Colorectal Surgery

Inside Front Cover
Colorectal Surgery
Copyright
Series Editors’ preface
Editors’ preface
Evidence-based practice in surgery
Contributors
Anorectal investigation
	Introduction
	Anatomy and physiology of the anal canal
	Rectoanal inhibitory reflex
	Manometry
		Ambulatory manometry
	Anal and rectal sensation
	Rectal compliance
	Pelvic floor descent
	Electrophysiology
		Electromyography
		Pudendal nerve terminal motor latency
		Spinal motor latency
	Defecography/evacuation proctography
		Dynamic pelvic MRI
		Dynamic transperineal and three-dimensional pelvic floor ultrasound
	Scintigraphy
	Imaging the rectum and anal sphincters
		Anal endosonography/endorectal ultrasound
		Endocoil receiver MRI
		Imaging in rectal cancer
		Imaging in anal sepsis and anal fistulas
		Imaging in faecal incontinence
	Summary
	Key references
Colonoscopy and flexible sigmoidoscopy
	Introduction
	Indications and contraindications
		Flexible sigmoidoscopy vs colonoscopy
		Contraindications
	Sedation
	Insertion technique
		Handling and scope control
		Insertion and steering
			Tips for insertion and steering
		Patient position change
			Abdominal hand pressure
		Three-dimensional imager
	Withdrawal technique
		Withdrawal time
		Optimal examination technique
		Bowel preparation
		Position change
		Antispasmodics
		Rectal and caecal retroflexion
	Quality assurance
	Endoscopy training
	New techniques in endoscopic mucosal visualisation
		Assisted-viewing devices
		Chromoendoscopy
		High-magnification endoscopy
	Endoscopic therapy
		Basic therapy
			Polypectomy
			Endoscopic mucosal resection (EMR)
			Investigation of acute lower gastrointestinal (GI) bleeding
			Colonic decompression
		Advanced therapy
			Endoscopic submucosal dissection (ESD)
			Stricture dilatation and stenting
		Novel therapies
	Competing technologies
		Computed tomography colonography (or virtual colonoscopy)
		Self-propelling colonoscopes
		Colon capsule
	Conclusions
	Key references
Colorectal cancer
	Introduction
	Natural history
		Direct spread
		Lymphatic spread
		Blood-borne spread
		Transcoelomic spread
	Aetiology
		Genetic factors
		Diet and lifestyle
		Predisposing conditions
	Presentation
	Investigation
	Screening
	Surveillance after adenoma detection
	The malignant polyp
	Surgery
	Adjuvant therapy
	Management of advanced disease
		Operable metastases
		Advanced local disease
		Inoperable disseminated disease
	Pathological staging
	Summary recommendations for best practice
	Key references
Colorectal cancer and genetics
	Introduction
	Assessment of risk
		Low-risk group
		Moderate-risk group
			Low-moderate risk
			High-moderate risk
		High-risk group
	Management
		Low-risk group
		Moderate-risk group
		High-risk group
	Lynch syndrome
		Clinical features
		Genetics
		Diagnosis
			Pedigree
			Analysis of tumour tissue
			Genetic testing
		Surveillance
		Intervention
			Surgery
				Prophylactic
				Treatment
			Medical
	Familial adenomatous polyposis
		Diagnosis
		Genetic testing
			Genotype–phenotype correlation
		Surveillance
		The large bowel
			Surgery
				Prophylactic
			Treatment
			Surveillance after surgery
		Upper gastrointestinal tract polyps
			Surveillance of the upper gastrointestinal tract
			Management of duodenal polyposis
		Desmoid tumours
			Management
	MYH-associated polyposis (MAP)
		Clinical features
			The large bowel
			The upper gastrointestinal tract
			Other manifestations
		Genetics
		Management
	Peutz–Jeghers syndrome
		Bowel obstruction
		Cancer risk
		Surveillance and management
	Juvenile polyposis
	Serrated polyposis syndrome
	Other inherited colorectal cancer syndromes
	Molecular pathways of colorectal cancer development
	Summary
	Key references
Surgery for colon cancer
	Preparation of the patient for elective surgery
		General issues
		Bowel preparation
		Venous thromboembolism prophylaxis
		Blood transfusion
		Antibiotic prophylaxis
	The principles of surgery
		The evidence for CME
			Dissection in the mesocolic plane
			Central vascular ligation
			The extent of longitudinal resection
	Practical guidance on the extent of resection
	Laparoscopic or open surgery?
	Vascular variations of the colon
	Obesity and difficulties in laparoscopic surgery
	Anastomotic leakage
		Diagnosis
		Management
			Defunctioning stoma
	Emergency management
		Obstruction
			Management of obstruction
		Perforation
	Future developments
	Acknowledgements
	Key references
Surgery for rectal cancer
	Introduction
	Objectives of surgery
		In-hospital mortality
		Local recurrence
	Circumferential resection margin and the role of preoperative radiotherapy
		Complications of preoperative radiotherapy
		Downstaging rectal cancer with preoperative radiotherapy
		MRI can predict T stage and CRM status
		Considerations for decision-making
		Tumour disruption
		Extent of excision – TME versus mesorectal transection, pelvic lymphadenectomy and level of vascular ligation
			TME
			Lateral pelvic lymph nodal involvement
			High versus low inferior mesenteric artery ligation
		Implantation of viable cells
	Quality of life
		Preservation of continence by restorative resection
			Distal clearance margin
			Tumour height – the importance of rectal palpation (PR)
			Aspects of anal and neo-rectal function
			Low rectal cancer and the English National Low Rectal Cancer Programme (LOREC)
			Abdominoperineal excision (APE)
			Reconstruction (colonic pouch, end-to-side or end-to-end anastomosis)
			Sexual and urinary disturbance
		Temporary defunctioning stomas
	Alternative approaches to standard surgery for rectal cancer
		Papillon/contact radiotherapy
		Transanal endoscopic microsurgery (TEMS) and transanal minimally invasive surgery (TAMIS)
		Laparoscopic surgery for rectal cancer
		Robotic rectal cancer surgery
		Transanal TME (TA-TME) for rectal cancer
		Non-operative approach for rectal cancer by\'watch and wait\' after chemoradiotherapy
		Alternative non-surgical options in rectal cancer
	Follow-up
		Synchronous tumours
		Metachronous tumours
		Surveillance for local and distant recurrence
	The way forward
	Key references
Perioperative chemotherapy and radiotherapy for colorectal cancer
	Introduction
	Adjuvant chemotherapy for colorectal cancer
		Acute and long-term toxicity
			The elderly
			Stage II disease
		Addition of ‘targeted’ therapy to chemotherapy
		Timing and duration of adjuvant chemotherapy
	Adjuvant chemotherapy in rectal cancer
	Radiotherapy
		Evidence base for the use of adjuvant radiotherapy in resectable rectal cancer
		Short-course radiotherapy and TME
		Preoperative concurrent chemoradiotherapy
		Short-course radiotherapy versus preoperative CRT
		Short-course radiotherapy and delay to surgery
		Late toxicity and second malignancy
		Patient selection
		Sphincter preservation
		Organ preservation
	Future directions: intensification of neoadjuvant treatment
		Addition of a second concurrent chemotherapy agent during LCCRT
		Neoadjuvant chemotherapy
	Key references
Advanced and recurrent colorectal cancer
	Introduction
	Incidence
	Diagnosis and staging of advanced and recurrent CRC
		Histological confirmation and biomarkers
		Radiology
			Computed tomography
			Magnetic resonance imaging
			Positron emission tomography
			Ultrasonography
	The advanced colorectal cancer MDT
	Locally advanced primary and recurrent rectal cancer
		Radiotherapy
		Perineal excision
		Pelvic multivisceral exenteration
			Patterns of rectal cancer recurrence
			Types of pelvic clearance
			Sacrectomy
			Perineal reconstruction
	Colorectal peritoneal metastases (CRPM)
		CRS/HIPEC
		Scoring systems
		Patient Selection
	Colorectal liver metastases
	Key references
Anal cancer
	Introduction
	Epidermoid tumours
		Aetiology and pathogenesis
		Premalignant lesions
		Histological types
		Patterns of spread
		Clinical presentation
		Investigation
		Clinical staging
		Treatment
			Historical
			Current
				Radiation-alone therapy
				Chemo-irradiation therapy (combined modality therapy)
		Role of surgery today
			Initial diagnosis
			Lesions at the anal margin
			Treatment complications and disease relapse
			Inguinal metastases
			Long-term outcomes
		Treatment of intraepithelial neoplasia
	Rarer tumours
		Adenocarcinoma
		Malignant melanoma
	Key references
Diverticular disease
	Historical perspectives
	Terminology
	Anatomical and physiological perspectives
	Incidence and geographical differences
		Race and geography
		Age and gender
		Diet
	Aetiology and pathogenesis
		Lifestyle
		Smoking
		NSAIDs
	Diverticulitis
		The extent of the problem
		Classification
	Segmental colitis-associated diverticulosis
	Diagnosis and imaging
	Treatment
		Conservative and medical options
	Emergency surgery
		Historical perspectives
		Laparoscopic peritoneal lavage for generalised purulent peritonitis
		Resection with primary anastomosis
	Elective resection – facts, fiction and functional outcome
	Diverticular haemorrhage
	Key references
Ulcerative colitis
	Introduction
	Epidemiology
	Aetiopathogenesis
	Clinical presentation
	Extraintestinal manifestations
		Musculoskeletal
		Hepatopancreatobiliary
		Dermatological
		Thromboembolic
		Ophthalmological
	Diagnosis and evaluation
		Microbiology
		Endoscopy
		Histopathology
		Imaging
		Serology and microbiome
	Colorectal cancer and surveillance
	Severity assessment
	Medical management
		Proctitis
		Mild to moderate distal colitis
		Mild to moderate extensive colitis
		Severe colitis
	Surgical management
		Emergency/urgent
		Elective
			Proctocolectomy with end ileostomy
			Proctocolectomy with continent ileostomy
			Ileorectal anastomosis
			Restorative proctocolectomy/ileal pouch–anal anastomosis (IPAA)
				Double-stapled technique
				Hand-sewn technique
				Outcomes in stapled versus hand-sewn anastomosis
				Complications following pouch surgery
				Functional outcomes
	Key references
Crohn’s disease
	Introduction
	Epidemiology
	Aetiology
		Smoking and oral contraception
		Infection
		Genes and the microbiome
	Pathogenesis
	Pathology
		Distribution
		Macroscopic appearance
		Microscopy
		Pitfalls in differentiating Crohn’s colitis from ulcerative colitis
	Clinical
		Gastrointestinal symptoms
		Systemic symptoms
		Extraintestinal manifestations
		Physical signs
		Paediatric age group
		Pregnancy
	Investigations
		Laboratory
		Radiology
		Endoscopy
		Disease activity assessment and quality of life
		Phenotyping
	Differential diagnosis
		Small-bowel Crohn’s disease
		Large-bowel Crohn’s disease
	Medical treatment
		Multidisciplinary care
		Aminosalicylates
		Steroids
		Antibiotics
		Nutrition for therapy
		Immunomodulatory therapy
		Biological agents’
		Surgery and immunosuppression
		Prophylaxis against recurrent disease after surgery
		Other drugs
	Surgery
		Development of surgery
		Risk of operation and re-operation
		Risk factors for recurrence
		Principles of surgery for Crohn’s disease
			Perioperative considerations
			Technique
		Surgery for small-bowel and ileocolic Crohn’s disease
			Indications
			Gastroduodenal disease
			Ileocolic disease
			Ileal and jejunal multisite disease
		Fistulas and abscesses
			Enterocutaneous fistulas and intra-abdominal abscess
				Management principles
			Spontaneous enterocutaneous fistulas
			Postoperative fistulas
			Intra-abdominal fistulas
			Spontaneous free perforation in the small bowel or colon
		Surgery for colonic and rectal Crohn’s disease
			Indications
			Emergency colectomy and colectomy and ileostomy
			Segmental colectomy
			Total colectomy and ileorectal anastomosis
			Panproctocolectomy
			Restorative proctocolectomy
			Crohn’s colitis and cancer
		Perianal disease
			Investigation
			Medical treatment
			Anal fissure
			Abscesses
			Anal fistulas
			Rectovaginal fistulas
			Defunctioning ileostomy for perianal disease
			Long-term complications of perianal disease
	Prognosis
	Key references
Intestinal failure
	Introduction
	Intestinal failure: criteria for referral
	Epidemiology
	Causes
		Loss of intestinal length
		Loss of functional absorptive capacity
		Loss of intestinal absorptive capacity
		Loss of intestinal function
	Pathophysiology
		The three stages of intestinal failure
			Stage I: hypersecretory phase
			Stage II: adaptation phase
			Stage III: stabilisation phase
		Fluid and electrolytes
		Nutrients
			Carbohydrates, proteins and water-soluble vitamins
			Fat, bile salts and fat-soluble vitamins
			Adaptation
		Role of the colon in short-bowel syndrome
	Surgical catastrophe and management
		Resuscitation
		Restitution
			Sepsis
			Nutrition
				Fluid and electrolytes
				Nutritional support
				Reduction of output
				Dietary modification
				Outcome aims and monitoring
				Parenteral nutrition
				Fistuloclysis
			Anatomy (mapping)
			Protection of skin
			Planned surgery
		Reconstruction
			Enterocutaneous fistula
		Rehabilitation
			Transplantation
	Supporting organisations
	Summary
	Key references
Incontinence
	Introduction
	Aetiology
		Sphincter injury
		Rectal compliance
		Idiopathic’ faecal incontinence
	Presentation
		History
		Examination
		Investigations
	Management of faecal incontinence in adults
		Conservative measures
			Dietary modification and medications
			Biofeedback and pelvic floor muscle retraining
			Anal plug
		Surgery
			Sphincteroplasty
			Pelvic floor repair (postanal, preanal or total)
			Sphincter reconstruction – muscle transposition
			Artificial sphincters
			Artificial bowel sphincter
			Magnetic anal sphincter
			Sacral nerve stimulation
			Percutaneous and transcutaneous tibial nerve stimulation
		Injection therapy
		Stoma formation
			Antegrade continence enema
			End stoma
	Conclusion
	Key references
Functional problems and their surgical management
	Introduction
	Rectal prolapse
		Mucosal prolapse
		Full-thickness rectal prolapse (see Table 15.1)
			Choice of abdominal or perineal surgical approaches
			Perineal approaches
			Abdominal approaches
			Laparoscopic approaches
			Recurrent rectal prolapse
	Obstructive defaecation, rectocele and rectal intussusception
		Rectocele
		Rectal intussusception
		Laparoscopic ventral rectopexy
		Stapled transanal rectal resection (STARR)
		Solitary rectal ulcer syndrome (SRUS)
	Key references
Functional problems and their medical management
	Introduction
	Irritable bowel syndrome
		Investigation
		Treatment
			Lifestyle modification
			Pharmacological treatments
			Psychological treatments
			Surgery
	Functional constipation
		Investigation
		Treatment
			Dietary fibre supplementation
			Laxatives, suppositories, enemas and novel prokinetics
			Behavioural therapy (biofeedback)
			Surgical treatment for constipation
			Putative treatments for constipation
	Idiopathic megarectum and megacolon
	Key references
Anal fistula: evaluation and management
	Introduction
	Aetiology
	Management of acute sepsis
	Classification of anal fistula
	Assessment
		Clinical
		Imaging
		Physiological
	Principles of fistula surgery
	Surgical treatment – general principles and interpreting the evidence
		Track preparation
		Fistulotomy
		Fistulotomy and immediate reconstitution
		Fistulectomy
		Setons
			The loose seton
			The tight seton
			The chemical seton
		Advancement flaps
		Intersphincteric approaches
		Infill materials – glues and plugs (Table 17.1)
			Fibrin glue
			Bioprosthetic plugs
		Newer techniques
			VAAFT (video assisted anal fistula treatment)
			FiLaC (fistula tract laser closure)
			OTSC (over the scope clip)
			Stem cells
	Management of the recurrent fistula
	Key references
Minor anorectal conditions
	Haemorrhoids
		Anatomy and physiology
		Aetiology and pathogenesis
		Classification
		Symptoms and diagnosis
		Management
			First-degree
				Dietary changes
				Phlebotonics
			Second-degree
				Rubber-band ligation
				Sclerotherapy
				Other treatments
			Third-degree
				Stapled haemorrhoidopexy
				Haemorrhoidal arterial ligation/transanal haemorrhoidal dearterialisation
			Fourth-degree
		Postoperative problems
			Postoperative pain
			Postoperative haemorrhage
				Anal stenosis
			Thrombosed haemorrhoids
		Conclusions
	Anal fissure
		Aetiology
		Classification
		Symptoms and diagnosis
		Management
			Initial treatment – conservative measures
			Glyceryl trinitrate
			Diltiazem
			Botulinum toxin
			Surgical treatments
				Anal dilatation
				Lateral anal sphincterotomy
				Fissurectomy
				Anal advancement flap
		Conclusion
	Pruritus ani
		Aetiology and pathogenesis
		Diagnosis
		Treatment
		Conclusion
	Pilonidal sinus
		Aetiology
		Clinical manifestation
		Treatment
			Pilonidal abscess
			Chronic pilonidal sinus
			Outpatient options
			Surgical options
			Recurrent pilonidal sinus
		Conclusion
	Anal stenosis
		Aetiology
		Clinical presentation
		Treatment
			Prevention
			Anal dilatation
			Sphincterotomy
			Stricturoplasty
			Flap procedures
				Mucosal advancement flap (above to down)
				Y–V advancement flap (outside to in)
				V–Y advancement flap (outside to in)
				Island advancement flap (outside to in)
		Conclusion
	Sexually transmitted diseases
		Human papillomavirus and anal warts
			Treatment
		Buschke–Lowenstein tumour: giant anal condyloma
		Other STDs affecting the anorectum
	Key references