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Hi, everyone. Thanks so much for joining. So, this is the Wales Foundation trainee Societies, uh, third event in the series of our MRCS revision. So tonight, I'm really pleased to have been, uh, with us who is a currently a court trainee in vascular surgery and general surgery. Um, he's going to be teaching us tonight about lower gi conditions. So the way we've done this before is, um, if you have any questions, just pop them in the chat, um, and we'll either answer them as you go along or at the end. Um, I'll also mention, uh, the second talk we've got, which will be on a separate event, lick be posting that um, near the end of this talk and that, that event will start at just after seven PM. So stay tuned. Uh Great. Thanks very much, Ben. All right, let's go see if this will work again. Looks good. So, yeah. Hello. Yeah, thanks Lucy. I'm my name's Ben. I'm uh corps trainee at the heath. Um, I think if you, uh come back again after listening to my one and end of crying conditions, thank you very much. I shall hopefully try and keep it similar level of quality. Listen to a bit of the feedback that I got included a few more questions. This time, I was also asked to include a bit more anatomy, but I feel like that probably is covered on the specific anatomy teaching sessions that meant to be scheduled. So as before I've taken a look at the syllabus um to try and really tease out all of the lower gi stuff that's in there, as you can imagine with the mrcs is very general surgical orientated. So it's an awful, awfully big topic. To be honest, as I discovered trying to prepare this talk, um, the was basically way too much to cover in an hour because these, uh, just the, the majority of the things I picked out that come up quite frequently. And yeah, it was, it was, it was, it was, but I probably could have done three separate talks on, on lower gi common conditions. So I condense it down to stuff that probably, or seems to be fairly poorly taught at university, um, which is a Perianal disease, not the sexiest topic in the world I, I appreciate, but it does come up every year and it's not stuff people seem to generally know that much about. And then I'm also going to talk about cancer because surgical oncology again. Very high, real topic. Yuck. I know I hate the words, higher yields as well. So we're going to go through some of this stuff. So as far as perianal disease is concerned for this talk, we're going to be talking about in erectile or perianal abscesses, fistulas, fissures, hemorrhoids, what? Pilonidal sinus diseases? And then a little bit about anal cancer at the end. So, starting off any rectal abscess is so abscess is, is not as defined as a collection of pus inside is a walled off area was like walled off by granulation tissue or a fibrotic tissue. Um In the case of perianal abscesses. A third of them are associated with perianal official disease as well. The pathophysiology of such is is thought to be uh due to the plugging of annual glands that you have are point out on the next anatomy slide. Um leading to like static fluid within these glands, which as we all know is just a breeding ground for bacterial infection, commonly caused by gram negative rods that uh yeah, normally respond to or on the roads. Even the response things like metronidazol orc amoxiclav. So this is a relevant anatomy for perianal abscesses. It's it's going to be become a bit more clear and surely why this is so important. But I don't think you can see my cursor. So I'm going to try my best to describe what I'm talking about. The anal glands are associated with the dentate line. That's very important bit of of anal canal anatomy. It's that portion towards the, the middle of the screen there that kind of as a sort of a sore tooth kind of appearance. Um Yeah, the those are like anal sinuses or anal valves. And within that are the glands that I mentioned and these can like back up and get blocked for various reasons. And uh infection can build up in and around. The anal sphincter is now the there are two anal sphincters is you can see on this picture is the internal, that's continuous with the muscularity layer of the rectum and the external anal sphincter, which is the somatic skeletal muscle that's continuous with the elevator. And I that's so important is the differentiation there. And the what, what, what's so cool about the dentate line was important. Well, it's where the to sort of different m biological uh origin tissues, meat. So on, superior to the dentate line, it comes from m biological endoderm. So the hind gut and it's where it fuses with the ectoderm of the, of the anus. And that's uh yeah, what the whether two different characteristics is, well, like one, for example, but superior to the dental line is lined with simple columnar epithelium. Whereas distal to the dentist line, it's stratified, non characterized squamous epithelium and that will come to be more important later in the cancer bit. There's also this band of perianal fascia that you can see that suspends the speak to complex between the issue of your bra cities and superior to this is all the issue rectal faucet. It has other names, but that's what's the one that would be most useful in the terminology we're about to discuss and just lateral to these. Those are the pudendal canals. So if you can see the vessels in case in that might sort of next door. Cajun tennis, that's the pudendal artery, pudendal nerves and associated veins. So how the terminology we use to describe perianal abscesses is as you can see on the screen here, the anal rectal, should I say the perianal ones that the most superficial, they're also the most common. They're just in the sub mucosal. We're not suddenly Kozel the subcutaneous layer of the skin in the perianal region, you can also get ones which are interesting to Terek. So these can happen within, I mean, that's a bit of a misleading picture. They tend to occur actually in between the two sphincters. So in between external and internal anal sphincter's and these are often very difficult to see on the outside. The same with the other two, which is the issue rectal which occur outside of the sphincter complex. But above that, uh this think did that that layer of fascia that we talked about? And then the most uncommon the super elevator abscess, which is the name suggests because above the elevator a nine. So get on some questions. Um So again, if you could just put your answer in the chat for this one. Um So you have a patient who has pain on defecation, who also happens to have a fever on examination. They are unable to tolerate a pr exam, but there's nothing you can really see on general inspection. So what do you think is the most appropriate management? I've got someone throwing the hat in the ring. Could be any other takers? Okay. So, so the the answer to question like this is normally uh yeah, there you go. It's normally an examination under anesthetic. So E U A, so let's break this down a little bit. So, pain on defecation is yes, you're absolutely right. Lucy is a feature of fish is anal fissures. However, if you have a abscess in between your two anal sphincter is, it is also painful to defecate because there's an inflammatory mass in there. And the compression of the feces going through your anal canal causes pain. They won't be able to tolerate pr very well. And if they've got a fever, you got to suspect that they've got an abscess based on these other features as well. So you would need to, if they can't tolerate pr, then they need a examination under anesthetic because it'll be too sore to do it. It's uh some of the other abscesses, all of them will be the same. It's just the perianal ones. You can see them on the outside, which means you could proceed straight to an eye and d yeah, a bit of a nuanced one that bit of a tricky one. But that is, that is a question that was asked when I sat the exam in September. So, jointing back to the clinical features that you might get in the presentation anorectal abscess. So they often complain of severe pain, very tender region when it's got an infection there. You might have systemic upset such as fever, generally a bit of their foods, rivals, even patient's can become quite septic from these, particularly if they have diabetes or the immuno suppress. Um And you're a non examination, you can sometimes see an erythematous like fluctuate mass, they probably won't really let you touch it to be honest. So examining the fluctuance will be difficult without anesthetic. Um but you also may not see anything at all. So as as I mentioned, now, if it's instinct, Terek or super or or issue erectile, then it'll be probably too painful to examine them without them having a general anesthetic. So pretty straightforward the in how you manage them, particularly in the case of Perianal abscesses because it is largely clinical diagnosis, but you would seek routine bloods and you would want an HBA one C because they might be diabetic. This could be a first presentation of the diabetes. If you are suspicious of a complex uh like Perianal Crohn's or a super elevator abscess, then you would be right in seeking an MRI of the Pelvis parayno. All abscesses do get antibiotics as well because you want to prevent severe sepsis. And then the definitive management is incision and drainage now the bottom. But I'm not kidding. Like these, although these will feel like, oh, it's just, I'm obsessed. You can leave them on the sequel list for however long. But we, we have seen plenty like one's in the groin or perianal ones that do can progress to like that spreading necrotizing fasciitis and be quite life threatening after a while. So, so they can't be left for too long. But that's the other reason to get them on antibiotics is to try and limit the extent of the infection in order to so you can drain it before it gets to bars ready. Okay. So another question server patient has, he's like is examined, found to have a perianal abscess for an incision and drainage. They're booked and consented for as such and go to theater. And when you examine them, you feel like they have a high fish today. What would be the most appropriate management of this patient? Give it a couple more seconds. If anyone wants to answer. If not, I'll crack on. So again, another tough one because it's trying to, it's, it's trying to lead you down the path of um yeah, the there we go. So we've got someone go to see is trying to lead you down the path of oh, it's a fistula. How do you treat high fistula? But the question, the answer is you need to drain the infection of the superficial abscess that you found lead to heal by secondary in tension. It's one of the main principles of emergency. General surgery is source control and by probing a fistula through a bunch of puss and so on, you have the risk of spreading that infection further in and around their perineum, which is something we tend to look like to avoid. We'll come back onto the treatments of fissula shortly. Um And which one of those would be appropriate in the absence of a superficial abscess. But yeah, it's all about source control, leave it to drain and heal by secondary attention. So yeah, as as promised, here we go, ferry anal fissures. So by definition, a fistula or a cabin anywhere in the body. But in the perianal region, it's the abnormal connection between the anal canal and the perianal skin. The most common cause is it's like secondary uh to an abscess formation. Uh like I said, all or a third of all perianal abscesses will have a fistula associated with them. But also like the other one to consider mainly perianal. Crohn's diabetics can get fistula for basically no reason and also due to trauma or already a therapy, they mostly present as written there, recurrent infections in the perianal region or with like a chronic discharge. Everyone loves a classification system in surgery. This is Parks classification system it's called and it's, it's useful in planning treatment for patient with fistulas. That's why I think it's useful. Um And they also, it's, if you see the words hi fistula, low fistula is useful to know what it means for the exam. So just an honorable mention for the sub mucosal fistula that isn't included in parks classification. Um It's uh but it is the easiest to treat, this will come on to the low fistulas, uh characterized as being either into sphincteric. It's the most common that goes, the tract is in between the external and internal anal spinster as you can see there or transfer enteric, which means it goes through both of them. That's um, so on. Uh on a, on a yes, there's through both of distinctive, isn't it on a relatively low trajectory? Now, the other two, uh more concerning clinically in a way, well, or at least more challenging to manage. I'll put it that way. Uh The super sphincteric, an extra sphincteric ones. I mean, it's, it's pretty simple nomenclature if you think about it. But yeah, hi. Is basically if we're breaking it down to those that occur above the origin of external anal sphincter or, well, yeah, that, that's it. That's the kind of point. It's just if they occur above that point, then they are high and if they occur below that, then they are low. But now, so further questions. So you examine the patient and you find an external fistula opening at the four o'clock position So, where are you most likely to find the internal opening? Give you a couple of seconds. Well, let's set the light on this what it's worth. All right. Yeah. Uh huh. Just since we got 11 answer for d any, anyone else willing to further hat in. Mm. All right. So, I believe the fact that I can remember this rightly myself, that it's see. Yes. There we go. So, this is all about good Saul's rule. I don't know if anyone's heard of good tools rule again. Like I said, it's just I didn't learn about this at medical school. I only learnt it for this exam. It's um it's a way of trying to, well an established convention. If you like where the internal opening officials are, what can be predicted to if the external fisheries in a certain position. So if you have a, so this is a patient in the lithotomy position, it's that and that's how they do. The bits on the clock is so if 12 o'clock is that superior bit just below the scrotum six is towards the coccyx, then you you imagine like a transverse line through that 9923 o'clock position there. And if the opening to the fixture is on or superior to that imaginary transverse line, the Fischler will have a linear course straight to uh the equivalent point on the inside. So a fishery at 10 o'clock on the outside will have an opening at 10 o'clock on the inside, whereas any fistulas with external openings inferior to that line will have a curved, curved course and always open on to the posterior midline at the six o'clock position. And apparently that it's mostly accurate. Bit weird. I don't really understand it myself. But again, questions that they do ask about and I've been asked about for the party. So, investigation of management, I am if you are suspecting like a so outside of this, you know, the acute presentation being a perianal abscess business. If you have complex fistula disease or suspicion of high disease, you would you often get an MRI um in advance to see how deep or how high rather or low the fistula tract is. Um because it affects how you manage the patient. So you can if you have very low tracks, so like incredibly superficial sees such as those sub mucosal ones or some of the transfer enteric type of ones or instinct Eric rather. Um you can do what's called a fistula to me, which is simple as you like, you just put it, you put a probe through, through the fistula from the external, into the internal opening and you just take a diathermy or a knife and cut down for it later tracked open and then it, and then it heals and that, that's good definitive management. However, is you might have detected if you have a higher fistula that goes through too many layers of muscle in the internal or external sphincter. For that matter, you could leave a patient with permanent fecal incontinence. If you were to do official ostomy, there could well be a question in your exam asking you how you manage each like. So it is a sort of trick to you a bit with that first question about the perianal abscess if you're asked about low or superficial disease, um then you can say you can lay it open, but in high track disease, particularly in the context of infection or sepsis. And this is where it gets a bit confusing because a lot of times it's an abscess inside rather than one over the top is you would insert the c tongue. Now in, in um in Perianal, Crohn's, um the only way that you manage fistulas is with or high fistulas is with Satan's lusitans because if you perform any perianal surgeon to them, they often don't heal very well. However, in the non Crohn's population that have high track disease, there's a number of different options. So the historic and, and relatively effective one, it's the cutting seat on that you might have heard of. It's, it's sort of a sharp er bit of stitch material that you essentially just tighten slowly over time, allowing a bit of cutting through the sphincter. It will scar up behind it. And then you do that over a period, months or a year until the whole tract has gone through and it's able to scar up and heal up until you brought the whole thing all the way through until the point where you can superficially cut on to it. Um And there's a number of other weird things that you might come across. So advancement flat, if you, obviously that local, local advancement flat for the treatment official. A disease is where you take a bit of the rectal mucosa and you just kind of, you make a small cut and you bring it over to the, to cover up the external opening to attempt to let the track sort dry up and scar up a bit on the inside and then you might be able to um and then that might make it go away. That sometimes works. You can gum up the tracks with the something called fiber and glue and that kind of makes it sort of from those and, or, and, or block something called lift. Am I going to be able to remember what lift stands for? I think it is uh yes, ligation of internal fistula tract. Yes. So feel free to fact check me on that one. But this one is quite interesting. It allows you where it means you, you do an interesting Terek dissection. So you to make a cut in between the two uh sphincter muscles there and you, until you get to the point of the official attractors in between the two sphincters and then you tie off and it doesn't let anything out anymore and then radio frequency ablation, you should burn it. It's a simple, simple as so I'm a bit conscious, I'm taking quite a lot of time getting through this stuff. Does, does anyone have any quick questions about that before, before I blast on with some more perianal stuff? Yeah. Once you identify a fistula, I and D would you then proceed to MRI once the infection is cleared? All right. So I would, yes, it's, that's certainly out of the remit of for your examination. But yes, like if, if you felt that there was too much infection present to do anything about it at the time. Yeah, I would. Absolutely, MRI because it could be complex. There could be multiple tracks that you can't see that you want to do something about. But, but yeah, I agree. I would do that and because it's all about source control, basically that's all they ever ask about in terms of its emergency general surgery. So, yeah. Cool. Right. So I'm gonna crack on because I'm a bit worried about time with this one. So, talk about anal fissures a bit. Hopefully most people know about these, um, uh, the, uh, tear in the mucosal lining, an anal canal. That's the definition they're often associated with skin tags. Um, uh, etiologically, well, it's caused by passing hard stool most often. Um, I don't know if this is how relevant this is, but they're considered acute if the course of the disease is less than six weeks and chronic, if it's more than that. Um And yeah, the you have the risk factors that you would imagine such as constipation, dehydration I B D as with everything, period in organ to come predispose you to it as well. So this is a tricky question. They always ask things like this like where basically you've got to correct sounding answers so bright you as a patient, you got bright red blood on the paper, painful defecation. And yeah, there's a skin tag on inspection. What is the most likely diagnosis? Any takers don't blame you if not, but it is essentially a 50 50. No, fair enough. So I think it's posteriorly cited from memory. Yes, there we go again. I'm sure there is a reason for this. Um But I don't know what it is. I just know in fact that the vast majority of all anal fissures occur in the posterior midline. One would imagine it has something to do with why those uh officials concur around the posterior midline. But like I say, it's beyond me. So I just learn, learn the facts. However, so this is important actually before I move on is that yeah, if you have complex like fissure in a know and or anteriorly cited ones, then you should investigate that further because it it could be related to a cancer or an undiagnosed inflammatory bowel disease so good old structure of your management plans here. So it can do it in terms of conservative medical or surgical approach. So, um you can ask your patient's to increase the fluid intake or, or fluid intake and fiber intake. Um There's also fiber supplements you can get for, for peoples' diets, the medical management for these, I suppose you could say it's like a first line is some sort of laxative because they're mostly caused by constipation and, and your soul is like a type of topical anesthetic. It's over the counter stuff. And the second line however, may have given these yourself in hospital to your patient's. So you can have topical dilTIAZem or G T N. The point of which is to relax the anal sphincter and to try and allow those pushes to heal on their own accord. Surgery is indicated if there's been a failure of medical management. So this is more coming across into your chronic angles, your chronic angle fissures, um Botox injection, it's kind of like that. It is what you would do first before a lateral sphincterotomy. But it kind of like flirts that line between what is medical and what is surgical because they require a G A for it usually because when you stick the needle in their sphincter complex, it would hit the roof there on anesthetized. So I I included in the surgical management. But yeah, lateral sphincterotomy for the very difficult to manage one's never seen one done, but it is a thing that happens. So, moving swiftly on two hemorrhoids. So yeah, the everyone has, well, not everyone has hemorrhoids. Every everyone has the the the precursor to hemorrhoids. If you like their, their, their physiological structures, these uh these these annual vascular cushions, you there are ones that exist above that dentate line that I mentioned. There are some that exist below um visible almost always three and they also always, almost always occur. And the 37 and 11 o'clock positions, I've never been asked about that in this exam, but it's useful for when you, you're fixing them. Um risk factors similar to the anal fissure ones, but it's like any raised intraabdominal pressure as well, can, can bring these on. They're also more common increasing age. So like in elderly women, for example, that had multiple Children or um yeah, again, a patient who does have chronic constipation will probably have hemorrhoids as well. But yeah, they typically produce a painless pr please and some sort of itching. Normally there's it. Again, everyone loves the classification. So if anyone ever writes that they can see or, or, or feel like a first degree hand or the lying, it's a diagnosis you make with a proctoscope or rigid sigmoidoscopy sort of sigmoidoscope because second degree is the only ones you can see externally unless when they're straining even which again, unusual things if someone in a clinical exam. So if you can see hemorrhoids, internal hemorrhoids on examination. So we bright red rectal mucosa as sort of appearance. Then that's third degree and then 4/4 when they're always out, if you can't, you can't reduce them. So they could be, but fourth degrees can be from those as well. And external hemorrhoids don't have their own separate classification. They just ones that can appear in those same positions 3, 11, 7 o'clock. Um but these have sensation because the internal ones above the dentate line don't, which is a bit of a spoiler alert for this next question. If you, if you were listening, so your patient has pain or pain, the complaining of some pr bleeding and a history of chronic constipation out of the below. What is the most likely diagnosis? Take a lot of water? And if no one's answered, by the time I get back, I will prove press on. Oh, we've got someone threw in the hat in the ring. Yes. Sure. I said e you're correct because I just, I almost spoiled for you that, yeah, in internal hemorrhoids, they're always painless unless the blood supply to them become strangulated because the upper anal canal. So that bit above the dentate line. As I said, it was important, there's no somatic sensation to the area, it's all this little sensation. So it's not really that painful unless the blood supply gets cut off. So that's why thrombosed hemorrhoid would be painful and the others wouldn't be. So, uh, where are we at now? Yeah. So, like your anal fissures, conservative medical surgical management. It's the same conservative management, similar medical management just without those topical muscle relaxants. Um, but then the surgery, the surgical options again are a bit different. Um, again, different grades get treated different ways. So, a symptomatic, like, incidentally found, first degree hemorrhoids are left well alone. However, if you get symptoms and proven hemorrhoids on, on proctoscopy, then you could proceed to a rubber band ligation. It's quite funny. It's just like a little like suction gun thing that you, you, you stick down the proctoscope and suck the hemorrhoid down into it and then click a button and it fires a elastic band on to the hemorrhoid. These can be done in the outpatient clinic apparently with the, it sounds very bold. But so long as you get the band on above the dentate line, because if you ban the hemorrhoid, if it's progressed lower than the dentate line, it'll be really painful. And that's why they're probably safer to do under general anesthetic as we were. But hey, there we go. That's, that's just me. So the next tier up in terms of treatment available, something called a halo. I believe that's the generic acronym. It stands for hemorrhoid artery ligation operation. I've encountered a couple of other acronyms that describe the same process is basically you're using a doctor probe. You are able to identify the artery that supplies the hemorrhoids with blood and you then put a stitch around it very easy. It doesn't take very long and then the hemorrhoid dies and just falls off again. If it's above the dental line, that's not a problem. Um, so, but yeah, you got, you got to get it on in the right place and then for the really bad ones you can do open hemorrhoidectomy knees. I'm afraid I can't impart much expertise that I've not really seen any. Um But just to know for the fourth degree ones, that's probably the best way to manage them. Otherwise they, they won't be effective. And then yeah, some honorable mention to pilonidal sinus disease. Basically every day that I work on call and general surgery, someone gets this confused with perianal abscesses. So it's good to know the difference. Um So these are describing abscesses that are in the natal cleft of the buttocks. So it's just a bit above your butt crack increase in your right down in your lower back as it were. Um, they affect people with like quite course dark hair, particularly sedentary individuals. Um And it's sort of thought to be like an infected hair follicle that kind of borrows backwards into the subcutaneous tissue and forms a bit of a weird hairball, abscess thing is really gross. Um But they, they can become infected and form an abscess, um acutely or they drain so chronically like serious fluids. Um So this is kind of what they look like. So you can probably picture on this right? One whereabouts? So this is a person standing up and that's affecting the top part of their uh well left their natal cleft, whereas a perianal abscess will be best visible in the position. And on this other picture on the on the right, you can see some sinus tracks, sometimes not always that easy to see, particularly you don't have zooming in eyes like this person's camera does. But yeah, that that's the general clinical appearance. Um The management of this is uh relatively straight. I mean, all of, yeah, all of the management of these things in principle is relatively straightforward. Um If you've got an acute infection, abscess, you drain it and then yeah, you don't stitch, you're shut, like with all dirty wounds, you just leave to heal by secondary attention. The, however, if you conservatively you can try to, this is, this is a bit more of a stupid one to do in this structure. But you advise your patient's who have this to keep the skin bare in that area, keep the hair removed and just to encourage good hygiene practices because quite often these well, these come to surgery other than when they're infected, if patients are really get in trouble, some symptoms of them. However, the recurrence rate is incredibly high. It'll just, they often just come back. But yeah, a bit like um the very anal fissures, you can, you can just cut them and lay them open. It's more of an ellipse stone you cut rather than just straight line down the middle. But if you find any of these like weird hairball things whilst you're doing it and then you just leave it open. And then like in this picture in the top corner of the slide, there, you can do a paradox procedure which is where you take the lips around the the affected area and then do a local advancement flat across the top and then close it primarily. But like I said, these come back. So you counsel your patient's that they might well not work cool. So that's basically all the perianal disease. Um I just like to impart some summary like, well, it's, it's like the little vignettes to watch out for too like patience present with like ankle pain or discharge kind of unwell and won't tolerate pr it's probably an age erectile abscess if they're recurrent perianal abscesses in the thing or like chronic perianal discharge or history of crows, you should be thinking about fish, la's pain defecation, bright red blood on paper. That's probably an anal fissure if it's just that kind of the painful defecation with blood mentioned in the vignette, um painless blood on paper, probably hemorrhoids. And yeah, they always say young hair email sedentary job or gamer or something like that. That's your part of the needles. Now, I'm going to crack on and I'm afraid because, because I, I've fearing my time is short and I'll come back for some questions at the end about that because we're going into some of the cancer stuff now. Um So angle cancer again, not one that I was really that aware of when I was um S C. Um it's about 4% of all lower gi cancer. So it's on, on the rarer end things like thinking about, you know, 32% of colorectal cancers are um rectal. Um Then it's not very common, but as I mentioned, because they are inferior to that dentate line, the histology of the area is different and therefore, the cancer is different. So you get squamous cell carcinomas in anal cancers, the vast majority of the time because the healthy cell type is a stratified squamous epithelium and they're almost all caused by the oncogenic variants of the HPV virus. So, 16 and 18, this is a really important slide because, well, the clinical practice as well because the differential diagnosis basically fits in with loads of those perianal disease that we've just mentioned. So they can present with rectal pain. Pr Bly's chronic itching and anal discharge, remembering. It's also important to ask about other red flag symptoms as well such as night sweats or weight loss. So this is a good little anatomy one. Um So if you have a suspicion of squamous cell anal carcinoma from histopathology, um which lymph nodes with this tumor likely metastasized to out of this list. So also I I think it's deep inguinal. We're about to find out. Uh No, you got me that time. Very good. Lucy. So yeah, absolutely. The pattern of metastasis above the dentate line goes to the internal lilacs and or local regional nodes like muse a rectal um distal to the dentate line. It's the superficial inguinal. Very good. So we're all learning together. Okay. So like like a lot of cancers, the you'll be doing some biopsies of this to confirm a histological diagnosis and staging as well. So staging also normally involves assessment of lymph nodes and CTS, chest abdomen pelvis and often an MRI of the pelvis in the case of it, of of anal cancer. Kind of quick mention to this because I don't recall ever being asked to stage a cancer in the exam, but it's good to be aware of TMM staging because they do ask about it sort of in the round. Um Yeah, there's a T sort of one to T four with anal cancers. Um It's always if it's m one that means the nodes are positive or m one there are distant metastases. That's just important. Basic stuff about staging to know. And the interesting thing I suppose from an exam reason about anal cancer is that the first line treatment for it isn't surgery in, in the, in the incidence of like a T two tumor for example, is curative chemo radiotherapy. Um So don't get caught out on that. I know I have in the past. It's only in second line of failure of chemo radiotherapy. Would you progress to like an abdominal Parini over section? Probably with some perennial reconstruction. That's what the rand flap is. Is, is just when you've had your perineum removed and you use, I think it's, is it rectus? I think that's probably what that the R stands for myocutaneous flat or pedicle flap that you just would rotate round and cover the perineum with. So yeah, like a T T two and 00. That's, that's like an example of a question I feel like I've seen in the past. So the answer is, is chemo radiotherapy rather than surgery. So cool. So let's move on to meet this. Hopefully, I got time to cover it in the last 15 minutes. Um Colorectal cancer, second highest cause of mortality for of any cancer. It's pretty common overall and remembering our cellular, well, histopathology stuff. So because it's like affecting kind of glandular tissues or like Columbia epithelium covered services mostly at know carcinoma and there are some rarer types that you can forget about the bottom. It's almost always an adenocarcinoma in code erectile. It's most commonly found. This summarizes just like the sites that it can occur. How common they are a bit of a visual overload. Now, I'm seeing it for myself, but it's uh yeah, the most common one to remember is it most commonly occurs in the rectum. I thought that it then most commonly occurred in the cecum. After that, this picture disagrees. So it's either the sigmoid or all the cecum is the next most common, but it's undisputedly the rectum, which is where the most common site for colorectal cancer is. There are some familial cancer syndromes you need to know about within the context of bowel cancer. Everyone seems to know about normally. Uh F A P C. Um So it's um yet also more dominant or all of the ones we're talking about today are um massively increases your risk of getting bowel cancer because you have hundreds and hundreds of these little uh these little polyps. Um As you can see in that picture there, it also is associated with some other types of tumours. Um I believe when it occurs with these other tumors. It's called something called Gardner syndrome. A question that I specifically remember being asked about in the exam, was that out of the list of these things, what's most likely to occur? Uh Well, like as a synchronous tumor with, with fat. See, and that is desmoid tumor is they're, they're kind of like connective tissue tumor's, I believe under the skin. But yeah, that's a bit less relevant. It's just that those are the most common types that occur alongside the co the colon cancers. And these patient's another one to everyone should be familiar about for mrcs is Lynch Syndrome. Um It's at one point in time, it's called hereditary nonpolyposis coli. It's um not one gene that's a, that's always affected, like in, in, in F APC. It's um a range of different DNA mismatch repair genes that can be affected most commonly. Those two are listed there. S H two and M A L H one, it's also an autosomal dominant. And if you're a woman, you're most likely to get endometrial cancer in this syndrome. Whereas if you're a man, you're most likely to get colon cancer. But outside of the gender specific organs. Yeah, these are the, you're, you're just, you're, you're likely to develop these things, your lifetime or more likely to than the regular population and they can occur synchronously as well. But you weren't expecting this a gene inheritance question, something about colorectal cancer. So, but this does happen and it happens again to me. So if a man with Lynch syndrome has Children with an unaffected woman, um so that is like a, a man who is a carrier, the where he's positive Rachel NBCC and he has Children with a person who is completely normal aerials. What is the risk or was the chance rather? Sorry. Was the chance of them having a child with Lynch syndrome? Let's see. I think it's a half. Yeah. So I I am because you only need one copy of the mutated gene to produce the phenotype, the disease, phenotype, your Children, uh It's going to be one and to your Children is going to be affected in terms of probability. Um as it's better demonstrated rather than my explanation by this diagram here. Another quick fire question. So, a 53 year old presents the GP with a P R bleat. What is the most appropriate investigation for this patient? Let's go. All right. So it is a her colonoscopy, I believe. Uh this crushed. Yeah, I agree with you guys. I think it's C as well, but my slides have have died. Oh, no, wait a minute. Yes, there we go. Come back to life again. Good. So, yeah, I think it's colonoscopy because that is what the two week wait advice from. Nice um indicates is that I believe is people over here we go. Thank God. I was trying to remember all that myself for a second. Yeah. Is the, is a two week wait criteria um are displayed here. You're the one that I was referencing. That last question is if your age at 50 with unexplained rectal bleeding, um your two week wait referral be for a colonoscopy. Um It's also worth noting that there's a national screening program for about cancer in the UK, which is if you're between the ages of 16 74 you get a fit test sent to use that, that's the poo test for sort of with them. What used to be called a fecal or cold blood test. You get sent that in the post every two years. But they are at some stage going to expand it to 50 and 59 but they haven't yet. And they've been talking about doing it for years. So, yeah, that's as alluded to with the two week wait thing. Gold's down the diagnosis, diagnostic tools, colonoscopy with biopsy. Some people are too old, which you could argue it. Look for a colonoscopy, which usually would indicate that they're too old for surgery. But anyway, that's another colored fish. You would do a ct colonography. So not a ct abdomen pelvis. That's importantly, it's not detailed enough for small lesion. So if you want to exclude cancer or try to in a patient, you can't have a colonoscopy, then a ct colonography or a CT colon. You would stage it as mentioned before. Um And yeah, the the they have cool clever treatments these days that they can prescribe based on immunohistochemical markings and tumor markings. But those kind of outside the remit, you just need to be aware that that is the thing that can happen. So we're moving on to staging to see if we can get this one. Now, rectal cancer extends through the muscular Rs appropriate. But was there a specific age ct colon in the guidelines? I don't believe so, just to quickly answer that it is purely done on patient factors. The gold standard that everyone should have to make a good diagnosis of cancer is colonoscopy, but there are some patients that can't tolerate it for reasons X Y or Zed. Um Yeah, some people too frail for example. So it's never a specific age. It's just on the patient factors. Um uh Yeah, so if anyone feels like they can answer this, go for it pleases. So yeah, rectal cancer that extends through the muscular s and it shows involvement of meat, erectile lymph nodes as well. What stage is that? Yes, I I agree. I think it's C as well because yeah, this Duke staging which is a little bit outdated, but they do ask about it. I was definitely asked, is detailed here. It's about how many layers of the bowel for the first two parts have as it eroded through, so beneath muscularis or through muscular these and then if it's got a regional lymph node, it doesn't matter. It's automatically see and D is anything with this um tested. So it's quite simple. I see why they do like to ask about it and it has studied five year survival things for it as well. However, the TMM staging will be most often cited in clinical practice. Um It has relation to the Dukes criteria. So in the sense that so if it's T one, um the T two, you can say it is Dukes A um Dukes A and then um yeah, it's gone through the muscular wrist, then it's at least Duke's B um And above where, as if this is one that isn't properly encapsulated in terms of the seriousness because it doesn't have to have lymph nodes, but it can spread into the perineum, for example, for local regional metastases. Right. Yeah, I mean, that's just going over again. What I said, to be honest, here's another good one. Let's see if Lucy can get this right again. Um Because I'm not really sure I won't. Um if what's the most likely location of a positive lymph node in someone with ascending colon cancer, they ask, you know, and stuff like this all the time. So I think that they go to oh interesting, right, internalized neck nodes. So I think they go to the superior mesenteric nodes. It's ascending colon cancer. Oops, yeah. So the the lymphatic drainage normally follows the blood supply normally. So for example, appendiceal tumor's will go to via the mesoappendix ones to ileocolic nodes. Same with the cecum because ascending transverse, you know that for about structures up until the splenic fletcher, you can go to the superior mesenteric and uh and so on is it gets a little bit more interesting around the rectum as mentioned previously, like how digital rectum goes to the internal AN X. Um And the national ones you had to the superficial inguinal management as with all cancers involve referral to end ETS, they're depending on the stage, you might end up doing chemotherapy before or shortly after surgery and then the curative reception is the goal if it's, if it's possible, you know, with a regional colectomy. But again, if this comes back to why I alluded to with the patient's, they're unfit for colonoscopy. If they can't tolerate a colonoscopy, then they might not tolerate surgery. So it would be considering palliative treatment for that patient population. Anyway, I think I've got just enough time to talk about the different types of regional colectomy. So if a patient has a T two stage and 00 rectal cancer, which is above the anal verge by 6.5 centimeters and they're basically healthy as kind of what former status of one is, which of these procedures would you do for them? So, yeah, like I say, in the interest of time, I'm afraid. So I believe the answer is c um anterior section. I feel like I have been answered this question before because there are, there's like uh that's a rough, it feels rough sentiment on where in relation of a rectal cancer is to the annual verge as to what type of these procedures you would do. Um So I believe I detail that here. So um kind of that's, it's in the following slide. But anyway, I'll come back to it. But yeah, there's a regional reception of colorectal cancers. One important learning point from this slide is that if you have a uh transverse colon tumor, you would do often work most commonly an extended right hemi rather than a extended left, for example. Um So that's something so important to remember these, all of these other ones that are possible, like you say, right? How many very common sequel tunes ascending colon tumor's uh signal and collected me. I don't see them as often. Um But it is a thing that can occur. It's where you dissect out all of the inferior mesenteric artery. But yeah, this is the bit that I want to talk about cause they do ask questions about this. Um So an anterior reception will be performed generically in a high rectal tumor and some sigma cancers as well. So that's defined as being greater than five centimeters from the anal verge. You're left with a defunction loop ileostomy and can go back to rejoin them later on. You're, you're just doing the ileostomy to rest about to allow your own s oh no, sorry if you perform the primary osmosis, but you bring out an ileostomy to rest the bowel. So the anastomosis can heal and then you reverse the ileostomy electively and allow the joint to do this thing. However, in low rectal tumor's, so those that are less than five centimeters from the annual verge, you would do an A P reception, abdominoperineal reception. These patient's will have a end colostomy for forever. And yeah, as the name suggests, they will be without a perineum. So it's like, do they do they still have an anus, that patient has had an anterior resection. If they don't, then they had an AP reception. This way. I used to remember anyway. But yeah, that, that is asked about. So it's worth remembering. I think I've just got through with cancer on under the, by the skin of my teeth. So we've talked about how HPV most common cause of anal cancer. And the first line is treated with chemo or radiotherapy, not surgery. There are colorectal cancers, these security amenable security reception, regional colectomies, what the Duke staging criteria is versus A TNM, some inherited conditions and the specifics of some of the regional colectomies as well. So I think I'm going to have to call it there because there is another talk coming at seven. Does anyone have any quick questions for me that I can answer? And because I do have about 10 slides on, on weird cancers in inverted commas. So I don't know if I could distribute slides to you guys. The ones about like pseudo Myxoma paratonia iron and, and Neuro wrecked that what they called neuroectodermal tumor's as well. But yeah, if you've got any quick questions for me about colorectal cancer, go for it. Otherwise I'll leave it there. Right. Oh, thank you so much, Ben. That was superb. No, thank you. Thank you very much. Yeah, sorry. I kind of ran out of time, but like I said, it was a big, it's a big old topic. No, you did really well, thanks everyone for coming. Um Please please get out the feedback. Um We'll get that to you, Ben. I'm just going to post the link to the next talk on the chest as well, which you can also find on medal page and that's on breast conditions. Thanks man. Well, thank you very much for listening. Everyone. I'm gonna leave. Goodbye.