Surgery Marrow Pg 221-230 (GIT)
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Surgery Marrow Pg 221-230 (GIT)

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Questions and Answers

What does T₄ indicate in the TNM staging system?

  • No tumour
  • Tumour invading muscularis propria
  • Tumour through muscularis propria
  • Tumour invading adjacent structures (correct)

    • In Duke's classification, Grade A involves lymph node involvement.

    False

    What is the minimum number of lymph nodes that should be removed according to the guidelines?

    1

    T₁ indicates carcinoma in _____

    <p>situ</p> Signup and view all the answers

    Match the following grades from the Duke's classification with their descriptions:

    <p>Grade A = Involvement of mucosa, Submucosa Grade B = Involvement with lymph nodes Grade C = Involvement of muscularis propria Grade D = Distant metastasis</p> Signup and view all the answers

    What is the indication for performing transanal total mesorectal excision (TaTME)?

    <p>T1, T2 tumors</p> Signup and view all the answers

    Retrograde ejaculation in men is a result of high IMA ligation injury.

    <p>True</p> Signup and view all the answers

    List one common complication of colorectal surgery.

    <p>Bleeding</p> Signup and view all the answers

    In cases involving T3 and T4 lesions, along with lymph node involvement, the treatment may involve __________.

    <p>chemotherapy</p> Signup and view all the answers

    Match the following surgical procedures with their descriptions:

    <p>Endoscopic stent placement = Provides temporary relief from obstruction Hartmann procedure = Surgical resection with colostomy creation Paul Mikulicz procedure = Used in the management of obstructive pathology Definitive Sx = Final surgical intervention to correct underlying issue</p> Signup and view all the answers

    What is the recommended follow-up for patients with MUTYH Associated Polyposis (MAP)?

    <p>Yearly colonoscopy</p> Signup and view all the answers

    Individuals with a first-degree relative affected by Familial Adenomatous Polyposis (FAP) should begin screening at age 10 if an APC gene mutation is present.

    <p>True</p> Signup and view all the answers

    What genetic mutation is most commonly associated with Hereditary Non-Polyposis Colonic Cancer Syndrome (HNPCC)?

    <p>MSH2</p> Signup and view all the answers

    MUTYH Associated Polyposis is an ______ condition that predisposes individuals to multiple colonic polyps.

    <p>autosomal recessive</p> Signup and view all the answers

    Match the following types of cancer with their associated syndromes:

    <p>Colonic cancer = Lynch I Uterine cancer = Lynch II Pancreatic cancer = Lynch II Ovarian cancer = Lynch II</p> Signup and view all the answers

    What is the primary risk associated with Familial Adenomatous Polyposis (FAP)?

    <p>100% risk of colorectal cancer</p> Signup and view all the answers

    The APC gene is located on chromosome 12.

    <p>False</p> Signup and view all the answers

    What variant of FAP is characterized by extra manifestations such as osteomas and sebaceous cysts?

    <p>Gardner's variant</p> Signup and view all the answers

    Total proctocolectomy with ileoanal pouch __________ is a common treatment for FAP.

    <p>anastomosis</p> Signup and view all the answers

    Match the following FAP variants with their characteristics:

    <p>FAP = Classic type with &gt;100 adenomatous polyps Gardner's variant = Osteomas and sulfanilamide cysts Turcot variant = FAP with CNS tumors APC gene = Located on chromosome 5</p> Signup and view all the answers

    What is one requirement for the Modified Amsterdam Criteria for diagnosing HNPCC?

    <p>Three or more cases of HNPCC related cancer in more than one generation</p> Signup and view all the answers

    According to the Modified Amsterdam Criteria, two affected individuals can be second-degree relatives if there is one first-degree relative.

    <p>False</p> Signup and view all the answers

    What is the significance of having a first-degree relative in the Modified Amsterdam Criteria?

    <p>It establishes a direct familial connection necessary for diagnosis.</p> Signup and view all the answers

    One HNPCC related cancer must be diagnosed in order to satisfy the Modified Amsterdam _____ .

    <p>Criteria</p> Signup and view all the answers

    Match the following components with their descriptions regarding the Modified Amsterdam Criteria:

    <p>3 or more cases = Indicates familial risk across generations First-degree relative = Direct relation necessary for the criteria HNPCC related cancer = Must be diagnosed for criteria to apply Affected individual = Must come from different generations</p> Signup and view all the answers

    In the Haggitt classification, what does Level 2 indicate?

    <p>Invades stalk</p> Signup and view all the answers

    The adenoma-carcinoma sequence begins with cancerous cells.

    <p>False</p> Signup and view all the answers

    What is the first genetic change associated with the adenoma-carcinoma sequence?

    <p>APC</p> Signup and view all the answers

    In the Haggitt classification, Level 4 indicates cancer that invades the ______.

    <p>submucosa; faster spread</p> Signup and view all the answers

    What is the primary purpose of a Low Anterior Resection (LAR)?

    <p>Retention of the majority of the sphincter</p> Signup and view all the answers

    Match the genetic changes with their respective stage in the adenoma-carcinoma sequence:

    <p>APC = First Hit KRAS = Intermediate p53 = Final Hit 18q = Chromosomal Instability</p> Signup and view all the answers

    Total mesorectal excision requires the removal of at least 10 lymph nodes.

    <p>False</p> Signup and view all the answers

    Which signaling pathway is often abnormal in the early stages of cancer formation?

    <p>Wnt signaling</p> Signup and view all the answers

    What is removed during an Abdominoperineal Resection (APR)?

    <p>Anal canal and rectum</p> Signup and view all the answers

    A Low Anterior Resection (LAR) involves performing a coloanal anastomosis by using a _____ stapler.

    <p>circular</p> Signup and view all the answers

    Hypermethylation is a process that may enhance gene activity.

    <p>False</p> Signup and view all the answers

    List one gene that plays a crucial role in the progression from adenoma to carcinoma.

    <p>SMAD4 or CDC4</p> Signup and view all the answers

    Match the surgical procedures with their characteristics:

    <p>Low Anterior Resection (LAR) = Retention of sphincter, no incontinence Abdominoperineal Resection (APR) = Loss of sphincter, leads to incontinence Total mesorectal excision = Requires removal of at least 12 lymph nodes Lymph node resection = Part of colorectal cancer surgery procedures</p> Signup and view all the answers

    What is the major disadvantage associated with the operation on the transverse colon?

    <p>Poor blood supply of splenic flexure</p> Signup and view all the answers

    The anal verge is located 12-2.5 cm above the anal verge.

    <p>False</p> Signup and view all the answers

    What structures are crucial for maintaining continence in the rectal area?

    <p>Internal anal sphincter and external anal sphincter</p> Signup and view all the answers

    The pain sensations are found _____ the dentate line.

    <p>below</p> Signup and view all the answers

    Match the surgical procedures with the relevant parts of the colon that are removed:

    <p>Left hemicolectomy = Left side of the colon Sigmoidectomy = Sigmoid colon Transverse colectomy = Transverse colon Right hemicolectomy = Right side of the colon</p> Signup and view all the answers

    Which artery primarily supplies the descending colon?

    <p>Inferior mesenteric artery (IMA)</p> Signup and view all the answers

    In a right hemicolectomy, the hepatic flexure is removed.

    <p>True</p> Signup and view all the answers

    What is one potential anatomical landmark mentioned that may be relevant during surgery?

    <p>Splenic flexure or Sudeck point</p> Signup and view all the answers

    What is the most common site for colorectal cancer?

    <p>Rectum</p> Signup and view all the answers

    The ______ artery supplies blood to parts of the transverse colon.

    <p>middle colic</p> Signup and view all the answers

    Match the surgical procedures with the corresponding parts removed:

    <p>Right Hemicolectomy = Terminal 10-12 cm of ileum, caecum, ascending colon, hepatic flexure, right part of transverse colon Extended Right Hemicolectomy = Terminal 10-12 cm of ileum, caecum, ascending colon, hepatic flexure, right part of transverse colon, splenic flexure Left Hemicolectomy = Descending colon and sigmoid colon</p> Signup and view all the answers

    Virtual colonoscopy is an invasive procedure.

    <p>False</p> Signup and view all the answers

    What type of lesion is associated with left-sided colon cancers?

    <p>Annular/apple core/napkin ring lesion</p> Signup and view all the answers

    The most common distant spread site for colorectal cancer is the _____

    <p>Liver</p> Signup and view all the answers

    Match the diagnostic tools with their features or uses:

    <p>FOBT = Yearly screening for blood in stool Colonoscopic biopsy = Investigative Objective Criteria MRI with endorectal coil = T&amp;N staging of rectal cancer PET-CT = Overall staging of cancer</p> Signup and view all the answers

    Study Notes

    Transanal Total Mesorectal Excision (TaTME)

    • NOTES procedure indicated for T1 and T2 tumors.
    • Sphincter is preserved.
    • Initial trials demonstrate safety.

    Complications of Colorectal Surgery

    • Abscesses.
    • Recurrence.
    • Bleeding.
    • Infection.
    • Leak.

    Nerve Injuries

    • High IMA Ligation: Superior hypogastric plexus near sacral promontory - Retrograde ejaculation in men (Sympathetic dysfunction).
    • Division of Lateral Stalks Close to Pelvic Sidewall: Pelvic plexus & nervi erigentes - Erectile dysfunction, Impotence & atonic bladder, Sexual & bladder dysfunction.

    Emergency Presentation with Obstruction

    • Endoscopic stent placement for temporary relief followed by definitive surgery.
    • Hartmann/Paul Mikulicz procedure: Proximal end connected to colostomy, distal end with mucus fistula to prevent perforation due to mucus accumulation. Definitive surgery is performed a few weeks later.

    TNM Staging

    • T₀: No tumor.
    • T₁: Carcinoma in situ.
    • T₁: Tumor invading submucosa.
    • T₂: Tumor invading muscularis propria.
    • T₃: Tumor through muscularis propria.
    • T₄: Tumor invading adjacent structures.

    Nodes

    • Minimum 1 lymph node removed.

    Duke's/Modified Astler Coller Classification

    • Grade A: Involvement of mucosa and submucosa.
    • Grade B: Involvement of submucosa.
    • Grade C: Involvement of submucosa and lymph nodes.
    • Grade D: Involvement of distant metastasis.

    Chemotherapy

    • Indications:
      • T3 and T4 lesions.
      • Lymph node involvement.
      • Metastasis.

    FAP: Familial Adenomatous Polyposis Coli Syndrome

    • Autosomal dominant condition.
    • Hallmark: Presence of >100 adenomatous polyps.
    • 100% risk of colorectal cancer.
    • APC gene located on chromosome 5.
    • Involves entire colon, potential extraintestinal manifestations (congenital hypertrophy of retinal pigment epithelium).
    • Variants:
      • FAP: Classic type.
      • Gardner's variant: Characterized by osteomas, sebaceous cysts, and desmoid tumors.
      • Turcot variant: Presents with CNS tumors (gliomas, medulloblastoma).
    • Management: Total proctocolectomy with ileoanal pouch anastomosis using circular stapler.

    HNPCC: Hereditary Non-polyposis Colonic Cancer Syndrome

    • Pathogenesis: Microsatellite instability, MLH & MSH gene mutations.
    • Features: Mutation of MSH2 gene (most common) and MLH1 gene.
    • Lynch I: Colonic cancer (60-70% risk).
    • Lynch II: Extracolonic cancer.
    • Associated with uterine cancer (most common), pancreatic cancer, and ovarian cancer.

    Colorectal Polyps & Cancer: Part 1

    • 1st degree relative of patient with FAP syndrome:
      • If polyps present: Surgery.
      • Genetic counseling and testing.
      • If APC gene mutation present: Screening at 10 years with annual sigmoidoscopy.
    • MUTYH Associated Polyposis (MAP): Autosomal recessive, predisposes to multiple colonic polyps.
    • No polyps until 18 years: Screen as general population.
    • Assess for duodenal adenomas in patients with MAP.

    Diagnosis of Colorectal Cancer

    • Modified Amsterdam Criteria:
      • 3 or more cases of HNPCC-related cancer in >1 generation.
      • At least one affected individual must be a first-degree relative of the other two.
      • One individual diagnosed with cancer must be diagnosed under the age of 50.

    Haggitt Classification for Cancer in Polyp

    • Level 0: Restricted to head.

    • Level 1: Invades neck.

    • Level 2: Invades stalk.

    • Level 3: Invades submucosa.

    • Level 4: Invades submucosa; Faster spread.

    • Level 1: Endoscopic resection.

    • Level 1, Cancer in sessile polyp: Indicative of more advanced stage.

    Adenoma-Carcinoma Sequence (Vogelstein)

    • Chromosomal Instability (CIN): Series of genetic changes (hits) leading to carcinogenesis starts with APC gene mutation (normal epithelium → early adenoma → intermediate adenoma → late adenoma → cancer).
    • Mnemonic: A (APC), K (KRAS), 53 (p53).
    • Other factors: Loss of 18q, SMAD4, CDC4 genes, Wnt signaling dysregulation, KRAS/BRAF/TGFβR2/BAX/IGFAR mutations, MMP gene inactivation, hypermethylation, and increasing CIN.

    Colorectal Polyps & Cancer: Part 2

    • Principles of rectal canal surgery: 5 cm proximal, 2 cm distal, 5 cm radially (due to radially situated lymph nodes).
    • Tumor Location: >5 cm from anal verge, mid-rectal, distal sigmoid.
    • Resection:
      • LAR (Low Anterior Resection): Majority of sphincter retained, no incontinence.
      • APR (Abdominoperineal Resection): Large part of sphincter resection, leads to incontinence.
    • Total mesorectal excision: Removal of minimum 12 lymph nodes.

    Rectal Cancer Surgery

    • Anorectal Ring: Formed by levator ani muscle.
    • Dentate Line: Located 2-2.5 cm above the anal verge.
    • Anal Verge: Located 12-2.5 cm above the anal verge.

    Surgical Management of Colorectal Cancer

    • Blood Supply of Colon and Rectum:
      • SMA (Superior Mesenteric Artery): Supplies most of the small intestine, ascending, and transverse colon.
      • IMA (Inferior Mesenteric Artery): Supplies descending and sigmoid colon.
    • Procedure & Parts Removed:
      • Right Hemicolectomy: Terminal ileum, caecum, ascending colon, hepatic flexure, right part of transverse colon (until right middle colic artery).
      • Extended Right Hemicolectomy: Terminal ileum, caecum, ascending colon, hepatic flexure, right part of transverse colon (splenic flexure may be removed for better outcomes during anastomosis).
    • Arteries Ligate:
      • Right Hemicolectomy: Right branch of middle colic, ileocolic, right colic.
      • Extended Right Hemicolectomy: Middle colic, ileocolic, right colic.

    Diagnostic Tools and Features

    • Fecal occult blood testing (FOBT): Yearly screening for blood in stool.
    • Virtual colonoscopy (CT scan with 3D reconstruction): Non-invasive, detailed extra-colonic views.
    • Clinical Features: Rectum (most common), sigmoid colon.
      • Right-sided colon cancers: Ulceroproliferative growth/exophytic.
        • Bleeding.
        • Iron-deficiency anemia.
        • Mass.
        • Obstruction and altered bowel habits (late).
      • Left-sided colon cancers: Annular/apple core/napkin ring lesion.
        • Constricting growth.
        • Altered bowel habits and obstruction (early).
    • Investigation:
      • FOBT.
      • Colonoscopic biopsy (IOC).
      • PET-CT.
      • MRI with endorectal coil.
      • CEA.

    Spread of Colorectal Cancer

    • Local invasion.
    • Lymphatic spread.
    • Distant spread: Liver (most common site).

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    Description

    This quiz covers essential notes on transanal total mesorectal excision (TaTME), common complications of colorectal surgery, nerve injuries associated with surgical procedures, and emergency treatments for obstruction. Test your knowledge on these key aspects of colorectal surgical care.

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