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# Hemorrhoids!
## Internal
- dilated **submucosal veins sup. rectal plexus**
## External
- dilated veins from **inferior hemorrhoidal plexus**
- usually asymptomatic UNTIL they are thrombosed! pain for days then subsides



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# Anal fissure

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# Rectal bleeding/blood in stool
### DDx
- **Diverticulosis**
- **Angiodysplasia**
- IBD
- Cancer
- Ischemic colitis
- hemorrhoids, fissures
- Small GI, rare

#### Hematochezia
- usually left sided
- **Scope it!** (COLON-, ano-, proctosigmoido-)


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# Fecal incontinence vs Constipation

## Constipation
### Causes
- MEDS:
- anti-psych; -depress.
- narcotics
- iron
- CCB
- antaacids
- obstruction (CRC, anal stricture, hemorhoids)
- endocrine
- hypo... thyroid, kalemia
- hyperCa
- NeuroMusc disorders

### MGMT
- bulk laxatives
- enema

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# Crohn's/UC + anal fistula

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# EUA + seton placement
### Post-op F/U

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# [JN] Case 1: Reversal of hartmann + ventral hernia repair
## Patient had an ileocolic anastmoses and end colostomy

#### Surgical Steps
- Skin incision and dissection of the ostomy down to the level of the abdominal wall fascia.
- Opening of the fascia and mobilization of the ostomy, freeing up two free ends for an anastomosis.
- Side-to-side functional end-to-end stapled anastomosis of the ileum.
- Primary closure of the fascia and of the skin.

`There are multiple accepted technical variations for the ileostomy reversal procedure. In order of sequence, these may include the skin incision (circular vs. tapered), creation of the anastomosis (hand-sewn vs. stapled), closure of the abdominal wall fascia (primary vs. mesh), and wound management (purse-string vs. skin closure).11,12 Both hand-sewn and stapled anastomotic techniques have similar morbidity and mortality in retrospective analyses.13 Although primary closure of the abdominal wall fascia has been the standard of care, recent evidence suggests that retromuscular placement of synthetic mesh at the time of ostomy closure significantly reduces subsequent hernia formation without increased wound complications.14 Further studies are needed to better clarify the role of mesh for ileostomy reversal. Finally, a recent meta-analysis evaluated purse-string vs. linear wound closure after ileostomy reversal, and it was observed that a purse-string closure was associated with significantly reduced infection rates.11`

https://jomi.com/article/298/ileostomy-reversal-for-a-two-stage-laparoscopic-proctocolectomy-with-ileoanal-j-pouch-for-ulcerative-colitis

# [ZY] Case 2: Altemeier procedure (perineal rectosigmoidectomy)
## for rectal prolapse

### Approach
- Abdominal vs perineal
- criteria is based on frailty
- Altemeier = full thickness
- Delorme = remove only mucosa layer

## operative steps
2. Patient Preparation
Patient Positioning
Preoperative Exam and Delivery of Prolapse
Exposure with Retractor
Examine Anatomy and Score Dissection Line Around Rectum
Inject Local Anesthetic Along Score Line for Hemostasis
3. Full-Thickness Rectal Dissection to the Mesentery on the Inside
4. Evert Rectum to See Entire Rectal Edge
Make Windows into Mesentery and Divide with LigaSure to Deliver More Rectum
5. Open Pouch of Douglas to Enter Abdominal Cavity
6. Inspect Sigmoid Colon and Determine Level of Resection
7. Posterior Levatorplasty
8. Close Pouch of Douglas
9. Transection
10. Complete Anastomosis
11. Inject Marcaine for Pudendal Nerve Block
## RELEVANT ANATOMY
- dentate line
- mesentery near rectum
- layers of sigmoid/rectum
- pouch of douglas
- blood supply of anorectal area
- pelvic floor muscles
- pudendal nerve


https://jomi.com/article/356/altemeier-perineal-proctosigmoidectomy-for-rectal-prolapse

# [TC] Case 3: Lap. R Colectomy for Crohn's
## mesalamine(asacol) for last 3 years
## cecal polyps unable to be removed via scope

Colonic polyps are projections from the surface of the colonic mucosa. Most are asymptomatic and benign. Over time, some colonic polyps develop into cancers. Colorectal polyps are classified as non-neoplastic and neoplastic. Non-neoplastic polyps include hyperplastic, inflammatory, and hamartomatous polyps. They are typically harmless and do not become cancerous. Neoplastic polyps include adenomas and serrated polyps. They are premalignant lesions that may progress to colon cancer over time. In general, the larger the polyp, the greater the risk of cancer, especially with neoplastic polyps. Polyps are diagnosed using colonoscopy and are removed via polypectomy if they are small and pedunculated. If the polyps are too large or cannot be removed safely, they may be removed by colonic resection.

Many randomized clinical trials including the COLOR, CLASSIC, and COST trials have shown that laparoscopic-assisted colectomy surgery has the same outcome (69%) as open surgery (68%) in terms of 5-year survival. In addition, retrospectively it has been found that open surgery resections have a higher positive margin rate at 5.3% with a hazard ratio of 3.39, 95% CI 2.41 – 4.77.7 The usual length of hospitalization following laparoscopic right colectomy is 2-3 days. The use of enhanced recovery after surgery (ERAS) protocols has been an essential component of post-operative care, shortening hospital stay, and reducing complication rates. Most patients with node-negative colon cancer ( i.e. Stages I-II) are cured by surgery alone. Some patients with Stage II adenocarcinoma that has aggressive histologic features (such as lymphovascular invasion) may benefit from adjuvant chemotherapy. The risk/benefit ratio is such that decision making should be individualized. However, adjuvant chemotherapy is clearly indicated for those with Stage III tumors. Treatment of patients with isolated liver metastases needs to be individualized and should be discussed by a multidisciplinary tumor board to optimize treatment planning
## Ileo-colic vascular pedicle






https://jomi.com/article/125/Laparoscopic-Right-Colectomy-with-Ileocolic-Anastomosis

===
# 10/24-28 UW
# SBO vs Ileus
Ileus is **uniform** dilated loops instead of discrete transition point/obstruction in SBO

# Acute colonic pseudo-obstruction aka Ogilvie syndrome
- Caused by surgery, trauma, infection, electrolyte imbalances
- thought to result from **autonomic disruption** of the colon
- MGMT: bowel rest + neostigmine

# Ulcerative colitis treatment
- FIRST LINE: 5-ASA aka salicylates enemas
- mesalamine
- sulfasalazine
- balsalazide

# Sudden severe LLQ pain --> spontaneous relief --> generalized, constant pain and a rebound tenderness
- likely a perforation of diverticulitis leading to peritonitis leading to **free air in peritoneal cavity**

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# 10/26
## Thoracotomy


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# Monday October 23 (CALL DAY)
## Mastectomy, Partial, SLN BX, LEFT SYMMETRY REDUCTION , RIGHT ONCOPLASTIC
50 y.o. female with right breast IDCA with focal lobular features T1 in size,, at 3 o'clock, ?grade, >90%ER+/>90%PR+/HER2 pending

We have discussed the diagnosis and reviewed her pathology report and imaging in detail.

I discussed that I would review her case at tumor board and would also need to have the OSH send the path slides.

We discussed the options for treatment, including mastectomy, lumpectomy, and oncoplastics. I believe that given her stage 1 breast cancer, mastectomy would be considered an extreme option, and I would recommend either lumpectomy or oncoplastics. We have reviewed that there is no difference in the overall survival between the three options. I explained that in the case of lumpectomy, the surgery would involve removal of the area of concern and we would monitor her closely to screen for further cancer. In the case of oncoplastic, I explained that reconstruction preserves the patient's breast using the patient's own breast tissue for reconstruction using volume displacement and replacement techniques, and a symmetrizing procedure on the contralateral side. This would entail either an extended superomedial pedicle or inferior pedicle with wise skin incision design on the cancer side with a symmetry operation on the contralateral side.  We went into detailed discussion on complications for each operative intervention.

The patient experiences significant symptoms associated with her breast hypertrophy and is thus interested in the oncoplastic option with a right inferior pedicle wise pattern and left symmetrization. Risks discussed include bleeding, infection, seroma, hematoma, wound separation, breast asymmetry, nipple necrosis, scarring and the possibility for a positive margin requiring additional surgery.

We reviewed the need for sentinel lymph node biopsy. We have reviewed the method of sentinel lymph node biopsy including the possible need for axillary lymph node dissection. We discussed that during sentinel lymph node biopsy, generally 1-3 axillary lymph nodes are identified with the use of blue dye and a radiotracer. With breast conservation therapy no further nodal dissection would be required unless more than 2 lymph nodes are positive (per ACOSOG Z0011 study)
Plan discussed with the patient and they are in agreement.

### PLAN
Surgical plan is oncoplastic breast surgery with right volume displacement using inferior pedicle wise pattern incision design and left breast symmetry surgery, and right sentinel lymph node biopsy

Will need to hold off on the estrogen pill at least 1 week before surgery

Will order genetic testing

Will order pre-op labs, EKG, CXR

Will need OSH path slides

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title: Decannulate or not Decannulate: That is the Question
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# Decannulate or not Decannulate: That is the Question
Yilun Zhang

![]()

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# Table of Contents

1. Problem
2. Question
3. Value Proposition
4. Literature
5. Proposed Protocol
6. Takeaways
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## 1. Problem
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- Since 2014, the incidence of tracheostomy has tripled in patients needing mechanical ventilation
- COVID times
- Not too soon, not too late, just right
- Difference in "expert opinion"
- RT's prefer tolerance of capping
- Physicians use level of conciousness
- Temporal Range (48-72h)

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## Question
=
Is our current practice at TMC of using the common 24h capping trials for patients with tracheostomy a good assessment of decannulation readiness?
- are there better objective and/or subjective metrics to track?
- can our rate of recannulation OR time to successful decannulation be improved upon?
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## Value Proposition
=

source: https://www.passy-muir.com/wp-content/uploads/2018/10/costs_related_to_tracheostomy.pdf

=

Patients who require tracheostomy for respiratory failure, diagnosis-related group (DRG) 483,
have a high consumption of resources. By DRG categories, they have the highest patient costs
and the highest hospital reimbursement.4

=

29 days Average length of stay for a tracheostomized patient5
$265,499 Average amount of hospital charges associated with tracheostomy5
$60 Billion Expected national bill in the year 2020 associated with prolonged mechanical ventilation6

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# mortality for those who get decannulated are significantly lower at one year
Four hundred twenty-nine patients were studied. Hospital mortality was 19%. Only 57% of
survivors were liberated from mechanical ventilation. At 100 days, 6 months, 1 year, and 2
years after discharge, 24%, 30%, 36%, and 42% of hospital survivors had died, respectively.
Patients liberated from mechanical ventilation and having their tracheostomy tubes
decannulated had the lowest mortality (8% at 1 year); the mortality of ventilator-dependent
patients was highest (57%). Sixty-six patients completed the SF-36 for functional status. While
emotional health was generally good, physical function was quite limited. **Median hospital direct
variable cost was $29,340. **

=

# trach teams have decreased times to decannulation

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https://jintensivecare.biomedcentral.com/articles/10.1186/s40560-017-0234-z

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# Current Literature/Standards
=