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_901_Библиотеки_им_академика_М_И_Перельмана
.pdf
8 Colon
Management of ulcerative colitis
Case Characteristic Management
251
Severe ulcerative
colitis
Fulminant
ulcerative colitis
Toxic megacolon Segmental or total colonic
Management of Crohn’s disease
Stricturing
Fistulous Diarrhea, fecal drainage from organs
Contained
perforation with
abscess
>6 stools/day+systemic toxicity Serial abdominal exam, steroids, biologics
>10 stools/day+profuse continuous
rectal bleeding, drop in hemoglobin
requiring transfusion, fever,
tachycardia, and an ESR >30mm/h
dilation+systemic toxicity
Obstruction, PO intolerance,
obstipation
with stulous tract
Abdominal pain, fever, tachycardia IV antibiotics, drainage if no acute abdomen
Rescue therapy if hemodynamically stable
If fails therapy 4–7days➔operation
Observe for 48h if no acute abdomen
Operative intervention if condition worsens at all or if
perforation, signicant GI bleeding, and peritonitis
Initial medical management with steroids, TPN, NPO
If non resolving➔stricturoplasty (Heineke- Mikulicz,
Finney, Michelassi), or segment resection
The presence of multiple small-segment strictures in a
given segment of small bowel should mandate bowel
resection
Obstruction➔resect (10% risk of associated
malignancy)
Anti-cytokine therapy, if failed➔segmental resection
with primary repair of affected organ
Surgical treatment of complex anal stulas may be
difcult and may require seton placement or fecal
diversion
Segmental resection. 35% abscess recurrence if
treatment without resection
Free air
perforation
Toxic megacolon Segmental or total colonic
Peritonitis, fevers, sepsis, possible
hemodynamic instability
dilation+systemic toxicity
Depending on degree of contamination, segmental
resection with primary anastomosis versus enterostomy
Total abdominal colectomy with ileorectal anastomosis
Avoid ileal pouch Anal anastomosis due to high risk of
pouchitis
Medications for IBD
Treatment type Medications Mechanism of action
Aminosalicylates Mesalamine, sulfasalazine
Immunomodulators Azathioprine, methotrexate, 6-Mercaptopurin Blocks purine synthesis
Corticosteroids Prednisone, methyprednisone, hydrocortisone,
budesonide (minimal systemic absorption)
Biologics Anti-cytokines: Iniximab, adalimumab,
Ustekinumab
Anti-cell adhesion: Vedolizumab, natalizumab Inhibits cell adhesions
Inhibits IL-1 and TNF-α
Blocks phospholipase A2in arachidonic
acid
Induction of apoptosis in
proinammatory cells and blocks TNF-α
252
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Types of strictureplasty
Type Characteristic Illustration
H. Hakmi et al.
Heinecke- Mikulicz
strictureplasty
Finney strictureplasty Medium-segment (10–15cm) stricture
Michelassi strictureplasty Long-segment (> 15cm) stricture, in
Single short-segment (5–7cm) stricture
patient already at risk for short bowel
syndrome
Research about IBD
Reference Findings
Fumery M, Seksik P, Auzolle C, Munoz-Bongrand
N; REMIND study group investigators.
Postoperative complications after ileocecal resection
in Crohn’s disease: a prospective study from the
REMIND group. Am J Gastroenterol.
2017;112(2):337–45
Spanjersberg WR, van Sambeeck JD, Bremers A,
Rosman C, van Laarhoven CJ.Systematic review
and meta-analysis for laparoscopic versus open
colon surgery with or without an ERAS
programme. Surg Endosc. 2015;29(12):3443–53.
https://doi.org/10.1007/s00464- 015- 4148- 3. Epub
2015 Mar 24
Preoperative steroids showed elevated postop complication
compared to preoperative anti-TNFs, which were not
associated with an elevated risk of postoperative
complications
Reduction in morbidity and hospital length of stay with
laparoscopy in colon surgery with or without ERAS
8 Colon
Research about IBD
Reference Findings
253
Ponsioen CY; LIR!C study group. Laparoscopic
ileocaecal resection versus iniximab for terminal
ileitis in Crohn’s disease: a randomised controlled,
open-label, multicentre trial. Lancet Gastroenterol
Hepatol. 2017;2(11):785–92. https://doi.org/10.1016/
S2468- 1253(17)30248- 0. Epub 2017 Aug 31.
Erratum in: Lancet Gastroenterol Hepatol. 2017
Nov;2(11):e7. PMID: 28838644
Fornaro R, Caratto M, Caratto E, Caristo G,
Fornaro F, Giovinazzo D, Sticchi C, Casaccia M,
Andorno E.Colorectal cancer in patients with
inammatory bowel disease: the need for a real
surveillance program. Clin Colorectal Cancer.
2016;15(3):204–12
Upfront laparoscopic resection in patients with limited
terminal ileal Crohn’s disease is a reasonable alternative to
iniximab therapy
Chromoendoscopy is highly effective and several
guidelines suggest its use with a targeted biopsy in patients
with IBD
Colectomy-Partial, Total, andSubtotal
Preoperative preparation and ERAS (enhanced recovery after surgery)
Mechanical bowel preparation and
antibiotics
Mechanical bowel prep is usually with osmotic laxatives. Oral
antibiotics neomycin or erythromycin and metronidazole
Addition of oral antibiotic preparation to mechanical bowel prep
reduces surgical site infection, CDI, and anastomotic leak
Ureteral stent • Ureteral uorescent stents may prevent ureteral injury
• Indications: Reoperation, prior pelvic surgery, prior radiation
Stoma and diet
Ostomy triangle: Umbilicus, ASIS and
pubic tubercle
• Preoperative stoma marking and teaching➔fewer ostomy
complications
• It should protrude and come through the rectus muscle
• The patient should be able to visualize the stoma and access it without
difculty
• In obese patients, can place above umbilicus through rectus sheath for
better visualization
• Be 5cm away from skin crease or bony prominence
• Clear liquid diet may be continued <2h before general
anesthesia• Carbohydrate loading should be encouraged before
surgery in nondiabetic patients
• Immediate postoperative feeding reduces time to return of bowel
function but higher risk of vomiting
• Chewing sugar free gum can be trialed to reduce postop ileus
254
Middle colic
Superior
Right hemicolectomy
Middle colic
Superior
Extended right hemicolectomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Preoperative preparation and ERAS (enhanced recovery after surgery)
Drains • Routine use of intra-abdominal drains confer no benet
• Nasogastric tube should not be continued postoperatively, as they
delay enteral nutrition
• Removal of urinary catheters 24h postop in elective colonic and upper
rectal surgeries without vesicular stula signicantly lowers urinary
tract infection
Others • Alvimopan hastens recovery in open colorectal surgery
• Avoid intraop and postop excess IV uid hydration >2.5kg/d, which
is associated with increased morbidity and prolonged hospital stay,
mostly due to ileus
• Dexamethasone and ondansetron reduce postoperative nausea and
vomiting (PONV)
• Minimally invasive approach should be utilized whenever the
expertise is available and appropriate, improving short term outcomes
• Multimodal, opioid-sparing pain management plan should be used
including non-narcotic oral meds, and transverses abdominis plane
(TAP) block
Colectomy key steps
Approaches Two common approaches to colon resection:
1. Medial to lateral starting with identication and ligation of major blood vessels followed by
mobilization of colon
2. Mobilization of bowel followed by major blood vessels ligation
H. Hakmi et al.
Right
hemicolectomy
Extended right
hemicolectomy
• Mobilization of right colon (avascular white
line of Toldt)➔transverse colon by dividing
gastrocolic ligament➔identication of the
ileocolic blood vessels and ligation after
identication of the right ureter
• Division of the transverse colon at
bifurcation of middle colic artery
• Division of the terminal ileum 4–6cm
proximal to the ileocecal valve
• Anastomosis of the terminal ileum and
transverse colon
• Indication: Transverse colon tumors
• Division right and middle colic arteries at
their origin and resection
mesenteric
artery
artery
Right colic
artery
IIeocolic
artery
mesenteric
artery
artery
Right colic
artery
IIeocolic
artery
Middle colic
Superior
Transverse colectomy
ic
ry
Left hemicolectomy
8 Colon
Colectomy key steps
255
Transverse
colectomy
Left
hemicolectomy,
sigmoidectomy,
and LAR (low
anterior resection)
• Mobilization of both hepatic and splenic
exures➔dissection of greater omentum off
transverse colon➔division of middle colic
blood vessels
• Proximal and distal colon division and
resection
• Anastomosis of the ascending to descending
colon
• Requires extensive mobilization for a tension
free anastomosis. Ligation of only the
middle colic artery may not be oncologically
appropriate for many tumors
• Left hemicolectomy indicated for splenic
exure mass
• Mobilization of left colon (white line of
Toldt)➔transverse colon mobilization by
dividing gastrocolic and gastrosplenic
ligaments
• Identication of left ureter at iliac bifurcation
• If the ureter is not visualized, check medially
under the reected peritoneum, as the ureter
may have been lifted anteriorly with the
investing retroperitoneal fascia
• Inferior mesenteric artery pedicle ligation
ONLY after ureter identication
• Division of the transverse colon proximal to
the splenic exure and distal colon at
rectosigmoid junction
• Primary anastomosis of the transverse colon
and rectum
• For a malignant lesion in the left colon,
resecting the mesentery of the inferior
mesenteric artery territory is necessary for
adequate resection
• Excess traction should be avoided at the
splenic exure so as not to tear the splenic
capsule
mesenteric
artery
artery
Right colic
artery
IIeocolic
artery
Marginal artery
of Drummond
Superior
mesenter
artery
Left
colic arte
Abdominoperineal
resection (APR)
• For sigmoid cancer, the sigmoid can be
resected with 5cm margins. For diverticulitis
resection from grossly normal colon to
rectum
• LAR, dissect rectum in presacral and
mesorectal plane avoiding autonomic nerves
and the presacral veins
• Anus, rectum, and sigmoid are excised
• Abdominal portion: Mobilization of rectum,
sigmoid, and creation of a descending
colostomy
• Perineal portion: Removal of anus, anal
sphincters, and distal rectum
• Can be done simultaneously as abdominal
and perineal portions if two teams used
256
Superior
Middle colic
Subtotal colectomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Colectomy key steps
H. Hakmi et al.
Subtotal colectomy • Mobilize the colon from the lateral
peritoneal reection, starting at the cecum
• The descending colon is then taken from its
lateral peritoneal attachments from the
sigmoid up, with early identication of the
left ureter and left gonadal vessels
• A long rectal stump should be left to avoid
injury to the pelvic plexus of nerves and
vessels, which is of greater likelihood in the
emergency setting
Total
proctocolectomy
with restorative
ileal pouch-anal
anastomosis
• Benets of the J pouch include the avoidance
of a permanent stoma. However, long-term
complications of the ileo-anal J pouch
include increased frequency and urgency of
bowel movements (should expect 6–8
movements a day), nocturnal incontinence,
anal irritation, and pouchitis
• Contraindications include fecal incontinence,
locally advanced low rectal cancer involving
the sphincters, and perianal Crohn disease
• Obesity increases leaks rate and difculty
with reach
Total proctocolectomy with end ileostomy:
• Preserve external sphincter and levator ani
for secure wound closure
Total proctocolectomy with ileo-anal J
pouch:
• The small bowel mesentery should be
completely mobilized
• Inferior portion of the head of the pancreas
should be exposed to allow for tension-free
anastomosis
• Division of inferior mesenteric artery close
to superior mesenteric artery to maintain
viability of ileal pouch and to reach the
pelvis
• Could need elongation of mesentery for J
pouch creation by peritoneal relaxing
incisions
Stages of IPAA (ileal pouch anal
anastomosis):
One stage: Total proctocolectomy (TPC) and
IPAA
Two stages: TPC+IPAA+loop
ileostomy➔ileostomy reversal
Three stages: Total abdominal
colectomy+end ileostomy➔completion
proctectomy+IPAA➔ileostomy reversal
mesenteric
artery
artery
Right colic
artery
IIeocolic
artery
8 Colon
Research
257
Reference Findings
Neutzling CB, Lustosa SA, Proenca IM, da Silva EM, Matos
D.Stapled versus handsewn methods for colorectal
anastomosis surgery. Cochrane Database Syst Rev.
2012;(2):CD003144
Burch JM, Franciose RJ, Moore EE, Bif WL, Offner
PJ.Single-layer continuous versus two-layer interrupted
intestinal anastomosis: a prospective randomized trial. Ann
Surg. 2000;231(6):832–7
Lovegrove RE, Constantinides VA, Heriot AG, Athanasiou T,
Darzi A, Remzi FH, Nicholls RJ, Fazio VW, Tekkis PP.A
comparison of hand-sewn versus stapled ileal pouch anal
anastomosis (IPAA) following proctocolectomy: a metaanalysis of 4183 patients. Ann Surg. 2006;244(1):18–26
COLOR Study Group. COLOR: a randomized clinical trial
comparing laparoscopic and open resection for colon cancer.
Dig Surg. 2000;17(6):617–22
Remzi FH, Fazio VW, Gorgun E, Ooi BS, Hammel J, Preen
M, Church JM, Madbouly K, Lavery IC.The outcome after
restorative proctocolectomy with or without defunctioning
ileostomy. Dis Colon Rectum. 2006;49(4):470–7
Hüser N, Michalski CW, Erkan M, Schuster T, Rosenberg
R, Kleeff J, Friess H.Systematic review and meta-analysis
of the role of defunctioning stoma in low rectal cancer
surgery. Ann Surg. 2008;248(1):52–60
Non-superiority of stapled over handsewn
techniques in colorectal anastomosis surgery,
regardless of the level of anastomosis
A single-layer continuous anastomosis has similar
rate of complications compared with the two-layer
technique in patients undergoing bowel anastomosis
excluding anastomosis to the rectum, stomach or
duodenum
Stapled IPAA compared to hand-sewn shows
similar short-term outcomes, but a higher rate of
nocturnal continence and dysplasia at the anal
transition zone
Laparoscopic surgery resulted in similar safety,
resection margins, and completeness of resection to
that of open surgery, and recovery was improved
after laparoscopic surgery for colorectal cancer
Omission of diverting ileostomy during pouch
creation can be safe in very select cases in a high
volume IBD center
A diverting stoma mitigates the clinical
consequences of an anastomotic leak but does not
prevent one in patients undergoing low anterior
resection
Case scenarios requiring colectomy
Case scenario Management
Patient with fulminant colitis • TAC/EI
• Preserve superior hemorrhoidal artery to help rectal stump
staple line to heal
• Preserve ileocolic artery for collateral blood ow for
future J-pouch
Familial adenomatous polyposis (FAP) with high
polyp burden (>1000 colonic polyp or >20 rectal
polyps)
FAP with rectal sparing TAC+IRA+Suldinac
Colonic inertia/chronic constipation refractory to
medical management
Patient with ulcerative colitis and high-grade
dysplasia in ascending colon
Low rectal cancer involving sphincter APR
TPC±IPAA
TAC+IRA or ileo-sigmoid
TPC+IPAA/EI
258
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Case scenarios requiring colectomy
Case scenario Management
H. Hakmi et al.
High rectal cancer with anal incontinence refractory
to medical management
Patient with complicated acute diverticulitis, prior
radiation or re-operative pelvis
TAC total abdominal colectomy, EI end ileostomy, TPC total proctocolectomy, IPAA ileal pouch anal anstomosis,
IRA ileorectal anastomosis, APR abdominal perineal resection, LAR low anterior resection
LAR+EI/end colostomy
Consider ureteral stent use
Colostomy andColostomy Closure
Ileostomy versus colostomy
Ileostomy Colostomy
Advantages • Higher reversal rate
• Lower rate of parastomal hernia
• Less stoma retraction
Disadvantages Does not decompress the colon if ileocecal
valve is intact
Case Scenarios for patients requiring ostomies
Case scenario Management
Patient with obstructing sigmoid mass Loop transverse colostomy
Left sided colostomies produce formed stool and
have lower rate of electrolyte abnormalities and
dehydration
• Higher rate of parastomal hernia
• Lower reversal rate
Perforated sigmoid
diverticulitis+peritonitis
Fulminant CDI Total abdominal colectomy with end ileostomy
Resection of sigmoid+stapled rectosigmoid stump+end descending
colostomy or sigmoidectomy with anastomosis and loop ileostomy
Ostomy creation
Key steps for
ostomy creation
End ostomy End ostomy: Created with one end of transected bowel
• All stomas should be externalized through the rectus abdominis to mitigate parastomal
hernias
• A disk of skin is removed
• Muscle-splitting technique is used to approach the fascia
• A fascial incision is created allowing two ngerbreadths to easily slide through
• A Babcock is used to pull the stoma through, and the bowel is visualized again for adequate
perfusion
• Creating some protrusion of the bowel above the skin level leads to easier stoma pouching
• The marginal artery should not be disrupted during mobilization
• The transected end is then brought through the abdominal wall, the staple line removed, and
matured by suturing the edges of bowel to the skin
8 Colon
Ostomy creation
Loop ostomy • Loop ostomy is created by bringing an entire loop of colon through the abdominal wall and
making a transverse incision on the antimesenteric wall of the bowel
• The cut edges are then folded back and sutured to the skin, opening both lumens to allow for
decompression
• A supporting rod or looped catheter is placed below the common edge of bowel to keep it
from retracting
259
Ostomy reversal
Key steps
• Circumferential peristomal incision is made at mucocutaneous junction and dissected to the
level of the fascia
• All adhesions to the fascia should be dissected for later fascial closure
• Loop ostomies should have the edges freshened and closed transversely with running sutures
or reestablish continuity with a side-to-side stapled anastomosis
Looped bowel reversals can often be performed solely through the stoma incision
• End ostomies often require the same mobilization and further intra-abdominal dissection to
mobilize the bowel requiring an open or laparoscopic mobilization of the bowel to reach the
anastomosis site
• Left colostomy reversal: A colorectal anastomosis is performed using a circular stapler most
commonly or a hand-sewn anastomosis after taking down of the ostomy
Complications ofColectomy/Colostomy andtheir Treatment
Complications of colectomy/colostomy and their treatment
Complications Characteristics Management
Anastomotic leak Present after postoperative day 5
Fever, tachycardia, abdominal pain
Triple-contrast CT (PO, IV, and rectal)
for distal colorectal anastomosis
• Risk increased with smoking albumin
<3.5g/dl, BMI >35, radiation,
immunosuppression
• Contained leak➔IV antibiotics, bowel rest and
percutaneous drainage
If positive intraoperative leak test➔resect
anastomosis and create a new one
Rectal stump
blowout
Ureteral injury Abdominal/ank pain, nausea/
Bowel obstruction Abdominal pain, distention, tympany,
Pouchitis Diarrhea, abdominal pain, fever,
Ileus Distention, nausea, vomiting Ambulation, minimize narcotics, bowel rest, sugar
Wound infection Most common complication Avoid skin closure in contaminated cases, washout
Pelvis sepsis picture: Pelvic pain,
fevers, sepsis, urinary retention
vomiting, fever, ileus, and/or hematuria
nausea, vomiting
increased stool frequency, urgency
• Transrectal or transabdominal drainage
• Unstable or abscesses not accessible
percutaneously➔washout+revision of rectal
stump
• Percutaneous nephrostomy tube
• Re-exploration and primary repair,
reimplantation, or psoas hitch
• Within 1–2weeks postop may require surgical
intervention
• 6–8weeks postop➔manage conservatively
• PO ciprooxacin/metronidazole. Probiotics,
anti-TNF-alpha inhibitors for multiple recurrences
If pouchitis with diverted colon, treatment w/short
chain fatty acids
free chewing gum
of fascia, drainage of fascial plane
260
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
H. Hakmi et al.
Rectum andAnus
Rectal Anatomy
Anatomy\histology\physiology
Rectum starts where the teniae merge
Rectosigmoid junction is the narrowest lumen site
12–16cm long, divided to three portions by valves of Houston (mucosal invaginations)
Upper third intraperitoneal, mid, and lower thirds extraperitoneal
Dentate line: Transition from columnar epithelium to squamous epithelium. Site of glandular crypt drainage
Anal verge: Transition from anoderm (non-hair bearing) to perianal skin (hair-bearing)
Anal margin: 5cm diameter from inter-sphincteric groove to surrounding skin
Rectal muscularis propria continues as the internal anal sphincter; Levator ani muscles continue as external anal
sphincter
Upper 2/3 of anus lined with columnar epithelium; lower 1/3 lined with squamous epithelium
Vascular supply: Upper rectum supplied by branch from IMA and drains to IMV, mid and lower supplied by
pudendal branches from internal iliac arteries and drain to internal iliac veins
Lymphatics: Lower third drains to inguinal lymph nodes; upper 2/3 drain to Para-aortic lymph nodes
The rectum acts as a reservoir to hold ~300cc of fecal material
The puborectalis muscle (part of the levator ani muscles) acts as a sling around the rectum, that relaxes to straighten
the rectum to allow passage of stool
Internal anal sphincter is round and provides resting tone for fecal continence
External anal sphincter is a voluntary muscle that allows patients to hold stool
Rectal Cancer
Rectal cancer
Epidemiology,
risk factors and
oncogenesis
Symptoms • Change in bowel habits, either diarrhea or constipation, change in caliber of stool,
Workup • CEA
Staging 0: Intraepithelial
Management Stage 0 and I: Surgical resection alone
Refer to colon cancer
incontinence, blood in stool, pelvic pain, and urinary symptoms inlocally advanced disease
• Colonoscopy to exclude synchronous tumors
• CT chest, abdomen, and pelvis with contrast to identify metastatic disease
• Pelvic MRI (preferred over endoscopic ultrasound) for tumor and lymph node staging
I: Invaded submucosa or musularis propria (not lamina propria)
II: Invading to serosa or perirectal tissue without lymph node involvement
III: Stage II+lymph node involvement
IV: Distant metastasis
Stage II and III: Totally neoadjuvant chemotherapy+surgical resection
Stage IV: Adjuvant therapy, if able to downstage tumor, can perform surgery
Surgery is contreversial in patients with complete radiologic response after totally neoadjuvant
chemotherapy
Соседние файлы в папке Библиотека им академика М.И. Перельмана