Colorectal Surgery Review

Allen Kamrava, MD MBA FACS FASCRS
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An academic, sponsor-free audio review of core concepts in colon and rectal surgery. Using the power of A.I., created by Dr. Allen Kamrava, Associate Teaching Faculty at Cedars-Sinai Medical Center, this series is designed for residents, fellows, and practicing surgeons to stay current with concise, evidence-based updates. Covering textbook foundations, landmark trials, and evolving ASCRS guidelines, each episode delivers practical surgical education for the commute, workout, or even to wind down at night. Learn more at https://drkamrava.com/podcast

  1. 3D AGO

    Lower GI Bleeds

    Essential knowledge for the management of Lower GI Hemorrhage (LGIB), a common and high-stakes emergency. Initial management requires recognizing if the source is likely upper GI (hematochezia plus instability) and strict transfusion targets (Hgb 7; Hgb 9 for cardiovascular risk patients). Risk stratification hinges on the Shock Index and the Oakland Score, where a score of eight or less predicts safe outpatient discharge. The diagnostic pathway utilizes CTA for low-flow bleeds and angiography for high-flow bleeds. For endoscopic intervention, clips are strictly preferred over thermal energy for diverticular bleeding due to perforation risk. Surgical intervention is the last resort, emphasizing the need for India Ink tattooing to localize the source, allowing for a targeted segmental colectomy rather than a high-morbidity blind subtotal colectomy.

    25 min

  2. JAN 29

    Large Bowel Obstruction

    A crucial review of Large Bowel Obstruction (LBO), emphasizing the foundational physiology of the closed-loop obstruction caused by a competent ileocecal valve, leading to imminent perforation risk dictated by the Law of Laplace (highest risk at the cecum). CT is the definitive modality for locating the transition point. Management of malignant LBO is highly sensitive; emergency right colectomy is associated with 10% mortality and 14% leak rate. While Subtotal Colectomy (STC) avoids a high-risk anastomosis, it carries a high functional cost (41% of patients report high bowel frequency). For Sigmoid Volvulus, initial endoscopic detorsion must be followed by mandatory elective resection due to high recurrence risk (45-70%). Acute Colonic Pseudo-Obstruction (ACPO) is managed with Neostigmine, a highly effective agent that requires continuous cardiac monitoring due to the risk of severe bradycardia.

    37 min

  3. JAN 26

    Diverticulosis

    This episode reviews the significant evolution in the management of colonic diverticular disease, moving past old dogmas like the "second episode rule" and simple fiber deficiency hypothesis. Level 1 trials (Diabolo/AVOD) definitively show that antibiotics are not mandatory for stable, uncomplicated diverticulitis. The current indication for elective surgery is now based solely on symptom burden and reduced quality of life (QOL). For Hinchey III (purulent peritonitis), Laparoscopic Lavage (LL) is a valid, evidence-based option, as the increased initial risk of reintervention is balanced by a profoundly reduced rate of long-term stoma formation. For emergency resection in Hinchey IV, primary anastomosis (PA) is preferred in stable patients due to demonstrably superior stoma reversal rates compared to a Hartman's procedure.

    36 min

  4. JAN 22

    Minimally Invasive Surgery

    Comprehensive review of Minimally Invasive Surgery (MIS) for colorectal cancer, distinguishing the settled science of laparoscopic colon resection from the ongoing controversy of rectal resection. The episode details how pivotal trials (ACOSOG, ALaCaRT) failed to prove non-inferiority for laparoscopic proctectomy, primarily due to higher rates of compromised Circumferential Radial Margin (CRM) in the deep pelvis. Technical solutions like the Reverse Smile technique for anastmosis are discussed to mitigate weak spots from stapler limitations. The RoLAR trial demonstrated that robotics is not clinically superior to standard laparoscopy but is significantly more costly. Transanal Total Mesorectal Excision (TaTME) is presented as a radical technique to improve CRM, though it remains under intense scrutiny due to international concerns over multifocal recurrence patterns. Hand Assisted Laparoscopic Surgery (HALS) is noted as a practical bridge that retains MIS benefits while providing crucial haptic feedback for quality control.

    42 min

  5. JAN 15

    Cytoreduction and HIPEC

    Explores Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Colorectal Peritoneal Metastases (CPM). Success relies entirely on meticulous patient selection and achieving complete macroscopic cytoreduction (CC0). The episode details the Peritoneal Cancer Index (PCI) for staging and emphasizes that for aggressive CPM, CC1 is essentially a failure to cure, whereas it may be acceptable for less aggressive PMP. The landmark Verwall trial proved a survival benefit for CRS + Mitomycin C HIPEC. However, the PRODIGE 7 trial introduced controversy by showing no survival benefit when using Oxaliplatin HIPEC after successful CRS alone, suggesting the choice of agent is critical. Current practice is shifting toward prevention and early detection in high-risk patients (e.g., T4 tumors, perforation).

    39 min

  6. JAN 12

    GIST, Neuroendocrine Tumors and Lymphoma

    Focuses on three complex non-epithelial entities that demand specialized algorithms. For GIST, diagnosis is based on CD117 (KIT) and DOG1, and management hinges on molecular genetics (Exon 11 is favorable; Exon 9 requires higher imatinib dosing). Rectal GIST presents a core dilemma, as local excision carries a strikingly high local recurrence rate (up to 77%); neo-adjuvant imatinib is used to downsize tumors and facilitate sphincter preservation. Adjuvant imatinib must be given for a minimum of 3 years for high-risk disease. For Neuroendocrine Tumors (NETs), management is anatomical and metric: Rectal NETs 2 cm require radical resection. For Colorectal Lymphoma, localized DLBCL is unique among GI malignancies, mandating upfront surgical resection followed by chemotherapy due to a clear survival advantage and the need to prevent catastrophic perforation from chemotherapy-induced tumor necrosis.

    43 min

  7. JAN 8

    Appendiceal Neoplasms

    A detailed analysis of appendiceal neoplasms, highlighting how management is strictly driven by histology and classification. For invasive adenocarcinoma, a formal right hemicolectomy (RHC) is the standard due to the high risk of nodal metastasis (up to 30%). For mucinous neoplasms (LAMN/HAMN), the management pivots away from RHC to aggressive surveillance, driven by the critical distinction between high-risk cellular mucin versus low-risk acellular mucin found outside the appendix. For Neuroendocrine Tumors (ANENs), RHC is mandatory for lesions > 2 cm, or those 1-2 cm with high-risk features like lymphovascular invasion or involvement of the base. Finally, the episode stresses the fundamental reclassification of Goblet Cell Carcinoma (GCC) as a highly aggressive adenocarcinoma, requiring RHC and corresponding surveillance protocols.

    36 min

  8. JAN 5

    Rectal Cancer - Local Recurrence

    This episode tackles the highly complex and morbid radical management of Locally Recurrent Rectal Cancer (LRC), a disease defined as extra-TME pathology, operating in dense, irradiated, fibrotic tissue. Achieving an R0 resection is the single biggest determinant of cure (40-50% 5-year OS). Planning requires mandatory Multidisciplinary Team (MDT) input and combined PTCT/MRI, recognizing the limitations of MRI in delineating small pelvic sidewall structures. The modern radical approach often necessitates major structural sacrifice, including internal iliac vascular resection and careful management of the sciatic nerve. A critical academic point discussed is the evolving R0 margin controversy, suggesting that margins wider than 0.1mm may not provide additional survival benefit, forcing a balance between radicality and functional outcome.

    47 min
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About

An academic, sponsor-free audio review of core concepts in colon and rectal surgery. Using the power of A.I., created by Dr. Allen Kamrava, Associate Teaching Faculty at Cedars-Sinai Medical Center, this series is designed for residents, fellows, and practicing surgeons to stay current with concise, evidence-based updates. Covering textbook foundations, landmark trials, and evolving ASCRS guidelines, each episode delivers practical surgical education for the commute, workout, or even to wind down at night. Learn more at https://drkamrava.com/podcast

Information

  • Creator
    Allen Kamrava, MD MBA FACS FASCRS
  • Years Active
    2025 - 2026
  • Episodes
    35
  • Rating
    Clean
  • Copyright
    © Allen Kamrava, MD MBA FACS FASCRS
  • Show Website
    Colorectal Surgery Review