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Surgery_Schwartz. should be sent to pathology as a specimen (true distal margin). A gap in an anastomotic ring suggests that the circular staple line is incomplete and the anastomosis should be reinforced with suture circumferentially, if technically feasible. A temporary proximal ileostomy may be indicated as well. Most surgeons will also leak test an anastomosis by instilling water or saline into the pelvis and insufflating the rectum with air via a proc-toscope to looking or alternatively instilling methylene blue or betadine into the rectum to look for extravasation. A leak test strongly suggests a defect and/or disruption of the anastomosis. As such, the suture should line reinforced and sometimes may require reanastomosis.23Brunicardi_Ch29_p1259-p1330.indd 127423/02/19 2:29 PM 1275COLON, RECTUM, AND ANUSCHAPTER 29Ostomies and Preoperative Stoma PlanningDepending on the clinical situation, a stoma may be temporary or permanent. It may be end-on or a loop. However, regardless of the indication


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Surgery_Schwartz. AND ANUSCHAPTER 29Ostomies and Preoperative Stoma PlanningDepending on the clinical situation, a stoma may be temporary or permanent. It may be end-on or a loop. However, regardless of the indication for a stoma, placement and construction are crucial for function.The preoperative preparation of a patient who is expected to require a stoma should include a consultation with an enter-ostomal therapy (ET) nurse. ET nurses are specially trained and credentialed by the Wound, Ostomy, and Continence Nurses Society. Preoperative planning includes counseling, education, and stoma siting. Postoperatively, the ET nurse assists with local skin care and pouching. Other considerations in stoma planning include evaluation of other medical conditions that may impact on a patient’s ability to manage a stoma (e.g., eyesight, manual dexterity). Family or other caregivers can prove invaluable in caring for these patients.Preoperative stoma siting is crucial for a patient’s postop-erative function and


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Surgery_Schwartz. stoma (e.g., eyesight, manual dexterity). Family or other caregivers can prove invaluable in caring for these patients.Preoperative stoma siting is crucial for a patient’s postop-erative function and quality of life. A poorly placed stoma can result in leakage and skin breakdown. Ideally, a stoma should be placed in a location that the patient can easily see and manipulate, within the rectus muscle, and below the belt line (Fig. 29-15). Because the abdominal landmarks in a supine, anesthetized patient may be dramatically different from those in an awake, standing, or sitting patient, the stoma site should always be marked with a tattoo, skin scratch, or permanent marker preoperatively, if possible. In an emergency operation where the stoma site has not been marked, an attempt should be made to place a stoma within the rectus muscle and away from 3BCAFigure 29-13. A. Sutured end-to-end colocolic anastomosis. B. Sutured end-to-side ileocolic anastomosis. C. Stapled side-to-side,


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Surgery_Schwartz. be made to place a stoma within the rectus muscle and away from 3BCAFigure 29-13. A. Sutured end-to-end colocolic anastomosis. B. Sutured end-to-side ileocolic anastomosis. C. Stapled side-to-side, functional end-to-end ileocolic anastomosis. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Brunicardi_Ch29_p1259-p1330.indd 127523/02/19 2:29 PM 1276SPECIFIC CONSIDERATIONSPART IIboth the costal margin and iliac crest. In emergencies, placement high on the abdominal wall is preferred to a more caudal site.For all stomas, a circular skin incision is created, and the subcutaneous tissue is dissected to the level of the anterior rec-tus sheath. The anterior rectus sheath is incised in a cruciate fashion, the muscle fibers separated bluntly, and the posterior sheath identified and incised. Care should be taken to avoid injuring and causing bleeding from the inferior


Surgery_Schwartz

Surgery_Schwartz. is incised in a cruciate fashion, the muscle fibers separated bluntly, and the posterior sheath identified and incised. Care should be taken to avoid injuring and causing bleeding from the inferior epigastric artery and vein. The size of the defect depends on the size of the bowel used to create the stoma, but it should be as small as possible without compromising the intestinal blood supply (usually the width of two to three fingers). The bowel is then brought through the defect and secured with sutures. The abdominal incision is usually closed and dressed prior to maturing the stoma to avoid contaminating the wound. In order to make appliance use easier, a protruding nipple is fashioned by everting the bowel. Three or four interrupted absorbable sutures are placed through the edge of the bowel, then through the serosa, approximately 2 cm proximal to the edge, and then through the dermis (Brooke tech-nique). After the stoma is everted, the mucocutaneous junction is sutured


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Surgery_Schwartz. edge of the bowel, then through the serosa, approximately 2 cm proximal to the edge, and then through the dermis (Brooke tech-nique). After the stoma is everted, the mucocutaneous junction is sutured circumferentially with interrupted absorbable suture (Fig. 29-16).Ileostomy Temporary Ileostomy A temporary ileostomy is often used to “protect” an anastomosis that is at risk for leakage (low in the rectum, in an irradiated field, in an immunocompromised or malnourished patient, and during some emergency operations). In this setting, the stoma is often constructed as a loop ileostomy (see Fig. 29-12). A segment of distal ileum is brought through the defect in the abdominal wall as a loop. An enterotomy is created and the stoma matured as described earlier. The loop may be secured with or without an underlying rod. A divided loop may also be created by firing a linear cutting/stapler across the distal limb of the loop flush with the skin followed by mat-uration of the proximal limb of the


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Surgery_Schwartz. an underlying rod. A divided loop may also be created by firing a linear cutting/stapler across the distal limb of the loop flush with the skin followed by mat-uration of the proximal limb of the loop. This technique pre-vents incomplete diversion that occasionally occurs with a loop ileostomy.The advantage of a loop or divided loop ileostomy is that subsequent closure can often be accomplished without a formal laparotomy. An elliptical incision is created around the stoma and the bowel gently dissected free of the subcutaneous tissues and fascia. A hand-sewn or stapled anastomosis can then be created and the intestine returned to the peritoneal cavity. This ABDCEFigure 29-14. Technique of end-to-end colorectal anastomosis using a circular stapler. A. The patient is in modified lithotomy position. B. After resection of the rectosigmoid and placement of purse-string sutures proximally and distally, the stapler is inserted into the anal canal and opened. C. Rectal purse-string suture


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Surgery_Schwartz. position. B. After resection of the rectosigmoid and placement of purse-string sutures proximally and distally, the stapler is inserted into the anal canal and opened. C. Rectal purse-string suture is tied to secure the rectal stump to the rod of the stapler, and the colonic purse-string is tied to secure the colon to the anvil of the stapler. D. The stapler is closed and fired. E. The stapler is removed, leaving a circular stapled end-to-end anastomosis.Brunicardi_Ch29_p1259-p1330.indd 127623/02/19 2:29 PM 1277COLON, RECTUM, AND ANUSCHAPTER 29avoids a long laparotomy incision and generally is well toler-ated. The timing of ileostomy closure should take into account anastomotic healing as well as the patient’s overall condition. A flexible endoscopy exam and a contrast enema (Gastrografin) are recommended prior to closure to ensure that the anastomosis has not leaked and is patent. A patient’s nutritional status should be optimized. Because the timing of adjuvant chemotherapy


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Surgery_Schwartz. are recommended prior to closure to ensure that the anastomosis has not leaked and is patent. A patient’s nutritional status should be optimized. Because the timing of adjuvant chemotherapy effects survival, cancer patients receiving adjuvant chemother-apy usually should defer ileostomy closure until completion of treatment.Permanent Ileostomy A permanent ileostomy is sometimes required after total proctocolectomy or in patients with obstruc-tion. An end ileostomy is the preferred configuration for a per-manent ileostomy because a symmetric protruding nipple can be fashioned more easily than with a loop ileostomy (see Fig. 29-16). The end of the small intestine is brought through the abdominal wall defect and matured. Stitches are often used to secure the bowel to the posterior fascia.Complications of Ileostomy Stoma necrosis may occur in the early postoperative period and is usually caused by skel-etonizing the distal small bowel and/or creating an overly tight fascial defect.


Surgery_Schwartz

Surgery_Schwartz. of Ileostomy Stoma necrosis may occur in the early postoperative period and is usually caused by skel-etonizing the distal small bowel and/or creating an overly tight fascial defect. Limited mucosal necrosis above the fascia may be treated expectantly, but necrosis below the level of the fascia requires surgical revision. Stoma retraction may occur early or late and may be exacerbated by obesity. Local revision may be necessary. The creation of an ileostomy bypasses the fluid-absorbing capability of the colon, and dehydration with fluid and electrolyte abnormalities is not uncommon. Ideally, ileos-tomy output should be maintained at less than 1500 mL/d to avoid this problem. Bulk agents and opioids (Lomotil, Imodium, tincture of opium) are useful. The somatostatin analogue, octreotide, has been used with varying success in this setting. Skin irritation can also occur, especially if the stoma appliance fits poorly. Skin-protecting agents and custom pouches can help to solve this


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Surgery_Schwartz. has been used with varying success in this setting. Skin irritation can also occur, especially if the stoma appliance fits poorly. Skin-protecting agents and custom pouches can help to solve this problem. Obstruction may occur intra-abdominally or at the site where the stoma exits the fascia. Parastomal hernia is less common after an ileostomy than after a colostomy but can cause poor appliance fitting, pain, obstruction, or strangulation. In general, symptomatic parastomal hernias should be repaired. A variety of techniques to repair these hernias have been described, including local repair (either with or without mesh), laparoscopic repair, and stoma resiting. Prolapse is a rare, late complication and is often associated with a parastomal hernia.Colostomy. Most colostomies are created as end colostomies rather than loop colostomies (Fig. 29-17). The bulkiness of the colon makes a loop colostomy awkward for use of an appliance, and prolapse is more likely with this configuration.


Surgery_Schwartz

Surgery_Schwartz. as end colostomies rather than loop colostomies (Fig. 29-17). The bulkiness of the colon makes a loop colostomy awkward for use of an appliance, and prolapse is more likely with this configuration. Most colos-tomies are created on the left side of the colon. An abdominal wall defect is created and the end of the colon mobilized through it. Because a protruding stoma is considerably easier to pouch, colostomies should also be matured in a Brooke fashion. The distal bowel may be brought through the abdominal wall as a mucus fistula or left intra-abdominally as a Hartmann’s pouch. Tacking the distal end of the colon to the abdominal wall or tagging it with permanent suture can make identification of the stump easier if the colostomy is closed at a later date. Closure of an end colostomy has traditionally required a laparotomy, but increasingly minimally invasive techniques have been adopted. The stoma is dissected free of the abdominal wall and the distal bowel identified. An end-to-end


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Surgery_Schwartz. traditionally required a laparotomy, but increasingly minimally invasive techniques have been adopted. The stoma is dissected free of the abdominal wall and the distal bowel identified. An end-to-end anastomosis is then created.MidlineincisionStoma siteLateral edgeof rectus sheathWaistlineHiplineFigure 29-15. Marking of an ideal site for ileostomy. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Diges-tive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)BACFigure 29-16. Brooke ileostomy. A. Four sutures incorporating the cut end of the ileum, the seromuscular layer at the level of the anterior rectus fascia, and the subcuticular edge of the skin are placed at 90° to each other. B. The sutures are tied to produce sto-mal eversion, and (C) simple sutures from the cut edge of the bowel to the subcuticular tissue complete the maturation of the ileostomy. (Reproduced with permission from Bell RH, Rikkers LF, Mulhol-land M:


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Surgery_Schwartz. and (C) simple sutures from the cut edge of the bowel to the subcuticular tissue complete the maturation of the ileostomy. (Reproduced with permission from Bell RH, Rikkers LF, Mulhol-land M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Brunicardi_Ch29_p1259-p1330.indd 127723/02/19 2:29 PM 1278SPECIFIC CONSIDERATIONSPART IIComplications of Colostomy Colostomy necrosis may occur in the early postoperative period and results from an impaired vascular supply (skeletonization of the distal colon or a tight fas-cial defect). Like ileostomy necrosis, limited suprafascial necro-sis may be followed expectantly, but necrosis below the fascia requires surgery. Retraction may also occur but is less problem-atic with a colostomy than with an ileostomy because the stool is less irritating to the skin than succus entericus. Obstruction is unusual, but may also occur. Parastomal hernia is the most common late complication of a colostomy and


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Surgery_Schwartz. ileostomy because the stool is less irritating to the skin than succus entericus. Obstruction is unusual, but may also occur. Parastomal hernia is the most common late complication of a colostomy and requires repair if it is symptomatic. Prolapse occurs rarely, but is more com-mon with a loop colostomy. Interestingly, it is almost always the efferent limb of the loop that prolapses. Dehydration is rare after colostomy, and skin irritation is less common than with ileostomy.Functional ResultsFunction following segmental colonic resection and primary anastomosis is generally excellent. A small percentage of patients following subtotal or total colectomy and ileosigmoid or ileorectal anastomosis may experience diarrhea and bowel frequency. This is especially true if the patient is elderly, if sig-nificant length of small bowel has been resected, and if residual proctocolitis is poorly controlled. In general, the more distal the anastomosis, the greater is the risk of troublesome diarrhea


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Surgery_Schwartz. sig-nificant length of small bowel has been resected, and if residual proctocolitis is poorly controlled. In general, the more distal the anastomosis, the greater is the risk of troublesome diarrhea and frequency. However, some patients develop significant diarrhea after right colectomy due to malabsorption of bile acids; in these cases, bile acid binding resins (e.g., cholestyramine) sometimes can be helpful.Function following anterior resection is highly dependent on the level of anastomosis, the use of preor postoperative pelvic radiation, and underlying sphincter function. Following low anterior or extended low anterior resection, some surgeons prefer to construct a short (5-cm) colon J-pouch to anastomose to the distal rectum or anal canal in order to increase the capacity of the neorectum. The reservoirs are thought to lessen urgency, frequency, and incontinence, but some patients have difficulty initiating defecation, and long-term superiority over a “straight” anastomosis has


Surgery_Schwartz

Surgery_Schwartz. The reservoirs are thought to lessen urgency, frequency, and incontinence, but some patients have difficulty initiating defecation, and long-term superiority over a “straight” anastomosis has yet to be proven. In addition, these reservoirs can be technically difficult, especially in an obese male with a narrow pelvis.20-22The physical and psychological problems associated with a permanent Brooke ileostomy led to development of the con-tinent Kock pouch ileostomy. Unfortunately, complications, especially complications related to valve slippage, are common. Despite variations of technique designed to improve the func-tion of the continent ileostomy, most surgeons have abandoned this operation and instead perform restorative proctocolectomy with ileal pouch–anal anastomosis.Although ileal pouch–anal reconstruction is anatomically appealing, functional outcome is far from perfect.26,27 Patients should be counseled to expect 8 to 10 bowel movements per day. Up to 50% have some degree of


Surgery_Schwartz

Surgery_Schwartz. pouch–anal reconstruction is anatomically appealing, functional outcome is far from perfect.26,27 Patients should be counseled to expect 8 to 10 bowel movements per day. Up to 50% have some degree of nocturnal incontinence. Pouchitis (see the following paragraph) occurs in nearly 50% of patients who undergo the operation for chronic ulcerative colitis, and small bowel obstruction is not uncommon. Other less com-mon complications include difficulties with pouch evacuation, pouch-perineal and/or pouch-vaginal fistula, and anal stricture. Pouch failure rate averages 5% to 10%. Patients who are sub-sequently diagnosed with Crohn’s disease have a considerably higher pouch failure rate (approximately 50%), whereas patients with indeterminate colitis have an intermediate pouch failure rate (15–20%). Despite these drawbacks, the vast majority of patients are satisfied and prefer ileal pouch–anal reconstruction to permanent ileostomy.26,27Pouchitis is an inflammatory condition that affects


Surgery_Schwartz

Surgery_Schwartz. Despite these drawbacks, the vast majority of patients are satisfied and prefer ileal pouch–anal reconstruction to permanent ileostomy.26,27Pouchitis is an inflammatory condition that affects both ileoanal pouches and continent ileostomy reservoirs. The inci-dence of pouchitis ranges from 30% to 55%. Symptoms include increased diarrhea, hematochezia, abdominal pain, fever, and malaise. Diagnosis is made endoscopically with biopsies. Dif-ferential diagnosis includes infection and undiagnosed Crohn’s disease. The etiology of pouchitis is unknown. Some believe pouchitis results from fecal stasis within the pouch, but empty-ing studies are not confirmatory. Antibiotics (metronidazole ± ciprofloxacin) are the mainstays of therapy, and most patients will respond rapidly to either oral preparations or enemas. Some patients develop chronic pouchitis that necessitates ongoing suppressive antibiotic therapy. Salicylate and corticosteroid enemas have also been used with some success.28-31


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Surgery_Schwartz. or enemas. Some patients develop chronic pouchitis that necessitates ongoing suppressive antibiotic therapy. Salicylate and corticosteroid enemas have also been used with some success.28-31 Biologic agents targeting TNFa (infliximab, vedulizumab, ustekinumab) are also being studied.32-34 Reintroduction of normal flora by ingestion of probiotics and/or an elemental diet have been sug-gested as a possible treatment in refractory cases. Occasionally, pouch excision is necessary to control the symptoms of chronic pouchitis.30Anesthesia ConsiderationsLocal Anesthesia. Many anorectal procedures can be per-formed with local anesthetic alone. Intravenous sedation is often provided to calm the patient. Injection of 0.5% lidocaine (short acting) and 0.25% bupivacaine (long acting) into the perianal skin, sphincter, and area around the pudendal nerves usually provides an adequate block. The addition of dilute epinephrine decreases bleeding and prolongs the anesthetic effect.Regional


Surgery_Schwartz

Surgery_Schwartz. the perianal skin, sphincter, and area around the pudendal nerves usually provides an adequate block. The addition of dilute epinephrine decreases bleeding and prolongs the anesthetic effect.Regional Anesthesia. Epidural, spinal, and caudal anesthetics can be used for anorectal procedures and transanal resections. In patients with severe medical comorbidity, regional anesthesia may occasionally be used for laparotomy and colectomy. Post-operative epidural anesthesia provides excellent pain relief and improves pulmonary function especially after an open operation.General Anesthesia. General anesthesia is required for the vast majority of intra-abdominal procedures. Patients should Figure 29-17. Intraperitoneal end colostomy.Brunicardi_Ch29_p1259-p1330.indd 127823/02/19 2:29 PM 1279COLON, RECTUM, AND ANUSCHAPTER 29undergo a thorough preoperative cardiovascular evaluation. In patients with significant comorbid disease, an anesthesia con-sultation may be appropriate.Positioning. Most


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Surgery_Schwartz. RECTUM, AND ANUSCHAPTER 29undergo a thorough preoperative cardiovascular evaluation. In patients with significant comorbid disease, an anesthesia con-sultation may be appropriate.Positioning. Most abdominal colectomies can be performed in the supine position. Anterior resection and APR require lithotomy positioning to facilitate the pelvic dissection and mobilization of the splenic flexure. Adequate padding should be provided for the patient’s sacrum, and care should be taken to avoid stirrup pressure on the peroneal nerves.Anorectal procedures may be performed in lithotomy or in the prone jackknife position. Some surgeons prefer the prone jackknife position because exposure may be better, espe-cially for anterior lesions. Distal posterior lesions can usually be accessed from either position, but more proximal posterior lesions are better accessed in the prone position.Operative PreliminariesBowel Preparation. The rationale for bowel preparation is that decreasing the bacterial load


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Surgery_Schwartz. but more proximal posterior lesions are better accessed in the prone position.Operative PreliminariesBowel Preparation. The rationale for bowel preparation is that decreasing the bacterial load in the colon and rectum will decrease the incidence of postoperative infection. Mechanical bowel preparation uses cathartics to rid the colon of solid stool the night before surgery. The most commonly used regimens include polyethylene glycol (PEG) solutions or magnesium citrate. PEG solutions require patients to drink a large volume of fluid and may cause bloating and nausea. Magnesium citrate solutions are generally better tolerated but are more likely to cause fluid and electrolyte abnormalities. Both are equally efficacious in bowel cleansing. Preparatory formulations have been recently introduced in tablet form in an attempt to improve tolerance. However, these methods of bowel cleansing require ingestion of 40 or more tablets with water over several hours. To date, these formulations have


Surgery_Schwartz

Surgery_Schwartz. in tablet form in an attempt to improve tolerance. However, these methods of bowel cleansing require ingestion of 40 or more tablets with water over several hours. To date, these formulations have not been proven to be superior to the more traditional products. Antibiotic prophylaxis also is recommended. The addition of oral antibiotics to the preopera-tive mechanical bowel preparation has been thought to decrease postoperative infection by further decreasing the bacterial load of the colon. A recent analysis of the Surgical Care Improve-ment Project-1 (SCIP-1) suggests that oral antibiotics reduce postoperative wound infection, especially if a mechanical bowel preparation is not used.35-37Longstanding, convincing data support the efficacy of parenteral antibiotic prophylaxis at the time of surgery. Broad-spectrum parenteral antibiotic(s) with activity against aerobic and anaerobic enteric pathogens should be administered just prior to the skin incision and redosed as needed depending


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Surgery_Schwartz. surgery. Broad-spectrum parenteral antibiotic(s) with activity against aerobic and anaerobic enteric pathogens should be administered just prior to the skin incision and redosed as needed depending on the length of the operation. There is no proven benefit to using antibiotics postoperatively after an uncomplicated colectomy.Despite widespread use of mechanical bowel prepara-tion, the necessity of bowel cleansing prior to colectomy has been questioned. European surgeons in particular have advo-cated abandoning this practice. Arguments against mechani-cal bowel preparation include dehydration and electrolyte abnormalities that often result from bowel cleansing, as well as the risk of spillage of liquid stool left over from the “prep.” Arguments in favor of mechanical bowel preparation included easier manipulation of an “empty” colon (especially in mini-mally invasive procedures) and avoidance of a “stool column” above an anastomosis, especially in the pelvis. Interestingly, a recent


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Surgery_Schwartz. easier manipulation of an “empty” colon (especially in mini-mally invasive procedures) and avoidance of a “stool column” above an anastomosis, especially in the pelvis. Interestingly, a recent meta-analysis of 14 randomized controlled trials sug-gested that mechanical bowel preparation does not prevent sur-gical site infection and should be abandoned in clinical practice. However, these studies did not include the use of oral antibiotics in the mechanical preparation groups, and further studies will be needed to determine the optimal preparation regimen.35-37Ureteral Stents. Ureteral stents may be useful for identify-ing the ureters intraoperatively and are placed via cystoscopy after the induction of general anesthesia and removed at the end of the operation. Stents can be invaluable during reopera-tive pelvic surgery or when there is significant retroperitoneal inflammation (such as complicated diverticulitis), as well as in obese patients. Lighted stents may be helpful in


Surgery_Schwartz

Surgery_Schwartz. during reopera-tive pelvic surgery or when there is significant retroperitoneal inflammation (such as complicated diverticulitis), as well as in obese patients. Lighted stents may be helpful in laparoscopic and robotic resections. Patients often have transient hematuria postoperatively, but major complications are rare.Multidisciplinary Teams. Patients with complex colorectal disease often benefit from a multidisciplinary approach to their care. Patients with pelvic floor disorders (especially inconti-nence) often require evaluation by both a colorectal surgeon and a urologist or urogynecologist. Preoperative evaluation of cancer patients by a medical oncologist and/or radiation oncolo-gist is crucial for planning either neoadjuvant or adjuvant ther-apy. Intraoperatively, complex pelvic resections often require the involvement of not only a colorectal surgeon but also a urologist, gynecologic oncologist, neurosurgeon, and/or plastic surgeon. Radiation oncologists should be involved in


Surgery_Schwartz

Surgery_Schwartz. often require the involvement of not only a colorectal surgeon but also a urologist, gynecologic oncologist, neurosurgeon, and/or plastic surgeon. Radiation oncologists should be involved in the opera-tion if brachytherapy catheters are to be placed for intracavi-tary radiation or if intraoperative radiation therapy is planned. Rarely, psychiatric disorders may manifest as colorectal prob-lems (especially functional disorders and chronic pain), and involvement of a psychiatrist or psychologist may be beneficial.INFLAMMATORY BOWEL DISEASEGeneral ConsiderationsEpidemiology. Inflammatory bowel disease includes ulcer-ative colitis, Crohn’s disease, and indeterminate colitis. Ulcerative colitis occurs in 8 to 15 people per 100,000 in the United States and Northern Europe. The incidence is consid-erably lower in Asia, Africa, and South America, and among the nonwhite population in the United States. Ulcerative coli-tis incidence peaks during the third decade of life and again in the seventh


Surgery_Schwartz

Surgery_Schwartz. lower in Asia, Africa, and South America, and among the nonwhite population in the United States. Ulcerative coli-tis incidence peaks during the third decade of life and again in the seventh decade of life. The incidence of Crohn’s disease is slightly lower, 1 to 5 people per 100,000. Crohn’s disease also affects Northern European and Caucasian populations dispro-portionately. Crohn’s disease has a similar bimodal incidence, with most cases occurring between ages 15 to 30 years and ages 60 to 70 years.38 In 15% of patients with inflammatory bowel disease, differentiation between ulcerative colitis and Crohn’s colitis is impossible; these patients are classified as having indeterminate colitis.Etiology. Inflammatory bowel disease is a multifactorial con-dition that includes environmental, genetic, and immune causal elements; the variation in disease distributions and severity, as well as the differential responses to medical therapy, reflect a complex pathophysiology that is not


Surgery_Schwartz

Surgery_Schwartz. genetic, and immune causal elements; the variation in disease distributions and severity, as well as the differential responses to medical therapy, reflect a complex pathophysiology that is not reducible to a single cause. Nonetheless, there are several consistent observations among IBD populations that allow some degree of generalization. The consistent differences in IBD incidence between different geographic regions strongly suggest that environmental factors such as diet and exposure to microorganisms have a causal role. Alcohol and oral contraceptive use have also been implicated, as has tobacco use, in the etiology and exacerbation of Crohn’s disease.Brunicardi_Ch29_p1259-p1330.indd 127923/02/19 2:29 PM 1280SPECIFIC CONSIDERATIONSPART IIIBD is a genetic disease, though one that is polygenic, explaining why IBD frequently affects multiple family mem-bers across more than one generation, while also explaining the large number of genes implicated in the development of IBD. Most


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Surgery_Schwartz. polygenic, explaining why IBD frequently affects multiple family mem-bers across more than one generation, while also explaining the large number of genes implicated in the development of IBD. Most of the data on the genetics of IBD focus on Crohn’s disease. Although ulcerative colitis has an association with at least 20 genetic loci based on genome-wide association studies (GWAS), this form of IBD has a weaker genetic link than does Crohn’s disease. Approximately 10% to 30% of IBD patients will have at least one other family member also affected by IBD.39,40 Additionally, there is 50% disease concordance among monozygotic twins and a 10% disease concordance among dizy-gotic twins.41Many of the genetic variants most consistently associated with IBD involve loci involved in innate immune function. These include NOD2 (nucleotide-binding oligomerization domain-containing protein 2), which is located on chromosome 16 and which is responsible for coordinating the function of several genes


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Surgery_Schwartz. These include NOD2 (nucleotide-binding oligomerization domain-containing protein 2), which is located on chromosome 16 and which is responsible for coordinating the function of several genes leading to the production of proinflammatory cytokines in response to gut microbes. This genetic variant is arguably the most strongly associated with IBD, being strongly connected with Crohn’s disease, although it is also associated with severe pouchitis in patients with a history of ulcerative colitis.42,43The ATG16L1 gene is located on chromosome 2, and its product is involved in the immune response to muramyl dipep-tide, a component of both gram-positive and gram-negative bac-teria that is recognized by the immune system. A related gene, IRGM, is located on chromosome 5, and its product is pivotal in the interferon-gamma–mediated clearance of intracellular pathogens. Variants in this gene are associated with a higher incidence of ileocolic resections in Crohn’s disease patients.42-44Patients


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Surgery_Schwartz. in the interferon-gamma–mediated clearance of intracellular pathogens. Variants in this gene are associated with a higher incidence of ileocolic resections in Crohn’s disease patients.42-44Patients with IBD appear to have a chronic immune dys-regulation, which may lead to an interplay with gut microbes which are also present in non-IBD patients, but which elicit pathologic immune responses in the IBD population leading to chronic, idiopathic inflammation of the alimentary tract. Bacteria such as Mycobacterium paratuberculosis and Liste-ria monocytogenes, as well as viruses such as paramyxovirus and measles virus, have been suggested as having a role in the development of Crohn’s disease. With the decreased cost of sequencing and with the expansion of reference databases for identification of organisms, microbiome studies have been applied to the study of IBD patients, both to learn about the pathogenesis of IBD as well as for disease prognostication. Recent studies have identified an


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Surgery_Schwartz. of organisms, microbiome studies have been applied to the study of IBD patients, both to learn about the pathogenesis of IBD as well as for disease prognostication. Recent studies have identified an abundance of Serratia marc-escens, E coli, and Candida tropicalis in the guts of patients with Crohn’s disease. In a study of 543 stool samples, patients with ulcerative colitis and primary sclerosing cholangitis (PSC) demonstrated a distinct bacterial community structure, with an enrichment of bacteria belonging to the Veillonella genus, which is associated with several diseases characterized by inflammation and fibrosis.45-49A defect in the gut mucosal barrier, which increases exposure to intestinal microbes as well as proinflammatory substances, is a potential etiologic factor related to immune dys-regulation. An autoimmune mechanism has also been postulated. Although there is no clear evidence linking an immunologic disorder to inflammatory bowel disease, the similarity of many of the


Surgery_Schwartz

Surgery_Schwartz. dys-regulation. An autoimmune mechanism has also been postulated. Although there is no clear evidence linking an immunologic disorder to inflammatory bowel disease, the similarity of many of the extraintestinal manifestations to rheumatologic disorders has made this theory attractive. In summary, IBD is primarily characterized by intestinal inflammation, and medical therapy is focused on reducing or preventing that inflammation.45-49Pathology and Differential Diagnosis. Although ulcer-ative colitis and Crohn’s colitis share many pathologic and clinical similarities, these conditions can be differentiated in 85% of patients. Ulcerative colitis is a mucosal process in which the colonic mucosa and submucosa are infiltrated with inflammatory cells. The mucosa may be atrophic, and crypt abscesses are common. Endoscopically, the mucosa is fre-quently friable and may possess multiple inflammatory pseu-dopolyps. In long-standing ulcerative colitis, the colon may be foreshortened and the


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Surgery_Schwartz. are common. Endoscopically, the mucosa is fre-quently friable and may possess multiple inflammatory pseu-dopolyps. In long-standing ulcerative colitis, the colon may be foreshortened and the mucosa replaced by scar. In quies-cent ulcerative colitis, the colonic mucosa may appear normal both endoscopically and microscopically. Ulcerative colitis may affect the rectum (proctitis), rectum and sigmoid colon (proctosigmoiditis), rectum and left colon (left-sided colitis), or the rectum and varying lengths of colon extending proxi-mal to the splenic flexure (pancolitis). Ulcerative colitis does not primarily affect the small intestine, but the terminal ileum may demonstrate inflammatory changes (“backwash ileitis”). A key feature of ulcerative colitis is the continuous involve-ment of the rectum and colon; rectal sparing or skip lesions suggest a diagnosis of Crohn’s disease. Symptoms are related to the degree of mucosal inflammation and the extent of coli-tis. Patients typically complain


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Surgery_Schwartz. and colon; rectal sparing or skip lesions suggest a diagnosis of Crohn’s disease. Symptoms are related to the degree of mucosal inflammation and the extent of coli-tis. Patients typically complain of bloody diarrhea and crampy abdominal pain. Proctitis may produce tenesmus. Severe abdominal pain and fever raise the concern of fulminant coli-tis or toxic megacolon. Physical findings are nonspecific and range from minimal abdominal tenderness and distention to frank peritonitis. In the nonemergent setting, the diagnosis is typically made by colonoscopy and mucosal biopsy.In contrast to ulcerative colitis, Crohn’s disease is a trans-mural inflammatory process that can affect any part of the gas-trointestinal tract from mouth to anus. Mucosal ulcerations, an inflammatory cell infiltrate, and noncaseating granulomas are characteristic pathologic findings. Chronic inflammation may ultimately result in fibrosis, strictures, and fistulas in either the colon or small intestine. The endoscopic


Surgery_Schwartz

Surgery_Schwartz. noncaseating granulomas are characteristic pathologic findings. Chronic inflammation may ultimately result in fibrosis, strictures, and fistulas in either the colon or small intestine. The endoscopic appearance of Crohn’s colitis is characterized by deep serpiginous ulcers and a “cob-blestone” appearance. Skip lesions and rectal sparing are com-mon. Symptoms of Crohn’s disease depend on the severity of inflammation and/or fibrosis and the location of inflammation in the gastrointestinal tract. Acute inflammation may produce diarrhea, crampy abdominal pain, and fever. Strictures may pro-duce symptoms of obstruction. Weight loss is common, both because of obstruction and from protein loss. Perianal Crohn’s disease may present with pain, swelling, and drainage from fis-tulas or abscesses. Physical findings are also related to the site and severity of disease.In 15% of patients with colitis from inflammatory bowel disease, differentiation of ulcerative colitis from Crohn’s colitis is


Surgery_Schwartz

Surgery_Schwartz. Physical findings are also related to the site and severity of disease.In 15% of patients with colitis from inflammatory bowel disease, differentiation of ulcerative colitis from Crohn’s colitis is impossible either grossly or microscopically (indeterminate colitis).50 These patients typically present with symptoms similar to ulcerative colitis. Endoscopic and pathologic findings usually include features common to both diseases. Increasingly, sero-logic markers have been employed to differentiate ulcerative colitis from Crohn’s disease. The anti-Saccharomyces cerevi-siae antibody (ASCA) and perinuclear anticytoplasmic antibody (pANCA) may be useful in differentiating these two processes but require prospective study.50 Further differential diagnoses include infectious colitides, especially cytomegalovirus (CMV), Campylobacter jejuni, Entamoeba histolytica, toxigenic E Coli, C difficile, Neisseria gonorrhoeae, Salmonella, and Shigella species.Brunicardi_Ch29_p1259-p1330.indd


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Surgery_Schwartz. cytomegalovirus (CMV), Campylobacter jejuni, Entamoeba histolytica, toxigenic E Coli, C difficile, Neisseria gonorrhoeae, Salmonella, and Shigella species.Brunicardi_Ch29_p1259-p1330.indd 128023/02/19 2:29 PM 1281COLON, RECTUM, AND ANUSCHAPTER 29Extraintestinal Manifestations. The liver is a common site of extracolonic disease in inflammatory bowel disease. Fatty infiltration of the liver is present in 40% to 50% of patients, and cirrhosis is found in 2% to 5%. Fatty infiltration may be reversed by medical or surgical treatment of colonic disease, but cirrhosis is irreversible. Primary sclerosing cholangitis is a progressive disease characterized by intraand extrahepatic bile duct stric-tures. Forty percent to 60% of patients with primary sclerosing cholangitis have ulcerative colitis. Colectomy will not reverse this disease, and the only effective therapy is liver transplanta-tion. Pericholangitis is also associated with inflammatory bowel disease and may be diagnosed with a


Surgery_Schwartz

Surgery_Schwartz. Colectomy will not reverse this disease, and the only effective therapy is liver transplanta-tion. Pericholangitis is also associated with inflammatory bowel disease and may be diagnosed with a liver biopsy. Bile duct carcinoma is a rare complication of long-standing inflamma-tory bowel disease. Patients who develop bile duct carcinoma in the presence of inflammatory bowel disease are, on average, 20 years younger than other patients with bile duct carcinoma.51Arthritis also is a common extracolonic manifesta-tion of inflammatory bowel disease, and the incidence is 20 times greater than in the general population. Arthritis usually improves with treatment of the colonic disease. Sacroiliitis and ankylosing spondylitis are associated with inflammatory bowel disease, although the relationship is poorly understood. Medical and surgical treatment of the colonic disease does not impact symptoms.51Erythema nodosum is seen in 5% to 15% of patients with inflammatory bowel disease and usually


Surgery_Schwartz

Surgery_Schwartz. is poorly understood. Medical and surgical treatment of the colonic disease does not impact symptoms.51Erythema nodosum is seen in 5% to 15% of patients with inflammatory bowel disease and usually coincides with clini-cal disease activity. Women are affected three to four times more frequently than men. The characteristic lesions are raised, red, and predominantly on the lower legs. Pyoderma gangreno-sum is an uncommon but serious condition that occurs almost exclusively in patients with inflammatory bowel disease. The lesion begins as an erythematous plaque, papule, or bleb, usu-ally located on the pretibial region of the leg and occasionally near a stoma. The lesions progress and ulcerate, leading to a painful, necrotic wound. Pyoderma gangrenosum may respond to resection of the affected bowel in some patients. In others, this disorder is unaffected by treatment of the underlying bowel disease. One of the challenges in managing pyoderma is that this manifestation of IBD exhibits


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Surgery_Schwartz. bowel in some patients. In others, this disorder is unaffected by treatment of the underlying bowel disease. One of the challenges in managing pyoderma is that this manifestation of IBD exhibits pathergy, where the disease will manifest and have its severity exacerbated by the creation of surgical-sites. Depending on the circumstances, a history or the presence of pyoderma should prompt consideration for avoid-ance of a stoma.51Up to 10% of patients with inflammatory bowel dis-ease will develop ocular lesions. These include uveitis, iritis, episcleritis, and conjunctivitis, as well as macular degenerative, hyperpigmented pigmented epithelium (CHRPE). They usu-ally develop during an acute exacerbation of the inflammatory bowel disease. The etiology is unknown.51Principles of Nonoperative Management. Medical therapy for inflammatory bowel disease focuses on decreasing inflam-mation and alleviating symptoms, and many of the agents used are the same for both ulcerative colitis and Crohn’s


Surgery_Schwartz

Surgery_Schwartz. therapy for inflammatory bowel disease focuses on decreasing inflam-mation and alleviating symptoms, and many of the agents used are the same for both ulcerative colitis and Crohn’s disease. In general, mild to moderate flares may be treated in the outpatient setting. More severe signs and symptoms mandate hospitaliza-tion. Pancolitis generally requires more aggressive therapy than limited disease. Because ulcerative proctitis and proctosigmoid-itis are limited to the distal large intestine, topical therapy with salicylate and/or corticosteroid suppositories and enemas can be extremely effective. Systemic therapy is rarely required in these patients.Salicylates Sulfasalazine (Azulfidine), 5-acetyl salicylic acid (5-ASA), and related compounds are first-line agents in the medical treatment of mild to moderate inflammatory bowel dis-ease. These compounds decrease inflammation by inhibition of cyclooxygenase and 5-lipoxygenase in the gut mucosa. They require direct contact with affected


Surgery_Schwartz

Surgery_Schwartz. of mild to moderate inflammatory bowel dis-ease. These compounds decrease inflammation by inhibition of cyclooxygenase and 5-lipoxygenase in the gut mucosa. They require direct contact with affected mucosa for efficacy. Mul-tiple preparations are available for administration to different sites in the small intestine and colon (sulfasalazine, mesalamine [Pentasa, Asacol, Rowasa]).Antibiotics Antibiotics are often used to decrease the intra-luminal bacterial load in Crohn’s disease. Metronidazole has been reported to improve Crohn’s colitis and perianal disease, but the evidence is weak. Fluoroquinolones may also be effec-tive in some cases. In the absence of fulminant colitis or toxic megacolon, antibiotics are not used to treat ulcerative colitis.Corticosteroids Corticosteroids (either oral or parenteral) are a key component of treatment for an acute exacerbation of either ulcerative colitis or Crohn’s disease. Corticosteroids are nonspecific inhibitors of the immune system, and 75%


Surgery_Schwartz

Surgery_Schwartz. or parenteral) are a key component of treatment for an acute exacerbation of either ulcerative colitis or Crohn’s disease. Corticosteroids are nonspecific inhibitors of the immune system, and 75% to 90% of patients will improve with the administration of these drugs. However, corticosteroids have a number of serious side effects, and use of these agents should be limited to the short-est course possible. In addition, corticosteroids should be used judiciously in children because of the potential adverse effect on growth. Failure to wean corticosteroids is a relative indication for surgery.Because of the systemic effects of corticosteroids, an effort has been made to develop drugs that act locally and have limited systemic absorption. Agents such as budesonide, beclomethasone dipropionate, and tixocortol pivalate undergo rapid hepatic degradation that significantly decreases systemic toxicity. Budesonide is available as an oral preparation. Corti-costeroid enemas provide effective


Surgery_Schwartz

Surgery_Schwartz. and tixocortol pivalate undergo rapid hepatic degradation that significantly decreases systemic toxicity. Budesonide is available as an oral preparation. Corti-costeroid enemas provide effective local therapy for proctitis and proctosigmoiditis and have fewer side effects than systemic corticosteroids.Immunomodulating Agents Azathioprine and 6-mercatopu-rine (6-MP) are antimetabolite drugs that interfere with nucleic acid synthesis and thus decrease proliferation of inflammatory cells. These agents are useful for treating ulcerative colitis and Crohn’s disease in patients who have failed salicylate therapy or who are dependent on, or refractory to, corticosteroids. It is important to note, however, that the onset of action of these drugs takes 6 to 12 weeks, and concomitant use of corticoste-roids almost always is required.Cyclosporine is an immunosuppressive agent that inter-feres with T-lymphocyte function. While cyclosporine is not routinely used to treat inflammatory bowel


Surgery_Schwartz

Surgery_Schwartz. corticoste-roids almost always is required.Cyclosporine is an immunosuppressive agent that inter-feres with T-lymphocyte function. While cyclosporine is not routinely used to treat inflammatory bowel disease, up to 80% of patients with an acute flare of ulcerative colitis will improve with its use. However, the majority of these patients will ulti-mately require colectomy. Cyclosporine is also occasionally used to treat exacerbations of Crohn’s disease, and approxi-mately two-thirds of patients will note some improvement. Improvement is generally apparent within 2 weeks of beginning cyclosporine therapy. Long-term use of cyclosporine is limited by its significant toxicities (e.g., nephrotoxicity, hirsutism, gum hypertrophy).Methotrexate is a folate antagonist that also has been used to treat inflammatory bowel disease. Although the efficacy of this agent is unproven, there are reports that more than 50% of patients will improve with administration of this


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Surgery_Schwartz. that also has been used to treat inflammatory bowel disease. Although the efficacy of this agent is unproven, there are reports that more than 50% of patients will improve with administration of this drug.52Brunicardi_Ch29_p1259-p1330.indd 128123/02/19 2:29 PM 1282SPECIFIC CONSIDERATIONSPART IIBiologic Agents In an effort to improve treatment for steroid-refractory inflammatory bowel disease, a class of agents has been developed based on inhibition of tumor necrosis factor alpha (TNF-α). Intravenous infusion of these agents decreases inflammation systemically. Infliximab is a monoclonal antibody directed against TNF-α and was the first biologic agent used to treat Crohn’s disease. More than 50% of patients with moderate to severe Crohn’s disease will improve with infliximab therapy. Infliximab is a chimeric monoclonal antibody directed against TNF-α and it was the first biologic agent used to treat Crohn’s disease. Based on the ACCENT I and II trials, infliximab was associated


Surgery_Schwartz

Surgery_Schwartz. Infliximab is a chimeric monoclonal antibody directed against TNF-α and it was the first biologic agent used to treat Crohn’s disease. Based on the ACCENT I and II trials, infliximab was associated with a greater incidence of clinical remission, the ability to discontinue corticosteroids, and a longer length of remission compared to placebo.53,54 There are also multiple studies demonstrating an improvement in fistulizing perianal Crohn’s disease, although studies define “improvement” in a variety of ways, some of which do not require fistula to com-pletely involute.53-56Because infliximab is a chimera partially consisting of mouse antibody, human antibodies directed against infliximab can mitigate the efficacy of this drug. For this reason, adali-mumab and certolizumab, that have no nonhuman component, were developed. These two drugs can be administered by sub-cutaneous injection, allowing patients to self-administer these therapies and to avoid the cost and inconvenience of


Surgery_Schwartz

Surgery_Schwartz. no nonhuman component, were developed. These two drugs can be administered by sub-cutaneous injection, allowing patients to self-administer these therapies and to avoid the cost and inconvenience of presenting to an infusion center. The ultimate goal of biologic agents, just as with other medical therapies for IBD, is mucosal healing.The use of biologic agents for the treatment of ulcerative colitis is an area where opinions between gastroenterologists and surgeons are more divergent. Unlike in the case of Crohn’s dis-ease, there is a putative surgical cure for ulcerative colitis, which casts the risks of long-term immunosuppression in a different light than in the setting of Crohn’s where there is no curative therapy available. For patients with moderate to severe ulcer-ative colitis not responding to other medical therapies, there is evidence supporting the use of infliximab (UC SUCCESS) and adalimumab (ULTRA I AND II). The use of infliximab as rescue therapy for inpatients with


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Surgery_Schwartz. not responding to other medical therapies, there is evidence supporting the use of infliximab (UC SUCCESS) and adalimumab (ULTRA I AND II). The use of infliximab as rescue therapy for inpatients with severe, steroid-dependent ulcerative colitis has more recently been investigated. Though gastroen-terologists may view this intervention as maintenance therapy that begins in an inpatient setting only to be continued following hospital discharge, it is still unclear whether inpatient infliximab is even a reliable bridge to elective surgery. Many of the stud-ies supporting inpatient rescue therapy with infliximab did not focus their analyses on patients with extensive (pan) colitis, the group at highest risk for requiring an unplanned admission due to a disease flare, and the subgroup of ulcerative colitis patients most likely to fail rescue therapy and to require colectomy.57-62Whether the preoperative use of biologics is associated with a higher incidence of postoperative complications


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Surgery_Schwartz. colitis patients most likely to fail rescue therapy and to require colectomy.57-62Whether the preoperative use of biologics is associated with a higher incidence of postoperative complications is a matter of contention. There are individual studies demonstrat-ing a higher incidence of postoperative sepsis, intra-abdominal abscess and readmissions for patients undergoing ileocolectomy for Crohn’s disease who also received preoperative infliximab within three months of surgery. Systematic reviews on this topic, primarily focusing on Crohn’s disease, have concluded that perioperative infliximab may or may not be associated with a higher incidence of postoperative complications, with most of these complications being infectious in nature.63Nutrition Patients with inflammatory bowel disease are often malnourished. Abdominal pain and obstructive symptoms may decrease oral intake. Diarrhea can cause significant protein loss. Ongoing inflammation produces a catabolic physiologic state.


Surgery_Schwartz

Surgery_Schwartz. are often malnourished. Abdominal pain and obstructive symptoms may decrease oral intake. Diarrhea can cause significant protein loss. Ongoing inflammation produces a catabolic physiologic state. Parenteral nutrition should be strongly considered early in the course of therapy for either Crohn’s disease or ulcerative colitis. The nutritional status of the patient also should be considered when planning operative intervention, and nutritional param-eters such as serum albumin, prealbumin, and transferrin should be assessed. In extremely malnourished patients, especially those who are also being treated with corticosteroids, creation of a stoma is often safer than a primary anastomosis.Ulcerative ColitisUlcerative colitis is a dynamic disease characterized by remis-sions and exacerbations. The clinical spectrum ranges from an inactive or quiescent phase to low-grade active disease to ful-minant disease. The onset of ulcerative colitis may be insidi-ous, with minimal bloody stools, or


Surgery_Schwartz

Surgery_Schwartz. The clinical spectrum ranges from an inactive or quiescent phase to low-grade active disease to ful-minant disease. The onset of ulcerative colitis may be insidi-ous, with minimal bloody stools, or the onset can be abrupt, with severe diarrhea and bleeding, tenesmus, abdominal pain, and fever. The severity of symptoms depends on the degree and extent of inflammation. Although anemia is common, massive hemorrhage is rare. Physical findings are often nonspecific.The diagnosis of ulcerative colitis is almost always made endoscopically. Because the rectum is invariably involved, proctoscopy may be adequate to establish the diagnosis. The earliest manifestation is mucosal edema, which results in a loss of the normal vascular pattern. In more advanced disease, char-acteristic findings include mucosal friability and ulceration. Pus and mucus may also be present. While mucosal biopsy is often diagnostic in the chronic phase of ulcerative colitis, biopsy in the acute phase will often reveal


Surgery_Schwartz

Surgery_Schwartz. mucosal friability and ulceration. Pus and mucus may also be present. While mucosal biopsy is often diagnostic in the chronic phase of ulcerative colitis, biopsy in the acute phase will often reveal only nonspecific inflammation. Evaluation with colonoscopy or barium enema during an acute flare is contraindicated because of the risk of perforation.Barium enema has been used to diagnose chronic ulcer-ative colitis and to determine the extent of disease. However, this modality is less sensitive than colonoscopy and may not detect early disease. In long-standing ulcerative colitis, the colon is foreshortened and lacks haustral markings (“lead pipe” colon). Because the inflammation in ulcerative colitis is purely mucosal, strictures are highly uncommon. Any stricture diag-nosed in a patient with ulcerative colitis must be presumed to be malignant until proven otherwise.Indications for Surgery. Indications for surgery in ulcer-ative colitis may be emergent or elective. Emergency surgery is


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Surgery_Schwartz. ulcerative colitis must be presumed to be malignant until proven otherwise.Indications for Surgery. Indications for surgery in ulcer-ative colitis may be emergent or elective. Emergency surgery is required for patients with massive life-threatening hemorrhage, toxic megacolon, or fulminant colitis who fail to respond rap-idly to medical therapy. Patients with signs and symptoms of fulminant colitis should be treated aggressively with bowel rest, hydration, broad-spectrum antibiotics, and parenteral corticoste-roids. Colonoscopy and barium enema are contraindicated, and antidiarrheal agents should be avoided. Deterioration in clinical condition or failure to improve within 24 to 48 hours mandates surgery.Indications for elective surgery include intractability despite maximal medical therapy and high-risk development of major complications of medical therapy such as aseptic necrosis of joints secondary to chronic steroid use. Elective surgery also is indicated in patients at significant


Surgery_Schwartz

Surgery_Schwartz. and high-risk development of major complications of medical therapy such as aseptic necrosis of joints secondary to chronic steroid use. Elective surgery also is indicated in patients at significant risk of developing colorec-tal carcinoma. The risk of malignancy increases with pancolonic disease and the duration of symptoms and is approximately 2% after 10 years, 8% after 20 years, and 18% after 30 years. Unlike sporadic colorectal cancers, carcinoma developing in the con-text of ulcerative colitis is more likely to arise from areas of Brunicardi_Ch29_p1259-p1330.indd 128223/02/19 2:29 PM 1283COLON, RECTUM, AND ANUSCHAPTER 29flat dysplasia and may be difficult to diagnose at an early stage. For this reason, it is recommended that patients with longstanding ulcerative colitis undergo colonoscopic surveillance with multiple (40–50), random biopsies to identify dysplasia before invasive malignancy develops. However, the adequacy of this type of screening is controversial. Recently,


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Surgery_Schwartz. colonoscopic surveillance with multiple (40–50), random biopsies to identify dysplasia before invasive malignancy develops. However, the adequacy of this type of screening is controversial. Recently, magnifying chro-moendoscopy has been used to improve sensitivity. This tech-nique uses topical dyes that are applied to the colonic mucosa at the time of endoscopy (Lugol’s solution, methylene blue, indigo carmine, and others). These dyes highlight contrast between normal and dysplastic epithelium, allowing more precise biopsy of suspicious areas.64,65 Surveillance is recommended annu-ally after 8 years in patients with pancolitis, and annually after 15 years in patients with left-sided colitis. Although low-grade dysplasia was long thought to represent minimal risk, more recent studies show that invasive cancer may be present in up to 20% of patients with low-grade dysplasia. For this rea-son, any patient with dysplasia should be advised to undergo proctocolectomy. Controversy exists


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Surgery_Schwartz. that invasive cancer may be present in up to 20% of patients with low-grade dysplasia. For this rea-son, any patient with dysplasia should be advised to undergo proctocolectomy. Controversy exists over whether prophylac-tic proctocolectomy should be recommended for patients who have had chronic ulcerative colitis for greater than 10 years in the absence of dysplasia. Proponents of this approach note that surveillance colonoscopy with multiple biopsies samples only a small fraction of the colonic mucosa, and dysplasia and carci-noma are often missed. Opponents cite the relatively low risk of progression to carcinoma (approximately 2.4%) if all biopsies lack dysplasia. Neither approach has been shown definitively to decrease mortality from colorectal cancer.Operative ManagementEmergent Operation In a patient with fulminant colitis or toxic megacolon, total abdominal colectomy with end ileostomy (with or without a mucus fistula), rather than total proctocolectomy, is recommended.


Surgery_Schwartz

Surgery_Schwartz. Operation In a patient with fulminant colitis or toxic megacolon, total abdominal colectomy with end ileostomy (with or without a mucus fistula), rather than total proctocolectomy, is recommended. Although the rectum is invariably diseased, most patients improve dramatically after an abdominal colectomy, and this operation avoids a difficult and time-consuming pelvic dissection in a critically ill patient. Rarely, a loop ileostomy and decompressing colostomy may be necessary if the patient is too unstable to withstand colectomy. Definitive surgery may then be undertaken at a later date once the patient has recovered. Complex techniques, such as an ileal pouch–anal reconstruction, generally are contraindicated in the emergent setting. However, massive hemorrhage that includes bleeding from the rectum may necessitate proctectomy and creation of either a permanent ileostomy or an ileal pouch–anal anastomosis.Elective Operation Elective resection for ulcerative colitis usually is


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Surgery_Schwartz. from the rectum may necessitate proctectomy and creation of either a permanent ileostomy or an ileal pouch–anal anastomosis.Elective Operation Elective resection for ulcerative colitis usually is performed for refractory inflammation and/or the risk of malignancy (dysplasia). Because of the risk of ongo-ing inflammation, the risk of malignancy, and the availability of restorative proctocolectomy, most surgeons recommend operations that include resection of the rectum. Total procto-colectomy with end ileostomy has been the “gold standard” for treating patients with chronic ulcerative colitis. This operation removes the entire affected intestine and avoids the functional disturbances associated with ileal pouch–anal reconstruction. Most patients function well physically and psychologically after this operation. Total proctocolectomy with continent ileostomy (Kock’s pouch) was developed to improve function and quality of life after total proctocolectomy, but morbidity is significant, and


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Surgery_Schwartz. this operation. Total proctocolectomy with continent ileostomy (Kock’s pouch) was developed to improve function and quality of life after total proctocolectomy, but morbidity is significant, and restorative proctocolectomy is generally preferred today. Since its introduction in 1980, restorative proctocolectomy with ileal pouch–anal anastomosis has become the procedure of choice for most patients who require total proctocolectomy but wish to avoid a permanent ileostomy (see Figs. 29-11 and 29-12).66 Abdominal colectomy with ileorectal anastomosis may be appropriate for a patient with indeterminate colitis and rectal sparing.Crohn’s DiseaseSimilar to ulcerative colitis, Crohn’s disease is characterized by exacerbations and remissions. Crohn’s disease, however, may affect any portion of the intestinal tract, from mouth to anus. Diagnosis may be made by colonoscopy or esophagogastroduo-denoscopy or by barium small bowel study or enema, depending on which part of the intestine is most


Surgery_Schwartz

Surgery_Schwartz. the intestinal tract, from mouth to anus. Diagnosis may be made by colonoscopy or esophagogastroduo-denoscopy or by barium small bowel study or enema, depending on which part of the intestine is most affected. The presence of skip lesions is key in differentiating Crohn’s colitis from ulcer-ative colitis, and rectal sparing occurs in approximately 40% of patients. The most common site of involvement of Crohn’s dis-ease is the terminal ileum and cecum (ileocolic Crohn’s disease), followed by the small bowel, and then by the colon and rectum. Perianal and anal canal Crohn’s disease manifest by complex anal fistulae and/or abscesses, anal ulcers, and large skin tags may be the initial site of presentation in up to 4% of cases.Indications for Surgery. Because Crohn’s disease is cur-rently incurable and because it can affect any part of the gas-trointestinal tract, the therapeutic rationale is fundamentally different from that of ulcerative colitis. Ulcerative colitis may be cured by


Surgery_Schwartz

Surgery_Schwartz. incurable and because it can affect any part of the gas-trointestinal tract, the therapeutic rationale is fundamentally different from that of ulcerative colitis. Ulcerative colitis may be cured by removal of the affected intestinal segment (the colon and rectum). In Crohn’s disease, it is impossible to remove all the at-risk intestine; therefore, surgical therapy is reserved for complications of the disease.Crohn’s disease may present as an acute inflammatory process or as a chronic fibrotic process. During the acute inflam-matory phase, patients may present with intestinal inflamma-tion complicated by fistulae and/or intra-abdominal abscesses. Maximal medical therapy should be instituted, including antiinflammatory medications, bowel rest, and antibiotics. Parenteral nutrition should be considered if the patient is malnourished. Most intra-abdominal abscesses can be drained percutaneously with the use of CT scan guidance. Although the majority of these patients will ultimately


Surgery_Schwartz

Surgery_Schwartz. be considered if the patient is malnourished. Most intra-abdominal abscesses can be drained percutaneously with the use of CT scan guidance. Although the majority of these patients will ultimately require surgery to remove the dis-eased segment of bowel, these interventions allow the patient’s condition to stabilize, nutrition to be optimized, and inflamma-tion to decrease prior to embarking on a surgical resection. Once an operation is undertaken, fistulae generally require resection of the segment of bowel with active Crohn’s disease; the sec-ondary sites of the fistula are often otherwise normal and do not generally require resection after division of the fistula. Simple closure of the secondary fistula site usually suffices.Chronic fibrosis may result in strictures in any part of the gastrointestinal tract. Because the fibrotic process is gradual, free perforation proximal to the obstructing stricture is rare. Chronic strictures almost never improve with medical therapy.


Surgery_Schwartz

Surgery_Schwartz. of the gastrointestinal tract. Because the fibrotic process is gradual, free perforation proximal to the obstructing stricture is rare. Chronic strictures almost never improve with medical therapy. Strictures may be treated with resection or stricturoplasty. Distal ileal strictures are sometimes amenable to colonoscopic balloon dilatation. Optimal timing for surgery should take into account the patient’s underlying medical and nutritional status.Once an operation is undertaken for Crohn’s disease, sev-eral principles should guide intraoperative decision making. In general, a laparotomy for Crohn’s disease should be performed through a midline incision because of the possible need for a stoma. Laparoscopy is also increasingly used in this setting. Because many patients with Crohn’s disease often will require multiple operations, the length of bowel removed should be Brunicardi_Ch29_p1259-p1330.indd 128323/02/19 2:29 PM 1284SPECIFIC CONSIDERATIONSPART IIminimized. Bowel should be


Surgery_Schwartz

Surgery_Schwartz. often will require multiple operations, the length of bowel removed should be Brunicardi_Ch29_p1259-p1330.indd 128323/02/19 2:29 PM 1284SPECIFIC CONSIDERATIONSPART IIminimized. Bowel should be resected to an area with grossly nor-mal margins; frozen sections are not necessary. Finally, a primary anastomosis may be created safely if the patient is medically stable, nutritionally replete, and taking few immunosuppressive medications. Creation of a stoma should be strongly considered in any patient who is hemodynamically unstable, septic, malnour-ished, or receiving high-dose immunosuppressive therapy and among patients with extensive intra-abdominal contamination.Ileocolic and Small Bowel Crohn’s Disease. The terminal ileum and cecum are involved in Crohn’s disease in up to 41% of patients; the small intestine is involved in up to 35% of patients. The most common indications for surgery are internal fistula or abscess (30–38% of patients) and obstruction (35–37% of patients). Psoas


Surgery_Schwartz

Surgery_Schwartz. the small intestine is involved in up to 35% of patients. The most common indications for surgery are internal fistula or abscess (30–38% of patients) and obstruction (35–37% of patients). Psoas abscess may result from ileocolic Crohn’s dis-ease. Sepsis should be controlled with percutaneous drainage of abscess(es) and antibiotics, if possible. Parenteral nutrition may be necessary in patients with chronic obstruction. The extent of resection depends on the amount of involved intestine. Short segments of inflamed small intestine and right colon should be resected and a primary anastomosis created if the patient is sta-ble, nutrition is adequate, and immunosuppression is minimal. Isolated chronic strictures should also be resected. In patients with multiple fibrotic strictures that would require extensive small bowel resection, stricturoplasty is a safe and effective alternative to resection. Short strictures are amenable to a trans-verse stricturoplasty, while longer strictures may be


Surgery_Schwartz

Surgery_Schwartz. extensive small bowel resection, stricturoplasty is a safe and effective alternative to resection. Short strictures are amenable to a trans-verse stricturoplasty, while longer strictures may be treated with a side-to-side small bowel anastomosis (Fig. 29-18).ABCDEFigure 29-18. Alternative stricturoplasty techniques. A. A short stricture is opened along the antimesenteric surface of the bowel wall. B. The enterotomy is closed transversely. C. A long stricture is opened along the antimesenteric surface of the bowel wall. D. The bowel is folded into an inverted “U.” E. A side-to-side anastomosis is made. (Reproduced with permission from Corman ML. Colon & Rectal Surgery, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1989.)Brunicardi_Ch29_p1259-p1330.indd 128423/02/19 2:29 PM 1285COLON, RECTUM, AND ANUSCHAPTER 29Risk of recurrence after resection for ileocolic and small bowel Crohn’s disease is high. More than 50% of patients will experience a recurrence within 10 years,


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Surgery_Schwartz. 1285COLON, RECTUM, AND ANUSCHAPTER 29Risk of recurrence after resection for ileocolic and small bowel Crohn’s disease is high. More than 50% of patients will experience a recurrence within 10 years, and the majority of these will require a second operation.Crohn’s Colitis. Crohn’s disease of the large intestine may present as fulminant colitis or toxic megacolon. In this set-ting, treatment is identical to treatment of fulminant colitis and toxic megacolon secondary to ulcerative colitis. Resuscitation and medical therapy with bowel rest, broad-spectrum antibiot-ics, and parenteral corticosteroids should be instituted. If the patient’s condition worsens or fails to rapidly improve, total abdominal colectomy with end ileostomy is recommended. An elective proctectomy may be required if the patient has refrac-tory Crohn’s proctitis. Alternatively, if the rectum is spared, an ileorectal anastomosis may be appropriate once the patient has recovered.Other indications for surgery in chronic


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Surgery_Schwartz. patient has refrac-tory Crohn’s proctitis. Alternatively, if the rectum is spared, an ileorectal anastomosis may be appropriate once the patient has recovered.Other indications for surgery in chronic Crohn’s colitis are intractability, complications of medical therapy, and risk of or development of malignancy. Unlike ulcerative colitis, Crohn’s colitis may be segmental, and rectal sparing is often observed. A segmental colectomy may be appropriate if the remaining colon and/or rectum appear normal. An isolated colonic stricture may also be treated by segmental colectomy. Although it was long thought that Crohn’s disease did not increase the risk of colorectal carcinoma, it is now recognized that Crohn’s colitis (especially pancolitis) carries nearly the same risk for cancer as ulcerative colitis. Annual surveillance colonoscopy with multiple biopsies is recommended for patients with long-standing Crohn’s colitis (>7 years in duration). As in ulcerative colitis, dysplasia is an


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Surgery_Schwartz. colitis. Annual surveillance colonoscopy with multiple biopsies is recommended for patients with long-standing Crohn’s colitis (>7 years in duration). As in ulcerative colitis, dysplasia is an indication for total proctocolectomy. Ileal pouch–anal reconstruction is not recommended in these patients because of the risk for development of Crohn’s disease within the pouch and the high risk of complications, such as fistula, abscess, stricture, pouch dysfunction, and pouch failure.Anal and Perianal Crohn’s Disease. Anal and perianal mani-festations of Crohn’s disease are very common and occur in 35% of all patients with Crohn’s disease. Isolated anal Crohn’s disease is uncommon, affecting only 3% to 4% of patients. Detection of anal Crohn’s disease, therefore, should prompt evaluation of the remainder of the gastrointestinal tract.The most common perianal lesions in Crohn’s disease are skin tags that are minimally symptomatic. Fissures are also common. Typically, a fissure from Crohn’s


Surgery_Schwartz

Surgery_Schwartz. remainder of the gastrointestinal tract.The most common perianal lesions in Crohn’s disease are skin tags that are minimally symptomatic. Fissures are also common. Typically, a fissure from Crohn’s disease is partic-ularly deep or broad and perhaps better described as an anal ulcer. These fissures are often multiple and located in a lateral position rather than anterior or posterior midline as seen in an idiopathic fissure in ano. A classic-appearing fissure in ano located laterally should raise the suspicion of Crohn’s disease. Perianal abscess and fistulas are common and can be particu-larly challenging. Fistulas tend to be complex and often have multiple tracts (Fig. 29-19). Hemorrhoids are not more common in patients with Crohn’s disease than in the general population, although many patients tend to attribute any anal or perianal symptom to “hemorrhoids.”Treatment of anal and perianal Crohn’s disease focuses on alleviation of symptoms. Perianal skin irritation from diarrhea often


Surgery_Schwartz

Surgery_Schwartz. tend to attribute any anal or perianal symptom to “hemorrhoids.”Treatment of anal and perianal Crohn’s disease focuses on alleviation of symptoms. Perianal skin irritation from diarrhea often responds to medical therapy directed at small bowel or colonic disease. In general, skin tags and hemorrhoids should not be excised unless they are extremely symptomatic because of the risk of creating chronic, nonhealing wounds. Fissures may respond to local or systemic therapy; sphincterotomy is relatively contraindicated because of the risk of creating a chronic, nonhealing wound and because of the increased risk of incontinence in a patient with diarrhea from underlying colitis or small bowel disease. Anal ulcers associated with Crohn’s dis-ease are usually not very painful unless there is an underlying abscess. Thus, in patients with significant anal pain, an exami-nation under anesthesia is indicated to exclude an underlying abscess or fistula and to assess the rectal mucosa. In the absence


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Surgery_Schwartz. abscess. Thus, in patients with significant anal pain, an exami-nation under anesthesia is indicated to exclude an underlying abscess or fistula and to assess the rectal mucosa. In the absence of active Crohn’s proctitis, one can proceed cautiously with a partial internal sphincterotomy if the examination under anes-thesia reveals a classic-appearing posterior or anterior fissure and anal stenosis.Recurrent abscess(es) or complex anal fistulae should raise the possibility of Crohn’s disease. Treatment focuses on control of infection, delineation of complex anatomy, treat-ment of underlying mucosal disease, and sphincter preserva-tion. Abscesses often can be drained locally, and mushroom catheters are useful for maintaining drainage. Endoanal ultra-sound and pelvic MRI are useful for mapping complex fistulous tracts. Liberal use of setons can control many fistulas and avoid division of the sphincter. Many patients with anal Crohn’s dis-ease function well with multiple setons left in


Surgery_Schwartz

Surgery_Schwartz. complex fistulous tracts. Liberal use of setons can control many fistulas and avoid division of the sphincter. Many patients with anal Crohn’s dis-ease function well with multiple setons left in place for years. Endoanal advancement flaps may be considered for definitive therapy if the rectal mucosa is uninvolved but will not heal due to rectal inflammation. In 10% to 15% of cases, intractable peri-anal sepsis requires proctectomy.Rectovaginal fistula can be a particularly difficult problem in these patients. A rectal or vaginal mucosal advancement flap may be used if the rectal mucosa appears healthy and scarring of the rectovaginal septum is minimal. Occasionally, proctec-tomy is the best option for women with highly symptomatic rectovaginal fistulae. Although proximal diversion is often employed to protect complex perianal reconstruction, there is no evidence that diversion alone increases healing of anal and perianal Crohn’s disease.Medical treatment of underlying proctitis with


Surgery_Schwartz

Surgery_Schwartz. employed to protect complex perianal reconstruction, there is no evidence that diversion alone increases healing of anal and perianal Crohn’s disease.Medical treatment of underlying proctitis with salicylate and/or corticosteroid enemas may be helpful; however, control of infection is the primary goal of therapy. Metronidazole has been used with some success in this setting. Anti-TNF-α agents (infliximab and adalimumab) have shown some efficacy in heal-ing chronic fistulas secondary to Crohn’s disease. The success of these agents has led to a concerted effort to identify other 4Figure 29-19. Photograph of a patient with multiple perianal fistulas secondary to Crohn’s disease.Brunicardi_Ch29_p1259-p1330.indd 128523/02/19 2:29 PM 1286SPECIFIC CONSIDERATIONSPART IIimmunomodulators that might prove useful. Proinflammatory cytokines such as interleukin-12 and interferon-γ are potential targets. Inhibition of immune cell migration has also been sug-gested as an approach. However, it is


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Surgery_Schwartz. prove useful. Proinflammatory cytokines such as interleukin-12 and interferon-γ are potential targets. Inhibition of immune cell migration has also been sug-gested as an approach. However, it is of paramount importance to drain any and all abscesses before initiating immunosuppres-sive therapy such as corticosteroids or anti-TNF-α monoclonal antibodies.54-55Indeterminate ColitisApproximately 15% of patients with inflammatory bowel dis-ease manifest clinical and pathologic characteristics of both ulcerative colitis and Crohn’s disease. Endoscopy, barium enema, and biopsy may be unable to differentiate ulcerative colitis from Crohn’s colitis in this setting. The indications for surgery are the same as those for ulcerative colitis: intracta-bility, complications of medical therapy, and risk of or devel-opment of malignancy. In the setting of indeterminate colitis in a patient who prefers a sphincter-sparing operation, a total abdominal colectomy with end ileostomy may be the best initial


Surgery_Schwartz

Surgery_Schwartz. or devel-opment of malignancy. In the setting of indeterminate colitis in a patient who prefers a sphincter-sparing operation, a total abdominal colectomy with end ileostomy may be the best initial procedure. Pathologic examination of the entire colon may then allow a more accurate diagnosis. If the diagnosis suggests ulcer-ative colitis, an ileal pouch–anal anastomosis procedure can be performed. If the diagnosis remains in question, the safest surgi-cal option is completion proctectomy with end ileostomy (simi-lar to Crohn’s colitis). Ileal pouch–anal reconstruction may also be considered with the understanding that the pouch failure rate is between 15% and 20%.50DIVERTICULAR DISEASEDiverticular disease is a clinical term used to describe the pres-ence of symptomatic diverticula. Diverticulosis refers to the presence of diverticula without inflammation. Diverticulitis refers to inflammation and infection associated with diverticula. The majority of colonic diverticula are false


Surgery_Schwartz

Surgery_Schwartz. refers to the presence of diverticula without inflammation. Diverticulitis refers to inflammation and infection associated with diverticula. The majority of colonic diverticula are false diverticula in which the mucosa and muscularis mucosa have herniated through the colonic wall. These diverticula occur between the teniae coli, at points where nutrient arterial blood vessels penetrate the colonic wall (presumably creating an area of relative weakness in the colonic muscle). They are thought to be pulsion diverticula resulting from high intraluminal pressure. Diverticular bleeding can be massive but usually is self-limited. True diverticula, which comprise all layers of the bowel wall, are rare and are usually congenital in origin.Diverticulosis is extremely common in the United States and Europe. It is estimated that half of the population older than age 50 years has colonic diverticula. The sigmoid colon is the most common site of diverticulosis (Fig. 29-20). Diverticulosis is


Surgery_Schwartz

Surgery_Schwartz. and Europe. It is estimated that half of the population older than age 50 years has colonic diverticula. The sigmoid colon is the most common site of diverticulosis (Fig. 29-20). Diverticulosis is thought to be an acquired disorder, but the etiology is poorly understood. The most accepted theory is that a lack of dietary fiber results in smaller stool volume, requiring high intraluminal pressure and high colonic wall tension for propulsion. Chronic contraction then results in muscular hypertrophy and develop-ment of the process of segmentation in which the colon acts like separate segments instead of functioning as a continuous tube. As segmentation progresses, the high pressures are directed radi-ally toward the colon wall rather than to development of propul-sive waves that move stool distally. The high radial pressures directed against the bowel wall create pulsion diverticula. A loss of tensile strength and a decrease in elasticity of the bowel wall with age have also been


Surgery_Schwartz

Surgery_Schwartz. stool distally. The high radial pressures directed against the bowel wall create pulsion diverticula. A loss of tensile strength and a decrease in elasticity of the bowel wall with age have also been proposed etiologies. Although none of these theories has been proven, a high-fiber diet does appear to decrease the incidence of diverticulosis. Although diverticulosis is common, most cases are asymptomatic, and complications occur in the minority of people with this condition.Inflammatory Complications (Diverticulitis)Diverticulitis refers to inflammation and infection associated with a diverticulum and is estimated to occur in 10% to 25% of people with diverticulosis. Peridiverticular and pericolic infection results from a perforation (either macroscopic or microscopic) of a diverticulum, which leads to contamination, inflammation, and infection. The spectrum of disease ranges from mild, uncomplicated diverticulitis that can be treated in the outpatient setting, to free perforation and


Surgery_Schwartz

Surgery_Schwartz. leads to contamination, inflammation, and infection. The spectrum of disease ranges from mild, uncomplicated diverticulitis that can be treated in the outpatient setting, to free perforation and diffuse peritonitis that requires emergency laparotomy. Most patients present with left-sided abdominal pain, with or without fever, and leukocytosis. A mass may be present. Plain radiographs are useful for detect-ing free intra-abdominal air. CT scan is extremely useful for defining pericolic inflammation, phlegmon, or abscess. Contrast enemas and/or endoscopy are relatively contraindicated because of the risk of perforation. The differential diagnosis includes malignancy, ischemic colitis, infectious colitis, and inflamma-tory bowel disease.Uncomplicated Diverticulitis. Uncomplicated diverticulitis is characterized by left lower quadrant pain and tenderness. CT findings include pericolic soft tissue stranding, colonic wall thickening, and/or phlegmon. Most patients with uncomplicated


Surgery_Schwartz

Surgery_Schwartz. is characterized by left lower quadrant pain and tenderness. CT findings include pericolic soft tissue stranding, colonic wall thickening, and/or phlegmon. Most patients with uncomplicated diverticulitis will respond to outpatient therapy with broadspectrum oral antibiotics and a low-residue diet. Antibiotics should be continued for 7 to 10 days. About 10% to 20% of patients with more severe pain, tenderness, fever, and leuko-cytosis are treated in the hospital with parenteral antibiotics Figure 29-20. Diverticulosis of sigmoid colon on barium enema. (Reproduced with permission from James EC, Corry RJ, Perry JCF: Basic Surgical Practice. Philadelphia, PA: Hanley & Belfus; 1987.)Brunicardi_Ch29_p1259-p1330.indd 128623/02/19 2:29 PM 1287COLON, RECTUM, AND ANUSCHAPTER 29and bowel rest. Most patients improve within 48 to 72 hours. Failure to improve may suggest abscess formation. CT can be extremely useful in this setting, and many pericolic abscesses can be drained percutaneously.


Surgery_Schwartz

Surgery_Schwartz. Most patients improve within 48 to 72 hours. Failure to improve may suggest abscess formation. CT can be extremely useful in this setting, and many pericolic abscesses can be drained percutaneously. Deterioration in a patient’s clini-cal condition and the development of peritonitis are indications for laparotomy.Most patients with uncomplicated diverticulitis will recover without surgery, and 50% to 70% will have no further episodes. It has long been believed that the risk of complications increases with recurrent disease. For this reason, elective sig-moid colectomy has often been recommended after the second episode of diverticulitis, especially if the patient has required hospitalization. Resection has often been recommended after the first episode in very young patients and is often recommended after the first episode of complicated diverticulitis. These gen-eral guidelines have been questioned in recent years, and more recent studies suggest that the risk of complications and/or


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Surgery_Schwartz. after the first episode of complicated diverticulitis. These gen-eral guidelines have been questioned in recent years, and more recent studies suggest that the risk of complications and/or need for emergent resection does not increase with recurrent disease. Moreover, the rate of complications is rare after elective sur-gery and recurrences do not increase the rate of complications. As such, the rate of resection in all patients, including young patients and those with complicated disease, has decreased.67-71Many surgeons now will not advise colectomy even after two documented episodes of diverticulitis assuming the patient is completely asymptomatic and that carcinoma has been excluded by colonoscopy. Immunosuppressed patients are gen-erally still advised to undergo colectomy after a single episode of documented diverticulitis. Medical comorbidities should be considered when evaluating a patient for elective resection, and the risks of recurrent disease should be weighed against the


Surgery_Schwartz

Surgery_Schwartz. episode of documented diverticulitis. Medical comorbidities should be considered when evaluating a patient for elective resection, and the risks of recurrent disease should be weighed against the risks of the operation.69,70 Because colon carcinoma may present in an identical fashion to diverticulitis (either complicated or uncom-plicated), all patients must be evaluated for malignancy after resolution of the acute episode. Colonoscopy is recommended 4 to 6 weeks after recovery. Inability to exclude malignancy is another indication for resection.In the elective setting, a sigmoid colectomy with a primary anastomosis is the procedure of choice. The resection should always be extended to the rectum distally because the risk of recurrence is high if a segment of sigmoid colon is retained. The proximal extent of the resection should include all thick-ened or inflamed bowel; however, resection of all diverticula is unnecessary. Increasingly, laparoscopy is being used for elec-tive sigmoid


Surgery_Schwartz

Surgery_Schwartz. proximal extent of the resection should include all thick-ened or inflamed bowel; however, resection of all diverticula is unnecessary. Increasingly, laparoscopy is being used for elec-tive sigmoid colectomy for diverticular disease.Complicated Diverticulitis. Complicated diverticulitis includes diverticulitis with abscess, obstruction, diffuse peri-tonitis (free perforation), or fistulas between the colon and adjacent structures. Colovesical, colovaginal, and coloenteric fistulas are long-term sequelae of complicated diverticulitis. The Hinchey staging system is often used to describe the severity of complicated diverticulitis: Stage I includes colonic inflam-mation with an associated pericolic abscess; stage II includes colonic inflammation with a retroperitoneal or pelvic abscess; stage III is associated with purulent peritonitis; and stage IV is associated with fecal peritonitis. Treatment depends on the patient’s overall clinical condition and the degree of peritoneal


Surgery_Schwartz

Surgery_Schwartz. stage III is associated with purulent peritonitis; and stage IV is associated with fecal peritonitis. Treatment depends on the patient’s overall clinical condition and the degree of peritoneal contamination and infection. Small abscesses (<2 cm in diame-ter) may be treated with parenteral antibiotics. Larger abscesses are best treated with CT-guided percutaneous drainage (Fig. 29-21) and antibiotics.72 Many of these patients will ultimately require resection, but percutaneous drainage may allow a one-stage, elective procedure and may obviate the need for colec-tomy if full recovery follows the drainage.Urgent or emergent laparotomy may be required if an abscess is inaccessible to percutaneous drainage, if the patient’s condition deteriorates or fails to improve, or if the patient pres-ents with free intra-abdominal air or peritonitis. In almost all cases, an attempt should be made to resect the affected seg-ment of bowel. Patients with small, localized pericolic or pel-vic abscesses


Surgery_Schwartz

Surgery_Schwartz. with free intra-abdominal air or peritonitis. In almost all cases, an attempt should be made to resect the affected seg-ment of bowel. Patients with small, localized pericolic or pel-vic abscesses (Hinchey stages I and II) may be candidates for a sigmoid colectomy with a primary anastomosis (a one-stage operation). Among patients with larger abscesses, peritoneal soiling, or peritonitis, sigmoid colectomy with end colostomy and Hartmann’s pouch is the most commonly used procedure.71 Success also has been reported after sigmoid colectomy, pri-mary anastomosis, with or without on-table lavage, and proxi-mal diversion (loop ileostomy). This option may be appropriate in stable patients and offers the great advantage that the subse-quent operation to restore bowel continuity is simpler than is BAFigure 29-21. A. Computed tomography scan demonstrating pelvic abscess from perforated diverticular disease. B. Posterolateral computed tomography–guided drainage of abdominal abscess from


Surgery_Schwartz

Surgery_Schwartz. than is BAFigure 29-21. A. Computed tomography scan demonstrating pelvic abscess from perforated diverticular disease. B. Posterolateral computed tomography–guided drainage of abdominal abscess from perforated diverticular disease. (Used with permission from Charles O. Finne III, MD, Minneapolis, MN.)Brunicardi_Ch29_p1259-p1330.indd 128723/02/19 2:29 PM 1288SPECIFIC CONSIDERATIONSPART IItakedown of a Hartmann’s pouch. The presence of inflammation and phlegmon may increase the risk of ureteral damage during mobilization of the sigmoid colon, and preoperative placement of ureteral catheters can be invaluable. In extremely unstable patients, or in the presence of such severe inflammation that resection would harm adjacent organs, proximal diversion and local drainage have been employed. However, this approach is generally avoided because of high morbidity and mortality rates, along with the requirement for multiple operations. More recently, several studies have suggested that


Surgery_Schwartz

Surgery_Schwartz. However, this approach is generally avoided because of high morbidity and mortality rates, along with the requirement for multiple operations. More recently, several studies have suggested that laparoscopic lavage and drainage without bowel resection may be safe and effective even in the presence of free perforation. However, a 20% risk of surgical reoperation can be expected.73,74Obstructive symptoms occur in approximately 67% of patients who develop acute diverticulitis, and complete obstruc-tion occurs in 10%. Patients with incomplete obstruction often respond to fluid resuscitation, nasogastric suction, and gentle, low-volume water or Gastrografin enemas. Relief of obstruction allows full bowel preparation and elective resection. A high-volume oral bowel preparation is contraindicated in the pres-ence of obstructive symptoms. Obstruction that does not rapidly respond to medical management mandates laparotomy. Sigmoid colectomy with end colostomy is the safest procedure to per-form


Surgery_Schwartz

Surgery_Schwartz. in the pres-ence of obstructive symptoms. Obstruction that does not rapidly respond to medical management mandates laparotomy. Sigmoid colectomy with end colostomy is the safest procedure to per-form in this setting. However, colectomy and primary anasto-mosis, with or without on-table lavage (depending on extent of fecal load in the proximal colon), and proximal diversion may be appropriate if the patient is stable and the proximal and distal bowel appear healthy.Approximately 5% of patients with complicated diverticu-litis develop fistulas between the colon and an adjacent organ. Colovesical fistulas are most common, followed by colovaginal and coloenteric fistulas. Colocutaneous fistulas are a rare com-plication of diverticulitis. Two key points in the evaluation of fistulas are to define the anatomy of the fistula and exclude other diagnoses. Contrast enema and/or small bowel stud-ies are extremely useful in defining the course of the fistula. CT scan can identify associated


Surgery_Schwartz

Surgery_Schwartz. define the anatomy of the fistula and exclude other diagnoses. Contrast enema and/or small bowel stud-ies are extremely useful in defining the course of the fistula. CT scan can identify associated abscesses or masses. The dif-ferential diagnosis includes malignancy, Crohn’s disease, and radiation-induced fistulas. While Crohn’s disease and radiation injury may be suspected based on the patient’s medical history, colonoscopy or sigmoidoscopy usually is required to rule out malignancy. In addition, in a patient who has received radia-tion therapy, a fistula must be considered to be recurrent cancer until proven otherwise. Once the anatomy of the fistula has been defined and other diagnoses excluded, operative management should include resection of the affected segment of the colon involved with diverticulitis (usually with a primary anastomo-sis) and simple repair of the secondarily involved organ. Sus-picion of carcinoma may mandate a wider, en bloc resection.HemorrhageBleeding from


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Surgery_Schwartz. with diverticulitis (usually with a primary anastomo-sis) and simple repair of the secondarily involved organ. Sus-picion of carcinoma may mandate a wider, en bloc resection.HemorrhageBleeding from a diverticulum results from erosion of the peri-diverticular arteriole and may result in massive hemorrhage. Most significant lower gastrointestinal hemorrhage occurs in elderly patients in whom both diverticulosis and angiodyspla-sia are common. Consequently, the exact bleeding source may be difficult to identify. Fortunately, in 80% of patients, bleed-ing stops spontaneously. Clinical management should focus on resuscitation and localization of the bleeding site as described for lower gastrointestinal hemorrhage. Colonoscopy may occa-sionally identify a bleeding diverticulum that may then be treated with epinephrine injection or cautery. Angiography may be diagnostic and therapeutic in this setting. In the rare instance in which diverticular hemorrhage persists or recurs, laparotomy and