Current therapy in colon and rectal surgery

✍ Scribed by Ravi P. Kiran (editor); Conor Patrick Delaney (editor); James M. Church (editor); Victor W. Fazio (editor)

• Publisher: Elsevier Inc.
• Year: 2017
• Tongue: English
• Leaves: 539
• Series: Current therapy
• Edition: 3
• Category: Library

✦ Table of Contents

Front Cover
IFC
Current therapy in colon and rectal surgery
Copyright
Dedication
Contributors
Preface to the third edition
Acknowledgments
Contents
1 - ANAL AND PERIANAL REGION
1 - Anatomy and Physiology of the Colon, Rectum, and Anal Canal*
ANATOMY OF THE COLON AND RECTUM
Colon
Course and Peritoneal Coverings
Rectum
Peritoneal Relations and Fascial Attachments
ARTERIAL SUPPLY
Superior Mesenteric Artery
Inferior Mesenteric Artery
Collateral Circulation
VENOUS DRAINAGE
Superior Mesenteric Vein
Inferior Mesenteric Vein
LYMPHATIC DRAINAGE
INNERVATION
COLON AND RECTUM PHYSIOLOGY
Colonic Physiology
Absorption and Secretion
Digestion
Propulsion and Storage
ANAL CANAL ANATOMY
Lining
Muscles of the Anorectal Region
Perineal Body
Pelvic Floor Muscles
Innervation of the Anus
Motor Innervation
Sensory Innervation
Arterial Supply of the Anus
Lymphatic Drainage of the Anus
Venous Drainage of the Anus
ANAL CANAL PHYSIOLOGY
Mechanisms of Continence
Defecation
Physiologic Testing
Anal Manometry
Defecography by Fluoroscopy or Magnetic Resonance Imaging
Balloon Expulsion Test
Saline Continence Test
Rectal Compliance
Electromyography
Nerve Stimulation Techniques
Suggested Reading
2 - Hemorrhoids
EXTERNAL HEMORRHOIDS
ANATOMY AND ETIOLOGY OF INTERNAL HEMORRHOIDS
CLINICAL EVALUATION
NONEXCISIONAL OPTIONS
Medical Management
Sclerotherapy
Energy-Based Destruction
Hemorrhoidal Ligation with Rubber Bands
EXCISIONAL HEMORRHOIDECTOMY
Instrumentation for Excisional Hemmorrhoidectomy
PROCEDURE FOR PROLAPSING HEMORRHOIDS (STAPLED HEMMORHOIDOPEXY)
DOPPLER-GUIDED HEMORRHOIDAL DEARTERIALIZATION
POSTOPERATIVE MANAGEMENT AFTER HEMORRHOID SURGERY
CONCLUSION
Suggested Reading
3 - Chronic Anal Fissure
INTRODUCTION
DIAGNOSIS
PATHOPHYSIOLOGY
High-Pressure Chronic Anal Fissure
Low- and Normal-Pressure Chronic Anal Fissure
MANAGEMENT
Topical Creams
Botulinum Toxin
Fissurectomy
Cutaneous Advancement Flap
Lateral Internal Sphincterotomy
Surgical Technique
Risk of Incontinence
Tailored Sphincterotomy
Treatment of Low/Normal Pressure Chronic Anal Fissure
SUMMARY: CHOICE OF TREATMENT
Suggested Reading
4 - Anorectal Abscess
SURGICAL ANATOMY
ETIOLOGY
NATURAL HISTORY OF THE DISEASE AND SPREAD PATHWAYS
CLINICAL FEATURES
Perianal Abscess
Ischiorectal Abscess
Intersphincteric Abscess
Supralevator Abscess
Deep Postanal Abscess
Submucosal Abscess
DIAGNOSIS
Treatment of Anorectal Abscesses
Large Abscesses
Searching for a Fistula
Ischiorectal Abscess
Intersphincteric Abscesses
Supralevator Abscess
Submucosal Abscess
Role of Antibiotics and Biopsy
Postoperative Care
Complications
RECURRENCE AND THE DEVELOPMENT OF FISTULA IN ANO
Suggested Reading
5 - Anal Fistula
INTRODUCTION
ETIOLOGY
CLASSIFICATION
PRESENTATION
DIAGNOSIS AND EVALUATION
Preparation and Examination
TREATMENT
INTERSPHINCTERIC ANAL FISTULA
Clinical Findings
TREATMENT
Incontinence Risk
TRANSSPHINCTERIC ANAL FISTULA
Clinical Findings
Treatment
Cutting Seton
Sphincter-Preserving Techniques
LIFT
ADVANCEMENT FLAP
PARTIAL FISTULOTOMY
SUPRASPHINCTERIC ANAL FISTULA
Fistula Plugs
EXTRASPHINCTERIC ANAL FISTULA
SPECIAL SITUATIONS
Crohn Disease
Deep Postanal Space Abscess with a Horseshoe Fistula
SUMMARY
Suggested Reading
6 - Rectovaginal Fistula
DEFINITION
CAUSES
HISTORY AND PHYSICAL EXAMINATION
TREATMENT OPTIONS
Medical
Nonsurgical Closure
Fistula Plug
Fibrin Glue
Surgical Closure
Anal Approach
Rectal Advancement Flap
Advancement Sleeve Flap
Turnbull-Cutait Anastomosis
Transvaginal Approach
Perineal Approach
Ligation of the Intersphincteric Fistula Tract
Episioproctotomy
Tissue Interposition
Gracilis. Placement of muscle (typically the gracilis) between the rectum and vagina via a transperineal approach is an option w...
Martius. The Martius flap is another procedure that brings healthy tissue into the area. The patient is usually in the lithotomy...
Biologic Mesh. Dissection in the rectovaginal plane and closure of the openings at the anal and vaginal side, followed by placem...
SPECIAL CONSIDERATIONS
Use of a Stoma
Postoperative Care
Sexual Function/Vaginal Dryness
Recurrence
CONCLUSION
Suggested Reading
7 - Pilonidal Sinus
ETIOLOGY
PRESENTATION
TREATMENT
Asymptomatic Pilonidal Sinus
Pilonidal Abscess
Chronic Pilonidal Sinus
NONOPERATIVE MANAGEMENT
Hair Removal
SURGERY
Lateral Drainage, Curettage, and Midline Pit Excision
Local Excision and Healing by Secondary Intention
Excision and Wound Closure: Midline or Off-Midline Closure?
FLAP-BASED PROCEDURES
Karydakis Procedure
Cleft Lift Procedure
Rhomboid Excision and Flap Repair
ADJUNCTS TO OPERATIVE MANAGEMENT
Cavity Drainage
CONCLUSION
Suggested Reading
8 - Perianal Hidradenitis Suppurativa
ETIOLOGY
CLINICAL PRESENTATION AND EVALUATION
ANTIBIOTIC TREATMENT
NONANTIBIOTIC TREATMENT
SURGICAL TREATMENT
SUMMARY
Suggested Reading
9 - Management of Pruritus Ani
INTRODUCTION
ETIOLOGY
PRIMARY CAUSES OF PRURITUS ANI
Pathophysiology
HISTORY
EXAMINATION
TREATMENT
SECONDARY PRURITUS ANI TREATMENT
Anorectal Conditions
Infections
Dermatologic Conditions
Neoplastic Causes
Systemic Disease
TREATMENT OF PRIMARY PRURITUS ANI
REFRACTORY OR PERSISTENT PRURITUS ANI
SUMMARY
Suggested Reading
10 - Cause and Management of Anal Stenosis
INTRODUCTION
DEFINITION
CLASSIFICATION OF ANAL STENOSIS
Cause
Spasm
Postoperative Scarring
Stenosis Due to Chronic Diarrhea
Age-Related Stenosis
Other Classification Schemes for Anal Stenosis
SYMPTOMS
Examination Findings
PREVENTION OF POSTOPERATIVE ANAL STENOSIS
TREATMENT
Nonoperative Management
Anal Dilation
Surgical Management
Anoplasty
Postoperative Complications of Anoplasty
Suggested Reading
11 - Management of Anal and Perianal Warts
BACKGROUND AND EPIDEMIOLOGY
PRESENTATION OF DISEASE AND DIAGNOSIS
TREATMENT OF ANAL CONDYLOMA
Medical Therapies
Podophyllum-Based Therapies: Podophyllin and Podofilox
Trichloracetic and Bichloracetic Acid
Imiquimod
Other Medical Treatments
Ablative Therapies
Cryotherapy
Surgical Excision/Fulguration
Laser
Recurrent Disease
Treatment Algorithm
CONCLUSION
Suggested Reading
12 - Anorectal Venereal Infections
BACTERIAL INFECTIONS
Gonorrhea
Preferred Clinical Approach
Chlamydia trachomatis and Lymphogranuloma venereum
Preferred Clinical Approach
Chancroid
Preferred Clinical Approach
Granuloma Inguinale
Preferred Clinical Approach
Syphilis (“The Great Masquerader”)
Preferred Clinical Approach
VIRAL INFECTIONS
Herpes Simplex Virus
Preferred Clinical Approach
Condylomata Acuminata
Clinical Manifestations
Treatment
Preferred Clinical Approach
Electrocautery
OTHER DISORDERS
Suggested Reading
13 - Management of High-Grade Squamous Intraepithelial Lesion (Formerly Bowen Disease) and Paget Disease
INTRODUCTION
HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION (FORMERLY BOWEN DISEASE)
Management
PERIANAL PAGET DISEASE
Management
Suggested Reading
14 - Anal Melanoma and Basal Cell Cancer of the Perianal Region
INTRODUCTION
EPIDEMIOLOGY AND RISK FACTORS
PATHOPHYSIOLOGY
CLINICAL PRESENTATION AND DIAGNOSIS
SURGERY
Management of the Primary Tumor
Management of Lymph Nodes
SURVIVAL
BASAL CELL CANCER OF THE PERIANAL REGION
Suggested Reading
15 - Anal Carcinoma
INTRODUCTION
ANATOMIC CONSIDERATIONS
EPIDEMIOLOGY
SQUAMOUS CELL CARCINOMA OF THE ANAL CANAL
Surveillance
Local Excision
Inguinal Lymph Node Management
Extrapelvic Metastases
PERIANAL SQUAMOUS CELL CARCINOMA
ANAL CANCER AND HIV INFECTION
Suggested Reading
16 - Pelvic Pain
A GENERAL APPROACH
CHRONIC PROCTALGIA
LEVATOR ANI SYNDROME
Diagnosis
Treatment
PROCTALGIA FUGAX
COCCYGODYNIA
CONCLUSION
Selected Readings
17 - Anorectal Congenital Disorders
DESCRIPTION OF DEFECTS
Perineal Fistula
Rectal Atresia
Vestibular Fistula
Imperforate Anus without Fistula
Rectourethral Bulbar Fistula
Rectourethral Prostatic Fistula
Cloaca
Recto-Bladder-Neck Fistula
NEONATAL MANAGEMENT
MAIN REPAIR
Anoplasty
Limited Posterior Sagittal Anorectoplasty
Posterior Sagittal Anorectoplasty with or without Laparotomy/Laparoscopy
Posterior Sagittal Anorectovaginourethroplasty with or without Laparotomy
Management of Functional Sequelae
Suggested Readings
18 - Hirschsprung Disease
INTRODUCTION AND HISTORY
ETIOLOGY, PATHOPHYSIOLOGY, AND INCIDENCE
CLINICAL MANIFESTATIONS
DIAGNOSIS
Anorectal Manometry
Rectal Biopsy
TREATMENT
Resuscitation
Surgery
Main Repair
Swenson Procedure
Duhamel Procedure
Soave Procedure
Laparoscopic Procedures
Transanal Approach
COMPLICATIONS
Fecal Incontinence
Dehiscence and Retraction
Constipation
Nonpreventable Complications
RESULTS
TOTAL COLONIC AGANGLIONOSIS
Suggested Reading
2 - RECTAL AND PARARECTAL REGION
19 - Fecal Incontinence
INTRODUCTION AND INCIDENCE
CAUSES
ASSESSMENT
TREATMENT
Medical Management
Biofeedback
Surgery
Anal Sphincter Repair (Sphincteroplasty)
Postanal Repair
Anal Encirclement
Muscle Transposition
Sacral Nerve Stimulation
Posterior Tibial Nerve Stimulation
Continence Enemas
Stem Cells, Bulking Agents, and Other Techniques
Fecal Diversion
CONCLUSIONS
Suggested Readings
20 - Rectal Stricture: Etiology and Management
DEFINITION
PRESENTATION AND DIAGNOSIS
ETIOLOGY
BENIGN RECTAL STRICTURES
Rectal Strictures Related to Inflammatory Bowel Disease
MALIGNANT RECTAL STRICTURES
SUMMARY
Suggested Readings
21 - Management of Fecal Impaction
INTRODUCTION
ETIOPATHOLOGY
Presentation
DIAGNOSIS
TREATMENT
Medical Treatment
Digital Evacuation
Enemas and Colonic Lavage
Oral Solutions
Stool Softeners
Laxatives
Endoscopic Disimpaction
SURGERY
Acute
Chronic
PREVENTION
CONCLUSION
Suggested Reading
22 - Rectal Prolapse
INTRODUCTION
PATHOPHYSIOLOGY
CLINICAL FEATURES
PREOPERATIVE CONSIDERATIONS
SURGICAL OPTIONS
Perineal Repairs
Abdominal Procedures
Recommendations
Problems
MANAGEMENT OF RECURRENT PROLAPSE
Suggested Reading
23 - Solitary Rectal Ulcer Syndrome
INTRODUCTION
CAUSE
PATHOPHYSIOLOGY
CLINICAL FEATURES
DIAGNOSIS
MANAGEMENT
Nonoperative Management
Surgery
CONCLUSIONS
Suggested Reading
24 - Rectocele
DEFINITION
CAUSES
SYMPTOMS
DIAGNOSIS
MANAGEMENT
SURGICAL TREATMENT
Transanal Repairs
Transvaginal Repairs
Transperineal Repairs
Comparison of Approaches
SUMMARY
Suggested Reading
25 - Rectal Foreign Bodies
EPIDEMIOLOGY
EVALUATION
CLASSIFICATION
American Association for the Surgery of Trauma Rectal Organ Injury Scale
Location of the Foreign Body
Intraperitoneal or Extraperitoneal
EXTRACTION
MANAGEMENT
POSTEXTRACTION CARE
Suggested Reading
26 - Diagnosis and Management of Sacral and Retrorectal Tumors
INTRODUCTION
ANATOMY OF THE RETRORECTAL SPACE
CLASSIFICATION SYSTEMS
CONGENITAL/DEVELOPMENTAL LESIONS
Germ Cell Tumors
Tailgut Cysts
Duplication Cysts
Anterior Sacral Meningocele
Chordoma
Osseous Tumors
Neurogenic Tumors
Nonosseous Mesenchymal Tumors
INFLAMMATORY LESIONS
METASTATIC LESIONS
DIAGNOSTIC APPROACHES TO SACRAL AND RETRORECTAL TUMORS
OPERATIVE APPROACHES
SUMMARY
Suggested Reading
27 - Management of Rectal Villous Tumors
INTRODUCTION
RECTAL ANATOMY AND PHYSIOLOGY
CLINICALLY SIGNIFICANT ASSOCIATIONS OF RECTAL FUNCTION
THERAPEUTIC OPTIONS RESULTING FROM THE LOCATION OF THE RECTUM
RECTAL VILLOUS TUMORS
ASSESSING THE LESION FOR CANCER
TREATMENT
Endoscopic Polypectomy
Transanal Excision
Transanal Endoscopic Microsurgery/Transanal Minimally Invasive Surgery
Delorme Procedure
Trans-sacral Resection
Anterior Resection
FOLLOW-UP
Suggested Reading
28 - Preoperative Evaluation of the Patient with Rectal Cancer: Staging and Strategy
INTRODUCTION
CLINICAL ASSESSMENT
History
Physical Examination
ENDOSCOPIC EVALUATION AND BIOPSY
PREOPERATIVE STAGING WITH IMAGING MODALITIES
Locoregional Evaluation
Tumor Stage and the Circumferential Resection Margin
Nodal Staging
Extramural Venous Invasion
Locoregional Imaging Synoptic Reports
Distant Metastatic Evaluation
Serum Tumor Markers
ROLE OF MULTIDISCIPLINARY CANCER CONFERENCES
Suggested Readings
29 - Cancer of the Rectum: Neoadjuvant Therapy
INTRODUCTION
RADIOTHERAPY TRIALS
ROLE OF CIRCUMFERENTIAL RESECTION MARGIN
MULTIMODALITY TREATMENT APPROACHES
RANDOMIZED TRIALS COMPARING NEOADJUVANT SHORT-COURSE RADIOTHERAPY WITH CHEMOTHERAPY–LONG-COURSE RADIOTHERAPY
RADIATION TREATMENT VOLUMES
RADIATION-RELATED TOXICITIES
OTHER PERIOPERATIVE RADIATION TREATMENT OPTIONS
Boosting the Dose
INTRAOPERATIVE RADIATION THERAPY
INTENSITY-MODULATED RADIATION THERAPY
HIGH-DOSE-RATE ENDORECTAL BRACHYTHERAPY
SUMMARY
Suggested Reading
30 - Cancer of the Rectum: Operative Management
INTRODUCTION
KEY ANATOMIC POINTS
PRESURGICAL PATIENT PREPARATION AND EVALUATION
PREOPERATIVE DECISION MAKING
Deciding Between an Open or Laparoscopic Approach
Should a Stapled or Hand-Sewn Restorative Procedure Be Performed?
SURGICAL PRINCIPLES
Total Mesorectal Excision
Ligation of the Inferior Mesenteric Artery
Distal Resection Margins
Choice of Anastomotic Configuration
Drainage
Diverting Stoma
KEY STEPS OF SURGICAL PROCEDURES
Low Anterior Resection
Positioning and Equipment
Trocar Placement
Exposure of the Operating Field
Identification of Inferior Mesenteric Vessels and Left Ureter
Division of the Vessels and Splenic Flexure Mobilization
Mobilization and Division of the Rectum
Exteriorization of the Specimen
Creation of the Anastomosis
Desufflation and Closure of Trocar Incisions
Abdominoperineal Resection
Closure of the Anal Opening
Mobilization of the Rectum
Proximal Division of the Left Colon
Perineal Dissection and Exteriorization
Closure of Pelvic Wound and Trocar Incisions and Creation of the Colostomy
PELVIC EXENTERATION
Surgical Approaches
Assessment Before Exenteration
Signs of Irresectability
Sacrectomy
Pelvic Sidewall Disease
Anterior Compartment/Urogenital Disease
Central Recurrence
Bladder Reconstruction
Perineal Reconstruction
OUTCOMES: SURVIVAL AND LOCAL RECURRENCE
Suggested Reading
31 - Local Treatment of Rectal Cancer
INTRODUCTION
PREOPERATIVE EVALUATION
INITIAL SELECTION
SURGICAL TECHNIQUE
Patient Preparation
Transanal Excision
Transanal Endoscopic Microsurgery/Transanal Endoscopic Operation
Transanal Minimally Invasive Surgery
MANAGEMENT OF THE SPECIMEN
FOLLOW-UP
RESULTS
Local Excision for T1N0 Rectal Cancer
Local Excision for T2N0 Rectal Cancer
Salvage Resection after Local Excision
ALTERNATIVE TO LOCAL EXCISION: ENDOCAVITARY CONTACT RADIATION
CONCLUSIONS: ALGORITHM FOR TREATMENT BY LOCAL EXCISION
32 - Locally Recurrent Rectal Cancer: Management and Follow-up
INTRODUCTION
NOMENCLATURE OF PELVIC RECURRENCE
CLINICAL EVALUATION FOR SUSPECTED PELVIC RECURRENCE
MANAGEMENT OF PELVIC RECURRENCE
Category I: Asymptomatic Local and Distant Recurrence
Category II: Symptomatic Local Recurrence in the Presence of Distant Disease
Category III: Unresectable, Isolated Local Recurrence
Category IV: Resectable Isolated Local Recurrence
Axial Recurrences
Anterior Recurrences
Posterior Recurrences
Lateral Recurrences
THE ROLE OF CHEMORADIATION FOR PELVIC RECURRENCE
PREOPERATIVE AND INTRAOPERATIVE CONSIDERATIONS
RECONSTRUCTION OPTIONS FOR PERINEAL DEFECTS
SUMMARY
Suggested Reading
33 - Perineal Hernia
INTRODUCTION
THERAPY
Patient Selection
Preoperative Preparation
Procedures
Alternative Methods
Postoperative Care
Complications
PREVENTION
SUMMARY
Suggested Reading
3 - COLON
34 - Preoperative Preparation of the Patient for Colon and Rectal Surgery
INTRODUCTION
RISK ASSESSMENT
CARDIOVASCULAR ASSESSMENT AND PREOPERATIVE MANAGEMENT
PREOPERATIVE PULMONARY ASSESSMENT AND MANAGEMENT
MANAGEMENT OF PATIENTS RECEIVING ANTITHROMBOTIC THERAPY
MANAGEMENT OF PREOPERATIVE ANEMIA
MANAGEMENT OF PREOPERATIVE MALNUTRITION
Suggested Reading
35 - Medical Treatment of Ulcerative Colitis and Other Colitides
ULCERATIVE COLITIS
Diagnosis
Treatment
Diet
5-Aminosalycilic Acid
Mild to Moderate Ulcerative Colitis
Proctitis and Left-Sided Ulcerative Colitis
Left-Sided Disease
Extensive Disease
Lack of Response to 5-Aminosalycilic Acid
Oral Budesonide
Corticosteroids
Severe Ulcerative Colitis
Cyclosporine
Azathioprine and 6-Mercaptopurine
Biologic Agents
Infliximab
Loss of Response. It is known that antibodies can develop in patients receiving anti-TNF-α agents with a loss of response to tre...
Infusion Reactions. Mild infusion reactions occur in 5% to 13% of patients, but severe infusion reactions requiring infliximab d...
Delayed Reactions. Delayed reactions occur 3 to 12 days after the administration of infliximab. These reactions result from the ...
Adalimumab
Golimumab
How to Choose an Anti-TNF-α Agent
Complications
What to Do Before Starting Anti-TNF-α Therapy
What to Do Once Treatment with an Anti-TNF-α Agent Is Started
Antiadhesion Molecules
Alternative Therapies
Nicotine
Clinical Scenarios
Quiescent Disease
Fulminant or Toxic Colitis
General Recommendations for Patients with Severe Ulcerative Colitis
Test for C. difficile Toxin A and B
Flexible Sigmoidoscopy with Biopsies
Deep Vein Thrombosis Prophylaxis
Evaluate for Tuberculosis and Hepatitis B
Avoid Narcotics and Antidiarrheal Medications
Do Not Use Antibiotics
Diet as Tolerated
Perform Close Observation and Consult Colorectal Surgery upon Admission
Vaccinations
Pregnancy
Cancer Risk
Colorectal Cancer Prevention
OTHER COLITIDES
Microscopic Colitis
Diversion Colitis
Radiation Colopathy
Drug-Induced Colitis
Suggested Reading
36 - Chronic Ulcerative Colitis: Surgical Options
INTRODUCTION
EVOLUTION OF SURGERY FOR ULCERATIVE COLITIS
INDICATIONS FOR SURGERY IN PERSONS WITH ULCERATIVE COLITIS
OPERATIONS FOR ULCERATIVE COLITIS
Ileostomy
Straight Ileoanal Anastomosis
Subtotal Colectomy
Abdominal Colectomy with Ileorectal Anastomosis
Ileostomy and Blowhole Colostomy
Total Proctocolectomy and Ileostomy
Proctectomy Surgical Technique
Continent Ileostomy
Restorative Proctocolectomy
Pouch Configuration and Anastomosis
Staging the Procedure
Technique of Creation of an Ileoanal J Pouch
Problems with Reach of the Pouch
OUTCOMES OF ILEAL POUCH–ANAL ANASTOMOSIS
Complications after Ileal Pouch–Anal Anastomosis
Overall Quality of Life
Function of the Pouch
Pouchitis
Pouch Failure
Pouch Fistula
Risk of Carcinoma
Fertility, Sexual Problems, and Obstetric Outcome
Extraintestinal Manifestations
Quantification of Risk for Pouch Failure after Ileal Pouch Anal Anastomosis Surgery
Salvage of the Failed Pelvic Pouch
Suggested Reading
37 - Management of Acute Toxic Colitis and Megacolon
INTRODUCTION
EPIDEMIOLOGY AND ETIOLOGY
PATHOPHYSIOLOGY
PRESENTATION
DIAGNOSIS
EVALUATION
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
Indications for Surgery
Surgical Options
CONCLUSION
Suggested Reading
38 - Pelvic Pouch: Complications and Their Management
INTRODUCTION
POUCH DYSFUNCTION
INTRAOPERATIVE COMPLICATIONS
POSTOPERATIVE COMPLICATIONS
Pelvis Sepsis and Anastomotic Leak
Postoperative Bleeding from the Pouch
Pouch-Perineal and Pouch-Vaginal Fistulae
Pouch Sinus
Leak from the Tip of the “J”
Pouch Prolapse
Pouchitis and Cuffitis
Crohn Disease of the Pouch
Outlet Dysfunction
Cancer of the Pouch
Pouch Failure
ABDOMINOPERINEAL APPROACH FOR POUCH SALVAGE
Operative Technique
Suggested Reading
39 - Pouchitis and Functional Complications of the Pelvic Pouch
INTRODUCTION
POUCHITIS
ETIOLOGY AND PATHOGENESIS
Genetic Factors
The Microbiome
Mucosal Immunity
DIAGNOSIS
Categories of Pouchitis
TREATMENT
IRRITABLE POUCH SYNDROME
OTHER FUNCTIONAL DISORDERS
CONCLUSIONS
Suggested Reading
40 - Continent Ileostomy
INTRODUCTION
EVOLUTION OF THE CONTINENT ILEOSTOMY
TECHNIQUES TO BETTER FIX THE VALVE
POUCH DESIGN MODIFICATIONS
CURRENT INDICATIONS AND CONTRAINDICATIONS
CURRENT SURGICAL TECHNIQUE AND STATUS
Key Surgical Points
Typical Pouch Function
COMPLICATIONS OF A CONTINENT ILEOSTOMY
Perioperative Complications
Early Complications
Late Complications
Valve Slippage
Parastomal Hernia
Crohn Disease
Pouchitis
Valve Stenosis
Pouch Excision
WHAT TO DO WHEN A PATIENT PRESENTS ACUTELY WITH THE INABILITY TO INTUBATE HIS OR HER POUCH
CONCLUSIONS
Suggested Reading
41 - Unhealed Perineal Wound
INTRODUCTION
SPECIAL SITUATIONS LEADING TO AN UNHEALED PERINEAL WOUND
CAUSES
Technical Factors
Patient-Specific Factors
Crohn Disease
Radiation
PREVENTION
Preoperative
Intraoperative
Reconstruction of the Perineum with a Flap
DIAGNOSIS/WORKUP
NONOPERATIVE TREATMENT
OPERATIVE MANAGEMENT
SUMMARY
Suggested Reading
42 - Medical Management of Crohn Disease
INTRODUCTION
MEDICAL THERAPIES
5-Aminosalicylates
Antibiotics
Corticosteroids
Immunomodulators
Biologic Agents
Combination Therapy
PERIANAL AND FISTULIZING CROHN DISEASE
APPROACH TO MANAGEMENT OF CROHN DISEASE
SURGERY
POSTOPERATIVE RECURRENCE
SMOKING
NUTRITION
Suggested Reading
43 - Management of Crohn Colitis
MEDICAL MANAGEMENT
OPERATIVE INDICATIONS
PREOPERATIVE CONSIDERATIONS
OPERATIVE APPROACH
OPERATIVE OPTIONS
Disease of the Colon Alone
Disease of the Rectum Alone
Disease of the Colon and Rectum
SPECIAL SITUATIONS
Medications
Abscess
Severe Colitis
Growth Retardation
Fistula
Neoplasia
OUTCOME
SUMMARY
Suggested Reading
44 - Management of Perianal Crohn Disease
INTRODUCTION
PATHOPHYSIOLOGY
OTHER CONSIDERATIONS
PRESENTATIONS
Anal Sepsis
Anal Tags
Fissures
Stenosis
Perianal Skin Irritation
Internal Hemorrhoidal Prolapse
TREATMENT OF SEPSIS: ABSCESS AND FISTULA
RECTO/ANOVAGINAL FISTULA
OTHER MANIFESTATION OF PERIANAL CROHN DISEASE
SUMMARY
Suggested Reading
45 - Cecal Ulcer
INTRODUCTION
CAUSES
DIAGNOSIS
MANAGEMENT
CONCLUSION
Suggested Reading
46 - Pseudomembranous Clostridium Difficile Colitis
INTRODUCTION
PRESENTATION OF CLOSTRIDIUM DIFFICILE INFECTION
DIAGNOSIS
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
CONCLUSION
Suggested Reading
47 - Cytomegalovirus Ileocolitis and Kaposi Sarcoma in HIV/AIDS
INTRODUCTION
CYTOMEGALOVIRUS COLITIS
SURGERY
KAPOSI SARCOMA
Suggested Reading
48 - Diagnosis and Management of Acute Colonic Diverticulitis
INTRODUCTION
PRESENTATION
DIAGNOSTIC EVALUATION
MEDICAL MANAGEMENT
SURGICAL MANAGEMENT
Surgery
Suggested Reading
49 - Surgical Treatment of Diverticulitis and its Complications
INTRODUCTION
UNDERSTANDING DIVERTICULAR DISEASE AND ITS MANAGEMENT
ACUTE UNCOMPLICATED DIVERTICULITIS
Who Requires Elective Surgery after Uncomplicated Diverticulitis?
COMPLICATED DIVERTICULITIS
Acute Diverticulitis Complicated by Abscess Formation: Converting an Emergency Situation into a Semi-Elective Procedure
Acute Diverticulitis Complicated by Purulent or Feculent Peritonitis: Surgical Options in the Emergency Setting
Hartmann Procedure and Reversal
COMPLICATED DIVERTICULITIS WITH FISTULA FORMATION
Colovesical Fistulas: Diagnosis and Management
Colovaginal Fistulas: Diagnosis and Management
Colocutaneous Fistulas: Diagnosis and Management
ACUTE COLONIC OBSTRUCTION: PATIENT SELECTION FOR EMERGENT VERSUS SEMI-ELECTIVE OPERATIONS
RECURRENT DIVERTICULITIS IN PATIENTS WHO HAVE PREVIOUSLY UNDERGONE RESECTION FOR DIVERTICULAR DISEASE
Suggested Reading
50 - Lower Gastrointestinal Hemorrhage
INTRODUCTION
ETIOLOGY
INITIAL EVALUATION AND RESUSCITATION
DIAGNOSTIC TESTING
Scintigraphy
Multidetector Computed Tomography
Angiography
Colonoscopy
SURGERY
THE PROBLEM PATIENT: INTERMITTENT RECURRENT GASTROINTESTINAL BLEEDING
Suggested Reading
51 - Large Bowel Obstruction
INTRODUCTION
CLINICAL AND DIAGNOSTIC EVALUATION
SURGICAL MANAGEMENT
MALIGNANT AND BENIGN OBSTRUCTION
Right-Sided Obstruction
Left-Sided Obstruction
Self-Expanding Metallic Stents
COLONIC VOLVULUS
SIGMOID VOLVULUS
CECAL VOLVULUS
Suggested Reading
52 - Colonic Volvulus
INTRODUCTION
CECAL VOLVULUS
Background and Demographics
Pathophysiology
Signs and Symptoms
Diagnostic Imaging
Treatment
SIGMOID VOLVULUS
Background and Demographics
Pathophysiology
Signs and Symptoms
Diagnostic Imaging
Treatment
TRANSVERSE COLON VOLVULUS
Background and Demographics
Pathophysiology
Diagnostic Imaging
Signs and Symptoms
Treatment
Suggested Readings
53 - Colonic Pseudo-obstruction (Ogilvie Syndrome)
INTRODUCTION
EPIDEMIOLOGY
ETIOLOGY
SIGNS AND SYMPTOMS
DIAGNOSIS
TREATMENT OPTIONS
Initial Management
Pharmacologic Management
Endoscopic Therapy
Surgery
SUMMARY
Suggested Reading
54 - Management of the Malignant Polyp
INTRODUCTION
BIOLOGY
ASSESSMENT OF POLYPS
POLYPECTOMY
HISTOLOGY
MARGIN
NODES
SURGICAL CONSIDERATIONS
COMORBIDITIES
SUMMARY
Suggested Reading
55 - Colorectal Cancer Screening and Surveillance
SCREENING FOR COLORECTAL CANCER
Who Should Be Screened? Determining Risk
Screening Average-Risk Persons
CANCER PREVENTION TESTS
Colonoscopy
Flexible Sigmoidoscopy
Computed Tomographic Colonography
CANCER DETECTION TESTS
Fecal Occult Blood Tests
Stool DNA
SCREENING IN PERSONS AT AN ABOVE-AVERAGE RISK FOR COLORECTAL CANCER
Surveillance Colonoscopy in Patients with Adenomatous Lesions at Baseline
Surveillance Colonoscopy in Patients with Serrated Lesions at Baseline
Surveillance Colonoscopy after Piecemeal Polypectomy
Surveillance Colonoscopy after Endoscopic Resection of a Malignant Polyp
Surveillance Colonoscopy in Patients with Colorectal Cancer
Surveillance Colonoscopy in Patients with Inflammatory Bowel Disease
Surveillance Colonoscopy in Patients with a Family History of Colorectal Cancer or Adenomatous Polyps
WHEN SHOULD SCREENING AND SURVEILLANCE STOP IN THE AVERAGE-RISK POPULATION?
CONCLUSION
Suggested Readings
56 - Molecular Genetics of Colorectal Cancer
INTRODUCTION
GROWTH CONTROL
DNA REPAIR
CLINICAL SIGNIFICANCE
COMPLEXITY
Suggested Reading
57 - Polyposis Syndromes
INTRODUCTION
REGISTRIES
DEFINITIONS
FAMILIAL ADENOMATOUS POLYPOSIS
Genetic Testing
Genotype/Phenotype
Colorectal Cancer in Familial Adenomatous Polyposis
Surgical Options for the Large Bowel
Extracolonic Manifestations
Ampullary Cancer and Duodenal Adenomas
Thyroid Cancer
Adrenal Masses
Brain Tumors
Hepatoblastoma
Gardner-Type Manifestations
Congenital Hypertrophy of the Retinal Pigmented Epithelium
Surveillance
The IRA
The IPAA
Oligopolyposis/Attenuated Familial Adenomatous Polyposis
MYH-ASSOCIATED POLYPOSIS (MAP)
POLYMERASE PROOFREADING–ASSOCIATED POLYPOSIS
SERRATED POLYPOSIS
HAMARTOMATOUS POLYPOSES
Peutz-Jegher Polyposis
Juvenile Polyposis
PTEN Tumor Hamartoma Syndrome
HEREDITARY MIXED POLYPOSIS SYNDROME
Suggested Reading
58 - Desmoid Disease
INTRODUCTION
BIOLOGY
EPIDEMIOLOGY
GENETICS AND DESMOID RISK
DESMOID SEVERITY: A STAGING SYSTEM
MANAGEMENT
Setting Expectations
A Philosophy of Care
Extra-abdominal Desmoid Tumors
Abdominal Wall Tumors
Intra-abdominal Desmoid Disease
Workup
Medical Treatment
Role of Surgery
Complications of Desmoid Disease
Small Bowel Obstruction
Ureteric Obstruction
Abscess/Enterocutaneous Fistula
Superior Mesenteric Artery Aneurysm
Points about Operating on Persons with Desmoid Disease
SUMMARY AND GENERAL COMMENTS ABOUT THE EFFECT OF DESMOID DISEASE ON SURGICAL STRATEGY IN FAMILIAL ADENOMATOUS POLYPOSIS
Suggested Reading
59 - Hereditary Nonpolyposis
Colorectal Cancer and Lynch Syndrome
INTRODUCTION
HISTORICAL PERSPECTIVE AND CLARIFICATION OF TERMS
GENETIC AND MOLECULAR CAUSE OF LYNCH SYNDROME
HISTOLOGIC FEATURES OF LYNCH TUMORS
DIAGNOSING LYNCH SYNDROME
Clinical Criteria
Models
Tumor Testing
GENETIC COUNSELING AND TESTING
CLINICAL MANIFESTATIONS AND MANAGEMENT
COLORECTAL CANCER RISK MANAGEMENT
Surveillance Colonoscopy and Polypectomy
Chemoprevention
Surgery
Colectomy in the Absence of Cancer
Treatment of Colon Cancer
Rectal Cancer in Persons with Lynch Syndrome
RISK MANAGEMENT OF EXTRACOLONIC MANIFESTIONS
Endometrial and Ovarian Cancer
Upper Gastrointestinal Tract
Urinary Tract
Skin Neoplasms
Other Cancers
CLINICAL VARIATIONS OF HNPCC AND LYNCH SYNDROME
Familial Colorectal Cancer Type X
Likely Lynch Syndrome: Amsterdam Criteria with a Microsatellite Instability High Colorectal Cancer, but Germline Testing Is Not ...
Tumor Lynch
SUMMARY
Suggested Reading
60 - Cancer of the Appendix and Pseudomyxoma Peritonei Syndrome
INTRODUCTION
PATHOLOGY OF APPENDICEAL MALIGNANT TUMORS
Carcinoid Tumors
Adenocarcinoid Tumors of the Appendix (Goblet Cell Carcinoid)
Epithelial (Noncarcinoid) Tumors of the Appendix
Mucinous Adenoma and Adenocarcinoma
Nonmucinous Adenocarcinoma
DIAGNOSIS OF APPENDICEAL MALIGNANT TUMORS
Carcinoid
Adenocarcinoma and Mucinous Adenocarcinoma
Pseudomyxoma Peritonei Syndrome
TREATMENT OF APPENDICEAL TUMORS
Carcinoid Tumors
Appendiceal Adenocarcinoma
Management of Appendiceal Neoplasms with Peritoneal Dissemination
Perioperative Chemotherapy
Serial Debulking
CYTOREDUCTIVE SURGERY AND PERIOPERATIVE CHEMOTHERAPY
Survival by Completeness of Cytoreduction
Survival by Histologic Assessment
Survival by Prior Surgical Score
Treatment of Adenocarcinoid Appendiceal Malignancy
Morbidity and Mortality Rates
Peritonectomy
Perioperative Chemotherapy
Suggested Reading
61 - Surgical Management of Cancer of the Colon
INTRODUCTION
EPIDEMIOLOGY
Prognostic Factors
PREOPERATIVE EVALUATION
PREOPERATIVE PREPARATION
OPERATIVE PRINCIPLES AND TECHNIQUES
Exploration
Surgical Treatment of Right Colon Cancer
Surgical Treatment of Transverse Colon Cancer
Surgical Treatment of Splenic Flexure and Descending Colon Cancer
Surgical Treatment of Sigmoid Colon Cancer
LAPAROSCOPIC COLECTOMY
SPECIAL CONSIDERATIONS
Obstruction and Perforation
Prophylactic Oophorectomy
ASSESSMENT OF QUALITY OF COLECTOMY
POSTOPERATIVE SURVEILLANCE
SUMMARY
Suggested Readings
62 - Management of Metastatic Colorectal Cancer
INTRODUCTION
CHEMOTHERAPY
5-Fu
Capecitabine
Irinotecan
Oxaliplatin
MAINTENANCE CHEMOTHERAPY
BIOLOGIC AGENTS
FIRST-LINE TARGETED OPTIONS
THIRD- AND FOURTH-LINE OPTIONS
OLIGOMETASTATIC DISEASE
ROLE OF RESECTION OF PRIMARY LESION
IMMUNOTHERAPY
CONCLUSIONS
Suggested Reading
63 - Management of Colorectal Liver Metastasis
INTRODUCTION
DIAGNOSIS AND PREOPERATIVE WORKUP
Imaging
Serologic and Molecular Markers
Histology
Needle Biopsy
Multidisciplinary Planning
STAGING AND PROGNOSIS
PROGNOSTIC SCORES
TREATMENT
Chemotherapy
Neoadjuvant Chemotherapy for Resectable Liver Disease
Neoadjuvant Chemotherapy for Unresectable Liver Disease
Adjuvant Chemotherapy
Hepatic Arterial Infusion
Resectability
Resectable Liver Disease
Synchronous Liver Metastasis
Unresectable Liver Disease
Repeat Resections for Multiple Liver Metastases
Local Ablative Therapy
Radiofrequency Ablation
Microwave Ablation
Cryotherapy
Irreversible Electroporation
Colorectal Liver Metastases with Extrahepatic Spread
Lung
Peritoneal
Lymph Node Involvement
Inferior Vena Cava
Recurrence
SURVEILLANCE
CONCLUSION
Suggested Readings
64 - Colorectal Metastases to the Lung
INTRODUCTION
INDICATIONS FOR RESECTION OF COLORECTAL METASTASES
OUTCOMES OF PATIENTS UNDERGOING RESECTION AND PROGNOSTIC FACTORS
LUNG AND LIVER METASTASIS
SURGICAL APPROACH
DEVELOPMENT OF A PROSPECTIVE RANDOMIZED TRIAL: THE PULMONARY METASTASECTOMY IN COLORECTAL CANCER TRIAL
CONCLUSION
Suggested Reading
65 - Nonepithelial Colorectal Tumors
INTRODUCTION
BENIGN NONADENOMATOUS LESIONS OF THE COLON AND RECTUM
Benign Lymphoid Hyperplasia
Lipomas
Treatment
CAVERNOUS HEMANGIOMA
Characteristic Features
Treatment
Surgery (Laparotomy/Laparoscopic)
LEIOMYOMA AND LEIOMYOSARCOMA
Characteristic Features
Surgery
PRIMARY LYMPHOMA OF THE COLON AND RECTUM
SUMMARY
Suggested Reading
66 - Management of Colonic Ischemia
INTRODUCTION
ETIOLOGY AND PATHOGENESIS
CLASSIFICATION
CLINICAL PRESENTATION
DIAGNOSIS
MANAGEMENT
OUTCOME
SPECIAL TOPICS
Ischemic Colitis after Aortic Surgery
Colonic Ischemia after Cardiopulmonary Bypass
Ischemic Colitis Associated with Colon Carcinoma and Obstructing Colon Lesions
Total Colonic Ischemia
Ischemic Proctosigmoiditis
CONCLUSION
Suggested Readings
67 - Colon and Rectal Trauma
INTRODUCTION
ETIOLOGY
DIAGNOSIS
Physical Examination
Imaging
Diagnostic Peritoneal Lavage
Laparoscopy
TREATMENT
Colon Injuries
Damage Control
Rectal Injuries
Overview
Diversion
Direct Repair
Drainage
Distal Washout
Rectal Foreign Bodies
Suggested Reading
68 - Endometriosis of the Colon and Rectum
INTRODUCTION
PAIN
INFERTILITY
DIAGNOSIS
Physical Examination
Endoscopy
Imaging
SURGICAL MANAGEMENT
Results after Surgical Therapy
Combined Medical and Surgical Therapy
CONCLUSION
Suggested Reading
69 - Pneumatosis Cystoides Intestinalis
INTRODUCTION
ETIOLOGY
CLASSIFICATION
HISTOLOGY AND GROSS PATHOLOGY
SYMPTOMS
DIAGNOSIS
TREATMENT
Suggested Readings
70 - Constipation
INTRODUCTION
CAUSES
CLASSIFYING CONSTIPATION
ASSESSMENT
History
Physical Examination
INVESTIGATIONS
TREATMENT
Medical
Newer Promotility Agents
Biofeedback for Pelvic Floor Dyssynergia
Change in Position of Defecation
Surgery
Outlet Obstruction Constipation
Suggested Reading
4 - SMALL INTESTINE
71 - Small Bowel Obstruction
EXTENT OF THE PROBLEM
CLINICAL PRESENTATION
IMAGING
MRI and Ultrasound
MANAGEMENT OF SMALL BOWEL OBSTRUCTION
Nonadhesive Obstruction
Hernias
Crohn Disease
Malignancy
Intussusception
Gallstone Ileus
Bariatric Patient
Surgical Technique
Adhesive Obstruction
Hernias
Crohn Disease and Other Inflammatory Conditions
Malignancy
Intussusception
Gallstone Ileus
The Bariatric Patient
Laparoscopic versus Open Lysis of Adhesions
Early Postoperative Bowel Obstruction
Prevention of Adhesions
SUMMARY
Suggested Reading
72 - Medical Management of Short Bowel Syndrome
INTRODUCTION
ANATOMY OF SHORT BOWEL SYNDROME
DIETARY MANAGEMENT OF SHORT BOWEL SYNDROME
PHARMACOLOGIC TREATMENT OF SHORT BOWEL SYNDROME
PARENTERAL AND ENTERAL NUTRITION
HORMONAL TREATMENT FOR SHORT BOWEL SYNDROME
COMPLICATIONS ASSOCIATED WITH SHORT BOWEL SYNDROME
CONCLUSION
Suggested Reading
73 - Surgery for Gut Failure: Auto-Reconstruction and Allo-Transplantation
INTRODUCTION
GUT ADAPTATION
MEDICAL MANAGEMENT
SURGICAL REHABILITATION
Strategy
Autologous Reconstruction
Intestinal Lengthening
INTESTINAL AND MULTIVISCERAL TRANSPLANTATION
Types
Indications
Contraindications
Early Referral
Transplantation Surgery
Postoperative Management
Current Global Activities
Long-Term Survival
Allograft Function
Quality of Life
New Insights
SUMMARY
Suggested Reading
74 - Crohn Disease of the Duodenum, Stomach, and Esophagus
INTRODUCTION
CLINICAL PRESENTATION
INVESTIGATIONS IN UPPER GASTROINTESTINAL CROHN DISEASE
MEDICAL TREATMENT
ENDOSCOPIC TREATMENT
SURGERY
SUMMARY
Suggested Readings
75 - Management of Small Bowel Crohn Disease
INTRODUCTION
MEDICAL MANAGEMENT
INDICATIONS FOR SURGERY
PREOPERATIVE CONSIDERATIONS
OPERATIVE APPROACH
SURGICAL OPTIONS
Bypass
Resection
Strictureplasty
SPECIAL SITUATIONS
Medications
Abscess
Free Perforation
Hemorrhage
Growth Retardation
Fistula
Neoplasia
Obstruction
OUTCOME
SUMMARY
Selected Reading
76 - Small Bowel Neoplasms
INTRODUCTION
PRESENTATION
DIAGNOSIS
MANAGEMENT
Adenocarcinoma without Metastatic Disease
Carcinoid Tumors
Lymphomas
GIST Tumors
CONCLUSION
ACKNOWLEDGMENT
Suggested Readings
77 - Neuroendocrine Tumors of the Small and Large Intestine
DEFINITION
INCIDENCE, EPIDEMIOLOGY, AND RESEARCH
CLINICAL PRESENTATION
DIAGNOSIS
CLASSIFICATION
SURGICAL TREATMENT
Small Intestine
Appendix
Colon
Rectum
Locally Advanced and Metastatic Disease
Hedinger Syndrome
ADJUVANT THERAPY
FOLLOW-UP
PROGNOSIS
Suggested Reading
78 - Enterocutaneous Fistulas
INTRODUCTION
PATHOGENESIS
GENERAL ASPECTS OF CARE
COMPLICATIONS
PLAN OF CARE
Prevention
Stabilization
Wound Care
Nutritional Support
Nasogastric Tubes and Other Drainage Tubes
Protection of the Gastric, Duodenal, and Upper Gastrointestinal Tract Mucosa from Ulceration
Other Supplements
Investigation/Elucidation
Therapeutic Decisions
Will It Close?
The Decision to Operate
Definitive Therapy
Timing of Surgery
Surgery
Choice of Incision
The Operation Itself
Anastomosis
Abdominal Wound Closure
What Type of Operation Should One Undertake?
Gastrostomy and Feeding Jejunostomy
The Healing Phase
Fibrin Glue
Short Bowel Syndrome
PROGNOSIS
Suggested Reading
79 - Acute and Chronic Mesenteric Ischemia
INTRODUCTION
ACUTE MESENTERIC ISCHEMIA
Clinical Presentation
Evaluation
Treatment
SMA Embolus
SMA Thrombus
Mesenteric Venous Thrombosis
Nonocclusive Mesenteric Ischemia
Bowel Viability
Laparoscopy
CHRONIC MESENTERIC ISCHEMIA
Presentation
Evaluation
Operative Treatment
Angioplasty
CONCLUSION
Suggested Readings
80 - Radiation Enteritis and Proctocolitis
BACKGROUND
PATHOPHYSIOLOGY
PREDISPOSING RISK FACTORS
GRADING SYSTEMS
DIAGNOSTIC WORKUP
PREVENTION
MANAGEMENT OF RADIATION ENTERITIS
Management of Radiation Injury to the Small Bowel
Acute Radiation Enteritis
Chronic Radiation Enteritis
Management of Radiation Injury to the Colon
Acute Radiation Colitis
Chronic Radiation Colitis
Management of Radiation Injury to the Rectum
Topical Therapy
Hyperbaric Oxygen
Medical Therapy
Endoscopic Management
Surgery
CONCLUSION
Suggested Readings
5 - COMPLICATIONS (AND OTHER MISCELLANEOUS TOPICS)
81 - Colorectal Surgery in the High-Risk Patient
INTRODUCTION
IDENTIFICATION OF THE HIGH-RISK PATIENT
MINIMIZING RISK ASSOCIATED WITH EMERGENCY SURGERY
MINIMIZING RISK ASSOCIATED WITH CARDIAC DISEASE
MINIMIZING RISK ASSOCIATED WITH PULMONARY DISEASE
MINIMIZING RISK ASSOCIATED WITH IMMUNOSUPPRESSION
Steroids
Diabetes
Chemoradiotherapy
MINIMIZING RISK ASSOCIATED WITH MALNUTRITION
MINIMIZING RISK ASSOCIATED WITH HEPATIC DISEASE
MINIMIZING RISK ASSOCIATED WITH RENAL DISEASE
MINIMIZING RISK IN MORBIDLY OBESE PATIENTS
Suggested Reading
82 - Reoperative Pelvic Surgery
INTRODUCTION
ANATOMIC FACTORS
The Ureters
Presacral Veins
Pelvic Nerves
POSTOPERATIVE CHANGES IN THE PELVIS
Approach to Reoperative Pelvic Surgery
Preoperative Planning
Timing
Patient Preparation
Define the Anatomy
Anticipate and Prepare for a Difficult Case
Functional Considerations
Intraoperative Conduct
Patient Positioning
Optimizing Visibility and Exposure
Access to the Pelvis
Identification of Specific Pelvic Structures
Ureter
Bladder
Rectal Stump
Vagina
Autonomic Nerves
Control of Bleeding
Drainage
SPECIFIC CLINICAL SITUATIONS
Reversal of Hartmann Procedure for Diverticulitis
Recurrent Rectal Cancer
Redo Ileoanal Pelvic Pouch Procedure
SUMMARY
Suggested Reading
83 - Nutritional Support in Colorectal Surgery
INTRODUCTION
NUTRITIONAL ASSESSMENT
INDICATIONS FOR NUTRITIONAL SUPPORT
General Indications
Severe Malnutrition
Postoperative Nutrition
Specific CRS Indications
Inflammatory Bowel Disease
Colorectal Cancer
ESTIMATION OF NUTRIENT REQUIREMENTS
Calories
Protein
DIETARY COMPOSITION AND DELIVERY
Hospital-Based Diets
Clear Liquid Diet
Regular Diet
Low-Residue Diet
Oral Supplements
Liquid Formula Diets
Enteral Nutrition
Access for EN
Early Postoperative Feeding: “Fast Track”
Parenteral Nutrition
Access for PN
Concomitant EN and PN
Overfeeding
NEW DIRECTIONS
Immunonutrition
Preoperative Carbohydrate Loading
SUMMARY
Suggested Reading
84 - Prevention and Management of Sepsis
BACKGROUND
PREVENTION
Defining Risk
Preventive Measures
Bowel Preparation
Prophylactic Antibiotics
Intact Anastomosis
Tension-Free Anastomosis
Well-Vascularized Anastomosis
Consideration for Diversion
Appropriate Use of Drains
MANAGEMENT OF INTRA-ABDOMINAL SEPSIS
Goal-Directed Hemodynamic Support
Evaluation
Nonoperative Interventions
Operation versus Observation
Open Abdomen
Return to the Operating Room
Suggested Readings
85 - Management of Anastomotic Leak
INTRODUCTION
WHAT DEFINES A LEAK?
PRINCIPLES OF MANAGEMENT
EARLY DIAGNOSIS
IMAGING
CRP LEVELS
ENDOSCOPY
VARIABLES DIRECTING MANAGEMENT
Location: Intraperitoneal versus Extraperitoneal
Type of Anastomosis: Ileocolic versus Colorectal/Ileorectal
Symptoms: Sepsis versus Symptomatic versus Asymptomatic
Previously Diverted: Proximal Diverting Ostomy versus Nondiverted
LEAK MANAGEMENT TOOLS
ENDO-VACUUM ASSISTED CLOSURE
ENDOSCOPIC STENTS, CLIPS, AND GLUE
TRANSANAL REPAIR TECHNIQUES
TURNBULL-CUTAIT PULL THROUGH
SUMMARY
Suggested Reading
86 - Complications of Colonoscopy
INTRODUCTION
RISK MANAGEMENT
HEMORRHAGE
Steps Prior to Colonoscopy
Risk Factors for Bleeding
Prevention of Bleeding
Treatment of Bleeding
PERFORATION
Causes of Perforation
Diagnosis of Perforation
Management of Perforation
Suggested Readings
87 - Management of Hemorrhage during Pelvic Surgery
INTRODUCTION
PERTINENT ANATOMY
BLEEDING
TACTICS FOR CONTROL OF PELVIC BLEEDING
Major Vessel Bleeding
Iliac Vessels
Minor Vessel Bleeding
Presacral Bleeding
Pelvic Packing
Suture Ligation
Thumbtacks
Muscle Fragment Welding
Bipolar Electrocautery
Hemostasis Step-by-Step Technique
Hemostatic Agents
Mechanical Hemostatic Agents
Active Hemostatic Agents
Flowable Hemostatic Agents
Fibrin Sealants
CONCLUSION
Selected Reading
88 - Urologic Issues in Colorectal Surgery
INTRODUCTION
INFECTION
URETER
BLADDER
URETHRA
REPRODUCTIVE STRUCTURES
NERVES
BLOOD VESSELS
Suggested Readings
89 - Prevention and Treatment of Complications of Laparoscopic Colorectal Surgery
INTRODUCTION
GENERAL COMPLICATIONS
Contraindications
Peritoneal Access Complications
Pneumoperitoneum Complications
Thromboembolic Complications
Electrosurgical Complications
Positioning Complications
Bleeding Complications
Tumor Identification Difficulties
Contamination
Anastomosis Complications
Urologic Complications
CONCLUSIONS
Suggested Reading
90 - Prevention and Management of Ostomy Complications
INTRODUCTION
OSTOMY CREATION
Preoperative Discussion and Consent
Siting the Stoma
Creating and Maturing the Stoma
End Ileostomy
Loop Ileostomy
COMPLICATIONS
Early Complications
Appliance Issues/Skin Irritation
Ischemia
Stoma Stenosis
Retraction
Late Complications
Parastomal Hernia
Prolapse
Stricture
Peristomal Pyoderma
Parastomal Ulcer
Abscess and Fistula
SUMMARY
Suggested Reading
91 - Stoma and Wound Considerations: Nursing Management
PREOPERATIVE PREPARATION
Preoperative Counseling
Stoma Site Marking
POSTOPERATIVE MANAGEMENT
SPECIAL CONSIDERATIONS
Continent ileostomy
WOUND MANAGEMENT
POSTDISCHARGE FOLLOW-UP
COLOSTOMY IRRIGATION
ILEOSTOMY LAVAGE
CONCLUSION
Suggested Readings
92 - Measuring Outcomes
INTRODUCTION
TYPES OF OUTCOME MEASURES
Structural Measures
Process Measures
Outcome Measures
Person-Centered Outcomes
MEASURING QUALITY OF LIFE
Instruments for Assessing Quality of Life
Colorectal Cancer Care
Inflammatory Bowel Disease
Fecal Incontinence
Sexual Function
CONSIDERATIONS IN CHOOSING OUTCOME MEASURES
SUMMARY
Suggested Readings
93 - Medical Documentation and Coding for the Colorectal Surgeon
INTRODUCTION
PROCESS OF CPT CODE DEVELOPMENT
CPT CODING FOR EVALUATION AND MANAGEMENT SERVICES
Office Evaluation and Management Coding
HOSPITAL-BASED EVALUATION AND MANAGEMENT DOCUMENTATION AND CODING
CPT CODING FOR SURGICAL PROCEDURES
SUMMARY
Suggested Reading
94 - Enhanced Recovery Pathways After Colorectal Surgery
BACKGROUND
COMPONENTS OF EVIDENCE-BASED CARE
EVIDENCE FOR IMPROVED OUTCOME
Colonic Surgery
Rectal Surgery
Other Colorectal Procedures
IMPLEMENTATION STRATEGY AND TREATMENT ALGORITHM
Colonic Surgery Protocol
Rectal Surgery Protocol
THE WAY FORWARD
Suggested Readings
95 - Managing Complex Ventral/Parastomal Hernias in Colorectal Surgical Patients
INTRODUCTION
PERMANENT ENTEROSTOMY—PARASTOMAL HERNIA REPAIR
Open Repair
Laparoscopic Repair
TEMPORARY ENTEROSTOMY
PROSTHETIC CHOICE
HERNIA REPAIR IN INFLAMMATORY BOWEL DISEASE
CONCLUSION
Selected Reading
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
Z
IBC