Colorectal Surgery ABSITE Review: Ulcerative Colitis, Crohn's, Colon & Rectal Cancer

Ulcerative Colitis Management

• 💡 Ulcerative colitis (UC) is a chronic inflammatory condition of the rectum and colon, always sparing the anus, characterized by mucosal disease, crypt abscesses, and pseudopolyps.
• 💊 Medical management includes steroids for acute flares and mesalamine or infliximab for maintenance.
• ⚠️ Surgery is indicated for medical intractability, malignancy, or complications like perforation or toxic colitis.
• 🧠 Medical intractability can manifest as growth failure in children, worsening symptoms despite therapy, or chronic steroid dependence.
• ⚠️ Conditions like primary sclerosing cholangitis do not respond to colectomy, while others like large joint arthropathy do.
• 📈 Patients with extensive colitis require endoscopic surveillance starting 8 years after diagnosis, with biopsies every 1-2 years.
• 🔪 In cases of malignancy or high-grade dysplasia, a total proctocolectomy with or without an ileal pouch-anal anastomosis (IPAA) is performed.
• 🏥 Emergency surgery may involve a total or subtotal colectomy with end ileostomy, with completion proctectomy and IPAA staged later.

Crohn's Disease Overview

• 🎯 Crohn's disease is a chronic, incurable inflammatory disorder that can affect any part of the GI tract, most commonly the terminal ileum, and usually spares the rectum.
• 🧩 Buzzwords include transmural involvement, segmental disease, and creeping fat.
• 🎭 Crohn's presents with three main phenotypes: inflammatory, fibrostenotic, and penetrating, which can overlap.
• 🌟 Extra-intestinal manifestations include arthritis, megaloblastic anemia, uveitis, and erythema nodosum.
• 💊 Medical therapies involve steroids for flares, mesalamine for maintenance, and infliximab for fistulizing or perianal disease.
• ✂️ Surgery for Crohn's is not curative and is reserved for complications like strictures, obstruction, or fistulas, emphasizing the preservation of small bowel.
• 📏 Symptomatic strictures can be managed endoscopically if proximal or distal, or with resection or stricturoplasty for longer segments.
• 🔍 Stricturoplasties include the Mikulicz (short), Finney (medium), and Heineke-Mikulicz (long) types, with biopsies always recommended to rule out malignancy.

Colon Cancer Screening and Staging

• 📅 Average-risk individuals should begin colon cancer screening at age 45 every 10 years.
• 👨‍👩‍👧‍👦 Those with a first-degree relative diagnosed before age 50 should start screening at 40 or 10 years prior to the relative's diagnosis, every 5 years.
• 🧬 Screening for FAP begins between 10-12 years old every 1-2 years, and for Lynch syndrome (HNPCC) between 20-25 years old every 1-2 years.
• 📈 Follow-up intervals for colonoscopies depend on polyp findings: 7-10 years for 1-2 tubular adenomas, 3 years for advanced adenomas, and 10 years for hyperplastic polyps.
• 🔬 Malignant polyps can be managed endoscopically if specific criteria are met, otherwise, oncologic resection is required.
• 📊 TNM staging for colon cancer defines tumor invasion (T), nodal involvement (N), and metastasis (M), guiding treatment.
• 🔪 Resections require 5-7 cm proximal and distal margins for adequate lymphadenectomy, with at least 12 lymph nodes examined.
• 🌟 Stage IV disease can be resectable, potentially resectable (with neoadjuvant chemotherapy), or unresectable, with treatment varying accordingly.
• 💊 Adjuvant chemotherapy (FOLFOX) is recommended for stage III and above, and for high-risk stage II disease.
• ☢️ Radiation therapy is not indicated for colon cancer.

Rectal Cancer Management

• 🩺 Workup for rectal cancer includes labs (CEA), rigid proctoscopy, CT scans, and endoscopic ultrasound or MRI for staging, focusing on the tumor circumferential margin (CRM).
• 🎯 Neoadjuvant chemoradiotherapy (50 Gy with 5FU) is given for locally advanced mid and distal rectal tumors (T3+ or any nodal disease), followed by surgery 8-12 weeks later.
• ✂️ Local excision may be considered for T1 lesions without high-risk features, but carries a risk of local recurrence and does not allow for lymph node examination.
• 🔪 Surgical management for upper rectal tumors involves tumor-specific mesorectal excision, while mid and lower rectal tumors require total mesorectal excision (TME) as part of an LAR or APR.
• 💊 Adjuvant FOLFOX is recommended for stage III+ who did not receive neoadjuvant therapy, and for high-risk stage II disease that did receive it.

Anal Squamous Neoplasms

• 🦠 Anal squamous cell carcinoma (SCC) has histologic variants including cloacogenic, basaloid, epidermoid, and mucoepidermoid, often associated with HPV types 16 and 18.
• 🛡️ Immunosuppressed patients have a higher incidence of anal SCC.
• 🔬 Anal intraepithelial neoplasia (AIN) is a precursor lesion, with AIN 1-2 considered low-grade and AIN 3 high-grade.
• 💊 Treatment for high-grade AIN includes topical 5-FU or imiquimod, photodynamic therapy, or targeted destruction, with close clinical follow-up.
• 🌟 The Nigro protocol (chemoradiotherapy with 5FU, mitomycin C, and XRT) is the standard treatment for anal canal SCC.
• 🔪 Salvage Abdominoperineal Resection (APR) is performed for persistent or recurrent anal SCC after primary chemoradiotherapy.
• ☀️ Anal margin SCC is treated like skin cancer with wide local excision, while anal melanoma requires APR.