Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_615_Библиотеки_им_академика_М_И_Перельмана
.pdf
LARGE BOWEL
https://t.me/med1917
267
Criteria for close surveillance after endoscopic removal of a
malignant polyp include complete excision, a microscopic margin
greater than 2 mm, no lymphatic or vascular invasion, moderate to
well differentiation, Haggitt level 1 to 3, or Sm level 1 to 2.
All other malignant polyps that do not meet the aforementioned
criteria should be considered for surgical resection. However, even
with some high-risk features, patients with serious medical comorbidities may be best managed with close surveillance and nonsurgical
treatment. An alternative to patients at high risk with a malignant
rectal polyp may be full-thickness surgical excision (TAE, TEM, or
TAMIS) with adjuvant chemoradiation.
Management of
Peritoneal Surface
Malignancies
Fabian M. Johnston, MD, and Juliet Siena Lumati, MD
eritoneal surface malignancies represent a heterogenous group
of intraperitoneal malignancies arising from the lining of the
P
abdominal and pelvic cavity. They include primary malignancies of
the peritoneum such as diffuse malignant peritoneal mesothelioma,
peritoneal serous papillary carcinoma, desmoplastic small round
cell tumors, and metastases from other primary tumors typically
involving the colon, stomach, and ovaries. Cytoreductive surgery
(CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)
have evolved over the past decade to provide a therapeutic advantage
to patients who otherwise have limited options beyond systemic
chemoradiation for locoregional control or palliation. The purpose
of this chapter is to review the epidemiology of peritoneal surface
malignancies as well as current treatment guidelines.
EPIDEMIOLOGY AND CLASSIFICATION
Appendiceal Neoplasm
The true incidence of appendiceal neoplasms is unknown but is
thought to be about 0.12 cases per 100,000 people per year in the
United States. They are more commonly diagnosed incidentally on
pathology in about 1% to 2% of appendectomy specimens. These
tumors can be of mucinous or non-mucinous histology and may
contain a signet ring cell component. Signet ring cell carcinomas
are very aggressive, with up to 60% of cases already showing distant
metastasis at the time of diagnosis. Patients with mucinous tumors
may clinically present with pseudomyxoma peritonei (PMP), which
is a condition characterized by mucinous ascites and peritoneal
implants. Because of the rarity of these neoplasms, histologic classification had been challenging until 2010, when the World Health
Organization recognized three categories of primary appendiceal
neoplasms: mucinous adenoma, low-grade appendiceal mucinous
neoplasm (LAMN), and mucinous adenocarcinoma. Subsequently
in 2016, The Peritoneal Surface Oncology Group International
Consensus developed a classification system to describe both the
primary lesion and peritoneal disease. It also classified noncarcinoid epithelial neoplasms of the appendix itself and added a
new term, high-grade appendiceal mucinous neoplasm (HAMN)
for lesions with the low-grade architectural features of low-grade
appendiceal mucinous neoplasm but with high-grade cytologic
features (Box 1).
S u g g e S t e d R e a d i n g
Leggett B, Whitehall V. Role of the serrated pathway in colorectal cancer
pathogenesis. Gastroenterology. 2010;138:2088–2100.
Rai V, Mishra N. Transanal approach to rectal polyps and cancer. Clin Colon
Rectal Surg. 2016;29(1):65–70.
Shaukat A, Kahi CJ, Burke CA, Rabeneck L, Sauer BG, Rex DK. ACG Clinical
Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol.
2021;116(3):458–479.
Wickham CJ, Wang J, Mirza KL, et al. “Unresectable” polyp management
utilizing advanced endoscopic techniques results in high rate of colon
preservation. Surg Endosc. 2022;36(3):2121–2128.
CLINICAL MANIFESTATION
Clinical symptoms on presentation can be quite nonspecific. Common presentations include increasing abdominal girth, weight loss,
fatigue, bloating, constipation, and pain. Not uncommonly the diagnosis is made on presentation with acute appendicitis obstruction
of the appendiceal lumen by malignant cells, which may lead to
inflammation and infection of the appendix. Similarly, mucinous
tumors may present with cystic dilation of the appendix, which could
also mimic symptoms of appendicitis or be found incidentally on
imaging for a different etiology. Men may also present with hernias
and women with a bulky pelvic mass. Anorexia, early satiety, and
massive ascites are also common manifestations, and in some ways,
likely underestimate the true incidence of the disease given the late
clinical presentation of these neoplasms.
PREOPERATIVE WORKUP
Preoperative workup should include staging CT of the chest, abdomen, and pelvis. Routine CBC, basic metabolic panel, and nutritional
markers are often helpful. Other parameters include serum tumor
markers including CEA, CA 19-9, CA125, and chromogranin A as
well as obtaining a preoperative colonoscopy to evaluate for synchronous or metachronous colonic lesions, which at times may be
negative. A diagnostic laparoscopy may be useful in determining eligibility for cytoreductive surgery in addition to obtaining histologic
assessment, which may help guide treatment plans.
PATIENT SELECTION
Patient selection is extremely important in deciding who will most
benefit from CRS and HIPEC and to avoid significant morbidity
and mortality in patients who are not expected to benefit. Surgeons
BOX 1 PSOGI 2016 Classification of Noncarcinoid
Appendiceal Epithelial Neoplasms
• Tubular,tubulovillousorvillousadenoma,low-orhigh-grade
dysplasia
• Serratedpolypwithorwithoutdysplasia(loworhighgrade)
• Low-gradeappendicealmucinousneoplasm
• High-gradeappendicealmucinousneoplasm
• Mucinousadenocarcinoma:well,moderately,orpoorly
differentiated
• Poorlydifferentiated(mucinous)adenocarcinomawithsignet
ring cells
• (Mucinous)signetringcellcarcinoma
• Adenocarcinoma:well,moderately,orpoorlydifferentiated
268 MANAGEMENT OF PERITONEAL SURFACE MALIGNANCIES
https://t.me/med1917
should consider the extent of disease, tumor biology, physiologic
age, comorbidities, and the ECOG/WHO functional and frailty
status when selecting patients. Scoring systems such as the peritoneal disease severity score (PDSC), which was devised to stage
patients with colon cancer based on clinical symptoms, extent of
carcinomatosis based on radiographic evidence, and tumor histopathology may be useful to facilitate appropriate patient selection.
For patients with LAMN (grade 1) CRS + HIPEC is the treatment
of choice if complete cytoreduction can be achieved. Patients with
adenocarcinoma and peritoneal metastasis are less likely to have
complete cytoreduction and overall have poorer survival than those
with LAMN. It is important to note that not all LAMNs or well-differentiated mucinous adenocarcinomas require a right hemicolectomy unless there is clear involvement of the colon serosa, which
would necessitate colectomy. Furthermore, The American College
of Surgeons’ NSQIP surgical risk calculator may also be used to
estimate perioperative risk, especially in patients with significant
cardiopulmonary comorbidities not captured by the PDSC. It is
important to note that no risk calculator is absolute; therefore, it is
the combination of risk factors and expected net benefit that guides
preoperative discussions with patients to set appropriate expectations. Furthermore, all patients should be presented at multidisciplinary team with considerations given to probability of extensive
organ resection, morbidity, quality of life, and recurrence risk. The
Chicago Consensus Guidelines on the management of appendiceal
neoplasms are highlighted in Figures 1 and 2.
COLORECTAL CANCERS
The care of patients with advanced colorectal cancer has evolved over the
past several decades, with overall improvement in the median survival
for patients with stage IV disease. This has been largely attributed to
improvements in the use of multimodal targeted therapy (i.e., neoadjuvant
chemotherapy [NACT] and chemoradiation for rectal tumors), surgical
technique, adjuvant chemotherapy for colon cancer, and improved patient
selection. This is in addition to improving evidence that metastasectomy
of liver and lung metastases improves 5-year survivorship.
In 2003, Verwall et al. randomized 105 patients with metastatic
colon cancer with peritoneal carcinomatosis to receive CRS + HIPEC
or systemic therapy alone that consisted of monotherapy 5FU/leucovorin. Results from this clinical trial showed an improvement in
median survival in the HIPEC arm at 22.3 months compared with
12 months in the standard group at the median follow-up of 22
months. However, a subsequent follow-up study published in 2008
found no difference at the 8-year follow-up. Similarly, the COLOPEC
trial, which was a multicenter randomized controlled trial (RCT) of
204 patients compared adjuvant HIPEC + systemic chemotherapy to
systemic chemotherapy alone. The authors found no difference in
metastasis-free survival at 18 months and a slight increase in postoperative complications in the HIPEC + chemotherapy group. Given
that HIPEC is typically performed concurrently with CRS, the first
study to evaluate HIPEC + CRS versus CRS alone was the PRODIGE
trial with results recently published as of February 2021. This was an
RCT comparing HIPEC + CRS versus CRS alone and recruited 265
patients across 7 centers. The authors found no significant difference
in the median survival in the HIPEC + CRS group versus the CRS
group (41 months vs. 40 months, respectively) at a median follow-up
of 63 months. In a subgroup analysis, patients with a moderate burden of peritoneal disease (peritoneal cancer index [PCI] 11–15) who
received HIPEC had a significant improvement in overall survival
at 41 months compared with 32 months in CRS, though outpatient
complication rates were higher in the HIPEC + CRS group versus
Low-Grade Appendiceal Mucinous Neoplasm
(LAMN)
*A positive appendiceal margin should be addressed with conservative
of the appendiceal cuff or partial cecectomy, avoiding if possible an anastomosis.
Routine right hemicolectomy is discouraged.
†A small percentage of tumors with low-grade histopathology will present
with high-grade peritoneal disease. These should be treated as high-grade
primary tumor.
No Evidence of
Peritoneal
Spread
Peritoneal
Negative
Margin
Positive
Margin
Cecectomy or
IIeocecectomy*
Surveillance if
Perforation
Observation,
Consider
Diagnostic
Laparoscopy
IPCT
Observation,
Consider
Diagnostic
Laparoscopy
CRS + IPCT
Progressive
or Recurrent
Disease
Interval < 1 y
Interval > 1 y
Noninvasive
Pathology
Invasive
Pathology
Consider
Pathology
Review
Observation
Consider
Clinical Trial
Consider CRS
+/– IPCT
Appendiceal
Adenocarcinoma
Guidelines
Repeat CRS
+/– IPCT
FIG. 1 The 2018 Chicago Consensus Guidelines on the Management of Low-Grade Appendiceal Mucinous Neoplasm (LAMN). (From Chicago Consensus
Working Group.The Chicago consensus on peritoneal surface malignancies: standards. Cancer.2020;126:2516–2524.)
R: Right
Appendiceal Adenocarcinoma
https://t.me/med1917
Incidental
Finding
After
Appendectomy
Biopsy
(if Possible)
Found on
Imaging or
Colonoscopy
Appendiceal
Adenocarcinoma
H&P
CT C/A/P or MRI
A/P and CT
Chest,
CEA, CA19-9,
CA125, CRP,
Consider
Colonoscopy
Tumor Board
Consultation
Concerning
Radiologic
Features/
Laparoscopic
Evidence for
Peritoneal
Disease
Extraperitoneal
Disease
Consider
Clinical Trial or
Systemic
Therapy
Complete
Cytoreduction
Predicted
Incomplete
Cytoreduction
Predicted
Reassess for
Response
LARGE BOWEL
CRS + IPCT (Well-Differentiated Preferred)
Selective R Hemicolectomy*
CRS + IPCT
R Hemicolectomy
3 mo
Systemic Therapy
6 mo
Systemic
Therapy 3-6 mo
Node Positive
Systemic Therapy
6 mo
CRS + IPCT
R Hemicolectomy
CRS + IPCT
R Hemicolectomy
Progression
Response/
Complete CRS
Predicted
Systemic Therapy 3 mo
Second-Line Chemotherapy/
Clinical Trial/
Best Supportive Care
CRS + IPCT
R Hemicolectomy
Consider
Systemic
Chemotherapy
269
Systemic
Therapy 3 mo if
Received 3 mo
Prior to CRS
*If well-differentiated mucinous adenocarcinoma pathology
is confirmed by expert pathologist, then observation may be
considered (no R hemicolectomy). High-grade appendiceal
mucinous neoplasms and well-differentiated mucinous
adenocarcinoma may be treated similar to low-grade lesions.
CA19-9: Carbohydrate Antigen 19-9
CA125: Cancer Antigen 125CEA: Carcinoembryonic Antigen
CRP: C-reactive Protein
CRS: Cytoreductive Surgery
CT C/A/P: Computed Tomography of Chest/Abdomen/Pelvis
H&P: History and Physical
IPCT: Intraperitoneal Chemotherapy
MRI A/P: Magnetic Resonance Imaging of Abdomen/Pelvis
No Metastatic
Disease
peritoneal disease (cytology/gross),
consult “Peritoneal Disease” pathway
Right
Hemicolectomy*
If any intraoperative concern of
above
Node Negative Observe
FIG. 2 The 2018 Chicago Consensus Guidelines on the Management of Appendiceal Adenocarcinomas. (From Chicago Consensus Working Group.The Chicago
consensus on peritoneal surface malignancies: standards. Cancer.2020;126:2516–2524.)
the CRS group (24% vs. 13%, respectively). The results of these
studies on prospective clinical trials highlight the need for a multidisciplinary approach to selecting patients who will maximally
benefit from CRS versus HIPEC+ CRS. It also highlights the benefit
of cytoreduction in combination with NACT.
should include a thorough history and physical examination along
with axial imaging including CT of the chest, abdomen, and pelvis.
PET/CT may be useful in patients with non-mucinous tumors. Laboratory workup includes CEA, CA-19, and CA-125 levels and nutritional markers. A complete colonoscopy is also recommended if not
already completed. Diagnostic laparoscopy may be helpful for staging
Epidemiology
Peritoneal disease is present in about 8% of CRC patients at the time
of primary resection, and up to 25% of patients with recurrent CRS
will develop metastatic disease confined to the peritoneal surface.
Risk factors for peritoneal metastases include mucinous histology,
T4 cancers, vascular invasion, spontaneous or iatrogenic perforation,
and right-sided tumors, which overall confer a worse prognosis. The
presence of untreated visceral solid organ metastasis is a relative
contraindication to HIPEC and CRS.
and assessment of surgical eligibility given the poor sensitivity of axial
imaging for detecting peritoneal metastasis. In addition, small tumors
in specific locations such as the root of the mesentery and serosal surface of the small bowel are harder to detect on CT scan. PET/CT has a
sensitivity of 78% to 100% and is not uncommonly ordered before surgery. It is however associated with false-negative results for tumors that
are not PET/CT avid (mucinous tumors) or false-positive results for
inflammatory processes. There have been limited studies evaluating
the role of diffusion weight MRI in detecting subcentimeter deposits
in difficult anatomic locations, though it is not widely adopted given
the contraindications, costs, and availability.
Clinical Manifestations
Peritoneal metastases secondary to CRC may present with ascites
manifesting as increasing intraabdominal girth, pain, or small bowel
obstruction. However, just as often, synchronous peritoneal disease
may be asymptomatic and detected at the time of primary surgery
or on staging imaging. For patients with metachronous disease, it is
most common to identify peritoneal metastases during surveillance
given the intensity of imaging use in current practice.
Preoperative Workup
Patient selection is very important in determining the appropriateness of cytoreductive surgery and HIPEC. Preoperative evaluation
Patient Selection for Surgery
Patient selection is critical in determining who would most benefit
from CRS + HIPEC. Generally, good candidates for CRS + HIPEC
are patients with good performance status who have an ECOG/WHO
status of 1 or less, have adequate physiologic and organ function,
have a low/moderate PCI, and can receive systemic chemotherapy.
In fact, response to initial chemotherapy is often used as prognostic
marker to screen patients with rapidly evolving tumor biology. PCI
scores range from 0 to 39, with a score less than 12 considered most
favorable for resection. A PCI greater than 20 is typically considered
a contraindication to resection. Patients with a PCI between 12
and 20 may be determined on a case-by-case basis depending on
270 MANAGEMENT OF PERITONEAL SURFACE MALIGNANCIES
PET: Positron Emission Tomography
https://t.me/med1917
Colorectal Cancer with Synchronous Peritoneal Metastasis
Newly Diagnosed
Colorectal
Adenocarcinoma with
Peritoneal Metastasis
Synchronous
H&P
CT C/A/P +/–MRI +/– PET
Complete Colonoscopy
with Biopsies
Pathology Review
Determine MSI, KRAS,
and BRAF Status
Pelvic MRI for Rectal
Cancer
CEA
Tumor Board
Consultation
CEA: Carcinoembryonic Antigen
CT C/A/P: Computed Tomography of Chest/Abdomen/Pelvis
CRS: Cytoreductive Surgery
H&P: History and Physical
IPCT: Intraperitoneal Chemotherapy
MRI A/P: Magnetic Resonance Imaging of Abdomen/Pelvis
MSI: Microsatellite Instability
PCI: Peritoneal Carcinomatosis Index
Peritoneal
Metastases
Only*
Widespread and/or
Unresectable Solid-
Organ Metastases
Patients with Resectable Liver and/or
Lung Metastases in the Context of
Associated
CRS +/– IPCT for
Selected Patients with
Low PCI
Chemotherapy for
3–6 mo
+/– Chemoradiotherapy
for Rectal Cancer
*Refer to Principles of Surgery for
Peritoneal Metastasis
Consider Palliative Surgery for
Symptomatic Patients
Restaging
Imaging
Systemic Chemotherapy
Best Supportive Care or
Clinical Trial
No
Progression
Progression
Consider
Diagnostic
Laparoscopy
Assess PCI,
Obtain
Biopsies as
Needed
Complete
Cytoreduction
Predicted
Incomplete
Cytoreduction
Predicted
Complete
Cytoreduction
Predicted
Incomplete
Cytoreduction
Predicted
CRS +/– IPCT
Finish First-Line or
Second-Line
Chemotherapy
Best Supportive Care
or Clinical Trial
Consider CRS +/– IPCT
Second-Line
Chemotherapy
(Preferred) or Best
Supportive Care or
Clinical Trial
Consider
Immunotherapy for
Patients with MSI-
High Tumors
Chemotherapy
(Total 6 mo),
Then Follow-Up
Reassess for
Potential CRS
Chemotherapy
(Total 6 mo),
Then Follow-Up
Reassess for
Potential CRS
FIG. 3 The 2018 Chicago Consensus Guidelines on the Management of Colorectal Cancers with Synchronous Peritoneal Metastasis. (From Chicago
Consensus Working Group.The Chicago consensus on peritoneal surface malignancies: standards. Cancer.2020;126:2516–2524.)
additional clinical parameters, such as extent of extraperitoneal
metastasis and tumor biology. A more conservative PCI cutoff of 17
has been proposed based on results of a prospective study by Goere
young age, and female gender. Prognosis of untreated gastric cancer
with peritoneal carcinomatous is quite poor, with a median 5-year
survival that approaches 0%.
et al., which showed no benefit of HIPEC + CRS in patients with
a PCI greater than 17. It is important to note that a preoperative
radiologic PCI score may not always correlate with an intraoperative PCI score, hence staging laparoscopy can be used as an adjunct
to assess borderline cases. The presence of malignant ascites, large
tumor burden, or multifocal bowel obstructions are relative contraindications to curative intent surgery in addition to the presence
of liver or lung metastasis that are untreated. Visceral metastases
should be considered for therapy on an individualized basis. Lastly,
the treatment options and timing for patients with synchronous or
metachronous lesions similar to appendiceal neoplasms should be
discussed among a multidisciplinary team. Figure 3 summarizes
the Chicago Consensus Guidelines on CRS and HIPEC in colorectal cancers.
Preoperative Workup
Preoperative workup includes history and physical examination,
upper endoscopic ultrasound, and endoscopic ultrasound with
biopsy for local regional staging. Imaging includes CT of the
chest, abdomen, and pelvis with contrast and PET/CT if there is
no evidence of M1 disease. HER2/NEU testing should be obtained
if metastatic disease is suspected. Molecular profiling to assess
for microsatellite stability and PDL1 positivity maybe helpful for
patients with unresectable disease. Genetic counseling is recom-
mended in young patients to evaluate for CDH1 mutations given
their high penetrance. Nutritional markers should be considered
in addition to smoking cessation and counseling. Patients typically
receive the most commonly used perioperative chemotherapy,
GASTRIC CANCER
Epidemiology and Clinical Manifestation
Gastric cancer is a leading cause of cancer-related deaths, with a
mortality rate of 8.9% after lung cancer (19.7%) and breast cancer
(12.9%), respectively. Overall 5-year survival approaches 90% in
which includes FOLFOX, XELOX, FLOT, ECF, +/– radiation for 3
to 6 months followed by restaging and diagnostic laparoscopy with
peritoneal washings. Patients with advanced tumors, clinical T3
or greater, or node-positive disease should undergo laparoscopic
staging with peritoneal washings to evaluate for extent of peritoneal
disease.
countries like Japan and varies between 10% and 30% in Western
countries. Peritoneal carcinomatosis occurs synchronously with
primary tumors in 14%% to 43% of patients with gastric cancer and
accounts for 35% of synchronous metastasis. Risk factors for peritoneal metastasis include extranodal involvement, diffuse infiltrated
type, signet cell histology, higher CEA levels, liver involvement,
Patient Selection for Surgery
All patients with biopsy-proven gastric cancer should be presented
to a multidisciplinary tumor board to discuss a tailored treatment
plan, which is largely dependent on the patient’s functional status and
LARGE BOWEL
https://t.me/med1917
271
tumor biology. Generally, patients with low peritoneal disease burden
and lack of progression of disease after systemic therapy should be
restaged and considered for HIPEC + CRS. Various options include
early postoperative chemotherapy (EPIC) or bidirectional intraperitoneal and systemic induction chemotherapy before CRS + HIPEC.
Ideal candidates should be young (<70 years of age) and have a good
performance status, a PCI score <10, small nodules, a resectable primary tumor, no evidence of paraaortic lymphadenopathy, no liver or
extraperitoneal metastasis, and have responded well to NACT.
Hoptopp et al. found an overall increase in survival in patients
with gastric cancer and confirmed peritoneal metastasis who
underwent NACT with FLOT followed by CRS + HIPEC versus
chemotherapy alone (17 months vs. 6 months) in a single-center
study. A more recent advancement is the use of neoadjuvant intraperitoneal and systemic chemotherapy protocol/bidirectional intraperitoneal and systemic induction chemotherapy (NIPS/BISIC),
which aims to reduce the stage and increase the incidence of complete cytoreduction. By simultaneously administering intravenous
and intraperitoneal chemotherapy, the cancer cells are targeted
both from the peritoneal cavity and subperitoneal blood vessels.
Several studies have examined the effectiveness of this therapy in
complete cytoreduction and improving survivorship. Yonemura et
al published a prospective study of 194 patients who had BIPSC
followed by CRS + HIPEC. Patients had (1) biopsy-proven peritoneal carcinomatosis, (2) no evidence of liver or lung metastasis, and
(3) good performance scores. In this study, 152 patients responded
to BIPSC and subsequently underwent CRS + HIPEC. Complete
cytoreduction was achieved in about 70% of these patients. Median
survival was 15.8 months in patients who had CRS + HIPEC after
BIPSC versus patients who did not (7 months). Completeness of
cytoreduction, pathologic response to NIPS, and PCI on multivariate analysis overall predicted survivorship. It is important to note
that the complication rate was 24%, which is similar to that found
in a study by Hultman et al., which also showed an improvement
in median survivorship (19 months vs. 14 months) but reported a
higher complication rate of 63%. This is most commonly caused
by anastomotic leak, sepsis, wound infections, and organ failure.
These studies show that appropriate patient selection and identification of patients with unresectable or disseminated disease who
are eligible for complete cytoreduction is paramount.
PERITONEAL MESOTHELIOMA
Epidemiology and Clinical Manifestation
Mesothelioma is a rare malignancy of serosal membranes. This
includes the pleura, peritoneum, pericardium, and the tunica vaginalis testes.The peritoneum is the second most common location
and is estimated to represent about 10% to 15% of all mesotheliomas. The highest incidence is reported in countries such as
New Zealand, the United Kingdom, and Australia, and the lowest
incidence is reported in countries such as Japan, Slovenia, and
Central Europe. The estimated incidence is 1.94 per 100,0000 and
0.41 per 100,000 for men and women, respectively, in the United
States. Mesothelioma is commonly associated with exposure to
asbestos, but 33% to 50% of patients diagnosed with malignant
pleural mesothelioma (MPM) have no prior asbestos exposures.
Other risk factors include exposure to radiation minerals such as
thorium, chronic peritonitis, and germline BRCA-1–associated
protein (BAP-1) gene mutation. Histologic classifications include
epithelioid, sarcomatous, and biphasic/mixed. About 75% of all
mesotheliomas are epithelioid in origin, which overall have the
most favorable prognosis.
Perioperative Workup
Making the diagnosis is often challenging as patients present with
mostly vague abdominal symptoms. On imaging, patients may
have ascites, evidence of omental caking, or mesenteric fatty infiltration. Definitive diagnosis is based on histology and pathologic
assessment, which could be obtained on percutaneous biopsy or
diagnostic laparoscopy. Diagnostic laparoscopy is indicated to
evaluate the extent of disease amenable to surgery. Pathologic
assessment is essential to differentiating subtypes of mesothelioma that may be more amenable to surgery versus chemotherapy alone. Epithelioid histology has overall the most favorable
response to HIPEC + CRS in contrast with sarcomatoid, biphasic
subtypes, which overall have a poorer prognosis and for which
surgery is less likely to offer a survival benefit. Furthermore, the
CA-125 and Ki-67 index are often obtained in addition to germline testing for a BAP-1 gene mutation.
Patient Selection for Surgery
The natural history of MPM is aggressive; without treatment,
median survival is approximately 6 months. Median survival with
systemic chemotherapy alone is approximately 16 months; however, it improves to approximately 40 months with HIPEC + CRS.
Patients with MPM are considered for surgical therapy with CRS/
HIPEC if their disease burden is amenable to resection of all or
nearly all (CC-0 or CC-1) visible disease and are suitably fit for
such extensive resection.
OVARIAN CANCER
Epidemiology and Clinical Manifestation
Ovarian cancer is associated with one of the highest mortalities
from gynecologic cancers in the world, with an estimated 5-year
survival rate of 39%. Despite efforts to screen for ovarian cancer,
35% to 43% of patients still present with advanced disease involving
the peritoneum at the time of diagnosis. Risk factors for peritoneal
disease include germline mutations, incomplete resection at initial
cytoreductive surgery, shorter treatment-free survival, higher FIGO
(International Federation of Gynecology and Obstetrics) stage, and
the present of malignant ascites. The most common type of ovarian
cancer is epithelial in origin; less common types include clear cell,
mucinous, carcinosarcoma, endometroid carcinoma, and malignant
germ cell tumors. Symptoms include early satiety, bloating, nonspecific abdominal pain, and urinary symptoms. Others may present
with massive ascites, which is typically associated with mucinous
neoplasms.
Preoperative Workup
The diagnosis is made based on clinical suspicion, imaging, and
tumor markers, with elevation of CA-125, inhibin, B-HCG, LDH,
and CEA levels being pathognomonic. Nutritional parameters, CBC,
and liver function tests and chemistries are routinely ordered. A
complete colonoscopy is recommended to evaluate for synchronous
gastrointestinal malignancies that can present similarly. Genetic
counseling is recommended for all patients given the incidence of
BRCA mutation, which may help guide adjuvant systemic therapy.
Surgery is the mainstay therapy and typically includes extensive
debulking and cytoreduction with a total abdominal hysterectomy
and bilateral salpingo-oophorectomy (TAH + BSO) but can include
appendectomy, colon or small bowel resection, cholecystectomy, and
omentectomy. Diagnostic laparoscopy is essential to quantify tumor
burden and identify patients whose disease is amenable to adequate
cytoreduction. The presence of omental caking, peritoneal and diaphragmatic extensive carcinomatosis, mesenteric retraction, bowel
and stomach infiltration, and spleen and/or liver superficial metastasis are typically assessed on laparoscopy. Importantly, these operations are typically conducted using a multidisciplinary approach
involving gynecology oncology and surgical oncology to improve the
chances of complete cytoreduction.
272 MANAGEMENT OF PERITONEAL SURFACE MALIGNANCIES
https://t.me/med1917
Patient Selection for Surgery
HIPEC is typically considered in patients with stage III disease of
epithelial origin as the other cell types are less chemosensitive. Furthermore, NACT with interval CRS is considered in patients with
advanced-stage ovarian cancer who are not good candidates for
upfront primary debulking surgery (PDS) because of advanced age,
frailty, poor performance status, or for those in whom the disease
is unlikely to be optimally cytoreduced. This has the potential to
facilitate medical optimization and to downstage the disease. The
addition of HIPEC to CRS has been evaluated in several studies
in the recurrent setting. In a 2015 RCT, Spilotis found a 13-month
improvement in survival with HIPEC + CRS versus CRS alone. In
a retrospective cohort study of 584 patients with stage III epithelial
ovarian cancer, Lei et al. found an overall 15-month improvement
in survival in patients undergoing CRS + HIPEC versus CRS alone,
and patients with complete CRS had the most favorable survival
outcomes. In an RCT of 245 patients randomized to HIPEC + CRS
versus CRS alone, Van Driel et al. found an increase in overall
median survival in the HIPEC + CRS group at 45.7 months versus
33.9 months in the CRS group alone. The CHIPPI-1808 trial comparing HIPEC + NACT + CRS versus NACT + CRS should have
results by 2026 and perhaps may help improve patient selection and
justify the use of upfront HIPEC in the primary setting versus the
current standard of care, which is typically in the recurrent setting
with interval CRS.
Intraoperative Management and Technique
The Chicago Consensus Working group publishes a consensus
on peritoneal surface malignancies that includes guidelines for
standard operations and metrics. Generally speaking, a fellowship
experience with CRS + HIPEC, documentation of number of
cases, and availability of two surgeons are necessary in addition
to established criteria for institutional credentials. Process standards include confirmed tissue diagnosis, relevant tumor markers
depending on the cancer type, cross-sectional imaging, and ideally
registry of all patients in a data repository. Quality standards also
exist for reporting of pathology, intraoperative monitoring, perfusion equipment used, and rating of the completeness of intraoperative cytoreduction. A complete list of standards, quality, and
process measures is available online.
Preoperatively patients undergo mechanical bowel preparation
with oral antibiotics before surgery. Patients are positioned supine
for lithotomy if any concern of needing lower pelvic work; DVT
prophylaxis with SCDs and subcutaneous heparin in addition to
perioperative IV antibiotics are administered. It is important to
maintain good communication with anesthesia and the intraoperative room staff to ensure that the patient’s core body temperature is
maintained and that the patient is adequately being resuscitated to
maintain good urine output given insensible losses that can occur
during the operation. Adequate monitoring of cardiovascular and
fluid resuscitation is crucial in the intraoperative and postoperative
period. If not closely monitored and managed, patients are at risk
for abdominal hypertension, coagulopathy, decreased systemic
vascular resistance, and high-output cardiac failure in addition
to toxicities directly related to the chemotherapy agent being
used. Therefore, early determination of the need for recovery in
the intensive care unit (ICU) should be determined intraoperatively. Increasingly, intraoperative goal-directed fluid therapy and
enhanced recovery pathways have been implemented in various
institutions with the goal to improve postoperative outcomes. For
example, tools such as stroke volume variation are used to guide
fluid management and maintain urine output. This strategy overall
leads to less overall fluid administration and is associated with less
postoperative morbidity.
The procedure begins with an exploratory laparotomy with
complete evaluation of the extent of peritoneal metastasizes and
probability of complete cytoreduction through a midline incision.
Diagnostic laparoscopy may be undertaken before laparotomy if
there is concern that the extent of disease may preclude cytoreduction. Lysis of adhesions may be required if the patient already had
prior surgeries or malignant adhesions that may preclude safe entry.
A pre-cytoreduction PCI is assessed followed by complete cytoreductive surgery with the intent of removing all tumors greater than 0.25
cm. (CC-0 or CC-1). We generally inspect systematically the bilateral
diaphragm surfaces, lesser sac, small bowel and its mesentery, porta
hepatis, aortocaval groove (IVC bursa) near the caudate and pelvis,
and all solid organs. Once all sites have been inspected, we recommend running the small bowel in its entirety from the ligament of
Treitz to the ileocecal valve as well as inspecting the right and left
colon and its mesentery to the level of the sacral promontory. All
prior anastomoses should also be inspected in addition to incising
the nodal tissue at the ligament of Treitz, falciform ligament, and
triangular ligament for liver mobilization. Small lesions can be
removed sharply, but larger lesions that are infiltrative or cannot be
separated easily require formal resection. Generally, extensive small
bowel disease or nodal disease involving the root of the mesentery
are contraindications to complete cytoreduction. Complete cytoreduction typically requires an omentectomy, selective peritonectomy,
and visceral resection.
For HIPEC, most units prefer a closed technique, which overall
reduces exposure of the operative room team and decreases heat
dissipation. Other institutions utilize an open technique for delivery.
Mitomycin C, oxaliplatin, or doxorubicin is typically used. Selection
of the type of chemotherapy agent is typically based on tumor histology and institutional protocol. Several studies have shown no difference in progression-free survival comparing HIPEC with mitomycin
C versus oxaliplatin, the two most used chemotherapy agents. These
studies also suggest differences in side-effect profiles, suggesting that
more studies are needed.
The inflow and outflow cannulas as well as a temperature probe
are placed into the abdomen, and the incision is temporary closed.
Using a hyperthermia perfusion pump, 3 to 6 L of warm fluid is
instilled until abdominal distension based on intraoperative determination of peritoneal volume. The fluid is heated to about 40° to
43°C. Once the target temperature is achieved, the chemotherapy
agent is infused over 30 to 120 minutes. Once this is complete, the
abdomen is opened and reinspected. There is no known difference
in outcomes based on anastomosis pre- or post-HIPEC. The fascia
is closed, and a completeness cytoreduction score is assigned at the
end of the case. In early postoperative intraperitonealchemotherapy
(EPIC), the abdomen is filled with 1 L of lactated Ringer solution,
then mitomycin +/– cisplatin is given continuously or on postoperative day 1 and 2 at varying doses. In NIPs + HIPEC + CRS, patients
are given intravenous chemotherapy preoperatively and administered docetaxel and/or cisplatin intraperitoneally on day 1 and day
8. This is repeated three times, and laparotomy with cytoreduction is
performed 2 weeks after the last administration of intravenous chemotherapy. These alternatives have shown some promising results in
select populations.
Postoperative Management
Depending on institutional support (e.g., nursing levels, telemetry) patients are admitted to the floor, step-down unit, or ICU.
Patients with larger cytoreductions or significant comorbidities
benefit from ICU management. Patients are generally at risk of
postoperative ileus. Commonly, a nasogastric tube is placed at the
time of surgery. Early ambulation and incentive spirometry are
strongly encouraged. If extensive diaphragm stripping or resection
is performed, some patients with respiratory comorbidities may
benefit from chest tubes. Patients are typically managed with fluid
restriction after the initial resuscitative phase, which typically is in
the first 72 hours. Early discontinuation of intravenous fluids when
LARGE BOWEL
https://t.me/med1917
273
tolerating a regular diet and/or adequately resuscitated is encouraged. Though ERAS protocols for HIPEC + CRS have not been
widely adopted, they do show some promising results in reducing
length of stay for patients undergoing HIPEC + CRS, though no
RCT has been conducted to date. In general, patients remain in
the hospital until they have adequate return of bowel function and
pain control. Initially some patients may have electrolyte and metabolic derangement caused by fluid shifts and should be monitored
closely. Risk factors associated with increased risk of complications
include number of anastomosis performed, diaphragm resection,
number of blood transfusions required, and thermal bowel injuries.
Overall postcomplication rates are described between 10% and
40%, depending on the series. Average length of stay is approximately 7 to 10 days. Advanced age, malnutrition, and multiple
visceral resections are associated with an increased length of stay,
hence early intervention to identify patients at most risk is crucial
to obtaining quality long-term outcomes for HIPEC and CRS.
S u g g e S t e d R e a d i n g S
Benzaquen E, Wang Y, Wiseman S, et al. Morbidity associated with the
use of oxaliplatin versus mitomycin C in hyperthermic intraperitoneal
chemotherapy (HIPEC) for peritoneal carcinomatosis of colorectal or
appendiceal origin: a multi-institutional comparative study. Can J Surg.
2021;64(2):E111–E118.
Boffetta P. Epidemiology of peritoneal mesothelioma: a review. Ann Oncol.
2007;18(6):985–990.
Canbay E, Mizumoto A, Ichinose M, et al. Outcome data of patients with
peritoneal carcinomatosis from gastric origin treated by a strategy of bidirectional chemotherapy prior to cytoreductive surgery and hyperthermic
intraperitoneal chemotherapy in a single specialized center in Japan. Ann
Surg Oncol. 2014;21(4):1147–1152.
Carr N, Sobin L. Tumors of the appendix. In: Bosman FT, Carneiro F, Hruban
RH, Theise ND, eds. WHO Classification of tumours of the digestive sys-
tem. World Health Organization classification of tumours 4th edition, vol
3. Lyon, France: IARC Press; 2010:122–125.
Carr NJ, Cecil TD, Mohamed F, Sobin LH, etal. Peritoneal Surface Oncology
Group International. A Consensus for Classification and Pathologic
Reporting of Pseudomyxoma Peritonei and Associated Appendiceal
Neoplasia: The Results of the Peritoneal Surface Oncology Group
International (PSOGI) Modified Delphi Process. Am J Surg Pathol.
2016;40(1):14–26.
Chicago Consensus Working Group. The Chicago consensus on peritoneal
surface malignancies: standards. Cancer. 2020;126(11):2516–2524.
Choti MA, Sitzmann JV, Tiburi MF, et al. Trends in long-term survival
following liver resection for hepatic colorectal metastases. Ann Surg.
2002;235:759–766.
Connor SJ, Hanna GB, Frizelle FA, etal. Appendiceal tumors. Dis Colon
Rectum. 1998;41(1):75–80.
de Bree E, Koops W, Kröger R, etal. Peritoneal carcinomatosis from colorectal
or appendiceal origin: Correlation of preoperative CT with intraoperative findings and evaluation of interobserver agreement. J Surg Oncol.
2004;86(2):64–73.
Dirisamer A, Schima W, Heinisch M, etal. Detection of histologically proven
peritoneal carcinomatosis with fused 18F-FDG-PET/MDCT. Eur J Radiol.
2009;69(3):536–541.
Eisenkop SM, Spirtos NM. Procedures required to accomplish complete
cytoreduction of ovarian cancer: is there a correlation with biological
aggressiveness and survival?. Gynecol Oncol. 2001;82(3):435–441.
Enblad M, Graf W, Birgisson H. Risk factors for appendiceal and colorectal
peritoneal metastases. Eur J Surg Oncol. 2018;44(7):997–1005.
Goere D, Souadka A, Faron M, et al. Extent of colorectal peritoneal
carcinomatosis: attempt to define a threshold above which HIPEC
does not offer survival benefit: a comparative study. Ann Surg Oncol.
2015;22(9):2958–2964.
Harter P, Hahmann M, Lueck HJ, etal. Surgery for recurrent ovarian cancer:
role of peritoneal carcinomatosis: exploratory analysis of the DESKTOP
I Trial about risk factors, surgical implications, and prognostic value of
peritoneal carcinomatosis. Ann Surg Oncol. 2009;16(5):1324–1330.
Hotopp T. HIPEC and CRS in peritoneal metastatic gastric cancer—who
really benefits?. Surg Oncol. 2019;28:159–166.
Hultman B, Lind P, Glimelius B, etal. Phase II study of patients with peritone-
al carcinomatosis from gastric cancer treated with preoperative systemic
chemotherapy followed by peritonectomy and intraperitoneal chemotherapy. Acta Oncol. 2014;52(4):824–830.
Kim J, Bhagwandin S, Labow DM. Malignant peritoneal mesothelioma: a
review. Ann Trad Med. 2017;5(11):236.
Klaver CE, Wisselink DD, Punt CJ, etal. Adjuvant HIPEC in patients with
colon cancer at high risk of peritoneal metastases: Primary outcome
of the COLOPEC multicenter randomized trial. J Clin Oncol. 2019;
37(4_suppl):482.
Krishnamurthy S, Balasubramaniam R, etal. Role of Imaging in Peritoneal
Surface Malignancies. Indian J Surg Oncol. 2016;7(4):441–452.
Lei Z, Wang Y, Wang J, et al. Evaluation of Cytoreductive Surgery With
or Without Hyperthermic Intraperitoneal Chemotherapy for Stage III
Epithelial Ovarian Cancer. JAMA Network Open. 2018;3(8):e2013940.
Levine EA, Votanopoulos KI, Shen P, etal. A multicenter randomized trial
to evaluate hematologic toxicities after hyperthermic intraperitoneal
chemotherapy with oxaliplatin or mitomycin in patients with appendiceal
tumors. J Am Coll Surg. 2018;226(4):434–443.
McCusker ME, Cote TR, Clegg LX, etal. Primary malignant neoplasms of the
appendix. Cancer. 2002;94(12):3307–3312.
Pfannschmidt J, Hoffmann H, Dienemann H. Reported outcome factors
for pulmonary resection in metastatic colorectal cancer. J Thorac Oncol.
2010;5(6 Suppl 2):S172–S178.
Prada-Villaverde A, Esquivel J, Lowy AM, et al. The American Society of
Peritoneal Surface Malignancies evaluation of HIPEC with Mitomycin C
versus Oxaliplatin in 539 patients with colon cancer undergoing a complete cytoreductive surgery. J Surg Oncol. 2014;110(7):779–785.
Quere P, Facy O, Manfredi S, etal. Epidemiology, management, and survival
of peritoneal carcinomatosis from colorectal cancer. Dis Colon Rectum.
2015;58(8):743–752.
Riihimäki M, Hemminki A, Sundquist J, etal. Patterns of metastasis in colon
and rectal cancer. Scientific Rep. 2016;6:29765.
Ruoff C, Hanna L, Zhi W, etal. Cancers of the appendix: review of the litera-
tures. ISRN Oncol. 2011;2011:728579.
Spiliotis J, Halkia E, Lianos E, et al. Cytoreductive surgery and HIPEC in
recurrent epithelial ovarian cancer: a prospective randomized phase III
study. Ann Surg Oncol. 2015;22(5):1570–1575.
Sung H, Ferlay J, Siegel RL, etal. Global Cancer Statistics 2020: GLOBOCAN
Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185
Countries. CA Cancer J Clin. 2021;71(3):209–249.
Turlakow A, Yeung HW, Salmon AS, etal. Peritoneal carcinomatosis: role of
(18)F-FDG PET. J Nuclear Med. 2003;44(9):1407–1412.
van Driel WJ, Koole SN, Sikorska K, etal. Hyperthermic intraperitoneal che-
motherapy in ovarian cancer. N Engl J Med. 2018;378(3):230–240.
Van Eden W J, Kok N, Woensdregt K, et al. Safety of intraperitoneal
Mitomycin C versus intraperitoneal oxaliplatin in patients with peritoneal
carcinomatosis of colorectal cancer undergoing cytoreductive surgery and
HIPEC. Eur J Surg Oncol. 2018;44(2):220–227.
Verwaal VJ, van Ruth S, de Bree E, etal. Randomized trial of cytoreduction
and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis
of colorectal cancer. J Clin Oncol. 2003;21(20):3737–3743.
274 MANAGEMENT OFLOWER GASTROINTESTINAL BLEEDING
https://t.me/med1917
Management ofLower
Gastrointestinal
Bleeding
Anna Liveris, MD, and Peter Muscarella II, MD
INTRODUCTION
Lower gastrointestinal bleeding (LGIB) is a frequently encountered
and complex clinical problem for surgeons. Classically defined as
gastrointestinal (GI) bleeding emanating from any point distal to
the ligament of Treitz, LGIB can originate anywhere from the small
bowel to the anus and accounts for an estimated 30% of all GI bleeding. Nearly all LGIB can be isolated to the colon and rectum, with
diverticular bleeding being the most common cause. Less than 10%
of LGIB originates from the small bowel or anus. Aggressive resuscitation, accurate localization, and control of bleeding are the primary
goals of treatment for patients who present with hemorrhagic shock.
A systematic approach to diagnosis and management is pivotal in
reducing morbidity and mortality.
Etiology
LGIB can be further categorized as massive, moderate, or occult.
Massive bleeds are the most life-threatening, with mortality rates
approaching 20%. Despite this, more than 80% of all LGIB will
resolve spontaneously, and the overall mortality rate is about 4%.
Patients presenting with massive LGIB are usually >65 years and
present with hematochezia or bright red blood per rectum in the
setting of hemodynamic instability. The most common causes are
diverticulosis and angiodysplasia. Interestingly, one-third of patients
with presumed massive LGIB will have an upper GI source, so assessing for risk factors of peptic ulcer disease is important.
Moderate and occult bleeding can occur at any age. Moderate
LGIB presents as hematochezia or melena in a hemodynamically stable patient. The differential diagnosis is broad (Table 1). Occult LGIB
is otherwise asymptomatic, except for microcytic anemia resulting
from chronic blood loss. The differential diagnosis of these patients
includes malignancy, inflammatory conditions, ischemia, and congenital causes such as bleeding Meckel’s diverticula.
Epidemiology
Approximately 30% of all patients presenting with major GI bleeding
are found to have bleeding distal to the ligament of Treitz. Among
patients with presumed LGIB, 80% originate distal to the ileocecal
valve, with only 10% originating from the small bowel. The remaining cases usually arise in the upper GI tract. The overall incidence of
LGIB is notably higher in older adult patients, particularly those who
are on multiple medications.
Diverticulosis accounts for over 40% cases of LGIB and often
presents as painless hematochezia. Diverticular bleeding frequently
recurs, and the prevalence increases in patients older than 80 years of
age or in those with chronic constipation. Ischemic colitis accounts
for 20% of LGIB and is also more prevalent in the elderly. This may
occur in response to reduced mesenteric flow to the colon caused
by decreased cardiac output, vasospasm, or atherosclerotic disease.
Treatment is generally supportive and conservative unless there is
evidence of full-thickness necrosis and/or peritonitis. The watershed
area of the splenic flexure is a common location for ischemic colitis,
and involvement of this area on imaging should alert the clinician to
the possibility of this diagnosis. The most common cause of LGIB
in patients younger than 50 years of age is benign anorectal disease,
TABLE 1 Differential Diagnosis of Lower
Gastrointestinal Bleeding
Anatomic Source of Bleeding Etiologies
Small intestine Angiodysplasia
Crohn’s disease
Mesenteric ischemia
Recent surgery/trauma
Meckel’s diverticulum
Dieulafoy’s lesion
Aortoenteric fistula
Intussusception
Colon Diverticulosis
Neoplasm
Angiodysplasia
Inflammatory bowel disease
Recent colorectal surgery/trauma
Recent colonoscopy/
polypectomy
Ischemic colitis
Infectious colitis
Enterohemorrhagic
Escherichia coli (EHEC)
Salmonella
Campylobacter
Shigella
Cytomegalovirus
Entamoeba histolytica
Fecal impaction
Aortoenteric fistula
Rectum Radiation proctitis
Neoplasm
Angiodysplasia
Rectal varices
Fecal impaction
Inflammatory bowel disease
Solitary rectal ulcer
Rectal prolapse
Recent colorectal surgery/trauma
Anus Hemorrhoids
Anal fissure
Inflammatory bowel disease
Local trauma
Perianal variceal disease
usually hemorrhoids or anal fissures. The possibility of inflammatory
bowel disease (IBD) or NSAID-induced mucosal ulceration should
also be considered in these patients. Post-polypectomy bleeding can
result in brisk bleeding following colonoscopy and polypectomy.
Risk factors include age greater than 65 years and polyp size larger
than 1 cm. Though the bleeding is usually self-limited, presentation
can be delayed for up to 1 week after the procedure; therefore ascertaining the history of colonoscopy with polypectomy is crucial.
History and Physical Examination
The differential diagnosis for LGIB is broad, so a thorough history and physical examination is necessary. The history may suggest a cause of LGIB and can inform decision-making regarding
LARGE BOWEL
https://t.me/med1917
275
diagnostic evaluation and management. Key details in the history
should include the quantity, quality, and frequency of the bleeding,
specifically whether the bleeding is recurrent or sporadic. Inquiry
into other associated symptoms such as presence of abdominal pain,
nausea, vomiting, or a recent change in bowel habits is also warranted. The clinician should specifically inquire about prior episodes
of LGIB, history of abdominopelvic radiation, trauma, symptomatic
arrhythmias, liver disease or cirrhosis, HIV status, and recent endoscopic or surgical procedures. A detailed review of the patient’s medications including antiplatelet agents, anticoagulants, and NSAIDs
as well as a family history of colon cancer or inflammatory bowel
disease should also be noted.
Abdominal examination and digital rectal examination should be
completed in all patients presenting with LGIB. Abdominal examination may reveal tenderness, distension, or a mass. Digital rectal
examination is important to inspect for anorectal pathology such as
hemorrhoids or fissures. Additionally, the quality of the stool in the
rectal vault, whether it is impacted, dark melena, maroon-colored, or
frank blood, should be documented. Importantly, the clinician should
pay close attention to the patient’s vital signs at all points during the
history and physical examination as any hemodynamic instability warrants a rapid resuscitation and aggressive diagnostic effort.
MANAGEMENT
All patients presenting with LGIBshould be triaged and evaluated
immediately as decompensation can be rapid. Administration of
supplemental oxygen, the establishment of intravenous lines access
with two large-bore peripheral venous catheters, and placement on
a cardiopulmonary monitor should be performed initially. Infusion
of crystalloid solutions should be started immediately to resuscitate
the patient. Laboratory examination should include a complete blood
count, metabolic panel, liver function tests, lactate, coagulation studies, and a type and screen.
important to minimize mortality. Aggressive efforts to correct coagulopathy and metabolic derangements before surgical intervention
should be undertaken, although salvage procedures may be required
in rare cases. This will be discussed further in later sections.
Special Hematologic Considerations
Early identification of hematologic disorders or medications is mandatory during the resuscitative process. Laboratory studies, including
traditional coagulation studies and possibly TEG, should be obtained
during the initial workup. Anticoagulants and antiplatelet agents
should be discontinued, and reversal should be considered in patients
with hemodynamic instability or ongoing bleeding. For patients who
are therapeutic or supratherapeutic on warfarin, a prothrombin concentrate complex should be considered. Vitamin K and fresh-frozen
plasma can also be utilized for this purpose, but prothrombin complex
concentrate has the advantage of rapid reversal with lower fluid volumes. In recent years, idarucizumab has become more readily available
to reverse dabigatran. Although not widely available yet, andexanet
alfa has also been approved by the US Food and Drug Administration
(FDA) for the reversal of apixaban and rivaroxaban. Currently, there
is no specific reversal agent for antiplatelet agents such as aspirin and
clopidogrel. Most clinicians favor early platelet transfusion and/or
desmopressin administration in the setting of active hemorrhage. Cardiology consultation should be considered for patients who have had
drug-eluting cardiac stents placed within the past year because they are
at risk for stent thrombosis if dual antiplatelet agents are discontinued,
and this can contribute to mortality. It may be reasonable to continue
aspirin therapy in some of these patients. Desmopressin administration can be particularly useful to reverse coagulopathy in the uremic
patient. For patients with inherited or acquired coagulation disorders,
specific reversal agents and therapies should be guided in consultation
with the hematology service. More specialized laboratory studies may
be indicated in some patients.
Resuscitation and Transfusion
Appropriate resuscitation of a patient with LGIB is crucial to minimize
morbidity. The process should begin as described earlier as soon as it
is recognized that the patient is actively bleeding. For patients with
evidence of multiple comorbidities or massive LGIB, a critical care
consultation and monitoring in a critical care setting is warranted.
Most patients with moderate or occult LGIB present without
signs of instability. These patients may warrant less aggressive resuscitation with crystalloid during their initial workup and evaluation.
Transfusion should be initiated to correct any overt coagulopathy
and to maintain a hemoglobin >7 g/dL for most patients. Some
patients, particularly those with other comorbidities, may require a
higher goal hemoglobin and should be treated on an individual basis.
International normalized ratio (INR) should be corrected to <1.5,
and platelets should be transfused to >50,000/L.
The massive LGIB patient who presents in hemorrhagic shock
is similar to a trauma patient. Therefore, activation of a massive
transfusion protocol and the use of empiric blood product ratios of
1:1:1 of packed red blood cells to fresh-frozen plasma to platelets in
order to correct coagulopathy is effective. Early use of fresh-frozen
plasma and platelets should be considered. The end goals of resuscitation are correction of coagulopathy and hemodynamic support.
A policy of permissive hypotension with systolic blood pressure >90
mm Hg is sufficient for most patients. Although crystalloid solutions
may be indicated in other cases of LGIB, care should be taken to
avoid the overuse of crystalloids in this subset of patients because
this may contribute to bowel edema and other complications such
as abdominal compartment syndrome or respiratory failure. The use
of thromboelastography (TEG) may also be a useful adjunct for the
care of the hemodynamically unstable LGIB patient in centers where
this technology is available. Prompt progression to the next phases
of management, bleeding localization and hemorrhagic control, is
Localization
The first step in management and hemorrhage control is localization of the bleeding site. As previously discussed, LGIB has a broad
differential, and identifying the source of bleeding is tantamount to
further management.
Nasogastric Lavage
An upper GI source should always be considered in patients with
suspected LGIB, particularly in patients with hemodynamic instability, brisk bleeding, or unrevealing evaluation of the lower GI tract.
Bleeding peptic ulcers, angiodysplasia, or esophageal varices can often
manifest as visible blood in the stool. Clearly, management diverges
drastically if the source of bleeding is in the upper GI tract. Nasogastric
lavage has classically been recommended as the first step in determining an upper versus lower GI source, particularly in the unstable
patient. A nasogastric tube is inserted bedside, and then the contents
of the stomach are suctioned. Alternatively, 200 to 300 mL saline is
instilled into the tube and then suctioned back to look for blood or coffee grounds in the stomach. Fluid with bile present but without blood
is considered to be a negative lavage. The lack of bilious fluid suggests
inadequate evaluation of the post-pyloric region. A clear effluent is
considered nondiagnostic and is not uncommon. Disadvantages of
nasogastric lavage include patient discomfort and lack of therapeutic
benefit. Nasogastric lavage has fallen out of favor in recent years and
should be reserved for cases of suspected upper GI hemorrhage to
improve visualization at the time of endoscopy. The authors liberally
employ the use of upper endoscopy for the evaluation and management of GI bleeding because of its numerous advantages.
Anoscopy/Rigid Sigmoidoscopy
In patients with a strong suspicion for GI bleeding from the anorectum or distal sigmoid, anoscopy or rigid sigmoidoscopy should
276 MANAGEMENT OFLOWER GASTROINTESTINAL BLEEDING
AB
AB
https://t.me/med1917
be considered. Anoscopy can be quickly performed with little to no
sedation at the bedside by inserting a tubular instrument into the
patient’s anus to visualize hemorrhoids, anal fissures, fecal impaction, or local trauma to the anus. Anoscopy can also be therapeutic
as it can be used to assist with banding or other treatment of bleeding hemorrhoids. Rigid sigmoidoscopy is also a technically simple
bedside procedure but generally requires additional sedation. The
instrument is longer and allows for insufflation, which can facilitate
visualization of the rectal and distal sigmoid mucosa. Both procedures can be uncomfortable for the patient and provide limited
visualization of the most distal GI tract. When possible, flexible
sigmoidoscopy or colonoscopy is preferred.
Colonoscopy
When there is a high degree of suspicion for a colorectal source of
LGIB, colonoscopy is the modality of choice to localize the source
if possible. It has been shown to correctly identify the location of
LGIBin more than 75% of patients. Colonoscopy is performed using
a flexible scope guided from the anus through the entirety of the rectum and colon until the ileocecal valve is reached. Colonoscopy can
detect discrete sources of bleeding, such diverticula, angiodysplasia,
and tumors, as well as more diffuse sources of bleeding, such as
inflammatory bowel disease, ischemic colitis, and radiation proctitis.
An important benefit of the procedure is the ability to perform
therapeutic intervention. Bleeding should only be ascribed to lesions
with stigmata of recent hemorrhage, including visualized bleeding,
exposed blood vessels, or adherent clots. Colonoscopic hemostasis can
be achieved with dilute epinephrine injections (1:10,000) in 1 to 2 mL
aliquots up to 30 mL total. This result is usually temporary, and a second hemostatic method is recommended. Epinephrine injections are
best suited to facilitate site identification in cases of active or copious
bleeding. Endoclip placement results in hemostasis for nearly all diverticular bleeds with stigmata of recent hemorrhage and in nearly 70%
with other forms of LGIB (Fig. 1). Other endoscopic techniques for
hemostasis include bipolar electrocoagulation, heater probe cautery,
argon plasma coagulation, and rubber band ligation. Angiodysplasia
is particularly amenable to argon plasma coagulation (Fig. 2). Rubber
band ligation has the highest rates of rebleeding and can add significant procedure time depending on the site. Tattooing is recommended
to expedite site identification in the event of recurrent bleeding, particularly if surgical intervention is determined to be necessary.
The timing of colonoscopy in the evaluation of LGIB remains
controversial. Ideally, a bowel prep should be attempted to maximize visualization during the procedure. Notably, early colonoscopy
performed while the patient is actively bleeding has been shown to
improve diagnostic yield. Colonoscopic evaluation following bowel
FIG. 1 (A) Colonic diverticulum with stigmata of recent hemorrhage. (B) Successful endoscopic clipping of bleeding diverticulum. (Courtesy Daniel S. Behin,
MD, Montefiore Medical Center/Albert Einstein College of Medicine, New York.)
FIG. 2 Cecal angiodysplasia before (A) and after (B) endoscopic argon beam plasma coagulation. (Courtesy Daniel S. Behin, MD, Montefiore Medical Center/
Albert Einstein College of Medicine, New York.)
Соседние файлы в папке Библиотека им академика М.И. Перельмана