Difficult Decisions in Colorectal Surgery (Difficult Decisions in Surgery: An Evidence-Based Approach)

Preface from First Edition
Preface
Introduction
	The Clinical Challenge: Reasoning, Decision-Making, and Action
Contents
Contributors
1: Evaluating Evidence
	Evaluating Evidence
	Assessing Methodology
	Was the Study Original?
	What’s the Patient Population?
	What Are the Exposures and Outcomes and Do They Make Sense?
	Was an Adequate Attempt Made to Control for Bias?
	Was the Study Large Enough and Continued Long Enough to Make the Results Believable?
	Final Thoughts
	Personal View
	Conclusion
	References
Part I: Inflammatory Bowel Disease
	2: Surgical vs Medical Management of Symptomatic Anal Fistulas in Patients with Crohn’s Disease
		Introduction
		Diagnosis
			Park’s Classification
		Treatment Goals
		Medical Management
			Corticosteroids
			Aminosalicylate (ASA) Derivatives
			Antibiotics
			Immunomodulators
			Biologics
			Hyperbaric Oxygen Therapy: An Alternative Therapy
		Surgical Management
			Incision & Drainage (I&D)
			Seton
			Fistulotomy vs Fistulectomy
			Fibrin Glue and Fistula Plug
			Endorectal Advancement Flap
			Ligation of Intersphincteric Fistula Tract (LIFT) Procedure
			Fecal Diversion
			Proctectomy
		Emerging Therapies
			Mesenchymal Stem Cells (MSCs)
			Fistula Laser Closure (FiLaC™)
			Video-Assisted Anal Fistula Treatment (VAAFT)
		Conclusion
		References
	3: What Are the Treatment Options for Painful Anal Fissure in Patients with Crohn’s Disease?
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		References
	4: Elective Surgical Management in Patients with Ulcerative Colitis: How Many Stages?
		Introduction
		Search Strategy
		Results
			Diverting Loop Ileostomy
			Initial Colectomy Prior to IPAA
		Recommendations Based on the Data
		A Personal View of the Data
		References
	5: Which Patients with Ulcerative Colitis Benefit from Ileal Pouch-Anal Anastomosis?
		Search Strategy
		Results
		Recommendations
		Personal View
			Patients with Obesity
			Elderly Patients
			Sphincter Abnormalities
			Primary Sclerosing Cholangitis
			Patients with Indeterminate Colitis or Crohn’s Disease
			Patients of Childbearing Age
			Redo IPAA
			Conclusion
		References
	6: Persistent Posterior Sinus After Ileal Pouch-Anal Anastomosis
		Introduction
		Search Strategy
		Results
			Delay Ostomy Closure/Watchful Observation
			Debridement
			Fibrin Glue
			Unroofing
			Ileostomy Closure with Persistent Sinus
			Redo Pouch
		Recommendations
		Personal View of the Data
		References
	7: How to Manage Pouch-Perineal and Pouch-Vaginal Fistula After Ileal Pouch–Anal Anastomosis
		Introduction
		Search Strategy (See Table 7.1)
		Results
		Perineal Approach
			Seton Drain
		Fistulectomy
		Biological Therapy
		Transanal Ileal Advancement Flap
		Transvaginal Repair
		Muscle Interposition Flap
		Transanal Pouch Advancement
		Abdominoperineal Approach
		Diversion
		Recommendations
		Personal View of the Data
		References
	8: Ileal Pouch–Anal Anastomosis Failure: What to Do?
		Introduction
		PICO Diagram (Table 8.1)
		Search Strategy
		Results
		Creation of Diverting Loop Ileostomy with Pouch Left In-Situ
			Patient Satisfaction of Pouch Left In-Situ
			Morbidity of Pouch Left In-Situ
		Ileostomy Creation with Pouch Excision
			Patient Satisfaction of Pouch Excision
		Recommendations Based on the Data
		Personal View
		References
	9: Perioperative Steroid Management in IBD Patients Undergoing Colorectal Surgery
		Introduction
		Search Strategy
		Results
		Recommendations Based on Data
		Personal View of the Data
		References
	10: Colonic Dysplasia in Patients with Ulcerative Colitis: Endoscopic or Surgical Management?
		Introduction
		Search Strategy (PICO Table)
			PICO Table
		Results
			Risk Factors for Dysplasia and Cancer in Patients with Ulcerative Colitis
			Surveillance Strategies and Techniques
			Classification of UC Associated Dysplasia
			Management of Colonic Dysplasia
			Endoscopic Submucosal Dissection (ESD)
			Surgical management of Colonic Dysplasia
		Recommendations Based on the Data
		A Personal View of the Data
		References
	11: Which Patients Benefit from Biologic Agents to Prevent Disease Recurrence After Resection in Crohn’s Disease?
		Introduction
		Search Strategy
		Results
			Definition of Recurrence
		Endoscopic Recurrence
		Clinical Recurrence
		Surgical Recurrence
			Risk Factors of Recurrence After Resection
		Biographic Feature
		Preoperative Treatment
		Surgery
		Postoperative Preventive Therapy
			TNFi
			Other Biologics
		Conclusion
		References
Part II: Colon Cancer
	12: Is Intensive Surveillance Necessary After Curative Resection for Colon Cancer?
		Introduction
		Search Strategy
		Results
		Recommendations Based on Data
		Personal View of the Data
		References
	13: Surgical Versus Endoscopic Options for Management of Malignant Large Bowel Obstruction
		Introduction
		Search Strategy
		Results
			Emergency Surgery
			SEMS as Bridge to Surgery
			SEMS as Definitive Palliation
			Special Considerations
		Recommendations Based on the Data
		Personal View of the Data
		Summary of Recommendations
		References
	14: Metastatic Colorectal Cancer in the Asymptomatic Patient: Is There a Benefit in Resection of Primary Tumor?
		Search Strategy
		Results
			Overall Survival
			Morbidity and Mortality
			Conversion to Resectability
			Natural History of Nonresected Primary Disease
				Recommendations Based on the Data
				Personal View of the Data
		References
	15: What Are the Options for Management of Large Colonic Polyps?
		Introduction
		Search Strategy
		Results
			En-Bloc, R0 and Complete Resection
			Postoperative/Procedural Complications
			Tumor Recurrence
			Secondary Outcomes
		Recommendation
		Personal View
		References
	16: Management of the Malignant Colon Polyp: Resection or Surveillance?
		Introduction
		Search Strategy
		Results
			Depth of Invasion
			Margin Positivity
			Lymphovascular Invasion
			Poor Differentiation
			Tumor Budding
			Recommendations
		Personal View
		References
	17: Stage II Colon Cancer: Towards an Individualized Treatment Approach
		Introduction
		Results
			Non-Risk-Stratified Patients
			Risk-Stratification: Clinical and Pathologic Factors
			Risk-Stratification: Molecular Factors
			Risk-Stratification: ctDNA and Minimal Residual Disease
			Duration of Adjuvant Therapy
			Recommendations Based on the Data
		References
	18: Is There a Benefit in Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy in Colorectal Cancer?
		Introduction
		Search Strategy
		Results
		Expert Opinion
		Personal View
		Abstract Recommendations
		References
	19: Colorectal Cancer Management in Older Adults: Use of Geriatric Assessment to Guide Patient-Centered Care
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		References
	20: Colon Cancer in the Splenic Flexure: Which Operation?
		Introduction
		Methods
		Results
			Intra-Operative Outcomes
				Extended Right Hemicolectomy vs Left Hemicolectomy
				Extended Right Hemicolectomy vs Segmental Colectomy
				Segmental Colectomy vs Left Hemicolectomy
				Direct Comparison of 4 Techniques: Subtotal Colectomy, Extended Right Hemicolectomy, Left Hemicolectomy and Segmental Colectomy
			Post-Operative Outcomes/Morbidity
				Extended Right Hemicolectomy Versus Left Hemicolectomy
				Extended Right Hemicolectomy vs Segmental Colectomy
				Segmental Colectomy vs Left Hemicolectomy
				Direct Comparison of 4 Techniques: Subtotal Colectomy, Extended Right Hemicolectomy, Left Hemicolectomy and Segmental Colectomy
				Laparoscopic Techniques (all Operations Combined) Versus Open Technique
			Survival Outcomes
		Recommendation
		Personal View of Data/ Expert Opinion
		References
Part III: Rectal Cancer
	21: Management of T1 Rectal Cancer
		Introduction
		Presentation and Evaluation
			Presentation
			Evaluation
		Management Approach
			Local Resection
			Radical Resection
			Neoadjuvant and Adjuvant Therapy
			Surveillance
		Outcomes
			Local Recurrence
			Metastasis
			Disease Free and Overall Survival
		Quality of Life
		Conclusion
		References
	22: Can Total Mesorectal Excision Be Avoided in T2 Rectal Cancer?
		Introduction
		Search Strategy
		Results
			TME Works: Why Replace it?
			Improving Oncologic Outcomes Associated with Local Excision
		Recommendations Based on the Data
		A Personal View of the Data
			T2N0 Rectal Cancer: The Goldilocks Effect
		References
	23: Watch and Wait Versus Conventional Surgical Treatment in Rectal Cancer
		Introduction
		Search Strategy
		Results
		Recommendation
		Personal View
		References
	24: Which Patients Are the Right Candidates for Total Neoadjuvant Therapy (TNT)?
		Introduction
		Search Strategy
		Results
		Recommendations Based on the Data
		A Personal View of the Data
		Abstracted Recommendations
		References
	25: Management of the Patient with Rectal Cancer Presenting with Synchronous Liver Metastases
		Introduction
		Search Strategy
		Results
			Initial Evaluation
				Imaging
				Goals
				Multidisciplinary Team
			Treatment
				Neoadjuvant Treatment
			Surgery Summary
				Rectum First
				Liver First
				Synchronous Resection
		Perioperative Outcomes
		Recommendations
			Imaging Evaluation
			Neoadjuvant Treatment
			Surgical Approach
		A Personal View of the Data
		References
	26: Who Needs a Loop Ileostomy After Low Anterior Resection for Rectal Cancer?
		Introduction
		Methods
		Risks of Diverting Enterostomy
		Does Fecal Diversion Decrease Anastomotic Leak Rate?
		Who Is at Highest Risk for Developing a Leak?
		What Type of Diverting Ostomy Should We Use?
		Are There Benefits to Early Ileostomy Closure?
		Personal View of the Data
		References
	27: Reoperative Surgery for Locally Recurrent Rectal Cancer
		Introduction
		Search Strategy
		Results
			Diagnosis
			Classification Systems and Outcomes
			Treatment and Oncologic Outcomes
			Nutritional Status and Postoperative Morbidity
			Patients Ineligible for Curative Surgery
		Recommendations Based on the Data
		A Personal View of the Data
		References
Part IV: Anal Dysplasia/Cancer
	28: Intensive vs Conservative Management of Patients with Low Grade Squamous Intraepithelial Lesions
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		References
	29: How Aggressive Should We Be in Management of Patients with High Grade Squamous Intraepithelial Lesion?
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		References
	30: Observation Versus Chemoradiotherapy for Management of Superficial Anal Cancer
		Background
		Defining the Problem
		Treatment Decisions
		Conclusion and Personal View of the Literature
		References
	31: Is High Resolution Anoscopy Superior to Direct Evaluation of Anal Dysplasia?
		Introduction
		Methodology
		Anal Dysplasia and High-Risk Groups
		High Resolution Anoscopy
		Treatment Options
		The ANCHOR Trial
		Conclusions
		References
Part V: Benign Colon Disease
	32: Surgical Management Options in Severe C Difficile Colitis
		Introduction
		Search Strategy
		Results
		Recommendations Based on the Data
		Personal View of the Data
		References
	33: Are Antibiotics Needed for the Management of Uncomplicated Diverticulitis?
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		References
	34: Do We Need to Operate on Patients After Successful Percutaneous Drainage of a Diverticular Abscess?
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		Recommendations
		References
	35: How to Manage Diverticular Abscess Not Amenable to Percutaneous Drainage?
		Introduction
		Search Strategy
		Results
		Recommendations Based on the Data
		A Personal View of the Data
		References
	36: Hartmann Procedure vs Primary Anastomosis for Acute Complicated Diverticulitis
		Introduction
		Search Strategy
		Results
			Mortality
			Post-operative Morbidity
			Stoma Reversal
		Recommendations Based on the Data
		Personal View
		References
	37: Deciding on an IRA vs. IPAA for FAP
		Introduction
		Search Strategy
		Results
			Surgical Outcomes
			Risk of Desmoid Tumor Development
			Risk of Metachronous Rectal Cancer
			Functional Outcomes and Quality of Life
		Data Based Recommendations
		Personal View of the Data
		References
	38: Rectal Prolapse: Rectopexy vs Perineal Proctosigmoidectomy
		Introduction
		Search Strategy
		Results
			Abdominal Versus Perineal Approach
		Morbidity
		Recurrence
		Function and Quality of Life
			Robotic Versus Laparoscopic Abdominal Approach
		Morbidity
		Recurrence
		Function and Quality of Life
			Anterior Versus Posterior Rectopexy
		Morbidity
		Recurrence
		Function and Quality of Life
			Altemeier Versus Delorme Procedure
		Morbidity
		Recurrence
		Function and Quality of Life
		Recommendations
		Personal View
		References
	39: Optimal Management of the Transsphincteric Anal Fistula
		Introduction
		Search Strategy
		Results
			Fistulotomy
			Seton
			Endorectal Advancement Flap
			Ligation of Intersphincteric Fistula Tract
			Fibrin Sealant
			Plugs
			Fistula Laser Closure
			Video-Assisted Anal Fistula Treatment
		Conclusion and Personal View
		References
	40: Chronic and Refractory Anal Fissure: What Are the Treatment Options?
		Introduction
			Search Strategy
		Results
		Recommendations
		Personal View
		References
	41: Benign Anal Disease: Third Degree Hemorrhoids—Who Really Needs Surgery?
		Introduction
			Search Strategy/Methods
			Results
			Control of Hemorrhoidal Symptoms
			Post-treatment Pain and Complications
			Lifestyle (Return to Work and Patient Satisfaction)
			Cost
			Recommendations
			Expert Opinion
		References
	42: Management Options for Bleeding Hemorrhoids in Patients on Anticoagulation
		Medical Treatment
		Office-Based Procedures
		Surgical Management
		References
	43: Sacral Nerve Stimulation: Choices vs Non-surgical Care for Fecal Incontinence
		Executive Summary
		Epidemiology/Incidence of Fecal Incontinence
		Diagnostic Criteria
		Causes of FI
		Non-surgical Management of Fecal Incontinence
		Sacral Nerve Stimulation
		Work Up
		Clinical Practice Guideline Summary
		SNS Candidate Selection
		Difficult Decisions Surrounding SNS Implantation vs Conservative/Medical Management
		Length of Percutaneous/Test Stimulation
			Pertinent Clinical Questions Prior to Choosing SNS
		LARS: Low Anterior Resection Syndrome
			Pertinent Clinical Questions Prior to Choosing SNS
		Mixed Constipation/Fecal Incontinence
			Pertinent Clinical Questions Prior to Choosing SNS
		Radiation Proctitis/Pelvic Radiation
			Pertinent Clinical Questions Prior to Choosing SNS
		Congenital Sacral Malformation, Spina Bifida, and Sacral Agenesis
			Pertinent Clinical Questions Prior to Choosing SNS
		Previous Implantation
			Pertinent Clinical Questions Prior to Choosing SNS
		Spinal Cord Injury
			Pertinent Clinical Questions Prior to Choosing SNS
		Radiculopathy or Other Known Neuropathic Pain
			Incidence of Radiculopathy in Patients with SNS Implantation
			Implantation for Radiculopathy, Chronic Anal or Pelvic Pain
		Final Notes
		References
	44: Surgical Management Options for Rectourethral Fistula
		Introduction
		Search Strategy
		Results
			Transsphincteric Repair
			Transanal Repair
			Transperineal and Combined Transperineal/Transabdominal Repair
		Recommendations Based on the Data
		A Personal View of the Data
		References
	45: Operative vs Non-operative Management of Outlet Obstruction
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		References
Part VI: Quality Improvement
	46: Is Bowel Prep Necessary for Patients Undergoing Colon Resection?
		Introduction
		Search Strategy
		Results
			Mechanical Bowel Preparation Alone
			Combined Mechanical and Oral Antibiotic Preparation
				Comparing MOABP to MBP Alone
				Comparing MOABP to NBP (Table 46.2)
			Oral Antibiotic Preparation Alone
				Comparing OAB Alone to MOABP
				Comparing OAB Alone to NBP (Table 46.2)
		Recommendations
		Personal View
		Recommendations Summary
		References
	47: Enhanced Recovery vs. Conventional Perioperative Management
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		References
	48: Quality Improvement: Is There a Benefit in Opioid-Sparing Strategies for Management of Postoperative Pain?
		Introduction
		Search Strategy
		Non-opioid Modes of Analgesia
			Gabapentinoids
			Non-steroidal Anti-Inflammatory Drugs
			Acetaminophen
			Ketamine
		Results
		Recommendations Based on Data
		A Personal View of the Literature
		References
	49: What Can Be Done to Prevent Readmission After Ileostomy Formation?
		Introduction
		Search Strategy
		Results
			Early ileostomy Reversal (GRADE Criteria: Low Quality Evidence) (Table 49.1)
			Outpatient Intravenous and Oral Hydration (GRADE Criteria: Low to Moderate Quality Evidence)
			Antimotility Therapy (GRADE Criteria: Low Quality Evidence)
			Patient-Centered Interventions (GRADE Criteria: Low Quality Evidence)
			Avoidance of ileostomy Creation (GRADE Criteria: Low to Moderate Quality Evidence)
		Recommendations Based on the Data
		Personal View of the Data
		References
	50: Do Bundles Help to Reduce Surgical Site Infections and Improve Safety?
		PICO Table
		Search Strategy
		Results
		Recommendations
		Personal View
		References
Part VII: Technique
	51: Total Mesorectal Excision for Rectal Cancer: Top Down or Bottom Up?
		Introduction
			Top Down (Low Anterior Resection)
			Bottom Up (taTME)
		Top Down vs. Bottom Up
			Search Strategy
		Results
			LapTME vs. taTME
				Postoperative Outcomes
				Oncologic Outcomes
				Functional Outcomes
			R-TME vs. taTME
				Postoperative Outcomes
				Oncologic Outcomes
				Functional Outcomes
		Recommendation
		Personal View
		References
	52: Intracorporeal vs Extracorporeal Anastomosis for Right Colectomy
		Search Strategy
		Results
			Operative Times
			Conversion Rates
			Complications
			Anastomotic Leak
			Return of Bowel Function
			Length of Stay
			Incision Length
			Incisional Hernia
		Randomized Controlled Trials
			Operative Times
			Conversion Rates
			Return of Bowel Function
			Length of Stay
			Incision Length
			Incisional Hernia
		Recommendations Based on the Data
		Personal View of the Data
		References
	53: Anastomotic Leak Management Following Low Anterior Resections
		Introduction
		Management of an Anastomotic Leak
		Intraperitoneal Anastomotic Leaks
		Search Strategy
		Personal View
		Newer Interventions for Anastomotic Leaks
		Conclusion
		References
	54: Colorectal Anastomosis Construction: Is there a Benefit to a Reservoir?
		Introduction
		Search Strategy
		Results
		Recommendations
		Personal View
		References
	55: Management of the Unhealed Perineal Wound After Proctectomy
		Introduction
		Literature Search Strategy
		Non-operative Strategies
		Debridement
		Local Antibiotic Agents
		Negative Pressure Wound Therapy
		Hyperbaric Oxygen Therapy
		Operative Strategies
		Omental Pedicle Grafts
		Wide Excision and Split Thickness Skin Grafts
		Meshes and Biological Implants
		Gracilis Muscle Flap
		Rectus Abdominus Myocutaneous Flap
		Pudendal Flaps
		Gluteus Maximus Flap
		Personal View of the Data
		References
	56: Gender Affirmation Procedure: What Are the Reconstructive Options?
		Introduction
		Search Strategy
		Results
			Evidence Synthesis for this Review
			Functional and Sexual Outcomes
				Functional/Neovaginal Length Outcomes
				Sexual Outcomes
			Complications
				Neovaginal Stenosis
				Fistulas
				Bleeding and Infection
				Neovaginal Discharge and Malodor
				Neovaginal Prolapse
				Intestinal Complications
		Recommendations
		Personal View
		References
Index