Colorectal Surgery Review

A crucial review of Large Bowel Obstruction (LBO), emphasizing the foundational physiology of the closed-loop obstruction caused by a competent ileocecal valve, leading to imminent perforation risk dictated by the Law of Laplace (highest risk at the cecum). CT is the definitive modality for locating the transition point. Management of malignant LBO is highly sensitive; emergency right colectomy is associated with 10% mortality and ...

This episode reviews the significant evolution in the management of colonic diverticular disease, moving past old dogmas like the "second episode rule" and simple fiber deficiency hypothesis. Level 1 trials (Diabolo/AVOD) definitively show that antibiotics are not mandatory for stable, uncomplicated diverticulitis. The current indication for elective surgery is now based solely on symptom burden and reduced quality of lif...

Comprehensive review of Minimally Invasive Surgery (MIS) for colorectal cancer, distinguishing the settled science of laparoscopic colon resection from the ongoing controversy of rectal resection. The episode details how pivotal trials (ACOSOG, ALaCaRT) failed to prove non-inferiority for laparoscopic proctectomy, primarily due to higher rates of compromised Circumferential Radial Margin (CRM) in the deep pelvis. Technical solution...

Explores Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Colorectal Peritoneal Metastases (CPM). Success relies entirely on meticulous patient selection and achieving complete macroscopic cytoreduction (CC0). The episode details the Peritoneal Cancer Index (PCI) for staging and emphasizes that for aggressive CPM, CC1 is essentially a failure to cure, whereas it may be acceptable for less aggres...

Focuses on three complex non-epithelial entities that demand specialized algorithms. For GIST, diagnosis is based on CD117 (KIT) and DOG1, and management hinges on molecular genetics (Exon 11 is favorable; Exon 9 requires higher imatinib dosing). Rectal GIST presents a core dilemma, as local excision carries a strikingly high local recurrence rate (up to 77%); neo-adjuvant imatinib is used to downsize tumors and facilitate sphincte...

A detailed analysis of appendiceal neoplasms, highlighting how management is strictly driven by histology and classification. For invasive adenocarcinoma, a formal right hemicolectomy (RHC) is the standard due to the high risk of nodal metastasis (up to 30%). For mucinous neoplasms (LAMN/HAMN), the management pivots away from RHC to aggressive surveillance, driven by the critical distinction between high-risk cellular mucin versus ...

This episode tackles the highly complex and morbid radical management of Locally Recurrent Rectal Cancer (LRC), a disease defined as extra-TME pathology, operating in dense, irradiated, fibrotic tissue. Achieving an R0 resection is the single biggest determinant of cure (40-50% 5-year OS). Planning requires mandatory Multidisciplinary Team (MDT) input and combined PTCT/MRI, recognizing the limitations of MRI in delineating small pe...

A deep dive into the aggressive, curative-intent management of stage IV colorectal cancer with distant metastasis, fueled by an average 40% 5-year overall survival rate for resectable liver metastases. The discussion centers on critical decision points, including sequencing for resectable synchronous metastases (neo-adjuvant chemo is preferred for high-volume disease to assess tumor biology). For liver lesions, modern resectability...

A high-yield review of the post-operative management of resected stage II and III colorectal cancer. Key topics include the non-negotiable need for adjuvant chemotherapy (chemo) in stage III patients, leveraging landmark trials like MOSAIC. The episode details the paradigm shift in duration: 3 months of CAPOX is now the standard for low-risk stage III disease following the IDEA collaboration, reducing debilitating oxaliplatin toxic...

This episode reviews the technical and academic principles governing Proctectomy for Rectal Cancer, highlighting that the foundation of modern care is Total Mesorectal Excision (TME). We emphasize the consequences of surgical failure, noting that a Circumferential Resection Margin (CRM) of less than 1 mm carries a local recurrence rate greater than 50%.

The episode details the meticulous anatomy required for nerve sparing, focusing ...

This episode details the revolutionary Watch and Wait (WW) strategy, the most significant paradigm shift in modern rectal cancer care. We distinguish PCR (Pathological Complete Response, post-surgical) from CCR (Clinical Complete Response, the goal for organ preservation), and discuss how Total Neoadjuvant Therapy (TNT) maximizes the CCR rate. The primary motivation for WW is avoiding the guaranteed morbidity of proctectomy, partic...

This deep dive focuses on the high-stakes risk-benefit analysis of Local Excision (LE) for rectal cancer, balancing the functional benefits of organ preservation against the critical risk of missing occult lymph node metastases. We trace the technical path from conventional surgery to the modern standard of TAMIS (Transanal Minimally Invasive Surgery), emphasizing that oncologic LE requires an en block, full thickness resection.

The...

This episode explores the evolution of rectal cancer management to Total Neoadjuvant Therapy (TNT), driven by the failure of traditional trimodal approaches to address the high (30–40%) risk of distant recurrence. We review the foundational role of Total Mesorectal Excision (TME) and high-resolution MRI staging, which identifies a threatened Circumferential Resection Margin (<1 mm) as a mandate for aggressive treatment.

The episo...

This academic review details the foundational principles and technical specifics of colectomy for colon cancer, emphasizing the oncologic triad of achieving negative circumferential margins, removing the entire mesentery, and accurate staging. We confirm the mandatory margin requirement is a minimum of 5 cm proximally and distally. We address localization challenges, detailing the critical technique for endoscopic tattooing using a...

This episode provides a comprehensive review of pre-operative evaluation and staging for colorectal cancer, emphasizing the shift toward highly reproducible imaging and personalized risk stratification. We detail screening methods and clarify when pre-operative biopsy is mandatory (absolutely required for rectal tumors to obtain immediate MMR testing). We establish the modern definition of the rectum using fixed MRI bony landmarks ...

This deep dive tackles the challenging management of the malignant polyp (early T1 colorectal cancer), focusing on the pivotal decision point: endoscopic cure versus formal surgical resection. We review key precursor lesions (adenomas, sessile serrated lesions or SSLs) and the critical anatomical distinction of invasion beyond the muscularis mucosa.

A major focus is on predicting invasion depth using enhanced endoscopic criteria, in...

This episode of Colorectal Surgery Review provides a focused, deep dive into the absolute current state-of-the-art management of Colorectal Cancer (CRC). Targeted specifically toward practicing clinicians and academic colorectal surgeons, the discussion dissects the fundamental molecular biology, changing epidemiology, screening variance, and the critical nuances in surgical and medical treatment guidelines for both sporadic and in...

The Deep Dive: Presacral Tumors – The Deep Dive on Anatomy, Nerve Preservation, & Oncologic Strategy

This episode tackles the incredibly rare but complex topic of presacral tumors. Though they are rarely encountered, maybe appearing in only one in 40,000 hospital admissions, they present high stakes due to their location near critical nerves and vessels, requiring a solid, almost academic understanding for effective management.

W...

This episode of Colorectal Surgery Review provides a comprehensive deep dive into the evolving management of anal cancer, focusing on key clinical updates and the minutiae essential for effective practice.

Key Discussion Points:

• The Paradigm Shift: The episode explores the foundational change in treatment from radical surgery to definitive chemoradiation (CRT) as the standard of care for most anal canal Squamous Cell Carcinoma of...