What are the white lines of Toldt?

What parts of the GI tract do not have a serosa?

What are the major anatomic differences between the colon and the small bowel?

What is the blood supply to the rectum:

Proximal?

Middle?

Distal?

What is the venous drainage of the rectum:

Proximal?

Middle?

Distal?

COLORECTAL CARCINOMA

Chapter 48 / Colon and Rectum 309

Lateral peritoneal reflections of the ascending and descending colon

Esophagus, middle and distal rectum

Colon has taeniae coli, haustra, and appendices epiploicae (fat appendages), whereas the small intestine is smooth

Superior hemorrhoidal (or superior rectal) from the IMA

Middle hemorrhoidal (or middle rectal) from the hypogastric (internal iliac)

Inferior hemorrhoidal (or inferior rectal) from the pudendal artery (a branch of the hypogastric artery)

Via the IMV to the splenic vein, then to the portal vein

Via the iliac vein to the IVC

Via the iliac vein to the IVC

How common is it as a cause of cancer deaths?

Second most common cause of cancer deaths

310 Section II / General Surgery

What is the lifetime risk of colorectal cancer?

What is the male to female ratio?

What are the risk factors?

6%

1:1

Dietary: Low-fiber, high-fat diets correlate with increased rates

Genetic: Family history is important when taking history

FAP, Lynch’s syndrome

IBD: Ulcerative colitis Crohn’s disease, age, previous colon cancer

What are current ACS recommendations for polyp/colorectal screening in asymptomatic patients without family (first-degree) history of colorectal cancer?

What are the current recommendations for colorectal cancer screening if there is a history of colorectal cancer in a first-degree relative

less than 60 years old?

Starting at age 50, at least one of the following test regimens is recommended:

Colonoscopy q 10 yrs

Double contrast barium enema (DCBE) q 5 yrs

Flex sigmoidoscopy q 5 yrs CT colonography q 5 yrs

Colonoscopy at age 40, or 10 years before the age at diagnosis of the youngest first-degree relative, and every 5 years thereafter

What is the differential diagnosis of a colon tumor/ mass?

Which diagnostic tests are helpful?

Adenocarcinoma, carcinoid tumor, lipoma, liposarcoma, leiomyoma, leiomyosarcoma, lymphoma, diverticular disease, ulcerative colitis, Crohn’s disease, polyps

History and physical exam (Note: 10% of cancers are palpable on rectal exam), heme occult, CBC, barium enema, colonoscopy

312 Section II / General Surgery

What disease does microcytic anemia signify until proven otherwise in a man or postmenopausal woman?

What tests help find metastases?

What is the preoperative workup for colorectal cancer?

What are the means by which the cancer spreads?

Is CEA useful?

What unique diagnostic test is helpful in patients with rectal cancer?

How are tumors staged?

Give the TNM stages: Stage I

Stage II

Colon cancer

CXR (lung metastases), LFTs (liver metastases), abdominal CT (liver metastases), other tests based on history and physical exam (e.g., head CT for left arm weakness looking for brain metastasis)

History, physical exam, LFTs, CEA, CBC, Chem 10, PT/PTT, type and cross 2 u PRBCs, CXR, U/A, abdominopelvic CT

Direct extension: circumferentially and then through bowel wall to later invade other abdominoperineal organs

Hematogenous: portal circulation to liver; lumbar/vertebral veins to lungs

Lymphogenous: regional lymph nodes Transperitoneal

Intraluminal

Not for screening but for baseline and recurrence surveillance (but offers no proven survival benefit)

Endorectal ultrasound (probe is placed transanally and depth of invasion and nodes are evaluated)

TMN staging system

Invades submucosa or muscularis propria (T1–2 N0 M0)

Invades through muscularis propria or surrounding structures but with negative nodes (T3–4, N0, M0)

What do all rectal cancer operations include?

What is the lowest LAR possible?

What do some surgeons do with any anastomosis less than 5 cm from the anus?

Total mesorectal excision—remove the rectal mesentery, including the lymph nodes (LNs)

Coloanal anastomosis (anastomosis normal colon directly to anus)

Temporary ileostomy to “protect” the anastomosis

What surgical margins are needed for colon cancer?

What is the minimal surgical margin for rectal cancer?

How many lymph nodes should be resected with a colon cancer mass?

What is the adjuvant treatment of stage III colon cancer?

What is the adjuvant treatment for T3–T4 rectal cancer?

What is the most common site of distant

(hematogenous) metastasis from colorectal cancer?

Traditionally 5 cm; margins must be at least 2 cm

2 cm

12 LNs minimum for staging, and may improve prognosis

5-FU and leucovorin (or levamisole) chemotherapy (if there is nodal metastasis postoperatively)

Preoperative radiation therapy and 5-FU chemotherapy as a “radiosensitizer”

Liver

What is the treatment of liver metastases from colorectal cancer?

Resect with 1-cm margins and administer chemotherapy if feasible