CRS Virtual Education: Mock Oral Boards – 8/28/22

OVERVIEW

FULL Patient History Below: (Video starts a bit late and does not include full history)
60F w/intense anal itching + burning for 1 mo. Tried using witch hazel + Prep H. No fiber, no laxatives, Western diet. 2 BM per day. No incontinence. Well-controlled DM. Anxiety, no medications. Monogamous, sexually active, no hx STI. CSP 7 years prior.
Exam: external excoriations. No masses. Normal tone.
Flex sig: no proctitis, masses
Causes?
Dietary
Systemic illnesses
Autoimmune + dermatologic conditions
Contact dermatitis (ex: fragrances in her hygiene regimen)
Topical steroid
1 mo. F/U w/o improvement
Consider stopping Metformin
Other treatment options?
Topical capsaicin, refer to Dermatology
Intra-dermal methylene blue injection using 27 Gg, non-hair bearing portion, 1:10 dilution
Complications?
Anaphylaxis, necrosis, temporary incontinence
Alternative: 2 cm perianal lesion distal to anal verge, erythematous + scaly
Poss. Paget’s? Punch BX w/local anesthesia
Inguinal exam
CSP (-)
OR: anal mapping
WLE w/2 mm margin + leave open
Other options? Raise flaps on either side + primarily close
Alternative: CSP showed 3.5 cm mass in rectum 7 cm from anal verge, ant.
BX: adenoCA
Stage w/MRI, CT C/A/P (-)
MRI: T2N0M0
Pathologic features: no adverse
Assess continence
Council re robotic LAR w/DLI
How to treat Paget’s w/rectal CA? APR
Alternative: 85F w/Paget’s only – topical treatment
Alternative: 60F w/pruritis found 3 cm ulcerated lesion in anal verge, tender, soiling, can’t get good exam in office
Additional Qs?
Gyn hx, abnormal paps, HPV vaccine, TOB or XRT, anoreceptive intercourse
Book for EUA w/BX
No invasion in vagina, invades into IAS
Path: SCC
HIV testing
Staging: MRI, CT C/A/P, CEA?
No inguinal LN
p16 (+), what does that mean?
HPV-related
Multiple BL liver lesions suspicious for mets
Refer to Med + RadOnc for neoadjuvant chemoTX w/checkpoint inhibitors
T2N0M0 stage 2
Neoadjuvant Nigro protocol 54Gy XRT, 5-FU, MMC
5 weeks post-TX F/U lesion smaller but wait until 3 mo.
Mass gone but scar remains
MRI, endoscopy
BX? No
Surveillance protocol
MRI, CT at 6 mo. w/anoscopy + exam/CEA Q6 mo.
Mass decreased in size at 3 mo.
Possibly grew at 6 mo.
Re-stage w/MRI + CT
Salvage APR
Metachronous inguinal LAD unilaterally
PET: isolated L groin
L lymphadenectomy – refer to Surg Onc
Inguinal + primary disease
Radiate groin

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Aug 29, 2022

Please join Dr. Sharon Stein to review the treatment of Enterocutaneous Fistula. Please visit https://behindtheknife.org to access other high-yield surgical