ASCRS Manual of Colon and Rectal Surgery (eBook)

David E. Beck, MDLouisiana State University Health Sciences Center, Department of Colon and Rectal Surgery, New Orleans, LA, USA

Preface 5
Contents 6
Contributors 11
1. Anatomy and Embryology of the Colon, Rectum, and Anus 25
A. Anatomy 25
B. Embryology 47
2. Physiology: Colonic 54
A. Colonic Function 54
B. Colonic Motility 56
C. Defecation and Colonic Sensation 58
D. Disturbances in Colonic Physiology 59
E. Implications of Colonic Physiology for the Surgeon 61
3. Anal Physiology 63
A. Introduction 63
B. Pelvic Floor Muscles 63
C. Reflexes 64
D. Mechanical Factors of Continence and Defecation 66
E. Pathologic Conditions 68
F. Continence 69
4. Physiologic Testing 71
A. Introduction 71
B. Manometry 71
C. Defecography 83
D. Balloon Expulsion Test 87
E. Anal Ultrasound 87
F. Magnetic Resonance Imaging 88
G. EMG of the Anal Sphincter 89
H. Evaluation of Transit 91
5. Diagnostic Evaluations: Endoscopy: Rigid, Flexible Complications 94
A. Anoscopy 94
B. Rigid Proctosigmoidoscope 99
C. Flexible Sigmoidoscopy 101
D. Ileoscopy 103
E. Pouchoscopy 104
F. Colonoscopy 105
6. Diagnostic Evaluations: Radiology, Nuclear Scans, PET, CT Colography 113
A. Plain Films 113
B. Contrast Studies 121
C. Computed Tomography 133
D. Radionuclide Imaging 143
E. Arteriography 145
F. CT Colonography 146
G. Positron Emission Tomography (PET) 149
H. Magnetic Resonance Imaging (MRI) 152
7. Endoluminal Ultrasound 154
A. Introduction 154
B. Endoanal Ultrasound 166
8. Preoperative Management: Risk Assessment, Medical Evaluation, and Bowel Preparation 177
A. Perioperative Risk Assessment Scoring Systems 177
B. Preoperative Medical Evaluation 183
C. Bowel Preparation 190
D. Prophylactic Antibiotic Usage ( See Appendix 2) 193
E. Prophylaxis for Endocarditis and Prosthesis 194
F. Communication with the Patient and Laying the Groundwork for Postoperative Recovery 194
G. Conclusion 194
Appendix 1: Practice Parameters for the Prevention of Venous Thromboembolism 195
Appendix 2: Practice Parameters for Antibiotic Prophylaxis to Prevent Infective Endocarditis or Infective Prosthesis During Colon and Rectal Endoscopy 196
9. Postoperative Management: Pain and Anesthetic, Fluids and Diet 199
A. Pain Control 199
B. Perioperative Fluid Management 205
C. Ulcer Prophylaxis 205
D. DVT Prophylaxis 207
E. Duration 210
F. Anticoagulation 211
G. Diet 211
H. Steroids 213
I. Clinical Pathways 215
10. Postoperative Complications 216
A. Unrecognized Enterotomies and Enterocutaneous Fistulae 216
B. Anastomotic Complications 218
C. Genitourinary Complications 224
D. Pelvic Bleeding 236
11. Benign Anorectal: Hemorrhoids 241
A. Anatomy 241
B. Etiology 243
C. Epidemiology 244
D. Classification 244
E. Symptoms 244
F. Differential Diagnosis 246
G. Examination 248
H. Treatment 249
I. Strangulated Hemorrhoids 267
J. Hemorrhoids, Varices, and Portal Hypertension 268
K. Hemorrhoids in Pregnancy 268
L. Hemorrhoids and Crohn’s Disease 269
M. Hemorrhoids and the Immunocompromised 269
N. Posthemorrhoidectomy Hemorrhage 269
Appendix: Practice Parameters for Ambulatory Anorectal Surgery 270
Ambulatory Facilities 270
Preoperative Evaluation 271
Intraoperative Considerations 272
Postoperative Considerations 272
12. Benign Anorectal: Anal Fissure 274
A. Epidemiology 274
B. Etiology 274
C. Symptoms 276
D. Diagnosis 276
E. Management 277
F. Special Situations 286
13. Benign Anorectal: Abscess and Fistula 288
A. Introduction 288
B. Abscess 288
C. Fistula-in-Ano 301
D. Rectourethral Fistulas 319
Appendix: Practice Parameters for Treatment of Fistula- in- Ano 321
Acute Suppuration (Abscess) 321
Chronic Suppuration (Fistula) 322
Special Considerations 323
14. Benign Anorectal: Rectovaginal Fistulas 325
A. Etiology 325
B. Evaluation 326
C. Classification 327
D. Conservative Management 328
E. Surgical Techniques 328
Choice of Treatment 333
15. Pilonidal Disease and Hidradenitis Suppurativa 338
A. Pilonidal Disease 338
B. Hidradenitis Suppurativa 351
16. Perianal Dermatology and Pruritus Ani 356
A. Introduction 356
B. Definitions 356
C. Physiologic Considerations 358
D. Etiology of Pruritus 359
E. Diagnosis of Perianal Disease 365
F. Treatment of Pruritus Ani 369
17. Sexually Transmitted Diseases 375
A. Introduction 375
B. Overview of Anorectal Immunology 376
C. Diagnosis and Management of Bacterial Pathogens 377
D. Diagnosis and Management of Viral Pathogens 381
18. Benign Colon: Diverticular Disease 391
A. Introduction 391
B. Incidence 391
C. Pathophysiology 392
D. Etiology 393
E. Epidemiology 394
F. Clinical Manifestations 395
G. Natural History 398
H. Presenting Symptoms 398
I. Physical Findings 399
J. Complications 400
H. Diagnostic Tests 402
I. Differential Diagnosis 404
J. Uncommon Presentations 407
K. Treatment 410
Appendix: Practice Parameters for the Treatment of Sigmoid Diverticulitis 419
19. Colonic Volvulus 420
A. Introduction/Historical Perspective 420
B. Cecal Volvulus 421
C. Transverse Colon Volvulus 425
D. Splenic Flexure Volvulus 428
E. Sigmoid Volvulus 429
F. Ileosigmoid Knotting 436
20. Lower Gastrointestinal Hemorrhage 438
A. Introduction 438
B. Etiologies 439
C. Initial Assessment, Resuscitation, and Stabilization 442
D. New Frontiers 449
21. Endometriosis 450
A. Introduction 450
B. Epidemiology 450
C. Etiology 451
D. Clinical Manifestations 451
E. Diagnosis 453
F. Treatment 455
22. Colon and Rectal Trauma and Rectal Foreign Bodies 460
A. Colon Injuries 460
B. Operative Management 462
C. Technique of Colon Repair 467
D. Rectal Injuries 468
E. Operative Management 469
F. Wound Management 471
G. Antibiotic Prophylaxis 471
H. Trauma Ostomy Complications 471
I. Rectal Foreign Bodies 472
23. Colorectal Cancer: Epidemiology, Etiology, and Molecular Basis 473
A. Epidemiology 473
B. Etiology 478
C. Molecular Basis 487
24. Screening for Colorectal Neoplasms 495
A. Introduction 495
B. Classification of Risk and Screening Recommendations 496
C. Future Directions 505
25. Polyps 507
A. Introduction 507
B. Adenomas 507
C. Nonneoplastic Polyps 519
26. Polyposis Syndromes 522
A. Familial Adenomatous Polyposis 522
B. Polyposis Registries 522
C. Features of FAP 523
D. Genetics 525
E. Clinical Variants of FAP 527
F. Diagnosis 528
G. Management of the Large Bowel 530
H. Upper Gastrointestinal Polyposis 532
I. Desmoid Disease 534
J. Peutz-Jeghers Syndrome 537
K. Clinical Issues 538
L. Management 538
M. Juvenile Polyposis 539
N. Genetics 540
O. Cancer Risk and Management 540
P. Other Juvenile Polyposes 540
Q. Metaplastic Polyposis 541
R. Cronkhite-Canada Syndrome 541
27. Colon Cancer Evaluation and Staging 543
A. Introduction 543
B. Clinical Presentation 543
C. Staging and Prognostic Factors 544
D. Clinical Prognostic Factors 545
E. Histologic/Biochemical/Genetic Factors 547
F. Spreading Patterns 549
Appendix: Practice Parameters for the Detection of Colorectal Neoplasms 553
28. Surgical Management of Colon Cancer 562
A. Preoperative Preparation 562
B. Surgical Technique 563
C. Special Circumstances 566
D. Sentinel Node Assessment 568
E. Outcome of Colectomy for Colon Cancer 568
Appendix: Practice Parameters for Colon Cancer 568
29. The Preoperative Staging of Rectal Cancer 572
A. Introduction 572
B. Clinical Evaluation 572
C. Local and Regional Staging 573
D. Distant Metastases 576
30. Surgical Treatment of Rectal Cancer 578
A. Introduction 578
B. Evaluation of the Patient with Rectal Cancer 578
C. Imaging for Rectal Cancer 580
D. Preparation of the Rectal Cancer Patient for Surgery 582
E. Anatomic and Biologic Issues 583
F. Surgical Procedures: Principles 584
G. Techniques of Rectal Excision 588
H. Local Excision 595
I. Technique 596
Appendix: Practice Parameters for the Treatment of Rectal Carcinoma 608
31. Adjuvant Therapy for Colorectal Cancer 612
A. Colon Cancer 612
B. Rectal Cancer 615
32. Colorectal Cancer Surveillance 620
A. Introduction 620
B. Types of Surveillance 620
C. Risk of Recurrence/Pattern of Recurrence 622
D. Surveillance Effectiveness 623
E. Cost of Surveillance 624
F. Quality of Life 625
G. Recommendations 625
33. Management of Locally Advanced and Recurrent Rectal Cancer 627
A. Introduction 627
B. Determining Resectability 630
C. Multimodality Therapy for Advanced or Locally Recurrent Rectal Cancer 631
D. Surgery 632
E. Use of IORT 633
F. Results of Multimodality Treatment for Advanced Primary or Locally Recurrent Rectal Cancer 633
G. Palliative Care for Advanced or Recurrent Rectal Cancer 634
34. Colorectal Cancer: Metastatic ( Palliation) 636
A. Introduction 636
B. Biology of Metastatic Disease 637
C. Diagnosis/Staging 639
D. Multidisciplinary Evaluation 640
E. Palliative Management of the Primary Cancer: Stents, Laser 640
F. Surgical Management of the Primary Cancer: Resection 642
G. Liver Metastasis 644
H. Natural History of Untreated Liver Metastases 644
I. Lung Metastasis 652
J. Peritoneal Metastasis 653
K. Ovarian Metastasis 654
L. Bone and Brain Metastases 655
35. Anal Cancer 656
A. New Anatomic Considerations 656
B. Terminology 658
C. Lymphatic Drainage 658
D. Etiology and Pathogenesis of Anal Dysplasia and Anal SCC 659
E. Epidemiology 661
F. Bowen’s Disease 661
G. SCC of the Anal Margin 662
H. SCC of the Anal Canal 667
I. Uncommon Anal Canal Neoplasms 672
J. Uncommon Anal Margin/Perianal Neoplasms 674
K. HIV-related Anal Cancer 676
36. Presacral Tumors 678
A. Introduction 678
B. Anatomy and Neurophysiology 678
C. Classification 681
D. Diagnosis and Management 686
E. Surgical Treatment 692
F. Results of Treatment 698
G. Algorithm 699
H. Conclusion 699
37. Miscellaneous Neoplasms 701
A Carcinoids 701
B. Local Symptoms 704
C. Systemic Symptoms and the Carcinoid Syndrome 704
D. GI Stromal Tumors 712
E. Leiomyomas 713
F. Squamous and Adenosquamous Carcinoma 713
G. Lymphomas 713
H. Colonic Complications of Leukemia 714
38. Hereditary Nonpolyposis Colon Cancer 716
A. Introduction 716
B. Genetics 717
C. Pathologic Features 720
D. Clinical Features of HNPCC 720
E. Genotype–Phenotype Relationships 722
F. Diagnosis 722
G. Genetic Testing 724
H. Registries 726
I. Surveillance 727
J. Treatment 727
K. Prognosis 728
L. Chemoprevention 728
Appendix 1: Practice Parameters for the Identifica-tion and Testing of Patients at Risk for Dominantly Inherited Colorectal Cancer 728
Appendix 2: Practice Parameters for the Treatment of Patients with Dominantly Inherited Colorectal Cancer ( FAP and Hereditary Nonpolyposis Color-ectal Cancer) 729
Section 1. Familial Adenomatous Polyposis 730
Section II: HNPCC 738
39. Inflammatory Bowel Disease: Diagnosis and Evaluation 742
A. Epidemiology 742
B. Signs and Symptoms 744
C. Disease Severity Assessment 747
D. Evaluation 749
E. Endoscopy 752
F. Pathology 755
40. Medical Management of Infl ammatory Bowel Disease 760
A. Introduction 760
B. Medical Management of Crohn's Disease 761
C. Medical Management of UC 767
41. Surgical Management of Ulcerative Colitis 774
A. Indications for Surgery 774
B. Emergency Versus Elective Procedures 775
C. Brooke Ileostomy 777
D. Continent Ileostomy 778
E. Ileorectal Anastomosis 779
F. Ileal Pouch–Anal Anastomosis 781
42. Surgery for Crohn’s Disease 789
A. Introduction 789
B. Etiology and Incidence 789
C. Disease Classification 790
D. Operative Indications 791
E. Operative Considerations 793
F. Operative Options 794
G. Specific Anatomic Locations 795
H. Special Circumstances 798
43. Less-Common Benign Disorders of the Colon and Rectum 801
A. Ischemic Colitis 801
B. Collagen Vascular-Associated Colitis 803
C. Microscopic Colitis 807
D. Eosinophilic Colitis 809
E. Fungal Colitis 809
F. Histoplasmosis 810
G. Cryptococcus 810
H. Bacterial Colitis 811
I. Escherichia coli 813
J. Shigella 814
K. Salmonella 815
L. Campylobacter 816
M. Yersinia 816
N. Tuberculosis 817
O. Neisseria gonorrhea 818
P. Syphilis 819
Q. Aeromonas 819
R. Brucellosis 820
S. Actinomycosis 820
T. Miscellaneous Colitis 821
U. Viral Colitis 824
V. Parasitic Colitis 825
W. AIDS Diarrhea 830
X. Radiation-Induced Bowel Injury 831
Y. C. difficile Colitis 835
44. Intestinal Stomas 838
A. Introduction 838
B. Indications for an Ostomy 838
C. Stoma Physiology 839
D. Preoperative Considerations 843
E. End Ostomies 844
F. Diverting Stomas 845
G. Minimally Invasive Stomas 849
H. Technical Tips for Difficult Stomas 850
I. Outcome and QOL 851
45. Stoma Complications 852
A. Introduction 852
B. Incidence 852
C. Skin Problems 853
46. Incontinence 861
A. Introduction 861
B. Symptoms 862
C. Causes of Incontinence 864
D. Physical Examination 867
E. Anal Manometry 869
F. Defecography 870
G. Endosonography 870
H. Magnetic Resonance Imaging 870
I. Pudendal Nerve Latency Time 871
J. Sensation Test 871
K. Endoscopy 871
L. Treatment 871
M. Conclusion 877
47. Rectal Prolapse 878
A. Introduction 878
B. Patient Evaluation 879
C. Surgical Procedures 881
48. Constipation and Irritable Bowel Syndrome 898
A. Introduction 898
B. Etiology 898
C. Evaluation 900
D. Medical Treatment of Constipation 902
E. Colonic Inertia 904
F. Irritable Bowel Syndrome 905
49. Pelvic Floor Disorders 909
A. Rectoceles 909
B. Pelvic Pain Syndromes 911
50. Laparoscopy 915
A. Learning Curve 915
B. Conversions 915
C. Outcomes 916
D. Operative Time 916
E. Return of Bowel Activity and Resumption of Diet 917
F. Postoperative Pain and Recovery of Pulmonary Function 917
G. Length of Stay 917
H. Quality of Life and Return to Work 917
I. Hospital Costs 918
J. Crohn’s Disease 918
K. Ulcerative Colitis 919
L. Diverticulitis 921
M. Rectal Prolapse 923
N. Colorectal Cancer 925
O. Laparoscopic Resection of Colon and Rectal Cancer 925
P. Training and Credentialing in Laparoscopic Colorectal Surgery 930
Q. Hand-Assisted Laparoscopy 930
51. Pediatric: Hirschsprung’s, Anorectal Malformations, and Other Conditions 931
A. Hirschsprung’s, Disease 931
B. Anorectal Malformations (Imperforate Anus) 935
C. Medical Management of Fecal Incontinence 942
D. Other Pediatric Colorectal Disorders 944
52. Healthcare Economics 947
A. Introduction 947
B. The Reimbursement Process 947
C. The Future 955
53. Ethical and Legal Considerations 958
A. Considerations for Surgeons 958
B. Principles of Bioethics 961
C. Legal Principles 963
D. A Familiar Case-Management System 964
E. Specific Dilemmas of Colon and Rectal Surgery 965
F. Categories of Patient Encounters 966
G. Autonomy/Decision-Making Capacity/ Competency 967
H. Telling the Truth/Disclosing Errors 968
I. Patients with Impaired Decision-Making Capacity 969
J. Advance Directives 970
K. Informed Consent 972
L. Patient-Surgeon Relationship 975
M. Communication and the Internet 975
N. Using Newly Deceased Patients for Teaching Purposes 976
O. Special Concerns for Participation in Research/ Innovation 976
P. Placebo Surgery 977
Q. Conflict of Interest: Industry and Drug Money 977
R. Confidentiality 978
S. Making and Managing a Genetic Diagnosis 978
T. Abuse of the Elderly 978
U. Futility/Withholding Treatment 979
V. DNR and the Need for Surgery 979
W. Withdrawal of Treatment 980
X. Euthanasia/Physician-Assisted Suicide/ Terminal Sedation 980
Y. Applying the Principles 981
Z. Palliative Care/Hospice 982
AA. Pain Relief and the Doctrine of "Double Effect" 982
AB. Determination of Death 984
AC. Organ Donation 984
AD. Ethics/Legal Consultation 985
AE. Good Samaritan 985
AF. Previous Suboptimal Care 986
AG. ÏBlowing the WhistleÓ and Going to Court 986
AH. Personal Challenges: Competition of Interests 986
54. Critically Reviewing the Literature for Improving Clinical Practice 988
A. Study Designs: Case Series, Case Control, Cohort, and RCTs 988
B. Levels of Evidence: Grading the Evidence 992
C. Assessing the Best Evidence 993
D. Critically Evaluating the Literature (How to…) 998
55. Surgical Education: A Time for Change 1004
A. Introduction 1004
B. Cognitive Learning 1004
C. Technical Skills Acquisition 1005
D. Educational Challenges 1005
E. New Directions 1006
F. Technology and Efficiency 1008
56. Legal Considerations 1009
A. Introduction 1009
B. Medical Malpractice 1009
C. Informed Consent 1011
D. Documentation 1013
E. Communication 1015
Index 1019