COLORECTAL SURGERY

(A)Anal fissure:
Anal fissures are a common cause of painful, bright red, rectal bleeding.
Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90%
cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous.
Multiple fissures and those which are located at other sites are more likely to be due to an underlying cause.
Diseases associated with fissure in ano include:
• Crohns disease
• Tuberculosis
• Internal rectal prolapse

Diagnosis
In most cases the defect can be visualised as a posterior midline epithelial defect. Where symptoms are
highly suggestive of the condition and examination findings are unclear an examination under anaesthesia
may be helpful. Atypical disease presentation should be investigated
with colonoscopy and EUA with biopsies of the area.

Treatment
Stool softeners are important as the hard stools may tear the
epithelium and result in recurrent symptoms. The most
effective first line agents are topically applied GTN (0.2%)
or Diltiazem (2%) paste. Side effects of diltiazem are better
tolerated.
Resistant cases may benefit from injection of botulinum toxin or lateral internal
sphincterotomy (beware in females). Advancement flaps may be used to treat resistant cases.
Sphincterotomy produces the best healing rates. It is associated with incontinence to flatus in
up to 10% of patients in the long term

(2)Anal Fistula
Fistula in ano is the most common form of ano rectal sepsis. Fistulae will have both an
internal opening and external opening, these will be connected by tract(s). Complexity arises
because of the potential for multiple entry and exit sites, together with multiple tracts.
Fistulae are classified into four main groups according to anatomical location and the degree
of sphincter involvement. Simple uncomplicated fistulae are low and do not involve more
than 30% of the external sphincter. Complex fistulae involve the sphincter, have multiple
branches or are non cryptoglandular in origin

Assessment
Examination of the perineum for signs of trauma, external openings or the stigmata of IBD is

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important. Digital rectal examination may
reveal the cord linking the internal and external
openings. At the same time the integrity of the
sphincter mechanism can be assessed. Low,
uncomplicated fistulas may not require any
further assessment, other groups will usually
require more detailed investigation. For the
fistula, the use of endo-anal USS with
instillation of hydrogen peroxide into the fistula
tract may be helpful. Ano-rectal MRI scanning
is also a useful tool, it is sensitive and specific
for the identification of fistula anatomy,
branching tracts and identifying occult
sphincter involvement.

Identification of the
internal opening
Fistulas with an external opening less than
3cm from the anal verge will typically obey
Goodsalls rule (see below).

Therapies

(1)Seton suture
A seton is a piece of material that is passed
through the fistula between the internal and external openings that allows the drainage of
sepsis. This is important as undrained septic foci may drain along the path of least resistance,
which may result in the development of accessory tracts and openings. Their main use is in
treating complex fistula. Two types of seton are recognised, simple and cutting.
(1)Simple setons lie within the fistula tract and encourage both drainage and fibrosis.
(2)A cutting seton is inserted and the skin incised. The suture is tightened and re-tightened
at regular intervals. This may convert a high fistula to a low fistula. Since the tissue will scar
surrounding the fistula it is hoped that this technique will minimise incontinence.
Unfortunately, a large retrospective review of the literature related to the use of cutting
setons has found that they are associated with a 12% long term incontinence rate

(2)Fistulotomy
Low fistulas, that are simple should be treated by fistulotomy once the acute sepsis has been

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controlled. Fistulotomy (where safe) provides the
highest healing rates. Because fistulotomy is
regarded as having a high cure rate, there are
some who prefer to use this technique with more
extensive sphincter involvement.
In these patients the fistulotomy is performed as
for a low fistula. However, the muscle that is
encountered is then divided and reconstructed
with an overlapping sphincter repair.
A price is paid in terms of incontinence with this
technique and up to 12.5% of patients who were
continent pre-operatively will have issues relating
to continence post procedure. The same group also randomised between fistulotomy and
sphincter reconstruction and ano-rectal advancement flaps for the treatment of complex
cryptoglandular fistulas and reported similar outcomes in terms of recurrence (>90%) and
disturbances to continence (20%).

Other authors have found adverse outcomes following fistulotomy in patients who have
undergone previous surgery, are of female gender or who have high internal openings , in
these patients careful assessment of pre-operative sphincter function should be considered
mandatory prior to fistulotomy.

(3)Anal Fistula Plugs And Fibrin Glue

The desire to avoid injury to the sphincter complex has led to surgeons using both fibrin glue
and plugs to try and improve fistula healing. Meticulous preparation of the tract and prior use
of a draining seton is likely to improve chances of success.
The use of anal fistula plugs in high transphincteric fistula of cryptoglandular origin is to be
discouraged because of the high incidence of non response in patients treated with such
devices. In most patients septic complications are the reasons for failure. Fibrin glue is a
popular option for the treatment of fistula. There is variability of reported healing rates In
some cases initial success rates of up to 50% healing at six months are reported (in patients
with complex cryptogenic fistula). Of these successes 25% suffer a long term recurrence of
fistula. There are, however, no obvious cases of damage to the sphincter complex and the use
of the devices does not appear to adversely impact on subsequent surgical options.

(4)Ano-rectal advancement flaps

This procedure is primarily directed at high fistulae, and is considered attractive as a
sphincter saving operation. The procedure is performed either with the patient in the prone

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jack knife position or in lithotomy (depending upon the site of the fistula). The dissection is
commenced in the sub mucosal plane (which may be infiltrated with dilute adrenaline
solution to ease dissection). The dissection is continued into healthy proximal tissue. This is
brought down and sutured over the defect.
Follow up of patients with cryptoglandular fistulas treated with advancement flaps shows a
success in up to 80% patients. With most recurrences occurring in the first 6 months
following surgery. Continence was affected in some patients, with up to 10% describing
major continence issues post operatively.

(5)Ligation of the intersphincteric tract

procedure
In this procedure an incision is made in the intersphincteric groove and the fistula tract dissected out in this plane and
divided. A greater than 90% cure rate within 4 weeks was initially reported[15]. Others have subsequently performed
similar studies on larger numbers of patients with similar success rates.

**Fistulotomy at the time of abscess drainage?

A Cochrane review conducted in 2010 suggests that primary fistulotomy for low, uncomplicated fistula in ano may be
safe and associated with better outcomes in relation to long term chronic sepsis[16]. However, there is a danger that
such surgery performed by non specialists may result in a higher complication rate and therefore the traditional
teaching is that primary treatment of acute sepsis is incision and drainage only. All agree that high/ complex fistulae
should never be subject to primary fistulotomy in the acute setting.

(3)Ano Rectal Disease

Location: 3, 7, 11 o'clock position
Haemorrhoids Internal or external
Treatment: Conservative, Rubber band ligation,
Haemorrhoidectomy
Fissure in ano Location: midline 6 (posterior midline 90%) and 12 o'clock position.
Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal
papillae
Proctitis Causes: Crohn's, ulcerative colitis, Clostridium difficile
Ano rectal E.coli, staph aureus
Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric
abscess
Anal fistula Usually due to previous ano-rectal abscess
Intersphincteric, transsphincteric, suprasphincteric, and
extrasphincteric. Goodsalls rule determines location

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Rectal Associated with childbirth and rectal intussceception. May be internal
or external
prolapse
Pruritus ani Systemic and local causes
Anal Squamous cell carcinoma commonest unlike adenocarcinoma in
rectum
neoplasm
Solitary rectal Associated with chronic straining and constipation. Histology shows
ulcer mucosal thickening, lamina propria replaced with collagen and
smooth muscle (fibromuscular obliteration)

(4)Rectal Prolapse
• Common especially in multiparous women.
• May be internal or external.
• Internal rectal prolapse can present insidiously.
• External prolapse can ulcerate and in long term impair continence.
• Diagnostic work up includes colonoscopy, defecating proctogram, ano rectal
manometry studies and if doubt exists an examination under anaesthesia.

Treatments For Prolapse

• In the acute setting reduce it (covering it with sugar may reduce swelling.
• Delormes procedure which excises mucosa and plicates the rectum (high
recurrence rates) may be used for external prolapse.
• Altmeirs procedure which resects the colon via the perineal route has lower
recurrence rates but carries the risk of anastamotic leak.
• Rectopexy is an abdominal procedure in which the rectum is elevated and usually
supported at the level of the sacral promontory. Post operative constipation may be
reduced by limiting the dissection to the anterior plane (laparoscopic ventral mesh
rectopexy).

Pruritus Ani
• Extremely common.
• Check not secondary to altered bowel
habits (e.g. Diarrhoea)
• Associated with underlying diseases such
as haemorrhoids.
• Examine to look for causes such as
worms.
• Proctosigmoidoscopy to identify
associated haemorrhoids and exclude
cancer.

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 • Treatment is largely supportive and patients should avoid using perfumed products
around the area.

Fissure In Ano
• Typically painful PR bleeding (bright red).
• Nearly always in the posterior midline.
• Usually solitary.

Treatment
• Stool softeners.
• Topical diltiazem (or GTN).
• If topical treatments fail then botulinum toxin should be injected.
• If botulinum toxin fails then males should probably undergo lateral internal
sphincterotomy.
• Females who do not respond to botulinum toxin should undergo ano rectal manometry
studies and endo anal USS prior to being offered surgery such as sphincterotomy

(5)Appendicitis
History
• Peri umbilical abdominal pain (visceral stretching of appendix lumen and appendix is
mid gut structure) radiating to the right iliac fossa due to localised parietal peritoneal
inflammation.
• Vomit once or twice but marked and persistent vomiting is unusual.
• Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation
and some loose stools. A pelvic abscess may also cause diarrhoea.
• Mild pyrexia is common - temperature is usually 37.5 -38oC. Higher temperatures are
more typical of conditions like mesenteric adenitis.
• Anorexia is very common. It is very unusual for patients with appendicitis to be
hungry.

Examination
• Generalised peritonitis if perforation has occurred or localised peritonism.
• Retrocaecal appendicitis may have relatively few signs.
• Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or
even tenderness with a pelvic appendix.

Diagnosis
• Typically raised inflammatory markers coupled with compatible history and
examination findings should be enough to justify appendicectomy.
• Urine analysis may show mild leucocytosis but no nitrites.

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 • Ultrasound is useful in females where pelvic organ pathology is suspected. Although it
is not always possible to visualise the appendix on ultrasound, the presence of free
fluid (always pathological in males) should raise suspicion.

Treatment
• Appendicectomy which can be performed via either an open or laparoscopic approach.
• Administration of metronidazole reduces wound infection rates.
• Patients with perforated appendicitis require copious abdominal lavage.
• Patients without peritonitis who have an appendix mass should receive broad spectrum
antibiotics and consideration given to performing an interval appendicectomy.
• Be wary in the older patients who may have either an underlying caecal malignancy or
perforated sigmoid diverticular disease

(7)Benign Proctology
Condition Features Treatment
Painful, bright red rectal Stool softeners, topical
Fissure In bleeding diltiazem or GTN, botulinum
Ano toxin, Sphincterotomy
Painless, bright red rectal Stool softeners, avoid
Haemorroids bleeding occurs following straining, surgery (see below)
defecation and bleeds onto the
toilet paper and into the toilet
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 pan
May initially present with an Lay open if low, no sphincter
Fistula In Ano abscess and then persisting involvement or IBD, if
discharge onto the perineum, complex, high or IBD insert
separate from the anus seton and consider other
options (see below)
Peri anal swelling and Incision and drainage, leave
Peri Anal surrounding erythema the cavity open to heal by
Abscess secondary intention
Peri anal itching, occasional Avoid scented products, use
Pruritus Ani mild bleeding (if severe skin wet wipes rather than tissue,
damage) avoidance of scratching,
ensure no underlying faecal
incontinence

Overview Of Surgical Therapies

(1)Haemorroidal Disease
The treatment of haemorroids is usually
conservative. Acutely thrombosed haemorroids
may be extremely painful. Treatment of this acute
condition is usually conservative and consists of
stool softeners, ice compressions and topical
GTN or diltiazem to reduce sphincter spasm.
Most cases managed with this approach will settle
over the next 5-7 days. After this period there
may be residual skin tags that merit surgical excision or indeed residual haemorroidal disease
that may necessitate haemorroidectomy.

Patients with more chronic symptoms are managed according to the stage of their disease,
small mild internal haemorroids causing little symptoms are best managed conservatively.
More marked symptoms of bleeding and occasional prolapse, where the haemorroidal
complex is largely internal may benefit from stapled haemorroidopexy. This procedure
excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply. At
the same time the excisional component of the procedure means that the haemorroids are less
prone to prolapse. Adverse effects of this procedure include urgency, which can affect up to
40% of patients (but settles over 6-12 months) and recurrence. The procedure does not
address skin tags and therefore this procedure is unsuitable if this is the dominant symptom.
Large haemorroids with a substantial external component may be best managed with a
Milligan Morgan style conventional haemorroidectomy. In this procedure three
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haemorroidal cushions are excised, together with their
vascular pedicle. Excision of excessive volumes of tissue
may result in anal stenosis. The procedure is quite painful
and most surgeons prescribe metronidazole post
operatively as it decreases post operative pain.

(2)Fissure In Ano
Probably the most efficient and definitive treatment for
fissure in ano is lateral internal sphincterotomy.
The treatment is permanent and nearly all patients will
recover. Up to 30% will develop incontinence to flatus.
There are justifiable concerns about using this procedure
in females as pregnancy and pelvic floor damage together with a sphincterotomy may result
in faecal incontinence.
The usual first line therapy is relaxation of the internal sphincter with either GTN or
diltiazem (the latter being better tolerated) applied topically for 6 weeks.
Treatment failures with topical therapy will usually go on to have treatment with botulinum
toxin. This leads to more permanent changes in the sphincter and this may facilitate healing.
Typical fissures usually present in the posterior midline, multiple or unusually located
fissures should prompt a search for an underlying cause such as inflammatory bowel disease
or internal prolapse.
Refractory cases where the above treatments have failed may be considered for advancement
flaps.

(3)Fistula In Ano
The most effective treatment for fistula is laying it open (fistulotomy). When the fistula is
below the sphincter and uncomplicated, this is a reasonable option. Sphincter involvement
and complex underlying disease should be assessed both surgically and ideally with imaging
(either MRI or endoanal USS). Surgery is then usually staged, in the first instance a
draining seton suture may be inserted.
This avoids the development of recurrent sepsis and may allow resolution. In patients with
Crohns disease the seton should be left in situ long term and the patient managed medically,
as in these cases attempts at complex surgical repair nearly always fail. Fistulas not
associated with IBD may be managed by advancement flaps, instillation of plugs and glue is
generally unsuccessful. A newer technique of ligation of intersphincteric tract (LIFT
procedure) is reported to have good results in selected centres

(8)Colonic Obstruction
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 Cause Features Treatment
• Usually insidious onset Establish diagnosis (e.g.
Cancer • History of progressive contrast enema/
constipation endoscopy)
• Systemic features (e.g. Laparotomy and
anaemia) resection, stenting,
• Abdominal distension defunctioning colostomy
• Absence of bowel gas or bypass
distal to site of obstruction
• Usually history of previous Once diagnosis
Diverticular acute diverticulitis established, usually
• Long history of altered surgical resection
stricture bowel habit Colonic stenting should
• Evidence of diverticulosis not be performed for
on imaging or endoscopy benign disease
• Twisting of bowel around Initial treatment is to
Volvulus its mesentery untwist the loop, a
• Sigmoid colon affected in flexible sigmoidoscopy
76% cases may be needed
• Patients usually present Those with clinical
with abdominal pain, evidence of ischaemia
bloating and constipation should undergo surgery
• Examination usually shows Patient with recurrent
asymmetrical distension volvulus should undergo
• Plain X-rays usually show resection
massively dilated sigmoid
colon, loss of haustra and
U shape are typical, the
loop may contain fluid
levels
• Symptoms and signs of Colonoscopic
Acute large bowel obstruction decompression
with no lesion Correct metabolic
colonic • Usually associated with disorders
pseudo- •
metabolic disorders
Usually a cut off in the left
IV neostigmine
Surgery
obstruction •
colon (82% cases)
Although abdomen tense
and distended, it is usually
not painful
• All patients should
undergo contrast enema
(may be therapeutic)

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(9)Colonic Polyps
May occur in isolation, or greater numbers as part of the polyposis syndromes. In FAP
greater than 100 polyps are typically present. The risk of malignancy in association with
adenomas is related to size, and is the order of 10% in a 1cm adenoma. Isolated adenomas
seldom give risk of symptoms (unless large and distal). Distally sited villous lesions may
produce mucous and if very large, electrolyte disturbances may occur.

Follow Up Of Colonic Polyps

Group Action
Colorectal cancer Colonoscopy 1 year post resection
Large non pedunculated colorectal One off scope at 3 years
polyps (LNPCP), R0 resection
Large non pedunculated colorectal Site check at 2-6 months and then
polyps (LNPCP) R1 or non en bloc a further scope at 12 months
resection
High risk findings at baseline One off surveillance at 3 years
colonoscopy
No high risk findings at baseline No colonoscopic surveillance and
colonoscopy invite participation in NHSBCSP
programme when due

High Risk Findings

• More than 2 premalignant polyps including 1 or more advanced colorectal polyps
OR
• More than 5 pre malignant polyps

Exceptions to guidelines
If patient more than 10 years younger than lower screening age and has polyps but no high
risk findings, consider colonoscopy at 5 or 10 years.

Segmental resection or complete colectomy should be considered when:

1. Incomplete excision of malignant polyp
2. Malignant sessile polyp
3. Malignant pedunculated polyp with submucosal invasion
4. Polyps with poorly differentiated carcinoma
5. Familial polyposis coli
-Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy
-Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy.

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Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.

Colonic Pseudo-Obstruction
Colonic pseudo-obstruction is characterised by the progressive and painless dilation of the
colon. The abdomen may become grossly distended and tympanic. Unless a complication
such as impending bowel necrosis or perforation occurs, there is usually little pain.
Diagnosis involves excluding a mechanical bowel obstruction with a plain film and
contrast enema. The underlying cause is usually electrolyte imbalance and the condition
will resolve with correction of this and supportive care.
Patients who do not respond to supportive measures should be treated with attempted
colonoscopic decompression and/ or the drug neostigmine. In rare cases surgery may be
required.

(10)Colorectal Cancer Treatment

Patients diagnosed as having colorectal cancer should be completely staged using CT of the
chest/ abdomen and pelvis. Their entire colon should have been evaluated with colonoscopy
or CT colonography. Patients whose tumours lie below the peritoneal reflection should
have their mesorectum evaluated with MRI.

Once their staging is complete patients should be discussed within a dedicated colorectal
MDT meeting and a treatment plan formulated.

(1)Treatment Of Colonic Cancer

Cancer of the colon is nearly always treated with surgery. Stents, surgical bypass and
diversion stomas may all be used as palliative adjuncts. Resectional surgery is the only
option for cure in patients with colon cancer.
The procedure is tailored to the patient and the tumour location. The lymphatic drainage of
the colon follows the arterial supply and therefore most resections are tailored around the
resection of particular lymphatic chains (e.g. ileo-colic pedicle for right sided tumours).
Some patients may have confounding factors that will govern the choice of procedure, for
example a tumour in a patient from a HNPCC
family may be better served with a
panproctocolectomy rather than segmental
resection.

Following resection the decision has to be made

regarding restoration of continuity. For an
anastomosis to heal the key technical factors
include; adequate blood supply, mucosal

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apposition and no tissue tension. Surrounding sepsis, unstable patients and inexperienced
surgeons may compromise these key principles and in such circumstances it may be safer to
construct an end stoma rather than attempting an anastomosis.
When a colonic cancer presents with an obstructing lesion; the options are to either stent it or
resect. In modern practice it is unusual to simply defunction a colonic tumour with a
proximal loop stoma. This differs from the situation in the rectum (see below).
Following resection patients with risk factors for disease recurrence are usually offered
chemotherapy, a combination of 5FU and oxaliplatin is common.

(2)Rectal Cancer:
The management of rectal cancer is slightly different to that of colonic cancer.
This reflects the rectum's anatomical location and the challenges posed as a
result.
Tumours located in the rectum can be surgically resected with either an anterior
resection or an abdomino - perineal resection.
The technical aspects governing the choice between these two procedures can be
complex to appreciate and the main point to appreciate for the MRCS is that
involvement of the sphincter complex or very low tumours require APER.

In the rectum a 2cm distal clearance margin is required and this may also impact
on the procedure chosen. In addition to excision of the rectal tube an integral part
of the procedure is a meticulous dissection of the mesorectal fat and lymph nodes
(total mesorectal excision/ TME).
In rectal cancer surgery invovlement of the cirumferential resection margin
carries a high risk of disease recurrence. Because the rectum is an extraperitoneal
structure (until you remove it that is!) it is possible to irradiate it, something
which cannot be offered for colonic tumours.

This has a major impact in rectal cancer treatment and many patients will be
offered neoadjuvent radiotherapy (both long and short course) prior to
resectional surgery. Patients with T1, 2 and 3 /N0 disease on imaging do not
require irradiation and should proceed straight to surgery. Patients with T4
disease will typically have long course chemo radiotherapy.
Patients presenting with large bowel obstruction from rectal cancer should not
undergo resectional surgery without staging as primary treatment (very different
from colonic cancer). This is because rectal surgery is more technically
demanding, the anastomotic leak rate is higher and the danger of a positive
resection margin in an unstaged patient is high. Therefore patients with
obstructing rectal cancer should have a defunctioning loop colostomy.

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Summary Of Procedures
The operations for cancer are segmental resections based on blood supply and lymphatic drainage. These
commonly performed procedures are core knowledge for the MRCS and should be understood.

Site of Type of resection Anastomosis Risk of

cancer leak
Right colon Right hemicolectomy Ileo-colic Low <5%
Transverse Extended right Ileo-colic Low <5%
hemicolectomy
Splenic flexure Extended right Ileo-colic Low <5%
hemicolectomy
Splenic flexure Left hemicolectomy Colo-colon 2-5%
Left colon Left hemicolectomy Colo-colon 2-5%
Sigmoid colon High anterior resection Colo-rectal 5%
Upper rectum Anterior resection (TME) Colo-rectal 5%
Low rectum Anterior resection (Low Colo-rectal 10%
TME) (+/-
Defunctioning
stoma)
Anal verge Abdomino-perineal excision None n/a
of colon and rectum
In the emergency setting, where the bowel has perforated, the risk of an anastomotic breakdown is much
greater, particularly when the anastomosis is colon-colon. In this situation, an end colostomy is often safer
and can be reversed later. When resection of the sigmoid colon is performed and an end colostomy is
fashioned the operation is referred to as a Hartmans procedure. Whilst left sided resections are more risky,
ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

Diverticular disease
Diverticular disease is a common surgical problem. It consists of herniation of colonic
mucosa through the muscular wall of the colon. The usual site is between the taenia coli
where vessels pierce the muscle to supply the mucosa. For this reason, the rectum, which
lacks taenia, is often spared.

Symptoms
• Altered bowel habit
• Bleeding
• Abdominal pain
Complications
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 • Diverticulitis
• Haemorrhage
• Development of fistula
• Perforation and faecal peritonitis
• Perforation and development of abscess
• Development of diverticular phlegmon

Diagnosis
Patients presenting in clinic will typically undergo either a colonoscopy, CT cologram or
barium enema as part of their diagnostic work up. All tests can identify diverticular disease.
It can be far more difficult to confidently exclude cancer, particularly in diverticular
strictures.

Acutely unwell surgical patients should be investigated in a systematic way. Plain abdominal
films and an erect chest x-ray will identify perforation. An abdominal CT scan (not a CT
cologram) with oral and intravenous contrast will help to identify whether acute
inflammation is present but also the presence of local complications such as abscess
formation.
Severity Classification- Hinchey
I Para-colonic abscess
II Pelvic abscess
III Purulent peritonitis
IV Faecal peritonitis
Treatment
• Increase dietary fibre intake.
• Mild attacks of diverticulitis may be managed conservatively with antibiotics.
• Peri colonic abscesses should be drained either surgically or radiologically.
• Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative
indication for a segmental resection.
• Hinchey IV perforations (generalised faecal peritonitis) will require a resection and
usually a stoma. This group have a very high risk of post operative complications and
usually require HDU admission

(11)Fistulas
• A fistula is defined as an abnormal connection between two epithelial surfaces.
• There are many types ranging from Branchial fistulae in the neck to entero-cutaneous
fistulae abdominally.
• In general surgical practice the abdominal cavity generates the majority and most of
these arise from diverticular disease and Crohn's.
• As a general rule all fistulae will resolve spontaneously as long as there is no distal
obstruction. This is particularly true of intestinal fistulae.

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The four types of fistulae are:
(1)Enterocutaneous
These link the intestine to the skin. They may be high (>500ml) or low output (<250ml)
depending upon source. Duodenal /jejunal fistulae will tend to produce high volume,
electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous
fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous
rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or
may occur as a result of iatrogenic input. In some cases it may even be surgically desirable
e.g. mucous fistula following sub total colectomy for colitis.
Suspect if there is excess fluid in the drain.
(2)Enteroenteric or Enterocolic
This is a fistula that involves the large or small intestine. They may originate in a similar
manner to enterocutaneous fistulae. A particular problem with this fistula type is that
bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly
serious in inflammatory bowel disease.

(3)Enterovaginal
Aetiology as above.

(4)Enterovesical
This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract
infections, or the passage of gas from the urethra during urination.

Management
Some rules relating to fistula management:
• They will heal provided there is no underlying
inflammatory bowel disease and no distal
obstruction, so conservative measures may be
the best option
• Where there is skin involvement, protect the
overlying skin, often using a well fitted stoma
bag- skin damage is difficult to treat
• A high output fistula may be rendered more
easily managed by the use of octreotide, this
will tend to reduce the volume of pancreatic
secretions.

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 • Nutritional complications are common especially with high fistula (e.g. high jejunal or
duodenal) these may necessitate the use of TPN to provide nutritional support together
with the concomitant use of octreotide to reduce volume and protect skin.
• When managing perianal fistulae surgeons should avoid probing the fistula where
acute inflammation is present, this almost always worsens outcomes.
• When perianal fistulae occur secondary to Crohn's disease the best management
option is often to drain acute sepsis and maintain that drainage through the judicious
use of setons whilst medical management is implemented.
• Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have
an intra abdominal source the use of barium and CT studies should show a track. For
perianal fistulae surgeons should recall Goodsall's rule in relation to internal and
external openings

(12)IBD
Ulcerative colitis Vs Crohns
Crohn's disease Ulcerative colitis
Distribution Mouth to anus Rectum and colon
Macroscopic Cobblestone appearance, Contact bleeding
changes apthoid ulceration
Depth of disease Transmural inflammation Superficial
inflammation
Distribution Patchy Continuous
pattern
Histological Granulomas (non caseating Crypt abscesses,
features epithelioid cell aggregates Inflammatory cells in
with Langerhans' giant cells) the lamina propria

Surgical Treatment
(1)Ulcerative Colitis
In UC the main place for surgery is when medical treatment has failed, in the emergency setting this will be a sub total
colectomy, end ileostomy and a mucous fistula. Electively it will be a pan proctocolectomy, an ileoanal pouch may be
a selected option for some. Remember that longstanding UC increases colorectal cancer risk.

(2)Crohn's Disease
Unlike UC Crohn's patients need to avoid surgeons, minimal resections are the rule. They should not have ileoanal

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pouches as they will do poorly with them. Management of Crohn's ano rectal sepsis is with a minimal approach,
simply drain sepsis and use setons to facilitate drainage. Definitive fistula surgery should be avoided

Ileostomy:
Ileostomies are generally fashioned in the right iliac fossa in a triangle between the anterior superior iliac spine,
symphysis pubis and umbilicus.
They should lie one-third of the distance between the umbilicus and anterior superior iliac spine.
A 2cm skin incision is made and dissection continued through the rectus muscle.
A cruciate incision should be made, and generally dilated to admit two fingers. The ileum is brought through the
incisions and should generally be spouted to a final length of 2.5cm. Ileostomies that are too short may cause problems
with appliance fixation and those which are too long may cause problems with tension and subsequent ulceration or
prolapse.
Complications following ileostomy construction include dermatitis (most common), bowel obstruction (usually
adhesional) and prolapse.
Ileostomy output is roughly in the range of 5-10ml/Kg/ 24 hours.
Output in excess of 20ml/Kg/24 hours usually requires supplementary intravenous fluids. Excessive fluid losses are
generally managed by administration of oral loperamide (up to 4mg QDS) to try and slow the output. Foods
containing gelatine may also thicken output. Early high output is not uncommon and most patients (50%) will respond
to conservative management.

Large bowel obstruction

Colonic obstruction remains a common surgical problem.
It is most commonly due to malignancy (60%) and diverticular disease (20%). Volvulus affecting the colon
accounts for 5% of cases.

Acute colonic pseudo-obstruction(OGLIVIE $)

remains a potential differential diagnosis in all cases. Intussusception affecting the colon (most often due to tumours in
the adult population) remains a rare but recognised cause.
The typical patient will present with gradual onset of progressive abdominal distension, colicky abdominal pain
and either obstipation or absolute constipation.(Four Cardinal Symptoms)

On examination abdominal distension is present, the presence of caecal tenderness (assuming no overt evidence of
peritonitis) is a useful sign to elicit. A digital rectal examination and rigid sigmoidoscopy should be performed.
A plain abdominal x-ray is the usual first line test and; the caecal diameter and ileocaecal valve competency should be
assessed on this film.

Imaging modalities
Debate long surrounds the use of CT versus
gastrograffin enemas.
The latter investigation has always been the traditional
method of determining whether a structural lesion is
indeed present. However, in the UK the use of this
technique has declined and in most units a CT scan will
be offered as the first line investigation by the majority
of radiologists (and is advocated by the ACPGBI). In
most cases this will provide sufficient detail to allow
operative planning, and since malignancy accounts for

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most presentations may also stage the disease. In the event that the radiologist cannot provide a clear statement of
lesion site, the surgeon should have no hesitation in requesting a contrast enema.

Surgical Options
The decision as to when to operate or not is determined firstly by the patients physiological status. Unstable patients
require resuscitation prior to surgery and admission to a critical care unit for invasive monitoring and potential
inotropic support may be needed. In patients who are otherwise stable the decision then rests on the radiological and
clinical findings.
As a general rule the old adage that the sun should not rise and set on unrelieved large bowel obstruction still holds
true. A caecal diameter of 12cm or more in the presence of complete obstruction with a competent ileocaecal valve
and caecal tenderness is a sign of impending perforation and a relative indication for prompt surgery.

(1)Right Sided And Transverse Lesions

Right sided lesions producing large bowel obstruction should generally be treated by right hemicolectomy or its
extended variant if the lesion lies in the distal transverse colon or splenic flexure. In these cases an ileocolic
anastomosis may be easily constructed and even in the emergency setting has a low risk of anastomotic leak.

(2)Left Sided Lesions

The options here lie between sub total colectomy and anastomosis, left hemicolectomy with on table lavage and
primary anastomosis, left hemicolectomy and end colostomy formation and finally colonic stent insertion.
The usefulness of colonic stents was the subject of a Cochrane review in 2011. The authors concluded that on the basis
of the data that they reviewed, there was no benefit from the use of colonic stents over conventional surgical
resection with a tendency to better outcomes seen in the surgical group.

A more recently conducted meta analysis met with the same conclusion. However, the recently concluded CREST
trial has suggested that self expanding metallic stents can improve outcomes and avoids a stoma.

(3)Rectosigmoid Lesions
Lesions below the peritoneal reflection that are causing obstruction should generally be treated with a loop colostomy.
Primary resection of unstaged rectal cancer would most likely carry a high CRM positivity rate and cannot be
condoned. Where the lesion occupies the distal sigmoid colon the usual practice would be to perform a high anterior
resection. The decision surrounding restoration of intestinal continuity would lie with the operating surgeon

(13) Laxatives
Bulk forming laxatives
Bran
Psyllium
Methylcellulose
Osmotic laxatives
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 Magnesium sulphate
Magnesium citrate
Sodium phosphate
Sodium sulphate
Potassium sodium tatrate
Polyethylene glycol
Docusate
Stimulant laxatives
Bisacodyl
Sodium picosulphate
Senna
Ricinoleic acid

(14)Lower Gastrointestinal bleeding

Colonic Bleeding
This typically presents as bright red or dark red blood per rectum. Colonic bleeding rarely
presents as malaena type stool, this is because blood in the colon has a powerful laxative
effect and is rarely retained long enough for transformation to occur and because the
digestive enzymes present in the small bowel are not present in the colon. Up to 15% of
patients presenting with haemochezia will have an upper gastrointestinal source of
haemorrhage.

As a general rule right sided bleeds tend to present with darker coloured blood than left sided
bleeds. Haemorrhoidal bleeding typically presents as bright red rectal bleeding that occurs
post defecation either onto toilet paper or into the toilet pan. It is very unusual for
haemorrhoids alone to cause any degree of haemodynamic compromise.

Causes
Cause Presenting features
Bleeding may be brisk in advanced cases, diarrhoea is
Colitis commonly present. Abdominal x-ray may show
featureless colon.
Acute diverticulitis often is not complicated by major
Diverticular bleeding and diverticular bleeds often occur
Disease sporadically. 75% all will cease spontaneously within
24-48 hours. Bleeding is often dark and of large
volume.
Colonic cancers often bleed and for many patients this
Cancer may be the first sign of the disease. Major bleeding

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 from early lesions is uncommon
Typically bright red bleeding occurring post
Haemorrhoidal defecation. Although patients may give graphic
bleeding descriptions bleeding of sufficient volume to cause
haemodynamic compromise is rare.
Apart from bleeding, which may be massive, these
Angiodysplasia arteriovenous lesions cause little in the way of
symptoms. The right side of the colon is more
commonly affected.

Management
• Prompt correction of any haemodynamic compromise is required. Unlike upper
gastrointestinal bleeding the first line management is usually supportive. This is
because in the acute setting endoscopy is rarely helpful.
• When haemorrhoidal bleeding is suspected a proctosigmoidoscopy is reasonable as
attempts at full colonoscopy are usually time consuming and often futile.
• In the unstable patient the usual procedure would be an angiogram (either CT or
percutaneous), when these are performed during a period of haemodynamic instability
they may show a bleeding point and may be the only way of identifying a patch of
angiodysplasia.
• In others who are more stable the standard procedure would be a colonoscopy in the
elective setting. In patients undergoing angiography attempts can be made to address
the lesion in question such as coiling. Otherwise surgery will be necessary.
• In patients with ulcerative colitis who have significant haemorrhage the standard
approach would be a sub total colectomy, particularly if medical management has
already been tried and is not effective.

Indications for surgery

Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension

Surgery
Selective mesenteric embolisation if life threatening bleeding. This is most helpful if
conducted during a period of relative haemodynamic instability. If all haemodynamic
parameters are normal then the bleeding is most likely to have stopped and any
angiography normal in appearance. In many units a CT angiogram will replace
selective angiography but the same caveats will apply.

If the source of colonic bleeding is unclear; perform a laparotomy, on table colonic

lavage and following this attempt a resection. A blind sub total colectomy is most
unwise, for example bleeding from an small bowel arterio-venous malformation will
not be treated by this manoeuvre.

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 Summary of Acute Lower GI bleeding
recommendations
Consider admission if:
* Over 60 years
* Haemodynamically unstable/profuse PR bleeding
* On aspirin or NSAID
* Significant co morbidity

Management
• All patients should have a history and examination, PR and proctoscopy
• Colonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding

(15)Pilonidal Sinus
• Occur as a result of hair debris creating sinuses in the skin (Bascom theory).
• Usually in the natal cleft of male patients after puberty.
• It is more common in Caucasians related to their hair type and growth patterns.
• The opening of the sinus is lined by squamous epithelium, but most of its wall consists
of granulation tissue. Up to 50 cases of squamous cell carcinoma have been described
in patients with chronic pilonidal sinus disease.
• Hairs become trapped within the sinus.
• Clinically the sinus presents when acute inflammation occurs, leading to an abscess.
Patients may describe cycles of being asymptomatic and periods of pain and discharge
from the sinus.
• Treatment is difficult and opinions differ. Definitive treatment should never be
undertaken when acute infection or abscess is present as this will result in failure.
• Definitive treatments include the Bascom procedure with excision of the pits and
obliteration of the underlying cavity. The Karydakis procedure involves wide excision
of the natal cleft such that the surface is recontoured once the wound is closed. This
avoids the shearing forces that break off the hairs and has reasonable results

(16)Rectal Bleeding
Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the
clinical history it is useful to try and localise the anatomical source of the blood. Bright red
blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a
proximally sited bleeding source. Blood which has entered the GI tract from a gastro-
duodenal source will typically resemble malaena due to the effects of the digestive enzymes
on the blood itself.

In the table below we give some typical bleeding scenarios together with physical

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examination findings and causation.

Cause Type Of Features In Examination

Bleeding History Findings
Bright red Painful bleeding that Muco-epithelial defect
Fissure In rectal occurs post usually in the midline
Ano bleeding defecation in small posteriorly (anterior
volumes. Usually fissures more likely to
antecedent features be due to underlying
of constipation disease)
Bright red Post defecation Normal colon and
Haemorroids rectal bleeding noted both rectum. Proctoscopy
bleeding on toilet paper and may show internal
drips into pan. May haemorrhoids. Internal
be alteration of haemorrhoids are
bowel habit and usually impalpable.
history of straining.
No blood mixed with
stool. No local pain.
Bright red or Bleeding that is Perineal inspection may
Crohns mixed blood accompanied by show fissures or
disease other symptoms such fistulae. Proctoscopy
as altered bowel may demonstrate
habit, malaise, indurated mucosa and
history of fissures possibly strictures. Skip
(especially anterior)
lesions may be noted at
and abscesses. colonoscopy.
Bright red Diarrhoea, weight Proctitis is the most
Ulcerative bleeding loss, nocturnal marked finding. Peri
colitis often mixed incontinence,
with stool passage of mucous
anal disease is usually
absent. Colonoscopy
PR. will show continuous
mucosal lesion.
Bright red Alteration of bowel Usually obvious
Rectal cancer blood mixed habit. Tenesmus may mucosal abnormality.
volumes be present. Lesion may be fixed or
Symptoms of mobile depending upon
metastatic disease. disease extent.
Surrounding mucosa
often normal, although
polyps may be present.

Investigation

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 • All patients presenting with rectal bleeding require digital rectal examination and
procto-sigmoidoscopy as a minimal baseline.
• Remember that haemorrhoids are typically impalpable and to attribute bleeding to
these in the absence of accurate internal inspection is unsatisfactory.
• In young patients with no other concerning features in the history a carefully
performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be
sufficient. If clear views cannot be obtained then patients require bowel preparation
with an enema and a flexible sigmoidscopy performed.
• In those presenting with features of altered bowel habit or suspicion of inflammatory
bowel disease a colonoscopy is the best test.
• Patients with excessive pain who are suspected of having a fissure may require an
examination under general or local anaesthesia.
• In young patients with external stigmata of fissure and a compatible history it is
acceptable to treat medically and defer internal examination until the fissure is healed.
If the fissure fails to heal then internal examination becomes necessary along the lines
suggested above to exclude internal disease.

Special tests
• In patients with a malignancy of the rectum the staging investigations comprise an
MRI of the rectum to identify circumferential resection margin compromise and to
identify mesorectal nodal disease. In addition to this CT scanning of the chest
abdomen and pelvis is necessary to stage for more distant disease. Some centres will
still stage the mesorectum with endo rectal ultrasound but this is becoming far less
common.

• Patients with fissure in ano who are being considered for surgical sphincterotomy and
are females who have an obstetric history should probably have ano rectal manometry
testing performed together with endo anal ultrasound. As this service is not universally
available it is not mandatory but in the absence of such information there are
continence issues that may arise following sphincterotomy.

Management
Disease Management
GTN ointment 0.2% or diltiazem cream applied topically is the
Fissure In usual first line treatment. Botulinum toxin for those who fail to
Ano respond. Internal sphincterotomy for those who fail with botox,
can be considered earlier in males.
Lifestyle advice, for small internal haemorrhoids can consider
Haemorroids injection sclerotherapy or rubber band ligation. For external
haemorrhoids consider haemorrhoidectomy. Modern options
include HALO procedure and stapled haemorrhoidectomy.

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 Medical management- although surgery may be needed for
Inflammatory fistulating Crohns (setons).
bowel disease
Anterior resection or abdomino-perineal excision of the colon
Rectal cancer and rectum. Total mesorectal excision is now standard of care.
Most resections below the peritoneal reflection will require
defunctioning ileostomy. Most patients will require preoperative
radiotherapy

(17)Rectal Prolapse
Rectal prolapse may be divided into internal and external prolapse. Patients with the former
condition may have internal intussceception of the rectum and present with constipation,
obstructed defecation and occasionally faecal incontinence. Patients with external rectal
prolapse have a full thickness external protrusion of the rectum. Risk factors for the
condition include multiparity, pelvic floor trauma and connective tissue disorders.

Diagnosis
External prolapse is usually evident. Internal prolapse may be identified by defecating
proctography and examination under anaesthesia.

Sinister pathology should be excluded with endoscopy

Treatment
Perineal approaches include the Delormes operation, this avoids resection and is relatively
safe but is associated with high recurrence rates.

An Altmeirs operation involves a perineal excision of the sigmoid colon and rectum, it may
be a more effective procedure than a

Delormes but carries the risk of anastomotic leak.

Rectopexy - this is an abdominal procedure. The rectum is mobilised and fixed onto the
sacral promontary. A prosthetic mesh may be inserted. The recurrence rates are low and the
procedure is well tolerated (particularly if performed laparoscopically).
Thirsch tape- this is a largely historical procedure and involves encircling the rectum with
tape or wire. It may be of use in a palliative setting.

(18)Surgery For Inflammatory

Bowel Disease
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Patients with inflammatory bowel disease (UC and Crohns) frequently present in surgical
practice. Ulcerative colitis may be cured by surgical resection (Proctocolectomy), this is not
the case in Crohns disease which may recur and affect other areas of the gastrointestinal
tract.

(1)Ulcerative Colitis
• Elective indications for surgery include disease that is requiring maximal therapy, or
prolonged courses of steroids.
• Longstanding UC is associated with a risk of malignant transformation. Dysplastic
transformation of the colonic epithelium with associated mass lesions is an absolute
indication for a proctocolectomy.
• Emergency presentations of poorly controlled colitis that fails to respond to medical
therapy should usually be managed with a sub total colectomy.

Excision of the rectum is a procedure with a higher morbidity and is not generally
performed in the emergency setting. An end ileostomy is usually created and the
rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be
brought to the surface as a mucous fistula.

• Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis
is mandatory.
• Restorative options in UC include an ileoanal pouch. This procedure can only be
performed whilst the rectum is in situ and cannot usually be undertaken as a delayed
procedure following proctectomy.
• Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor
physiological function with seepage and soiling.

(2)Crohns Disease
• Surgical resection of Crohns disease does not equate with cure, but may produce
substantial symptomatic improvement.
• Indications for surgery include complications such as fistulae, abscess formation and
strictures.
• Extensive small bowel resections may result in short bowel syndrome and localised
stricturoplasty may allow preservation of intestinal length.

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 • Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g.
MRI enteroclysis).
• Complex perianal fistulae are best managed with long term draining seton sutures,
complex attempts at fistula closure e.g. advancement flaps, may be complicated by
non healing and fistula recurrence.
• Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch
reconstruction in Crohns carries a high risk of fistula formation and pouch failure and
is not recommended.
• Terminal ileal Crohns remains the commonest disease site and these patients may
be treated with limited ileocaecal resections.
• Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk
of gallstones.

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