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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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AV malformation (angiodysplasia): right colon > left colon.
Diverticulosis: left colon > right colon.
Neoplasm: epithelial, nonepithelial.
Colitis: ischemic, infectious, idiopathic, postradiation.
Stercoral ulcers.
Endometriosis cyclic bleeding.
Iatrogenic: post-polypectomy/-biopsy.
Anorectal Origin
Radiation proctitis.
Hemorrhoids.
SRUS.
Rectal varices.
Dieulafoy ulcer.
Fissure.
Traumatic/posttraumatic.
Origin Proximal to Colon
Upper GI bleeding: esophageal varices, peptic ulcer disease, Mallory-Weiss, aortoduodenal fistula, tumor.
Small intestine: tumor (epithelial, nonepithelial), Crohn disease.
Meckel diverticulum.
Pathology
Dependent on underlying cause of bleeding.
Evaluation
REQUIRED MINIMAL STANDARD
Overall clinical and hemodynamic assessment, ICU monitoring if unstable.
Lab work: evidence of coagulopathy/thrombocytopenia?, type and cross, transfusion if critical.
Anoscopy/rigid sigmoidoscopy: rule out anorectal bleeding source (even if colonoscopy planned).
Further tests depending on acuity of presentation:
Acute:
– NGT placement: discrimination of upper GI bleeding vs lower GI bleeding.
– Colonoscopy/EGD: acute setting—limited by poor visibility (unprepped colon, strong light absorption of blood
darkness); distribution of blood in the colon has only limited value in localization of bleeding source; after
acute bleeding stopped: evaluation after bowel prep.
– Tagged red blood cell scan: sensitive if > 0.5 mL bleeding, particularly the first 15–30 minutes are meaningful
for localization.
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– Angiography with possible embolization: sensitive if > 1 mL/min bleeding.
Not acute or outpatient:
– Colonoscopy, EGD.
– Further tests depending on findings.
ADDITIONAL TESTS (OPTIONAL)
Capsule endoscopy: indicated for GI bleeding not amenable to EGD or colonoscopy.
Meckel scan.
Classification
Origin: upper GI bleeding, lower GI bleeding, anorectal bleeding, GI bleeding of unknown origin.
Severity: transfusion-requiring bleeding, mild/sporadic bleeding, occult bleeding, anemia.
Nonoperative Treatment
Patient stable and no evidence of localized morphologic problem watchful waiting, correction of coagulopathy, possible
platelet transfusion, periodical reassessment.
Super-selective embolization.
Operative Treatment
INDICATION
Localizable bleeding source.
Bleeding not localizable, but ongoing, massive bleeding, unstable patient:
Acute life-threatening hemorrhage with persistent hypotension.
Transfusion requirements:
– > 1500 mL of blood (> 6 units of blood) transfused and continuation of bleeding.
– > 2000 mL (> 6–8 units of blood) of blood needed to maintain vital signs within 24-hour period.
– Perform surgery prior to 10 units of transfusion.
Continued bleeding after 72 hours.
Significant rebleeding within 1 week after initial cessation.
OPERATIVE APPROACH
Localization successful: appropriate segmental resection/treatment.
Efforts to localize lower GI bleeding unsuccessful: laparotomy with intraoperative assessment of small bowel,
including enteroscopy: if bleeding still most likely from colon
empirical total abdominal colectomy with ileorectal
anastomosis.
Outcome
Majority of bleeding stops spontaneously without surgical or endovascular intervention. Recurrent bleeding episodes in 25–
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40%.
Risk of intestinal necrosis after embolization: 5–10%.
Emergency surgery: historical mortality 30–40% down to 10–20%.
Risk of recurrent bleeding:
Minimal after surgery for identifiable bleeding source.
3–10% after total colectomy for unidentifiable bleeding source.
50–75% after "blind" segmental colectomy.
Mortality commonly related to shock-induced organ failures: myocardial infarction, shock liver, kidney failure, brain injury,
ARDS.
Follow-Up
Dependent on nature and severity of the bleeding.
Repeat colonoscopy under elective conditions once patient stabilized.
Potential capsule endoscopy to rule out bleeding from small bowel.
Cross-Reference
Bleeding per rectum (Ch. 1)
Capsule endoscopy (Ch. 2)
Angiography with possible embolization (Ch. 2)
Nuclear scintigraphy (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Diverticular disease (divertuclosis, diverticulitis, 562.IX) (Ch. 4)
(Sub-)Total colectomy, ileorectal anastomosis (open) (Ch. 5)
ENTEROCUTANEOUS FISTULAE (569.81)
Overview
Enterocutaneous fistulae (in contrast to ostomies) are unintended abnormal communications between the intestines and the
skin. The loss of intestinal integrity with leakage of intestinal content results in intra-abdominal abscesses, sepsis, and
decompression through wound or other skin areas.
Most common scenarios: intraoperative enterotomies (eg, after adhesiolysis: primarily not recognized vs leak after repair),
anastomotic leak, eroding foreign bodies (eg, mesh), neoplastic bowel erosion (eg, carcinomatosis), IBD, diverticulitis.
Enterocutaneous fistulae are associated with significant long-term morbidity and a mortality of 5–20%. The individual degree
of symptoms and output depends on the number of fistulae, the primary site(s) in the intestine (proximal > distal), and the
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overall size/diameter, ie, high output vs low-output fistula.
Some enterocutaneous fistulae will spontaneously close; others remain open
FRIEND (Foreign body, Radiation, Infection,
Epithelialization, Neoplasm, Distal obstruction).
Epidemiology
Incidence unknown; 85–90% related to previous intervention, 10–15% spontaneous (IBD, diverticulitis).
Symptoms
Primary symptoms:
– Prodromal stage: bowel dysfunction, ileus, erythematous wound, wound dehiscence, sepsis.
– Established fistula: various degrees of constant or intermittent leakage of fecal content, gas, pus, resolving vs
persistent sepsis.
Secondary symptoms: skin irritation with significant pain, fluid loss, dehydration, malnutrition, weight loss, decubitus, etc;
need for parenteral nutrition with TPN-induced problems (hepatopathy, line sepsis); depression.
Differential Diagnosis
Draining abscess/hematoma/fascial dehiscence without communication to the intestines.
Delayed wound healing.
Ulcerating cancer implant.
Urachus fistula.
Wet umbilicus.
Pancreatic fistula.
Pathology
Dependent on the nature of the cause.
Evaluation
REQUIRED MINIMAL STANDARD
History: previous interventions collection of all reports: operative notes, pathology, previous imaging studies
understanding time frame of events, problems, underlying tissue condition, mesh implants, etc.
Clinical examination: general appearance, vital signs, nutritional status, abdominal distention, focal tenderness, underlying
induration, skin condition
photographic documentation.
Assessment of nutritional status: weight loss, albumin, prealbumin, lymphocyte count, transferrin.
Imaging: CT abdomen with oral and IV: persistent active abscesses, visible contrast extravasation, anatomy.
Additional Tests (Optional)
Confirmation of enterocutaneous fistula: measuring amylase in output, oral ingestion of charcoal positive if black particles
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show up in fistula output.
Contrast studies: small bowel follow-through, contrast enema (to rule distal obstruction), fistulogram; timing of these
investigations: no impact on management at time of acute fistula occurrence, only in planning phase prior to corrective
surgery.
Classification
Output per 24 hours: low (< 200 mL), moderate (200–500 mL), high (> 500 mL).
Manageable vs unmanageable.
With/without secondary pathology.
FRIEND-positive vs FRIEND-negative.
Nonoperative Treatment
Fistula management gaining time for tissue and nutritional recovery:
Nutrition: optimization of nutritional parameters—oral diet/enteral feeding preferable if tolerated (ie, not resulting in
unmanageable increase of output), potentially fistuloclysis (feeding through fistula), parenteral nutrition (total or
complementary in addition to oral/enteral feeding).
Wound management: need for creativity and individual adjustments; wound-VAC (vacuum-assisted closure), suction
drains, skin protection, catheter for collection of enteric content.
Antibiotic and antifungal treatment: to continue as long as active internal infection, not for fistula as such.
Output control: no benefit from long-term NGT; no proven benefit from somatostatin or other drugs, except for
Crohn disease: infliximab improves fistula symptoms even though it rarely results in lasting closure; role for fibrin glue
injection?
Operative Treatment
INDICATIONS
Acute unmanageable enterocutaneous fistula.
Chronic/persistent symptomatic enterocutaneous fistula after minimum of 6–12 weeks (up to 6 months) of
conservative optimization.
OPERATIVE APPROACH
Acute: proximal fecal diversion.
Chronic: abdominal exploration with most careful adhesiolysis isolation of defective bowel segment and removal of
all foreign material (eg, mesh).
Segmental resection of involved bowel with primary anastomosis.
Complete exclusion of segment continued minimal mucus drainage but no enteric content.
Not recommended: simple fistula closure (> 40% recurrence).
Abdominal wall closure without mesh direct closure; if needed component separation or flaps.
Outcome
Even under best circumstances: 10% failure rate (depending on the nature of the problem). Once healed complete
recovery.
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Follow-Up
Functional and nutritional follow-up until complete normalization. Additional follow-up if underlying disease (cancer,
Crohn disease).
Cross-Reference
Fistula (Ch. 1)
Contrast enemas (Ch. 2)
Small bowel follow-through (SBFT) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
General perioperative management—abdominal (Ch. 7)
Selected colorectal reference values (App. 2)
DIVERSION COLITIS (V44.2)
Overview
Reversible morphologic (and symptomatic) changes in the large intestine that develop from a lack of nutrients as a result of
proximal fecal diversion (ostomy). Common scenarios: status diverting ileostomy/colostomy, status post Hartmann resection.
Pathogenesis:
70% of colonic mucosal nutrition comes from lumen.
Short-chain fatty acids (SCFAs: acetate/propionate/n-butyrate) are of particular importance for the colon.
(Contrast: for small intestine, glutamine is the most relevant component for nutrition.)
Epidemiology
To some degree present every time diversion is performed (100% prevalence) but only fraction of these patients are
symptomatic.
Symptoms
Rectal bleeding, mucus or mucopurulent discharge, occasionally cramps.
Differential Diagnosis
IBD: ulcerative colitis, Crohn colitis (caveat: assessment of IBD activity impossible after diversion has to be described at
the time of diversion).
Radiation proctitis.
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Pathology
Mild: friability of colonic mucosa difference between colonoscopy on way in (normal appearance) and out (diffuse injuries
from contact with instrument).
Moderate to severe; diffuse and increasingly confluent ulcerations.
Microscopic: crypt atrophy and distortion with acute (polymorphonuclear) and chronic (lymphoplasmocellular) infiltrates.
Evaluation
REQUIRED MINIMAL STANDARD
History: suggestive circumstances.
Clinical examination: endoscopic evaluation.
ADDITIONAL TESTS (OPTIONAL)
Evaluation for options to reverse ostomy.
Classification
Symptomatic vs asymptomatic diversion colitis.
Diversion colitis with/without prospect of ostomy reversal.
Nonoperative Treatment
Asymptomatic patients.
Symptomatic patients: SCFA enemas (good but pharmacologically unstable)
more practical to use milk or tube feed
enemas (daily to weekly).
Operative Treatment
INDICATION
Treatment-refractory symptomatic diversion colitis.
OPERATIVE APPROACH
Reversal of ostomy possible ostomy takedown.
Reversal of ostomy not possible resection of diverted colon segment.
Outcome
Generally relatively benign course.
Follow-Up
Functional reassessment at regular intervals.
Cancer surveillance of diverted segments is still indicated.
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Cross-Reference
Bleeding per rectum (Ch. 1)
Colonoscopy (Ch. 2)
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Ileostomy takedown (Ch. 5)
Loop colostomy takedown (Ch. 5)
Hartmann reversal (laparoscopic vs open) (Ch. 5)
"STOMATOLOGY"—THE SCIENCE OF OSTOMIES (V44.2)
Overview
Stoma/ostomy is an intentionally created intestinal opening to the skin in order to allow controlled decompression and
elimination of waste, to provide access for nutrition, or to divert stool from a more distal area of concern (anastomosis,
inflammation, rectovaginal fistula, incompetent sphincter muscle, etc). Ostomies are overall less frequently needed than in
the past, but remain one of the "necessary evils" of colorectal surgery. Much worse than having an ostomy is having a bad
ostomy.
Classification
Different aspects to be considered when classifying ostomies:
Organ of origin: colostomy, ileostomy, jejunostomy, gastrostomy; urostomy.
Specific colonic location: cecostomy, transverse colostomy, descending/sigmoid colostomy, perineal colostomy.
Type of construction: end- vs loop ostomy, blowhole, continent ostomy, tube/catheter ostomy
Intended appearance: nipple, skin-level, rose, catheter.
Planned duration: temporary ostomy vs permanent ostomy.
Purpose of ostomy: waste management, diversion of stool from more distal area of concern, decompression/venting
of stomach or intestines, nutrition.
Common Problems (All Types of Stomas)
Patient anxiety/frustration: need for continued patient education and support (ideally to start before surgery),
enterostomal nurse, ostomy support group, Internet chat rooms.
Inadequate stoma location: preoperative marking—ideally through rectus muscle, avoidance of folds, belt line,
uneven/concave surface, bony prominences. Skinny patients
below umbilical transverse line. Obese patients
generally much higher location (upper abdomen) needed because of down-shift of abdominal pannus in upright
position.
Inadequate configuration and maturation (Figure 4–21A): mainly a problem in obese patients or if bowels
significantly distended.
Peristomal skin irritation: insufficient management vs insufficient ostomy ( enterostomal nurse), allergic reactions (
change of products), peristomal candidiasis ( topical antifungal medications), peristomal pyoderma gangrenosum (
topical or systemic immunosuppressives).
Inflammatory polyps: on exposed mucosa or mucocutaneous junction ablation with topical silver nitrate or with
cautery.
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Stoma prolapse (Figure 4–21B): increasing protrusion with discomfort, bleeding, and aesthetic problem resection,
relocation, possible extraperitoneal tunnel, button-fixation.
Peristomal herniation: increasing bulging and management difficulties fascial narrowing and reinforcement with
implant (Gore-Tex or collagen: keyhole technique vs Sugarbaker onlay technique), stoma relocation. Mesh not
recommended as sharp edges risk erosion into bowel.
Figure 4–21A.
Ileostomy: correct (top) and incorrect configuration (bottom).
Figure 4–21B.
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Colostomy prolapse: before and after correction.
Stoma necrosis/retraction (acute): (1) epifascial
conservative management possible, acceptance of stricture/retraction
later complete stoma revision or final takedown; (2) subfascial risk of free bowel perforation urgent stoma revision.
Stoma retraction, stricturing (chronic): takedown if possible, otherwise complete stoma revision, possible
relocation.
Internal hernia/wrapping of small bowel around ostomy-bearing bowel with resulting bowel obstruction. Prevented at
least in permanent stomas by closing lateral aspect.
Peristomal abscess: drainage either close (into the bag) or far (not to be located right underneath the appliance
wafer).
Peristomal fistula: depending on output doing nothing, fibrin glue/collagen plug, complete revision/relocation (if
related to mesh implant
mesh removal necessary), placement of coated stent (?).
High ostomy output: possible causes include idiopathic/incomplete adjustment ( regular food, fibers, antidiarrheals),
partial SBO (
avoid antidiarrheals), excessive oral fluid consumption ( reduce excessive oral fluids), "serositis" (
trial with antibiotics).
Peristomal varices (portal hypertension): (1) prevention: avoid long-term ostomy wherever possible in patients with
liver cirrhosis; (2) treatment: reseparation of mucocutaneous junction and reimplantation of stoma.
Leakage of ascites (eg, liver cirrhosis): avoid stoma, routine placement of peritoneal overflow drain until healed
(even in low severity cirrhotics).
Stoma Takedown
Generally simpler for loop ostomies, often complex for discontinuous resection/stoma (Hartmann type). Takedown facilitated
by application of antiadhesion products (Seprafilm, SprayGel, etc). Laparoscopic vs open approach. Timing preferably not
before 6–12 weeks after previous surgery.
Preoperative evaluation of current anatomy (water-soluble contrast studies).
In case of stoma complication: evaluate whether ostomy still needed (
revision) or not needed anymore, eg, healed distal
anastomosis ostomy takedown.
Assessment Tools
Clinical assessment: inspection, digitalization, flash light/test tube to determine the level of viability above or below the
fascia, positional changes ( hernia?), etc.