11 ABSITE_colorectal2_edited_error fixed
[00:00:00] Okay. Behind the knife, ab site review. We're on colorectal part two. So I'm here back again with Kevin and John. So let's do it.
So part two, colorectal ulcerative colitis. Kevin, how do we define ulcerative colitis? So this is a chronic inflammatory condition affecting
the rectum and extending proximally always spares the anus.

Okay, great. And what are some buzzwords associated with ulcerative colitis that you might see? Yeah, this is a mucosal disease. It's
contiguous. And it has characteristic crypt abscesses and pseudopolyps. Okay. What are some basic management principles? The
majority of these patients can be managed medically, which we'll dive into shortly, but 15 to 30 percent will eventually require surgery.

Okay. And what are your medical therapies? So steroids for acute flares, mesalamine for maintenance. and then infliximab also for
maintenance if resistant to the misalamine. Okay, perfect. Indications for surgical intervention in ulcerative colitis? So, medical
intractability, then of course malignancy and other complications from colitis, such as a stricture, perforation, or [00:01:00] fulminant slash
toxic colitis.

Okay, so you mentioned medical intractability. You were a little bit vague there. So what actually constitutes medical intractability? So
things such as growth failure in children, the conditioning worsening while in medical therapy, If the condition is insufficiently controlled
while on maximal medical therapy, if patients don't tolerate the medical therapy chronically, such as being on chronic steroids and then
disabling extra intestinal manifestations that do respond to colectomy.

Yeah, so those things that do respond, like you say, like large joint arthropathy, erythema and dosum, episcleritis, those do respond to a
colectomy. Are there things that don't? You know, associated conditions that don't respond to a colectomy. Yeah. Unfortunately, primarily
primary sclerosing cholangitis does not.

Yeah. So some of those hepatobiliary manifestations, unfortunately, as you say, do not respond to colectomy. So what is the association
between ulcerative colitis and malignancy? So you have an increased risk of malignancy associated with the prolonged [00:02:00]
inflammation state that you're in with ulcerative colitis.

Okay. So how should we survey these patients? So it depends, but patients with extensive colitis. Going from proximal to the splenic
flexor, they need endoscopy after 8 years of disease, and then every 1 2 years. Okay, so endoscopy every 8 years, and then every 1 2
years, and what do we do during that endoscopy?

So they're going to do a 4 quadrant random biopsy, should be performed at 10 cm intervals throughout the involved segment of colon.
Along with directed biopsies of suspicious lesions. Great, yeah. Four quadrant, random biopsy every 10 centimeters for the involved
segment, as well as targeted, as you say. So what do you do then if it does come back as a malignancy or a high grade dysplasia?

So in this situation, you have to do a total proctocolectomy with or without IPAA. Yep, total proctocolectomy with or without IPAA. Great,
okay. What are the surgical options in ulcerative colitis? So, if it's an emergent case you can do a total or subtotal colectomy with
endileostomy. You can do the, perform the [00:03:00] completion proctectomy and IPA later if it's an emergent case.

For elective options, once again, you can do the total proctocolectomy with endileostomy. This is curative and removes all pathologic
tissue and commits, but does commit the patient to a lifelong ostosomy. You can do a total proctocolectomy with IPAA is the most
common procedure in the elective setting.

The advantage is no long term stoma, but you may have complications in the pouch such as pouchitis. You must have good baseline
continence to have an IPAA performed. And you have to be sure that it's UC and not Crohn's as Crohn's won't be curative. Okay. Great. I
think that's, that's good. So in that emergent setting, right?

Yeah. Toxicolitis perforation. I mean, you're doing a total or subtotal colectomy and you're doing an endeliosomy and then you're going to
later stage in and potentially, you know, complete that proctectomy with the IPAA. Now, if you have the advantage of being an elective,
you're doing your definitive operation.

You're doing that total procto colectomy and then depending on, you know, individual patient factors, you, you, you might do an end
[00:04:00] ileostomy. You might do an IPAA made with a diversion or without a diversion. So there are multiple stages or single stages
that these procedures can be done in. And that's gonna depend a lot on individual patient factors as well as the surgeon preference and
experience.

So, what about total? A, a abdominal colectomy? Not protal colectomy. So total abdominal colectomy with ileal rectal anastomosis in uc?
Yeah, so they must have an uninvolved rectum, so it's only used in highly selective cases and the rectum is still at risk for undergoing.
Ongoing disease and risk of cancer.

Yeah, so if you do that in that select circumstance that you stated, you need annual surveillance of that residual rectal cuff. Okay, great.
Okay, John. So you see, you know, Kevin rightfully said that if you're going to do a pouch, you need to make sure that it's not Crohn's
disease. So let's go down that pathway.

Let's talk a little bit about Crohn's. How do you describe or define Crohn's disease? Yeah, Crohn's is defined as a chronic, incurable,
inflammatory disorder that can [00:05:00] affect any segment of the intestinal tract. Where terminal alien is the most common and it
usually spares the rectum. Okay. So you get rectal sparing TI most common, as you say, this is one of those ones that has a bimodal
distribution.

So see it present in patients in their twenties to thirties. And then again, in patients in their fifties and sixties. But what are some, some
buzzwords that you may see in like a question stem that's going to tip you off that you're dealing with Crohn's. Yeah. If the stem is
mentioning transmural involvement, segmental, or the characteristic creeping fat.

You may see a picture of that too. Yeah, so remember UC is limited to the mucosa and it affects the colon continuously, whereas in
Crohn's we have, it's segmental and transmural. Okay, there are some different phenotypes that are going to affect how patients present.
So what are the three main phenotypes of Crohn's disease?

So you have your inflammatory type, fibrostenotic, And penetrating and these are all kind of overlap and change and can be a mixture of
[00:06:00] the two. Yeah, those are the three you remember though. Inflammatory, fibrostatic, penetrating, that's going to affect how the
disease presents. And as you say, there can be overlap, combination, that can change within the same patient.

How about some extra intestinal manifestations of Crohn's disease? Yeah, these are kind of how you would actually so arthritis,
arthralgias, megaloblastic anemia, and that's secondary to the malabsorption of B12 in the terminal ileum, uveitis and urethema nodosum.
Okay. Okay. What's, what are medical therapies for Crohn's?

So typically steroids are kind of the hallmark treatment for most acute flares. You can use mesalamine for maintenance and infliximab it
can be used for resistant disease or you know, a lot of rectal disease Okay. So what is that? So infliximab that anti TNF, right? So anti
TNF therapy, that's infliximab, adalimumab What is that primarily used for?

Yeah, like I mentioned it's used to treat the fistulizing disease and the perianal disease associated with Crohn's Okay, great.[00:07:00]
Okay. When is surgery indicated with Crohn's? So surgery is not curative unlike in UC, where you can get a potential cure. It's mostly
reserved for complications of the disease.

So strictures, obstruction, malignancy, perforation, and fistulas. It takes an experienced surgeon to deal with Crohn's disease, but you
want to preserve as much small bowel as possible because they're going to most likely need multiple resections. Okay. So what about,
you know, especially in the setting of like a fibrostatic Crohn's disease, how do you manage symptomatic strictures?

So if it's proximal or, you know, extremely distal in the small bowel you can try to treat it endoscopically and then you can do endoscopic
dilation. Otherwise, you may need to perform a resection or strictioplasty. Okay. And I think we should mention that, you know, I put this in
the setting of that fibrostenotic, but remember that you can get inflammatory Crohn's that can cause a partial obstruction and those you
can decompress and, you know, treat with the steroids.

And often once the inflammation goes down, things [00:08:00] will open up. So this is, you know, specifically talking to that, that
fibrostenotic. Crohn's disease. So let's talk more about those stricturoplasties too. So what types of stricturoplasties and how does the
length of the stricture affect our choice of stricturoplasty?

Yeah. So you go back. So if you do have a very short segment disease, resection is the most commonly performed. And like you said, just
take as much small bowel as you need. But if you do need to do a stricturoplasty, there are a few different types. So for short strictures,
less than 10 centimeters. You can do a Heineken Mikowitz stricturoplasty.

And what's that? It's a longitudinal incision on the stricture, and then you would close it transversely. For medium length strictures, 10 to
20 centimeters long, you only do a finny stricturoplasty. Or at least it's an option. This is where you fold the stricture segment on itself, and
make a common channel within the loop.

It's best if you look these up, and look at a good diagram of how these stricture plasties are performed to kind of, you know, ingrain them
into your mind. Long strictures greater than [00:09:00] 20 centimeters. You can do a McKellassie stricture plasty. It's similar to a Finney.
It's a side to side iso peristaltic stricture plasty.

Excellent. Yeah. So the length of your stricture is really going to dictate what your options are. So be familiar with those, you know, in
case they give you that description of these long strictures and, you know, ask you what the best way of, of of the surgically managed and
these are, what's one thing you have to remember when you're dealing with these strictured segments.

And that's, it's very important that you don't want to miss. Yeah, you want to always perform stricture segment to rule out malignancy.
Yep. Okay. Exactly. So biopsy the strictures, make sure you're not inadvertently leaving a malignancy behind. Most common complication
after these things is, is typically bleeding.

Okay. And you, you of course, you know, these patients can be high risk. So you, you need to look out for malnutrition, any presence of
inflammation, perforation, fistula and suspicion for malignancy would be a, a contraindication to just simply perform a stricter plasty. Okay,
so moving on, let's dive [00:10:00] into malignancies and colon cancers.

So, Kevin, let's go through some screening recommendations for colon cancer. So let's just say it's you or me, average, your average
person, asymptomatic, average risk. When do we start screening? Well, it's coming up pretty soon for you. You need to start at 45 and do
it every 10 years. Thank you for the reminder.

Okay. Yeah. 45 every 10 years. So let's say I had a first degree relative that had colon cancer. When should my screening start? So you
should start at 40 or 10 years before the age of the youngest relative's diagnosis. Okay, and then how often do I need my colonoscopy?
Yeah, you got to do it more frequently, every five years.

Okay. Well, let's say I had a cousin or a second degree relative with colorectal cancer. Does that change anything? No, that doesn't. Back
to 45 years old and every 10 years. Yeah, so second degree relative is just treated, you're just treated like your average asymptomatic,
average risk patient. Okay, what about in the setting of FAP?

When do I need to start screening? Between the ages of 10 and 12. Okay, and[00:11:00] how, and the frequency? Every 1 to 2 years.
What about hereditary nonpolyposis colorectal cancer, HNPCC? So this, you start it at 20 between 20 and 25, and they need it every 1 to
2 years also. Okay. Another thing that frequently comes up is findings, you know, we have some abnormal findings on colonoscopy.

And then when do we need to repeat that colonoscopy for that patient? So let's, let's go through some of those. So let's say we have one
to two tubular adenomas. When's the, your colonoscopy interval seven to 10 years, greater than three, three years, three years. Okay.
Advanced adenomas. So those are defined as greater than one centimeter high grade.
They had dysplasia or the villus. When do you need to repeat colonoscopy? And that's also provided that, that, that adenoma is
completely endoscopically resected. Yeah. Three years. Three years. Okay. And let's say hyper, what about hyperplastic polyps? 10
years. Yeah. So this is just considered average risk.

So those are, those are very high yields and those will come up. So you do need to[00:12:00] know those. So what if you found a
malignant polyp on, on your colonoscopy? So a malignant pedunculated or sessile polyp may be managed endoscopically if the following
criteria are met, the polyp can be removed in one piece.

The resection margins are free of dysplasia or cancer. The lesion is well or moderately differentiated and no angiolymphatic invasion. And
there's limited submucosal invasions, cancer cells, two millimeters or less past the muscularis mucosa. Yeah, so yeah, those so it is
possible for pendunculated polyps, malignant polyps to manage those endoscopically, but they have to meet all of those criterias.

So malignant polyps that do not meet low risk criteria or cannot be adequately removed via endoscopic techniques require an oncologic
resection. So colon cancers is unfortunately one of those ones that you need to know the TNM staging and you need to have committed
to memory. So we're going to go through it.

It's, it's also in the book. So spend some minutes looking at it. So let's just go through it. So your tumor stage in[00:13:00] situ is when it
involves only the lamina propria. Your T1 tumors invades the submucosa. T2 invades the muscularis propria. T three invades through the
mus muscularis propria and into the pericolonic tissue, whereas T four penetrates the cirr rosa as T four A or invades and is adherent to
surrounding structures.

That's T four B. So with regard to nodal status, N one is one to three nodes N two is broken up into A and B. So N two A is four to six, and
N two B is seven plus nodes. And your M stage, of course, M0 is no distant metastasis, whereas M1 is distant metastasis. Now to
translate that over to the staging, so, you know, stage 1 is a T1 or T2 tumor with no nodes, no metastasis.

Stage 1, T1, T2, no nodes, no metastasis. Stage 2 is a T3 or T4 lesion, again, with no nodes and no metastasis.[00:14:00] Stage three is
where you start to see some nodal spread. So that's NET stage N one or two and no metastasis. And then stage four, N-E-T-N-E-N-N.
And then there is metastasis. So this is, as we talk into our treatments knowing these T stage distinctions is gonna be important into
guiding management.

So it is very important to know. Yeah, I will say there's a pretty good chart within the text. That kind of divides these out nicely. Probably
one of the best charts I've seen, honestly. So be sure you listen to it over and over again, and look at this chart, and make sure you
commit that to memory.

This is one of the things you're just going to need to know. Kevin, how do we, you know, I said nodal status and positive nodes. How do
we define a positive node? Yeah, that's if there's 0. 2 millimeters of cancer deposit. Yeah, 0. 2 millimeters deposit of cancer cells, that
constitutes a positive node. So when we, we're going to talk about some resections, but to what extent a proximal and distal margin is
required?

5 to 7 centimeters. Okay, and that's to ensure [00:15:00] that we get and it has more to do with the blood supply than it has to do with the
margin itself, but it's in order so we can get that adequate lymphadenectomy. And speaking of lymphadenectomy, how many nodes do we
need to get during our resection? At least 12.

Okay. How about stage four disease? So, stage four disease, reminder, NET, NEM, and there's a distant metastasis. So, how should we
classify these? So, you can break it down into resectable, potentially resectable if able to do down the stage with chemotherapy, or
unresectable. Okay. So, what is considered a resectable?

So, if it's resectable and medically fit patients, a curative resection of hepatic and pulmonary metastasis can be performed. Okay. So, the
sequence of chemotherapy and the resection of the primary tumor and the resection of the metastasis vary widely by surgeon, institution,
and individual patient tumor characteristics.

It's safe to answer if given a resectable colon cancer with hepatic metastasis. Three months of preoperative full FOX followed by surgery
and three months of [00:16:00] post op full FOX. Okay, good So purity of resection without hepatic and or pulmonary metastasis and
colon cancer And I think that's a great way of approaching it three months of preoperative full FOX surgery three months of post op full
FOX But again that as you say, it's highly institution dependence Okay, so that was for resectable colon cancers, but now for potentially
resectable colon cancers, which means they're not resectable at the time, you give them preoperative full FOX and then reevaluate the
resectability based on the response to that.

And then finally, if it's unresectable, you do surgery only for palliation, whether it's obstruction, bleeding, or perforation. Yeah. I think an
important principle for most cancers is if you're doing neoadjuvant therapy, don't forget to restage after that and see what the response is
because for, you know, a disease that progresses through neoadjuvant therapy, that of course has a very, very poor prognosis, but
absolutely agree.

Okay. So, what about adjuvant therapy? So who who gets adjuvant therapy with colon cancer? So adjuvant therapy for colorectal cancer
is [00:17:00] stage three and above. So it's positive nodes or M1 disease. Yeah, that's a very clear answer. So certainly if you have
positive nodes. And you, stage three or greater, you're going to get adjuvant therapy.

So there are some stage two diseases that are considered high risk, like a T4 primary, you know, perforation obstruction, poorly
differentiated, some microsatellite instability. Or if you got less than 12 nodes on your resection where adjuvant therapy is offered, that's a
little bit controversial and probably outside of the scope of the ab site, but just be aware that there are some high risk stage two diseases
that are offered chemotherapy.

So what is the adjuvant chemotherapy regimen? So that is full Fox for six months or three months pre op and three months post op,
which that includes falenic acid. Fluorouracil and Oxyplatinin. Yeah, so Lucaborin, 5 FPU and Oxyplatinin, absolutely. What about the,
what's the role of radiation for colon cancer?
Yeah, it's not indicated for colon cancer. Alright, [00:18:00] John, so let's move on to rectal cancer. So, what's the workup for a newly
diagnosed rectal cancer? So, the labs you want to focus on are getting a CEA. You also want to do a rigid proctoscopy to document the
level of the tumor. Do a chest, CT chest, abdomen, pelvis to evaluate for metastatic disease, that's your staging workup.

You also want to do an endoscopic ultrasound, EOS or you can do an erectal MRI for T and N staging. The MRI is particularly helpful to
determine the tumor circumferential margin, the CRM. The CRM is the total distance between tumor and mesorectal fascia. And it's a very
important prognostic indicator.

Okay. Yeah, it's very important prognostic and it helps guide our management based on what we find there. So, so along those lines, who
gets neoadjuvant chemo radiotherapy for rectal cancer? So locally advanced tumors of the mid and distal rectum, we get these that's T3
or greater or any nodal disease.

Absolutely. Those are the key words there. T3 or greater or any end disease. That's why those[00:19:00] you know, knowing the extent of
invasion and the nodal status is so important up front. What's the regimen for neoadjuvant chemo radiotherapy for rectal cancer? So that's
5000 centigrade radiotherapy. That's delivered concurrently with 5FU chemotherapy over a period of five to six weeks.

Yeah. So that 5FU is a radiosensitizer. And then when do we follow with surgery? About eight to 12 weeks after. And again, like I said
before, if we're giving you adjuvant therapy, be sure you assess the response and then restage prior to proceeding with resection. So with
regard to the surgical management of this is, is there a, a, an option for local excision for rectal cancers?

Yeah, we can consider this in T1 lesions without high risk features. Lower risk features include well to moderately differentiated lesions.
with no lymphovascular or perineural evasion, the lesions that are less than three centimeters and a less than a third of the circumference
of the bowel movement.

So what's the, you know, the big issue or big concern[00:20:00] with a local excision for rectal cancer? Yeah, you're not able to
pathologically examine the regional lymph nodes. Yeah, exactly. So that's why these T1 well differentiated No high risk features that
would be the only ones you could really consider it.

And, and really, it takes, this is advanced decision making. And patient counseling is key because it can be an up to 20 percent local
recurrence rate for even T1 lesions. So, if the patient's a good surgical candidate, you know, myself not being a colorectal surgeon and
taking an abside, I would probably lean towards resection.

In reality out there, there are people pushing the boundaries and even doing local examinations. Decision for some T two lesions in poor
surgical candidates. But again, you're not assessing the lymph nodes high recurrence rate. That's likely not gonna be the answer that I
would put on the AB site. So let's move on, John.

Let's say, how would we wanna imagine rectal tumors in the upper third of the rectum? Yeah, here you want to do a tumor specific
mesorectal [00:21:00] excision with at least 5 centimeter distal margin. Yeah, so if they're proximal up in the rectum, you can get a 5
centimeter distal margin. Again, that, that mesorectal excision, perfect.

So what about tumors in the mid to lower third of the rectum? So the standards total mesorectal excision, or TME. As part of an LAR and
APR. Okay. So with total meso rectal excision, two centimeter distal margins are a deal. You know, one centimeter is okay if you're very,
very, very distal. And if you're not able to get this with, you know, speaking for preservation, then as you say that, that would be a patient
that you need to do an APR on adjuvant therapy for rectal cancer.

Yeah, so FOLFOX is recommended for stage three or greater. Who did not receive neoadjuvant, in other words, the patient who was
understaged during preoperative workup. Okay. Also, Folfax is indicated in high risk stage two or greater that he received neoadjuvant
therapy. In these cases, we assume that the pathologic high grade stage two disease is a result of the [00:22:00] downstaging by the
neoadjuvant therapy.

Perfect. So finally, we're going to move on to anal squamous neoplasms. So Kevin, how do, how are these described? For instance, what
are the histologic variants of anal squamous neoplasms? So you have the coicogenic, the basaloid, the epidermoid and the
mucoepidermoid. Okay, great. And you actually need to know these because they're going to try and trick you.

They're going to give you a patient with an anal mass that was biopsied and the path returns as one of these variants. And you need to
recognize that you're dealing with anal squamous cell cancer. Okay, they're going to actually try to get you to do an APR when what the
patient needs is primary chemotherapy or the Niagara protocol.

Okay, so what HPV serotypes are associated with anal squamous cell cancer? 16 and 18. Okay. What patients have a higher incidence of
anal squamous cell cancer? Immunosuppressed patients. Okay, great. So let's talk a little bit about AIN or anal intraepithelial neoplasm.
So this is a precursor lesion to squamous cell cancer.

And [00:23:00] there are many confusing classifications systems. So what's important to know about AINs Kevin? So AIN correspond to
low, moderate, and high grade dysplasia respectively. So low grade AIN or LG AIN. Is AIN 1 and 2. Okay, and then high grade AIN? Is
AIN 3. How about the treatment for high grade AIN or low grade AIN?

So, we know that overall these have a low rate of conversion to squamous cell cancer. Certainly it's higher in the immunosuppressed
population. But there are some local treatments. So, what are those local treatments? So, you can do topical, 5%, and miquimod. You can
do topical 5 percent 5FU, you can do photodynamic therapy, and you can do targeted destruction.

Yeah, and probably the most important part of any of these above treatments is close clinical follow up with surveillance every four to six
months. And some people just advocate observation and surveillance, surveillance allowance. But yeah, certainly be aware of those. How
[00:24:00] about the treatment for squamous cell cancer of the anal canal?

So this is your NIGRO protocol. It's chemo radiotherapy with 5FU, mitomycin C in 3000. Gray of XRT. Yeah, 3, 000 centigrade XRT. But
yeah, 5FU, minimized MC, 3, 000 centigrade XRT. The key there is, is everybody kind of knows the buzzword NIGRO protocol with anal
squamous cell cancer. You're not gonna see NIGRO protocol written on the test.

It's gonna say chemo radiotherapy. So just make sure you're choosing that chemo radiotherapy and not just chemotherapy. How about
persistent or recurrent squamous cell cancer after primary chemo radiotherapy? Yeah, now you're gonna have to do your abdominal
peroneal resection. Yeah, so salvage APR is what you do for persistent or recurrent squamous cell cancer after they've been treated with
chemoradiotherapy.

What about squamous cell cancer of the, of the anal margin? Yeah, so you treat this more like skin cancer, so you do a wide local
excision. And remind us what we, what the, the anal margin is. This extends five centimeters radially from the squamous [00:25:00]
mucocutaneous junction. Okay. Yeah. So, so squamous cell cancer of the anal margin is treated like skin cancer and anal canal is treated
like squamous cell cancer of the anal canal.

Okay. Okay. And what about the anal melanoma? What do we do with anal melanoma? Yeah. For that, you need an APR. Yeah. So
that's why it's important to know those systologic subtypes and know exactly what kind of cancer they're giving you on the biopsy.
Because it's just those squamous cell variants that we treat with chemoradiotherapy and the senile melanoma is, is, is going to need a
resection with an APR.

All right, so let's finish this out with some quick hits. Kevin and John, quick hits. You guys ready? Yup. Okay, so let's start with Kevin.
Kevin, transverse colon cancer with local invasion of the head of the pancreas. There's no evidence of metastatic disease. How do you,
how do you treat this? So that'd be a Whipple plus.

Yeah. So you can resect these colon cancers that are invading other structures and blocks a Whipple plus extended hemicolectomy,
John, a treatment of an isolated peritoneal carcinomatosis secondary to colon [00:26:00] cancer. Yeah. Carcinomatosis is often
associated with widespread metastases. So if it's isolated, cytoreductive surgery with interperitoneal chemotherapy can be an option.

Okay. Yeah. Cytoreductive surgery, interperitoneal chemotherapy. Great. Thank you. Kevin. What do you do with a rectal cancer with a
parent's complete clinical response to neoadjuvant therapy? Yeah. So this patient, current imaging cannot reliably predict the clinical,
complete clinical response. They still need resection.

Yeah. So even though you have a, you think you have a complete response, you still need resection. Perfect. John, a patient referred for
a hemorrhoid on exam, he has a one centimeter palpable mass of the anal canal and biopsy performed in clinic returns epidermoid
cancer. I actually just had one of these in clinic a couple of weeks ago, almost exact same presentation of how do you manage this?

So he manages with the NIGR protocol, which once again is the chemo radiotherapy. It's a variant of the squamous cell cancer. Again,
know those histologic variants because that's how they're gonna show up in the question stem. [00:27:00] Kevin, a patient with a prior
proctocolectomy and IPAA for ulcerative colitis presents with a fever, Pelvic pain, increased frequency of stools, perform a flexible
endoscopy, which shows mucosal inflammation of the ileal pouch.

What's the diagnosis and what's the treatment? Yeah, so this is classic pouchitis and the treatment is antibiotics of cipro and
metronidazole and then supportive care. And then, you know, decide if it's not responsive to antibiotics. Okay. Well, let's say that this
keeps happening and they have chronic pouchitis no matter what you do.

Yeah, then you have to start suspecting Crohn's. Yeah, and so, unfortunately, some of these patients and that's why it's very important to
rule out Crohn's and make sure you're not dealing with Crohn's when you do these IPAAs, but it's not always clear because it is a
continuum. But severe refractory pouchitis may even require pouch excision and, and ileostomy, unfortunately.

John, so during a laparoscopic exploration for a presumed acute appendicitis, The appendix appears to be normal, but you notice that the
terminal ileum is inflamed. So, what's [00:28:00] what's happening, and what do you do here? So, you have to be a suspect of Crohn's. If
the cecum is uninvolved, you can, you can form your appendectomy to prevent future diagnostic infusion.

If the cecum's inflamed, you want to leave the appendix in place. Either way, treat medically for acute currents flare. Alright, and that
wraps up our colorectal review for the abscites. I hope you found that helpful and thanks for listening and we'll see you next time.