DISEASES OF THE COLON, RECTUM, & ANUS
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1 DISEASES OF THE COLON, RECTUM, & ANUS Rocco Ricciardi, MD, MPH Chief, Section of Colon & Rectal Surgery Massachusetts General Hospital Associate Professor of Surgery Harvard Medical School
2 CASE 1 Hemorrhoid Prolapsed mucosa Cancer
3 INTERNAL VS. EXTERNAL
4 EXTERNAL HEMORRHOIDS Innocent Thrombosed
5 Pain THROMBOSED EXTERNAL HEMORRHOID Excise Days
6 INTERNAL HEMORRHOIDS OFFICE MANAGEMENT Fiber and sitz baths Rubber band ligation Infrared coagulation Injection therapy Doppler-guided hemorrhoidal artery ligation
7 INTERNAL HEMORRHOIDS
8 Symptoms Pain Bleeding CASE 2
9 FISSURE: PATHOPHYSIOLOGY Trauma Tear Pain Spasm Ischemia Chronic fissure
10 FISSURE: PATHOPHYSIOLOGY irregular stools tearing of anal lining anal hypertonia reduced anodermal perfusion ischemic (!) ulcer
11 ANAL FISSURE Location & appearance Idiopathic Atypical Crohn s disease Malignancy Tuberculosis Syphilis CMV HIV Trauma
12 ANAL FISSURE TREATMENT First line treatment Fiber and sitz baths Topical Nitroglycerine Diltiazem Injectable Botulinum toxin Surgical sphincterotomy Same day surgery
13 CASE 3
14 ABSCESS/ FISTULA Incidence 12.3/100,00 (men), 5.6/100,000 women Sainio. ACG 1984:73:219. Peak incidence 3 rd & 4th decade Ramanujam. DCR 1984;27:593. Symptoms Pain Swelling Fever Etiology?
15 CONTINENCE FISTULA PLUG FIBRIN GLUE
16 LIFT
17 Case 4 45 y.o. male presents for routine colo PMHx: None Colonoscopy: lesions at ATZ (biopsied)
18 HPV: CERVIX AND ANUS Analogous to the cervical transformation zone Immature squamous cells Squamo-columnar junction Susceptible to HPV
19 HPV INFECTION Low risk and high risk HPV High risk HPV From: Wright and Schiffman, NEJM 2003
20 DYSPLASIA PROGRESSION
21 PROGRESSION OF DISEASE
22 HPV VACCINE: ONE LESS Anal warts 6, 11, 30, 42, 43, 44, 45, 51, 52, 54 Anal cancer 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82 HPV Vaccine contains 6, 11, 16, 18
23 ANAL CANCER RX Combo therapy Excellent results 2.5% have surgery No colostomy
24 CONSEQUNCES ANAL CANCER RX Incontinence Pruritis Bleeding GU issues
25 CASE STUDY 45 y.o. male presents for with rectal bleeding PMHx: None Colonoscopy: Mid rectal mass
26 RECTAL CANCER
27 Dr. Bert Vogelstein COLORECTAL CANCER
28 COLONOSCOPY Intervention Cost/yr life saved Motorcycle helmets $2,000 Colorectal Cancer Screen $25,000 Breast Cancer Screening $35,000 Dual Airbags $120,000 Smoke detectors $210,000 Seat Belts in School Buses $2,800,000
29 RECTAL CANCER Prior approach Surgeon referral Open surgery Colostomy Postop chemo/rads Today Extensive w/u MDT Preop chemorads? Surgery Keep your anus
30 ABDOMINOPERINEAL RESECTION Described by Sir Ernest Miles surgeons TME rectal dissection Anus sutured closed Wide perineal dissection
31 SURGERY
32 TEMS TAMIS Developed for lesions out of usual reach Can be used for benign and malignant lesions LOCAL EXCISION
33 PATIENT CONCERNS Concern 3 months 9 months 15 months 24 months 1 Urinary frequency (48%) Impotence (51%) Impotence (47%) Impotence (45%) 2 Impotence (47%) Urinary frequency (37%) Urinary frequency (32%) Urinary frequency (24%) 3 Fatigue (38%) Fatigue (33%) Bowel issues (24%) Fatigue (24%) 4 Insomnia (26%) Bowel issues (26%) Fatigue (23%) Bowel issues (22%) 5 Bowel issues (25%) Flatulence (23% Flatulence (22%) Flatulence (20%) Data from ColoRectal Wellbeing (CREW) cohort study
34 WATCH & WAIT 35 participating institutes 11 countries > 800 patients Valk et al. Gastrointestinal Cancers Symposium, 2017
35 CAN WE AVOID SURGERY? JCO. 2011;29:35
36 CONCLUSIONS Many simple remedies for anorectal dx Minimally invasive techniques Robotic Transanal Many cancers now treated nonop Reduce consequences
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