Clinical Scenario

Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1205_Библиотеки_им_академика_М_И_Перельмана.pdf

Скачиваний:

Добавлен:

15.09.2026

Размер:

17 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 45 / 265 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

During Sigmoid Resection forDiverticulitis, thePatient Is Found toHave Diuse Diverticulosis

DanielL.Feingold andStevenA.Lee-Kong

Clinical Scenario

During sigmoidectomy for diverticulitis, the colon is resected and delivered off the eld. You excise the colonic linear staple line in order to place a purse-string suture to secure the circular stapler’s anvil and nd diverticula lining the descending colon that you were going to use for the colorectal anastomosis.

Key Points

1. As per convention, the extent of resection in this setting should include the entire sigmoid colon with margins of healthy colon and rectum. The purpose of the resection is not to remove all proximal diverticula.

2. Care should be taken to avoid incorporating diverticula into the mechanism of the circular stapler as false diverticula are comprised of only mucosa, submucosa, and serosa and stapling across a diverticulum can result in anastomotic leak.

D. L. Feingold (*) · S. A. Lee-Kong Division of Colorectal Surgery, Department of Surgery, Columbia University, New York, NY, USA e-mail: df347@cumc.columbia.edu

3. The distal transection point should be the most proximal healthy rectum.

Technical Pearls (Tips andTricks)

1. The goal is to exclude diverticula from where the head of the stapler and the body of the anvil come together when the stapler mechanism is married.

2. Once the linear staple line is removed and prior to placing the purse string suture, incise any diverticulum along the cut edge of the colon so that the purse string will pull in a circumference of full-thickness colon wall.

3. Secure the anvil with a purse string, and if a diverticulum lays on the edge of the circumference of the anvil, use a “u” stitch around the shaft of the anvil to pull the diverticulum in toward the shaft of the anvil (Fig.8.1). This maneuver can be repeated, as needed, to pull in other diverticula causing the diverticula to be included in the proximal donut. After ring the device, check the donuts to conrm the anticipated tissue was in fact pulled in (this can be veried by looking for the “u” stitch suture that was placed). Using colonoscopy to leak test will also conrm that no diverticula were incorporated in the anastomosis.

4. When using “u” stitches as described above, avoid pulling in too much colon and making

https://doi.org/10.1007/978-3-030-11181-6_8

Fig. 8.1 Use a “u” stitch to pull in a diverticulum and exclude it from the anastomosis

D. L. Feingold and S. A. Lee-Kong

the tissue too bulky as this may cause the circular stapler to misre. When tissue is pulled in toward the shaft of the anvil, it can cause a wrinkle in the colon coming over the edge of the device that crimps over itself, and this can also result in a misring.

5. If there are too many diverticula or the diverticula are too large such that pulling them in bulks up the tissue too much, amputate the distal most segment of the colon, and place another purse string, and work with the tissue at that level to exclude any more diverticula. Occasionally, this will need to be repeated until you are satised with the quality of the colon going to the anastomosis. Mobilizing the splenic exure may provide the needed colon length for this maneuver.

6. In cases where too much bulk is pulled in above the purse string around the anvil, using a scissors to remove the excess tissue is acceptable as long as the purse string is intact and tight around the anvil post.

7. In cases where diverticula line up away from the anti-mesenteric wall, consider conguring a side-to-end (Baker type) colorectal anastomosis.

8. In the extremely rare situation of severe diverticulosis not amenable to the above maneuvers, it may be reasonable to create an anastomosis and divert proximally as opposed to performing a completion colectomy with a diverticulum-free ileum to rectal anastomosis. The decision to forego anastomosis and create an end colostomy in this setting is almost always due to the poor quality of the colon coming down to the anastomosis rather than simply the presence of extensive diverticulosis in this segment.

Clinical Scenario

During interval laparoscopic appendectomy in a patient with prior appendicitis treated non-operatively several weeks ago, a Meckel’s diverticulum is discovered.

Key Points

1. The treatment for incidentally discovered small bowel or colonic inammation during an abdominal operation for some other indication depends on the circumstances of the particular patient, and, in many situations, the operative plan is not signicantly inuenced by these ndings. A decision needs to be made whether or not to proceed with the planned operation and what, if anything, should be done in the operating room to address the inammation. Depending on the extent and severity of the inammation and the underlying condition of the patient, aborting the planned operation may expedite the needed diagnostic journey and facilitate treatment. Aborting and postponing the operation

D. L. Feingold (*) · S. A. Lee-Kong Division of Colorectal Surgery, Department of Surgery, Columbia University, New York, NY, USA e-mail: df347@cumc.columbia.edu

until the new-found inammation has been addressed may also improve the surgical outcome.

Operative Assessment

1. In a situation where unanticipated bowel inammation is encountered, the entire abdomen should be carefully surveyed looking for the extent of the problem and any other pathology.

2. Depending on the circumstances and what options are available at that point, consider speaking with the waiting family either to update them regarding the plan or to get their input to help make a plan.

Technical Pearls (Tips andTricks)

1. The nding of unexpected sigmoid inammation, ascending colon inammation, or ileitis can usually be managed similarly, and assessing the anatomy can often point to a plausible diagnosis. For instance, is the inammation and its distribution consistent with diverticulitis? Are there skip areas with intervening normal bowel or areas of creeping fat consistent with Crohn’s disease? Is the appendix normal or is it chronically festering

https://doi.org/10.1007/978-3-030-11181-6_9

D. L. Feingold and S. A. Lee-Kong

and secondarily affecting the right colon, a loop of small bowel, or a redundant sweep of the sigmoid colon?

2. Meckel’s diverticula, the most common congenital anomaly of the gastrointestinal tract, are due to incomplete obliteration of the vitelline duct. These diverticula may contain ectopic mucosa, most commonly of gastric origin, which secretes acid and can bleed. Meckel’s are true diverticula containing all layers of the bowel wall and are asymptomatic in up to 95% of patients. The risks of removing an incidentally found asymptomatic Meckel’s diverticulum outweigh the benets, and prophylactic resection is not supported by the literature. An inamed appearing Meckel’s found during an operation for another indication should be considered symptomatic, and resection is recommended in this situation. While the choice of diverticulectomy versus small bowel resection with anastomosis remains controversial, the chosen operative

technique should remove all abnormal tissue, and, in cases of Meckel’s diverticulitis, bowel resection will usually be required.

Special Postoperative Care

1. Disclosure to the patient with a plan to address the newly discovered pathology

Clinical Scenario

A patient undergoes diagnostic colonoscopy as part of an evaluation for bleeding and is found, as per the procedure report, to have a colon cancer “in the sigmoid at 25cm.” The patient’s BMI is

37. The CT scans and CEA are noncontributory, and the location of the cancer is difcult to discern on the CT images. At operation, laparoscopy does not demonstrate the tattoo that had been placed, and the cancer site is not readily apparent. On-table CO2 colonoscopy demonstrates the cancer at the middle valve of Houston.

Key Points

1. Given how the treatment algorithm differs between colon cancer and rectal cancer, it is important to differentiate between these cancers and accurately diagnose patients. If any doubt, perform your own endoscopy to conrm location.

2. If you encounter an unexpected rectal cancer, consider avoiding resection at the time, and ensure the patient is appropriately staged.

3. Patients with proximal third rectal cancers are usually treated similarly to patients with sigmoid colon cancer.

4. Patients with middle and distal third rectal cancers may benet from neoadjuvant chemoradiotherapy as determined by endo-anal ultrasound or rectal cancer protocol MRI.These patients should have appropriate rectal cancer staging and possibly neoadjuvant therapy before undergoing proctectomy, as circumstances permit.

5. Patients with a colorectal malignancy should be presented at a multidisciplinary tumor board, when possible in advance of surgery, to optimize treatment. This kind of dedicated review can help determine the need for better or more convincing preoperative localization differentiating colon from rectal cancer.

Operative Assessment

D. L. Feingold (*) · S. A. Lee-Kong Division of Colorectal Surgery, Department of Surgery, Columbia University, New York, NY, USA e-mail: df347@cumc.columbia.edu

https://doi.org/10.1007/978-3-030-11181-6_10

1. Accurately determine the location of the cancer endoscopically.

2. Carefully survey the patient looking for evidence of metastasis that may inuence the decision to resect at this point.

D. L. Feingold and S. A. Lee-Kong

Operative Checklist

1. Additional resources and equipment (a) A colonoscope or proctoscope to localize

the tumor endoscopically.

Technical Pearls (Tips andTricks)

1. When performing colonoscopy and assessing the location of a colorectal neoplasm, larger buttocks can articially increase the length of scope insertion and inaccurately localize the mass in what is presumed to be the sigmoid colon. Avoid the mistake of describing the height of a tumor based on the distance from the buttocks; instead, rely on the distance from the anal verge, rigid proctoscopy evaluation, and/or anatomic landmarks of the proximal, middle, and distal valves of Houston.

2. In general, intraoperatively conrm tumor location before committing to a resection or ligating the main artery to a segment of the colon.

3. Correlate the endoscopy ndings with crosssectional imaging to ensure the correct level of the tumor.

Special Postoperative Care

1. Full disclosure to the patient including the operative ndings and facilitate medical/radiation oncology consultation.

Clinical Scenario

During laparoscopic colectomy for what was described as a splenic exure cancer, no tattoo is found, and the cancer site is not grossly appreciated.

Key Points

1. Condently localizing lesions preoperatively reafrms the operative plan and facilitates resection.

2. Under almost all circumstances, blind resection without a condent degree of intraoperative localization should be avoided.

3. Patients with colorectal malignancy should be presented at a multidisciplinary tumor board, when possible in advance of surgery, to optimize treatment. This kind of dedicated review by committee can help determine things like the need for better or more convincing preoperative localization.

Operative Assessment

1. Start by looking for the tattoo and/or the cancer in the area that was targeted by preoperative localization. If the target is not localized, evaluate the colon segment by segment looking for the tattoo or lesion. Depending on the redundancy of the colon and the experience of the endoscopist, relying solely on the endoscopy to localize a lesion can carry a high margin of error.

Operative Checklist

1. Additional resources and equipment (a) A CO2 colonoscope to localize the tumor.

Using ambient air for the colonoscopy will jeopardize the ability to complete a laparoscopic operation due to distension of the colon.

Technical Pearls (Tips andTricks)

D. L. Feingold (*) · S. A. Lee-Kong Division of Colorectal Surgery, Department of Surgery, Columbia University, New York, NY, USA e-mail: df347@cumc.columbia.edu

https://doi.org/10.1007/978-3-030-11181-6_11

1. Reliable localization includes colonoscopically visualizing the target in relation to the ileocecal valve preoperatively, locating a previously placed tattoo intraoperatively, identifying the tumor on cross-sectional imaging in advance of surgery and correlating this with

the operative ndings, appreciating the mass laparoscopically, or nding the target using on-table intraoperative colonoscopy. Other means of localizing like combining endoscopic clips and x-rays or relying on barium enemas are not commonly used any longer.

2. In cases of absent or questionable localization, on-table CO2 colonoscopy is the preferred method to localize targets. It may be helpful in this situation to also reach out to the colonoscopist who performed the colonoscopy to begin with for input.

3. In general, intraoperatively condently conrm tumor location before committing to a resection by ligating the main artery to a segment of the colon.

4. When localizing a lesion during colonoscopy, tattooing the mucosa distal to the target in multiple quadrants facilitates intraoperative localization as some of the tattoo can be obscured by the mesentery, omentum, or epiploica (Fig.11.1).

5. Move the omentum cephalad out of the way, and manipulate large epiploica to better expose the colon serosa actively looking for a tattoo.

6. When needed, on-table colonoscopy should provide localization. In cases where other methods for localization were unsuccessful, if intraoperative colonoscopic localization fails because of a poor bowel preparation, conversion to an open procedure to manually

D. L. Feingold and S. A. Lee-Kong

Fig. 11.1 Effective tattooing performed in multiple quadrants just distal to a mass

palpate the colon can be considered but is unlikely to help given the stool burden. In this situation, aborting the procedure may be most prudent.

Clinical Scenario

A 63-year-old patient at index screening colonoscopy undergoes piecemeal polypectomy of a medium-sized sessile lesion in the descending colon using a snare, and several days later the pathology report reveals adenocarcinoma arising within adenomatous tissue.

Key Points

1. When a patient has unanticipated cancer described in their polypectomy pathology report, it is important to consider whether or not the site of the lesion has been adequately localized. Given the presumed benign nature of the lesion, often the site is not tattooed at the time of polypectomy. Once this situation is recognized, it is important to timely repeat the colonoscopy to accurately localize and tattoo the area of the scar. Ideally, the colonoscopist who performed the polypectomy to begin with should localize the site in this fashion.

D. L. Feingold (*) · S. A. Lee-Kong Division of Colorectal Surgery, Department of Surgery, Columbia University, New York, NY, USA e-mail: df347@cumc.columbia.edu

2. A malignant polyp contains adenocarcinoma in the submucosa. The assessment in these situations usually centers on the likelihood of mucosal recurrence at the site of polypectomy as well as the risk of having occult nodal disease. Favorable histologic features include malignant polyps removed in one piece, welldifferentiated cancer, absent lymphovascular invasion, and negative margins. The pathologic description of tumor budding may be taken as an unfavorable or poor prognostic factor in this situation. As much of the decision-making in these circumstances is based on histopathology, review of the outside pathology slides may inuence the recommended treatment plan and should be considered if in-house expertise is available.

3. An assessment of the histologic parameters, usual cancer staging, and the patient’s unique medical status allows the surgeon to individualize the recommendation for surgery in these circumstances. In general, patients with an unfavorable histologic factor are recommended to undergo colorectal resection as denitive treatment of their malignant polyp. In terms of setting expectations, it is important that patients who undergo colectomy in the setting of a previously removed malignant polyp understand, in advance of their surgery, the likelihood of having no pathology in their operative specimen and documenting this understanding is advisable.

https://doi.org/10.1007/978-3-030-11181-6_12

D. L. Feingold and S. A. Lee-Kong

4. Patients with malignant polyps should be evaluated in a multidisciplinary tumor board, when possible in advance of surgery, to optimize treatment.

5. In cases with an unlocalized scar, if repeat colonoscopy fails to localize the polypectomy site and the patient meets criteria for colectomy based on the assessment outlined above, a decision needs to be made whether or not colectomy should be performed based on the information available from the colonoscopy that removed the polyp to begin with. The use of PET-CT to localize under these circumstances is not well established but may be considered. In general, blind resections are not advised.

6. If there are concerns regarding the completeness of the malignant polyp excision, a repeat colonoscopy should be performed to evaluate the site.

7. In cases where colectomy is not performed, patients should typically undergo short-interval surveillance colonoscopy followed by further colorectal surveillance at appropriate intervals. As usual, medical oncology consul-

tation should determine the need for systemic surveillance.

8. Patients with high-grade dysplasia or intramucosal adenocarcinoma described within their adenoma are not classied as having had cancer. As these histologies do not risk nodal metastasis, the treatment in these cases is to remove the lesion completely and perform surveillance.

Clinical Scenario

Key Points

Suggested Reading

Clinical Scenario

Key Points

Operative Assessment

Special Postoperative Care

Suggested Reading

Clinical Scenario

Key Points

Operative Assessment

Operative Checklist

Special Postoperative Care

Suggested Reading

Clinical Scenario

Key Points

Operative Assessment

Operative Checklist

Suggested Reading

Clinical Scenario

Key Points

Suggested Reading