Surgery_Schwartz

Surgery_Schwartz. of necrotizing peri-neal soft tissue infections remains approximately 50%.ABCFigure 29-37. A through C. Technique of drainage of perianal abscess.Figure 29-38. Drainage of horseshoe abscess. The deep postanal space is entered, incising the anococcygeal ligament. Counter drain-age incisions are made for each limb of the ischiorectal space.Brunicardi_Ch29_p1259-p1330.indd 131623/02/19 2:30 PM 1317COLON, RECTUM, AND ANUSCHAPTER 29surgical treatment is dictated by the location of the internal and external openings and the course of the fistula. The exter-nal opening is usually visible as a red elevation of granu-lation tissue with or without concurrent drainage. The internal opening may be more difficult to identify. Injection of hydrogen peroxide or dilute methylene blue may be helpful. Care must be taken to avoid creating an artificial internal opening (thus often converting a simple fistula into a complex fistula).Simple intersphincteric fistulas can often be treated by


Surgery_Schwartz

Surgery_Schwartz. helpful. Care must be taken to avoid creating an artificial internal opening (thus often converting a simple fistula into a complex fistula).Simple intersphincteric fistulas can often be treated by fistulotomy (opening the fistulous tract), curettage, and healing by secondary intention (see Fig. 29-40A). “Horseshoe” fistulas usu-ally have an internal opening in the posterior midline and extend anteriorly and laterally to one or both ischiorectal spaces by way of the deep postanal space. Treatment of a transsphincteric fistula depends on its location in the sphincter complex. Fistulas that include less than 30% of the sphincter muscles can often be treated by sphincterotomy without significant risk of major incontinence (see Fig. 29-40B). High transsphincteric fistulas, which encircle a greater amount of muscle, are more safely treated by initial place-ment of a seton. Similarly, suprasphincteric fistulas are usually treated with seton placement (see Fig. 29-40C). Extrasphincteric


Surgery_Schwartz

Surgery_Schwartz. a greater amount of muscle, are more safely treated by initial place-ment of a seton. Similarly, suprasphincteric fistulas are usually treated with seton placement (see Fig. 29-40C). Extrasphincteric fistulas are rare, and treatment depends on both the anatomy of the fistula and its etiology. In general, the portion of the fistula outside the sphincter should be opened and drained. A primary tract at the level of the dentate line may also be opened if pres-ent. Complex fistulas with multiple tracts may require numerous procedures to control sepsis and facilitate healing. Liberal use of drains and setons is helpful. Failure to heal may ultimately require fecal diversion (see Fig. 29-40D). Complex and/or non-healing fistulas may result from Crohn’s disease, malignancy, radiation proctitis, or unusual infection. Proctoscopy should be performed in all cases of complex and/or nonhealing fistulas to assess the health of the rectal mucosa. Biopsies of the fistula tract should be taken to


Surgery_Schwartz

Surgery_Schwartz. or unusual infection. Proctoscopy should be performed in all cases of complex and/or nonhealing fistulas to assess the health of the rectal mucosa. Biopsies of the fistula tract should be taken to rule out malignancy.A seton is a drain placed through a fistula to maintain drain-age and/or induce fibrosis. Cutting setons consist of a suture or a rubber band that is placed through the fistula and intermittently tightened in the office. Tightening the seton results in fibrosis and gradual division of the sphincter, thus eliminating the fis-tula while maintaining continuity of the sphincter. A noncutting seton is a soft plastic drain (often a vessel loop) placed in the fistula to maintain drainage. The fistula tract may subsequently be laid open with less risk of incontinence because scarring pre-vents retraction of the sphincter. Alternatively, the seton may be left in place for chronic drainage. Higher fistulas may be treated by an endorectal advancement flap. Fibrin glue and a variety


Surgery_Schwartz

Surgery_Schwartz. pre-vents retraction of the sphincter. Alternatively, the seton may be left in place for chronic drainage. Higher fistulas may be treated by an endorectal advancement flap. Fibrin glue and a variety of collagen-based plugs also have been used to treat persistent fistulas with variable results. A more recent technique, ligation of the intersphincteric fistula tract (LIFT), also shows promise. In this procedure, the fistula is identified in the intersphincteric plane (usually by placement of a lacrimal probe), divided, and the two ends ligated. Early reports have shown success with this technique, but long-term outcome is not yet known.166-168Rectovaginal FistulaA rectovaginal fistula is a connection between the vagina and the rectum or anal canal proximal to the dentate line. Recto-vaginal fistulas are classified as low (rectal opening close to the dentate line and vaginal opening in the fourchette), middle (vaginal opening between the fourchette and cervix), or high (vaginal opening


Surgery_Schwartz

Surgery_Schwartz. fistulas are classified as low (rectal opening close to the dentate line and vaginal opening in the fourchette), middle (vaginal opening between the fourchette and cervix), or high (vaginal opening near the cervix). Low rectovaginal fistulas are 10Posterior(curved tracts)Transverse Anal LineAnterior(straight tracts)3 cmExceptionFigure 29-39. Goodsall’s rule to identify the internal opening of fistulas in ano.Fistula In AnoDrainage of an anorectal abscess results in cure for about 50% of patients. The remaining 50% develop a persistent fistula in ano. The fistula usually originates in the infected crypt (internal opening) and tracks to the external opening, usually the site of prior drainage. The course of the fistula can often be predicted by the anatomy of the previous abscess.While the majority of fistulas are cryptoglandular in ori-gin, trauma, Crohn’s disease, malignancy, radiation, or unusual infections (tuberculosis, actinomycosis, and chlamydia) may also produce


Surgery_Schwartz

Surgery_Schwartz. the majority of fistulas are cryptoglandular in ori-gin, trauma, Crohn’s disease, malignancy, radiation, or unusual infections (tuberculosis, actinomycosis, and chlamydia) may also produce fistulas. A complex, recurrent, or nonhealing fis-tula should raise the suspicion of one of these diagnoses.Diagnosis. Patients present with persistent drainage from the internal and/or external openings. An indurated tract is often palpable. Although the external opening is often easily identifi-able, identification of the internal opening may be more chal-lenging. Goodsall’s rule can be used as a guide in determining the location of the internal opening (Fig. 29-39). In general, fis-tulas with an external opening anteriorly connect to the internal opening by a short, radial tract. Fistulas with an external open-ing posteriorly track in a curvilinear fashion to the posterior midline. However, exceptions to this rule often occur if an ante-rior external opening is greater than 3 cm from the anal


Surgery_Schwartz

Surgery_Schwartz. external open-ing posteriorly track in a curvilinear fashion to the posterior midline. However, exceptions to this rule often occur if an ante-rior external opening is greater than 3 cm from the anal margin. Such fistulas usually track to the posterior midline.Fistulas are categorized based on their relationship to the anal sphincter complex, and treatment options are based on these classifications. An intersphincteric fistula tracks through the distal internal sphincter and intersphincteric space to an external opening near the anal verge (Fig. 29-40A). A trans-sphincteric fistula often results from an ischiorectal abscess and extends through both the internal and external sphincters (Fig. 29-40B). A suprasphincteric fistula originates in the inter-sphincteric plane and tracks up and around the entire external sphincter (Fig. 29-40C). An extrasphincteric fistula originates in the rectal wall and tracks around both sphincters to exit later-ally, usually in the ischiorectal fossa (Fig.


Surgery_Schwartz

Surgery_Schwartz. the entire external sphincter (Fig. 29-40C). An extrasphincteric fistula originates in the rectal wall and tracks around both sphincters to exit later-ally, usually in the ischiorectal fossa (Fig. 29-40D).Treatment. The goal of treatment of fistula in ano is eradica-tion of sepsis without sacrificing continence. Because fistulous tracks encircle variable amounts of the sphincter complex, Brunicardi_Ch29_p1259-p1330.indd 131723/02/19 2:30 PM 1318SPECIFIC CONSIDERATIONSPART IIcommonly caused by obstetric injuries or trauma from a foreign body. Mid-rectovaginal fistulas may result from more severe obstetric injury, but they also occur after surgical resection of a mid-rectal neoplasm, radiation injury, or extension of an und-rained abscess. High rectovaginal fistulas result from operative or radiation injury. Complicated diverticulitis may cause a colo-vaginal fistula. Crohn’s disease can cause rectovaginal fistulas at all levels, as well as colovaginal and enterovaginal


Surgery_Schwartz

Surgery_Schwartz. operative or radiation injury. Complicated diverticulitis may cause a colo-vaginal fistula. Crohn’s disease can cause rectovaginal fistulas at all levels, as well as colovaginal and enterovaginal fistulas.Diagnosis. Patients describe symptoms varying from the sen-sation of passing flatus from the vagina to the passage of solid stool from the vagina. Most patients experience some degree of fecal incontinence. Contamination may result in vaginitis. Large fistulas may be obvious on anoscopic and/or vaginal speculum examination, but smaller fistulas may be difficult to locate. Occasionally, a barium enema or vaginogram may identify these fistulas. Endorectal ultrasound may also be useful. With the patient in the prone position, installation of methylene blue into the rectum while a tampon is in the vagina may confirm the presence of a small fistula.Treatment. The treatment of rectovaginal fistula depends on the size, location, etiology, and condition of surrounding tis-sues. Because up to


Surgery_Schwartz

Surgery_Schwartz. the vagina may confirm the presence of a small fistula.Treatment. The treatment of rectovaginal fistula depends on the size, location, etiology, and condition of surrounding tis-sues. Because up to 50% of fistulas caused by obstetric injury heal spontaneously, it is prudent to wait 3 to 6 months before embarking on surgical repair in these patients. If the fistula was caused by a cryptoglandular abscess, drainage of the abscess may allow spontaneous closure.Low and mid-rectovaginal fistulas are usually best treated with an endorectal advancement flap. The principle of this procedure is based on the advancement of healthy mucosa, submucosa, and circular muscle over the rectal opening (the high-pressure side of the fistula) to promote healing (Fig. 29-41). If a sphincter injury is present, an overlapping sphincteroplasty ABCDFigure 29-40. The four major categories of fistula in ano (left side of drawings) and the usual operative procedure to correct the fistula (right side of drawings).


Surgery_Schwartz

Surgery_Schwartz. overlapping sphincteroplasty ABCDFigure 29-40. The four major categories of fistula in ano (left side of drawings) and the usual operative procedure to correct the fistula (right side of drawings). A. Intersphincteric fistula with simple low tract. B. Uncomplicated transsphincteric fistula. C. Uncomplicated suprasphinc-teric fistula. D. Extrasphincteric fistula secondary to anal fistula.Brunicardi_Ch29_p1259-p1330.indd 131823/02/19 2:30 PM 1319COLON, RECTUM, AND ANUSCHAPTER 29should be performed concurrently. Fecal diversion is rarely required. High rectovaginal, colovaginal, and enterovaginal fis-tulas are usually best treated via a transabdominal approach. The diseased tissue, which caused the fistula (upper rectum, sigmoid colon, or small bowel), is resected and the hole in the vagina closed. Healthy tissue, such as omentum or muscle, frequently is interposed between the bowel anastomosis and the vagina to prevent recurrence.Rectovaginal fistulas caused by Crohn’s disease,


Surgery_Schwartz

Surgery_Schwartz. vagina closed. Healthy tissue, such as omentum or muscle, frequently is interposed between the bowel anastomosis and the vagina to prevent recurrence.Rectovaginal fistulas caused by Crohn’s disease, radia-tion injury, or malignancy almost never heal spontaneously. In Crohn’s disease, treatment is based on adequate drainage of perianal sepsis and nutritional support. An endorectal advance-ment flap may be performed if the rectum is spared from active Crohn’s disease. Fistulas resulting from radiation damage are not amenable to local repair with an advancement flap because of damage to the surrounding rectal and vaginal tissues. Such midand high rectovaginal fistulas are occasionally repaired successfully with a transabdominal approach in which healthy tissue (omentum, muscle, or nonradiated bowel) is interposed between the damaged rectum and vagina. Fistulas caused by malignancy should be treated with resection of the tumor. Because differentiating radiation damage from malignancy can


Surgery_Schwartz

Surgery_Schwartz. bowel) is interposed between the damaged rectum and vagina. Fistulas caused by malignancy should be treated with resection of the tumor. Because differentiating radiation damage from malignancy can be extremely difficult, all fistulas resulting from radiation should be biopsied to rule out the presence of cancer.Perianal DermatitisPruritus Ani. Pruritus ani (severe perianal itching) is a com-mon problem with a multitude of etiologies. Surgically cor-rectable (anatomic) causes include prolapsing hemorrhoids, ectropion, fissure, fistula, and neoplasms. Perianal infection may also present with pruritus ani. Infections may be caused by fungus (Candida species and Epidermophyton organisms), parasites (Enterobius vermicularis [pinworms], Pediculus pubis [a louse], and Sarcoptes scabiei [scabies]), bacteria Probe inrectovaginalfistulaRectal mucosa andinternal sphinctermuscle incisedAttenuatedrectovaginalseptumExcess flap ofmucosa excisedInternal sphinctermuscle mobilizedInternal


Surgery_Schwartz

Surgery_Schwartz. [scabies]), bacteria Probe inrectovaginalfistulaRectal mucosa andinternal sphinctermuscle incisedAttenuatedrectovaginalseptumExcess flap ofmucosa excisedInternal sphinctermuscle mobilizedInternal sphinctermuscle approximatedFlap of mucosaand internalsphincter muscleFigure 29-41. Endorectal advancement flap for rectovaginal fistula. (Reproduced with permission from Gordon PH, Nivatvongs S: Principles and Practice of Surgery for the Colon, Rectum, and Anus, 2nd ed. New York, NY: Marcel Dekker, Inc; 1999.)Brunicardi_Ch29_p1259-p1330.indd 131923/02/19 2:30 PM 1320SPECIFIC CONSIDERATIONSPART II(Corynebacterium minutissimum [erythrasma] and T pallidum [syphilis]), or viruses (HPV [condyloma acuminata]). Antibi-otic use may also cause itching, usually by precipitating fungal infection. Noninfectious dermatologic causes include seborrhea, psoriasis, and contact dermatitis. Contact dermatitis can be par-ticularly troublesome because many over-the-counter topical agents used by patients to


Surgery_Schwartz

Surgery_Schwartz. dermatologic causes include seborrhea, psoriasis, and contact dermatitis. Contact dermatitis can be par-ticularly troublesome because many over-the-counter topical agents used by patients to relieve itching may exacerbate the problem. Occasionally, systemic diseases such as jaundice and diabetes may present with pruritus ani.Despite the myriad of causes, the majority of pruritus ani is idiopathic and probably related to local hygiene, neurogenic, or psychogenic causes. Treatment focuses on removal of irritants, improving perianal hygiene, dietary adjustments, and avoiding scratching. Biopsy and/or culture may be required to rule out an infectious or dermatologic cause. Hydrocortisone ointment 0.5% to 1.0% can provide symptomatic relief but should not be used for prolonged periods of time because of the risk of dermal atrophy. Skin barriers such as Calmoseptine can also provide relief. Systemic antihistamines or tricyclic antidepressants have also been used with some


Surgery_Schwartz

Surgery_Schwartz. periods of time because of the risk of dermal atrophy. Skin barriers such as Calmoseptine can also provide relief. Systemic antihistamines or tricyclic antidepressants have also been used with some success.Nonpruritic Lesions. Several perianal skin conditions may present with perianal skin changes. Leprosy, amebiasis, actino-mycosis, and lymphogranuloma venereum produce characteris-tic perianal lesions. Neoplasms such as squamous intraepithelial lesions, Paget’s disease, and invasive carcinomas may also appear first in the perianal skin. Biopsy can usually distinguish these diagnoses.Sexually Transmitted DiseasesBacterial Infections. Proctitis is a common symptom of ano-rectal bacterial infection. Neisseria gonorrhoeae is the most common bacterial cause of proctitis and causes pain, tenes-mus, rectal bleeding, and mucus discharge. Chlamydia tracho-matis infection may be asymptomatic or may produce similar symptoms. Treponema pallidum, the microbe causing syphilis, causes a chancre at


Surgery_Schwartz

Surgery_Schwartz. rectal bleeding, and mucus discharge. Chlamydia tracho-matis infection may be asymptomatic or may produce similar symptoms. Treponema pallidum, the microbe causing syphilis, causes a chancre at the site of inoculation, which may be asymp-tomatic or may present as an atypical fissure (primary syphilis). Condyloma lata are characteristic of secondary syphilis. Chan-croid, caused by Haemophilus ducreyi, is a disease manifested by multiple painful, bleeding lesions. Inguinal lymphadenopathy and fluctuant, draining lymph nodes are characteristic. Donova-nia granulomatis infection produces shiny, red masses on the perineum (granuloma inguinale). Diarrheal illnesses caused by organisms such as Campylobacter or Shigella may also be sexually transmitted. Treatment consists of antimicrobial agents directed against the infecting organism.Parasitic Infections. Entamoeba histolytica is an increas-ingly common sexually transmitted disease. Amebas produce ulcerations in the gastrointestinal mucosa


Surgery_Schwartz

Surgery_Schwartz. directed against the infecting organism.Parasitic Infections. Entamoeba histolytica is an increas-ingly common sexually transmitted disease. Amebas produce ulcerations in the gastrointestinal mucosa and can infect any part of the gut. Symptoms include diarrhea, abdominal pain, and tenesmus. Giardia lamblia is also common and produces diarrhea, abdominal pain, and malaise.Viral Infections Herpes Simplex Virus Herpes proctitis is extremely common. Proctitis is usually caused by type 2 herpes simplex virus and less commonly by type 1 herpes simplex virus. Patients complain of severe, intractable perianal pain and tenesmus. Pain often precedes the development of characteristic vesicles, and these patients may require an examination under anesthesia to exclude another diagnosis such as an intersphincteric abscess. Diagnosis is confirmed by viral culture of tissue or vesicular fluid.Human Papillomavirus HPV causes condyloma acuminata (anogenital warts) and is associated with squamous


Surgery_Schwartz

Surgery_Schwartz. intersphincteric abscess. Diagnosis is confirmed by viral culture of tissue or vesicular fluid.Human Papillomavirus HPV causes condyloma acuminata (anogenital warts) and is associated with squamous intraepithe-lial lesions and squamous cell carcinoma (see previous section, “Anal Canal and Perianal Tumors”). Condylomas occur in the perianal area or in the squamous epithelium of the anal canal. Occasionally, the mucosa of the lower rectum may be affected. There are approximately 30 serotypes of HPV. As previously mentioned, HPV types 16 and 18, in particular, appear to pre-dispose to malignancy and often cause flat dysplasia in skin unaffected by warts. In contrast, HPV types 6 and 11 commonly cause warts, but do not appear to cause malignant degeneration.Treatment of anal condyloma depends on the location and extent of disease. Small warts on the perianal skin and distal anal canal may be treated in the office with topical application of bichloracetic acid or podophyllin. Although 60%


Surgery_Schwartz

Surgery_Schwartz. on the location and extent of disease. Small warts on the perianal skin and distal anal canal may be treated in the office with topical application of bichloracetic acid or podophyllin. Although 60% to 80% of patients will respond to these agents, recurrence and reinfection are common. Imiquimod (Aldara) is an immunomodulator that was recently introduced for topical treatment of several viral infections, including anogenital condyloma.100 Initial reports suggest that this agent is highly effective in treating condyloma located on the perianal skin and distal anal canal. Larger and/or more numerous warts require excision and/or fulguration in the operating room. Excised warts should be sent for pathologic examination to rule out dysplasia or malignancy. It is impor-tant to note that prior use of podophyllin may induce histologic changes that mimic dysplasia. The recent introduction of a vaccine against HPV holds promise for preventing anogenital condylomas.169,170Human Immunodeficiency


Surgery_Schwartz

Surgery_Schwartz. of podophyllin may induce histologic changes that mimic dysplasia. The recent introduction of a vaccine against HPV holds promise for preventing anogenital condylomas.169,170Human Immunodeficiency Virus See later section, “The Immunocompromised Patient.”Pilonidal DiseasePilonidal disease (cyst, infection) consists of a hair-containing sinus or abscess occurring in the intergluteal cleft. Although the etiology is unknown, it is speculated that the cleft creates a suction that draws hair into the midline pits when a patient sits. These ingrown hairs may then become infected and pres-ent acutely as an abscess in the sacrococcygeal region. Once an acute episode has resolved, recurrence is common.An acute abscess should be incised and drained as soon as the diagnosis is made. Because these abscesses are usually very superficial, this procedure can often be performed in the office, clinic, or emergency department under local anesthetic. Because midline wounds in the region heal poorly, some


Surgery_Schwartz

Surgery_Schwartz. are usually very superficial, this procedure can often be performed in the office, clinic, or emergency department under local anesthetic. Because midline wounds in the region heal poorly, some sur-geons recommend using an incision lateral to the intergluteal cleft. A number of procedures have been proposed to treat a chronic pilonidal sinus. The simplest method involves unroof-ing the tract, curetting the base, and marsupializing the wound. The wound must then be kept clean and free of hair until heal-ing is complete (often requiring weekly office visits for wound care). Alternatively, a small lateral incision can be created and the pit excised. This method is effective for most primary pilo-nidal sinuses. In general, extensive resection should be avoided. Complex and/or recurrent sinus tracts may require more exten-sive resection and closure with a Z-plasty, advancement flap, or rotational flap.Hidradenitis SuppurativaHidradenitis suppurativa is an infection of the cutaneous


Surgery_Schwartz

Surgery_Schwartz. sinus tracts may require more exten-sive resection and closure with a Z-plasty, advancement flap, or rotational flap.Hidradenitis SuppurativaHidradenitis suppurativa is an infection of the cutaneous apo-crine sweat glands. Infected glands rupture and form subcutane-ous sinus tracts. The infection may mimic complex anal fistula disease, but stops at the anal verge because there are no apocrine Brunicardi_Ch29_p1259-p1330.indd 132023/02/19 2:30 PM 1321COLON, RECTUM, AND ANUSCHAPTER 29glands in the anal canal. Treatment involves incision and drain-age of acute abscesses and unroofing of all chronically inflamed fistulas and debridement of granulation tissue. Radical excision and skin grafting are almost never necessary.TRAUMAPenetrating Colorectal InjuryColorectal injury is common following penetrating trauma to the abdomen and has historically been associated with high mortality. In the first half of the 20th century, the mortality rate from colorectal injury was as high as 90%. The


Surgery_Schwartz

Surgery_Schwartz. penetrating trauma to the abdomen and has historically been associated with high mortality. In the first half of the 20th century, the mortality rate from colorectal injury was as high as 90%. The introduction of exteriorization of colonic injuries and fecal diversion during World War II dramatically decreased mortality, and this princi-ple has governed the management of large bowel injury for over 50 years. Recently, however, this practice was challenged, and trauma surgeons are increasingly performing primary repairs in selected patients.Management of colonic injury depends on the mechanism of injury, the delay between the injury and surgery, the over-all condition and stability of the patient, the degree of perito-neal contamination, and the condition of the injured colon. A primary repair may be considered in hemodynamically stable patients with few additional injuries and minimal contamination if the colon appears otherwise healthy. Contraindications to pri-mary repair include


Surgery_Schwartz

Surgery_Schwartz. repair may be considered in hemodynamically stable patients with few additional injuries and minimal contamination if the colon appears otherwise healthy. Contraindications to pri-mary repair include shock, injury to more than two other organs, mesenteric vascular damage, and extensive fecal contamina-tion. A delay of greater than 6 hours between the injury and the operation also is associated with increased morbidity and mor-tality and is a relative contraindication to primary repair. Inju-ries caused by high-velocity gunshot wounds or blast injuries are often associated with multiple intra-abdominal injuries and tissue loss and therefore are usually treated by fecal diversion after debridement of all nonviable tissue. Patient factors, such as medical comorbidities, advanced age, and the presence of tumor or radiation injury, must also be considered (Table 29-4).Like injuries to the intraperitoneal colon, penetrating trauma to the rectum traditionally has been associated with high


Surgery_Schwartz

Surgery_Schwartz. presence of tumor or radiation injury, must also be considered (Table 29-4).Like injuries to the intraperitoneal colon, penetrating trauma to the rectum traditionally has been associated with high morbidity and mortality. Primary repair of the rectum is more difficult than primary repair of the colon, however, and most rectal injuries are associated with significant contamination. For that reason, the majority of penetrating rectal injuries should be treated with proximal fecal diversion. Distal washout (copious irrigation of the rectum) and presacral drains are not routinely recommended.158 Small, clean rectal injuries may be closed pri-marily without fecal diversion in an otherwise stable patient. Intractable rectal bleeding may require angiographic emboliza-tion. Very rarely, hemorrhage or extensive tissue loss (espe-cially if the anal sphincter is severely damaged) may require an emergent APR. However, this operation should be avoided, if at all possible, because of the morbidity


Surgery_Schwartz

Surgery_Schwartz. or extensive tissue loss (espe-cially if the anal sphincter is severely damaged) may require an emergent APR. However, this operation should be avoided, if at all possible, because of the morbidity associated with an extensive pelvic dissection in a severely injured patient.171Blunt Colorectal InjuryBlunt injury to the colon and rectum is considerably less com-mon than penetrating injury. Nevertheless, blunt trauma can cause colon perforation, and shear injury to the mesentery can devascularize the intestine. Management of these injuries should follow the same principles outlined for management of penetrat-ing injuries. Small perforations with little contamination in a stable patient may be closed primarily; more extensive injury requires fecal diversion. A serosal hematoma alone does not Table 29-4Criteria for use of an ostomyInjuring agent factors High-velocity bullet wounds Shotgun wounds Explosive blast wounds Crush injuryPatient factors Presence of tumor Radiated tissue Medical


Surgery_Schwartz

Surgery_Schwartz. Table 29-4Criteria for use of an ostomyInjuring agent factors High-velocity bullet wounds Shotgun wounds Explosive blast wounds Crush injuryPatient factors Presence of tumor Radiated tissue Medical condition Advanced ageInjury factors Inflamed tissue Advanced infection Distal obstruction Local foreign body Impaired blood supply Mesenteric vascular damage Shock with blood pressure <80/60 mmHg Hemorrhage >1000 mL More than two organs (especially kidney) injured Interval to operation >6 h (pancreatic, splenic, hepatic) Extensive injury requiring resection Major abdominal wall loss Thoracoabdominal penetrationReproduced with permission from Gordon PH, Nivatvongs S: Principles and Practice of Surgery for the Colon, Rectum, and Anus, 2nd ed. New York, NY: Marcel Dekker, Inc; 1999.mandate resection, but the bowel should be carefully inspected to ensure that there is not an associated perforation or significant bowel ischemia.Blunt injury to the rectum may result from significant trauma,


Surgery_Schwartz

Surgery_Schwartz. but the bowel should be carefully inspected to ensure that there is not an associated perforation or significant bowel ischemia.Blunt injury to the rectum may result from significant trauma, such as a pelvic crush injury, or may result from local trauma caused by an enema or foreign body. Crush injuries, especially with an associated pelvic fracture, are often associ-ated with significant rectal damage and contamination. These patients require debridement of all nonviable tissue, proximal fecal diversion, and a distal rectal washout, with or without drain placement. Blunt trauma from an enema or foreign body may produce a mucosal hematoma, which requires no surgical treatment if the mucosa is intact. Small mucosal tears may be closed primarily if the bowel is relatively clean and there is little contamination.Iatrogenic InjuryIntraoperative Injury. The colon and rectum are at risk for inadvertent injury during other procedures, especially during pelvic operations. The key to managing


Surgery_Schwartz

Surgery_Schwartz. little contamination.Iatrogenic InjuryIntraoperative Injury. The colon and rectum are at risk for inadvertent injury during other procedures, especially during pelvic operations. The key to managing these injuries is early recognition. The vast majority of iatrogenic colorectal injuries may be closed primarily if there is little contamination and if the patient is otherwise stable. Delayed recognition of colorectal injuries may result in significant peritonitis and life-threatening sepsis. In these cases, fecal diversion is almost always required, and the patient may need repeated exploration for drainage of abscesses.Injury From Barium Enema. Colorectal injury from a bar-ium enema is an extremely rare complication associated with a high rate of morbidity and mortality. Perforation with spillage Brunicardi_Ch29_p1259-p1330.indd 132123/02/19 2:30 PM 1322SPECIFIC CONSIDERATIONSPART IIof barium, especially above the peritoneal reflection, may result in profound peritonitis, sepsis,


Surgery_Schwartz

Surgery_Schwartz. spillage Brunicardi_Ch29_p1259-p1330.indd 132123/02/19 2:30 PM 1322SPECIFIC CONSIDERATIONSPART IIof barium, especially above the peritoneal reflection, may result in profound peritonitis, sepsis, and a systemic inflam-matory response. If the perforation is recognized early, it may be closed primarily and the abdomen irrigated to remove stool and barium. However, if the patient has developed sepsis, fecal diversion (with or without bowel resection) is almost always required. Rarely, a small mucosal injury to the extraperitoneal rectum may be managed with bowel rest, broad-spectrum anti-biotics, and close observation.Colonoscopic Perforation. Perforation is the most common major complication after either diagnostic or therapeutic colo-noscopy. Fortunately, this complication is rare and occurs in less than 1% of procedures. Perforation may result from trauma from the tip of the instrument, from shear forces related to the formation of a “loop” in the colonoscope, or from barotrauma


Surgery_Schwartz

Surgery_Schwartz. occurs in less than 1% of procedures. Perforation may result from trauma from the tip of the instrument, from shear forces related to the formation of a “loop” in the colonoscope, or from barotrauma from insufflation. Biopsy or fulguration can also cause perfo-ration. Polypectomy using electrocautery may produce a full-thickness burn, resulting in postpolypectomy syndrome in which a patient develops abdominal pain, fever, and leukocytosis with-out evidence of diffuse peritonitis.Management of colonoscopic perforation depends on the size of the perforation, the duration of time since the injury, the overall condition of the patient, and the underlying diagnosis. A large perforation recognized during the procedure requires surgical exploration. Because the bowel has almost always been prepared prior to the colonoscopy, there is usually little contamination associated with these injuries, and most can be repaired primarily. If there is significant contamination, if there has been a delay


Surgery_Schwartz

Surgery_Schwartz. prior to the colonoscopy, there is usually little contamination associated with these injuries, and most can be repaired primarily. If there is significant contamination, if there has been a delay in diagnosis with resulting peritonitis, or if the patient is hemodynamically unstable, proximal diversion with or without resection is the safest approach. It is also important to know the indication for and findings at the time of colonos-copy. If the patient has an underlying neoplasm and is stable, definitive resection is best. Occasionally, a patient will develop abdominal pain and localized signs of perforation after what was thought to be an uneventful colonoscopy. Many of these patients will have a “microperforation,” which will resolve with bowel rest, broad-spectrum antibiotics, and close observation. Evidence of peritonitis or any deterioration in clinical condition mandates exploration. Similarly, free retroperitoneal or intra-peritoneal air may be discovered incidentally after


Surgery_Schwartz

Surgery_Schwartz. observation. Evidence of peritonitis or any deterioration in clinical condition mandates exploration. Similarly, free retroperitoneal or intra-peritoneal air may be discovered incidentally after colonoscopy. In a completely asymptomatic patient, this finding is thought to result from barotrauma and dissection of air through tissue planes without a free perforation. Many of these patients can be successfully treated with bowel rest and broad-spectrum antibi-otics. Surgical exploration is indicated if any clinical deteriora-tion occurs.Anal Sphincter Injury and IncontinenceThe most common cause of anal sphincter injury is obstetric trauma during vaginal delivery. The risk of sphincter injury is increased by a laceration that extends into the rectum (fourth-degree tear), infection of an episiotomy or laceration repair, prolonged labor, and possibly by use of a midline episiotomy. Sphincter damage may also result from hemorrhoidectomy, sphincterotomy, abscess drainage, or fistulotomy.


Surgery_Schwartz

Surgery_Schwartz. or laceration repair, prolonged labor, and possibly by use of a midline episiotomy. Sphincter damage may also result from hemorrhoidectomy, sphincterotomy, abscess drainage, or fistulotomy. Patients with incontinence and a suspected sphincter injury can be evaluated with anal manometry, EMG, pudendal nerve motor latency, and endoanal ultrasound. Mild incontinence, even in the presence of a sphincter defect, may respond to dietary changes and/or biofeedback. More severe incontinence may require surgical repair.The anal sphincter can also be injured by penetrating or blunt mechanisms (impalement, blast injury, crush injuries of the pelvis). Because damage to the anal sphincter is not life-threatening, definitive repair of the sphincter is often deferred until other injuries have been repaired and the patient’s clinical condition is stable. Isolated sphincter injuries that do not involve the rectum may be repaired primarily. Rectal injury accompa-nied by sphincter injury should be


Surgery_Schwartz

Surgery_Schwartz. repaired and the patient’s clinical condition is stable. Isolated sphincter injuries that do not involve the rectum may be repaired primarily. Rectal injury accompa-nied by sphincter injury should be treated with fecal diversion and distal rectal washout, with or without drain placement. Sig-nificant perineal tissue loss may require extensive debridement and a diverting colostomy.Surgical Repairs. The most common method of repair of the anal sphincter is a wrap-around sphincteroplasty (Fig. 29-42).172 The procedure involves mobilization of the divided sphincter muscle and reapproximation without tension. The internal and external sphincters may be overlapped together or separately. Postanal intersphincteric levatorplasty is less commonly used to repair sphincter defects but may be useful for incontinence caused by prolapse and/or loss of the anorectal angle (see “Continence”). The approach is via the intersphincteric plane posteriorly. It may be performed concomitantly with a


Surgery_Schwartz

Surgery_Schwartz. useful for incontinence caused by prolapse and/or loss of the anorectal angle (see “Continence”). The approach is via the intersphincteric plane posteriorly. It may be performed concomitantly with a perineal repair of rectal prolapse. The levator ani muscle is approximated to restore the anorectal angle, and the puborectalis and external sphincter muscles are tightened with sutures. These elective pro-cedures usually do not require a diverting colostomy.In cases where there has been significant loss of sphincter muscle or in which prior repairs have failed, more complex tech-niques, such as gracilis muscle transposition with or without Inferior rectal nervePudendal nerveFibrotic portion ofexternal sphincterTransverse superficialperineal muscleABCDFigure 29-42. Overlapping sphincteroplasty for incontinence from sphincter disruption. A. The external sphincter muscle with scar at site of injury is mobilized. B. The muscle edges are aligned in an overlapping fashion. C. Mattress sutures


Surgery_Schwartz

Surgery_Schwartz. for incontinence from sphincter disruption. A. The external sphincter muscle with scar at site of injury is mobilized. B. The muscle edges are aligned in an overlapping fashion. C. Mattress sutures are used to approximate the muscle. D. The completed operation.Brunicardi_Ch29_p1259-p1330.indd 132223/02/19 2:30 PM 1323COLON, RECTUM, AND ANUSCHAPTER 29chronic, low-frequency electrostimulation, have been used with some success.173 In this procedure, the gracilis muscle is mobi-lized from the thigh, detached from its insertion on the tibial tuberosity, tunneled through the perineum, and wrapped around the anal canal. Another alternative in patients who have failed other repairs is the artificial anal sphincter. This device consists of an inflatable silastic cuff, a pressure-regulating balloon, and a control pump. Patients deflate the cuff manually to open the anal canal; the cuff then reinflates spontaneously to maintain clo-sure of the anal canal. Frequent infections and erosion can


Surgery_Schwartz

Surgery_Schwartz. and a control pump. Patients deflate the cuff manually to open the anal canal; the cuff then reinflates spontaneously to maintain clo-sure of the anal canal. Frequent infections and erosion can lead to device loss.173,174 Sacral nerve stimulation via an implanted pulse generator is a technique used for neurogenic incontinence when the sphincter is intact.12-14 In some patients, an end stoma provides the best relief for intractable incontinence.176Foreign BodyForeign body entrapment in the rectum is not uncommon. Depending on the level of entrapment, a foreign body may cause damage to the rectum, rectosigmoid, or descending colon. Generalized abdominal pain suggests intraperitoneal perfo-ration. Evaluation of the patient includes inspection of the perineum and a careful abdominal examination to detect any evidence of perforation. Plain films of the abdomen are manda-tory to detect free intra-abdominal air.Foreign bodies lodged low in the rectum may often be removed under conscious


Surgery_Schwartz

Surgery_Schwartz. to detect any evidence of perforation. Plain films of the abdomen are manda-tory to detect free intra-abdominal air.Foreign bodies lodged low in the rectum may often be removed under conscious sedation with or without a local anes-thetic block. Objects impacted higher in the rectum may require regional or general anesthesia for removal. Only rarely will a laparotomy be required to remove the object, either through manual manipulation of the object to expel from the anus, or via colotomy. After removal of the foreign body, it is crucial to evaluate the rectum and sigmoid colon for injury. Proctos-copy and/or flexible sigmoidoscopy should be performed. A hematoma without evidence of perforation requires no surgical treatment. Perforation of the rectum or sigmoid colon should be managed as described in the preceding sections.THE IMMUNOCOMPROMISED PATIENTHuman Immunodeficiency VirusPatients infected with HIV may present with a myriad of gastro-intestinal symptoms. Diarrhea, in particular,


Surgery_Schwartz

Surgery_Schwartz. in the preceding sections.THE IMMUNOCOMPROMISED PATIENTHuman Immunodeficiency VirusPatients infected with HIV may present with a myriad of gastro-intestinal symptoms. Diarrhea, in particular, is extremely com-mon. The severity of gastrointestinal disease depends in part on the degree of immunosuppression; however, both ordinary and opportunistic pathogens may affect patients at any stage of the disease. Opportunistic infections with bacteria (Salmonella, Shi-gella, Campylobacter, Chlamydia, and Mycobacterium species), fungi (histoplasmosis, coccidiosis, Cryptococcus), protozoa (toxoplasmosis, cryptosporidiosis, isosporiasis), and viruses (CMV, herpes simplex virus) can cause diarrhea, abdominal pain, and weight loss. CMV in particular may cause severe enterocolitis and is the most common infectious cause of emer-gency laparotomy in acquired immunodeficiency syndrome (AIDS) patients. Clostridium difficile colitis is a major concern in these patients, especially because many patients


Surgery_Schwartz

Surgery_Schwartz. infectious cause of emer-gency laparotomy in acquired immunodeficiency syndrome (AIDS) patients. Clostridium difficile colitis is a major concern in these patients, especially because many patients are main-tained on suppressive antibiotic therapy. The incidence of gas-trointestinal malignancy is also increased in patients with HIV infection.177 Kaposi’s sarcoma is the most common malignancy in AIDS patients and can affect any part of the gastrointestinal tract. Patients may be asymptomatic or may develop bleeding or obstruction. Gastrointestinal lymphoma (usually non-Hodg-kin’s lymphoma) is also common. The incidence of colorectal carcinoma may also be increased in this population, although definitive data are lacking.Perianal disease is extremely common in patients with HIV infection. Because HIV is sexually transmitted, it is com-mon to find concomitant infection with other sexually trans-mitted diseases such as Chlamydia, herpes simplex virus, and HPV (anal condyloma). Anal


Surgery_Schwartz

Surgery_Schwartz. Because HIV is sexually transmitted, it is com-mon to find concomitant infection with other sexually trans-mitted diseases such as Chlamydia, herpes simplex virus, and HPV (anal condyloma). Anal condyloma in particular are very common, and the incidence of dysplasia (HGAIN) is high in the HIV-infected population.105 Abscesses and fistulas may be more difficult to diagnose in these patients and may be com-plex. Many patients require an examination under anesthesia with biopsy and cultures to determine the etiology of many of these perianal problems. The introduction of highly active anti-retroviral therapy (HAART) has changed the natural history of HIV infection, but it remains to be seen how these medications will affect the incidence and outcome of colorectal disease in this patient population.177IMMUNOSUPPRESSION FOR TRANSPLANTATIONThe gastrointestinal tract is a common site for posttransplanta-tion complications that are responsible for significant morbid-ity and mortality. In


Surgery_Schwartz

Surgery_Schwartz. population.177IMMUNOSUPPRESSION FOR TRANSPLANTATIONThe gastrointestinal tract is a common site for posttransplanta-tion complications that are responsible for significant morbid-ity and mortality. In these patients, infection and medication are the most common causes of diarrhea. Immunosuppressant medications, in particular, may cause diarrhea. CMV infection is common and may be severe. Clostridium difficile colitis also occurs commonly. Diverticulitis appears to be more common in some populations of transplant patients and may be more likely to present with abscess or free perforation. Elective resection after recovery from one episode of confirmed diverticulitis may be indicated in the transplant population.178 Graft-versus-host disease is unique to transplant patients and often requires endoscopy and biopsy to diagnose gastrointestinal involvement. Patients are subject to the same opportunistic infections outlined earlier; however, sexually transmitted infections and Kaposi’s


Surgery_Schwartz

Surgery_Schwartz. endoscopy and biopsy to diagnose gastrointestinal involvement. Patients are subject to the same opportunistic infections outlined earlier; however, sexually transmitted infections and Kaposi’s sarcoma are somewhat less prevalent. Perianal disease is some-what less common in the transplant population than in patients infected with HIV; however, similar infections may occur, and immunosuppression often makes diagnosis and treatment challenging.With increasing long-term survival among transplant recipients, the development of posttransplant malignancy has become a major concern. Posttransplant lymphoprolifera-tive disease is increasingly common and may occur anywhere in the gastrointestinal tract. The risk of colorectal carcinoma is increased in patients with predisposing conditions such as ulcerative colitis. However, immunosuppression alone does not appear to increase the incidence of colorectal cancer, and current screening recommendations are similar to those for the average risk


Surgery_Schwartz

Surgery_Schwartz. as ulcerative colitis. However, immunosuppression alone does not appear to increase the incidence of colorectal cancer, and current screening recommendations are similar to those for the average risk population. In contrast, the incidence of anal squamous cell carcinoma is dramatically increased in transplant patients, and patients with known HPV infection should undergo more vigor-ous screening.THE NEUTROPENIC PATIENTNeutropenic enterocolitis (typhlitis) is a life-threatening prob-lem with a mortality rate of greater than 50%. This syndrome is characterized by abdominal pain and distention, fever, diarrhea (often bloody), nausea, and vomiting in a patient with fewer than 1000 neutrophils/μL blood from any cause (bone marrow transplantation, solid-organ transplantation, or chemotherapy). Its etiology is poorly understood. Histologic features can be Brunicardi_Ch29_p1259-p1330.indd 132323/02/19 2:30 PM 1324SPECIFIC CONSIDERATIONSPART IIseen on biopsy or surgical resection and


Surgery_Schwartz

Surgery_Schwartz. Its etiology is poorly understood. Histologic features can be Brunicardi_Ch29_p1259-p1330.indd 132323/02/19 2:30 PM 1324SPECIFIC CONSIDERATIONSPART IIseen on biopsy or surgical resection and include a paucity of inflammatory and leukemic infiltrates but with mucosal and submucosal edema, villous sloughing, stromal hemorrhage, and patchy-to-complete epithelial necrosis. CT scan of the abdomen often shows a dilated cecum with pericolic stranding. However, a normal-appearing CT scan does not exclude the diagnosis. Some patients will respond to bowel rest, broad-spectrum anti-biotics, parenteral nutrition, and granulocyte infusion or col-ony-stimulating factors.179 Evidence of perforation, generalized peritonitis, and deterioration in clinical condition are indications for operation.Neutropenic patients often develop perianal pain, and diagnosis may be difficult because of a lack of inflammatory response to infection. While broad-spectrum antibiotics may cure some of these patients,


Surgery_Schwartz

Surgery_Schwartz. patients often develop perianal pain, and diagnosis may be difficult because of a lack of inflammatory response to infection. While broad-spectrum antibiotics may cure some of these patients, an examination under anesthesia should not be delayed because of neutropenia. An increase in pain or fever and/or clinical deterioration mandates an exam under anesthesia. Any indurated area should be incised and drained, biopsied to exclude a leukemic infiltrate, and cultured to aid in the selection of antimicrobial agents.REFERENCESEntries highlighted in bright blue are key references. 1. Keller J, Fibbe C, Rosien U, et al. Recent advances in capsule endoscopy: development of maneuverable capsules. Expert Rev Gastroenterol Hepatol. 2012;6:561-566. 2. Mang T, Bogoni L, Salganicoff M, et al. Computer-aided detection of colorectal polyps in CT colonography with and without fecal tagging: a stand-alone evaluation. Invest Radiol. 2012;47:99-108. 3. Grady E. Gastrointestinal bleeding scintigraphy in


Surgery_Schwartz

Surgery_Schwartz. detection of colorectal polyps in CT colonography with and without fecal tagging: a stand-alone evaluation. Invest Radiol. 2012;47:99-108. 3. Grady E. Gastrointestinal bleeding scintigraphy in the early 21st Century. J Nucl Med. 2016;57:252-259. 4. Allen TW, Tulchinsky M. Nuclear medicine tests for acute gastrointestinal conditions. Semin Nucl Med. 2013;43:88-101. 5. Garcia-Aguilar J, Pollack J, Lee SH, et al. Accuracy of endorectal ultrasonography in preoperative staging of rectal tumors. Dis Colon Rectum. 2002;45:10-15. 6. Lee JK, Liles EG, Bent S, Levin TR, Corley DA. Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis. Ann Intern Med. 2014;160:171. 7. Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Multitarget stool DNA testing for colorectal-cancer screening. N Engl J Med. 2014;370(14):1287-1297. 8. Thirunavukarasu P, Talati C, Munjal S, Attwood K, Edge SB, Francescutti V. Effect of incorporation of pretreatment serum


Surgery_Schwartz

Surgery_Schwartz. for colorectal-cancer screening. N Engl J Med. 2014;370(14):1287-1297. 8. Thirunavukarasu P, Talati C, Munjal S, Attwood K, Edge SB, Francescutti V. Effect of incorporation of pretreatment serum carcinoembryonic antigen levels into AJCC staging for colon cancer on 5-year survival. JAMA Surg. 2015;150(8):747-755. doi: 10.1001/jamasurg.2015.0871. PMID: 26083632. 9. Offit K. Genetic prognostic markers for colorectal cancer. N Engl J Med. 2000;342:124-125. 10. Lynch HT, Lynch JF, Lynch PM, et al. Hereditary colorectal cancer syndromes: molecular genetics, genetic counseling, diagnosis and management. Fam Cancer. 2008;7:27-39. This reference is included in an issue of Familial Cancer that is devoted to discussion of hereditary forms of colorectal can-cer. The paper summarizes the evaluation of patients suspected to have familial colorectal cancer with a special emphasis on HNPCC (Lynch Syndrome) and FAP. Recommendations are provided for genetic testing, surveillance strategies, and


Surgery_Schwartz

Surgery_Schwartz. of patients suspected to have familial colorectal cancer with a special emphasis on HNPCC (Lynch Syndrome) and FAP. Recommendations are provided for genetic testing, surveillance strategies, and treatment. 11. FitzHarris GP, Garcia-Aguilar J, Parker SC, et al. Quality of life after subtotal colectomy for slow-transit constipa-tion: both quality and quantity count. Dis Colon Rectum. 2003;46:433-440. 12. Paquette IM, Varma MG, Kaiser AM, Steele SR, Raf-ferty JF. The American Society of Colon and Rectal Sur-geons’ clinical practice guideline for the treatment of fecal incontinence. Dis Colon Rectum. 2015;58:623-636. The Standards Task Force of the American Society of Colon and Rectal Surgeons evaluated existing data on treatment of fecal incontinence based upon quality. The guidelines provided in this manuscript represent evidence based management of this condition. 13. Ganio E, Ratto C, Masin A, et al. Neuromodulation for fecal incontinence: outcome in 16 patients with definitive


Surgery_Schwartz

Surgery_Schwartz. in this manuscript represent evidence based management of this condition. 13. Ganio E, Ratto C, Masin A, et al. Neuromodulation for fecal incontinence: outcome in 16 patients with definitive implant. The initial Italian Sacral Neurostimulation Group (GINS) experience. Dis Colon Rectum, 2001;44:965-970. 14. Forte ML1, Andrade KE, Lowry AC, Butler M, Bliss DZ, Kane RL. Systematic review of surgical treatments for fecal incontinence. Dis Colon Rectum. 2016;59(5):443-469. doi: 10.1097/DCR.0000000000000594 15. Ky AJ, Sonoda T, Milsom JW. One-stage laparoscopic restor-ative proctocolectomy: an alternative to the conventional approach? Dis Colon Rectum. 2002;45:207-210. 16. Lezoche E, Feliciotti F, Paganini AM, et al. Laparoscopic colonic resections versus open surgery: a prospective non-randomized study on 310 unselected cases. Hepatogastroen-terology. 2000;47:697-708. 17. Martinez-Perez A, Cara MC, Brunetti F, de’Angelis N. Patho-logic outcomes of laparoscopic vs. open mesorectal excision


Surgery_Schwartz

Surgery_Schwartz. study on 310 unselected cases. Hepatogastroen-terology. 2000;47:697-708. 17. Martinez-Perez A, Cara MC, Brunetti F, de’Angelis N. Patho-logic outcomes of laparoscopic vs. open mesorectal excision for rectal cancer: a systematic review and meta-analysis. JAMA Surg. 2017;8:165665. doi:10.1001/jamasurg.20165665 18. Weeks JC, Nelson H, Gelber S, et al. Short-term quality-of-life outcomes following laparoscopic-assisted colectomy vs. open colectomy for colon cancer: a randomized trial. JAMA. 2002;287:321-328. 19. deSouza AL, Prasad LM, Ricci J, et al. A comparison of open and robotic total mesorectal excision for rectal adenocarci-noma. Dis Colon Rectum. 2011;54:275-282. 20. Biondo S, Frago R, Codina Cazador A, et al. Long-term func-tional results from a randomized clinical study of transverse coloplasty compared with colon J-pouch after low anterior resection for rectal cancer. Surgery. 2013;153:383-392. 21. Heah SM, Seow-Choen F, Eu KW, et al. Prospective, random-ized trial comparing


Surgery_Schwartz

Surgery_Schwartz. coloplasty compared with colon J-pouch after low anterior resection for rectal cancer. Surgery. 2013;153:383-392. 21. Heah SM, Seow-Choen F, Eu KW, et al. Prospective, random-ized trial comparing sigmoid vs. descending colonic J-pouch after total rectal excision. Dis Colon Rectum. 2002;45: 322-328. 22. Machado M, Nygren J, Goldman S, et al. Similar outcome after colonic pouch and side-to-end anastomosis in low ante-rior resection for rectal cancer: a prospective randomized trial. Ann Surg. 2003;238:214-220. 23. Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz DJ. Anastomotic leak testing after colo-rectal resec-tion: what are the data? Arch Surg. 2009;144(5):407-411. 24. Prytz M, Angenete E, Bock D, Haglind E. Extralevator abdom-inoperineal excision for low rectal cancer—extensive surgery to be used with discretion based on 3 year local recurrence results. Ann Surg. 2016;263(3):516-521. 25. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal


Surgery_Schwartz

Surgery_Schwartz. surgery to be used with discretion based on 3 year local recurrence results. Ann Surg. 2016;263(3):516-521. 25. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg. 2007;94:232-238. 26. Farouk R, Pemberton JH, Wolff BG, et al. Functional out-comes after ileal pouch-anal anastomosis for chronic ulcer-ative colitis. Ann Surg. 2000;231:919-926. 27. Bullard KM, Madoff RD, Gemlo BT. Is ileoanal pouch func-tion stable with time? Results of a prospective audit. Dis Colon Rectum. 2002;45:299-304. 28. Segal JP, Ding NS, Worley G, et al. Systematic review with meta-analysis: the management of chronic refractory pouchitis with an evidence-based treatment algorithm. Aliment Pharma-col Ther. 2017;45(5):581-592. doi:10.1111/apt.13905.Brunicardi_Ch29_p1259-p1330.indd 132423/02/19 2:30 PM 1325COLON, RECTUM, AND ANUSCHAPTER 29 29. Sandborn W, McLeod R, Jewell D.


Surgery_Schwartz

Surgery_Schwartz. Aliment Pharma-col Ther. 2017;45(5):581-592. doi:10.1111/apt.13905.Brunicardi_Ch29_p1259-p1330.indd 132423/02/19 2:30 PM 1325COLON, RECTUM, AND ANUSCHAPTER 29 29. Sandborn W, McLeod R, Jewell D. Pharmacotherapy for inducing and maintaining remission in pouchitis. Cochrane Database Syst Rev. 2000;2:CD001176. 30. Stocchi L, Pemberton JH. Pouch and pouchitis. Gastroenterol Clin North Am. 2001;30:223-241. 31. Sandborn W, McLeod R, Jewell D. Pharmacotherapy for inducing and maintaining remission in pouchitis. Cochrane Database Syst Rev. 2000;2:CD001176. 32. Tran-Minh ML, Allez M, Gornet JM. Successful treatment with ustekinumab for chronic refractory pouchitis. J Crohns Colitis. 2017;11(9):1156. doi:10.1093/ecco-jcc/jjx018. 33. Kelly OB, Rosenberg M, Tyler AD, et al. Infliximab to treat refractory inflammation after pelvic pouch surgery for ulcer-ative colitis. J Crohns Colitis. 2016;10(4):410-417. doi: 10.1093/ecco-jcc/jjv225 34. Schmid M, Frick JS, Malek N, Goetz M. Successful


Surgery_Schwartz

Surgery_Schwartz. refractory inflammation after pelvic pouch surgery for ulcer-ative colitis. J Crohns Colitis. 2016;10(4):410-417. doi: 10.1093/ecco-jcc/jjv225 34. Schmid M, Frick JS, Malek N, Goetz M. Successful treat-ment of pouchitis with Vedolizumab, but not fecal micro-biota transfer (FMT), after proctocolectomy in ulcerative colitis. Int J Colorectal Dis. 2017;32(4):597-598. doi: 10.1007/s00384-017-2761-4 35. Cannon JA, Altom LK, Deierhoi RJ, et al. Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections. Dis Colon Rectum. 2012;55:1160-1166. 36. Scarborough JE, Mantyh CR, Sun Z, Migaly J. Com-bined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection. Ann Surg. 2015;262(2):331-337. This study assessed the effect of com-bined mechanical and oral antibiotic bowel preparation (prep) and 30-day outcomes after colorectal resection using data from the 2012


Surgery_Schwartz

Surgery_Schwartz. Surg. 2015;262(2):331-337. This study assessed the effect of com-bined mechanical and oral antibiotic bowel preparation (prep) and 30-day outcomes after colorectal resection using data from the 2012 Colectomy-Targeted American College of Sur-geons National Surgical Quality Improvement (ACS NSQIP) data (4999 patients). The combination of oral and mechani-cal bowel preparation decreased the incidence of surgical site infection, anastomotic leak, and hospital readmission when compared to mechanical prep alone, oral antibiotic prep alone, or no prep. 37. Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-anal-ysis. Int J Colorectal Dis. 2012;27:803-810. 38. Hadithi M, Cazemier M, Meijer GA, et al. Retrospective anal-ysis of old-age colitis in the Dutch inflammatory bowel dis-ease population. World J Gastroenterol. 2008;14:3183-3187. 39. Bonen DK, Cho JH. The genetics of inflammatory bowel dis-ease. Gastroenterology.


Surgery_Schwartz

Surgery_Schwartz. of old-age colitis in the Dutch inflammatory bowel dis-ease population. World J Gastroenterol. 2008;14:3183-3187. 39. Bonen DK, Cho JH. The genetics of inflammatory bowel dis-ease. Gastroenterology. 2003;124:521-536. 40. Yamamoto-Furusho JK. Genetic factors associated with the development of inflammatory bowel disease. World J Gastro-enterol. 2007;13:5594-5597. 41. Halme L, Paavola-Sakki P, Turunen U, et al. Family and twin studies in inflammatory bowel disease. World J Gastroenterol. 2006;12:3668-3672. 42. Hugot JP, Chamaillard M, Zouali H, et al. Association of NOD2 leucine-rich repeat variants with susceptibility to Crohn’s disease. Nature. 2001;411:599-603. 43. Sehgal R, Berg A, Hegarty JP, et al. NOD2/CARD15 muta-tions correlate with severe pouchitis after ileal pouch-anal anastomosis. Dis Colon Rectum. 2010;53(11):1487-1494. 44. Sehgal R, Berg A, Polinski JI, et al. Mutations in IRGM are associated with more frequent need for surgery in patients with ileocolonic Crohn’s disease.


Surgery_Schwartz

Surgery_Schwartz. Dis Colon Rectum. 2010;53(11):1487-1494. 44. Sehgal R, Berg A, Polinski JI, et al. Mutations in IRGM are associated with more frequent need for surgery in patients with ileocolonic Crohn’s disease. Dis Colon Rectum. 2012;55(2):115-121. 45. Hoarau G, Mukherjee PK, Gower-Rousseau C, et al. Bac-teriome and mycobiome interactions underscore microbial dysbiosis in familial Crohn’s disease. mBio. 2016;7(5). pii: e01250-16. 46. Strisciuglio C, Duijvestein M, Verhaar AP, et al. Impaired autophagy leads to abnormal dendritic cell-epithelial cell interactions. J Crohns Colitis. 2013;7(7):534-541. 47. Brinar M, Vermeire S, Cleynen I, et al. Genetic variants in autophagy-related genes and granuloma formation in a cohort of surgically treated Crohn’s disease patients. J Crohns Colitis. 2012;6(1):43-50. 48. Strisciuglio C, Duijvestein M, Verhaar AP, et al. Impaired autophagy leads to abnormal dendritic cell-epithelial cell interactions. J Crohns Colitis. 2013;7(7):534-541. 49. Brinar M, Vermeire S,


Surgery_Schwartz

Surgery_Schwartz. C, Duijvestein M, Verhaar AP, et al. Impaired autophagy leads to abnormal dendritic cell-epithelial cell interactions. J Crohns Colitis. 2013;7(7):534-541. 49. Brinar M, Vermeire S, Cleynen I, et al. Genetic variants in autophagy-related genes and granuloma formation in a cohort of surgically treated Crohn’s disease patients. J Crohns Colitis. 2012;6(1):43-50. 50. Tremaine WJ. Is indeterminate colitis determinable? Curr Gastroenterol Rep. 2012;14:162-165. 51. Lakatos PL, Lakatos L, Kiss LS, et al. Treatment of extraintes-tinal manifestations in inflammatory bowel disease. Digestion. 2012;86(suppl 1):28-35. 52. Alfadhli AA, McDonald JW, Feagan BG. Methotrexate for induction of remission in refractory Crohn’s disease. Cochrane Database Syst Rev. 2005;1:CD003459. 53. Hanauer SB, Feagan BG, Lichtenstein GR, et al. Main-tenance infliximab for Crohn’s disease: the ACCENT I randomised trial. Lancet. 2002;359:1541-1549. This study reports a randomized, controlled trial to assess main-tenance


Surgery_Schwartz

Surgery_Schwartz. GR, et al. Main-tenance infliximab for Crohn’s disease: the ACCENT I randomised trial. Lancet. 2002;359:1541-1549. This study reports a randomized, controlled trial to assess main-tenance therapy with infliximab for Crohn’s Disease. In this trial, 573 patients were treated with intravenous inf-liximab (single dose) and then randomized to repeat infu-sions of infliximab versus placebo. The investigators found that patients who responded to the first infusion of inflix-imab were more likely to stay in remission and discon-tinue corticosteroids when maintained on infliximab every 8 weeks. 54. Sands BE, Blank MA, Patel K, van Deventer SJ; ACCENT II Study. Long-term treatment of rectovaginal fistulas in Crohn’s disease: response to infliximab in the ACCENT II Study. Clin Gastroenterol Hepatol. 2004;2:912-920. 55. Yarur AJ, Kanagala V, Stein DJ, et al. Higher infliximab trough levels are associated with perianal fistula healing in patients with Crohn’s disease. Aliment Pharmacol Ther.


Surgery_Schwartz

Surgery_Schwartz. 2004;2:912-920. 55. Yarur AJ, Kanagala V, Stein DJ, et al. Higher infliximab trough levels are associated with perianal fistula healing in patients with Crohn’s disease. Aliment Pharmacol Ther. 2017;45(7):933-940. 56. Bamias G, Cominelli F. Novel strategies to attenuate immune activation in Crohn’s disease. Curr Opin Pharmacol. 2006;6:401-407. 57. Panaccione R, Ghosh S, Middleton S, et al. Combination therapy with infliximab and azathioprine is superior to mono-therapy with either agent in ulcerative colitis. Gastroenterology. 2014;146(2):392-400.e3. 58. Reinisch W, Sandborn WJ, Hommes DW, et al. Adalimumab for induction of clinical remission in moderately to severely active ulcerative colitis: results of a randomised controlled trial. Gut. 2011;60(6):780-787. 59. Sandborn WJ, van Assche G, Reinisch W, et al. Adalim-umab induces and maintains clinical remission in patients with moderate-to-severe ulcerative colitis. Gastroenterology. 2012;142(2):257-265.e1-e3. 60. Sjöberg M, Magnuson


Surgery_Schwartz

Surgery_Schwartz. G, Reinisch W, et al. Adalim-umab induces and maintains clinical remission in patients with moderate-to-severe ulcerative colitis. Gastroenterology. 2012;142(2):257-265.e1-e3. 60. Sjöberg M, Magnuson A, Björk J, et al; Swedish Organiza-tion for the Study of Inflammatory Bowel Disease (SOIBD). Infliximab as rescue therapy in hospitalised patients with steroid-refractory acute ulcerative colitis: a long-term fol-low-up of 211 Swedish patients. Aliment Pharmacol Ther. 2013;38(4):377-387. 61. Su C, Lewis JD, Deren JJ, et al. Efficacy of anti-tumor necrosis factor therapy in patients with ulcerative colitis. Am J Gastro-enterol. 2002;97:2577-2584. 62. Actis GC, Bruno M, Pinna-Pintor M, et al. Infliximab for treat-ment of steroid-refractory ulcerative colitis. Dig Liver Dis. 2002;34:631-634. 63. Appau KA, Fazio VW, Shen B, et al. Use of infliximab within 3 months of ileocolonic resection is associated with adverse Brunicardi_Ch29_p1259-p1330.indd 132523/02/19 2:30 PM 1326SPECIFIC


Surgery_Schwartz

Surgery_Schwartz. KA, Fazio VW, Shen B, et al. Use of infliximab within 3 months of ileocolonic resection is associated with adverse Brunicardi_Ch29_p1259-p1330.indd 132523/02/19 2:30 PM 1326SPECIFIC CONSIDERATIONSPART IIpostoperative outcomes in Crohn’s patients. J Gastrointest Surg. 2008;12(10):1738-1744. 64. Matsumoto T, Iwao Y, Igarashi M, et al. Endoscopic and chro-moendoscopic atlas featuring dysplastic lesions in surveillance colonoscopy for patients with long-standing ulcerative colitis. Inflamm Bowel Dis. 2008;14:259-264. 65. Wong Kee Song LM, Adler DG, Chand B, et al. Chromoen-doscopy. Gastrointest Endosc. 2007;66:639-649. 66. Heuschen UA, Hinz U, Allemeyer EH, et al. Oneor two-stage procedure for restorative proctocolectomy: ratio-nale for a surgical strategy in ulcerative colitis. Ann Surg. 2001;234:788-794. 67. Hall JF, Roberts PL, Ricciardi R, et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum.


Surgery_Schwartz

Surgery_Schwartz. Ann Surg. 2001;234:788-794. 67. Hall JF, Roberts PL, Ricciardi R, et al. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum. 2011;54:283-288. 68. Daniels L, de Korte N, Winter D, et al. Overtreatment of sig-moid diverticulitis: plea for a less aggressive approach. Dig Dis. 2012;30:86-91. 69. Li D, Baxter NN, McLeod R, Nathans AB. The decline of elective colectomy following diverticulitis: a population based analysis. Dis Colon Rectum. 2016;4:332-339. 70. Li D, Baxter NN, McLeod RS, Moineddin R, Wilton AS, Nathens AB. Evolving practice patterns in the acute manage-ment of acute colonic diverticulitis: a population-based analysis. Dis Colon Rectum. 2014;57(12):1397-1405. 71. Morris AM, Regebogen SE, Hardima KM. Surgery for diver-ticulitis: a systematic review. JAMA. 2014;311:902-302. 72. Bernini A, Spencer MP, Wong WD, et al. Computed tomog-raphy-guided percutaneous abscess drainage in intestinal disease: factors


Surgery_Schwartz

Surgery_Schwartz. for diver-ticulitis: a systematic review. JAMA. 2014;311:902-302. 72. Bernini A, Spencer MP, Wong WD, et al. Computed tomog-raphy-guided percutaneous abscess drainage in intestinal disease: factors associated with outcome. Dis Colon Rectum. 1997;40:1009-1013. 73. Schultz JK, Yaqub S, Wallon C, et al. Laparoscopic lavage versus primary resection for acute perforated diverticulitis: the SCANDIV randomized clinical trial. JAMA. 2015;314 (13):1364-1375. 74. Vennix S, Musters GD, Mulder IM, et al. Laparoscopic perito-neal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicenter parallel group randomised open label trial. Lancet. 2015;386:1269-1277. 75. Siegel RL, Miller KD, Fedewa SA, et al. Colorectal cancer statistics, 2017. CA Cancer J Clin. 2017;67(3):177-193. 76. Calle EE, Rodriguez C, Walker-Thurmond K, et al. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med.


Surgery_Schwartz

Surgery_Schwartz. Cancer J Clin. 2017;67(3):177-193. 76. Calle EE, Rodriguez C, Walker-Thurmond K, et al. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348:1625-1638. 77. Woodhouse CR. Guidelines for monitoring of patients with ureterosigmoidostomy. Gut. 2002;51(suppl 5):V15-V16. 78. Baxter NN, Tepper JE, Durham SB, et al. Increased risk of rectal cancer after prostate radiation: a population-based study. Gastroenterology. 2005;128:819-824. 79. Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorec-tal, and endometrial cancers. CA Cancer J Clin. 2001;51: 38-75. 80. Al-Tassan N, Chmiel NH, Maynard J, et al. Inherited vari-ants of MYH associated with somatic G:C–>T:A mutations in colorectal tumors. Nat Genet. 2002;30:227-232. 81. Lefevre JH, Rodrigue CM, Mourra N, et al. Implication of MYH in colorectal polyposis. Ann


Surgery_Schwartz

Surgery_Schwartz. of MYH associated with somatic G:C–>T:A mutations in colorectal tumors. Nat Genet. 2002;30:227-232. 81. Lefevre JH, Rodrigue CM, Mourra N, et al. Implication of MYH in colorectal polyposis. Ann Surg. 2006;244: 874-879. MYH is a base excision repair gene that removes adenines from DNA that have been mispaired with a nucle-otide product of oxidative reaction (8oxoG). Without MYH, mispaired adenines will lead to somatic transversions G:C→ T:A in genes such as APC or K-ras. The authors reviewed 433 patients who underwent prophylactic surgery for colorectal polyposis over a 25-year time frame and evaluated 31 patients who did not have APC, finding biallelic MYH mutations in 6 patients. They conclude that MYH is a new gene responsible for approximately 1.4% of all adenomatous polyposis and 20% of polyposis without an APC mutation identified. 82. Martin M, Simon-Assmann P, Kedinger M, et al. DCC regu-lates cell adhesion in human colon cancer derived HT-29 cells and associates with ezrin. Eur


Surgery_Schwartz

Surgery_Schwartz. polyposis without an APC mutation identified. 82. Martin M, Simon-Assmann P, Kedinger M, et al. DCC regu-lates cell adhesion in human colon cancer derived HT-29 cells and associates with ezrin. Eur J Cell Biol. 2006;85: 769-783. 83. Lao VV, Grady WM. Epigenetics and colorectal cancer. Nat Rev Gastroenterol Hepatol. 2011;8:686-700. 84. Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 2017;49(3):270-297. doi:10.1055/s-0043-102569. 85. Rex DK, Ahnen DJ, Baron JA, et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol. 2012;107:1315-1329. An expert panel provide their recommendation after a thorough literature review and 2-day conference. Hyperplastic polyps, sessile ser-rated adenomas/polyps, and traditional serrated adenomas are all included in the category of serrated lesions of the colon. This


Surgery_Schwartz

Surgery_Schwartz. review and 2-day conference. Hyperplastic polyps, sessile ser-rated adenomas/polyps, and traditional serrated adenomas are all included in the category of serrated lesions of the colon. This review outlines the histologic features of these lesions. Sessile serrated adenomas are predominantly flat, often with indistinct borders, right sided. They are associated with inter-val colon adenocarcinomas and are thought to progress to cancer, possibly through a promotor CpG island hypermeth-ylation pathway. The panel recommends that these lesions are completely excised and points to the variability in detection rates between endoscopists, hypothesizing that difficulty in endoscopic detection is related to the high rate of subsequent cancer diagnosis in these patients. 86. Regimbeau JM, Panis Y, Pocard M, et al. Handsewn ileal pouch-anal anastomosis on the dentate line after total proc-tectomy: technique to avoid incomplete mucosectomy and the need for long-term follow-up of the anal


Surgery_Schwartz

Surgery_Schwartz. Y, Pocard M, et al. Handsewn ileal pouch-anal anastomosis on the dentate line after total proc-tectomy: technique to avoid incomplete mucosectomy and the need for long-term follow-up of the anal transition zone. Dis Colon Rectum. 2001;44:43-50. 87. Remzi F, Fazio VW, Delaney CP, et al. Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years. Dis Colon Rectum. 2003;46:6-13. 88. Janne PA, Mayer RJ. Chemoprevention of colorectal cancer. N Engl J Med. 2000;342:1960-1968. 89. Steinbach G, Lynch PM, Phillips RK, et al. The effect of cele-coxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis. N Engl J Med. 2000;342:1946-1952. 90. Kasper B, Gruenwald V, Reichardt P, et al. Imatinib induces sustained progression arrest in RECIST progressive desmoid tumours: Final results of a phase II study of the German Inter-disciplinary Sarcoma Group (GISG). Eur J Cancer. 2017;76: 60-67. doi:


Surgery_Schwartz

Surgery_Schwartz. induces sustained progression arrest in RECIST progressive desmoid tumours: Final results of a phase II study of the German Inter-disciplinary Sarcoma Group (GISG). Eur J Cancer. 2017;76: 60-67. doi: 10.1016/j.ejca.2017.02.001. 91. Church J, Xhaja X, LaGuardia L, O’Mally M, Burke C, Kalady M. Desmoids and genotype in familial adenomatous polyposis. Dis Colon Rectum. 2015;58(4):444-448. 92. Bulow C, Vasen H, Järvinen H, et al. Ileorectal anastomosis is appropriate for a subset of patients with familial adenomatous polyposis. Gastroenterology. 2000;119:1454-1460. 93. Hampel H, Panescu J, Lockman J, et al. Screening for the Lynch syndrome (hereditary nonpolyposis colorectal cancer). N Engl J Med. 2005;352:1851-1860. 94. Jarvinen HJ, Aarnio M, Mustonen H, et al. Controlled 15-year trial on screening for colorectal cancer in families with hereditary nonpolyposis colorectal cancer. Gastroenterology. 2000;118:829-834. 95. National Quality Forum. Appendix A: Specifications of the National


Surgery_Schwartz

Surgery_Schwartz. screening for colorectal cancer in families with hereditary nonpolyposis colorectal cancer. Gastroenterology. 2000;118:829-834. 95. National Quality Forum. Appendix A: Specifications of the National Voluntary Consensus Standards for Breast and Colon Cancer. Available at: https://www.qualityforum.org/Publica-tions/2009/05/National_Voluntary_Consensus_Standards_for_Quality_of_Cancer_Care.aspx. Accessed July 23, 2018. 96. Lieberman DA, Weiss DG, Bond JH, et al. Use of colonos-copy to screen asymptomatic adults for colorectal cancer. Brunicardi_Ch29_p1259-p1330.indd 132623/02/19 2:30 PM 1327COLON, RECTUM, AND ANUSCHAPTER 29Veterans Affairs Cooperative Study Group 380. N Engl J Med. 2000;343:162-168. 97. Pignone M, Rich M, Teutsch SM, et al. Screening for colorec-tal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:132-141. 98. U.S. Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al.


Surgery_Schwartz

Surgery_Schwartz. average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:132-141. 98. U.S. Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;315:2564-2575. 99. Mandel JS, Church TR, Bond JH, et al. The effect of fecal occult-blood screening on the incidence of colorectal cancer. N Engl J Med. 2000;343:1603-1607. 100. Hardcastle JD, Armitage NC, Chamberlain J, et al. Fecal occult blood screening for colorectal cancer in the general popula-tion. Results of a controlled trial. Cancer. 1986;58:397-403. 101. Winawer SJ, Flehinger BJ, Schottenfeld D, et al. Screening for colorectal cancer with fecal occult blood testing and sigmoid-oscopy. J Natl Cancer Inst. 1993;85:1311-1318. 102. Levin B, Brooks D, Smith RA, et al. Emerging technologies in screening for colorectal cancer: CT colonography, immu-nochemical fecal occult blood


Surgery_Schwartz

Surgery_Schwartz. J Natl Cancer Inst. 1993;85:1311-1318. 102. Levin B, Brooks D, Smith RA, et al. Emerging technologies in screening for colorectal cancer: CT colonography, immu-nochemical fecal occult blood tests, and stool screening using molecular markers. CA Cancer J Clin. 2003;53:44-55. 103. Yee J, Akerkar GA, Hung RK, et al. Colorectal neoplasia: per-formance characteristics of CT colonography for detection in 300 patients. Radiology. 2001;219:685-692. 104. Imperiale TF, Wagner DR, Lin CY, et al. Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med. 2000;343:169-174. 105. Holme O, Løberg M, Kalager M, et al. Effect of flexible sig-moidoscopy screening on colorectal cancer incidence and mor-tality: a randomized clinical trial. JAMA. 2014;312:606-615. 106. Greene FL, Fleming PD, Fleming ID, et al. AJCC Cancer Staging Manual. Springer: New York; 2002. 107. Chang GJ, Kaiser AM, Mills S, Rafferty JE, Buie WD, on behalf of the Standards


Surgery_Schwartz

Surgery_Schwartz. FL, Fleming PD, Fleming ID, et al. AJCC Cancer Staging Manual. Springer: New York; 2002. 107. Chang GJ, Kaiser AM, Mills S, Rafferty JE, Buie WD, on behalf of the Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of colon cancer. Dis Colon Rectum. 2012;55:831-843. 108. Gunderson LL, Sargent DJ, Tepper JE, et al. Impact of T and N substage on survival and disease relapse in adjuvant rec-tal cancer: a pooled analysis. Int J Radiat Oncol Biol Phys. 2002;54:386-396. 109. Monson JRT, Weiser MR, Buie WD, Chang GJ, Rafferty JF; Prepared by the Standards practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013;56:535-550. 110. Qiu H, Sirivongs P, Rothenberger M, et al. Molecular prognos-tic factors in rectal cancer treated by radiation and surgery. Dis Colon Rectum. 2000;43:451-459. 111. Johnson PM, Porter GA,


Surgery_Schwartz

Surgery_Schwartz. H, Sirivongs P, Rothenberger M, et al. Molecular prognos-tic factors in rectal cancer treated by radiation and surgery. Dis Colon Rectum. 2000;43:451-459. 111. Johnson PM, Porter GA, Ricciardi R, et al. Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer. J Clin Oncol. 2006;24:3570-3575. 112. Chang GJ, Rodriguez-Bigas MA, Skibber JM, et al. Lymph node evaluation and survival after curative resec-tion of colon cancer: systematic review. J Natl Cancer Inst. 2007;99:433-441. 113. Ricciardi R, Madoff RD, Rothenberger DA, et al. Population-based analyses of lymph node metastases in colorectal cancer. Clin Gastroenterol Hepatol. 2006;4:1522-1527. 114. Ricciardi R, Baxter NN. Association versus causation versus quality improvement: setting benchmarks for lymph node eval-uation in colon cancer. J Natl Cancer Inst. 2007;99:414-415. 115. Puthillath A, Dunn KB, Rajput A, et al. Safety and efficacy of first-line


Surgery_Schwartz

Surgery_Schwartz. quality improvement: setting benchmarks for lymph node eval-uation in colon cancer. J Natl Cancer Inst. 2007;99:414-415. 115. Puthillath A, Dunn KB, Rajput A, et al. Safety and efficacy of first-line chemotherapy in unresected metastatic colorectal cancer. Clin Colorectal Cancer. 2007;6:710-715. 116. Francescutti V, Miller A, Satchidanand Y, Alvarez-Perez A, Dunn KB. Management of bowel obstruction in patients with stage IV cancer: predictors of outcome after surgery. Ann Surg Oncol. 2013;20(3):707-714. doi: 10.1245/s10434-012-2662-2. 117. Kashida H, Kudo SE. Early colorectal cancer: concept, diag-nosis, and management. Int J Clin Oncol. 2006;11(1):1-8. 118. Sargent DJ, Marsoni S, Monges G, et al. Defective mismatch repair as a predictive marker for lack of efficacy of fluoro-uracil-based adjuvant therapy in colon cancer. J Clin Oncol. 2010;28:3219-3226. 119. Mahmoud N, Bullard Dunn K. Metastasectomy for stage IV colorectal cancer. Dis Colon Rectum. 2010;53:1080-1092. 120. Demmy TL,


Surgery_Schwartz

Surgery_Schwartz. adjuvant therapy in colon cancer. J Clin Oncol. 2010;28:3219-3226. 119. Mahmoud N, Bullard Dunn K. Metastasectomy for stage IV colorectal cancer. Dis Colon Rectum. 2010;53:1080-1092. 120. Demmy TL, Dunn KB. Surgical and nonsurgical therapy for lung metastasis: indications and outcomes. Surg Oncol Clin N Am. 2007;16:579-605. 121. Stitzenberg KB, Sanoff HK, Penn DC, Meyers MO, Tepper JE. Practice patterns and long-term survival for early-stage rectal cancer. J Clin Oncol. 2013;31(34):4276-4282. 122. Taylor FGM, Quirke P, Heald RJ, et al. Preoperative high-res-olution magnetic resonance imaging can identify good prog-nosis stage I, II and III rectal cancer best managed by surgery alone. Ann Surg. 2011;253:711-719. 123. Garcia-Aguilar J, Shi Q, Thomas CR, Jr, et al. A phase II trial of neoadjuvant chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol. 2012;19:384-391. 124. Garcia-Aguilar J, Renfro LA, Chow OS, et al. Organ


Surgery_Schwartz

Surgery_Schwartz. chemoradiation and local excision for T2N0 rectal cancer: preliminary results of the ACOSOG Z6041 trial. Ann Surg Oncol. 2012;19:384-391. 124. Garcia-Aguilar J, Renfro LA, Chow OS, et al. Organ preserva-tion for clinical T2N0 distal rectal cancer using neoadjuvant chemoradiotherapy and local excision (ACOSOG Z6041): results of an open-label, single-arm, multi-institutional, phase 2 trial. Lancet Oncol. 2015;16(15):1537-1546. 125. Sun Z, Adam MA, Kim J, et al. Determining the optimal timing for initiation of adjuvant chemotherapy after resec-tion for Stage II and III colon cancer. Dis Colon Rectum. 2016;59(2):87-93. 126. Sauer R, Liersch T, Merkel S, et al. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004;351:1731-1740. The German Rectal Cancer Study Group randomized patients with clinical stage II and III rectal cancer to preoperative or postoperative long-course chemoradiation. The study occurred between 1994 and 2002 and, of note, the


Surgery_Schwartz

Surgery_Schwartz. Study Group randomized patients with clinical stage II and III rectal cancer to preoperative or postoperative long-course chemoradiation. The study occurred between 1994 and 2002 and, of note, the approach to staging did not include MRI. Among the 799 patients who were analyzed, fewer local recurrences were seen in patients assigned to preoperative chemoradiation compared with patients assigned to postopera-tive chemoradiation (6% vs. 13%; P = 0.006) at 5 years. The authors also found that in the long term, 72% of local recur-rences were associated with distant metastases. A subgroup analysis showed that the strongest difference in hazard ratios between preoperative and postoperative chemoradiation were in the patients who had intersphincteric or abdominoperineal resections (hazard ratio 2.24; P = 0.03). 127. Cercek A, Garcia-Aguilar J. Rectal cancer: neoadjuvant ther-apy. In: Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, eds. The ASCRS Textbook of Colon and


Surgery_Schwartz

Surgery_Schwartz. 2.24; P = 0.03). 127. Cercek A, Garcia-Aguilar J. Rectal cancer: neoadjuvant ther-apy. In: Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, eds. The ASCRS Textbook of Colon and Rectal Surgery. 3rd ed. New York: Springer; 2016:481-494. 128. Smith FM, Wiland H, Mace A, Pai RK, Kalady MF. Clinical criteria underestimate complete pathological response in rec-tal cancer treated with neoadjuvant chemoradiotherapy. Dis Colon Rectum. 2014;57(3):311-315. 129. Sammour T, Price BA, Krause KJ, Chang GJ. Nonoperative management of “watch and wait” for rectal cancer with com-plete clinical response after neoadjuvant chemoradiotherapy: a critical appraisal. Ann Surg Oncol. 2017;24:1904-1915. doi: 10.1245/s10434-017-5841-3. 130. Berends FJ, Kazemier G, Bonjer HJ, et al. Subcutaneous metastases after laparoscopic colectomy. Lancet. 1994; 344:58.Brunicardi_Ch29_p1259-p1330.indd 132723/02/19 2:30 PM 1328SPECIFIC CONSIDERATIONSPART II 131. Jayne DG, Guillou PJ, Thorpe H, et al.


Surgery_Schwartz

Surgery_Schwartz. metastases after laparoscopic colectomy. Lancet. 1994; 344:58.Brunicardi_Ch29_p1259-p1330.indd 132723/02/19 2:30 PM 1328SPECIFIC CONSIDERATIONSPART II 131. Jayne DG, Guillou PJ, Thorpe H, et al. Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol. 2007;25:3061-3068. 132. Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg. 2010;97(11):1638-1645. doi: 10.1002/bjs.7160. This study presents 5-year follow-up from the UK Medical Research Council CLASSIC Trial comparing the safety and efficacy of laparoscopic vs. open surgery for colorectal cancer. Outcomes included overall and disease free survival and local, distant, and port site recurrences. The investigators found no differ-ences between the two groups. They conclude, therefore, that


Surgery_Schwartz

Surgery_Schwartz. Outcomes included overall and disease free survival and local, distant, and port site recurrences. The investigators found no differ-ences between the two groups. They conclude, therefore, that long-term outcomes are not compromised by a laparoscopic approach. 133. Nelson H, Sargent D, Wieand HS, et al; for the Clinical Out-comes of Surgical Therapy Study Group. Laparoscopically assisted colectomy is as safe and effective as open colectomy in people with colon cancer. Abstracted from: A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004;350:2050-2059. Cancer Treat Rev. 2004;30(8):707-709. 134. Hazebroek EJ. COLOR: a randomized clinical trial compar-ing laparoscopic and open resection for colon cancer. Surg Endosc. 2002;16:949-953. 135. Jeong SY, Park JW, Nam BH, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority,


Surgery_Schwartz

Surgery_Schwartz. Park JW, Nam BH, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol. 2014;15(7):767-774. 136. Martínez-Pérez A, Carra MC, Brunetti F, de’Angelis N. Pathologic outcomes of laparoscopic vs open mesorectal excision for rectal cancer: a systematic review and meta-analysis. JAMA Surg. 2017;152(4):e165665. doi: 10.1001/jamasurg.2016.5665. 137. Collinson FJ, Jayne DG, Pigazzi A, et al. An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparo-scopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis. 2012; 27:233-241. 138. Fleshman J, Branda M, Sargent DJ, et al. Effect of laparo-scopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical


Surgery_Schwartz

Surgery_Schwartz. J, Branda M, Sargent DJ, et al. Effect of laparo-scopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA. 2015;314(13):1346-1355. 139. Stevenson AR, Solomon MJ, Lumley JW, et al; ALaCaRT Investigators. Effect of laparoscopic-assisted resection vs open resection on pathological outcomes in rectal cancer: the ALaCaRT randomized clinical trial. JAMA. 2015;314(13): 1356-1363. 140. Bonjer HJ, Deijen CL, Abis GA, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015;372(14):1324-1332. 141. Collinson FJ, Jayne DG, Pigazzi A, et al. An international, multicentre, prospective, randomised, controlled, unblinded, parallel-group trial of robotic-assisted versus standard laparo-scopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis. 2012;27(2):233-241. 142. Rindi G, Arnold R, Bosman FT. Nomenclature and classifica-tion of


Surgery_Schwartz

Surgery_Schwartz. versus standard laparo-scopic surgery for the curative treatment of rectal cancer. Int J Colorectal Dis. 2012;27(2):233-241. 142. Rindi G, Arnold R, Bosman FT. Nomenclature and classifica-tion of neuroendocrine neoplasms of the digestive system. In Bosman FT, Carneiro F, Hruban RH, Theise ND, eds. WHO Classification of Tumors of Digestive System. Lyon, France: International Agency for Research on Cancer (IARC) Press; 2010:13-14. 143. Volkan Adsay N, Klimstra DS. Neuroendocrine tumors of the gastrointestinal and pancreatobiliary tracts. In: Odze RD, Goldblum JR, eds. Odze and Goldblum Surgical Pathology of the GI Tract, Liver, Biliary Tract and Pancreas. 3rd ed. Philadelphia: Saunders/Elsevier; 2015. 144. Bullard Dunn KM. Other rectal neoplasms. In: Beck DE, Steele SR, Wexner SD, eds. Fundamentals of Anorectal Surgery. 3rd ed. New York: Springer; 2018. 145. Merchea AL, Hubner M, Wenger D, Rose P, Dozois E. The value of preoperative biopsy in the management of solid pre-sacral tumors.


Surgery_Schwartz

Surgery_Schwartz. of Anorectal Surgery. 3rd ed. New York: Springer; 2018. 145. Merchea AL, Hubner M, Wenger D, Rose P, Dozois E. The value of preoperative biopsy in the management of solid pre-sacral tumors. Dis Colon Rectum. 2013;56:756-760. 146. Merchea A, Dozois EJ. Lesions originating within the retrorec-tal space. J Gastrointest Surg. 2014;18(12):2232-2233. 147. Dozois EJ, Jacofsky DJ, Billings BJ, et al. In: Wards CY, Larson DW. Surgical approach and oncologic outcomes fol-lowing multidisciplinary management of retrorectal sarcomas. Ann Surg Oncol. 2011;18(4):983-988. 148. Steele SR, Varma MG, Melton GB, Ross HM, Rafferty JF, Buie WD. Practice parameters for anal squamous neoplasms. Dis Colon Rectum. 2012;55:735-749. 149. Darragh TM, Colgan TJ, Cox JT, et al. The lower anogenital squamous terminology standardization project for HPV-asso-ciated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical


Surgery_Schwartz

Surgery_Schwartz. standardization project for HPV-asso-ciated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. J Low Genit Tract Dis. 2012;16:205-242. 150. Messick CA, Rodriguez-Bigas. Anal dysplasia. Surg Oncol Clin North Am. 2017;26:33-43. The authors review the litera-ture on anal dysplasia with a focus on the natural history and the impact of ablative techniques with high resolution anos-copy on recurrence rates. High-risk patients are categorized as HIV-positive, immunosuppressed transplant recipients, and men who have sex with men. The authors emphasize the lack of literature in patients who are not non–high risk and overall emphasize close follow-up in all patients with high grade squamous intraepithelial lesion (HSIL)/high grade anal intraepithelial neoplasia (HGAIN). 151. Stanley MA. Imiquimod and the imidazoquinolones: mecha-nism of action and therapeutic potential. Clin Exp Dermatol.


Surgery_Schwartz

Surgery_Schwartz. lesion (HSIL)/high grade anal intraepithelial neoplasia (HGAIN). 151. Stanley MA. Imiquimod and the imidazoquinolones: mecha-nism of action and therapeutic potential. Clin Exp Dermatol. 2002;27:571-577. 152. Chen H, Cai Y, Liu Y, et al. Incidence, surgical treatment, and prognosis of anorectal melanoma from 1973 to 2011: a population based SEER analysis. Medicine (Baltimore). 2016;95:e2770. 153. Bullard KM, Tuttle TM, Rothenberger DA, et al. Surgi-cal therapy for anorectal melanoma. J Amer Coll Surg. 2003;196:206-211. 154. D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc. 2006;20:1919-1923. 155. Ponec RJ, Saunders MD, Kimmey MB. Neostigmine for the treatment of acute colonic pseudo-obstruction. N Engl J Med. 1999;341:137-141. 156. Turgeon DK, Novicki TJ, Quick J, et al. Six rapid tests for direct detection of Clostridium difficile and its toxins in fecal samples compared with the fibroblast


Surgery_Schwartz

Surgery_Schwartz. N Engl J Med. 1999;341:137-141. 156. Turgeon DK, Novicki TJ, Quick J, et al. Six rapid tests for direct detection of Clostridium difficile and its toxins in fecal samples compared with the fibroblast cytotoxicity assay. J Clin Microbiol. 2003;41:667-670. 157. Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA. 2015;313(4):398-408. 158. Cecil JA. Clostridium difficile: changing epidemiology, treat-ment and infection prevention measures. Curr Infect Dis Rep. 2012;14:612-619. 159. Manfredelli S, Montalto G, Leonetti G, et al. Conventional (CH) vs. stapled hemorrhoidectomy (SH) in surgical treat-ment of hemorrhoids. Ten years experience. Ann Ital Chir. 2012;83:129-134. 160. Shao WJ, Li GC, Zhang ZH, Yang BL, Sun GD, Chen YQ. Systematic review and meta-analysis of randomized Brunicardi_Ch29_p1259-p1330.indd 132823/02/19 2:30 PM 1329COLON, RECTUM, AND ANUSCHAPTER 29controlled trials comparing stapled haemorrhoidopexy


Surgery_Schwartz

Surgery_Schwartz. Systematic review and meta-analysis of randomized Brunicardi_Ch29_p1259-p1330.indd 132823/02/19 2:30 PM 1329COLON, RECTUM, AND ANUSCHAPTER 29controlled trials comparing stapled haemorrhoidopexy with conventional haemorrhoidectomy. Br J Surg. 2008;95: 147-160. 161. Schuurman JP, Borel Rinkes IH, Go PM. Hemorrhoidal artery ligation procedure with or without Doppler transducer in grade II and III hemorrhoidal disease: a blinded randomized clinical trial. Ann Surg. 2012;255:840-845. 162. Jonas M, Speake W, Scholefield J. Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures: a prospective study. Dis Colon Rectum. 2002;45:1091-1095. 163. Mentes BB, Irkörücü O, Akin M, et al. Comparison of botu-linum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum. 2003;46:232-237. 164. Nelson RL, Thomas K, Morgan J, et al. Nonsurgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;2:CD003431. 165. North JH, Jr,


Surgery_Schwartz

Surgery_Schwartz. anal fissure. Dis Colon Rectum. 2003;46:232-237. 164. Nelson RL, Thomas K, Morgan J, et al. Nonsurgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;2:CD003431. 165. North JH, Jr, Weber TK, Rodriguez-Bigas MA, et al. The management of infectious and noninfectious anorectal complications in patients with leukemia. J Am Coll Surg. 1996;183:322-328. 166. Jacob TJ, Perakath B, Keighley MR. Surgical interven-tion for anorectal fistula. Cochrane Database Syst Rev. 2010;5:CD006319. This meta-analysis evaluated 10 random-ized trials on outcomes after anorectal fistula procedures, with the ideal procedure stated to be associated with low recurrence rates, minimal incontinence, and good quality of life. Evalu-ated surgical interventions included: fistulotomy, fistulectomy, myo-mucosal advancement flap, fibrin glue, and cutting or loose setons. There were no differences in the procedures compared, except that fibrin glue had more recurrences. Trial sample sizes were noted to be


Surgery_Schwartz

Surgery_Schwartz. advancement flap, fibrin glue, and cutting or loose setons. There were no differences in the procedures compared, except that fibrin glue had more recurrences. Trial sample sizes were noted to be small, and more recently dis-cussed procedures such as the anal fistula plug and Ligation of Intersphincteric Fistula Tract (LIFT) were not evaluated in this review. 167. De Groof EJ, Cabral VN, Buskens CJ, et al. Systematic review of the evidence and consensus on perianal fistula: an analy-sis of national and international guidelines. Colorectal Dis. 2016;18(4):O119-O134. 168. Shanwani A, Nor AM, Amri N. Ligation of the intersphincteric fistula tract (LIFT): a sphincter-saving technique for fistula-in-ano. Dis Colon Rectum. 2010;53:39-42. 169. Gunter J. Genital and perianal warts: new treatment opportuni-ties for human papillomavirus infection. Am J Obstet Gynecol. 2003;189(3 suppl):S3-S11. 170. Palefsky JM. Anal squamous intraepithelial lesions: relation to HIV and human papillomavirus