ Anal fissure
∙ Sebaceous cyst
∙ Crohn’s disease
∙ Thrombosed external haemorrhoid
Anal canal
Rectum
Fig. 12.1
Conditions predisposing to fistula-in-ano:
• Crohn’s
• TB
• Diverticular disease
• Malignancy
DEFINITION: abnormal connection between 2 mucosal surfaces
TYPES:
Intrinsic: entero- enteric (SB–SB) / entero-colonic (SB–colon) / entero-vesical
(SB–bladder)
Extrinsic: entero-cutaneous (SB–skin) / entero-vaginal (SB–vagina) /
recto-vaginal etc.
SYMPTOMS:
To skin: discharging sinus or abscess
Bowel–bowel: nothing / diarrhoea / weight loss / pain
To bladder: pneumaturia, debris in urine, recurrent UTIs
To vagina: PV discharge
FISTULAINANO = tract between rectum / anal canal & skin
Symptoms: discharging tract + recurrent perianal infection
Investigations:
• Acute perianal pain: examination under anaesthetic (EUA)
• Chronic/complex presentation: MRI
Management:
1. Very superficial – watch and wait
2. Superficial/intersphincteric: lay open (fistulotomy) → ABX → leave to heal
by 2° intention
3. Higher level (involves external sphincter): ABX + seton suture drainage
Seton suture:
tightened to enable healing & closure
→ Infections commonly occur in anal crypts/glands
→ symptoms of fever, pain, swelling, discharge
SB = small bowel
piece of thread remains in fistula tract to keep it open & allow drainage → gradually
Conditions predisposing to anal fissure:
• Crohn’s
• Anal cancer
• HIV, HSV, syphilis
• Hard faeces
Perianal abscess
SYMPTOMS: red, sore, swollen lesion
(± discharge)
ASSOCIATIONS: Crohn’s, DM, malignancy, anal sex
MANAGEMENT: incision & drainage (under GA) → ABX → apply dressings
→ Aim to treat before ruptures & discharges to form fistula
Abscess usually contains gut organisms:
E. coli, bacteroides, enterococcus
Anal ssure
DEFINITION: tear in squamous lining of anal canal below dentate line
AETIOLOGY:
• 90% = posterior to anus
• 10% = anterior to anus
SYMPTOMS:
• Very painful → esp. defecating & for hours after (cannot tolerate PR exam)
• Bleeding on defecation (bright red)
• Constipation (avoid defecating due to pain)
• Pruritus ani
• Mucosal skin tag / sentinel pile
MANAGEMENT1:
1. Conservative: fluids & fibre, bulking laxatives, lubricants, topical analgesia
2. Fissures unresponsive to conservative measures: topical GTN cream for 6–8w
3. Unresponsive to medical management: EUA ± further management
→ Botox or sphincterotomy = last resort
Surgery
1
NICE CKS Clinical scenario (2021) Anal ssure
Chapter 12: Gastrointestinal surgery 167
Anoder
https://t.me/med1917
Haemorrhoids
DEFINITION: distension & prolapse of normal anal cushions
(masses of spongy, venous tissue)
CAUSES/AETIOLOGY:
• Idiopathic – weakened muscular wall with age
• Chronic constipation/straining (low fibre diet)
• Raised IAP (pregnancy, portal HTN, pelvic tumour)
CLINICAL PRESENTATION:
• Painless, bright red PR bleed (coats stool & dripping into pan)
• Itching
• Mucous discharge
→ If thrombosed: painful & tender, purple mass
Asymptomatic haemorrhoids
MANAGEMENT2:
1. Conservative: fluid & fibre, laxatives, topical analgesia, toileting advice
(correct position, avoid straining)
2. Non-operative: rubber band ligation / injectable sclerosants
3. Surgical: haemorrhoid artery ligation / haemorrhoidectomy
→ Management of acutely painful thrombosed haemorrhoid: analgesia +
icepack + Instillagel + laxative
↳ No role for surgery
ANATOMY:
Fig. 12.3
require no further investigation
11
Cushions found at
3, 7 & 11 o’clock
Fig. 12.2 External haemorrhoid.
7
Investigations:
• DRE + abdo exam
• Proctoscopy (shows pink mucosal swellings)
• Flexible sigmoid-/colonoscopy (r/o sinister bleed)
3
Internal Anal
Sphincter
Fig. 12.3
External Anal
Sphincter
m
External Hemorrhoid
Prolapsing Internal
Hemorrhoid
Internal Hemorrhoid
Pectinate Line
Perianal Vessels
DDx of PR bleed
With pain Without pain*
Blood mixed with stool Colitis Colorectal cancer / colitis
Blood streaked on stool Anal tumour Rectal tumour
Blood separated from stool Colitis Haemorrhoids
Diverticular disease
Angiodysplasia
Tumour
Colitis (with mucus)
Blood streaked on paper Anal fissure Haemorrhoids
*Sometimes these can present with pain as well!
2
European Society of ColoProctology (2020) Guideline for haemorrhoidal disease
Internal haemorrhoids = above dentate line
→ Epithelium: columnar
→ Venous drainage: portal system
→ Somatic innervation: none = painless
External haemorrhoids = below dentate line
→ Epithelium: squamous
→ Venous drainage: internal iliac
→ Somatic innervation: present = painful if
thrombosed or become irritated
Important questions to ask:
• How long?
• How much?
• Mixed with stool?
(above colon = usually mixed in)
• Pain?
• Altered bowel habits?
(compare to normal for the patient)
• FHX / personal Hx
→ check red flag symptoms
(see Colorectal cancer on next page)
Surgery
168 Chapter 12: Gastrointestinal surgery
https://t.me/med1917
Colorectal cancer
↳ most = adenocarcinomas
Risk factors
Familial adenomatous polyposis (FAP):
Auto dominant mutation in APC gene
→ Hundreds of polyps
→ Presents at 35–45y (consider if <50y with
colorectal cancer)
→ Colonoscopy every 2y from 25 to 75y
HNPCC / Lynch syndrome:
Auto dominant mutation in DNA repair
genes
→ Cancers of colon, endometrium, ovary,
stomach, bladder, brain, skin
→ Presents >40y (consider if <50y with
colorectal cancer)
→ Colonoscopy every 2y from 25 to 75y
NB: non-polyposis condition (no polyps
present)
Amsterdam criteria to Dx
Bowel cancer screening programme3:
qFIT (quantifiable faecal immunochemical
test)
→ if >120mcg/g refer for colonoscopy to
remove any polyps
Every 2y from the age of 50y
May present as an acute emergency:
• Bowel obstruction
• Bowel perforation
• Extreme pain
• Polyps (UC, HNPCC, FAP) → identify & remove
• Age (90% are aged >50 y)
• Diet – low fibre, high fat, processed meat
• Smoking/alcohol/obesity
• IBD (UC especially)
• Genetics (FAP & HNPCC / Lynch syndrome)
Clinical presentation
7%
14%
Rectum
Right side Left side Rectal
= Late presentation
• Weight loss / fatigue
• IDA
± Abdo pain/mass
→ 20% present with signs of disseminated disease e.g. liver mets = jaundice
Investigations
→ 3rd most common cancer
→ 2nd most common cause of
cancer deaths
4%
3%
37%
• Weight loss / fatigue
• Change in bowel habit
• Obstruction
• Blood-streaked stools
± Abdo pain/mass
→ Peak age: >60y
→ M>F
→ 1 in 30 risk
Polypectomy + follow-up
endoscopy (complications =
bleeding & perforation)
• FHx
3%
Liver = common site of colorectal
cancer metastases
5%
27%
Sigmoid
Fig. 12.4 Sites of colorectal cancer.
• Weight loss / fatigue
• Tenesmus
• Bright PR bleed
• DRE: palpable mass
Red flags for 2ww referral4:
1. ≥40y with unexplained weight loss & abdo
pain
2. ≥50y with unexplained rectal bleeding
3. ≥60y with altered bowel habit or IDA
4. Occult blood present when faeces tested
Also consider if:
• Rectal or abdominal mass
• ≤50y with rectal bleeding and any of:
▶ Abdominal pain
▶ Altered bowel habit
▶ Weight loss
▶ IDA
Surgery
1. DRE
2. Bloods – FBC (for IDA), LFTs, U&Es
3. Tumour marker: CEA (not specific –
use for monitoring)
4. Colonoscopy & biopsy = gold
standard
5. MRI – if rectal cancer
6. CT (chest, abdo, pelvis)– for TNM
staging
Classication & staging
Stage Duke’s stage Features 5y survival
1 A Mucosa only 90–95%
2 B1 Into muscularis 80–85%
B2 Through wall
3 C1 T2 + nodes 60–65%
C2 T3 + nodes
4 D Distant mets <11%
3
Bowel cancer screening programme (www.gov.uk/guidance/bowel-cancer-screening-
programme-overview)
4
NICE (2015, updated 2021) Suspected cancer: recognition and referral [NG12]
5
Cancer survival by stage at diagnosis for England, 2019. ONS.
5
Duke’s criteria or TNM staging
Chapter 12: Gastrointestinal surgery 169
https://t.me/med1917
Management of colorectal cancer
6
→ colectomy + ‘en bloc’ lymph node removal ± chemotherapy
Different levels of resection: = location of tumour
Left hemicolectomy Right hemicolectomy
Anterior resection Abdominoperineal resection
Fig. 12.5
Sigmoid colectomy
Panproctocolectomy
MANAGEMENT OF OBSTRUCTING COLON CANCER: emergency
1. ABCDE
2. Analgesia + NG tube decompression
3. CT scan if no small bowel distension = competent ileocaecal valve = BAD
4. Endoscopic stenting or colectomy (often with stoma) → colectomy type
depends on obstruction location
Lymph drainage:
→ Ascending & transverse drain to superior
mesenteric LNs
→ Descending & sigmoid drain to inferior
mesenteric LNs
→ Rectum (above pectinate line) to internal
iliac LNs
Hartmann’s
= sigmoid colectomy with colostomy
(stoma formation)
Panproctocolectomy
= if synchronous cancer or inflammatory bowel
disease
Stoma formation:
Elective or emergency
Decision depends on:
• location of resection
• indication for operation
• patient comorbidities
• patient lifestyle/preference
Management of rectal cancer
6
1. Total mesorectal excision (removal of rectum)
• Low tumours <5cm above anus: abdominoperineal excision
(resect + stoma)
• Higher tumours >5cm from anus: anterior resection
(resect + anastomosis)
2. ± Chemotherapy ± radiotherapy
Colorectal cancer follow-up
Follow-up for 5y post-surgery
1. CEA – check every 6m
2. CT CAP – annually
3. Colonoscopy – at 1 & 5y
MDT input
including stoma nurse / specialist nurse
6
NICE (2020, updated 2021) Colorectal cancer [NG151]
20–30%
recurrence
Surgery
170 Chapter 12: Gastrointestinal surgery
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Anal cancer
Aetiology
→ RARE (associated with HIV & HPV infection)
→ 80% = SQUAMOUS CELL
Clinical presentation
• Anal pain / pruritus
• Anal bleeding/discharge
• Mass/ulcer
• Incontinence
• Fistula-in-ano
Investigations
Methods of spread:
1. Local invasion of rectum, scrotum, vagina
2. LN drainage → to inguinal lymph nodes
• EUA
• HIV testing
• CT chest, abdo, pelvis – for mets
• MRI – assess local spread
• PET – assess LN involvement
Staging
NB: Different T staging to colorectal cancer (based on size)
T1 <2cm
T2 <4cm
T3 >4cm
T4a Invades vagina
T4b Invades other structures
Management
1. Small tumours at margin – local excision
2. All others: chemoradiotherapy (60–70% success)
Surgery
171
https://t.me/med1917
THE BREAST
Breast conditions ����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������172
13
ABBREVIATIONS
ALND – Axillary lymph node dissection
BRCA – Breast cancer gene
ER – Oestrogen receptor
FNA(C) – Fine needle aspiration
(cytology)
HER2 – Human epidermal growth factor
receptor 2
HRT – Hormone replacement therapy
LN – Lymph node
NACT – Neoadjuvant chemotherapy
NAET – Neoadjuvant endocrine therapy
NATT – Neoadjuvant targeted therapy
SLNB – Sentinel lymph node biopsy
SOB – Shortness of breath
TNM – Tumour, nodes, metastases
172 Chapter 13: The breast
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Breast conditions
NICE GUIDELINES ON REFERRAL
Non-urgent referral:
Patient <30y with unexplained breast symptoms
Urgent 2ww:
1. Patient ≥30y with unexplained breast/
axillary lump
2. Patient ≥50y with any unilateral nipple/
breast changes
3. Anyone with skin changes suspicious of
breast cancer
When to refer nipple discharge:
1. Persistent, spontaneous unilateral discharge
2. Nipple inversion / eczematous skin changes
→ Ix: Examine for lump, if >35y refer for
mammography
→ Mx: duct removal
Benign lumps
Fibroadenoma Fibroadenosis /
Pathogenesis Benign overgrowth of
breast lobule
Who? <30y
May grow in pregnancy
Presentation
Management 1. Reassurance
→ firm, smooth, solid
lump
→ highly mobile =
‘breast mice’
→ usually painless
2. Surgical excision if
large (>4cm)
1/3 regress, 1/3 stay
same, 1/3 grow
fibrocystic change
Localised fibrosis,
inflammation & cyst
formation
Between menarche &
menopause
Most common breast
lump
→ lumpy breasts
→ may be mobile or fixed
→ cyclical pain/swelling
1. Reassurance
± Anti-inflammatories
± Hormone manipulation
Fat necrosis: similar presentation to
fibroadenosis, but usually with history
oftrauma to the area (RF = obesity)
Cysts
Fluid-filled lump that
may associate with
fibroadenosis
Perimenopause
(35–50y)
→ rounded lump
→ mobile
→ occasionally painful
1. Reassurance
2. US-guided
drainage (FNA)
3. Surgical removal if
large
When to refer mastalgia for triple assessment:
1. Pain not responsive to 3m of initial medical
management
2. If any breast cancer red flags present
(NICE guidelines above)
→ Mx: reassurance, NSAIDs/paracetamol,
tamoxifen
Paget’s disease of nipple:
→ rare spread of intraductal carcinoma
→ red, itchy, scaly areola
→ DDx: eczema
→ Ix: biopsy
Risk factors for breast carcinoma:
Genetic (FHx): BRCA +ve = 25% of risk
Environmental: = 75% of risk
• early menarche / late menopause
• nullip / late age of 1st child
• not breastfeeding
• HRT
• obesity, smoking
Oestrogen
exposure
Breast carcinoma
CLASSIFICATION: → can be ductal or lobular
1. Non-invasive / in situ (5%) = not breached basement membrane
2. Invasive (85%) = breached basement membrane
Invasive ductal carcinoma = most common (70%)
CLINICAL PRESENTATION:
• Breast lump: hard & irregular →
fixed/tethered
• Palpable lymph nodes
• Nipple discharge / retraction ± Paget’s
disease rash
• Overlying skin changes – peau d’orange
(dimpling)
• Metastatic symptoms: bone, lung,
brain, liver, ovaries
INVESTIGATIONS: triple assessment
1. Clinical examination
2. Imaging → <35y = USS (tissue too dense for mammography)
→ >35y = mammography (+USS if abnormal)
3. Histology/cytology:
→ FNAC if cystic
→ Core biopsy if solid (can grade tumour)
Prevalence & prognosis
Breast cancer = very common
(1 in 8 women)
15% breast cancers = HER2 +ve
70% breast cancers = ER +ve
Best prognosis → Worst prognosis
ER +ve → HER2 → Triple –ve
If USS of axilla shows lymph
involvement then core biopsy of
nodes
Screening for all women 50–70y (every 3y)
Surgery
Chapter 13: The breast 173
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TNM STAGING AND SURVIVAL
Tumour
size
Nodes N0 no
Metastases M0 no
T1 <2cm T2 2–5cm T3 >5cm T4 extends to
N1 ipsilateral,
nodes
axillary, mobile
nodes
M1 mets
1
N2 ipsilateral fixed
axillary/mammary
nodes
skin / chest wall
N3 clavicular, axillary or
mammary nodes
mets
Stage 1 Stage 2 Stage 3 Stage 4
T1, N0, M0
<2cm, no nodes
T1/2, N0/1, M0
<5cm ± axillary nodes
T3, N1/N2, M0
>5cm + any nodesM1Any mets
98% 5y survival 93% 5y survival 72% 5y survival 22% 5y survival
Management of breast carcinoma
2
1. NEOADJUVANT TREATMENT
• NACT (neoadjuvant chemotherapy) for any receptor status
• NAET (neoadjuvant endocrine therapy) if ER +ve
e.g. tamoxifen, anastrozole
• NATT (neoadjuvant targeted therapy) if HER2 +ve
e.g. Herceptin (trastuzumab)
2. PRIMARY TREATMENT
• Surgery to the breast – mastectomy or wide local excision ±
oncoplastic/reconstruction procedures
• Surgery to the axilla – sentinel lymph node biopsy (SLNB) ± axillary lymph
node dissection (ALND)
• Primary endocrine therapy if elderly / more frail
3. ADJUVANT TREATMENT → reduces recurrence
• Radiotherapy, chemotherapy, endocrine therapy, targeted therapy (see
examples in neoadjuvant treatment)
4. TREATMENT OF METASTATIC DISEASE → depends on location of mets
• If solitary node = consider surgery
• Symptomatic relief = radiotherapy, chemotherapy, endocrine therapy
Management depends on:
1. TNM stage (including size)
2. Location of lump
3. If lump is uni- or multifocal
4. HER2 / ER receptor status
5. Patient health & preference
6. Family history of breast cancer
Indications for neoadjuvant treatment:
• Reduce size of inoperable tumours
• Reduce size to allow breast conservation
• In inflammatory breast cancer
• Temporary contraindications to surgery
• Preparation to allow new drug testing
SLNB = dye injected into areolar area
to identify drainage to sentinel node
→ biopsy to assess spread
Breast cancer recurrence
Recurrence usually occurs in first 5y following treatment
→ Needs reassessment & discussion with MDT to decide most appropriate
management plan
NB: risk of recurrence s with size of tumour & LN involvement
Must closely monitor patients for symptoms of recurrence:
• New lump in breast/axilla
• Constant arm/chest/shoulder pain
• Bone pain, weak/numbness, cough/SOB
1
Cancer survival by stage at diagnosis for England, 2019. ONS.
2
NICE (2018) Early and locally advanced breast cancer [NG101]
• Nausea, anorexia, weight loss
• Headaches/confusion
Inflammatory breast cancer
= rare & aggressive subtype
Sx: sudden, red/swollen breast, peau d’orange
→ no lump
→ early axillary spread
Mx: neoadjuvant chemo, then surgery
DDx: infection
Surgery
174 Chapter 13: The breast
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Risk factors for abscess/mastitis:
• lac tation / milk stasis
• skin infection
• underlying breast condition
Breast abscess & mastitis
DEFINITIONS:
Breast abscess: walled-off collection of localised infection
Mastitis: inflammation of breast ± infection
Duct ectasia: periductal inflammation
Tight bra, difficulties breastfeeding
Risk factors for duct ectasia
• smokers around menopause
GENERAL SYMPTOMS:
• Warm, swollen, tender, erythematous breast/lump
• Milk stasis
• Nipple discharge (particularly in duct ectasia)
• ± Systemic infection / fever
MANAGEMENT:
1. Effective milk removal – if lactating
2. Empiric antibiotics
3. Analgesia (paracetamol ± NSAID)
→ If abscess: aspiration & drainage (US-guided or in theatre)
Surgery
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