1
Q
What is the imaging modality of choice for appendicitis?
A
- CT scan is generally preferred
- in pregnant women and children, US and MRI are preferred
2
Q
What should you do during a lap appy if the appendix is normal?
A
look throughout the abdomen for alternative etiologies of the patient’s pain and then perform an appendectomy as long as the cecum is healthy (e.g. Crohns)
3
Q
How should you treat appendiceal adenocarcinoma or a goblet cell carcinoid?
A
both are concerning for adenocarcinoma and should be treated like a colon cancer, need right colectomy +/- adjuvant therapy
4
Q
Describe an open appendectomy through a Rocky Davis incision.
A
- oblique incision over the appendix
- sharply incise the external oblique aponeurosis
- bluntly divide the internal oblique aponeurosis and transversus abdominis
- sharply incise the peritoneum
- eviscerate the appendix
- ligate the mesentery and the base of the appendix
- close
5
Q
If a patient with perforated appendicitis is being managed non-operatively and is failing to improve, what should you consider as a next step?
A
- consider interval imaging to see if a new collection has formed or has become drainable
- consider surgical intervention if failing
6
Q
When should you perform an interval appendectomy?
A
6-8 weeks after an episode of acute appendicits
7
Q
Which patients should get an interval appendectomy after being managed non-operatively?
A
- recurrent appendicitis
- persistent RLQ pain
- fecalith
- age over 40
- symptoms or findings concerning for malignancy (weight loss, hematochezia, melena, stool changes)
8
Q
Which appendiceal NETs require surveillance? What is the schedule?
A
- lesions > 2cm, with positive margins, positive nodes, or incomplete surgical resction
- get axial imaging and chromagranin levels at 12 weeks and then every 12 months for ten years
9
Q
Which appendiceal neuroendocrine tumors require formal resection? What is the pre-operative workup?
A
- need right colectomy if > 2cm, have mesoappendieceal invasion > 3mm, mitotic index > 2, Ki-67 > 3%, lymphovascular invasion, involvement of the appendiceal base, positive margin
- get a CT C/A/P, colonoscopy, serum chromogranin A, and 24hr urine 5-HIAA before oncologic resection
- PET-dotatate can be used for patients with symptoms of carcinoid syndrome or findings on axial imaging concerning for nodal or distant disease
10
Q
What is the appropriate surgery for those with an appendiceal LAMN or HAMN?
A
appendectomy alone unless there is evidence of perforation or peritoneal involvement
11
Q
All patients diagnosed with an appendiceal neoplasm should also be evaluated for what other neoplasm?
A
they should all get a colonoscopy
12
Q
What are the symptoms of carcinoid syndrome?
A
- bronchospasm
- flushing
- diarrhea
13
Q
What is a high-grade appendiceal mucinous neoplasm?
A
a HAMN is basically an appendiceal adenocarcinoma without invasive features, meaning it can be treated with appendectomy alone
14
Q
What is the workup for patients with appendiceal mucinous neoplasms and adenocarcinomas?
A
- tumor markers: CA 125, CEA, CA 19-9
- CT C/A/P
- MRI is more sensitive for extraluminal mucin and may help detect peritoneal disease
15
Q
How is a mucinous appendiceal neoplasm managed if there is peritoneal involvement with widespread or cellular mucin?
A
cytoreductive surgery with HIPEC is an option as well as oxaliplatin-based chemotherapy for distant disease
16
Q
What defines the anal canal, anal verge, and anal margin?
A
- anal canal is from the puborectalis sling to the anal verge
- anal verge is the transition from squamous epithelium to perianal skin (squamous mucocutaneous junction)
- anal margin is the area within 5cm of the anal verge
17
Q
Describe the management of anal fissures.
A
- first line is medical therapy: fiber, sitz baths, topical anesthetics
- next is topical calcium channel blockers (better than topical nitrates given side effect profile)
- next is botox injection
- last line is surgery: lateral internal sphincterotomy (better efficacy but risk of incontinence) or anocutaneous flap
18
Q
What is the indication for and what are the contraindications to lateral internal sphincterotomy?
A
- indicated for failed non-operative management of anal fissure
- contraindicated in those with baseline incontinence, with incontinence after botox, with obstetric trauma, of child bearing age, or with a history of IBD
19
Q
How are the various types of anorectal abscess drained?
A
- perianal and ischiorectal are drained via external incision
- intersphincteric and supralevator are via internal, transanal incision
- horseshoe via modified Hanley procedure (posterior midline incision with bilateral counter incisions)
20
Q
Describe drainage of a horseshoe anorectal abscess.
A
- arise in the deep postanal space, bordered inferiorly by the anococcygeal ligament and superiorly by the levators
- make a posterior midline incision and enter through the anococcygeal ligament
- make bilateral counter incisions for drainage
21
Q
Which patients require an antibiotic course after drainage of a anorectal abscess?
A
- immunocompromised
- associated cellulitis
- systemic signs of infection
22
Q
Which anal fistulae are amenable to fistulotomy? What is the alternative?
A
- those that involve less than 25% of the sphincter complex can be opened
- if more, place a draining seton
23
Q
What surgical options are available for those with a high anal fistulae that cannot be converted to a low fistula with use of a draining seton?
A
- ligation of intersphincteric fistula tract
- anorectal advancement flap
24
Q
What distinguishes internal and external hemorrhoids?
A
- internal are above the dentate line and have autonomic innervation
- external are below the dentate line and have somatic sensation
25
Describe the management of hemorrhoids.
- begin with bowel hygiene: fiber, lots of fluid, no prolonged sitting or straining
- can band internal hemorrhoids
- can perform hemorrhoidectomy for both internal and external
26
What is the correct procedure for an acute, thrombosed external hemorrhoid with significant symptoms?
incision and evacuation versus hemorrhoidectomy
27
Every patient with a new diagnosis of diverticulitis needs what?
a colonoscopy 6 weeks after the acute episode to evaluate for ischemia, inflammatory bowel disease, or malignancy
28
Which patients should undergo elective sigmoidectomy for diverticulitis?
those who have had a complicated episode (phlegmon alone doesn't count) or who have had uncomplicated episodes but prefer surgery
29
What do we know about the natural history of diverticulitis?
we now know that the first episode is often the worst and multiple uncomplicated episodes doesn't necessarily increase your risk of needing an emergent colectomy and stoma
30
What kind of bacterium is C. diff?
an anaerobic, gram-positive rod
31
Describe the preferred antibiotic regimens for C. diff treatment.
- first line is 200mg fixaxomicin BID for 10 days
- alternatively can use 125mg PO vanc QID for 10 days
- if recurrence, treat with the alternative agent (fixoxamicin versus vanco taper)
- for severe disease, use PO vanc and IV flagyl, add PR vanco if ileus
- can consider fecal transplant for multiply recurrent or fulminant disease
32
What are the initial steps for a patient thought to have a sigmoid volvulus?
- get a KUB to help establish the diagnosis
- CT A/P can help identify colonic ischemia and help decide on emergent OR versus endoscopic reduction
33
What are the supportive care options for those with colonic ileus versus pseudo obstruction?
- correct electrolytes
- fluid resuscitation
- minimize narcotics and anticholinergics
- treat any underlying infections
- bowel rest and decompression
34
What is neostigmine, what are its indications, and what are the major side effects?
- it is an anti-acetylcholinesterase the promotes colonic transit
- indicated for Ogilvie's that is not improving with supportive care alone
- major side effect is bradycardia so must be given in a monitored setting with atropine available
35
When should you add a sigmoidectomy or LAR to a rectopexy for prolapse?
for patients that also have baseline constipation
36
Describe a Delorme procedure.
- patient is supine and in lithotomy
- circumferential mucosal incision above the dentate line and dissection away from the underlying muscularis
- suture plication of the muscular tube, creating a mucosal anastamosis
37
Describe an Altemeier procedure.
- patient is supine and in lithotomy
- circular incision 2-5cm above the dentate line through the mucosa
- retract the rectum downward and complete a full thickness division, ligating the mesentery
- create a tension-free end-to-end anastomosis
38
Which studies are most sensitive for GI bleeding?
tagged RBC > CT angiography > conventional angiography
39
Crypt abscesses and pseudo polyps are characteristic of what type of IBD?
ulcerative colitis
40
What is the medical management of UC?
- steroids for flares
- mesalamine for maintenance
- infliximab for recalcitrant disease
41
What are the indications for surgery in patients with UC?
- medical intractability (growth failure in children, disease progression while on therapy, poor quality of life despite therapy, desire to avoid lifelong therapy, disabling extra-intestinal manifestations)
- malignancy including HGD
- complications of colitis (stricture, perforation, fulminant colitis)
42
What extra-intestinal manifestations of UC respond to colectomy?
- erythema nodosum
- episcleritis
- large joint arthropathy
- NOT PSC
43
What is considered medically unresponsive UC?
- growth failure in children
- disease progression while on therapy
- poor quality of life despite maximal medical therapy
- desire to avoid lifelong medical therapy (steroids)
- disabiling extra-intestinal manifestations that respond to colectomy (e.g. erythema nodosum, episcleritis, large joint arthropathy)
44
What is the recommended surveillance for those with ulcerative colitis?
- endoscopy within 8 years of diagnosis and then every 1-2 years
- include 4 quadrant random biopsies every 10cm of involved colon as well as directed biopsies of suspicious lesions
45
What is the next step for a patient with UC who is found to have high-grade dysplasia on random biopsy?
total proctocolectomy
46
What surgical options are available for those with ulcerative colitis?
- total proctocolectomy with end ileostomy
- total proctocolectomy with IPAA (must have good baseline continence and be willing to have 6-8 stools a day)
- total colectomy with ileorectal anastomosis (must have uninvolved rectum and be agreeable to annual surveillance)
47
Creeping fat is characteristic of which form of IBD?
Crohn's disease
48
What are the extra-intestinal manifestations of Crohn's?
- arthritis/arthralgias
- megaloblastic anemia
- uveitis
- erythema nodosum
49
What is the medical management of Crohn's disease?
- budesonide or systemic steroids for acute flares
- 5-ASA or mesalamine for maintenance
- infliximab (or other anti-TNFa therapy) for resistant disease or perianal disease
50
In general terms, describe the three different stricturoplasty options for those with Crohn's disease.
- Heineke-Mikulicz: longitudinal incision and transverse closure for short (<10cm) strictures
- Finney: fold structured segment on itself and make a common channel in the loop for intermediate strictures (10-20cm)
- Michelassi: divide the bowel and create a side-to-side isoperistaltic anastomosis for longer strictures (>20cm)
51
When should patients begin colon cancer screening?
- average risk: age 45, repeat every 10 years
- first degree relative with CRC or advanced adenoma: age 40 or 10 years before youngest diagnosis, repeat every 5 years
- two secondary relatives with CRC: age 40, repeat every 10 years
- IBD: 8 years after diagnosis, every 1-2 years
- FAP: age 10-12, every 1-2 years
- Hereditary Nonpolyposis CRC: age 20-25, every 1-2 years
52
What defines an advanced colon adenoma?
- size > 1 cm
- villous architecture
- or with high-grade dysplasia
53
When should a colonoscopy be repeated if polyps are found?
- piecemeal resection: 6 months
- more than 10 adenomas: 1 year
- 5-10 adenomas or SSP, advanced adenoma: 3 years
- HP polyp > 1cm, 3-4 adenomas or SSP: 3-5 years
- 1-2 SSP: 5-10 years
- 1-2 adenomas: 7-10 years
- < 20 HP polyps: 10 years
54
Which malignant polyps can be managed endoscopically?
must meet all the criteria:
- can be removed in 1 piece
- margins negative for dysplasia or malignancy
- well or moderately differentiated
- no angiolymphatic invasion
- less than 2mm submucosal invasion
55
Describe TNM staging of colon cancer.
T1: invades submucosa
T2: invades muscular propria
T3: invades pericolonic tissue
T4: penetrates serosa
N1: 1-3 nodes
N2: 4+ nodes
56
How do we generally define a positive lymph node for oncologic purposes?
a deposit of tumor cells more than 0.2mm
57
What is considered adequate surgery for colon cancer?
high ligation of the vascular pedicle, must have a 5cm margin, and must take at least 12 lymph nodes as well as any clinically positive nodes
58
What is the staging workup for colon cancer?
CT C/A/P, colonoscopy with biopsy and MMR testing, and CEA
59
What is the role for PET scan in patients with colon cancer?
generally only used for patients with metastatic disease being considered for metastectomy
60
Which patient with colon cancer should be considered for neoadjuvant chemotherapy? What is the preferred regimen?
patients get 3 months of FOLFOX (folinic acid, fluorouracil, and oxaliplatin) or immunotherapy with pembrolizumab if dMMR/MSI-H
- T4b disease
- stage III disease
- stage IV disease
61
Which patients with colon cancer get adjuvant chemotherapy? What is the preferred regimen?
patients get 6 months of FOLFOX (folinic acid, fluorouracil, and oxaliplatin) or pembrolizumab if dMMR/MSI-H
- high risk stage II (inadequate LN sample, poorly differentiated histology, lymphovascular invasion, bowel obstruction, localized perforation, positive or close margins, T4b disease) unless MSI-H since these have a good prognosis
- stage III disease
- stage IV disease
62
Which sites of metastatic colon cancer are amenable to resection?
liver and lung
63
What is the appropriate surveillance following treatment for colon cancer?
- stage I disease: colonoscopy at 1 year and the follow up as per normal guidelines
- for stage II/III disease: CEA every 6 months for 5 years, CT every 6-12 months for 5 years, colonoscopy at 1 year and then follow up as per normal guidelines
64
What is the significance of a BRAF mutation in those with dMMR/MSI-H colon cancer?
patients with this mutation will have down regulated MLH1 expression that is not due to Lynch syndrome
65
What are the MMR genes relevant to colon cancer?
MLH1, MSH2, MSH6, and PMS2
66
What endoscopic finding is consistent with C. diff infection?
pseudomembranes
67
Which antibiotics should be avoided in those with C. diff?
- cephalosporins
- fluoroquinolones (ciprofloxacin and levofloxacin)
- clindamycin
68
What options are available if you're having difficulty bringing up a descending colostomy?
- decompress the bowel
- completely mobilize the bowel (splenic flexure takedown)
- divide inferior mesenteric and left colon vessels, relying on marginal
- fenestrate the mesentery
- widen the fascial defect or removing subcutaneous fat
- move to the upper abdominal wall which is thinner
69
How should you manage the rectal stump after TAC for C. diff?
- inspect health and degree of inflammation
- options include leaving it as is, oversewing it, bringing it up as a mucous fistula, or tacking it in the subcutaneous tissue
- leave a rectal tube for ongoing vanc enemas
70
What should be the extent of a sigmoidectomy for diverticulitis?
- proximal = normal tissue
- distal = rectosigmoid junction
71
What pre-operative safety step can be taken when doing colon surgery?
ask for ureteral stents
72
What are some keys to operations for diverticular fistulas.
- get pre-operative imaging, usually gastrograffin enema to help with planning
- consider a Hartmann's
- interpose a flap of tissue between an anastomosis and the fistulized structure
- leave a foley if bladder repair
73
How should you manage sigmoid volvulus during pregnancy?
- endoscopic decompression in the first trimester
- sigmoidectomy in the second trimester
- endoscopic decompression in the third trimester
- sigmoidectomy postpartum for all
74
What should you ask an endoscopic doing colonoscopy for LGIB?
to tattoo any source that is found in case subsequent localization is needed
75
Which patients with LGIB should get angiography or endoscopy as first line evaluation?
- if hemodynamically unstable or with massive bleeding, consider CT angiography or conventional angiography
- if stable, consider endoscopy
76
What is the preferred operation for unlocalized LGIB?
TAC with end ileostomy (likely too unstable for anastomosis)
77
Describe the appropriate incision for drainage of a peri-anal abscess.
- circumferential
- over the point of maximal fluctuance
- in elliptical fashion to remove skin
78
Describe the incision and evacuation of a thrombosed external hemorrhoid.
- inject local anesthetic into the dermis
- make an elliptical incision
- evacuate any small thrombi
- leave the wound open
- cover with an absorbable dressing
- manage post-op pain with sitz baths and NSAIDs
79
Splenic flexure neoplasms generally drain via what vascular supply?
the left colic (rather than the middle colic)
80
When evaluating someone with LBO, what other imaging finding is important to evaluate for next steps?
whether or not there is a competent ileocecal valve
81
If patients present with an obstructing colon cancer and can't have a scope performed pre-operatively, what should be the timing of their colonoscopy?
3-6 months post-op
82
When can chemotherapy be begun after most surgery?
8 weeks post-op
83
What are your options for dealing with a colocolonic anastomotic leak?
- perc drainage, antibiotics, bowel rest
- repair of anastomosis with diversion
- re-do anastomosis
- re-do anastomosis with diversion
- resection of anastomosis with diversion
84
Which portion of bowel prep for colon surgery is more efficacious?
oral antibiotics > mechanical prep
85
If you're having trouble bringing the EEA stapler up through the rectum, what steps can you take?
- additional rectal mobilization
- use of rectal sizers
- endoscopic evaluation
- can bring the spike out through the anterior rectal wall
- can perform a hand-sewn anastomosis
86
What should you do during an LAR if you have a positive leak test?
consider redoing the anastomosis or diverting the patient rather than simply oversewing
87
What should the evaluation for ischemic colitis include?
- CT A/P to rule out alternative pathologies (consider angiographic study)
- endoscopy
- infectious workup (C. diff, stool O&P, stool culture)
- basic labs
88
How is uncomplicated ischemic colitis managed?
supportive care: bowel rest, IV fluids, antibiotics
89
How do you know how much bowel to resect in someone with ischemic colitis?
- palpate the vasculature
- doppler the vasculature
- flash the marginal artery
- use ICG
- perform on-table endoscopy
90
In someone with ischemic colitis following open AAA repair, what is the appropriate operation should they fail non-operative management?
should give them an ostomy since an anastomotic leak will contaminate the graft
91
What are the risks associated with IPAA?
- incontinence
- pouchitis
- pouch failure
- infertility
- late diagnosis of Crohns disease
92
If an IPAA won't reach, what can you do?
- mobilize the entire small bowel mesentery to its root at the duodenum
- kocherize the duodenum
- ligate selective vessels including the ileocolic
- serial relaxing incisions on the mesenteric peritoneum
- creation of an S- or W-shaped pouch
93
Describe the creation of an IPAA.
- take down existing ileostomy
- perform completion proctectomy with low stapled division
- mobilize the small bowel +/- lengthening options
- create a 20cm J-pouch in stapled fashion
- insert the EEA anvil and create an EEA anastomosis to the rectal cut
- create a diverting loop ileostomy
94
Granulomas are characteristic of what form of IBD?
Crohns
95
If a patient with Crohns presents with an intra-abdominal abscess but is clinically well, how should this be managed?
- initial medical management with antibiotics and perc drainage
- once infection is controlled, initiate immunomodulators or biologics and optimize nutrition
- bring them back for elective interval resection of diseased or fistulized segment
96
What would drive you to operate on someone with a Crohn's flare?
- worsening abdominal pain
- obstructive symptoms
- persistent fevers
- tachycardia
- rising ESR/CRP
97
Describe an ileocolonic resection with primary anastomosis for Crohn's stricture.
- port placement
- run entire bowel to evaluate extent of disease
- identify the ileocolonic pedicle and make a medial window to access the avascular plane between the mesocolon and retroperitoneum
- identify and preserve the duodenum
- take down the white Line and gastrocolic ligaments
- extra-corporealize the bowel for resection and anastomosis
- close the abdomen
98
Which Crohn's fistulas require resection?
- unresolved infection
- malabsorption
- intractable diarrhea
99
How can you manage a Crohn's stricture?
- consider treatment for an acute flare if it is inflammatory in nature
- consider endoscopic or surgical management if it is fibrostenotic, this may include dilation, diversion, enteric bypass, stricturoplasty, or resection
100
Describe the technique for a Heineke-Mikulicz stricturoplasty.
- make a single, full-thickness, longitudinal incision in the anti-mesenteric border over the stricture and extending 2cm beyond it in both directions
- close the enterotomy transversely
101
Describe the technique for a Finney stricturoplasty.
- loop the stricture on itself
- make a U-shaped incision over it;s length
- close the enterotomy in side-to-side fashion, creating a large diverticulum
102
Describe the technique for a Michelassi stricturoplasty.
- divide the stricture in half with a GIA
- advance the ends past one another in side-to-side isoperistaltic manner
- make longitudinal incisions in both limbs
- suture them together to form a new common limb
103
When should an interval colectomy be performed for appendiceal NET after simple appendectomy?
within 3 months
104
What is the workup for newly diagnosed rectal cancer?
- labs including CEA
- endoscopy
- CT C/A/P
- MRI pelvis (or endorectal EUS) to evaluate circumferential margin
105
How are rectal tumors in the upper ⅓ managed?
like colon cancer with a 5cm distal TME
106
What is an acceptable distal margin for low rectal cancers?
okay to get 1cm distal margin, otherwise need APR
107
Which patients with rectal cancer get TNT? What does TNT involve?
- mid- and distal tumors that are stage II or III
- for most patients this is long-course chemoradiation (5-FU) followed by FOLFIRINOX
- re-staging scans at 6 weeks
- undergo surgery at 8-12 weeks
108
What does surveillance for rectal cancer involve?
- CEA every 6 months for 5 years
- DRE every 3 months for 2 years, then every 6 months
- MRI every 6 months for 3 years with CT chest and abdomen
- colonoscopy at 1 year and then based on guidelines
109
Which patients with rectal cancer can undergo local excision?
must meet all the below criteria:
- T1
- well-to-moderately differentiated
- no lymphovascular or perineurial invasion
- < 3cm and < ⅓ circumference
but formal excision is still preferred in healthy patients
110
Which patients with low rectal cancer would get adjuvant chemotherapy?
stage III that did not receive neoadjuvant therapy (assume they were understaged pre-operatively)
111
What are potential adverse effects of a low anterior dissection for rectal cancer?
- low anterior syndrome (urgency, diarrhea)
- bladder dysfunction
- sexual dysfunction
112
Where is the posterior TME plane?
between the visceral and parietal layers of the end-pelvic fascia
113
Describe a LAR.
- evaluate for metastatic disease
- divide the IMA and IMV and mobilize the left colon, including splenic flexure takedown
- divide the mesocolon onto the bowel at the proximal transection site
- carry the mesocolonic dissection inferiorly into the pelvis, beginning the TME and identifying the ureter early
- sharply dissect the avascular plane between the visceral and parental layers of the end-pelvic fascia
- divide the mesorectum and distal rectum
- perform a double stapled anastomosis
- perform a leak test
- divert with DLI
- close
114
What are the histologic variants of anal SCC?
- cloacogenic
- basaloid
- epidermoid
- mucoepidermoid
115
Anal SCC is associated with which HPV serotypes?
16 and 18
116
What is the difference between AIN and HSIL/LSIL? How are these lesions managed?
- low grade squamous intra-epithelial lesions are AIN I and II
- high grade is AIN III
- both have low rates of progression to SCC
- many destructive treatments (topical imiquimod, topical 5-FU, photodynamic therapy, ablation)
- no matter what, need surveillance every 4-6 months
117
What is the protocol for treating SCC of the anal canal?
Nigro protocol (5-FU, mitomycin C, 45 Gy radiation)
118
How do you manage SCC of the anal margin?
- T1N0 (< 2cm) is like skin cancer with WLE (1cm), if you can't achieve an adequate margin then refer for Nigro protocol
- T2+ or N+ or poorly differentiated, treat with Nigro protocol
119
How do you manage anal melanoma?
with an APR
120
A lateral or anterior anal fissure should prompt concern for what?
- malignancy
- Crohn's
- HIV
121
What is the treatment for pouchitis?
antibiotics, supportive care, and budesonide enemas
122
Chronic pouchitis should raise suspicion for what?
Crohn's disease
123
What are the screening recommendations for anal cancer?
- no well accepted guidelines
- NYS recommends cytology (anal pap) for those over 35 years old with HIV who have receptive anal intercourse
- shared decision making for those over 35 years old with HIV who do not have receptive anal intercourse
- positive cytology would prompt high-resolution anoscopy
124
What is the workup for someone with a new diagnosis of anal SCC?
- history of physical, including inguinal lymph nodes and DRE
- basic labs
- CT C/A/P
- biopsy of suspicious nodes
- anoscopy
- HIV testing and cervical cancer screening
- discussion of fertility preservation
125
How long after undergoing the Nigro protocol should a patient be given to have a response before moving on to APR?
- re-evaluate at 12 weeks with DRE
- can see a response for up to 6 months
126
What is the surveillance protocol for someone who had a complete remission with Nigro protocol?
- DRE and inguinal node assessment every 6 months for 5 years
- anoscopy every 6 months for 3 years
- CT C/A/P every year for 3 years if primary was > 5cm or N+
127
How should you manage inguinal disease in those with anal SCC?
for either primary disease or with nodal recurrence:
- groin dissection
- radiation to groin
128
If 12 weeks after Nigro protocol, a patient with anal SCC has progressive disease, what is the next step?
APR
129
Describe the technique for an APR.
- starts like an LAR
- once the pelvic floor is reached, dissection begins via the perineum
- wide dissection around the anal canal through the levators
- closure of the perineal defect in layers with dissolvable suture
130
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