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Colorectal Surgery E-Book

Colorectal Surgery E-Book

Robin K. S. Phillips | Sue Clark

(2013)

Additional Information

Abstract

Colorectal Surgery meets the needs of surgeons in higher training and practising consultants for a contemporary and evidence-based account of this sub-specialty that is relevant to their general surgical practice. It is a practical reference source incorporating the most current information on recent developments, management issues and operative procedures. The text is thoroughly referenced and supported by evidence-based recommendations wherever possible, distinguishing between strong evidence to support a conclusion, and evidence suggesting that a recommendation can be reached on the balance of probabilities.

This is a title in the Companion to Specialist Surgical Practice series whose eight volumes are an established and highly regarded source of information for the specialist general surgeon.

  • The Companion to Specialist Surgical Practice series provides a current and concise summary of the key topics within each major surgical sub-specialty.
  • Each volume highlights evidence-based practice both in the text and within the extensive list of references at the end of every chapter.
  • An expanded authorship team across the series includes additional European and World experts with an increased emphasis on global practice.
  • The contents of the series have been extensively revised in line with recently published evidence.
  • New techniques, such as percutaneous and transcutaneous tibial nerve stimulation for faecal incontinence as well as extralevator abdomino-perineal excision, are fully covered.

Table of Contents

Section Title Page Action Price
Front Cover Cover
Colorectal Surgery: A Companion to Specialist Surgical Practice iii
Copyright iv
Contents v
Contributors vii
Series Editors' preface ix
Editors' preface xi
Acknowledgements xi
Evidence-based practice in surgery xiii
Chapter 1: Anorectal investigation 1
Introduction 1
Anatomy and physiology of the anal canal 1
Rectoanal inhibitory reflex 2
Manometry 3
Ambulatory manometry 5
Anal and rectal sensation 5
Rectal compliance 6
Pelvic floor descent 6
Electrophysiology 6
Electromyography 7
Pudendal nerve terminal motor latency 7
Spinal motor latency 7
Defecography/evacuation proctography 8
Dynamic pelvic MRI 8
Dynamic transperineal and three-dimensional pelvic floor ultrasound 8
Scintigraphy 9
Imaging the rectum and anal sphincters 9
Anal endosonography/endorectal ultrasound 9
Endocoil receiver MRI 9
Imaging in rectal cancer 10
Imaging in anal sepsis and anal fistulas 11
Imaging in faecal incontinence 11
Summary 13
References 13
Chapter 2: Colonoscopy and flexible sigmoidoscopy 17
Introduction 17
Indications and contraindications 17
Flexible sigmoidoscopy vs. colonoscopy 17
Contraindications 17
Sedation 17
Insertion technique 18
Handling and scope control 18
Insertion and steering 18
Tips for insertion and steering 18
Patient position change 19
Abdominal hand pressure 19
Three-dimensional imager 19
Withdrawal technique 19
Withdrawal time 19
Optimal examination technique 20
Bowel preparation 21
Position change 21
Antispasmodics 21
Rectal retroflexion 21
Quality assurance 21
Endoscopy training in the UK 21
New optical techniques in endoscopy 22
Chromoendoscopy 22
Narrow band imaging (NBI) 23
High-magnification endoscopy 23
Retrograde viewing devices 23
Confocal laser endomicroscopy 23
Endoscopic therapy 24
Basic therapy 24
Polypectomy 24
Endoscopic mucosal resection (EMR) 24
Lower gastrointestinal (GI) bleeding investigation 25
Colonic decompression 25
Advanced therapy 26
Endoscopic submucosal dissection (ESD) 26
Stricture dilatation and stenting 26
Natural orifice transluminal endoscopic surgery (NOTES) 26
Competing technologies 26
Computed tomography colonography (or virtual colonoscopy) 27
Self-propelling colonoscopes 27
Colon capsule 27
Conclusions 27
References 28
Chapter 3: Inherited bowel cancer 32
Introduction 32
Assessment of risk 32
Chapter 4: Colonic cancer 49
Introduction 49
Natural history 49
Direct spread 50
Lymphatic spread 50
Blood-borne spread 50
Transcoelomic spread 50
Aetiology 51
Genetic factors 51
Diet and lifestyle 52
Predisposing conditions 52
Presentation 52
Investigation 52
Screening 53
Surveillance after adenoma detection 54
Elective surgery 54
Preparation for surgery 54
Blood transfusion 54
Bowel preparation 55
Thromboembolism prophylaxis 55
Antibiotic prophylaxis 55
Bladder catheterisation 56
Resection 56
Splenic flexure carcinoma 56
Advanced tumours 57
Operative technique 57
Right hemicolectomy 57
Left hemicolectomy 58
Anastomosis 58
Appositional serosubmucosal anastomosis 58
Stapled anastomoses 59
Results of anastomotic techniques 59
Drains 60
Postoperative care/complications 60
Anastomotic dehiscence 60
Management of the polyp cancer 61
Emergency management 61
Investigation 61
Management of obstruction 61
Management of perforation 63
Management of advanced disease 63
Operable metastases 63
Inoperable disseminated disease 63
Pathological staging 64
Recommendations for best practice 65
References 66
Chapter 5: Rectal cancer 69
Introduction 69
Objectives of surgery 69
In-hospital mortality 70
Local recurrence 70
Magnetic resonance imaging in assessment of circumferential resection margin and the role of preoperative radiotherapy 71
Complications of preoperative radiotherapy 71
Downstaging rectal cancer with preoperative radiotherapy 71
MRI can predict T stage and CRM status 72
Tumour disruption 72
Extent of excision – TME versus mesorectal transection, pelvic lymphadenectomy and level of vascular ligation 73
Tme 73
Lateral pelvic lymph nodal involvement 74
High versus low inferior mesenteric artery ligation 74
Implantation of viable cells 74
Quality of life 74
Preservation of continence by restorative resection 75
Distal clearance margin 75
Tumour height – the importance of rectal palpation (PR) 76
Quality of the anal function 76
Abdominoperineal excision 76
Reconstruction (colonic pouch, end-to-side or end-to-end anastomosis) 77
Sexual and urinary disturbance 77
Temporary defunctioning stomas 77
Follow-up 77
Synchronous tumours 78
Metachronous tumours 78
Surveillance for local and distant recurrence 78
The way forward 78
References 78
Chapter 6: Adjuvant therapy for colorectal cancer 82
Introduction 82
Adjuvant chemotherapy for colorectal cancer 82
Refining the role of fluoropyrimidine chemotherapy 82
Oral fluoropyrimidine therapy 83
Doublet chemotherapy 83
Addition of ‘targeted’ therapy to chemotherapy 85
Patient selection for adjuvant chemotherapy 85
Acute and long-term toxicity 85
Timing and duration of chemotherapy 86
Adjuvant therapy for rectal cancer 86
Radiotherapy 86
Evidence base for the use of adjuvant radiotherapy in resectable rectal cancer 87
Short-course radiotherapy and TME 87
Preoperative concurrent chemoradiotherapy 88
Short-course radiotherapy or preoperative CRT? 88
Short-course radiotherapy and delay to surgery 89
Late toxicity and second malignancy 89
Patient selection 89
Sphincter preservation 89
Organ preservation 89
Conclusion 91
References 92
Chapter 7: Anal cancer 95
Introduction 95
Epidermoid tumours 95
Aetiology and pathogenesis 95
Premalignant lesions 96
Histological types 97
Patterns of spread 97
Clinical presentation 97
Investigation 98
Clinical staging 98
Treatment 98
Historical 98
Current 98
Radiation-alone therapy 98
Chemo-irradiation therapy (combined modality therapy) 99
Role of surgery today 100
Initial diagnosis 100
Lesions at the anal margin 100
Treatment complications and disease relapse 100
Inguinal metastases 101
Treatment of intraepithelial neoplasia 101
Rarer tumours 101
Adenocarcinoma 101
Malignant melanoma 102
References 102
Chapter 8: Diverticular disease 103
Historical perspectives 103
Anatomical and physiological perspectives 103
Incidence and geographical differences 103
Race and geography 103
Age and gender 104
Diet 104
Aetiology and pathogenesis 104
Lifestyle 104
Smoking 105
Non-steroidal anti-inflammatory drugs (NSAIDs) 105
Diverticulitis 105
The extent of the problem 105
Classification 105
Segmental colitis associated with diverticulosis 106
Diagnosis and imaging 106
Treatment 108
Conservative and medical options 108
Emergency surgery 110
Historical perspectives 110
Laparoscopic peritoneal lavage for generalised purulent peritonitis 110
Resection with primary anastomosis 111
Elective resection: facts, fiction and functional outcome 111
Diverticular haemorrhage 113
References 114
Chapter 9: Ulcerative colitis 119
Introduction 119
Epidemiology 119
Aetiopathogenesis 119
Clinical presentation 120
Extraintestinal manifestations 120
Musculoskeletal 120
Hepatopancreatobiliary 121
Dermatological 121
Thromboembolic 121
Ophthalmological 121
Diagnosis and evaluation 122
Microbiology 122
Endoscopy 122
Histopathology 122
Imaging 123
Colorectal cancer and surveillance 123
Severity assessment 124
Medical management 125
Proctitis 125
Mild to moderate distal colitis 125
Mild to moderate extensive colitis 126
Severe colitis 126
Surgical management 126
Emergent/urgent 127
Elective 128
Proctocolectomy with end ileostomy 128
Proctocolectomy with continent ileostomy 128
Ileorectal anastomosis 129
Restorative proctocolectomy/ileal pouch–anal anastomosis (IPAA) 129
Double-stapled technique 130
Hand-sewn technique 130
Outcomes in stapled versus hand-sewn anastomosis 130
Complications following pouch surgery 133
Functional outcomes 136
References 137
Chapter 10: Crohn's disease 141
Introduction 141
Epidemiology 141
Aetiology 141
Smoking and oral contraception 141
Infection 142
Genetic 142
Pathogenesis 142
Pathology 142
Distribution 142
Macroscopic appearance 143
Microscopy 143
Pitfalls in differentiating Crohn's colitis from ulcerative colitis 143
Clinical 144
Gastrointestinal symptoms 144
Systemic symptoms 144
Extraintestinal manifestations 144
Physical signs 145
Paediatric age group 145
Pregnancy 145
Investigations 146
Laboratory 146
Radiology 146
Endoscopy 148
Disease activity assessment and quality of life 148
Phenotyping 148
Differential diagnosis 148
Small-bowel Crohn's disease 148
Large-bowel Crohn's disease 149
Medical treatment 149
Multidisciplinary care 150
Aminosalicylates 150
Steroids 150
Antibiotics 151
Nutrition for therapy 151
Immunomodulatory therapy 151
‘Biological agents’ 151
Surgery and immunosuppression 152
Prophylaxis against recurrent disease after surgery 153
Other drugs 153
Surgery 153
Development of surgery 153
Risk of operation and re-operation 153
Risk factors for recurrence 154
Principles of surgery for Crohn's disease 154
Perioperative considerations 154
Technique 154
Surgery for small-bowel and ileocolic Crohn's disease 155
Indications 155
Gastroduodenal disease 155
Ileocolic disease 155
Ileal and jejunal multisite disease 156
Fistulas and abscesses 156
Enterocutaneous fistulas and intra-abdominal abscess 156
Management principles 157
Spontaneous enterocutaneous fistulas 157
Postoperative fistulas 157
Intra-abdominal fistulas 157
Spontaneous free perforation in the small bowel or colon 158
Surgery for colonic and rectal Crohn's disease 158
Indications 158
Emergency colectomy and colectomy and ileostomy 158
Segmental colectomy 158
Total colectomy and ileorectal anastomosis 158
Panproctocolectomy 159
Restorative proctocolectomy 160
Crohn's colitis and cancer 160
Perianal disease 160
Investigation 161
Medical treatment 161
Anal fissure 161
Abscesses 161
Anal fistulas 161
Rectovaginal fistulas 162
Defunctioning ileostomy for perianal disease 162
Long-term complications of perianal disease 162
Prognosis 162
References 163
Chapter 11: Incontinence 167
Introduction 167
Aetiology 167
Sphincter injury 167
Rectal compliance 169
‘Idiopathic’ faecal incontinence 169
Presentation 170
History 170
Examination 170
Investigations 171
Management of faecal incontinence in adults 171
Conservative measures 172
Dietary modification and medications 172
Biofeedback, pelvic floor muscle training and electrostimulation 172
Anal plug 173
Surgery 173
Sphincteroplasty 173
Pelvic floor repair (postanal, preanal or total) 174
Sphincter reconstruction – muscle transposition 174
Artificial sphincters 174
Artificial bowel sphincter 174
Magnetic anal sphincter 176
Sacral nerve stimulation 177
Percutaneous and transcutaneous tibial nerve stimulation 178
Injection therapy 179
Stoma 179
Antegrade continence enema 179
End stoma 179
Conclusion 180
References 181
Chapter 12: Functional problems and their surgical management 184
Introduction 184
Rectal prolapse 184
Mucosal prolapse 184
Full-thickness rectal prolapse (see Table 12.1) 185
Choice of surgical approach 185
Perineal approaches 185
Abdominal approaches 185
Laparoscopic approaches 188
The PROSPER trial 189
Recurrent rectal prolapse 190
Obstructive defecation, rectocele and rectal intussusception 190
Rectocele 190
Rectal intussusception 191
Laparoscopic ventral rectopexy 193
Stapled transanal rectal resection (STARR) 193
The external pelvic rectal suspension (EXPRESS) procedure 195
Solitary rectal ulcer syndrome (SRUS) 196
References 197
Chapter 13: Functional problems and their medical management 202
Introduction 202
Irritable bowel syndrome 202
Investigation 203
Treatment 203
Lifestyle modification 203
Pharmacological treatments 203
Psychological treatments 204
Surgery 204
Functional constipation 204
Investigation 205
Treatment 205
Dietary fibre supplementation 205
Laxatives, suppositories, enemas and novel prokinetics 205
Behavioural therapy (biofeedback) 206
Surgical treatment for constipation 206
Putative treatments for constipation 207
Idiopathic megarectum and megacolon 208
References 209
Chapter 14: Anal fistula: evaluation and management 212
Introduction 212
Aetiology 213
Management of acute sepsis 214
Classification of anal fistula 216
Assessment 217
Clinical 217
Imaging 219
Physiological 220
Principles of fistula surgery 221
Surgical treatment 221
Fistulotomy 221
Fistulotomy and immediate reconstitution 223
Fistulectomy 223
Setons 223
The loose seton 223
The tight seton 224
The chemical seton 225
Advancement flaps 225
Intersphincteric approaches 226
Plugs and glues ( Table 14.1) 226
Fibrin glue 226
Bioprosthetic plugs 227
Management of the recurrent fistula 227
References 228
Chapter 15: Minor anorectal conditions 231
Haemorrhoids 231
Pathogenesis and aetiology 231
Management 232
Non-prolapsing or mildly prolapsing haemorrhoids 232
Rubber-band ligation 232
Injection sclerotherapy 233
Other methods 233
Irreducible prolapsed piles 233
Stapled haemorrhoidectomy (haemorrhoidopexy) 234
Transanal haemorrhoidal dearterialisation 234
Postoperative problems 235
Sepsis after treatment of haemorrhoids 235
Conclusion 236
Anal fissure 236
Clinical findings 236
Aetiology and classification 237
Initiating factors 237
Perpetuating factors 238
From ‘acute vs. chronic’ to ‘superficial vs. deep’ anal fissure 238
Medical treatment 239
Surgical treatment 240
Recurrent or atypical fissures 240
Conclusion 241
Pruritus ani 241
Aetiology and pathogenesis 241
Diagnosis 242
Treatment 242
Conclusion 242
Pilonidal sinus 242
Aetiology 242
Clinical manifestation 243
Treatment 243
Pilonidal abscess 243
Chronic pilonidal sinus 243
Outpatient options 243
Inpatient options 244
Recurrent pilonidal sinus 244
Conclusion 245
Anal stenosis 245
Aetiology 246
Clinical presentation 246
Treatment 246
Prevention 246
Anal dilatation 246
Sphincterotomy 247
Stricturoplasty 247
Flap procedures 247
Mucosal advancement flap (above to down) 247
Y-V advancement flap (outside to in) 248
V-Y advancement flap (outside to in) 248
Island advancement flap (outside to in) 248
S-anoplasty (outside to in) 248
Conclusion 248
Dietary fibre – more harm than good? 248
References 249
Chapter 16: Sexually transmitted diseases and the anorectum 253
Introduction 253
Viral 253
Human immunodeficiency virus 253
Herpes simplex virus 256
Human papillomavirus 257
Buschke–Lowenstein tumour: giant anal condyloma 260
Molluscum contagiosum 260
Bacterial 261
Chlamydia trachomatis and Lymphogranuloma venereum (LGV) 261
Chancroid 262
Neisseria gonorrhoeae 262
Granuloma inguinale (Donovanosis) 263
Syphilis 264
Empirical treatment 265
References 266
Chapter 17: Minimally invasive surgery and enhanced recovery programmes in colorectal disease 269
Introduction 269
Outcomes of laparoscopic colorectal surgery 269
Oncological outcomes 269
Hospital stay and complications 270
Blood loss 271
Mortality 271
Economic considerations 271
Conversion to open surgery 271
The definition of conversion 271
Predicting the risk of conversion 272
Outcome after conversion 273
Benign colorectal conditions suitable for laparoscopic surgery 273
Laparoscopic colorectal technique 274
Difficult aspects of laparoscopic resection 276
The learning curve and training in laparoscopic colorectal surgery 277
Future developments 278
Transanal endoscopic surgery 278
Summary 279
Enhanced recovery programmes 280
Traditional perioperative care 280
Perioperative interventions in enhanced recovery programmes 281
Reducing metabolic stress 281
Preoperative bowel preparation 281
Perioperative fluid balance 281
Surgical technique and wound drainage 282
Mobilisation 282
Pain control 282
Enhanced recovery trials 282
ERPs applied to laparoscopic surgery 283
Who should have ER care? 283
Starting an ERP 283
Summary 283
References 284
Chapter 18: Intestinal failure 289
Introduction 289
Intestinal failure: criteria for referral 290
Epidemiology 290
Causes 290
Loss of intestinal length 290
Loss of functional absorptive capacity 291
Loss of intestinal absorptive capacity 291
Loss of intestinal function 291
Pathophysiology 291
The three stages of intestinal failure 291
Stage I: hypersecretory phase 291
Stage II: adaptation phase 292
Stage III: stabilisation phase 292
Fluid and electrolytes 292
Nutrients 292
Carbohydrates, proteins and water-soluble vitamins 292
Fat, bile salts and fat-soluble vitamins 292
Adaptation 293
Role of the colon in SBS 293
Surgical catastrophe and management 293
Resuscitation 294
Restitution 294
Sepsis 294
Nutrition 294
Fluid and electrolytes 294
Nutritional support 294
Reduction of output 295
Dietary modification 295
Outcome aims and monitoring 296
Total parenteral nutrition 297
Anatomy (mapping) 297
Protection of skin 297
Planned surgery 298
Reconstruction 298
Enterocutaneous fistula 299
Rehabilitation 299
Transplantation 300
Supporting organisations 300
Summary 301
References 302
Index 305