SCORE 10-12

fiber supplements + sitz baths → topical nitroglycerin or a calcium channel blocker → BT injection (40-100U botox injection into internal anal sphincter) → LIS +/- anocutaneous flap.

VY anocutaneous flap for patients with baseline incontinence

1. The patient is brought to the operating room, and general, spinal, or monitored anesthesia care is induced. Local anesthesia is also frequently used.
2. The patient is usually placed in the lithotomy or prone jackknife position.
Key steps of an LIS:
1. Dilate the anus gently with an anoscope, and locate the intersphincteric groove between the internal and external sphincter muscles. To better identify the internal sphincter, use a Pratt speculum to put the internal sphincter under tension.
2. Closed technique: Insert the scalpel into the intersphincteric groove, and turn the scalpel medially to break the fibers of the internal sphincter.

Closed : Perform a radial skin incision distal to the dentate line to expose the intersphincteric groove. Identify, elevate, and divide the internal sphincter. Close the wound primarily.

1. CT CAP
2. Urinary 5-HIAA
3. Octreotide scan

1. Appendectomy
2. Biopsy lesions
3. TAke pictures
4. Stage with CT CAP
5. Colonoscopy
6. Refer for cytoreductive surgery

-- Pedunculated polyps with invasion into the head (Haggitt Level 1), stalk (Haggitt Level 2) or neck (Haggitt Level 3) can be treated with margin-negative polypectomy.
- Pedunculated polyps with invasion into submucosa and sessile polyps (Haggitt Level 4) that are snared in one piece with a margin of at least 2 mm are considered adequately treated.
1. High-risk lesions with invasion into the lower 1/3 of the submucosa, a resection margin <2 mm, lymphovascular invasion, piecemeal polypectomy, and/or poor differentiation should undergo appropriate oncologic resection.

No polyps: 10-year colonoscopy
Small distal hyperplastic polyps: 10-year colonoscopy
1–2 small (<1 cm) tubular adenomas: 5- to 10-year colonoscopy, timing based on clinical factors (family history, patient preference, clinical judgment).
3–10 adenomas or 1 adenoma >1 cm or an adenoma with villous features or high-grade dysplasia: 3-year colonoscopy
>10 adenomas: <3-year colonoscopy, consider polyposis syndrome
Adenoma(s) removed piecemeal: 2- to 6-month colonoscopy to ensure complete excision

1. Stage I-III colorectal CA surgically treated: 1 year, then every 3-5 years depending on findings
2. All patients with curative resection and anastomosis and LAR: proctosigmoidoscopy +/- endorectal u/s every 6-12 months for 3-5 years; every 6 months for 3-5 years if higher risk of local recurrence
3. Transanal local excision of rectal CA: proctosigmoidoscopy +/- endorectal u/s every 6 months for 3-5 years

Physical examination and biopsy of the primary tumor, palpation of the groin, CT of the chest, CT or MRI of the abdomen and pelvis, and PET scan. For women, a gynecologic examination should be done, including screening for cervical cancer.

And colonoscopy

T1 0-2cm, T2 2-5cm, T3 >5cm T4 - invades other structure not including sphincter muscle

For localized disease (stages I to III [any T, any N, M0]), the standard treatment is radiation therapy combined with chemotherapy.
Current recommendations include mitomycin plus 5-fluorouracil (5-FU) plus radiation. The modified Nigro protocol consists of mitomycin plus 5-FU together with 45 Gy of radiation.
Metastatic disease is treated with cisplatin-based chemotherapy.
Tumor response is assessed clinically 8 to 12 weeks after completion of chemoradiotherapy.
It may take up to 6 months for complete remission to occur.

DRE, anoscopy, inguinal node palpation q3-6 M x 5 years
CT of the chest, CT or MRI of the abdomen and pelvis annually

Cisplatin based chemotherapy

Inguinal LN dissection and APR

1. Perianal within 5cm
2. If completely staged and it is T1, N0 well differentiated squamous cell cancer and able to get 2cm margins

1. 8 years from diagnosis , every 1-2 years
2. Take 33 biopsies

1. fiber (daily recommendation: 25 g and 38 g for women and men, respectively) and 64 ounces of fluid per day.
2. Stool softeners can be added if needed.
3. Sitz baths can be used in acute settings such as a thrombosed hemorrhoid or an acute flare-up.

1. Position the patient in the prone jackknife or left lateral decubitus position with adequate light and visualization through a slotted anoscope.
2. Deploy the rubber band at the apex of the hemorrhoid. It should be 1 to 2 cm above the dentate line to avoid the sensate tissue of the anal canal.
3. One to three columns can be banded at a time, but the risk of pain and complications increases when more columns are banded.

1. Lithotomy position
2. V-shape incision on the anal skin on the hemorrhoid pedicle
3. Grasp the hemorrhoid pedicle and put a clamp on it. Suture ligate the hemorrhoidal pedicle.
4. Take care to dissect hemorrhoidal cushion off of the underlying sphincter muscle to avoid damage to the sphincter complex.
5. To remove the hemorrhoidal cushion, use whatever method is preferred by the surgeon—sharply, with cautery, or with various vessel sealing devices. Close the excision site or leave it open, again at the surgeon's discretion.

FOLFOX and AVASTIN
- SE of oxaliplatin : peripheral neuropathy

Divides upper and lower rectum. If lesion above the anterior peritoneal reflection = treated like colon cancer

5cm

Aim for 2cm, Shoot for 1cm margin

1. Unable to get distal margin
2. Involvement of external anal sphincter

MLH 1, MSH 2 , MSH 6, PMS 2
MLH 1 positive --> send for BRAF mutation testing V600E (it is a somatic mutation in BRAF that can cause MLH to be positive falsely negative, so BRAF needs to be negative for MLH 1 positive to be called as Lynch)

Total abdominal colectomy with ileorectal anastomosis
Total proctocolectomy if have rectal cancer
Can offer prophylactic TAHBSO at time of colectomy

q1 year flex sig

1. Endometrial , ovaries
2. Brain
3. STomach
4. Hepatobiliary
5. Urinary tract
6. PAncreatic

colonoscopy at 20 yo every 1-2 years
annual pelvic exam and ultrasound at 30yo
EGD at 35 yo

Delorme works for smaller sectin prolapse, but Altmeier can be logner. Delorme has lower morbidity .

The white blood cell count may be elevated, and there may be a metabolic acidosis. Abdominal radiographs are not generally helpful unless there is severe ischemic colitis and free air is demonstrated. A CT scan may demonstrate colonic wall thickening.
Unprepped colonoscopy is the diagnostic test of choice, unless there is peritonitis on examination or free air is demonstrated. Colonoscopy allows for direct visualization of the colonic mucosa. In mild to moderate ischemic colitis, the mucosa will be edematous and erythematous with ulcerations. In severe ischemic colitis, the mucosa will appear gray or black, representing full-thickness ischemia.

1. Nonsevere disease: nonspecific lower abdominal pain, cramping; leukocytosis with a total white blood count greater than 15,000/µL with serum creatinine less than 1.5 mg/dL
2. Severe disease: fever, diffuse abdominal pain, abdominal distention; leukocytosis with a total white blood count greater than 15,000/µL or serum creatinine greater than 1.5 mg/dL
3. Fulminant disease: hypotension, shock, ileus, toxic megacolon, possible multisystem organ failure

1. For nonsevere disease, initial therapy is oral vancomycin. Oral fidaxomicin is similar in efficacy but is more expensive. If neither is available, oral metronidazole is acceptable. Duration of therapy is 10 days.
2. For severe disease, antibiotic therapy is 10 days of oral vancomycin or oral fidaxomicin. Metronidazole is not recommended in severe disease.
3. For fulminant disease, therapy includes oral vancomycin with intravenous metronidazole. Rectal vancomycin enemas can be administered if ileus is present.

Colonoscopy beginning 8 years after onset of symptoms
Recommended procedures
Chromoendoscopy with targeted biopsy, including extensive sampling of strictures or masses (high-definition colonoscopy suggested), with at least two biopsies in every bowel segment to document microscopic disease activity and extent of disease involvement. Additional extensive sampling of any strictures or masses is necessary.
White light endoscopy (high- or standard-definition) with random four-quadrant biopsies every 10 cm (≥ 32 total samples) and additional extensive sampling of any strictures or masses
No endoscopic/histologic active inflammation or only left-sided disease. Repeat colonoscopy in 2 to 3 years.

Any first-degree relative with colorectal cancer at any age. Have a colonoscopy beginning at age 40 years or 10 years before earliest colorectal cancer diagnosis. If negative, repeat every 5 years. If positive, repeat per colonoscopy finding

In patients with complete obstruction by suspected tumor, the diagnosis should be established by resection without abating colonoscopy or staging scans. The general principles of resection for elective resections apply, including:
Colectomy according to vascular supply with greater than 5-cm margin
Regional lymphadenectomy en bloc with specimen along the origin of the feeding vessel
Primary anastomosis. If this is performed, a proximal diverting ileostomy should be considered if the proximal bowel is distended.
After the tumor is resected or diversion performed, a complete colonoscopy is indicated to evaluate for synchronous lesions.

History and physical examination every 3 to 6 months for 2 years; then every 6 months for a total of 5 years
CEA every 3 to 6 months for 2 years; then every 6 months for 5 years
CT of the chest, abdomen, and pelvis every 6 to 12 months (every 3-6 months for stage IV cancer) for a total of 5 years
PET-CT scans for patients with stage IV disease. (Note: These studies are not indicated for stage IV disease only.)
Colonoscopy 1 year after surgery except if no preoperative colonoscopy due to obstructing lesion; then colonoscopy in 3 to 6 months
Advanced adenoma: repeat in 1 year
No advanced adenoma: repeat in 3 years and then every 5 years

A thorough examination of the intestines is performed to identify Meckel diverticulum or palpable masses. See the SCORE module Meckel Diverticulum for additional information. Transillumination of the small bowel is used to evaluate for angiodysplasia.
Intraoperative colonoscopy is warranted in hemodynamically stable patients.
If no obvious source is identified, the default surgical procedure is a subtotal colectomy with end ileostomy.

Stool studies (infectious workup)
Colonoscopic evaluation to rule out primary colonic pathology
Sitzmark/scintigraphic (defecography) study

Incomplete evacuation distally consistent with pelvic floor dysfunction
More than 20% of sitz markers retained after 5 days is diagnostic of colonic inertia

Dietary Modifications–fiber supplementation, caffeine avoidance, adjust water intake, probiotics, and fermentable, oligosaccharides, disaccharides, monosaccharides, and polyvols (FODMAP) avoidance
Pharmacologic–antidiarrheals, anticholinergics, SSRI/TCAs, laxatives, antispasmodics, guanylate cyclase agonists, chloride channel activators
Psychological–cognitive behavioral therapy, dynamic psychotherapy

Correction of medical co-morbidities
Fiberulking agents, osmotic laxatives, colonic irritants
Consideration of total abdominal colectomy in severe colonic inertia with failure of medical therapies
Neostigmine, colonoscopic decompression for pseudo-obstruction

Colonoscopy should occur annually beginning at age 12. If the rectum is spared during surgery, flexible proctoscopy should occur yearly.
Esophagogastroduodenoscopy should occur every 1 to 5 years (based on endoscopic findings) beginning at age 20 to 25.
Gastric polyps are typically hyperplastic and do not require removal.
Duodenal polyps are adenomatous and can lead to cancer.
Prophylactic/preventive colectomy is recommended in patients with FAP, unlike in those with other syndromes.
In the absence of debilitating symptoms, colectomy is delayed until early adulthood, when patients have reached both physical and emotional maturity.
Development of colon cancer during childhood is very uncommon in FAP.

Colonoscopy should occur every 1 to 2 years beginning at age 20 to 25.
Women with Lynch syndrome should undergo endometrial biopsy every 1 to 2 years beginning at age 35.

Patients with the classic FAP phenotype are treated with a total proctocolectomy and ileal J pouch–anal anastomosis (TPC/IPAA).
Those with attenuated FAP, with rectal sparing, may be treated with total abdominal colectomy and ileorectal anastomosis (TAC/IRA).
This decision is individualized; higher polyp burdens in the rectum (> 20) are associated with a high risk of metachronous rectal malignancies.

Patients with colon cancer typically undergo TAC/IRA.
Patients with rectal cancer typically undergo TPC/IPAA.
Select patients with advanced age and/or comorbidities can be considered for segmental colectomy when the risk of TAC/IRA exceeds the risk of metachronous malignancy. Segmental colectomy is associated with a risk of metachronous colorectal cancer of 26% to 62% depending on the specific MMR gene mutation and the length of follow-up.
Women with Lynch syndrome should be considered for total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) at the time of colectomy.

If partial, observation is appropriate and the defect can be filled with absorptive material.
If circumferential, the ostomy should be revised due to risk of stomal stenosis

If the lesions are extensive, care must be taken to avoid creating a circumferential perianal wound that can heal as an anal stricture. In this setting, a staged procedure with excision of a portion of the disease, time for healing, and return for excision of the remainder, may be prudent.
It is important to remember that this is an epithelial disease, so excisions deeper than the dermis are usually not necessary. Additionally, HPV is not obliterated with surgery, so condyloma recurrence is common. For this reason, wide margins are also unnecessary. The goal of the surgeon should be to excise the larger, raised lesions, fulgurate or ablate the smaller flat lesions, and always to rule out invasive disease which would then be treated with chemoradiation.
Preoperative counseling should include a discussion of the risk of significant postoperative pain during the healing period as well as risk of recurrence.

Patients at high risk are typically screened with anal examination, anoscopy, and cytology. Patients with external lesions should undergo serum testing for syphilis and HIV as well as cell culture or polymerase chain reaction (PCR) testing for HSV with lesion swabs.

superficial fistulas, intersphincteric fistulas, and low transsphincteric fistulas. During a fistulotomy, a probe is placed into the fistula tract, and the tract is then unroofed along its length.

Surgical treatment with seton placement is followed by medical therapy with tumor necrosis factor-α inhibitors.
Fecal diversion may be necessary in severe cases.
Final closure of the fistula with endorectal advancement flap may be pursued only after perianal sepsis is cleared and the tissue is soft.
Some patients may require permanent setons to manage their perianal fistula disease.

1. A wide local excision with a 1-cm margin is indicated for well-differentiated anal margin cancers less than 2 cm. The remainder of anal margin squamous cell cancers should receive chemoradiation as initial treatment.
2. Flap closure, such as a V-Y advancement flap, or skin graft, may be required.

Patient is positioned in lithotomy
Abdominal phase (open, laparoscopic, robotic)
1.Mobilization and division of the sigmoid colon with identification of the left ureter
2.High ligation of the inferior mesenteric artery (IMA)
3.Total mesorectal excision (TME) - sharp dissection circumferentially around the mesorectum in an avascular areolar plane between the visceral and parietal layers of the endopelvic fascia down to the level of the levator ani musculature. TME also entails identification and preservation of the autonomic nerve plexus (hypogastric & nervi erigentes)
Perineal phase
4.Elliptical incision extending from the perineal body anteriorly, the coccyx posteriorly, and the ischium laterally.
5.The dissection is deepened into the ischiorectal fossa.and the anococcygeal ligament is divided allowing the perineal surgeon to insert his finger into the pelvis posteriorly.
6.Circumferential dissection is then performed from posterior to anterior until the aperture is large enough to pass the specimen between the coccyx and anus. 7.The anterior dissection is then completed taking care not to injure the vaginal wall (females) or urethra and prostatic capsule (males).
Option to create omental pedicle flap or utilize muscle flap reconstruction (rectus abdominis, gracilis, or gluteal) with multilayered perineal closure
Creation of an end colostomy

1. Perineal wound complications
2. Radiation proctitis - telangiectasia, atrophy, friable tissue. Tx with sucralfate enemas, topical formalin , or APC
3. Anal stenosis may occur - bulk laxatives, sequential dilation or colostomy

1.Surveillance involves evaluation by DRE, anoscopy, and inguinal lymph node palpation 8 to 12 weeks after completion of chemoradiation. At that time, patients' conditions are classified as (1) complete remission, (2) persistent disease, or (3) progressive disease.
2.For complete remission, DRE, anoscopy, and inguinal lymph node palpation every 3 to 6 months for 5 years are necessary. Annual chest, abdominal, and pelvic CT with intravenous contrast is recommended for the first 3 years.
3.For persistent disease, initial examination at 8 to 12 weeks with repeat examinations every 4 weeks to assess ongoing tumor response are necessary. The benefits of radiation may continue for up to 6 months after completion of radiation. If the disease is still present at 6 months, biopsy is warranted.
4.For progressive disease, a 10% to 30% chance of locoregional failure after chemoradiation exists. Evidence of progression on examination should be followed by a biopsy and restaging with CT and/or PET. Surgical treatment with an APR with or without inguinal node dissection is then indicated.

1. A high-fiber diet and fiber supplements to bulk stools
2. Antidiarrheal agents and bile acid binders to harden stools
3. Enemas and suppositories, along with manual disimpaction for fecal impaction

1. Endoanal ultrasonography and magnetic resonance imaging (MRI) are the key modalities for mapping sphincter characteristics (eg, sphincter size, tears, or atrophy).
2. Anal manometry can establish baseline resting and squeeze pressures. Although this technique may aid in therapy selection, it does not necessarily correlate with operative outcomes.
3. Defecography plays a role in the workup as an adjunct to operative planning to identify unrecognized problems such as prolapse or a rectocele.

Sacral nerve stimulation. This avoids surgery in the anal area and has a low morbidity.
Overlapping sphincteroplasty. This is indicated in patients with anatomic sphincter injury. It has poor long-term durability.
Artificial anal sphincter devices. These are used in patients who have failed or are otherwise unable to undergo more conventional therapy. There is a risk of device infection and erosion.

Anoscopy/colonoscopy: allows visualization of prolapsing tissue, but is more useful in ruling out other causes of presenting symptoms
Anal manometry: may demonstrate low resting pressures
Defecography: evaluation of other associated defects

table sugar to reduce edema, general anesthesia to allow for relaxation of pelvic floor / muscles, anal block for sphincter relaxation

Position the patient in the lithotomy or prone jackknife position per surgeon preference.
Recreate the prolapse.
Use a self-retaining anal retractor to aid in exposure.
Make a circumferential incision above the dentate line.
Enter the peritoneal cavity through the anterior cul-de-sac.
Deliver the redundant rectum and sigmoid while progressively ligating the mesorectum and mesocolon, if applicable.
Perform a levatorplasty if indicated.
Transect the bowel, and perform a handsewn anastomosis.

Position the patient in the lithotomy position.
Place laparoscopicobotic ports, or perform the desired type of open incision.
Enter the posterior mesorectal fascial plane, avoiding injury to hypogastric nerves and other structures.
Perform rectal mobilization to the levators, and determine whether to divide or spare the lateral rectal stalks.
Place sutures or mesh, as applicable.
Perform sigmoid resection and anastomosis, if applicable, including the air leak test.
Perform intraoperative flexible endoscopy to verify the patency of the lumen (optional).

Recognize the location of the tumor, and plan for the appropriate proximal transection margin.
Identify the bilateral ureters.
Safely ligate the inferior mesenteric artery at its origin.
Dissect in the total mesorectal excision plane to the levators.
Identify the hypogastric nerves.
Identify the right and left common, internal, and external iliac arteries and veins.
Identify the anterior border of the mesorectal envelope while preserving the surrounding organs and nerves.
Mobilize the left hemicolon along the lateral peritoneal reflection (white line of Toldt).
Divide the colon with an appropriate proximal margin, which should include the divided inferior mesenteric artery.
Identify the viability of the remaining colon.
Create an end colostomy.
Consider repositioning the patient in the prone position or in a modified lithotomy position for perineal dissection.
Identify the borders of perineal dissection: ischial tuberosities, midpoint of the perineum, and coccyx.
Identify the dissection plane to include the entire levator complex.
Consider placing pelvic closed-suction drains.
Securely close abdominal and perineal wounds.

1. Topical lidocaine may be used in the awake patient, with no more than 4 to 5 mg/kg being typically necessary. Administration of local anesthetic should be directed at the carina and other bronchopulmonary branch points.
2. Sedation is typically achieved intravenously using fentanyl (25-100 mcg) and midazolam (1-2.5 mg). A paralytic may be used in conjunction with sedation in the appropriate setting.
The patient should be preoxygenated with 100% inspired oxygen.
3. Prior to bronchoscopy, inline suctioning should be undertaken to minimize contamination by upper airway secretions.
4 Advance the bronchoscope into the desired lung segment.
5. Keeping the bronchoscope steady, infuse 100 mL of nonbacteriostatic normal saline in 20-mL aliquots into the desired bronchopulmonary segment.
6. After each 20-mL instillation, gently aspirate using the same syringe. Total volume returned is variable.
7. The pooled specimen is then sent for quantitative culture.