Colon,Colon, Rectum,Rectum, andand AnusAnus SouthSouth CollegeCollege PAPA SurgicalSurgical CourseCourse ColonColon andand RectumRectum TerminalTerminal portionportion ofof GIGI tracttract TwoTwo functionsfunctions AbsorptionAbsorption ofof water,water, electrolyteselectrolytes StorageStorage ofof fecesfeces BiologicallyBiologically notnot essentialessential DiseaseDisease isis veryvery commoncommon AnatomyAnatomy MultipleMultiple partsparts RetroperitonealRetroperitoneal andand peritonealperitoneal portionsportions ExternalExternal longitudinallongitudinal musclemuscle layerslayers——teniaeteniae colicoli RectumRectum——1515 cm,cm, externalexternal layerlayer continuouscontinuous AnusAnus——33--44 cmcm fromfrom dentatedentate lineline toto analanal vergeverge AboveAbove dentatedentate lineline----insensateinsensate AnatomyAnatomy BloodBlood supplysupply toto coloncolon fromfrom superiorsuperior andand inferiorinferior mesentericmesenteric arteriesarteries JunctionJunction——relativelyrelatively poorpoor bloodblood supplysupply RectumRectum——threethree sourcessources——IMA,IMA, internalinternal iliac,iliac, internalinternal pudendalpudendal VenousVenous drainagedrainage ofof rectumrectum toto IMV/portalIMV/portal andand toto systemicsystemic circulationcirculation ConnectedConnected byby venousvenous cushionscushions----rrhoidsrrhoids DiagnosisDiagnosis DigitalDigital rectalrectal examexam EndoscopyEndoscopy——routineroutine afterafter 50,50, qq 33--55 yearsyears AbdominalAbdominal seriesseries——pneumoperitoneumpneumoperitoneum,, obstruction,obstruction, volvulusvolvulus ContrastContrast studiesstudies CTCT scanscan Angiography/nuclearAngiography/nuclear studystudy TerminologyTerminology OstomyOstomy——externalexternal openingopening Colostomy,Colostomy, ileostomyileostomy DistalDistal segmentsegment MucusMucus fistula,fistula, HartmannHartmann’’ss pouch,pouch, looploop --ectomyectomy——resectionresection Colectomy,Colectomy, proctocolectomyproctocolectomy,, abdominoperinealabdominoperineal resectionresection (APR),(APR), lowlow anterioranterior resectionresection DiverticularDiverticular DiseaseDisease TrueTrue diverticuladiverticula——allall layers,layers, rarerare inin coloncolon AcquiredAcquired (false(false oror pseudopseudo--)) diverticuladiverticula—— mucosalmucosal herniationherniation throughthrough musclemuscle RelatedRelated toto diet,diet, straining,straining, ageage DiverticulosisDiverticulosis——presencepresence ofof diverticuladiverticula DiverticulitisDiverticulitis——infectiousinfectious processprocess DiverticulosisDiverticulosis MultipleMultiple falsefalse diverticuladiverticula ofof coloncolon MostMost commonlycommonly inin sigmoidsigmoid 80%80% asymptomaticasymptomatic findingfinding onon BE,BE, otherother studystudy SymptomsSymptoms——LLQLLQ pain,pain, changechange inin bowelbowel habits,habits, bleedingbleeding TreatmentTreatment——highhigh fiberfiber dietdiet DiverticulitisDiverticulitis Obstructed, infected diverticula Micro or macro perforation 1/6 of patients with –osis will have –itis Pain, change in bowel habits, possible mass, fever, white count, peritoneal signs Complications—44% perf or abscess, 8% fistula, 4% obstruction Diagnosis—CT, BE, scope later Treatment—antibiotics, hydration, NPO Surgery for severe complication or repeated bouts FistulaFistula formationformation ColovesicalColovesical mostmost commoncommon (4%)(4%) UTI,UTI, fecaluriafecaluria,, pneumaturiapneumaturia OtherOther causescauses——cancer,cancer, CrohnCrohn’’s,s, radiation,radiation, traumatrauma DiagnosisDiagnosis——contrastcontrast——BE,BE, cystocysto,, IVP,IVP, methylenemethylene blueblue TreatmentTreatment----surgicalsurgical DiverticularDiverticular BleedingBleeding BleedingBleeding primaryprimary symptomsymptom inin 55--10%10% OccasionallyOccasionally massivemassive (>4(>4 unitsunits inin 2424 hours)hours) BleedingBleeding distaldistal toto LigamentLigament ofof TreitzTreitz——70%70% diverticular,diverticular, 25%25% isis massivemassive DifferentialDifferential——angiodysplasiaangiodysplasia,, solitarysolitary ulcers,ulcers, varicesvarices,, cancer,cancer, rarelyrarely IBDIBD DiagnosisDiagnosis——endoscopy,endoscopy, angioangio ColonicColonic PolypsPolyps InflammatoryInflammatory polypspolyps ((pseudopolypspseudopolyps))——IBDIBD HamartomasHamartomas (juvenile(juvenile polyps,polyps, PeutzPeutz--JehgersJehgers syndrome)syndrome)——benign,benign, maymay regressregress AdenomasAdenomas——premalignant,premalignant, esp.esp. >2>2--33 cmcm Tubular-7%, tubulovillous-20%, villous-33% PedunculatedPedunculated——onon stalk,stalk, removeremove byby scopescope SessileSessile (flat)(flat)--removeremove surgicallysurgically FamilialFamilial polyposispolyposis oror GardnerGardner’’ss syndromesyndrome——totaltotal abdominalabdominal colectomy,colectomy, mucosalmucosal proctectomyproctectomy,, ileoanalileoanal pullthroughpullthrough ColonColon CancerCancer 55,00055,000 deathsdeaths annuallyannually 140,000140,000 newnew casescases eacheach yearyear MoreMore occuroccur onon lowerlower leftleft side?side? SynchronousSynchronous (simultaneous)(simultaneous) inin 5%5% MetachronousMetachronous (second(second developsdevelops afterafter resection)resection) inin 33--5%5% th PeakPeak atat 70,70, startstart inin 44th decadedecade FamilialFamilial polyposispolyposis,, GardnerGardner’’s,s, UC,UC, CrohnCrohn’’s,s, polypspolyps ColonColon CancerCancer 55 yearyear survivalsurvival——60%60% EffectiveEffective screeningscreening EffectiveEffective screeningscreening strategies,strategies, basedbased onon riskrisk Mild risk factors—age, diet, physical inactivity, obesity, smoking, race, alcohol Intermediate risk factors—personal history of colon cancer or adenoma or strong family history High risk factors—familial polyposis, Gardner’s, patients with UC or Crohn’s for > 10 years ScreeningScreening——MildMild RiskRisk BeginningBeginning atat ageage 50,50, oneone ofof below:below: YearlyYearly fecalfecal occultoccult bloodblood testtest plusplus flexibleflexible sigmoidoscopysigmoidoscopy qq 55 yearsyears FlexFlex sigsig qq 55 yearsyears YearlyYearly fecalfecal occultoccult bloodblood testtest ColonoscopyColonoscopy qq 1010 yearsyears DoubleDouble contrastcontrast BEBE qq 55 yearsyears ScreeningScreening——GreaterGreater RiskRisk IntermediateIntermediate riskrisk BeginBegin atat 4040 DoDo moremore frequentlyfrequently——qq 33--55 yearsyears HighHigh riskrisk——functionfunction ofof durationduration BloodBlood teststests forfor familialfamilial polyposispolyposis,, HNPCCHNPCC ScreeningScreening beginbegin inin teensteens UC/CrohnUC/Crohn’’ss forfor 1010 years,years, annualannual colonoscopycolonoscopy ConsiderConsider prophylacticprophylactic totaltotal colectomycolectomy ColonColon CancerCancer——SignsSigns andand SymptomsSymptoms RightRight--sidedsided——occultoccult bloodblood loss,loss, anemiaanemia LeftLeft--sidedsided——obstruction,obstruction, macromacro bleedingbleeding RectalRectal——bleeding,bleeding, obstruction,obstruction, alternatingalternating diarrheadiarrhea andand constipationconstipation ChangeChange inin bowelbowel habitshabits and/orand/or bleeding:bleeding: RectalRectal exam,exam, occultoccult bloodblood testtest BEBE oror colonoscopycolonoscopy ColonColon CancerCancer——PreopPreop EvaluationEvaluation ColonoscopyColonoscopy——synchronoussynchronous lesionslesions CTCT---- ++ oror –– CEACEA bloodblood testtest TreatmentTreatment——surgerysurgery toto removeremove primary,primary, evaluateevaluate extentextent ofof spread,spread, allowallow stagingstaging andand planplan furtherfurther therapytherapy ColonColon CancerCancer----StagingStaging DukesDukes--AstlerAstler--CollerColler SystemSystem TMNTMN StagingStaging BothBoth evaluateevaluate extentextent ofof penetrationpenetration throughthrough colon,colon, nodalnodal involvement,involvement, andand distaldistal metsmets AdjuvantAdjuvant chemotherapychemotherapy——5FU,5FU, othersothers Radiation,Radiation, especiallyespecially inin pelvispelvis StagingStaging AJCC/TNM Dukes Astler-Coller 0 IAA, B1 IIA B B2 IIB B B3 IIIA C C1 IIIB C C2, C3 IIIC C C1, C2, C3 IV D ColonColon CancerCancer----FollowupFollowup CurativeCurative resection,resection, nono adjuvantadjuvant therapytherapy indicatedindicated MonthlyMonthly exam,exam, bimonthlybimonthly CEA,CEA, scopescope oror BEBE qq 66 monthsmonths forfor firstfirst twotwo yearsyears PETPET scanscan CTCT scansscans IBDIBD——UlcerativeUlcerative ColitisColitis MucosaMucosa andand submucosasubmucosa ofof coloncolon andand rectumrectum BimodalBimodal distributiondistribution——2/32/3 occuroccur atat 1515--30,30, remainderremainder atat 5555 10/100,00010/100,000 populationpopulation FamilyFamily historyhistory inin 20%20% RectumRectum involvedinvolved inin >90%>90% withwith proximalproximal extensionextension UlcerativeUlcerative ColitisColitis PresentationPresentation——variablevariable Watery diarrhea with blood, pus, mucus Cramping, abdominal pain, tenesmus, urgency Weight loss, dehydration, pain, fever Fulminant—toxic megacolon, sepsis, shock Extraintestinal signs: ankylosing spondylitis, peripheral arthritis, uveitis, pyoderma gangrenosum, sclerosing cholangitis, pericholangitis, pericarditis Complications: toxic megacolon, colon perforation, massive hemorrhage, anorectal complication, cancer IBDIBD——CrohnCrohn’’ss DiseaseDisease TransmuralTransmural disease,disease, anywhereanywhere inin GIGI tracttract MinorityMinority——limitedlimited toto colorectalcolorectal