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    Colorectal non-tumour

    Background

    Colorectal resection may be required to treat conditions other than tumours of the bowel such as inflammatory bowel disease (ulcerative colitis), diverticulosis, volvulus, intussusception and severe haemorrhage.1

    In some cases the whole colon (total colectomy) from terminal ileum to rectum may be resected for ulcerative colitis or familial adenomatous polyposis.


    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

    • No
      • Non-routine fixation (not formalin), describe.
    • Yes
      • Special studies required, describe.
      • Ensure samples are taken prior to fixation.
    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify the anatomical features of the specimen.

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    Photograph the intact specimen if required.

    The pathologist on call or reporting pathologist should be consulted and may need to view the specimen before cut-up proceeds.

    Describe the following features of the specimen:

    Procedure

    Record as stated by the clinician.
    • Right hemicolectomy
    • Right extended hemicolectomy
    • Left hemicolectomy
    • Sigmoid colectomy
    • Anterior resection
    • Abdominoperineal resection
    • Subtotal colectomy
    • Sigmoid colectomy
    • Hartmann’s procedure
    • Total colectomy
    • Stomal reversal
    • Other procedure(s), describe

    Anatomical components included (more than one may apply) and dimensions (mm)

    Specimen size

    • Length (in total)

    Describe and measure the anatomical components present.

    • Terminal ileum, length and circumference
    • Caecum
    • Colon, length
    • Rectum
    • Omentum, three dimensions
    • Appendix see also specific instructions
    • Other, describe and measure in three dimensions

    Specimen integrity

    • Intact
    • Opened, specify

    Evidence of previous biopsy or surgery, if present

    • Scar
    • Sutures/staple line
      • State what structures are joined, if possible, and record dimensions (mm)

    Serosal surface

    • Normal
    • Abnormality (more than one may apply)
      • Adhesions
      • Fibrosis/puckering
      • Exudate
      • Congestion
      • Fat wrapping
      • Anastomosis
      • Perforation/serosal defect

    Abnormalities present

    For each abnormality, describe:

    • Number
    • Structures involved/affected
    • Distance (mm) from anatomical structure or the closest margin
    • Size in three dimensions (mm)

    Dissection

    The lumen of specimens should be gently rinsed on arrival in laboratory.2-4

    After sufficient fixation, paint the relevant surgical margins with ink (e.g. non-peritonealised margin. It is not recommended that you ink serosa) and record the colours applied.2-4

    Open longitudinally along the antimesenteric border.

    After opening the specimen may require longer fixation in larger quantity of formalin.


    Internal Inspection

    Internal inspection, sectioning and block taking should be guided by the clinical history and/or macroscopic findings. If none are supplied consideration should be given to contacting the reporting Pathologist or surgeon that performed the operation.

    Describe the internal appearance of the specimen, either generically describing the mucosa or specifically describing the condition involved (e.g. inflammatory bowel disease).

    Mucosa

    • Normal
    • Abnormal
      • Polyps see also cut-up instructions for colorectal polyps
      • Prominent vessels
      • Abscess formation (seen after transverse sectioning)
      • Ulceration
      • Dusky blue (ischaemia)
      • Flattened (seen proximal to an obstruction or volvulus)
      • Cobblestone appearance (suggests inflammatory bowel disease)
      • Erythematous
        • Number

    Abnormalities present

    For each abnormality, describe

    • Size in three dimensions
    • Location(s) involved/relationship to sites involved
      • Location
      • Arising from or close to (diverticulum/fistula/anastomosis)

    If the surgery is for inflammatory bowel disease, describe:

    • Area and location of mucosal abnormality
    • Dimensions of the areas involved
    • Distance from the proximal and distal margins
    • Any solid areas
      • Describe and designate accordingly
    • Polyps
      • Location
      • Arising within
      • Normal-appearing colon
      • Mucosal abnormality
      • Size (mm)

    Retrieved from resection specimen

    • Describe site(s)
    • Number retrieved

    Separately submitted

    • For each container, record specimen number and designation
    • Collective size of tissue in three dimensions (mm)
    • Number of lymph nodes submitted
    • Maximum diameter of each (mm)

    Lymph nodes present in the specimen should be assessed and submitted, especially if abnormal. A meticulous hunt for large numbers of lymph nodes is not required.


    Processing

    Dissect the specimen further and submit sections for processing according to the diagram provided.4

    Meticulously close transverse sectioning is recommended in specimens with essentially normal macroscopic appearances to exclude the presence of a small abscess. Serially section either proximal to distal or vice versa and section longitudinally i.e. perpendicular to the mucosal folds.2

    Submit representative sections:

    • At least four sections of the lesion, one of which should include the interface with the adjacent normal mucosa
    • Shave sections of the surgical margins unless lesion is within 20mm, in which case the margin should be inked and longitudinal (perpendicular) sections to the margin taken2

    Submit representative sections:

    • Serial sampling of mucosa every 100mm with additional sections from any solid/suspicious polypoid areas with transverse and longitudinal sections
    • Sections from appendix and ileocaecal valve
    • Shave sections of the surgical margins unless lesion is within 20mm, in which case the margin should be inked and longitudinal (perpendicular) sections to the margin taken

    Submit all lymph nodes.

    Record details of each cassette.

    An illustrated block key similar to those below may be useful.

    Block allocation keys

    Cassette id
    Site
    No. of pieces
    A
     Distal margin
     
    B-E
    Lesion including interface with normal mucosa
     
    F
    Proximal margin
     
    Cassette id Site No. of pieces
    A Distal margin  
    B-H Serial sampling of mucosa including all lesions and interface with normal mucosa  
     I Ileocaecal valve  
    J Appendix  
    K Proximal margin  
    L Lymph nodes  
     

    Acknowledgements

    Dr Ian Brown for his contribution in reviewing and editing this protocol.

    References

    1. Fry RD, Mahmoud N, Maron DJ and Bleier JIS. Colon and rectum. In: Sabiston Textbook of Surgery, Elsevier Saunders, Philadelphia, PA, 2012.
    2. Feakins R, Campbell F, Mears L, Moffat C, Scott N and Allen D. Tissue pathways for gastrointestinal and pancreatobiliary pathology, The Royal College of Pathologists, London, 2009.
    3. Burroughs SH and Williams GT. ACP Best practice no 159. Examination of large intestine resection specimens. J Clin Pathol 2000;53(5):344-349.
    4. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.

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      Inflammatory bowel disease

      Inflammatory bowel disease, suggested blocks

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      22-Mar-2019
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