The ASCRS Manual of Colon and Rectal Surgery

Preface
Contents
Contributors
Part I: Perioperative/ Endoscopy
	1: Anatomy and Embryology of the Colon, Rectum, and Anus
		Anatomy of the Anal Canal and Pelvic Floor
			Anal Canal Epithelium
			Internal Anal Sphincter
			Conjoined Longitudinal Muscle
			External Anal Sphincter
			Perineal Body
			Pelvic Floor Muscles
				Puborectalis Muscle
				Iliococcygeus Muscle
				Pubococcygeus Muscle
		Anatomy of the Rectum
			Mesorectum
			Presacral Fascia
			Retrosacral Fascia
			Waldeyer’s Fascia
			Denonvilliers’ Fascia
			Lateral Ligaments
			Valves of Houston
		Anorectal Spaces
			Perianal Space
			Intersphincteric Space
			Submucous Space
			Ischioanal/Ischiorectal Space
			Supralevator Space
			Superficial and Deep Postanal Spaces
			Retrorectal Space
			Rectal Blood Supply
				Superior Rectal Artery
				Middle Rectal Artery
				Inferior Rectal Artery
			Venous and Lymphatic Drainage of the Rectum and Anus
			Innervation of the Rectum and Anus
		Anatomy of the Colon
			Cecum
			The Appendix
			Ascending Colon
			Transverse Colon
			Descending Colon
			Sigmoid Colon
			Rectosigmoid Junction
			Blood Supply
			Superior Mesenteric Artery
			Inferior Mesenteric Artery
			The Marginal Artery and Other Mesenteric Collaterals
			Venous Drainage
			Lymphatic Drainage
			Nervous Innervation
		Embryology
			Anus and Rectum
			Colon and Small Intestine
			Major Anomalies of Rotation
				Non-rotation
				Malrotation
				Reversed Rotation
				Omphalocele
				Internal Hernias
			Other Congenital Malformations of the Colon and Small Intestine
				Proximal Colon Duplication
				Meckel’s Diverticulum
				Atresia of the Colon
				Hirschsprung’s Disease
			Anorectal Malformations
				Anal Stenosis
				Membranous Atresia
				Anal Agenesis
				Anorectal Agenesis
				Rectal Atresia or “High Atresia”
				Persistent Cloaca
	2: Colonic Physiology
		Colonic Anatomy
			Introduction
			Colonic Wall Anatomy
			Colonic Epithelial Cell Types
			Colonic Flora
		Electrolyte Regulation and Water Absorption
		Short-Chain Fatty Acid Absorption
		Secretory Role of the Colonic Epithelium
		Regulation of Electrolyte and Water Absorption and Secretion
		Colonic Innervation
		Colonic Motility
			Cellular Basis of Motility
			Motility Patterns and Measurement
	3: Anal Physiology: The Physiology of Continence and Defecation
		Introduction
		Normal Anatomy and Physiology
		Innervation of the Anus and Pelvic Floor
		Normal Continence
			Rectal Capacity
			Pressure and Motility
			Rectoanal Sensation and Sampling
			Structural Considerations
			Role of Hemorrhoids in Normal Continence
		Sensation and Innervation
		Normal Defecation
		Physiology of Tibial Nerve and Sacral Nerve Root Stimulation in Fecal Continence (FI)
		Spinal Cord Injuries and Defecation
		Obstructed Defecation
		Functional Anorectal Pain
		Pathophysiology of Obstetric-Related Problems
		Urogynecological Considerations and Pelvic Pain
	4: Endoscopy
		Introduction
		The Complete Anorectal Examination
			Patient Position
			Prone Jackknife
			Left Lateral
			Inspection and Palpation
			Digital Rectal Examination
		Anoscopy/Proctoscopy
			Anoscopy
			Proctoscopy
		Anal and Rectal Ultrasound
		Flexible Endoscopy
			Flexible Endoscopic Insertion Techniques
			Torque
			Tip Deflection
			Dithering/Jiggle
			Aspiration of Air and Breath Holding
			Slide-By
			Adjunctive Maneuvers for More Difficult Examinations
			Patient Position
			Abdominal Pressure
			Turning the Scope
				Sigmoidoscopy
		Colonoscopy
		Indications and Contraindications
			Bowel Preparation
		Special Considerations
			The Difficult-to-Prep Patient
			The Patient Requiring Antibiotics
			The Anticoagulated Patient
			Incomplete Colonoscopy
		Procedure
			The Endoscopy Suite
			Instruments
			Sedation
			Nitrous Oxide
			Ketamine
			Propofol
			Colonoscopy Technique
			Anal Intubation
			The Rectum and Rectosigmoid
			Sigmoid Colon
			Sigmoid-Descending Junction
			Descending Colon
			Splenic Flexure
			Transverse Colon
				Hepatic Flexure
			Ascending Colon and Ileocecal Valve
			Cecum
			Ileocecal Valve Intubation
			Terminal Ileum
			Alternate Techniques
				CO2 Insufflation
				Water Insufflation
				Chromocolonoscopy (Chromoendoscopy)
				High-Definition/NBI Endoscopy
				Full-Spectrum Endoscopy
				Retroflexion
		Complications
			Sedation Complications
			Vasovagal/Cardiac Arrhythmia
			Pulmonary
			Procedural Complications
				Splenic Injury
			Perforation
			Post-polypectomy Syndrome
			Bleeding
			Infectious Complications
		Training and the Use of Simulation
		Simulation
		Documentation and Quality
			Documentation
			Quality
		PillCam Endoscopy
	5: Endoscopic Management of Polyps, Polypectomy, and Combined Endoscopic and Laparoscopic Surgery
		Introduction
		Identification of Polyps
		Criteria for Polypectomy
		Polypectomy Techniques
		Endoscopic Mucosal Resection
		Endoscopic Submucosal Dissection
		Combined Endo-Laparoscopic Surgery (CELS)
	6: Preoperative Assessment of Colorectal Patients
		Evaluation of the Routine Colorectal Patient
			In Office by Surgeon
				Major Abdominal Surgery
				Anorectal Surgery
			Preoperative Testing
				Laboratory Studies
				Electrocardiogram
				Chest X-ray
		Patients with Specific Comorbidities
			Assessment of Cardiac Risk
				Initial Workup
				Who Needs Additional Testing?
					Preoperative “Optimization”
				Coronary Stent Management
				AICD/Pacemaker Management
			Assessment of Pulmonary Risk
				COPD
				Obstructive Sleep Apnea (OSA)
			Diabetes
			Obesity
			Malnutrition
			Solid Organ Transplant Recipients
			Substance Abuse
				Alcohol
				Tobacco
				Opioids
		Medications
			Anticoagulation
			Immunosuppressive Agents
			Chemotherapy
	7: Optimizing Outcomes with Enhanced Recovery
		Introduction
		What Is an Enhanced Recovery Pathway (ERP)?
		Where Does the Pathway Start?
		Components of an ERP
		Preoperative Management
			Preoperative Evaluation: Frailty Score and Prehabilitation
			Fasting Prior to Surgery, Mechanical Bowel Preparation, and Preoperative Antibiotics Usage
			Patient Education
		Intraoperative Pathway
			Minimally Invasive Colorectal Surgery
			Intraoperative Fluid Administration
			Analgesia
			Venous Thromboembolism (VTE) Prophylaxis
		Postoperative Recovery
			Analgesia
			Intravenous Fluid Management
			Early Oral Feeding, Ambulation, and Role of Nasogastric Tube
			Prevention of Postoperative Nausea and Vomiting (PONV) and Postoperative Ileus (POI): Role of Nasogastric Tube and Motility Agents
			Venous Thromboembolism (VTE) Prophylaxis
			Discharge Planning, Follow-Up, and Coordination of Care
		Quality Pathway Evaluation Measures
			Electronic Order Sets Creation and Updates to Comply with Best Practice Parameters Guidelines and Evidence-Based Literature
			Implementation and Monitoring of Pathway Application
			Quality Improvement Measures
	8: Postoperative Complications
		Introduction
		Preoperative Considerations and Prediction of Postoperative Complications
		Intraoperative Factors that Contribute to Postoperative Outcomes
			Operative Approach and Postoperative Impact
			Luminal Organ Injuries and Postoperative Impact
			Vascular Injury and Failure of Hemostatic Devices
			Urologic Injuries and Their Management
				Ureteral Injury
				Bladder Injury
				Urethral Injury
		Postoperative Management Decisions that Contribute to Postoperative Complications
			IV Fluid Management
			Wound Management
			Bladder Management
			Pain Management
		Impact of Hospital Structure on Postoperative Complications
			Academic Medical Center
			Surgical Volume and Postoperative Complications
		Prevention and Management of Specific Complications
			Wound Complications
			Preoperative Considerations
			Perioperative Interventions
			Management of Superficial Surgical Site Infection
		Cardiovascular and Respiratory Complications
		Mortality and Failure to Rescue
		Long-Term Complications
			Genitourinary Complications
			Fertility Complications
			Bowel Dysfunction
			Impact of Postoperative Complications on Oncologic Outcomes
	9: Anastomotic Construction
		Introduction
		General Principles of Anastomoses
			Surgical Staplers
			Handsewn Anastomoses
			Compression Anastomoses
			Tension
			Blood Supply
			Prophylactic Drainage
			Treatment of Mesenteric Defects
			Diversion
			High-Risk Anastomoses
		Abdominal Anastomoses
			Small Bowel Anastomoses
			Ileocolic Anastomoses
		Pelvic Anastomoses
			Basic Principles of Pelvic Anastomoses
			Stapled Colorectal Anastomoses
			Handsewn Colorectal Anastomosis
			Ileorectal Anastomosis
			Ultralow Colorectal and Coloanal Anastomoses
			Neorectal Reservoirs
			Handsewn Coloanal Anastomosis
			Assessment of Pelvic Anastomosis
		Troubleshooting Problems with Pelvic Anastomoses
			Unanticipated Pelvic Anastomosis
			Inadequate Colonic Length
			Intraoperative Anastomotic Failure
	10: Anastomotic Complications
		Anastomotic Leak
			Overview
			Scope of the Problem
			Consequences
			Prevention
			Diagnosis
			Treatment
		Anastomotic Stricture
		Anastomotic Bleeding
Part II: Anorectal Disease
	11: Approach to Anal Pain
		Introduction
		Patient History
			Anal Fissure (Fig. 11.1)
			Acutely Thrombosed External Hemorrhoid (Figs. 11.2 and 11.3)
			Perianal, Perirectal, or Ischiorectal Abscess (Fig. 11.4)
			Pruritus Ani (Fig. 11.5)
			Levator Syndrome
			Anal or Rectal Cancer (Fig. 11.6)
		Physical Examination
			Abdominal Examination
			Inguinal Examination
			Perianal, Gluteal, and Intergluteal Examination
		Digital Rectal Examination
		Anorectal Inspection, Anoscopy, and Sigmoidoscopy
		Imaging and Diagnostic Testing
		Conclusion
	12: Hemorrhoids
		Anatomy
		Etiology
		Epidemiology
		Classification
		Clinical Presentation
		Evaluation and Physical Examination
			History
			Physical Examination
			Treatment
				Medical Management
					Dietary
					Topical Therapies
					Oral Therapy
					Office-Based Treatments
					Rubber Band Ligation
					Infrared Photocoagulation
					Sclerotherapy
				Operative Management of Hemorrhoids
					Excisional Hemorrhoidectomy-Closed Technique
					Excisional Hemorrhoidectomy Open Technique (Milligan-Morgan)
					Excisional Hemorrhoidectomy (Circumferential or Whitehead)
					Results of Hemorrhoidectomy
					Complications of Hemorrhoidectomy
						Urinary Retention
						Postoperative Hemorrhage
						Anal Stenosis
						Postoperative Infection
						Fecal Incontinence
					Stapled Hemorrhoidopexy
					Transanal Hemorrhoidal Dearterialization
		Special Clinical Scenarios
			Thrombosed External Hemorrhoid
			Strangulated (Thrombosed Prolapsed) Hemorrhoids (Fig. 12.10)
			Portal Hypertension and Hemorrhoids
			Pregnancy
			Crohn’s Disease
			Immunocompromised Patients
	13: Anal Fissure
		Definition/Clinical Presentation
		Pathogenesis
		Non-operative Treatment
			Healing Rates in Acute Anal Fissure
			Healing Rates in Chronic Anal Fissure
			Topical
				Nitroglycerin
				Calcium Channel Blockers
				Botulinum Toxin Type A
		Operative Treatment
			Anal Dilation
			Anal Sphincterotomy (Technique)
			Outcomes Between Closed and Open Anal Sphincterotomy
			Extent of Sphincterotomy
			Fissurectomy
			Results of Sphincterotomy
			Fissures Without Anal Hypertonicity
			Crohn’s Disease
			Human Immunodeficiency Virus
			Conclusions
	14: Anorectal Abscess and Fistula
		Introduction and Epidemiology
		Pathophysiology
			Anatomy
			Etiology
			Classification
		Evaluation
			History and Symptoms
			Physical Examination
		Imaging
			Computed Tomography (CT)
			Magnetic Resonance Imaging (MRI)
			Endoanal Ultrasound (EAUS)
			Transperineal Sonography (TP-US)
		Treatment
			Role of Antibiotics
			Incision and Drainage
			Catheter Drainage
			Drainage with Primary Fistulotomy
		Postoperative Management
		Complications
			Immediate Postoperative Period
			Abscess Recurrence and Fistula Formation
			Misdiagnosis
		Special Considerations
			Necrotizing Anorectal Infection (Fournier’s Gangrene)
			Diagnosis
			Treatment
			Outcomes
			Anorectal Infections in Immunosuppressed Patients
				Hematologic Abnormalities in Immunosuppression
				Human Immunodeficiency Virus (HIV)
		Anal Fistula
			Etiology
			Classification
			Diagnosis
				Fistulography
				Endoanal Ultrasound
				Magnetic Resonance Imaging
			Treatment
				Lay-Open Technique (Fistulotomy)
				Setons
				Advancement Flap
					Technique
				Ligation of Intersphincteric Fistula
					Technique
				Fibrin Glue
					Technique
				Anal Fistula Plug
					Technique
			Novel Techniques
	15: Complex Anorectal Fistulas
		Introduction
		Complex or Recurrent Cryptoglandular Fistulas
			Definition, Classification, and Pathophysiology
			Clinical Assessment and Diagnostic Evaluation
			Surgical Treatment
				Seton
				Anal Flap
				Ligation of the Intersphincteric Fistula Tract
				Fistulotomy with Sphincter Reconstruction
				Anal Fistula Plug
				Fibrin Glue
				Newer and Evolving Technologies: VAAFT, FiLaC™, and Stem Cell
			Outcomes
				Seton
				Advancement Flap
				Ligation of the Intersphincteric Fistula Tract
				Anal Fistula Plug
				Fibrin Glue
				Fistulotomy with Sphincter Reconstruction
				Newer and Evolving Technologies: VAAFT, FiLaC™, and Stem Cell
		Rectourethral Fistulas
			Definition, Classification, and Pathophysiology
			Clinical Assessment and Diagnostic Evaluation
			Surgical Treatment
				Transanal Approach
				Posterior Approach
				Transperineal Approach
				Transabdominal Approach
			Outcome
		Postoperative Fistulas
			Definition, Classification, and Pathophysiology
			Clinical Assessment and Diagnostic Evaluation
			Surgical Treatment
			Outcome
	16: Rectovaginal Fistula
		Etiology of Rectovaginal Fistulas
			Obstetric Injury
			Cryptoglandular Disease
			Crohn’s Disease
		Evaluation of a Patient with a Rectovaginal Fistula
		Surgical Approaches to Repair of Rectovaginal Fistulas
		Endorectal Repairs
			Transperineal Repairs
			Tissue Transposition Repairs
				Martius Flap
				Gracilis Muscle Transposition
			Transvaginal Repairs
			Transabdominal Repair
			Alternate Repairs
		Choice of Technique for Repair
	17: Pilonidal Disease and Hidradenitis Suppurativa
		Background
			Etiology
				Clinical Presentation/Diagnosis
					Treatment
						Non-operative Management
						Operative/Excisional Management
						Basic Procedures
						Complex Procedures
						Karydakis Flap
						Cleft Lift Procedure (See Video 17.1)
						Rhomboid/Limberg Flap (See Video 17.2)
		Disease Recurrence
			Hidradenitis Suppurativa
				Etiology/Presentation/Diagnosis
				Treatment
					Medical Therapy
					Surgical/Excisional Therapy
	18: Dermatology and Pruritus Ani
		Introduction
		Pathophysiology of Perianal Signs and Symptoms
		Etiology and Contributing Factors
			Irritants
			Steroid-Inducing Itching
			Infectious
			Dermatologic
			Neoplasms
			Anorectal Conditions
			Systemic Diseases
		Diagnoses of Perianal Disease
			Physical Examination
				Infectious
				Dermatologic
				Neoplasms
			Biochemical Testing
			Microbiology Testing
			Patch Testing
			Anoscopy: Proctoscopy
			Biopsy
		Evidence-Based Management
			Aims of Treatment
			Primary Prutitis Ani
			Secondary Prutitis Ani
				Infectious
				Dermatologic
				Systemic Diseases
	19: Sexually Transmitted Infections
		Introduction
		Screening Guidelines for Asymptomatic High-Risk Patients
		Screening Guidelines for Symptomatic Patients
			Perianal or Genital Lesions
			Proctitis
			Proctocolitis
			Enteritis
		Diagnosis and Management of Sexually Transmitted Bacterial Infections
			Testing for Chlamydia and Gonorrhea
			Gonorrhea
				Epidemiology
				Clinical Presentation
				Screening and Testing for N. gonorrhoeae
				Treatment and Management of Gonorrhea
				Emerging Antibiotic Resistance
			Chlamydia
				Epidemiology
				Clinical Presentation
				Screening and Testing for C. trachomatis
				Treatment and Repeat Testing
			Lymphogranuloma Venereum
				Epidemiology
				Clinical Presentation
				Treatment
			Syphilis
				Epidemiology
				Clinical Presentation
				Testing Recommendations
				Treatment
			Chancroid
			Granuloma Inguinale aka Donovanosis
		Diagnosis and Management of Sexually Transmitted Viral Infections
			Herpes
				Epidemiology
				Clinical Presentation
				Testing and Screening
				Treatment
			Human Papillomavirus
				Epidemiology
				Clinical Presentation
				Testing
				Treatment
				Vaccine
			HIV and AIDS
				Epidemiology
				Testing
				Anorectal Issues
			Molluscum Contagiosum
			Pubic Lice: Phthirus pubis
			Scabies
	20: Anal Intraepithelial Neoplasia
		Introduction
			Symptoms
			Epidemiology
			Screening/Surveillance
			Diagnosis
		Treatment
		Management Strategies
		Progression
		Prevention
Part III: Malignant Disease
	21: Anal Cancer
		Anal Squamous Cell Carcinoma
		Anal Melanoma
		Anal Adenocarcinoma
	22: Presacral Tumors
		General Considerations
		Anatomic Considerations
		Classification
		Diagnosis
		Management
		Outcomes
	23: Molecular Basis of Colorectal Cancer and Overview of Inherited Colorectal Cancer Syndromes
		Chromosomal Instability
		Microsatellite Instability
		CpG Island Methylator Phenotype (CIMP)
		General Approach and Classification of Suspected Hereditary Syndromes
		Adenomatous Polyposis Syndromes
			Familial Adenomatous Polyposis
				Clinical Presentation
				Underlying Genetics
				Diagnosis
				CRC Risk
				FAP Extracolonic Manifestations
				Management
					Screening
				Treatment
					Colorectal
						Timing of Surgery
						Extent of Resection
					Duodenal Adenomas
					Desmoid Disease
					Thyroid Neoplasia
				Evaluation of At-Risk Relatives
			MUTYH-Associated Polyposis
				Clinical Presentation
				Underlying Genetics
				Diagnosis
				CRC Risk
				Extracolonic Cancer Risk
				Management
					Screening
					Treatment
				Evaluation of At-Risk Relatives
			Polymerase Proofreading-Associated Polyposis
		Hamartomatous Polyposis Syndromes
			Juvenile Polyposis Syndrome
				Clinical Presentation
				Underlying Genetics
				Diagnosis
				CRC and Extracolonic Risk
				Management
					Screening
					Treatment
				Evaluation of At-Risk Relatives
			Peutz-Jeghers Syndrome
				Clinical Presentation
				Underlying Genetics
				Diagnosis
				CRC and Extracolonic Risk
				Management
					Surveillance
					Polypectomy
					Surgery
				Evaluation of At-Risk Relatives
			PTEN Hamartoma Tumor Syndrome (PHTS)
				Clinical Presentation
				Underlying Genetics
				Diagnosis
				CRC and Extracolonic Risk
				CRC Risk Management
				Evaluation of At-Risk Relatives
		Serrated Polyposis Syndrome (SPS)
			Clinical Presentation
			Underlying Genetics
			Diagnosis
			CRC Risk
			Management
				Screening
				Treatment
			Evaluation of At-Risk Relatives
		Lynch Syndrome
			Underlying Genetics and Molecular Profile
				Distinguishing Lynch from Sporadic Epigenetic Changes: Methylation of MLH1 Gene Promoter
			Clinical Presentation and Spectrum of Disease
				Genotype-Phenotype Correlations
				Muir-Torre Syndrome (MTS)
				Turcot’s Syndrome
			Colorectal Cancer Risk
			Endometrial and Ovarian Cancer Risk
			Other LS-Associated Cancer Risk
			Diagnosis
				Screening and Diagnostic Strategies
					CRC in a Patient Without Known LS
					Individual with a Family Diagnosis of LS
					Individual Whose Family Meets Amsterdam Criteria but Does Not Have Any Clinical Phenotype
			Clinical Management
				Screening
				Modifiers of Risk for Colorectal and Other Cancers
				Surgery for Colorectal Cancer
				Prophylactic Surgery for Endometrial and Ovarian Cancer
			Evaluation of At-Risk Relatives
	24: Colorectal Neoplasms: Screening and Surveillance After Polypectomy
		Introduction
		Recommended Screening Guidelines
			Screening Options and Timing for Average-Risk Individuals
			Screening Guidelines for Individuals at an Increased Risk Based on Family History
			Screening Guidelines for Individuals Considered at High Risk Based on Genetics
			Screening Cessation
		Methods of Screening
			Colonoscopy
				Incomplete Colonoscopy
				Adjuncts to Colonoscopy
				Complications
			CT Colonography (CTC) or Virtual Colonoscopy
			Flexible Sigmoidoscopy
				Complications
			Fecal Occult Blood Testing (FOBT)/Fecal Immunochemical Testing (FIT)
			Stool DNA Testing
			Double-Contrast Barium Enema (DCBE)
		Status of Screening in the  United States
		Surveillance
			Guidelines for Surveillance After Polypectomy
				History
			Surveillance Based on Pathology of Polyp
				Hyperplastic and Serrated Polyps
				Adenoma
				Inflammatory Polyps
				Hamartomas Polyps
				Inflammatory Bowel Disease
			Surveillance with Cancer Resection
				Early Cancer (T1) Within Polyp
			When to Tattoo an Area After Polypectomy
			Benefits of Surveillance
			Status of Surveillance
				Chemoprevention
	25: Colon Cancer: Preoperative Evaluation and Staging
		Background
		Clinical Presentation
		Preoperative Evaluation
			Tumor Localization
			Total Colon Evaluation
			Carcinoembryonic Antigen (CEA)
			Radiographic Evaluation
		Preoperative Evaluation of Coexisting Medical Conditions
		Staging of Colon Cancer
			Lymph Node Evaluation
			Lynch Syndrome Phenotype
	26: The Surgical Management of Colon Cancer
		Preoperative Preparation
			Physiologic Assessment
			Tumor Localization
		Surgical Technique
			Extent of Resection
			Mesocolic Resection
			Right Colectomy
				Open Approach
				Lateral-to-Medial Approach
				Posterior (Inferior-to-Superior) Approach
				Superior to Inferior Approach
				Medial-to-Lateral Approach
				Anastomosis
				Laparoscopic Approach
				Medial-to-Lateral Approach
				Posterior (Inferior-to-Superior) Approach
			Left Colectomy
				Open
				Anastomotic Assessment
				Straight Laparoscopic Medial-to-Lateral Approach
				Hand-Assisted Medial-to-Lateral Approach
				Laparoscopic Identification of the Left Ureter
			Subtotal Colectomy
				Open Approach
				Laparoscopic Approach
			Total Abdominal Colectomy with Ileorectal Anastomosis
		Special Circumstances
			Laparoscopy
			Obstructing Colon Cancers
			Perforated Colon Cancers
			Management of Primary Colon Cancer in the Setting of Distant Metastasis
		Outcomes for Colon Cancer
			Short-Term Outcomes
			Long-Term Outcomes
	27: Rectal Cancer: Preoperative Evaluation and Staging
		Introduction
		History and Physical Examination
		Endoscopic Evaluation of the Rectum
		Total Colon Evaluation
		Locoregional Imaging
			Computed Tomography
			Endorectal Ultrasound
				T Staging
				N Staging
			Magnetic Resonance
		Whole-Body Imaging
			Computed Tomography
			Positron Emission Tomography (PET)
	28: Rectal Cancer: Neoadjuvant Therapy
		Introduction
		Historical Context
		Postoperative Radiotherapy
		Preoperative Radiotherapy
		Radiosensitizing Agents
		Preoperative Versus Postoperative Radiation
		Short- Versus Long-Course Preoperative Radiotherapy
		Impact of Pelvic Radiotherapy on Quality of Life
		Adjuvant Systemic Chemotherapy in Patients Treated with Chemoradiotherapy and Proctectomy
		Choosing Optimal Treatment Regimens
			The European Approach
			Selected Adjuvant Systemic Chemotherapy
			Chemotherapy Only to Improve Local Tumor Control
			Selective Nonoperative Management
	29: Local Excision of Rectal Neoplasia
		Transanal Surgery: A Historical Perspective
		Techniques
			Technique for Conventional Transanal Excision
			Technique for TEM and TEO
			Technique for TAMIS
		Transanal Excision of Benign Rectal Polyps
			Results
		TES for Rectal Cancer
			Predicting Risk of Lymph Node Metastasis
			Depth of Invasion
			Lymphovascular Invasion
			Poor Differentiation
			Tumor Budding
			Location and Mucinous Histology
			Imaging for Early Rectal Cancer Staging
		Oncologic Results Following Local Excision of Rectal Cancer
		Local Excision for T1 Cancer
		Local Excision for T2NX Cancer
		Surveillance and Salvage Following Local Excision of Rectal Cancer
		Complications of TAE
	30: Rectal Cancer: Watch and Wait
		Introduction
		Neoadjuvant Chemoradiotherapy
		The Watch and Wait Approach
		Clinical Assessment of Treatment Response
		Increasing the Rate of Complete Response
	31: Proctectomy
		Background and General Concepts
		Anatomy of the Mesorectum/Rectal Fascia
		Surgical Principles of Proctectomy for Rectal Cancer
			Pathological Assessment
		Preoperative Preparation
		Operative Approaches
			Abdominal Exploration and Decision-Making
			Open Low Anterior Resection (LAR)
			Laparoscopic Low Anterior Resection
			Robotic Low Anterior Resection
		Abdominoperineal Resection (APR)
		Extralevator or “Cylindrical” APR
		Special Considerations
			Distal Margin
			Coloanal Anastomosis
				Options for Reconstruction of the Gastrointestinal Tract
				Fecal Diversion
			Extended Resection
			Intraoperative Radiation Therapy
			Flap Closure Following Abdominoperineal Resection
		Functional Outcomes
		Oncologic Outcomes
		Multidisciplinary Rectal Cancer Care
	32: Rectal Cancer Decision-Making
		Assessment
		Early Rectal Neoplasms
			Local Excision
			Endoscopically Excised Malignant Polyps
			Operable and Locally Advanced Lesions
		Surgical Considerations
			Intraoperative Decisions
			Midrectal Cancers
			Low Rectal Cancers
			Low Hartmann Resection Versus APR
		Special Situations
			Obstructing Rectal Cancer
			Perforated Rectal Cancer
			Synchronous Hepatic Metastases
	33: Colorectal Cancer: Postoperative Adjuvant Therapy
		Colon Cancer
			Stage III Colon Cancer
			Stage II Colon Cancer
			Radiotherapy for Colon Cancer
		Rectal Cancer
			Patients Who Did Not Undergo Neoadjuvant Therapy
			Patients Who Underwent Neoadjuvant Radiotherapy/Chemoradiotherapy
			Patients Undergoing Local Excision
	34: Colorectal Cancer: Surveillance After Curative-Intent Therapy
		Introduction
		Timing and Choice of Surveillance Modalities
			Intensity of Surveillance
			Physical Examination
			Laboratory Testing
			Abdominal Imaging
			Chest Imaging
			Colonoscopy
		Stage 1 Disease
		Local Surveillance for Rectal Cancer
		Compliance with Guidelines
		Quality of Life
		Cost
	35: Colorectal Cancer: Management of Local Recurrence
		Introduction
		Diagnosis of Local Recurrence
		Preoperative Evaluation and Patient Selection
			Classification of Local Recurrence
			Determining Resectability
		Multimodal Therapy Including Intraoperative Radiation
		Technical Aspects of Surgical Resection
			General Considerations
			Recurrent Colon Cancer
			Recurrent Rectal Cancer
				Recurrences that Extend Anteriorly
			Resection that Includes Sacrectomy
				Stage I: Anterior Component
				Stage II: Posterior Component
				Stage III: Spinal Reconstructive Component
			Soft Tissue Reconstruction
		Results of Surgery
			Recurrent Colon Cancer
			Recurrent Rectal Cancer
			Surgery for Re-recurrent Disease
			Resection that Includes the Aortoiliac Axis
			Sacropelvic Resections
			Postoperative Complications and Quality of Life
		Palliative Approach
	36: Colorectal Cancer: Management of Stage IV Disease
		Introduction
		Diagnostic Strategies
			Computed Tomography
			Positron Emission Tomography (PET)
			Magnetic Resonance Imaging
			Contrast-Enhanced Ultrasound
			Biopsy
		Multidisciplinary Evaluation
		Surgical Emergency
		Palliative Management of Primary Cancer: Laser, Fulguration, and Stents
			Incidence and Presentation
			Laser Therapy and Fulguration
			Self-Expanding Intraluminal Metal Stents
		The Challenge of Primary Tumor Management in Asymptomatic Stage IV Colorectal Cancer: To Resect or Not to Resect?
		Surgical Therapy of Liver Metastases
			Combination Liver and Colon Resection
				Liver-First Strategy
				Colon-First Strategy
					Margin Status
					Ablation of Liver Metastases
					Other Liver Metastasis Strategies: Hepatic Intra-arterial Chemotherapy/Chemoembolization
		Pulmonary Metastasis
		Peritoneal Metastasis
		Ovarian Metastases
		Other Sites of Metastasis
			Bone
			Brain
			Pancreas
			Adrenal
			Retroperitoneal Lymph Nodes
		Metastatic Disease in the Elderly
	37: Appendiceal Neoplasms
		Introduction
		Epidemiology
		Anatomical Pathology and Staging
			Epithelial Neoplasms
			Neuroendocrine Appendiceal Lesions/Carcinoid Tumors
			Goblet Cell Carcinoids
		Clinical Features
		Diagnostic Procedures
		Medical Management
		Surgical Treatment of Appendiceal Lesions
			Appendectomy
			Right Hemicolectomy
			Cytoreductive Surgery and HIPEC
	38: Carcinoids, GISTs, and Lymphomas of the Colon and Rectum
		Carcinoid Tumors
			Histology
			Incidence and Distribution
			Clinical Presentation
			Carcinoid Syndrome
			Diagnostic Tests
			Treatment
		GISTs
			Histology
			Incidence and Distribution
			Clinical Presentation
			Diagnostic Tests
			Treatment
		Lymphomas
			Histology
			Incidence and Distribution
			Clinical Presentation and Diagnostic Tests
			Treatment
	39: Diverticular Disease
		Introduction
		Incidence
		Pathophysiology, Etiology, and Epidemiology
		Histology and Pathology
			Role of Fiber
		Alternative Pathophysiology Pathways and Taenia-Specific Elastosis
		Additional Risk Factors
			Age
			Geographic Factors
			Obesity
		Clinical Manifestations and Physical Findings
			Symptoms
			Diagnostic Evaluation
			Endoscopic Evaluation
			Differential Diagnosis
		Treatment of Acute Diverticulitis
			Treatment of Uncomplicated Diverticulitis
				Antibiotics
		Elective Surgical Management of Recurrent Uncomplicated Diverticulitis
		Young Patients
		Complicated Diverticular Disease
			Diverticular Abscess
			Perforated Diverticulitis
			Fistulas
				Colovesical Fistulas
				Colovaginal Fistulas
				Colocutaneous Fistula
			Diverticular Stricture/Obstruction
		Operative Therapy
			Elective Management
			Minimally Invasive Surgery
			Urgent and Emergent Procedures
			Minimally Invasive Colectomy for Complicated Disease
		“Special Situations”
			Recurrent Diverticulitis
			Giant Colonic Diverticulum
		Diverticulitis: Other Sites
			Right Colonic Diverticulitis
			Rectal Diverticulitis
			Transverse Colonic Diverticulitis
		Immunocompromised Patients
	40: Large Bowel Obstruction
		Introduction
		Etiology
		Pathophysiology
		Presentation
		Initial Resuscitation (Fig. 40.5)
		Diagnostic Imaging
			Abdominal Plain Film
			Contrast Enema (CE)
			Computed Tomography
		Management
			Emergent Setting (Fig. 40.5)
				Unresectable Lesion (Fig. 40.9)
				Resectable Lesion (Fig. 40.10)
			Non-emergent Setting (Fig. 40.10)
				Endoscopy and CE
				Self-Expanding Metallic Stents
					Technique
					Results
				Palliation
			Benign Disease and Right-Sided Lesions
				Resection
				On-Table Colonic Lavage
					Technique
					Results
		Special Circumstances
			Volvulus
				Sigmoid Volvulus
					Presentation and Diagnosis
					Treatment
				Cecal Volvulus
					Presentation and Diagnosis
					Treatment
				Uncommon Types
					Ileosigmoid Knotting
				Splenic and Transverse Colon Volvulus
			Acute Colonic Pseudo-Obstruction (ACPO)
		Other
			Endometriosis
			Fecal Impaction
			Gallstone
			Intussusception
	41: Lower Gastrointestinal Hemorrhage
		Introduction
		Epidemiology
		Etiologies of Lower Gastrointestinal Bleeding
			Benign Anorectal Causes: Hemorrhoidal Bleeding and Fissures
			Diverticulosis Coli
			Angioectasia
			Ischemic Colitis
			Neoplasms of the Large Intestine
			Additional Causes of LGIB
		Models Predicting Severity of Lower Gastrointestinal Bleeding
		Presentation, Evaluation, and Management
			Colonoscopy
			Radionucleotide Scintigraphy
			Computed Tomography Angiography (CTA)
			Angiography
				Diagnostic Angiography
				Therapeutic Angiography
			Localization of Small Bowel Bleeding
			Surgery
		Summary
	42: Endometriosis
		Introduction
		Epidemiology
		Etiology
		Clinical Manifestations
			Pelvic Pain and Dysmenorrhea
			Infertility
			Intestinal Symptoms
			Malignant Transformation
		Diagnosis
			Physical Examination
			Laboratory Evaluation
			Endoscopy
			Imaging Techniques
			Laparoscopy
		Treatment
			Medical Management
				Oral Contraceptives
				Danazol
				Gonadotropin-Releasing Hormone Agonists
			Surgical Management
			General Principles
				Rectovaginal Endometriosis
			Small Bowel and Appendiceal Endometriosis
			Results After Surgical Therapy
			Combined Medical and Surgical Therapy
	43: Trauma of the Colon, Rectum, and Anus
		Introduction
		Colon Trauma
			Epidemiology
			Diagnosis
			History of Military Colon Injury Management
			Current Operative Management
			Technical Considerations
		Rectal and Anal Trauma
			Epidemiology
			Diagnosis
			Current Management and Technical Considerations
	44: Inflammatory Bowel Disease: Pathobiology
		Introduction
			The Host Environment in UC and CD
				Possible Infectious Causes of IBD
				Smoking
				Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
				The Microbiome
				Appendectomy
		The Role for Genetics in IBD
		Innate Immunity in Crohn’s Disease
			Epithelial Barrier Function
			Autophagy
			Macrophages
			APCs: The Bridge Between the Innate and Adaptive Immune Systems
		Adaptive Immunity in Crohn’s Disease
			Cytokine Signaling
		Innate Immunity in Ulcerative Colitis
		Adaptive Immunity in Ulcerative Colitis
		Genetic Correlates Suggesting Mechanisms of Disease in IBD
			Innate Immunity
				Epithelial Barrier
				Pathogen Recognition and Autophagy
					NOD2/CARD15
			The Adaptive Immune System
		The Molecular Basis of Malignant Degeneration
		Surgical Genetics in IBD
	45: IBD Diagnosis and Evaluation
		Inflammatory Bowel Disease: Diagnosis and Evaluation
			Context
			Ulcerative Colitis
			Crohn’s Disease
			IBD Histology
				Ulcerative Colitis
				Crohn’s Disease
				Indeterminate Colitis
			Serology and Markers of Disease
				ASCA and pANCA
				Fecal Markers
				Inflammatory Markers
			Endoscopy in IBD
				Flexible Endoscopy
				Capsule Endoscopy
			Radiology in IBD
				Plain Radiography
				CT
				MRI
				Ultrasound
				Evolving Role of CTE and MRE
	46: Medical Management of Chronic Ulcerative Colitis
		Part 1: Defining CUC
			Introduction
			Diagnosis
			Colonoscopy
			Imaging
			Serology
			Infectious Work-Up
			Epidemiology
			Colorectal Adenocarcinoma
			Classification of CUC
			Treatment Endpoints
			Cost Considerations
		Part 2: Specific Treatments
			Bottom-Up Versus Top-Down Strategies
			Aminosalicylates (5-ASA Moieties)
			Immunomodulator Therapy (6-MP, Azathioprine)
			Biologic Agents
				Anti-TNF-Alpha Antibodies
					Infliximab (Remicade®)
					Adalimumab (Humira®)
					Certolizumab Pegol (Cimzia®)
						Golimumab (Simponi®)
				Anti-integrin Antibodies
					Vedolizumab (Entyvio®)
			“Rescue” Therapy
				Corticosteroids
				Cyclosporine/Tacrolimus
				Methotrexate (MTX)
		Part 3: Medical Management of Mild-to-Severe CUC
			Mild-to-Moderate Distal Colitis/Proctitis (Fig. 46.13)
			Mild-to-Moderate Extensive Colitis (Fig. 46.13)
			Severe Colitis (Fig. 46.14)
	47: Medical Management of Crohn’s Disease
		Introduction
		Disease Classification
		Disease Severity
		Medications
			Probiotics
			Antibiotics
			5-Aminosalicylate Compounds
			Glucocorticoids
			Immunomodulators
				Thiopurines
				Methotrexate
			Biologic Agents (See Also Chap. 46)
				Antitumor Necrosis Factor (TNF) Agents
				Integrin Receptor Antagonists
		Induction and Maintenance of Remission
			Induction of Remission
				Mild Disease
				Moderate Disease
				Severe Disease
			Maintenance of Remission
		Medical Prophylaxis After Surgery
	48: Anorectal Crohn’s Disease
		Introduction
		Incidence and Natural History
		Etiology
		Clinical Presentation
		Diagnosis
		Classification
		Skin Tags
			Management
		Hemorrhoids
			Management
		Anal Fissure and Ulcer
			Management
		Abscess and Fistula
			Abscess
				Management
			Fistula
				Management
					Medical Therapy
						Aminosalicylates and Corticosteroids
						Antibiotics
						Immunosuppressives
						Biologics
							Infliximab
							Adalimumab
							Certolizumab Pegol
							Natalizumab
							Vedolizumab
					Surgical Therapy
						Seton
						Fistulotomy
						Fibrin Glue
						Anal Fistula Plug
						Adipose Tissue-Derived Stem Cells
						Ligation of Intersphincteric Tract
						Endorectal Advancement Flap
						Diversion
						Proctectomy
		Anorectal Stricture
			Management
		Anal Cancer
			Management
	49: Crohn’s Disease: Surgical Management
		Surgery in the Treatment of Crohn’s Disease
		Changing Trends in the Era of Immunomodulators and Biologics
		Indications for Surgery
			Failure of Medical Management
			Obstruction
			Perforation
			Bleeding
			Abscesses
			Fistula
			Cancer and Dysplasia
			Toxic Colitis
		Surgical Considerations
			Preoperative Evaluation
			History and Physical
			Nutritional Assessment and Role of TPN in Crohn’s Treatment
		Operative Considerations: Overview
			Laparoscopic Surgery and Crohn’s Disease
		Operative Considerations for Specific Locations
			Upper Small Bowel Disease
			Terminal Ileal Disease
			Colonic and Rectal Disease
		Special Considerations
			Ileosigmoid Fistula
			Complex Perineal Wounds After Proctectomy
			Recurrence of Disease
	50: Ulcerative Colitis: Surgical Management
		Introduction
		Indications for Surgery
			Elective Surgery
			Emergent Surgery
			Staged Operations
		Operative Technique and Surgical Decision-Making
			Preoperative Planning
			Brooke Ileostomy
				Operative Details
				Operative Considerations
				Outcomes
			Continent Ileostomy
				Operative Details
				Operative Considerations
				Outcomes
			Total Abdominal Colectomy with Ileorectal Anastomosis (TAC-IRA)
				Operative Details: Open Approach
				Operative Details: Laparoscopic Approach
				Outcomes
		Total Proctocolectomy with End Ileostomy
			Operative Details: Open Proctectomy
			Operative Details: Laparoscopic Proctectomy
			Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis (RPC-IPAA)
				Operative Technique
				Special Considerations
					Pouch Configuration
					Anastomosis
					Optimizing Reach
					Crohn’s Disease
	51: Complications of the Ileal Pouch
		Introduction
		Intraoperative Complications
		Problems with Reach of the Pouch
		Pouch Ischemia
		Problems with Stoma Creation
		Problems with Staplers and Creating the Anastomosis
		Early Postoperative Complications
		Anastomotic Leak and Pelvic Sepsis
		Bleeding from the Pouch
		Late Postoperative Complications
		Pouch-Vaginal Fistula
		Treatment Options for PVF
			Advancement Flap Repair
			Transvaginal Repair
			Perineal Pouch Advancement
			Redo IPAA
			Proximal Diversion
		Pouch-Perineal Fistula
		Pouch Sinus
		Crohn’s Disease After Pouch Surgery
		Incontinence
		Outlet Obstruction
		Pouchitis and Cuffitis
		Pouch Prolapse
		Leak from the Tip of the “J”
		Dysplasia and Cancer After Pouch Surgery
		Small Bowel Obstruction
		Sexual Dysfunction
		Infertility
	52: Infectious Colitides
		Introduction
		Bacterial Colitides
			Campylobacter
			Salmonella
			Shigella
			Escherichia coli
			Yersinia
			Vibrio
			Other Bacterial Colitides
		Parasitic Colitides
			Entamoeba
			Anisakis
			Ascaris
			Strongyloides
			Trichuris
			Enterobius
			Cryptosporidium
			Balantidium
			Giardia
			Schistosomiasis
			Tapeworms
			Trypanosoma
		Viral Colitides
			Cytomegalovirus
			Other Viruses
		Fungal Colitides
			Histoplasma
			Candida
			Other Fungi
		Special Situations
			Traveler’s Diarrhea
			Infections in Inflammatory Bowel Disease
			Diarrhea and HIV
			Diarrhea and Solid Organ Transplantation
	53: Clostridium difficile Infection
		Introduction
		Epidemiology
			Rising Incidence and Increasing Severity
		Clinical Risk Factors for CDI
			Advanced Age
			Contact with a Healthcare Facility
			Use of Antibiotics and Their Effect on the Microbiome
		Perioperative Prophylactic Antibiotics and Mechanical Bowel Preparations
		Immunocompromised States
		Inflammatory Bowel Disease (IBD)
		Proton Pump Inhibitors
		Hospital Environmental Factors
		Microbiological Considerations for Clostridium difficile
			Pathogenicity Locus Genes
		Diagnosis of C. difficile Infection
			Clinical Presentation
			Laboratory Diagnosis
		Clinical Severity Scores
		Antibiotic Therapy for CDI
			Metronidazole and Vancomycin
			Fidaxomicin
		Surgery for CDI
		Fecal Microbiota Transplant (FMT)
	54: Radiation, Microscopic, and Ischemic Colitis
		Radiation Colitis
			Introduction
			Pathogenesis of Radiation Injury
			Prevention
			Acute Radiation Colitis and Proctitis
			Chronic Radiation Colitis and Proctitis
			Diagnosis
			Management
			Medications
				Endoscopy
				Surgery
		Microscopic Colitis
			Introduction
			Epidemiology
		Etiology and Risk Factors
			Smoking
			Medications
			Autoimmunity
		Clinical Manifestations
			Clinical Presentation
			Complications
		Diagnosis
		Management
			Budesonide
			Prednisolone
			Cholestyramine and Loperamide
			Aminosalicylates
			Immunosuppressive and Anti-TNF Medications
			Bismuth Subsalicylate
			Surgery
		Ischemic Colitis
			Introduction
			Anatomy and Physiology
			Epidemiology and Risk Factors
			Pathophysiology
				Nonocclusive Ischemia
				Arterial Thrombosis and Emboli-Related Ischemia
				Venous Thrombosis
			Clinical Presentation
			Diagnosis
				Laboratory Studies
				Imaging
					Plain Films and Contrast Enema
					Abdominal CT Scan
					Endoscopy
					Arteriography
					Ultrasound
			Management
				General Principles
				Antibiotics
				Antithrombotic
				Surgical Management
			Prognosis
	55: Intestinal Stoma
		Introduction
		Colostomy
			Configuration (Fig. 55.1)
			Physiology
		Small Bowel Stomas
			Configuration
			Physiology
		Preoperative Considerations for the Ostomate
			Stoma Site Marking (Fig. 55.3)
			Preoperative Stoma Education
		Technical Considerations of Stoma Creation
			Small Bowel: Making the Aperture
			Small Bowel End Stoma
			Small Bowel Loop Stoma
			End Colostomy
			Loop Colostomy
		Postoperative Care for the Stoma
			Early Inpatient Postoperative Care
			Postoperative Outpatient Care
			Stoma Appliances
		Stoma Complications
			Stomal Ischemia: Necrosis, Retraction, and Stenosis
			Peristomal Skin Disorders
			Peristomal Pyoderma Gangrenosum
			Peristomal Varices
			Stomal Prolapse
			Parastomal Hernia
			Peristomal Abscess
			High-Output Small Bowel Stomas
		Stoma Reversal
			Preoperative Preparation
			Timing
			Technical Consideration of Loop Stoma Reversal
			Technical Consideration of End Stoma Reversal
			Stoma Reversal Complications
		Special Considerations
			The Difficult Stoma
			Temporary Fecal Diversion: Loop Ileostomy Versus Loop Colostomy
			Genitourinary Stomas
			Ileostomy and Foodstuff Bolus Obstruction
			The Turnbull-Blowhole Colostomy (Fig. 55.17)
	56: Functional Complications After Colon and Rectal Surgery
		Introduction
		Low Anterior Resection Syndrome
			Symptoms and Prevalence
			Etiology of LARS
			Risk Factors for LARS
			Evaluation and Bowel Dysfunction After LAR
			Treatment for Bowel Dysfunction After LAR
			Retrograde Colonic Irrigation
			Sacral Nerve Stimulation (SNS)
		Colorectal Reconstruction and Effects on Function After Colorectal Surgery
			Colonic J Pouch
			Transverse Coloplasty
			Side-to-End Anastomosis
		Sexual and Urologic Dysfunction After Surgery for Rectal Cancer
			Nerves of the Pelvis
			Sexual Dysfunction After Surgery for Rectal Cancer
			Urologic Dysfunction
		Perianal Skin Irritation After Colorectal Surgery
	57: Common Tests for the Pelvic Floor
		Introduction
		History
		Questionnaires
			Fecal Incontinence: Four Will Be Reviewed Below
			Constipation
		Physical Exam
		Anatomic Evaluation
			Ultrasound 2-D
			Ultrasound 3-D
			Dynamic US
			MRI
		Functional Evaluation
			Anal Manometry (AM)
				Manometry Technique
				Resting Pressure (RP)
				Squeeze Pressure
				Cough Reflex
				Valsalva
				Rectoanal Inhibitory Reflex (RAIR)
				Rectal Sensation
				Compliance
				Balloon Expulsion
				Neurophysiologic Testing
				Needle EMG
				Surface
				Pudendal Nerve Terminal Motor Latency (PNTML)
			Transit Testing
				Radiopaque Markers
				Breath Testing
				Scintigraphy
				Wireless Motility Capsules
		Anatomic and Functional Evaluation
			Defecography
				Normal Parameters
				Rectocele
				Rectal Intussusception
				Rectal Prolapse
				Enterocele and Sigmoidocele
				Descending Perineum Syndrome
			Dynamic MRI
	58: Evaluation of Constipation and Treatment of Abdominal Constipation
		Prevalence
		Etiology of Constipation
		Constipation Subtypes
			Slow Transit Constipation
			Normal Transit Constipation
			Pelvic Constipation
		History and Physical Examination
		Diagnostic Testing
		Slow Transit Constipation
			Medical Management of Slow Transit Constipation
			Surgical Therapy of Slow Transit Constipation
			Abdominal Colectomy
			Segmental Colectomy
			Proctocolectomy with Ileal Pouch-Anal Anastomosis
			Ileostomy Creation
			Antegrade Colonic Enema
			Sacral Nerve Stimulation
		Summary
	59: Obstructed Defecation
		Introduction
		Etiology of Constipation
		Evaluation of Obstructed Defecation
			Endoscopy
			Colon Transit Study
			Balloon Expulsion Study
			Anorectal Manometry
			Anorectal Electromyography
			Defecography
		Interpretation of Test Results
		Etiology and Treatment of Obstructed Defecation
			Hydration/Lifestyle Modification/Fiber Intake
			Pelvic Floor Physical Therapy Retraining
		Pelvic Organ Prolapse
			Rectal Prolapse: Overt
			Rectal Prolapse: Occult
			Rectocele
			Enterocele with or Without Vaginal Vault Prolapse
		Nonanatomic Causes of Obstructed Defecation
			Paradoxical Puborectalis Contraction
			Rectal Hyposensitivity
		Fecal Diversion
		Conclusion
	60: Rectal Prolapse
		Introduction
		Patient Evaluation
			Non-operative Treatment
			Surgical Approaches for Rectal Prolapse
		Description of Surgical Interventions
			Anal Encirclement
			Perineal Procedures
				Delorme
				Perineal Rectosigmoidectomy (Fig. 60.1)
			Abdominal Procedures
				Transabdominal Rectopexy
				Transabdominal Resection Rectopexy
			Mesh Rectopexy
			Ripstein Procedure (Anterior Sling Rectopexy)
			Posterior Mesh Rectopexy
			Laparoscopic Ventral Rectopexy
			Robotic Rectopexy
		Rectal Prolapse in the Elderly
		Recurrent Rectal Prolapse: What Is the NEXT Operation?
		Combined Vaginal and Rectal Prolapse Procedures
		Solitary Rectal Ulcer Syndrome
	61: Evaluation and Treatment of FI
		Introduction
		Assessment Instruments
		Management
			Medications and Lifestyle Modifications
				Biofeedback
		Preoperative Testing
			Anorectal Physiology Testing
			Ultrasound
		Surgical Techniques
			General Considerations
			Overlapping Sphincteroplasty
			Sacral Neuromodulation
			Sphincter Augmentation Procedures
				Radiofrequency Energy Delivery
				Biomaterial Injection
			Sphincter Replacement Strategies
		Stoma and Alternatives
		Conclusions
	62: Functional Bowel Disorders for the Colorectal Surgeons
		Introduction
		Irritable Bowel Syndrome
			Epidemiology
			Pathophysiology
			Diagnosis and Symptoms
			Treatment
			Diarrhea-Predominant IBS (IBD-D)
			Constipation-Predominant IBS (IBS-C)
		Chronic Functional Pelvic Pain
			Chronic Proctalgia
				Coccygodynia
			Pudendal Neuralgia
		Conclusion
	63: Middle and Anterior Compartment: Issues for the Colorectal Surgeon
		Introduction
		Anatomy of the Pelvic Floor
		Evaluation of Pelvic Organ Prolapse
		Overview of Urodynamics
		Surgical Management of Middle and Anterior Compartment
			Transvaginal Repair
			Abdominal Repair
		Surgical Management of the Posterior Compartment: Approach to the Rectocele Repair
			Transvaginal
			Transanal Repair
Part IV: Miscellaneous
	64: Pediatric Colorectal Disorders
		Congenital Anomalies
			Cloacal Anomalies
				Mechanisms Underlying Cloacal Anomalies
				Current Therapy
			Anorectal Atresia
				Current Therapies
			Hirschsprung Disease
				Current Therapies
		Acquired Diseases
			Necrotizing Enterocolitis
				Current Therapies
		Constipation and Anorectal Incontinence (Fig. 64.7)
			Surgical Treatment for Chronic Functional Constipation
		Constipation and Fecal Incontinence in Children with Hirschsprung Disease (HD) or Anorectal Malformations (ARM)
			Diagnostic Workup and Therapy
		Inflammatory Bowel Disease in Children
			Treatment
	65: Considerations for Geriatric Patients Undergoing Colorectal Surgery
		Introduction
		Current Outcomes in the Geriatric Population
			Fecal Incontinence
			Diverticulosis/Diverticulitis
			Rectal Prolapse
			Colonic Volvulus
			Inflammatory Bowel Disease
			Colon Cancer
			Rectal Cancer
		Laparoscopic Surgery in the Elderly
		Re-operative Evaluation in the Geriatric Patient
			Cardiac Evaluation
			Pulmonary Evaluation
			Diabetes and Glucose Management
			Nutritional Assessment
			Anemia and Hematologic Disorder Evaluation
			Dementia and Mental Status Evaluation
			Current Risk Assessment
				Frailty
				Comprehensive Geriatric Assessment (CGA)
		Current Recommendations
	66: Health-Care Economics
		Introduction
		Physician Reimbursement
			Fee-for-Service (FFS): Resource-Based Relative Value Scale (RBRVS)
		Fee-For-Service: Why Did It Fail?
		The Patient Protection and Affordable Care Act of 2010 (P.L. 111–148)
			ACA: Cost Containment Changes
			Improving Quality/Health System Performance
			National Quality Strategy
		Alternative Payment Models
			The Patient-Centered Medical Home
			Accountable Care Organizations
			Bundled Payment Pilot Projects
			Clinical Integration
			Clinical Integration and the Employed Physician: What About Contracting?
			Fee-for-Service Model: Based on the Work-RVU
			Geisinger Health System Physician Compensation Model
				Base Salary
				Performance Incentives for Specialist Physicians
			Massachusetts General Physicians Organization’s Incentive Program
		Appendix 66.1
		Physician Compensation Model 1: Guaranteed Salary
		Appendix 66.2
		Physician Compensation Model 2: Work-RVU-Based Compensation
		Appendix 66.3
		Physician Compensation Model 3: Work-RVU Compensation with a Base Salary (Guaranteed)
	67: Ethical Issues in Colorectal Surgery
		Introduction
		Ethical Reasoning
		Informed Consent
			Threshold Elements (Preconditions)
			Transformation Elements
			Consent Elements
		Surrogate Decision-Making
		Futility
		Refusal of Care
		Outcome Disparities in Colorectal Surgery
		Physician Financial Conflicts of Interest
		Conclusion
	68: Welcome to Litigation
		Preparation: The Key to Success
		Stages of the Litigation Process
			Initiation of the Litigation Process
				Notice of an Occurrence Likely to Lead to Litigation
		Teaching Points
			Notice of Events Which Suggest that Litigation Is Imminent: Handling Requests for Medical Records
			Service of the Summons and Complaint: Initial Meeting with Counsel
		Teaching Points
		Teaching Points
			The Discovery of the Process
				Written Discovery
				Your Deposition
		Teaching Points
			The Trial
		Teaching Points
	69: Surgical Education
		Introduction
		Challenges to Surgical Education
			Competency-Based Medical Education (CBME)
		Strategies Outside of the Operating Room
		Understanding Competency-Based Medical Education (CBME)
		Assessment of Performance
		In-Training Evaluation Report (ITER)
		Mini-CEX
		360-Degree Evaluation
		Oral Examinations
		Portfolios
		Technical Skills Assessment
			Logbooks and Case Numbers
			Procedure-Based Assessment
			Simulation/Virtual Reality in Technical Skills Assessment
			GAS and L-CAT of the National Training Programme in England
			Colorectal Objective Structured Assessment of Technical Skills (COSATS)
			Global Rating Forms
		How Can CBME Be Applied to Colorectal Residency Training?
		Conclusions
	70: Maintenance of Certification: Current Status and Future Considerations
		Introduction: How We Came to Be Here
		The Reasoning and Evidence for Institution of the ABMS MOC Program
		Is the MOC Program Performing as It Should?
		Challenges Presented to Diplomates
		Challenges for Member Boards
		Decreasing the Burden of MOC
		ABCRS: Current Requirements, Initiatives Under Consideration
	71: Quality and Safety in Colon and Rectal Surgery
		Background
		The Conceptual Model of Quality Measurement: Donabedian Model
			Structural Measures
			Process Measures
			Outcomes
		Safety
			High Reliability Organizations
			Creating a Culture of Safety
			Measuring Safety Culture
			Teamwork and Communication
			Measuring Teamwork
			Tools for Improving Safety Culture, Teamwork, and Communication
			“Never Events” in Surgery
			Patient and Families as Partners
		Appendix 71.1: American College of Surgeons National Quality Improvement Program-Targeted Colectomy and Proctectomy Procedure Measures. With Permission from © American College of Surgeons
	72: Practice Management
		Introduction
		Practice Models
			Practice Philosophies in Hospital and Private Practice Models
				The Hospital Model
				The Private Practice Model
		The Basics of Payment, Compensation, Profits, and Billing
			Compensation
				Relative Value Scale System
				RVU-Based Compensation
			Production-Based Compensation
				Non-production-Based Compensation
			Bonus Structure
			Budgets, Billing, and Collections
			Billing and Coding
		Setting Up Your Office
			Attracting Patients
			Playing Nicely with Others
			Staff and Colleagues
			Contracts
		Considerations When Moving Between Practice Models
Index