Perioperative & Surgical Care

Colectomy: indications and post-op complications

Clinical Overview and When to Suspect Colectomy Need

— Segmental resections: right hemicolectomy (cecum, ascending, hepatic flexure), transverse colectomy, left hemicolectomy (splenic flexure, descending), sigmoidectomy, low anterior resection (LAR)

— Total/subtotal colectomy: ulcerative colitis (UC), familial polyposis, fulminant Clostridioides difficile, synchronous cancers

— Total proctocolectomy ± IPAA (ileal pouch-anal anastomosis): UC, FAP after rectal involvement

— Colon adenocarcinoma (any stage I–III with resectable disease; selected stage IV for palliation, obstruction, or oligometastatic resection)

— Polyps not amenable to endoscopic resection, malignant polyps with adverse features

— Carcinoid >2 cm, GIST, lymphoma when symptomatic

— Diverticulitis: emergent for perforation/peritonitis, obstruction, uncontrolled bleeding; elective only after shared decision-making (no longer routine after 2 episodes)

— Inflammatory bowel disease: medically refractory UC, dysplasia, toxic megacolon, fulminant colitis

— Ischemic colitis with gangrene or perforation

— Volvulus (sigmoid > cecal) after failed endoscopic detorsion, or any cecal volvulus

— Lower GI bleed refractory to colonoscopy/angiographic intervention

— Fulminant C. difficile: WBC >35k or <2k, lactate >5, vasopressors, or megacolon — subtotal colectomy with end ileostomy is lifesaving

Colectomy = partial or total resection of the colon, performed emergently or electively for a spectrum of benign and malignant disease

Indications — malignant

Indications — benign

Step 3 management: When you see toxic megacolon (colon >6 cm, systemic toxicity), order NPO, NG decompression, IV fluids, broad-spectrum antibiotics, IV steroids if UC, hold anticholinergics/opioids/antidiarrheals, and surgical consult within hours — delayed colectomy massively increases mortality

Board pearl: Right-sided lesions present with occult bleeding and iron-deficiency anemia; left-sided with obstruction and hematochezia — this directs both workup and resection planning

Presentation Patterns and Key History

— Screening colonoscopy finding (USPSTF: average risk 45–75)

— Iron-deficiency anemia in any man or postmenopausal woman → mandatory colonoscopy

— Change in bowel caliber, tenesmus, unintentional weight loss

— Family history: Lynch syndrome (HNPCC), FAP, MUTYH — alters resection extent (total abdominal colectomy preferred over segmental in Lynch given metachronous cancer risk)

— Obstruction: progressive distension, obstipation, feculent emesis; left-sided lesions most common culprit; high-grade obstruction may need decompressive stent as bridge to surgery in select cases

— Perforation: sudden severe pain, peritonitis, sepsis

— Lower GI bleed: massive hematochezia, hemodynamic instability after failed colonoscopy/angio

— Diverticulitis: LLQ pain, fever; Hinchey III/IV → surgery

— Ischemic colitis: postprandial pain, bloody diarrhea in vasculopath; watershed (splenic flexure) most common

— Duration of UC >8–10 years, pancolitis, PSC → dysplasia surveillance; dysplasia or DALM lesion is a colectomy indication

— Steroid dependence, biologic failure (anti-TNF, vedolizumab, JAK inhibitors) signals refractory disease

— Prior abdominal surgery → adhesions, possible open approach

— Cirrhosis, severe COPD, EF <30% → escalate perioperative risk discussion

— Anticoagulation (DOAC, warfarin, antiplatelets) — timing of hold per ACC/CHEST guidelines

— Smoking: stop ≥4 weeks preop to reduce wound and anastomotic complications

Elective oncologic presentation

Emergent presentations

Inflammatory bowel disease history

Prior surgical and medical history that changes the plan

CCS pearl: On a CCS case with hematochezia and instability, the correct early orders are two large-bore IVs, type and crossmatch, CBC/coags/lactate, transfuse to Hgb >7 (>8 if cardiac disease), then colonoscopy after rapid prep; CT angiography if bleeding >0.3 mL/min; surgery only after localization fails or persistent instability

Board pearl: Always ask about family cancer history before age 50 — it changes both the operation and the genetic counseling referral

Physical Exam Findings and Hemodynamic Assessment

— Tachycardia, hypotension, narrow pulse pressure → hypovolemia from bleed, sepsis, or third-spacing

— Fever + tachycardia + altered mentation in an IBD patient = toxic colitis until proven otherwise

— qSOFA ≥2 (RR ≥22, SBP ≤100, altered mental status) signals sepsis; activate sepsis bundle

— Peritonitis: rigidity, rebound, involuntary guarding → emergent laparotomy, no further imaging if patient unstable

— Distension with tympany + absent bowel sounds → obstruction or ileus; "silent abdomen" with severe pain → ischemia

— Palpable LLQ mass → diverticular phlegmon or sigmoid cancer

— RLQ mass → cecal cancer, appendiceal tumor, ileocecal Crohn

— Hepatomegaly, nodular liver → metastatic disease

— Palpable mass within 7–10 cm: rectal cancer (changes operation from colectomy to LAR/APR + neoadjuvant chemoradiation)

— Gross blood, melena, or guaiac-positive stool

— Sphincter tone for continence planning (matters for ileostomy vs IPAA decision)

— Acanthosis nigricans, Sister Mary Joseph nodule, Virchow node — advanced malignancy

— Pyoderma gangrenosum, erythema nodosum, episcleritis — IBD

— Sebaceous tumors → Muir-Torre (Lynch variant); osteomas, desmoids → Gardner (FAP variant)

— Capillary refill, mottling, lactate, urine output >0.5 mL/kg/hr

— POCUS of IVC and cardiac function guides resuscitation

General and vital signs

Abdominal exam

Rectal exam (DRE) — required

Stigmata of underlying disease

Volume and perfusion assessment

Step 3 management: In suspected perforated diverticulitis with peritonitis, do not delay for CT if unstable — resuscitate, broad-spectrum antibiotics (piperacillin-tazobactam), surgical consult, OR. If stable, CT confirms Hinchey stage and dictates operative vs percutaneous drainage

Board pearl: Pain out of proportion to exam in an elderly patient with AFib = acute mesenteric ischemia until proven otherwise — CT angiography immediately, not colonoscopy

Diagnostic Workup — Initial Labs and Imaging

— CBC: microcytic anemia → right colon cancer; leukocytosis → infection/perforation; leukopenia in fulminant C. diff

— BMP: electrolyte derangements from obstruction/diarrhea; AKI from sepsis or contrast risk

— LFTs and albumin: albumin <3.0 predicts anastomotic leak and mortality; elevated alk phos/transaminases → liver metastases

— Coags (PT/INR, PTT): especially on anticoagulants or with liver disease

— Type and screen/crossmatch for any emergent or major elective case

— Lactate: ischemia, sepsis severity

— CEA: baseline for colon cancer; useful for surveillance, not screening

— C. difficile PCR/toxin for any colitis presentation, especially recent antibiotics, hospitalization, PPI use

— Stool cultures, ova/parasites if indicated

— CRP/ESR for IBD severity (Truelove-Witts criteria in UC)

— Upright CXR: free air under diaphragm = perforation

— CT abdomen/pelvis with IV contrast: workhorse — staging, perforation, abscess, obstruction, ischemia, diverticulitis Hinchey grading

— CT angiography: active LGIB localization, mesenteric ischemia

— Plain abdominal films: volvulus ("coffee bean" sigmoid, "embryo sign" cecal), megacolon (>6 cm transverse)

— Preop ECG if age >65, known CAD, or symptoms

— RCRI (Revised Cardiac Risk Index): colectomy = intraperitoneal high-risk surgery (1 point); guides need for further testing per ACC/AHA

Baseline labs (every preop colectomy)

Infectious/inflammatory workup

Imaging

ECG and cardiac risk

Key distinction: A CT showing pneumoperitoneum in a stable patient with localized pain may still warrant urgent surgery, but in a frail patient with contained perforation (Hinchey I/II), percutaneous drainage + antibiotics can avoid emergent colectomy and convert to elective resection

Board pearl: Iron deficiency anemia in a man or postmenopausal woman is colon cancer until proven otherwise — colonoscopy is mandatory regardless of FOBT result

Diagnostic Workup — Advanced and Confirmatory Studies

— Gold standard for tissue diagnosis, tattoo localization of tumor (essential — surgeons cannot palpate laparoscopically), and synchronous lesion screening

— Full colonoscopy should be completed before or within 6 months after colectomy for cancer to exclude synchronous lesions (3–5% incidence)

— In obstruction: limited scope to confirm diagnosis; full eval done postop

— CT chest/abdomen/pelvis for metastatic workup

— CEA preoperatively (baseline for surveillance)

— MRI liver if equivocal CT findings

— PET-CT: reserved for equivocal lesions or rising CEA postop without identifiable disease

— Rectal cancers: pelvic MRI + endorectal US for T/N staging — guides neoadjuvant therapy

— Universal MMR/MSI testing on all colorectal cancers (Lynch screen)

— Germline testing if young (<50), strong family history, or MMR-deficient tumor

— Result changes surveillance, family counseling, and use of immunotherapy (pembrolizumab in MSI-high metastatic disease)

— Stress testing only if poor functional capacity (<4 METs) + elevated RCRI + result would change management

— PFTs for known severe COPD undergoing major resection

— Echo if new murmur, decompensated HF, or unexplained dyspnea

— Albumin, prealbumin, weight loss >10% identify malnutrition — preop nutritional optimization reduces leak rates

— Frailty index (clinical frailty scale, modified frailty index) predicts mortality independent of age

Colonoscopy

Staging studies for colon cancer

Genetic testing

Cardiopulmonary risk stratification

Frailty and nutrition assessment

CCS pearl: Before scheduling elective colectomy on CCS, order colonoscopy with biopsy + tattoo, CT chest/abd/pelvis, CEA, CBC, BMP, type and screen, ECG, anesthesia consult, and stoma marking by WOC nurse if ileostomy/colostomy possible — missing the stoma marking is a common CCS trap

Board pearl: MSI-high colon cancer in a young patient → Lynch syndrome workup → lifetime colonoscopy q1–2 yr, endometrial/ovarian screening, urinary tract surveillance

Risk Stratification and Preoperative Optimization

— ACS NSQIP risk calculator: patient-specific 30-day morbidity/mortality, length of stay, readmission

— RCRI for cardiac events; ARISCAT for pulmonary complications

— Frailty assessment in elderly drives prehab decisions

— Smoking cessation ≥4 weeks preop reduces wound and anastomotic complications

— Glycemic control: HbA1c <8%; perioperative glucose 140–180; hold SGLT2 inhibitors 3–4 days preop (euglycemic DKA risk)

— Anemia: IV iron if Hgb <12 and time permits; reduces transfusion needs

— Nutrition: oral immunonutrition 5–7 days preop if malnourished

— Anticoagulation hold: warfarin 5 days, DOACs 48–72 hr (longer if renal dysfunction), aspirin often continued for cardiac indication

— Mechanical bowel prep + oral antibiotics (neomycin + metronidazole or erythromycin) the day before surgery — reduces SSI and anastomotic leak per current ACS/SAGES recommendations

— IV antibiotic prophylaxis within 60 min of incision (cefoxitin or ertapenem)

— Carbohydrate loading drink up to 2 hr preop

— Multimodal analgesia (avoid opioid-only)

— Epidural or TAP block for open cases

— Goal-directed fluid therapy

— Early ambulation, early diet, early Foley removal (POD 1)

— Reduces LOS by 2–3 days, decreases ileus

— Mechanical (SCDs) intraop, chemical (LMWH or UFH) starting 12 hr postop unless bleeding contraindication

— Extended prophylaxis for 28 days post-discharge in cancer resections (high VTE risk)

Preoperative risk tools

Optimization (the "prehab" window — 2–6 weeks ideal)

Bowel preparation

ERAS (Enhanced Recovery After Surgery) protocol

VTE prophylaxis

Step 3 management: For a diabetic on metformin and empagliflozin scheduled for elective colectomy: hold empagliflozin 3–4 days before, hold metformin morning of surgery, use sliding scale insulin perioperatively, resume metformin only after normal renal function and tolerating diet

Board pearl: Extended VTE prophylaxis (28 days) after colectomy for cancer is a frequently missed quality measure

Operative Approach and Intraoperative Considerations

— Laparoscopic and robotic approaches preferred when feasible — less ileus, shorter LOS, fewer wound complications, equivalent oncologic outcomes

— Open indicated for unstable patients, dense adhesions, locally advanced T4 tumors, or surgeon experience

— Hand-assisted laparoscopic as middle ground

— Right hemicolectomy: ligate ileocolic, right colic, right branch of middle colic; ileocolic anastomosis (stapled side-to-side preferred)

— Left hemicolectomy/sigmoidectomy: ligate IMA at origin (or just below left colic for benign disease); colorectal anastomosis

— Low anterior resection (LAR): rectal cancer with adequate distal margin (1–2 cm); often with diverting loop ileostomy

— Abdominoperineal resection (APR): low rectal cancer not amenable to sphincter preservation → permanent end colostomy

— Total abdominal colectomy with end ileostomy: emergent for fulminant colitis, toxic megacolon; preserves rectum for later restoration

— Total proctocolectomy + IPAA (J-pouch): definitive for UC, FAP

— High vascular ligation at vessel origin

— ≥12 lymph nodes harvested for adequate staging

— Proximal/distal margins ≥5 cm for colon, 2 cm distal for rectum (1 cm acceptable in low rectal)

— Total mesorectal excision (TME) for rectal cancer

— No-touch technique for tumor manipulation

— Tension-free, well-vascularized, no distal obstruction

— Stapled vs hand-sewn — equivalent outcomes

— Diverting loop ileostomy if low pelvic anastomosis, prior radiation, or high-risk patient — reduces clinical leak severity

— Frozen section for margins

— Liver inspection ± intraop ultrasound for occult metastases

— Convert to open if poor visualization, bleeding, or progress stalled

Approach selection

Specific resections and anatomy

Oncologic principles

Anastomosis considerations

Intraoperative decision points

CCS pearl: A Hartmann procedure (sigmoid resection + end colostomy + rectal stump) is the right answer for an unstable patient with Hinchey III/IV diverticulitis — primary anastomosis with diversion is acceptable in stable patients per recent trials

Postoperative Management Pathway (CCS-Style)

— Admit to surgical floor (or ICU if unstable, frail, major comorbidity)

— NPO initially, advance per ERAS (clears POD 0–1, regular as tolerated)

— IV fluids — euvolemic, not aggressive (overload worsens ileus); transition to oral hydration POD 1–2

— Multimodal analgesia: scheduled acetaminophen, ketorolac (if no AKI/bleed risk), gabapentin, TAP block; opioids PRN only — minimize to prevent ileus

— Avoid NGT routinely — not needed and prolongs LOS

— Foley removal POD 1 (POD 3 for LAR with epidural)

— Early ambulation POD 0 evening

— DVT prophylaxis: LMWH 12 hr postop

— Antibiotics: 24 hr postop only unless source control incomplete

— Incentive spirometry q1h while awake

— ERAS: clear liquids day of surgery, regular diet POD 1 if tolerated — no need to wait for flatus

— Monitor for nausea, distension, vomiting → suggests ileus

— Vitals, urine output, pain, ambulation, diet tolerance, bowel function (flatus, BM)

— Wound check

— Stoma output and viability if applicable (pink/red = healthy; dusky/black = ischemia → urgent consult)

— Labs PRN, not routine daily

— Tolerating regular diet, pain controlled on PO meds, ambulating, return of bowel function, stable vitals, no fever, ostomy teaching complete if applicable

— Typical LOS: 3–5 days laparoscopic, 5–7 days open

Immediate postop orders

Diet advancement

Daily assessment (CCS rounds)

Discharge criteria

Step 3 management: Postop ileus vs early small bowel obstruction: ileus typically resolves by POD 3–5, diffuse distension, no transition point on CT, conservative management (NPO, NGT if vomiting, correct electrolytes, minimize opioids, alvimopan if available). SBO has transition point on CT and may need return to OR

CCS pearl: Order stoma nurse consult, home health, and follow-up appointment in 2 weeks before discharge — failing to schedule follow-up loses CCS points and increases real-world readmission

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher baseline frailty, polypharmacy, cognitive impairment, sarcopenia

— 30-day mortality rises sharply with emergent colectomy (10–20% vs 1–3% elective)

— Delirium prevention: avoid benzodiazepines, anticholinergics, meperidine; orient frequently, mobilize early, restore glasses/hearing aids, sleep hygiene

— Geriatric co-management improves outcomes

— Goals of care discussion preop is essential — palliative colostomy may be more appropriate than curative resection in advanced frailty

— Avoid nephrotoxins: NSAIDs (ketorolac), contrast unless essential, aminoglycosides

— Dose-adjust LMWH (or use UFH if CrCl <30)

— Hold ACE/ARB on day of surgery to avoid intraop hypotension and AKI

— Higher risk of postop AKI — strict euvolemia, avoid hypotension

— Metformin: hold morning of surgery, resume only after Cr returns to baseline and tolerating PO

— Child-Pugh and MELD predict mortality — MELD >15 carries high perioperative mortality (>25%)

— Address portal hypertension, ascites, coagulopathy preop

— Avoid hepatotoxins; dose-adjust opioids and benzodiazepines

— High risk of bleeding, infection, encephalopathy postop

— Transjugular shunt (TIPS) consideration before elective surgery if significant portal hypertension

— Continue beta-blockers perioperatively if already on them (do not start day of surgery)

— Continue aspirin if secondary prevention indication, hold P2Y12 inhibitors 5–7 days unless recent stent

— Recent DES <6 months → delay elective surgery if possible

Elderly (age >75)

Chronic kidney disease

Hepatic impairment / cirrhosis

Cardiac disease

Board pearl: Anastomotic leak risk doubles in malnourished elderly (albumin <3.0) — preop nutritional optimization with oral supplements or even short-course TPN can be lifesaving

Step 3 management: For a frail 82-year-old with obstructing left colon cancer, consider decompressive colonic stent as a bridge to elective resection — converts emergent to elective and dramatically lowers mortality

Special Populations — Pregnancy, IBD, and Hereditary Syndromes

— Colectomy in pregnancy is rare but indicated for fulminant UC, perforated diverticulitis, obstructing cancer, toxic megacolon

— Second trimester is optimal for elective surgery; minimize fetal radiation (use MRI or US when possible)

— Multidisciplinary team: OB, MFM, surgery, anesthesia

— Left lateral decubitus positioning after 20 weeks to avoid IVC compression

— Continue VTE prophylaxis — pregnancy is hypercoagulable

— Ulcerative colitis indications for colectomy: medically refractory disease, dysplasia or cancer, toxic megacolon, fulminant colitis, growth failure (children)

— Operation of choice: restorative proctocolectomy with IPAA in 2 or 3 stages; emergent → 3-stage (subtotal colectomy first, then completion proctectomy + pouch, then ileostomy reversal)

— Pouchitis is the most common late complication (40–50% lifetime) — treat with ciprofloxacin or metronidazole

— Crohn disease: colectomy reserved for refractory colonic disease, dysplasia, fistulizing disease; IPAA is contraindicated in Crohn (recurrence and pouch failure)

— FAP: prophylactic total proctocolectomy with IPAA by late teens/early 20s; if rectal-sparing, total abdominal colectomy with ileorectal anastomosis (requires rectal surveillance)

— Lynch syndrome (HNPCC): when cancer diagnosed, extended colectomy (total abdominal colectomy with ileorectal anastomosis) is often preferred over segmental due to high metachronous risk; women should consider prophylactic hysterectomy-BSO after childbearing

— MUTYH-associated polyposis: similar to attenuated FAP, surgical timing individualized

— UC, FAP, Hirschsprung disease (more commonly in infancy)

— Growth and pubertal considerations may drive timing

Pregnancy

Inflammatory bowel disease

Hereditary colorectal cancer syndromes

Pediatric

CCS pearl: A 22-year-old with >100 colonic adenomas and a father who died of colon cancer at 42 = FAP — order APC gene testing, ophthalmology (CHRPE), upper endoscopy (duodenal polyps), and surgical referral for prophylactic colectomy

Board pearl: In Lynch syndrome, endometrial cancer often precedes colon cancer in women — coordinate gynecologic surveillance

Complications and Adverse Outcomes

— Risk factors: low pelvic anastomosis, malnutrition, steroids, smoking, emergent surgery, contamination, tension, ischemia

— Presentation: POD 3–7 — fever, tachycardia, leukocytosis, abdominal pain, ileus, increased drain output (feculent), or sepsis

— Workup: CT with rectal contrast (for low anastomoses) or oral/IV contrast

— Management: NPO, broad antibiotics, percutaneous drainage if contained; reoperation with washout + diversion (Hartmann or loop ileostomy) if peritonitis or unstable

— Superficial, deep, or organ/space (abscess)

— Reduced by oral antibiotics + mechanical prep, glucose control, normothermia, hair clipping (not shaving), proper antibiotic timing

— Universal mild ileus expected; prolonged ileus = no bowel function by POD 4–5

— Risk: opioids, electrolyte abnormalities (hypoK, hypoMg), open surgery, inflammation

— Management: NPO, NG decompression if vomiting, correct electrolytes, minimize opioids, ambulate, alvimopan if started preop

— Early (adhesions, internal hernia) or late

— Distinguished from ileus by CT transition point

— Intra-abdominal or anastomotic — tachycardia, dropping Hgb, hypotension

— Transfuse, reverse coagulopathy, return to OR or angio-embolization

— Ischemia (dusky stoma), retraction, prolapse, parastomal hernia, high output (>1500 mL/day → dehydration, AKI — manage with loperamide, fiber, oral rehydration)

— Highest risk surgery group; extended prophylaxis 28 days post-discharge for cancer

Anastomotic leak (1–10%) — most feared complication

Surgical site infection (SSI)

Ileus

Small bowel obstruction

Bleeding

Stoma complications

VTE

Cardiopulmonary: MI, arrhythmia, atelectasis, pneumonia, aspiration

AKI: hypovolemia, NSAIDs, contrast, sepsis

C. difficile: postop antibiotics + altered flora

Long-term: incisional hernia (10–20% open), adhesive SBO, sexual/urinary dysfunction (especially after rectal surgery — pelvic autonomic nerves), low anterior resection syndrome (urgency, frequency, incontinence)

Board pearl: Tachycardia on POD 3–5 is anastomotic leak until proven otherwise — do not attribute to pain or dehydration without ruling out leak

When to Escalate Care — ICU, Consult, and Triage

— Hemodynamic instability requiring vasopressors

— Respiratory failure requiring intubation or high oxygen requirements

— Sepsis with organ dysfunction

— Major intraop blood loss with ongoing resuscitation needs

— Elderly with multiple comorbidities and prolonged open procedure

— New arrhythmia with instability

— SBP <90 or MAP <65 despite fluid

— HR persistently >120

— RR >24 or SpO2 <92% on supplemental O2

— Urine output <0.5 mL/kg/hr for 2+ hours

— Lactate >2 and rising

— New AMS, oliguria, or worsening pain

— GI for endoscopic management of postop bleeding, stricture dilation

— Interventional radiology for percutaneous drainage of abscess, embolization of bleeding

— Nephrology for AKI not responsive to volume resuscitation

— Cardiology for postop MI, new HF, or arrhythmia

— Infectious disease for complex infections, multidrug resistance

— Palliative care for advanced cancer, goals of care

— Stoma/WOC nurse for any new ostomy

— Nutrition for prolonged NPO, malnutrition, TPN initiation

— Diffuse peritonitis from anastomotic leak

— Uncontrolled bleeding

— Bowel ischemia

— Closed-loop obstruction

— Compartment syndrome (abdominal)

— Community hospital → tertiary center for complex reoperation, advanced IBD/cancer care, or available IR/endoscopic rescue

ICU admission criteria postop

Rapid response / escalation triggers on floor

Subspecialty consultation

Reoperation indications

Transfer to higher level of care

CCS pearl: A patient on POD 4 with tachycardia, fever, and a soft abdomen still warrants CT and surgical re-eval — "soft abdomen" does not exclude contained leak. Order CT abd/pelvis with IV + rectal contrast (for distal anastomoses), CBC, lactate, blood cultures, broad-spectrum antibiotics, and surgical attending notification

Step 3 management: Escalate care early rather than late — patient safety scoring rewards proactive consultation, especially with deteriorating vitals or labs

Key Differentials — Same-Category (Colonic) Causes

— Insidious, weight loss, anemia, change in bowel habits

— Confirmed on colonoscopy with biopsy

— Staged with CT chest/abd/pelvis, CEA

— Acute LLQ pain, fever, leukocytosis

— CT: pericolonic fat stranding, wall thickening, +/- abscess, free air

— Most managed nonoperatively; surgery for complications or refractory

— UC: continuous, mucosal, starts at rectum, bloody diarrhea, never small bowel (except backwash ileitis)

— Crohn: skip lesions, transmural, anywhere mouth-to-anus, perianal disease, fistulas

— Distinguish via colonoscopy + biopsy (granulomas in Crohn), imaging, serology

— Elderly, vasculopath, hypotensive episode, recent cardiac surgery

— Watershed (splenic flexure, rectosigmoid)

— "Thumbprinting" on imaging

— Most resolve with bowel rest; surgery for full-thickness necrosis or perforation

— Sigmoid: elderly, institutionalized, chronic constipation — "coffee bean" sign

— Cecal: younger, mobile cecum — needs surgery (no endoscopic option reliable)

— Sigmoid: endoscopic detorsion first, then elective resection (recurrence high)

— Recent antibiotics, hospitalization, PPI

— Watery diarrhea, leukocytosis (sometimes massive)

— Confirm via stool PCR/toxin

— Fulminant → colectomy with end ileostomy

— Shigella, Salmonella, Campylobacter, E. coli O157:H7, CMV (immunosuppressed)

— Prior pelvic radiation — endoscopic argon plasma coagulation or surgery for refractory cases

— Cyclic pain in reproductive-age women

When evaluating a patient with colonic symptoms that may require colectomy, distinguish among:

Colon cancer

Diverticulitis

Inflammatory bowel disease

Ischemic colitis

Volvulus

C. difficile colitis

Infectious colitis (other)

Radiation colitis/proctitis

Endometriosis (rectosigmoid)

Key distinction: UC vs Crohn drives operative choice — IPAA acceptable in UC, contraindicated in Crohn due to high recurrence and pouch failure. When pathology is ambiguous ("indeterminate colitis"), default surgical plan is total colectomy with end ileostomy, reserving pouch creation until disease behavior clarifies

Key Differentials — Other-Category Causes

— AFib, atherosclerosis, hypercoagulability

— Pain out of proportion to exam, lactic acidosis

— CTA — needs urgent embolectomy or bypass, not colectomy

— Can mimic cecal mass or diverticulitis

— Right hemicolectomy not first choice unless cecal involvement or carcinoid found

— Tubo-ovarian abscess, torsion, ectopic — get pelvic US, β-hCG

— Bulky mass on imaging; biopsy first — treatment may not be surgical

— Ovarian, gastric, pancreatic

— Cytology and imaging guide

— Mimics IBD or ischemia; treat medically (oral vancomycin/fidaxomicin, IV metronidazole if ileus) before surgery

— Chronic watery diarrhea, normal colonoscopy appearance, biopsy diagnostic — never requires colectomy

— Functional, no alarm features, normal workup — colectomy not indicated

— Painless hematochezia in elderly; usually self-limited, colonoscopy ± angio

— Stop offending agent; steroids for immune-mediated colitis

Mimics of surgical colonic disease — important to exclude before committing to colectomy:

Acute mesenteric ischemia (small bowel)

Appendicitis with phlegmon

Ovarian/gynecologic pathology

Urinary: pyelonephritis, nephrolithiasis — UA, renal imaging

Lymphoma, GIST

Peritoneal carcinomatosis from another primary

Pseudomembranous colitis (severe C. diff)

Microscopic colitis

Irritable bowel syndrome

Diverticular bleeding without diverticulitis

Medication-induced colitis: NSAIDs, ipilimumab/checkpoint inhibitors, mycophenolate

Behçet, vasculitic colitis: rare, biopsy-driven diagnosis

Board pearl: Checkpoint inhibitor colitis (ipilimumab, pembrolizumab) is increasingly common — high-dose steroids first line, infliximab or vedolizumab if refractory; avoid colectomy unless perforation or megacolon because patients often recover with immunosuppression

Step 3 management: Always confirm tissue diagnosis before elective colectomy for "mass" — empiric surgery for presumed cancer that turns out to be lymphoma or infection is a serious quality and ethics issue

Secondary Prevention, Discharge Medications, and Long-Term Plan

— Analgesia: acetaminophen scheduled, short opioid course (3–7 days), bowel regimen (docusate ± senna) — counsel on opioid disposal

— VTE prophylaxis: extended LMWH for 28 days post cancer colectomy

— PPI: only if indicated (stress ulcer prophylaxis NOT routinely needed at discharge)

— Stoma supplies, loperamide PRN for high-output ileostomy

— Resume home medications thoughtfully: ACE/ARB after volume status stable, metformin after Cr at baseline

— Adjuvant chemotherapy for stage III (FOLFOX or CAPOX) and high-risk stage II within 6–8 weeks of surgery

— Surveillance per NCCN/ASCO:

— H&P + CEA every 3–6 months for 2 years, then every 6 months for years 3–5

— CT chest/abd/pelvis annually for 3–5 years

— Colonoscopy at 1 year postop (or 3–6 months if not done preop due to obstruction), then 3 years, then every 5 years if normal

— Smoking cessation, alcohol moderation, healthy weight, physical activity — reduce recurrence

— UC patients post-IPAA: monitor for pouchitis (cipro/flagyl), pouch surveillance endoscopy

— Continue biologics in Crohn after ileocolic resection — postop prophylactic therapy reduces recurrence

— Fiber-rich diet, hydration, weight management

— Routine elective resection after 2 episodes is no longer recommended — shared decision-making

— FAP: upper endoscopy q1–3 yr (duodenal polyps), thyroid US, desmoid surveillance

— Lynch: continued surveillance per syndrome

— Influenza annually, COVID per current rec, pneumococcal if immunosuppressed

— Live vaccines contraindicated on biologics

Discharge medications checklist

Cancer survivorship plan

IBD postcolectomy

Diverticulitis prevention

Genetic syndrome follow-up

Vaccinations and prevention

Step 3 management: A patient discharged on POD 4 after sigmoid resection for stage III colon cancer needs: oncology referral within 2 weeks, extended LMWH 28 days, CEA in 1 month, follow-up with surgery in 2 weeks, MMR/MSI testing review, and surveillance colonoscopy at 1 year

Board pearl: CEA that rises after a normal postop nadir mandates imaging — recurrence found early may be resectable (oligometastatic liver metastasectomy is curative in ~25%)

Follow-Up, Monitoring Parameters, and Rehab/Counseling

— 2 weeks: wound check, staple/suture removal, pathology review, address pain and bowel function, ostomy assessment

— 6 weeks: full recovery assessment, lifting restrictions lifted, return to work discussion

— Oncology referral within 2 weeks for cancer cases — adjuvant chemo window matters

— Stoma nurse at 2 weeks and PRN

— Fever >38.3, worsening pain, wound drainage or dehiscence

— No bowel movement >4 days, intractable nausea/vomiting (recurrent obstruction or ileus)

— Stoma changes: dusky color, no output >12 hr, high output >1500 mL/day with dehydration symptoms (dizziness, dark urine)

— Calf swelling, dyspnea — VTE

— Rectal bleeding, melena

— CEA q3–6 mo × 2 yr, then q6 mo to year 5

— CT C/A/P annually for 3–5 yr

— Colonoscopy at 1 yr, then 3 yr, then q5 yr

— Gradual return to activity: walking encouraged immediately; no heavy lifting (>10–15 lb) for 6 weeks to prevent incisional hernia

— Physical therapy if deconditioned, especially elderly

— Pelvic floor physiotherapy after LAR for low anterior resection syndrome

— Sexual function counseling (especially after rectal surgery — autonomic nerve injury)

— Low-residue diet first 2–4 weeks, then advance

— Ileostomy: increase fluids and salt, watch for dehydration

— B12 supplementation if ileal resection (terminal ileum)

— Body image, ostomy adjustment — support groups (UOAA), counseling

— Depression and anxiety screening at follow-up

— Sexual health, intimacy concerns

Postdischarge follow-up cadence

What to monitor — and what triggers a call

Surveillance for cancer (see chunk 15)

Rehabilitation

Nutritional counseling

Psychosocial

CCS pearl: Order home health for ostomy management, outpatient PT, oncology and surgery follow-up, and labs (CEA, CBC, BMP) before next visit at discharge — front-loading these orders on CCS prevents readmission penalties

Board pearl: Low anterior resection syndrome (urgency, fragmentation, incontinence) affects up to 50% after LAR — proactively discuss, refer to pelvic floor PT, consider transanal irrigation or sacral neuromodulation

Ethical, Legal, and Patient Safety Considerations

— Operation, alternatives (including no surgery and palliative options), risks (bleeding, infection, anastomotic leak, ostomy permanent or temporary, sexual/urinary dysfunction, death)

— Possibility of intraoperative findings requiring ostomy — patient must consent to possibility of stoma even if "planned" reconnection

— Preoperative stoma marking by WOC nurse — both patient safety and quality measure

— Special consent considerations: cancer staging not fully known, possibility of additional procedures

— Elderly, septic, or encephalopathic patients may lack capacity — invoke surrogate per state hierarchy

— Emergent life-saving surgery under implied consent if no surrogate reachable and delay would cause harm

— Advance directives, POLST/MOLST must be reviewed preoperatively, especially for elderly and frail patients — clarify code status in OR

— For metastatic or terminal patients, palliative diverting colostomy may be more appropriate than aggressive resection — early palliative care consultation improves quality of life and may extend survival

— Document shared decision-making clearly

— OR → PACU → floor: handoff including drains, fluid balance, antibiotics, anticoagulation plan

— Hospital → home: medication reconciliation (especially anticoagulants, diabetes meds, opioids), follow-up appointments, teach-back on stoma care and warning signs

— Readmission within 30 days is a publicly reported quality metric; clear discharge instructions and early follow-up reduce it

— Suspected elder abuse if frail patient presents with neglect-related delays

— Surgical never events: wrong-site surgery, retained foreign object, fire — reportable

— Disclosure of medical error (e.g., anastomotic leak from technical issue) — honest, timely, documented

— Disparities in colorectal cancer screening, stage at diagnosis, and outcomes — address screening barriers

— Insurance navigation for adjuvant chemo, ostomy supplies, home health

Informed consent — colectomy-specific elements

Capacity and surrogate decision-making

Goals of care

Transitions of care — high-risk handoff points

Mandatory reporting and special situations

Health equity

Step 3 management: When a patient with advanced dementia and metastatic colon cancer presents with obstruction, the right answer is often a goals-of-care meeting with surrogate before any operation — and a palliative diverting colostomy if surgery is pursued, not curative resection

Board pearl: Preop stoma marking by an enterostomal therapist is a quality measure that reduces stoma complications and improves QoL — its omission is a safety failure

High-Yield Associations and Rapid-Fire Clinical Facts

Colon cancer screening (USPSTF 2021): average risk age 45–75, individualized 76–85, stop after 85

Right colon cancer → anemia, occult bleed, weight loss; left colon → obstruction, hematochezia

CEA: not for screening; baseline and surveillance only

Universal MMR/MSI testing on every colorectal cancer

Lynch syndrome = HNPCC: extended colectomy preferred, lifelong surveillance

FAP: APC mutation, >100 adenomas, prophylactic colectomy in late teens

MSI-high stage IV colon cancer: pembrolizumab first-line

Diverticulitis: CT-based Hinchey staging; I/II nonop, III/IV operative

Toxic megacolon: transverse colon >6 cm + systemic toxicity

Cecal volvulus → surgery (no reliable endoscopic option); sigmoid volvulus → endoscopic detorsion first, then elective resection

Anastomotic leak: POD 3–7, tachycardia is the earliest sign

Stoma color: pink/red = healthy; dusky/black = ischemia (emergent)

High-output ileostomy = >1500 mL/day → dehydration, AKI

B12 deficiency after terminal ileum resection

Pouchitis after IPAA → cipro/flagyl

Extended VTE prophylaxis = 28 days post cancer colectomy

Mechanical bowel prep + oral antibiotics reduces SSI and leak

Smoking cessation ≥4 weeks preop reduces wound complications

Albumin <3.0 doubles anastomotic leak risk

ERAS reduces LOS by 2–3 days

≥12 lymph nodes needed for adequate colon cancer staging

Adjuvant chemo for stage III: FOLFOX or CAPOX within 6–8 weeks

Synchronous cancer rate 3–5% — full colonoscopy before or within 6 mo of surgery

Postop ileus vs SBO: transition point on CT

Hartmann procedure for unstable diverticulitis

Loop ileostomy to protect low pelvic anastomosis

APR → permanent end colostomy (low rectal cancer)

Incisional hernia 10–20% in open colectomy

Low anterior resection syndrome: up to 50% after LAR — pelvic floor PT

Checkpoint inhibitor colitis: steroids first, not surgery

C. difficile fulminant: WBC >35k or <2k, lactate >5 → subtotal colectomy

Board pearl: POD 3–5 tachycardia + low-grade fever = anastomotic leak until ruled out — always re-image

Board Question Stem Patterns

— Answer: Colonoscopy (not iron alone) — iron deficiency anemia in any man or postmenopausal woman is colon cancer until proven otherwise

— Answer: CT abd/pelvis with IV + rectal contrast — anastomotic leak; soft abdomen does not exclude leak

— Answer: IV antibiotics + percutaneous drainage (Hinchey II), interval colonoscopy 6 wks, elective resection only after shared decision-making

— Answer: Total proctocolectomy with IPAA (not surveillance)

— Answer: Subtotal colectomy with end ileostomy after resuscitation — fulminant C. diff

— Answer: Prophylactic total proctocolectomy (or TAC with IRA if rectum sparable)

— Answer: CTA for mesenteric ischemia (NOT colonoscopy)

— Answer: Postop ileus — minimize opioids, correct K/Mg, ambulate; image if not resolving

— Answer: FOLFOX, 28-day extended VTE prophylaxis, MMR testing review

— Answer: Elective sigmoidectomy during same admission — high recurrence (~50%) without resection

— Answer: Neoadjuvant chemoradiation, then LAR with TME + loop ileostomy

Stem 1: 67-year-old with fatigue, dyspnea on exertion, Hgb 8.2, MCV 72, ferritin 8. Stool guaiac positive.

Stem 2: 72-year-old POD 4 after sigmoidectomy with HR 118, T 38.4, soft abdomen, WBC 16, foul-smelling drain output.

Stem 3: 58-year-old with LLQ pain, fever, WBC 14, CT shows pericolonic abscess 5 cm, no free air.

Stem 4: 28-year-old with UC × 10 years, pancolitis, high-grade dysplasia on biopsy.

Stem 5: 82-year-old hospitalized for pneumonia on cefepime, develops profuse diarrhea, WBC 32k, lactate 6, hypotensive.

Stem 6: Patient with FAP and >200 polyps, age 19.

Stem 7: 70-year-old with AFib not on anticoagulation, presents with severe diffuse pain, lactate 8, soft abdomen.

Stem 8: 65-year-old POD 1 sigmoidectomy, no flatus by POD 5, NGT removed POD 1, abdomen distended.

Stem 9: 55-year-old s/p right hemicolectomy for stage III colon cancer 4 weeks ago, discussing adjuvant therapy.

Stem 10: 75-year-old with sigmoid volvulus, successfully detorsed endoscopically.

Stem 11: 60-year-old with rectal cancer 5 cm from anal verge, T3N1, MRI confirmed.

CCS pearl: Recognize when interval imaging or percutaneous drainage is the answer rather than immediate reoperation — only unstable peritonitis mandates urgent return to OR

One-Line Recap

Colectomy is indicated for colorectal cancer, refractory/dysplastic IBD, complicated diverticulitis, fulminant C. difficile, ischemia, volvulus, and select polyposis syndromes — with operative approach, timing, and reconstruction tailored to disease, patient frailty, and goals of care, while perioperative optimization (nutrition, glycemic control, smoking cessation, ERAS, VTE prophylaxis) and vigilant postop monitoring for anastomotic leak, ileus, and stoma complications drive outcomes.

Indications recap: emergent (perforation, obstruction, ischemia, fulminant colitis, massive bleed) vs elective (cancer, dysplasia, refractory IBD, hereditary syndromes, recurrent complicated diverticulitis)

Optimization recap: smoking cessation ≥4 weeks, albumin >3, HbA1c <8, oral + mechanical bowel prep, ERAS protocol, stoma marking, anticoagulation timing per CHEST/ACC, extended 28-day VTE prophylaxis for cancer

Complication recap: anastomotic leak (POD 3–7, tachycardia first sign), ileus vs SBO (transition point on CT), stoma ischemia (dusky = emergent), high-output ileostomy → dehydration/AKI, low anterior resection syndrome after LAR, incisional hernia long term

Follow-up recap: surgery 2 weeks, oncology within 2 weeks for stage II–III, CEA q3–6 mo, CT C/A/P annually × 3–5 yr, colonoscopy at 1 yr → 3 yr → q5 yr; Lynch and FAP require lifelong syndrome-specific surveillance

Board pearl: Master the decision tree of emergent vs elective, segmental vs total, primary anastomosis vs Hartmann vs diverting ileostomy — Step 3 stems will test all three layers simultaneously, and the right answer balances oncologic principles with patient stability, frailty, and goals of care

Step 3 management: Always pair the operative decision with the outpatient transition plan — discharge medications, follow-up cadence, surveillance schedule, and shared decision-making documentation are as exam-relevant as the operation itself