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Surgery_Schwartz. radiation therapy cite more accurate pathologic staging and fewer operative/postoperative complications. How-ever, large, bulky tumors may be unresectable or require a more extensive operation (APR, pelvic exenteration) without preop-erative therapy. In addition, postoperative pelvic radiation may compromise function of the neorectum.Comparisons of perioperative toxicity and oncologic out-come have been addressed by the German CAO/ARO/AIO-94 trial. In this study, preand postoperative chemoradiation were associated with equivalent acute toxicity and equivalent post-operative complication rates. Postoperative chemoradiation, however, doubled the risk of postoperative stricture forma-tion. In addition, preoperative chemoradiation halved the risk of local recurrence (6% vs. 12%). Based on these data, most surgeons consider preoperative chemoradiation to be the most appropriate therapy for locally advanced rectal cancer.126 In the United States, this generally consists of 5-FU based


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Surgery_Schwartz. these data, most surgeons consider preoperative chemoradiation to be the most appropriate therapy for locally advanced rectal cancer.126 In the United States, this generally consists of 5-FU based chemother-apy and 5 to 6 weeks of external beam radiation (“long course”) followed by surgery 6 to 8 weeks later. It is important to note, however, that many European centers utilize a “short course” preoperative radiation regimen consisting of 5 days of radia-tion followed by surgery within 1 to 2 weeks. At present, these modalities have not been compared in any randomized, prospec-tive trial.125,127With advances in chemoradiation, an increasing number pf patients with locally advanced rectal cancer will have com-plete shrinkage of their tumor (a clinical complete response; cCR). In light of the potential morbidity of proctectomy, it has been suggested that select patients can be managed nonopera-tively (“watch and wait”). However, data from current stud-ies are contradictory and concern


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Surgery_Schwartz. the potential morbidity of proctectomy, it has been suggested that select patients can be managed nonopera-tively (“watch and wait”). However, data from current stud-ies are contradictory and concern remains about the ability to predict which patients with clinical complete response actually have a pathologic complete response.128 Patients selected for nonoperative management must be examined by a surgeon at a frequent intervals. Additional adjuvant chemotherapy adminis-tered after the decision for a nonoperative approach is another important consideration.128,129 At present, this approach is not recommended outside of a specialty center and/or clinical trial.Stage IV: Distant Metastasis (Tany, Nany, M1) Like stage IV colon carcinoma, survival is limited in patients with distant metastasis from rectal carcinoma. Isolated hepatic Brunicardi_Ch29_p1259-p1330.indd 130123/02/19 2:29 PM 1302SPECIFIC CONSIDERATIONSPART IIand/or pulmonary metastases are rare, but when present may be


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Surgery_Schwartz. from rectal carcinoma. Isolated hepatic Brunicardi_Ch29_p1259-p1330.indd 130123/02/19 2:29 PM 1302SPECIFIC CONSIDERATIONSPART IIand/or pulmonary metastases are rare, but when present may be resected for cure in selected patients.119,120 Some patients will require palliative procedures. Radical resection may be required to control pain, bleeding, or tenesmus, but highly morbid pro-cedures such as pelvic exenteration and sacrectomy should generally be avoided in this setting. Local therapy using cau-tery, endocavitary radiation, or laser ablation may be adequate to control bleeding or prevent obstruction. Intraluminal stents may be useful in the uppermost rectum but often cause pain and tenesmus lower in the rectum. Occasionally, a proximal divert-ing colostomy will be required to alleviate obstruction. A mucus fistula should be created if possible to vent the distal colon. It is critical that the morbidity of any procedure be realistically weighed against potential benefit in


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Surgery_Schwartz. alleviate obstruction. A mucus fistula should be created if possible to vent the distal colon. It is critical that the morbidity of any procedure be realistically weighed against potential benefit in these patients with limited life expectancy. The assistance of a palliative care team can be invaluable in this setting.116Follow-Up and SurveillancePatients who have been treated for one colorectal cancer are at risk for the development of recurrent disease (either locally or systemically) or metachronous disease (a second primary tumor). In theory, metachronous cancers should be preventable by using surveillance colonoscopy to detect and remove polyps before they progress to invasive cancer. For most patients, a colonoscopy should be performed within 12 months after the diagnosis of the original cancer (or sooner if the colon was not examined in its entirety prior to the original resection). If that study is normal, colonoscopy should be repeated every 3 to 5 years thereafter.The


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Surgery_Schwartz. original cancer (or sooner if the colon was not examined in its entirety prior to the original resection). If that study is normal, colonoscopy should be repeated every 3 to 5 years thereafter.The optimal method of following patients for recurrent cancer remains controversial. The goal of close follow-up observation is to detect resectable recurrence and to improve survival. Re-resection of local recurrence and resection of dis-tant metastasis to liver, lung, or other sites are often technically challenging and highly morbid, with only a limited chance of achieving long-term survival. Thus, only selected patients who would tolerate such an approach should be followed intensively. Because most recurrences occur within 2 years of the original diagnosis, surveillance focuses on this time period. Patients who have undergone local resection of rectal tumors also should be followed with frequent endoscopic examinations (every 3–6 months for 3 years, then every 6 months for 2 years). CEA


Surgery_Schwartz

Surgery_Schwartz. Patients who have undergone local resection of rectal tumors also should be followed with frequent endoscopic examinations (every 3–6 months for 3 years, then every 6 months for 2 years). CEA is often followed every 3 to 6 months for 2 years. CT scans are often performed annually for 5 years, but there are few data to support this practice. More intensive surveillance is appro-priate in high-risk patients such as those with possible Lynch syndrome or T3, N+ cancers. Although intensive surveillance improves detection of resectable recurrences, it is important to note that a survival benefit has never been proven. Therefore, the risks and benefits of intensive surveillance must be weighed and treatment individualized.Treatment of Recurrent Colorectal CarcinomaBetween 20% and 40% of patients who have undergone cura-tive intent surgery for colorectal carcinoma will eventually develop recurrent disease. Most recurrences occur within the first 2 years after the initial diagnosis, but


Surgery_Schwartz

Surgery_Schwartz. who have undergone cura-tive intent surgery for colorectal carcinoma will eventually develop recurrent disease. Most recurrences occur within the first 2 years after the initial diagnosis, but preoperative chemo-radiation therapy may delay recurrence. While most of these patients will present with distant metastases, a small propor-tion will have isolated local recurrence and may be considered for salvage surgery. Recurrence after colon cancer resection usually occurs at the local site within the abdomen or in the liver or lungs. Resection of other involved organs may be nec-essary. Recurrence of rectal cancer can be considerably more difficult to manage because of the proximity of other pelvic structures. If the patient has not received chemotherapy and radiation, then adjuvant therapy should be administered prior to salvage surgery. Radical resection may require extensive resection of pelvic organs (pelvic exenteration with or without sacrectomy). Ideally, the aim of a salvage


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Surgery_Schwartz. should be administered prior to salvage surgery. Radical resection may require extensive resection of pelvic organs (pelvic exenteration with or without sacrectomy). Ideally, the aim of a salvage operation should be to resect all of the tumor with negative margins. However, if the ability to achieve a negative margin is in question, the addi-tion of intraoperative radiation therapy (usually brachytherapy) can help improve local control. Pelvic MRI is useful for identi-fying tumor extension that would prevent successful resection (extension of tumor into the pelvic sidewall, involvement of the iliac vessels or bilateral sacral nerves, sacral invasion above the S2-S3 junction). Patients should also undergo a thorough pre-operative evaluation to identify distant metastases (CT of chest, abdomen, and pelvis, and PET scan) before undergoing such an extensive procedure. Nevertheless, radical salvage surgery can prolong survival in selected patients.Minimally Invasive Techniques for


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Surgery_Schwartz. abdomen, and pelvis, and PET scan) before undergoing such an extensive procedure. Nevertheless, radical salvage surgery can prolong survival in selected patients.Minimally Invasive Techniques for ResectionLaparoscopic colectomy for cancer has been controversial. Early reports of high port site recurrence dampened enthusiasm for this technique.130 The ability to perform an adequate onco-logic resection for cancer has also been questioned. Several tri-als have laid to rest many of these fears. The Clinical Outcomes of Surgical Therapy (COST) Study Group, the Colon Car-cinoma Laparoscopic or Open Resection (COLOR) trial, and the United Kingdom Medical Research Council Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASSICC) trial all have shown oncologic equivalence between open and laparoscopic techniques. In these multi-institutional studies, the rates of cancer recurrence, survival, and quality of life were similar, suggesting that, in the hands of an


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Surgery_Schwartz. between open and laparoscopic techniques. In these multi-institutional studies, the rates of cancer recurrence, survival, and quality of life were similar, suggesting that, in the hands of an appropriately trained surgeon, laparoscopic colectomy is appropriate for colon cancer.131-136 The recent introduction of robotic surgery offers an additional minimally invasive approach. Early studies suggest that robotic surgery may be the oncologic equivalent to laparo-scopic surgery for colon cancer.137Laparoscopic surgery for rectal cancer has been more controversial. Multiple studies of laparoscopic total mesorectal excision for rectal cancer have demonstrated decreased blood loss, earlier return of bowel function and shorter length of stay compared with open TME. While a laparoscopic approach to mobilization of the left colon and splenic flexure can be used in rectal resection procedures, laparoscopic TME refers to comple-tion of the pelvic dissection laparoscopically and not through the


Surgery_Schwartz

Surgery_Schwartz. to mobilization of the left colon and splenic flexure can be used in rectal resection procedures, laparoscopic TME refers to comple-tion of the pelvic dissection laparoscopically and not through the abdominal extraction site. Technical challenges in the retraction of the rectum and surrounding soft tissues and transection of the distal rectum mandate careful evaluation oncologic outcomes. Two recent randomized controlled trials from the United States (ACOSOG Z6051)138 and Australia and New Zealand (ALaC-aRT: Australasian Laparoscopic Cancer of the Rectum Trial)139 have shown that laparoscopic surgery is not superior to open surgery in this regard. When the totality of evidence from nine randomized trials is evaluated, CRM was positive in 7.9% of laparoscopic and 6.1% of open rectal resections, a difference that was not statistically significant.17 In trials that reported the completeness of mesorectal excision (n = 5), inadequate TME was significantly more likely in laparoscopic


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Surgery_Schwartz. a difference that was not statistically significant.17 In trials that reported the completeness of mesorectal excision (n = 5), inadequate TME was significantly more likely in laparoscopic (13.2%) com-pared with open (10.4%) resections. Long-term recurrence and 6Brunicardi_Ch29_p1259-p1330.indd 130223/02/19 2:29 PM 1303COLON, RECTUM, AND ANUSCHAPTER 29survival data from ACOSOG and ALaCaRT studies will be needed to determine what role laparoscopy should play in rectal cancer surgery. Two earlier trials, COLOR (COlon cancer Lapa-roscopic or Open Resection) II134 and COREAN (Comparison of Open versus laparoscopic surgery for mid and low Rectal cancer After Neoadjuvant chemoradiotherapy),135 have shown equivalent 3-year recurrence and survival. It is possible that spe-cific subsets of patients are more appropriate for open surgery. For example, ALaCaRT authors thought laparoscopic surgery may be less successful in patients who had neoadjuvant therapy, larger T3 tumors, or higher BMIs,


Surgery_Schwartz

Surgery_Schwartz. are more appropriate for open surgery. For example, ALaCaRT authors thought laparoscopic surgery may be less successful in patients who had neoadjuvant therapy, larger T3 tumors, or higher BMIs, but their study was under-powered to make definitive conclusions in these patients. A laparoscopic approach should not be considered for T4 tumors.The inferior quality of laparoscopic rectal cancer surgery suggested by recent randomized trials is attributed to techni-cal limitations, leading to the suggestion that robotic surgery, with its wristed instruments, fixed platform, and potentially improved visualization could offer an improvement. The results of the ROLARR (Robotic vs Laparoscopic Resection for Rectal Cancer) randomized trial will offer more data on the quality of TME and margins after robotic surgery; however, a trial com-paring open to robotic dissection will also be important.141OTHER NEOPLASMSRare Colorectal TumorsNeuroendocrine Tumors. Neuroendocrine tumors occur most commonly


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Surgery_Schwartz. robotic surgery; however, a trial com-paring open to robotic dissection will also be important.141OTHER NEOPLASMSRare Colorectal TumorsNeuroendocrine Tumors. Neuroendocrine tumors occur most commonly in the gastrointestinal tract, and up to 25% of these tumors are found in the rectum. Well-differentiated neuroendo-crine tumors (also known as carcinoid tumors) are commonly identified on colonoscopy as small (<1 cm) nodules and have a benign clinical course, with overall survival is greater than 80%. However, the risk of malignancy increases with size, and more than 60% of tumors greater than 2 cm in diameter are associated with distant metastases. Rectal neuroendocrine tumors appear to be less likely to secrete vasoactive substances than carcinoids in other locations, and carcinoid syndrome is uncommon in the absence of hepatic metastases. Small carcinoids can be locally resected transanally. Larger tumors, poorly differentiated tumors (such as small cell or large cell neuroendocrine


Surgery_Schwartz

Surgery_Schwartz. is uncommon in the absence of hepatic metastases. Small carcinoids can be locally resected transanally. Larger tumors, poorly differentiated tumors (such as small cell or large cell neuroendocrine carcinomas), and those with obvious invasion into the muscularis require more radical surgery. Neuroendocrine tumors in the proximal colon are less common and are more likely to be malignant. Size also correlates with risk of malignancy, and tumors less than 2 cm in diameter rarely metastasize. However, the majority of neuroendocrine tumors in the proximal colon present as bulky lesions, and up to two-thirds of patients will have metastatic spread at the time of diagnosis. These tumors should usually be treated with radical resection. Because well-differentiated neuroendocrine tumors are typically slow growing, patients with distant metastases may expect reasonably long survival. Symptoms of carcinoid syndrome can often be alleviated with somatostatin analogues (octreotide) and/or


Surgery_Schwartz

Surgery_Schwartz. typically slow growing, patients with distant metastases may expect reasonably long survival. Symptoms of carcinoid syndrome can often be alleviated with somatostatin analogues (octreotide) and/or interferon-α. Tumor debulking can offer effective palliation in selected patients.142-144Mixed Adenoneuroendocrine Carcinomas. Mixed adeno-neuroendocrine carcinomas, also known as composite carcinoid carcinomas, adenocarcinoids tumors, amphicrine or collision tumors, have histologic features of both neuroendocrine tumors and adenocarcinomas. The natural history of these tumors more closely parallels that of adenocarcinomas than neuroendocrine tumors, and regional and systemic metastases are common. Carcinoid carcinoma of the colon and rectum should be treated according to the same oncologic principles as followed for man-agement of adenocarcinoma.Lipomas. Lipomas are benign lesions that occur most com-monly in the submucosa of the colon and rectum. The major-ity of lipomas are asymptomatic


Surgery_Schwartz

Surgery_Schwartz. as followed for man-agement of adenocarcinoma.Lipomas. Lipomas are benign lesions that occur most com-monly in the submucosa of the colon and rectum. The major-ity of lipomas are asymptomatic and discovered incidentally. Small asymptomatic lesions do not require resection. However, larger lesions may occasionally cause bleeding, obstruction, or intussusception, especially when greater than 2 cm in diameter. Larger lipomas should be resected by colonoscopic techniques or by a colotomy and enucleation or limited colectomy.144Lymphoma. Gastrointestinal lymphoma may be primary or generalized/secondary. Primary GI lymphomas occur most fre-quently in the terminal ileum and cecum. Lymphoma involv-ing the colon and rectum is rare, but it accounts for about 10% of all gastrointestinal lymphomas. Presentation, treatment and prognosis differ between patients with lymphoma occurring as a localized entity in the colon and rectum versus those inoccur-ing in patients who have generalized lymphoma


Surgery_Schwartz

Surgery_Schwartz. Presentation, treatment and prognosis differ between patients with lymphoma occurring as a localized entity in the colon and rectum versus those inoccur-ing in patients who have generalized lymphoma with colorectal involvement. Symptoms in isolated rectal lymphoma include bleeding, obstruction, and pain, and these tumors may be clini-cally indistinguishable from adenocarcinomas. The cecum is most often involved, probably as a result of spread from the terminal ileum. Symptoms include bleeding and obstruction. Bowel resec-tion is the treatment of choice for isolated colorectal lymphoma. Adjuvant therapy may be given based on the stage of disease.144Leiomyoma and Leiomyosarcoma. Leiomyomas are benign tumors of the smooth muscle of the bowel wall and occur most commonly in the upper gastrointestinal tract. Most patients are asymptomatic, and lesions are often diagnosed inciden-tally when a mass is seen on endoscopy or felt on digital rec-tal examination. However, large lesions can cause


Surgery_Schwartz

Surgery_Schwartz. tract. Most patients are asymptomatic, and lesions are often diagnosed inciden-tally when a mass is seen on endoscopy or felt on digital rec-tal examination. However, large lesions can cause bleeding or obstruction. Because it is difficult to differentiate a benign leio-myoma from a malignant leiomyosarcoma, these lesions should be resected. Recurrence is common after local resection, but most small leiomyomas can be adequately treated with limited resection. Lesions larger than 5 cm should be treated with radi-cal resection because the risk of malignancy is high.Leiomyosarcoma is rare in the gastrointestinal tract. When this malignancy occurs in the large intestine, the rectum is the most common site. Leiomyosarcoma of the rectum is usually low grade, and, as such, can be difficult to differentiate from leiomyoma. Definitive diagnosis is usually made after resection. Symptoms, when they occur, are usually bleeding or obstruc-tion. A radical resection is indicated for most of these


Surgery_Schwartz

Surgery_Schwartz. differentiate from leiomyoma. Definitive diagnosis is usually made after resection. Symptoms, when they occur, are usually bleeding or obstruc-tion. A radical resection is indicated for most of these tumors. Despite complete resection, recurrence is not uncommon, and prognosis is generally poor.144Gastrointestinal Stromal Tumor (GIST). Gastrointestinal Stromal Tumors (GIST) are most common in the proximal GI tract but do occasionally occur in the colorectum (5–10%) and may be mistaken for leiomyomas. GISTs are mesenchy-mal tumors that arise from the interstitial cells of Cajal. The vast majority (>95%) of GISTs express CD117 (KIT), and as such, are sensitive to tyrosine kinase inhibitors (TKIs), such as imatinib mesylate and sunitinib malate. Risk stratification is based on tumor size and mitotic activity, and 30% to 50% are malignant. Although small GISTs may be asymptomatic and discovered incidentally, larger lesions can cause bleeding, obstruction, or abdominal pain. Treatment of


Surgery_Schwartz

Surgery_Schwartz. mitotic activity, and 30% to 50% are malignant. Although small GISTs may be asymptomatic and discovered incidentally, larger lesions can cause bleeding, obstruction, or abdominal pain. Treatment of choice is surgi-cal resection (either local excision or radical resection) with Brunicardi_Ch29_p1259-p1330.indd 130323/02/19 2:29 PM 1304SPECIFIC CONSIDERATIONSPART IImicroscopically negative margins, if possible; however, local recurrence is common. For larger marginally resectable tumors, TKIs (imatinib) can be used to shrink the tumor. These agents can also be considered for adjuvant therapy after resection and are useful for treating metastatic disease.144Retrorectal/Presacral TumorsTumors occurring in the retrorectal space are rare. This region lies between the upper two-thirds of the rectum and the sacrum above the rectosacral fascia. It is bound by the rectum anteri-orly, the presacral fascia posteriorly, and the endopelvic fascia laterally (lateral ligaments). The retrorectal


Surgery_Schwartz

Surgery_Schwartz. rectum and the sacrum above the rectosacral fascia. It is bound by the rectum anteri-orly, the presacral fascia posteriorly, and the endopelvic fascia laterally (lateral ligaments). The retrorectal space contains mul-tiple embryologic remnants derived from a variety of tissues (neuroectoderm, notochord, and hindgut). As such, tumors that develop in this space are often heterogeneous.Congenital lesions are most common, comprising almost two-thirds of retrorectal lesions. The remainder are classified as neurogenic, osseous, inflammatory, or miscellaneous lesions. Malignancy is more common in the pediatric population than in adults, and solid lesions are more likely to be malignant than are cystic lesions. Inflammatory lesions may be solid or cystic (abscess) and usually represent extensions of infection either in the perirectal space or in the abdomen.Developmental cysts constitute the majority of congenital lesions and may arise from all three germ cell layers. Dermoid and epidermoid


Surgery_Schwartz

Surgery_Schwartz. of infection either in the perirectal space or in the abdomen.Developmental cysts constitute the majority of congenital lesions and may arise from all three germ cell layers. Dermoid and epidermoid cysts are benign lesions that arise from the ecto-derm. Enterogenous cysts arise from the primitive gut. Anterior meningocele and myelomeningocele arise from herniation of the dural sac through a defect in the anterior sacrum. A “scimitar sign” (sacrum with a rounded, concave border without any bony destruction) is the pathognomonic radiographic appearance of this condition.Solid lesions include teratomas, chordomas, neurologic tumors, or osseous lesions. Teratomas are true neoplasms and contain tissue from each germ cell layer. They often contain both cystic and solid components. Teratomas are more com-mon in children than in adults, but when found in adults, 30% are malignant. Chordomas arise from the notochord and are the most common malignant tumor in this region. These are


Surgery_Schwartz

Surgery_Schwartz. are more com-mon in children than in adults, but when found in adults, 30% are malignant. Chordomas arise from the notochord and are the most common malignant tumor in this region. These are slow-growing, invasive cancers that show characteristic bony destruc-tion. Neurogenic tumors include neurofibromas and sarcomas, neurilemomas, ependymomas, and ganglioneuromas. Osseous lesions include osteomas and bone cysts, as well as neoplasms such as osteogenic sarcoma, Ewing’s tumor, chondromyxosar-coma, and giant cell tumors.Patients may present with pain (lower back, pelvic, or lower extremity), gastrointestinal symptoms, or urinary tract symptoms. Most lesions are palpable on digital rectal examina-tion. While plain X-rays and CT scans often are used to evalu-ate these lesions, pelvic MRI is the most sensitive and specific imaging study. Myelogram is occasionally necessary if there is central nervous system involvement. Treatment is almost always surgical resection. The approach depends in


Surgery_Schwartz

Surgery_Schwartz. most sensitive and specific imaging study. Myelogram is occasionally necessary if there is central nervous system involvement. Treatment is almost always surgical resection. The approach depends in part on the nature of the lesion and its location. Lesions high in the pelvis may be approached via a transabdominal route, whereas low lesions may be resected transsacrally. Intermediate lesions may require a combined abdominal and sacral operation. Although survival is excellent after resection of benign lesions, local recurrence is not uncommon. Prognosis after resection of malignant lesions is highly variable and reflects the biology of the underlying tumor.The role of biopsy in this setting has been controversial. Historically, the recommendation was to avoid biopsy because of the risk of infection or needle tract seeding. This recommen-dation has recently been challenged, especially for large and/or unusual tumors that would be better treated with multimodality neoadjuvant therapy


Surgery_Schwartz

Surgery_Schwartz. of infection or needle tract seeding. This recommen-dation has recently been challenged, especially for large and/or unusual tumors that would be better treated with multimodality neoadjuvant therapy (GIST, sarcoma, metastatic adenocarci-noma). A recent study confirmed the utility of needle biopsy of solid lesions and refuted concerns about needle tract seeding. As such, most solid lesions should be biopsied regardless of resectability. Biopsy or aspiration of cystic lesions, especially meningoceles, should still be avoided because of the risk of infection.144-147Anal Canal and Perianal TumorsCancers of the anal canal are uncommon and account for approx-imately 2% of all colorectal malignancies. Neoplasms of the anal canal have traditionally been divided into those affecting the anal margin (distal to the dentate line) and those affecting the anal canal (proximal to the dentate line) based on lymphatic drainage patterns. Lymphatics from the anal canal proximal to the dentate line


Surgery_Schwartz

Surgery_Schwartz. margin (distal to the dentate line) and those affecting the anal canal (proximal to the dentate line) based on lymphatic drainage patterns. Lymphatics from the anal canal proximal to the dentate line drain cephalad via the superior rectal lymphat-ics to the inferior mesenteric nodes and laterally along both the middle rectal vessels and inferior rectal vessels through the ischiorectal fossa to the internal iliac nodes. Lymph from the anal canal distal to the dentate line usually drains to the inguinal nodes. It can also drain to the superior rectal lymph nodes or along the inferior rectal lymphatics to the ischiorectal fossa if primary drainage routes are blocked with tumor (Fig. 29-27).A more clinically useful classification divides anal lesions into those that are perianal (can be completely visualized with gentle eversion of the buttocks) and those that are intra-anal (cannot be completely visualized with gentle eversion of the buttocks). In many cases, therapy depends on whether


Surgery_Schwartz

Surgery_Schwartz. visualized with gentle eversion of the buttocks) and those that are intra-anal (cannot be completely visualized with gentle eversion of the buttocks). In many cases, therapy depends on whether the tumor is perianal or intra-anal.Squamous Intraepithelial Lesions. Anal canal and peri-anal dysplasia have long had a potpourri of nomenclature. Anal intraepithelial neoplasia (AIN), Bowen’s disease, and carci-noma in situ all refer to human papillomavirus (HPV)–induced Inferiormesenteric a.Superiorrectal a.Middlerectal a.Inferiorrectal a.Common iliac a.Figure 29-27. Lymphatic drainage of the anal canal. a. = artery.Brunicardi_Ch29_p1259-p1330.indd 130423/02/19 2:29 PM 1305COLON, RECTUM, AND ANUSCHAPTER 29dysplasia. Because these entities are pathologically identical, there has been an effort to standardize nomenclature. High-grade squamous intraepithelial lesions (HSIL) include highand intermediate-grade dysplasia, AINII and AINIII, Bowen’s disease, and carcinoma in situ. Low-grade


Surgery_Schwartz

Surgery_Schwartz. to standardize nomenclature. High-grade squamous intraepithelial lesions (HSIL) include highand intermediate-grade dysplasia, AINII and AINIII, Bowen’s disease, and carcinoma in situ. Low-grade squamous intraepi-thelial lesions (LSIL) includes low-grade dysplasia and AINI. Recently, the terms High-grade AIN (HGAIN; AINIII) and low-grade AIN (LGAIN; AIN I/II) have been suggested.146-148 Both highand low-grade lesions are associated with infection with HPV, especially types 16 and 18.High-grade lesions are precursors to invasive squamous cell carcinoma (epidermoid carcinoma) and may appear as a plaque or may only be apparent with high-resolution anoscopy and application of acetic acid and/or Lugol’s iodine solution. The incidence of both squamous intraepithelial lesions and epidermoid carcinoma of the anus has increased dramatically among human immunodeficiency virus (HIV)–positive men who have sex with men. This increase is thought to result from increased rates of HPV infection along


Surgery_Schwartz

Surgery_Schwartz. of the anus has increased dramatically among human immunodeficiency virus (HIV)–positive men who have sex with men. This increase is thought to result from increased rates of HPV infection along with HIV-induced immu-nosuppression. Treatment of high-grade dysplasia is ablation. Because of a high recurrence and/or reinfection rate, these patients require close surveillance. High-risk patients should be followed with frequent anal Papanicolaou (Pap) smears every 3 to 6 months. An abnormal Pap smear should be followed by an examination under anesthesia and anal mapping using high-resolution anoscopy. High-resolution anoscopy shows areas with abnormal telangiectasias that are consistent with high-grade dysplasia. Many centers now consider this technique for repeated ablation of high-grade lesions to be the optimal method for following these patients.148-150 It should be noted, however, that the practice has not been universally adopted, and it is unclear whether close surveillance in


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Surgery_Schwartz. lesions to be the optimal method for following these patients.148-150 It should be noted, however, that the practice has not been universally adopted, and it is unclear whether close surveillance in lower-risk (nonimmu-nosuppressed) patients is necessary. Rarely, extensive disease may require resection with flap closure. Medical therapy for HPV has also been proposed. Topical immunomodulators such as imiquimod (Aldara) have been shown to induce regression in some series.151 Topical 5-fluorouracil has also been used in this setting. Finally, the introduction of a vaccine against HPV may help decrease the incidence of this disease in the future.Epidermoid Carcinoma. Epidermoid carcinoma of the anus includes squamous cell carcinoma, cloacogenic carcinoma, tran-sitional carcinoma, and basaloid carcinoma. The clinical behav-ior and natural history of these tumors are similar. Epidermoid carcinoma is a slow-growing tumor and usually presents as an intra-anal or perianal mass. Pain and


Surgery_Schwartz

Surgery_Schwartz. carcinoma. The clinical behav-ior and natural history of these tumors are similar. Epidermoid carcinoma is a slow-growing tumor and usually presents as an intra-anal or perianal mass. Pain and bleeding may be present. Perianal epidermoid carcinoma may be treated in a similar fash-ion as squamous cell carcinoma of the skin in other locations because wide local excision can usually be achieved without resecting the anal sphincter. Intra-anal epidermoid carcinoma cannot be excised locally, and first-line therapy relies on chemo-therapy and radiation (the Nigro protocol: 5-fluorouracil, mitomycin C, and 30 Gy of external beam radiation). This regimen cures 70% to 80% of these tumors. It is important to note that epidermoid carcinomas continue to respond after com-pletion of chemoradiation. Lesions that persist greater than 3 to 6 months after therapy may represent persistent disease and should be biopsied. Recurrence usually requires radical resec-tion (APR). Metastasis to inguinal lymph


Surgery_Schwartz

Surgery_Schwartz. that persist greater than 3 to 6 months after therapy may represent persistent disease and should be biopsied. Recurrence usually requires radical resec-tion (APR). Metastasis to inguinal lymph nodes is a poor prog-nostic sign.148Verrucous Carcinoma (Buschke-Lowenstein Tumor, Giant Condyloma Acuminata). Verrucous carcinoma is a locally aggressive form of condyloma acuminata. Although these lesions do not metastasize, they can cause extensive local tissue destruction and may be grossly indistinguishable from epider-moid carcinoma. Wide local excision is the treatment of choice when possible, but radical resection may sometimes be required. Topical immunomodulators such as imiquimod (Aldara) may shrink some tumors, but they are almost never curative.151 Very large lesions may respond to external beam radiation, but resec-tion is almost always required.Basal Cell Carcinoma. Basal cell carcinoma of the anus is rare and resembles basal cell carcinoma elsewhere on the skin (raised, pearly


Surgery_Schwartz

Surgery_Schwartz. beam radiation, but resec-tion is almost always required.Basal Cell Carcinoma. Basal cell carcinoma of the anus is rare and resembles basal cell carcinoma elsewhere on the skin (raised, pearly edges with central ulceration). This is a slow-growing tumor that rarely metastasizes. Wide local excision is the treatment of choice, but recurrence occurs in up to 30% of patients. Radical resection and/or radiation therapy may be required for large lesions.Adenocarcinoma. Adenocarcinoma of the anus is extremely rare and usually represents downward spread of a low rectal ade-nocarcinoma. Adenocarcinoma may occasionally arise from the anal glands or may develop in a chronic fistula. Radical resection, usually after neoadjuvant chemoradiation, is usually required.Extramammary perianal Paget’s disease is adenocarci-noma in situ arising from the apocrine glands of the perianal area. The lesion is typically plaque-like and may be indistin-guishable from high-grade intraepithelial lesions.


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Surgery_Schwartz. disease is adenocarci-noma in situ arising from the apocrine glands of the perianal area. The lesion is typically plaque-like and may be indistin-guishable from high-grade intraepithelial lesions. Characteristic Paget’s cells are seen histologically. These tumors are often associated with a synchronous gastrointestinal adenocarcinoma, so a complete evaluation of the intestinal tract should be per-formed. Wide local excision is usually adequate treatment for perianal Paget’s disease.Melanoma. Anorectal melanoma is rare, comprising less than 1% of all anorectal malignancies and 1% to 2% of melanomas. Diagnosis is often delayed, and symptoms are attributed to hem-orrhoidal disease. Despite many advances in the treatment of cutaneous melanoma, prognosis for patients with anorectal dis-ease remains poor. Overall 5-year survival is less than 10%, and many patients present with systemic metastasis and/or deeply invasive tumors at the time of diagnosis. A few patients with anorectal melanoma,


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Surgery_Schwartz. poor. Overall 5-year survival is less than 10%, and many patients present with systemic metastasis and/or deeply invasive tumors at the time of diagnosis. A few patients with anorectal melanoma, however, present with isolated local or locoregional disease that is potentially resectable for cure, and both radical resection (APR) and wide local excision have been advocated. Recurrence is common and usually occurs systemi-cally regardless of the initial surgical procedure. Local resection with free margins does not increase the risk of local or regional recurrence, and APR offers no survival advantage over local excision. Because of the morbidity associated with APR, wide local excision is recommended for initial treatment of localized anal melanoma. In some patients, wide local excision may not be technically feasible, and APR may be required if the tumor involves a significant portion of the anal sphincter or is circum-ferential. The addition of adjuvant chemotherapy, biochemo-therapy,


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Surgery_Schwartz. not be technically feasible, and APR may be required if the tumor involves a significant portion of the anal sphincter or is circum-ferential. The addition of adjuvant chemotherapy, biochemo-therapy, vaccines, or radiotherapy may be of benefit in some patients, but efficacy remains unproven.152,153OTHER BENIGN COLORECTAL CONDITIONSRectal Prolapse and Solitary Rectal Ulcer SyndromeRectal Prolapse. Rectal prolapse refers to a circumferential, full-thickness protrusion of the rectum through the anus and has also been called “first-degree” prolapse, “complete” prolapse, or 7Brunicardi_Ch29_p1259-p1330.indd 130523/02/19 2:29 PM 1306SPECIFIC CONSIDERATIONSPART IIprocidentia. Internal prolapse occurs when the rectal wall intus-suscepts but does not protrude and is probably more accurately described as internal intussusception. Mucosal prolapse is a partial-thickness protrusion often associated with hemorrhoidal disease and is usually treated with banding or hemorrhoidectomy.In adults,


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Surgery_Schwartz. as internal intussusception. Mucosal prolapse is a partial-thickness protrusion often associated with hemorrhoidal disease and is usually treated with banding or hemorrhoidectomy.In adults, this condition is far more common among women, with a female-to-male ratio of 6:1. Prolapse becomes more prevalent with age in women and peaks in the sev-enth decade of life. In men, prevalence is unrelated to age. Symptoms include tenesmus, a sensation of tissue protruding from the anus that may or may not spontaneously reduce, and a sensation of incomplete evacuation. Mucus discharge and leak-age may accompany the protrusion. Patients also present with a myriad of functional complaints, from incontinence and diar-rhea to constipation and outlet obstruction.A thorough preoperative evaluation, including colonic transit studies, anorectal manometry, tests of pudendal nerve terminal motor latency, EMG, and cinedefecography, may be useful. The colon should be evaluated by colonoscopy, aircontrast


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Surgery_Schwartz. colonic transit studies, anorectal manometry, tests of pudendal nerve terminal motor latency, EMG, and cinedefecography, may be useful. The colon should be evaluated by colonoscopy, aircontrast barium enema, or CT colonography to exclude neo-plasms or diverticular disease. Cardiopulmonary condition should be thoroughly evaluated because comorbidities may influence the choice of surgical procedure.The primary therapy for rectal prolapse is surgery, and more than 100 different procedures have been described to treat this condition. Operations can be categorized as either abdominal or perineal. Abdominal operations have taken three major approaches: (a) reduction of the perineal hernia and closure of the cul-de-sac (Moschowitz repair); (b) fixation of the rectum, either with a prosthetic mesh or fascia lata sling (Ripstein and Wells rectopexy; ventral rectopexy) or by suture rectopexy; or (c) resection of redundant sigmoid colon (Fig. 29-28). In some cases, resection is combined with


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Surgery_Schwartz. mesh or fascia lata sling (Ripstein and Wells rectopexy; ventral rectopexy) or by suture rectopexy; or (c) resection of redundant sigmoid colon (Fig. 29-28). In some cases, resection is combined with rectal fixation (resection rectopexy). The recently described ventral rectopexy involves dissection of the anterior rectum down to the pelvic floor. Mesh is sutured to the anterior rectum at one end and anchored to the sacral promontory at the other end.154 Abdominal procedures for rectal prolapse are increasingly performed laparoscopically or robotically. Perineal approaches have focused on tightening the anus with a variety of prosthetic materials, reefing the rectal mucosa (Delorme procedure), or resecting the prolapsed bowel from the perineum (perineal rectosigmoidectomy or Altemeier procedure) (Fig. 29-29).Because rectal prolapse occurs most commonly in elderly women, the choice of operation depends in part on the patient’s overall medical condition. Abdominal rectopexy (with or


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Surgery_Schwartz. procedure) (Fig. 29-29).Because rectal prolapse occurs most commonly in elderly women, the choice of operation depends in part on the patient’s overall medical condition. Abdominal rectopexy (with or with-out sigmoid resection) offers the most durable repair, with recurrence occurring in less than 10% of patients. Perineal rectosigmoidectomy avoids an abdominal operation and may be preferable in high-risk patients but is associated with a higher recurrence rate. Reefing the rectal mucosa is effective for patients with limited prolapse. Anal encirclement procedures generally have been abandoned.Solitary Rectal Ulcer Syndrome. Solitary rectal ulcer syn-drome and colitis cystica profunda are commonly associated with internal intussusception. Patients may complain of pain, bleeding, mucus discharge, or outlet obstruction. In solitary rec-tal ulcer syndrome, one or more ulcers are present in the distal rectum, usually on the anterior wall. In colitis cystica profunda, nodules or a mass may


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Surgery_Schwartz. or outlet obstruction. In solitary rec-tal ulcer syndrome, one or more ulcers are present in the distal rectum, usually on the anterior wall. In colitis cystica profunda, nodules or a mass may be found in a similar location. Evalu-ation should include anorectal manometry, defecography, and either colonoscopy or barium enema to exclude other diagnoses. Biopsy of an ulcer or mass is mandatory to exclude malignancy or infection due to cytomegalovirus (CMV) in an immunosup-pressed patient. Nonoperative therapy (high-fiber diet, def-ecation training to avoid straining, and laxatives or enemas) is effective in the majority of patients. Biofeedback has also been reported to be effective in some patients. Surgery (either abdominal or perineal repair of prolapse as described earlier) is reserved for highly symptomatic patients who have failed all medical interventions.VolvulusVolvulus occurs when an air-filled segment of the colon twists about its mesentery. The sigmoid colon is involved in up


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Surgery_Schwartz. highly symptomatic patients who have failed all medical interventions.VolvulusVolvulus occurs when an air-filled segment of the colon twists about its mesentery. The sigmoid colon is involved in up to 90% of cases, but volvulus can involve the cecum (<20%) or trans-verse colon. A volvulus may reduce spontaneously, but more commonly produces bowel obstruction, which can progress to strangulation, gangrene, and perforation. Chronic constipation may produce a large, redundant colon (chronic megacolon) that predisposes to volvulus, especially if the mesenteric base is narrow.The symptoms of volvulus are those of acute bowel obstruction. Patients present with abdominal distention, nau-sea, and vomiting. Symptoms rapidly progress to generalized abdominal pain and tenderness. Fever and leukocytosis are her-alds of gangrene and/or perforation. Occasionally, patients will report a long history of intermittent obstructive symptoms and distention, suggesting intermittent chronic volvulus.Sigmoid


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Surgery_Schwartz. are her-alds of gangrene and/or perforation. Occasionally, patients will report a long history of intermittent obstructive symptoms and distention, suggesting intermittent chronic volvulus.Sigmoid Volvulus. Sigmoid volvulus can often be differenti-ated from cecal or transverse colon volvulus by the appearance of plain X-rays of the abdomen. Sigmoid volvulus produces a characteristic bent inner tube or coffee bean appearance, with the convexity of the loop lying in the right upper quadrant (opposite the site of obstruction). Gastrografin enema shows a 8Figure 29-28. Transabdominal proctopexy for rectal prolapse. The fully mobilized rectum is sutured to the presacral fascia. A. Anterior view. B. Lateral view. If desired, a sigmoid colectomy can be performed con-comitantly to resect the redundant colon.BABrunicardi_Ch29_p1259-p1330.indd 130623/02/19 2:29 PM 1307COLON, RECTUM, AND ANUSCHAPTER 29narrowing at the site of the volvulus and a pathognomonic bird’s beak (Fig. 29-30).Unless


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Surgery_Schwartz. colon.BABrunicardi_Ch29_p1259-p1330.indd 130623/02/19 2:29 PM 1307COLON, RECTUM, AND ANUSCHAPTER 29narrowing at the site of the volvulus and a pathognomonic bird’s beak (Fig. 29-30).Unless there are obvious signs of gangrene or peritoni-tis, the initial management of sigmoid volvulus is resuscitation followed by endoscopic detorsion. Detorsion is usually most easily accomplished by using a rigid proctoscope, but a flexible sigmoidoscope or colonoscope may also be effective. A rec-tal tube may be inserted to maintain decompression. Although these techniques are successful in reducing sigmoid volvulus in the majority of patients, the risk of recurrence is high (up to 40%). For this reason, an elective sigmoid colectomy should be performed after the patient has been stabilized and undergone an adequate bowel preparation.Clinical evidence of gangrene or perforation mandates immediate surgical exploration without an attempt at endoscopic decompression. Similarly, the presence of


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Surgery_Schwartz. undergone an adequate bowel preparation.Clinical evidence of gangrene or perforation mandates immediate surgical exploration without an attempt at endoscopic decompression. Similarly, the presence of necrotic mucosa, ulcer-ation, or dark blood noted on endoscopy examination suggests strangulation and is an indication for operation. If dead bowel is present at laparotomy, a sigmoid colectomy with end colostomy (Hartmann’s procedure) may be the safest operation to perform.Cecal Volvulus. Cecal volvulus results from nonfixation of the right colon. In the majority of cases, rotation occurs around the ileocolic blood vessels and vascular impairment occurs early, although 10% to 30% of the cecum folds upon itself (cecal bascule). Plain X-rays of the abdomen show a characteristic kidney-shaped, air-filled structure in the left upper quadrant (opposite the site of obstruction), and a Gastrografin enema confirms obstruction at the level of the volvulus.Unlike sigmoid volvulus, cecal volvulus


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Surgery_Schwartz. air-filled structure in the left upper quadrant (opposite the site of obstruction), and a Gastrografin enema confirms obstruction at the level of the volvulus.Unlike sigmoid volvulus, cecal volvulus can almost never be detorsed endoscopically. Moreover, because vascular com-promise occurs early in the course of cecal volvulus, surgical exploration is necessary when the diagnosis is made. Right hemicolectomy with a primary ileocolic anastomosis can usu-ally be performed safely and prevents recurrence. Simple detor-sion or detorsion and cecopexy are associated with a high rate of recurrence.Transverse Colon Volvulus. Transverse colon volvulus is extremely rare. Nonfixation of the colon and chronic consti-pation with megacolon may predispose to transverse colon AFCEDBFigure 29-29. Perineal rectosigmoidectomy shown in lithotomy position. A. A circular incision is made 2 cm proximal to the dentate line. B. The anterior peritoneal reflection is opened. C. The mesentery is divided and


Surgery_Schwartz

Surgery_Schwartz. rectosigmoidectomy shown in lithotomy position. A. A circular incision is made 2 cm proximal to the dentate line. B. The anterior peritoneal reflection is opened. C. The mesentery is divided and ligated. D. The peritoneum may be sutured to the bowel wall. E. The bowel is resected. F. A hand-sewn anastomosis is performed.Brunicardi_Ch29_p1259-p1330.indd 130723/02/19 2:29 PM 1308SPECIFIC CONSIDERATIONSPART IIvolvulus. The radiographic appearance of transverse colon volvulus resembles sigmoid volvulus, but Gastrografin enema will reveal a more proximal obstruction. Although colonoscopic detorsion is occasionally successful in this setting, most patients require emergent exploration and resection.MegacolonMegacolon describes a chronically dilated, elongated, hypertro-phied large bowel. Megacolon may be congenital or acquired and is usually related to chronic mechanical or functional obstruction. In general, the degree of megacolon is related to the duration of obstruction. Evaluation


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Surgery_Schwartz. may be congenital or acquired and is usually related to chronic mechanical or functional obstruction. In general, the degree of megacolon is related to the duration of obstruction. Evaluation must always include examination of the colon and rectum (either endoscopically or radiographically) to exclude a surgically correctable mechanical obstruction.Congenital megacolon caused by Hirschsprung’s disease results from the failure of migration of neural crest cells to the distal large intestine. The resulting absence of ganglion cells in the distal colon results in a failure of relaxation and causes a functional obstruction. The proximal, healthy bowel becomes progressively dilated. Surgical resection of the aganglionic seg-ment is curative. Although Hirschsprung’s disease primarily is a disease of infants and children, it occasionally presents later in adulthood, especially if an extremely short segment of the bowel is affected (ultrashort-segment Hirschsprung’s disease).Acquired


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Surgery_Schwartz. a disease of infants and children, it occasionally presents later in adulthood, especially if an extremely short segment of the bowel is affected (ultrashort-segment Hirschsprung’s disease).Acquired megacolon may result from infection or chronic constipation. Infection with the protozoan Trypanosoma cruzi (Chagas’ disease) destroys ganglion cells and produces both megacolon and megaesophagus. Chronic constipation from slow transit or secondary to medications (especially anticholinergic medications) or neurologic disorders (paraplegia, poliomyelitis, amyotrophic lateral sclerosis, multiple sclerosis) may produce progressive colonic dilatation. Diverting ileostomy or subtotal colectomy with an ileorectal anastomosis is occasionally neces-sary in these patients.Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)Colonic pseudo-obstruction (Ogilvie’s syndrome) is a func-tional disorder in which the colon becomes massively dilated in the absence of mechanical obstruction. Pseudo-obstruction


Surgery_Schwartz

Surgery_Schwartz. (Ogilvie’s Syndrome)Colonic pseudo-obstruction (Ogilvie’s syndrome) is a func-tional disorder in which the colon becomes massively dilated in the absence of mechanical obstruction. Pseudo-obstruction most commonly occurs in hospitalized patients and is associated with the use of narcotics, bed rest, and comorbid disease. Pseudo-obstruction is thought to result from autonomic dysfunction and severe adynamic ileus. The diagnosis is made based on the pres-ence of massive dilatation of the colon (usually predominantly the right and transverse colon) in the absence of a mechanical obstruction. Initial treatment consists of cessation of narcotics, anticholinergics, or other medications that may contribute to ileus. Strict bowel rest and intravenous hydration are crucial. Most patients will respond to these measures. In patients who fail to improve, colonoscopic decompression often is effective. However, this procedure is technically challenging, and great care must be taken to avoid causing


Surgery_Schwartz

Surgery_Schwartz. to these measures. In patients who fail to improve, colonoscopic decompression often is effective. However, this procedure is technically challenging, and great care must be taken to avoid causing perforation. Up to 40% of patients recur. Intravenous neostigmine (an acetylcholines-terase inhibitor), administered as a single 2 mg dose, also is extremely effective in decompressing the dilated colon and is associated with a low rate of recurrence (20%).155 However, neostigmine may produce transient but profound bradycardia and may be inappropriate in patients with cardiopulmonary ABFigure 29-30. Sigmoid volvulus: (A) Illustration and (B) Gastrografin enema showing “bird-beak” sign (arrow). (B. Reproduced with per-mission from James EC, Corry RJ, Perry JCF: Basic Surgical Practice. Philadelphia, PA: Hanley & Belfus; 1987.)Brunicardi_Ch29_p1259-p1330.indd 130823/02/19 2:29 PM 1309COLON, RECTUM, AND ANUSCHAPTER 29disease. Because the colonic dilatation is typically greatest in the


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Surgery_Schwartz. PA: Hanley & Belfus; 1987.)Brunicardi_Ch29_p1259-p1330.indd 130823/02/19 2:29 PM 1309COLON, RECTUM, AND ANUSCHAPTER 29disease. Because the colonic dilatation is typically greatest in the proximal colon, placement of a rectal tube is rarely effective. It is crucial to exclude mechanical obstruction (usually with a Gastrografin enema) prior to medical or endoscopic treatment.Ischemic ColitisIntestinal ischemia occurs most commonly in the colon. Unlike small bowel ischemia, colonic ischemia rarely is associated with major arterial or venous occlusion. Instead, most colonic isch-emia appears to result from low flow and/or small vessel occlu-sion. Risk factors include vascular disease, diabetes mellitus, vasculitis, hypotension, and tobacco use. In addition, ligation of the inferior mesenteric artery during aortic surgery predisposes to colonic ischemia. Occasionally, thrombosis or embolism may cause ischemia. Although the splenic flexure is the most com-mon site of ischemic colitis,


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Surgery_Schwartz. artery during aortic surgery predisposes to colonic ischemia. Occasionally, thrombosis or embolism may cause ischemia. Although the splenic flexure is the most com-mon site of ischemic colitis, any segment of the colon may be affected. The rectum is relatively spared because of its rich col-lateral circulation.Signs and symptoms of ischemic colitis reflect the extent of bowel ischemia. In mild cases, patients may have diarrhea (usually bloody) without abdominal pain. With more severe ischemia, intense abdominal pain (often out of proportion to the clinical examination), tenderness, fever, and leukocytosis are present. Peritonitis and/or systemic toxicity are signs of full-thickness necrosis and perforation.The diagnosis of ischemic colitis is often based on the clinical history and physical examination. Plain films may reveal thumb printing, which results from mucosal edema and submucosal hemorrhage. CT often shows nonspecific colonic wall thickening and pericolic fat stranding.


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Surgery_Schwartz. examination. Plain films may reveal thumb printing, which results from mucosal edema and submucosal hemorrhage. CT often shows nonspecific colonic wall thickening and pericolic fat stranding. Angiography is usually not helpful because major arterial occlusion is rare. While sigmoidoscopy may reveal characteristic dark, hemor-rhagic mucosa, the risk of precipitating perforation is high. For this reason, sigmoidoscopy is relatively contraindicated in any patient with significant abdominal tenderness. Contrast studies (Gastrografin or barium enema) are similarly contraindicated during the acute phase of ischemic colitis.Treatment of ischemic colitis depends on clinical severity. Unlike ischemia of the small bowel, the majority of patients with ischemic colitis can be treated medically. Bowel rest and broad-spectrum antibiotics are the mainstay of therapy, and 80% of patients will recover with this regimen. Hemodynamic parameters should be optimized, especially if hypotension and low flow


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Surgery_Schwartz. rest and broad-spectrum antibiotics are the mainstay of therapy, and 80% of patients will recover with this regimen. Hemodynamic parameters should be optimized, especially if hypotension and low flow appear to be the inciting cause. Long-term sequelae include stricture (10–15%) and chronic segmental ischemia (15–20%). Colonoscopy should be performed after recovery to evaluate strictures and to rule out other diagnoses such as inflammatory bowel disease or malignancy. Failure to improve after 2 to 3 days of medical management, progression of symp-toms, and deterioration in clinical condition are indications for surgical exploration. In this setting, all necrotic bowel should be resected. Primary anastomosis should be avoided. Occasion-ally, repeated exploration (a second-look operation) may be necessary.Infectious ColitisPseudomembranous Colitis (Clostridium difficile Colitis). Pseudomembranous colitis is caused by C difficile, a gram-positive anaerobic bacillus. Clostridium difficile


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Surgery_Schwartz. be necessary.Infectious ColitisPseudomembranous Colitis (Clostridium difficile Colitis). Pseudomembranous colitis is caused by C difficile, a gram-positive anaerobic bacillus. Clostridium difficile colitis is extremely common and is the leading cause of nosocomially acquired diarrhea. The spectrum of disease ranges from watery diarrhea to fulminant, life-threatening colitis. Clostridium dif-ficile is carried in the large intestine of many healthy adults. Colitis is thought to result from overgrowth of this organism after depletion of the normal commensal flora of the gut with the use of antibiotics. Although clindamycin was the first anti-microbial agent associated with C difficile colitis, almost any antibiotic may cause this disease. Moreover, although the risk of C difficile colitis increases with prolonged antibiotic use, even a single dose of an antibiotic may cause the disease. Immunosup-pression, medical comorbidities, prolonged hospitalization or nursing home residence, and


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Surgery_Schwartz. increases with prolonged antibiotic use, even a single dose of an antibiotic may cause the disease. Immunosup-pression, medical comorbidities, prolonged hospitalization or nursing home residence, and bowel surgery increase the risk.The pathogenic changes associated with C difficile colitis result from production of two toxins: toxin A (an enterotoxin) and toxin B (a cytotoxin). Diagnosis of this disease was tradition-ally made by culturing the organism from the stool. Detection of one or both toxins (either by cytotoxic assays or by immuno-assays) has proven to be more rapid, sensitive, and specific.156 The diagnosis may also be made endoscopically by detection of characteristic ulcers, plaques, and pseudomembranes.157Management should include immediate cessation of the offending antimicrobial agent. Patients with mild disease (diar-rhea but no fever or abdominal pain) may be treated as outpatients with a 10-day course of oral metronidazole. Oral vancomycin is a second-line agent used


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Surgery_Schwartz. agent. Patients with mild disease (diar-rhea but no fever or abdominal pain) may be treated as outpatients with a 10-day course of oral metronidazole. Oral vancomycin is a second-line agent used in patients allergic to metronidazole or in patients with recurrent disease. More severe diarrhea associ-ated with dehydration and/or fever and abdominal pain is best treated with bowel rest, intravenous hydration, and oral met-ronidazole or vancomycin. Proctosigmoiditis may respond to vancomycin enemas. Recurrent colitis occurs in up to 20% of patients and may be treated by a longer course of oral vanco-mycin (up to 1 month) or rifaximin (a rapamycin derivative). Reintroduction of normal flora by ingestion of probiotics or stool transplantation has been suggested as a possible treatment for recurrent or refractory disease. Fulminant colitis, characterized by septicemia and/or evidence of perforation, requires emergent laparotomy. A total abdominal colectomy with end ileostomy may be


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Surgery_Schwartz. for recurrent or refractory disease. Fulminant colitis, characterized by septicemia and/or evidence of perforation, requires emergent laparotomy. A total abdominal colectomy with end ileostomy may be lifesaving. Over the past decade, C difficile colitis has increased in prevalence, and new, more virulent strains have appeared, making this disease increasingly challenging to treat.157,158Other Infectious Colitides. A variety of other infections with bacteria, parasites, fungi, or viruses may cause colonic inflammation. Common bacterial infections include enterotoxic E coli, C jejuni, Yersinia enterocolitica, S typhi, Shigella, and N gonorrhoeae. Less commonly, Mycobacterium tuberculosis, M bovis, Actinomycosis israelii, or Treponema pallidum (syphi-lis) may cause colitis or proctitis. Parasitic infections such as amebiasis, cryptosporidiosis, and giardiasis are also relatively common. Fungal infections (Candida species, histoplasmosis) are extremely rare in otherwise healthy


Surgery_Schwartz

Surgery_Schwartz. Parasitic infections such as amebiasis, cryptosporidiosis, and giardiasis are also relatively common. Fungal infections (Candida species, histoplasmosis) are extremely rare in otherwise healthy individuals. The most common viral infections that produce colitic symptoms are HIV, herpes simplex viruses, and CMV.Most symptoms are nonspecific and consist of diarrhea (with or without bleeding), crampy abdominal pain, and mal-aise. A thorough history may offer clues to the etiology (other medical conditions, especially immunosuppression; recent travel or exposures; and ingestions). Diagnosis is usually made by identification of a pathogen in the stool, either by microscopy or culture. Serum immunoassays may also be useful (amebia-sis, HIV, CMV). Occasionally, endoscopy with biopsy may be required. Treatment is tailored to the infection.Brunicardi_Ch29_p1259-p1330.indd 130923/02/19 2:29 PM 1310SPECIFIC CONSIDERATIONSPART IIANORECTAL DISEASESAny patient with anal/perianal symptoms


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Surgery_Schwartz. required. Treatment is tailored to the infection.Brunicardi_Ch29_p1259-p1330.indd 130923/02/19 2:29 PM 1310SPECIFIC CONSIDERATIONSPART IIANORECTAL DISEASESAny patient with anal/perianal symptoms requires a careful his-tory and physical, including a digital rectal examination. Other studies such as defecography, manometry, CT scan, MRI, con-trast enema, endoscopy, endoanal ultrasound, or exam under anesthesia may be required to arrive at an accurate diagnosis.HemorrhoidsHemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth muscle fibers that are located in the anal canal (see Fig. 29-4). Three hemorrhoidal cushions are found in the left lateral, right anterior, and right poste-rior positions. Hemorrhoids are thought to function as part of the continence mechanism and aid in complete closure of the anal canal at rest. Because hemorrhoids are a normal part of anorectal anatomy, treatment is only indicated if they become symptom-atic. Excessive


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Surgery_Schwartz. mechanism and aid in complete closure of the anal canal at rest. Because hemorrhoids are a normal part of anorectal anatomy, treatment is only indicated if they become symptom-atic. Excessive straining, increased abdominal pressure, and hard stools increase venous engorgement of the hemorrhoidal plexus and cause prolapse of hemorrhoidal tissue. Bleeding, thrombo-sis, and symptomatic hemorrhoidal prolapse may result.External hemorrhoids are located distal to the dentate line and are covered with anoderm. Because the anoderm is richly innervated, thrombosis of an external hemorrhoid may cause significant pain. It is for this reason that external hemorrhoids should not be ligated or excised without adequate local anes-thetic. A skin tag is redundant fibrotic skin at the anal verge, often persisting as the residua of a thrombosed external hemor-rhoid. Skin tags are often confused with symptomatic hemor-rhoids. External hemorrhoids and skin tags may cause itching and difficulty with


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Surgery_Schwartz. persisting as the residua of a thrombosed external hemor-rhoid. Skin tags are often confused with symptomatic hemor-rhoids. External hemorrhoids and skin tags may cause itching and difficulty with hygiene if they are large. Treatment of exter-nal hemorrhoids and skin tags is only indicated for symptomatic relief.Internal hemorrhoids are located proximal to the dentate line and covered by insensate anorectal mucosa. Internal hem-orrhoids may prolapse or bleed, but they rarely become painful unless they develop thrombosis and necrosis (usually related to severe prolapse, incarceration, and/or strangulation). Inter-nal hemorrhoids are graded according to the extent of prolapse. First-degree hemorrhoids bulge into the anal canal and may prolapse beyond the dentate line on straining. Second-degree hemorrhoids prolapse through the anus but reduce spontane-ously. Third-degree hemorrhoids prolapse through the anal canal and require manual reduction. Fourth-degree hemorrhoids prolapse but


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Surgery_Schwartz. hemorrhoids prolapse through the anus but reduce spontane-ously. Third-degree hemorrhoids prolapse through the anal canal and require manual reduction. Fourth-degree hemorrhoids prolapse but cannot be reduced and are at risk for strangulation.Combined internal and external hemorrhoids straddle the dentate line and have characteristics of both internal and external hemorrhoids. Hemorrhoidectomy is often required for large, symptomatic, combined hemorrhoids. Postpartum hemorrhoids result from straining during labor, which results in edema, thrombosis, and/or strangulation. Hemorrhoidectomy is often the treatment of choice, especially if the patient has had chronic hemorrhoidal symptoms. Portal hypertension was long thought to increase the risk of hemorrhoidal bleeding because of the anastomoses between the portal venous system (middle and upper hemorrhoidal plexuses) and the systemic venous system (inferior rectal plexuses). It is now understood that hemorrhoidal disease is no more


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Surgery_Schwartz. between the portal venous system (middle and upper hemorrhoidal plexuses) and the systemic venous system (inferior rectal plexuses). It is now understood that hemorrhoidal disease is no more common in patients with portal hypertension than in the normal population. Rectal varices, however, may occur and may cause hemorrhage in these patients. In general, rectal varices are best treated by lowering portal venous pres-sure. Rarely, suture ligation may be necessary if massive bleed-ing persists. Surgical hemorrhoidectomy should be avoided in these patients because of the risk of massive, difficult-to-control variceal bleeding.Treatment Medical Therapy Bleeding from firstand second-degree hem-orrhoids often improves with the addition of dietary fiber, stool softeners, increased fluid intake, and avoidance of straining. Associated pruritus often may improve with improved hygiene. Many over-the-counter topical medications are desiccants and are relatively ineffective for treating


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Surgery_Schwartz. intake, and avoidance of straining. Associated pruritus often may improve with improved hygiene. Many over-the-counter topical medications are desiccants and are relatively ineffective for treating hemorrhoidal symptoms.Rubber Band Ligation Persistent bleeding from first-, sec-ond-, and selected third-degree hemorrhoids may be treated by rubber band ligation.Mucosa located 1 to 2 cm proximal to the dentate line is grasped and pulled into a rubber band applier. After firing the ligator, the rubber band strangulates the underlying tissue, causing scarring and preventing further bleeding or prolapse (Fig. 29-31). In general, only one or two quadrants are banded per visit. Severe pain will occur if the rubber band is placed at or distal to the dentate line where sensory nerves are located. Other complications of rubber band ligation include urinary retention, infection, and bleeding. Urinary retention occurs in approximately 1% of patients and is more likely if the ligation has


Surgery_Schwartz

Surgery_Schwartz. Other complications of rubber band ligation include urinary retention, infection, and bleeding. Urinary retention occurs in approximately 1% of patients and is more likely if the ligation has inadvertently included a portion of the internal sphincter. Necrotizing infection is an uncommon, but life-threatening complication. Severe pain, fever, and urinary retention are early signs of infection and should prompt immediate evaluation of the patient usually with an exam under anesthesia. Treatment includes debridement of necrotic tissue, drainage of associated abscesses, and broad-spectrum antibiotics. Bleeding may occur approximately 7 to 10 days after rubber band ligation, at the time when the ligated pedicle necroses and sloughs. Bleeding is usually self-limited, but persistent hemorrhage may require exam under anesthesia and suture ligation of the pedicle.Infrared Photocoagulation Infrared photocoagulation is an effective office treatment for small firstand second-degree hemorrhoids.


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Surgery_Schwartz. may require exam under anesthesia and suture ligation of the pedicle.Infrared Photocoagulation Infrared photocoagulation is an effective office treatment for small firstand second-degree hemorrhoids. The instrument is applied to the apex of each hem-orrhoid to coagulate the underlying plexus. All three quadrants may be treated during the same visit. Larger hemorrhoids and hemorrhoids with a significant amount of prolapse are not effec-tively treated with this technique.Sclerotherapy The injection of bleeding internal hemorrhoids with sclerosing agents is another effective office technique for treatment of first-, second-, and some third-degree hemorrhoids. One to 3 mL of a sclerosing solution (phenol in olive oil, sodium morrhuate, or quinine urea) is injected into the submucosa of each hemorrhoid. Few complications are associated with sclero-therapy, but infection and fibrosis have been reported.Excision of Thrombosed External Hemorrhoids Acutely thrombosed external hemorrhoids


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Surgery_Schwartz. hemorrhoid. Few complications are associated with sclero-therapy, but infection and fibrosis have been reported.Excision of Thrombosed External Hemorrhoids Acutely thrombosed external hemorrhoids generally cause intense pain and a palpable perianal mass during the first 24 to 72 hours after thrombosis. The thrombosis can be effectively treated with an elliptical excision performed in the office under local anesthe-sia. Because the clot is usually loculated, simple incision and drainage is rarely effective. After 72 hours, the clot begins to resorb, and the pain resolves spontaneously. Excision is unnec-essary, but sitz baths and analgesics are often helpful.Operative Hemorrhoidectomy A number of surgical proce-dures have been described for elective resection of symptomatic hemorrhoids. All are based on decreasing blood flow to the hem-orrhoidal plexuses and excising redundant anoderm and mucosa.9Brunicardi_Ch29_p1259-p1330.indd 131023/02/19 2:29 PM 1311COLON, RECTUM, AND


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Surgery_Schwartz. All are based on decreasing blood flow to the hem-orrhoidal plexuses and excising redundant anoderm and mucosa.9Brunicardi_Ch29_p1259-p1330.indd 131023/02/19 2:29 PM 1311COLON, RECTUM, AND ANUSCHAPTER 29Closed Submucosal Hemorrhoidectomy The Parks or Fer-guson hemorrhoidectomy involves resection of hemorrhoidal tissue and closure of the wounds with absorbable suture. The procedure may be performed in the prone or lithotomy position under local, regional, or general anesthesia. The anal canal is examined and an anal speculum inserted. The hemorrhoid cush-ions and associated redundant mucosa are identified and excised using an elliptical incision starting just distal to the anal verge and extending proximally to the anorectal ring. It is crucial to identify the fibers of the internal sphincter and carefully brush these away from the dissection in order to avoid injury to the sphincter. The apex of the hemorrhoidal plexus is then ligated and the hemorrhoid excised. The wound is then


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Surgery_Schwartz. and carefully brush these away from the dissection in order to avoid injury to the sphincter. The apex of the hemorrhoidal plexus is then ligated and the hemorrhoid excised. The wound is then closed with a running absorbable suture. All three hemorrhoidal cushions may be removed using this technique; however, care should be taken to avoid resecting a large area of perianal skin in order to avoid postoperative anal stenosis (Fig. 29-32).Open Hemorrhoidectomy This technique, often called the Milligan and Morgan hemorrhoidectomy, follows the same principles of excision described earlier, but the wounds are left open and allowed to heal by secondary intention.Whitehead’s Hemorrhoidectomy Whitehead’s hemorrhoid-ectomy involves circumferential excision of the hemorrhoidal cushions just proximal to the dentate line. After excision, the rectal mucosa is then advanced and sutured to the dentate line. While some surgeons still use Whitehead’s hemorrhoidectomy, most have abandoned this approach


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Surgery_Schwartz. to the dentate line. After excision, the rectal mucosa is then advanced and sutured to the dentate line. While some surgeons still use Whitehead’s hemorrhoidectomy, most have abandoned this approach because of the risk of ectro-pion (Whitehead’s deformity).Procedure for Prolapse and Hemorrhoids/Stapled Hemor-rhoidectomy Procedure for prolapse and hemorrhoids (PPH) is also referred to as a stapled hemorrhoidopexy. Best suited for patients with secondand third-degree hemorrhoids, this out-patient procedure uses a stapling device similar in appearance and mechanism of action to an end-to-end anastomotic (EEA) stapling device used for rectal surgery. Just as with an EEA sta-pler, proximal and distal tissue donuts, in this case consisting of mucosa and submucosa, are generated by the PPH stapler though the primary means by which this procedure provides relief for internal hemorrhoids is by pexying the redundant hemorrhoidal tissue, ligating the venules feeding the hemorrhoidal plexus and


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Surgery_Schwartz. though the primary means by which this procedure provides relief for internal hemorrhoids is by pexying the redundant hemorrhoidal tissue, ligating the venules feeding the hemorrhoidal plexus and fixing redundant mucosa proximal to the dentate line. Several studies suggest that this procedure is safe and effective, that it is associated with less postoperative pain and disability, and that it has an equivalent risk of postoperative complications when compared to excisional hemorrhoidectomy. Complications associated with this procedure include chronic anal pain, bac-teremia, rectovaginal fistula, formation of an obstructing rectal stricture and even rectal perforation. In at least one systematic review comparing outcomes between PPH and excisional hem-orrhoidectomy, overall incidence of complications was similar, ElasticbandsElasticbandsElasticbandsFigure 29-31. Rubber band ligation of internal hemorrhoids. The mucosa just proximal to the internal hemorrhoids is


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Surgery_Schwartz. overall incidence of complications was similar, ElasticbandsElasticbandsElasticbandsFigure 29-31. Rubber band ligation of internal hemorrhoids. The mucosa just proximal to the internal hemorrhoids is banded.Brunicardi_Ch29_p1259-p1330.indd 131123/02/19 2:29 PM 1312SPECIFIC CONSIDERATIONSPART IIthough the incidence of recurrent hemorrhoids was lower fol-lowing excisional hemorrhoidectomy.159,160Doppler-Guided Hemorrhoidal Artery Ligation Another recent approach to treating symptomatic hemorrhoids is Doppler-guided hemorrhoidal artery ligation (also called trans-anal hemorrhoidal dearterialization). In this procedure, a Dop-pler probe is used to identify the artery or arteries feeding the hemorrhoidal plexus. These vessels are then ligated. Early reports have shown promise, but long-term durability remains to be determined.161Complications of Hemorrhoidectomy. Postoperative pain following excisional hemorrhoidectomy requires analgesia usually with oral narcotics. Nonsteroidal


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Surgery_Schwartz. durability remains to be determined.161Complications of Hemorrhoidectomy. Postoperative pain following excisional hemorrhoidectomy requires analgesia usually with oral narcotics. Nonsteroidal anti-inflammatory drugs, muscle relaxants, topical analgesics, and comfort mea-sures, including sitz baths, are often useful as well. Urinary retention is a common complication following hemorrhoidec-tomy and has been reported to be as high as 10% to 50% in some series. The risk of urinary retention can be minimized by limiting intraoperative and perioperative intravenous flu-ids and by providing adequate analgesia. Pain can also lead to fecal impaction. Risk of impaction may be decreased by pre-operative enemas or a limited mechanical bowel preparation, liberal use of laxatives postoperatively, and adequate pain con-trol. While a small amount of bleeding, especially with bowel movements, is to be expected, massive hemorrhage can occur after hemorrhoidectomy. Bleeding may occur in the immediate


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Surgery_Schwartz. adequate pain con-trol. While a small amount of bleeding, especially with bowel movements, is to be expected, massive hemorrhage can occur after hemorrhoidectomy. Bleeding may occur in the immediate postoperative period (often in the recovery room) as a result of inadequate ligation of the vascular pedicle. This type of hemorrhage mandates an urgent return to the operating room where suture ligation of the bleeding vessel will often solve the problem. Bleeding may also occur 7 to 10 days after hemor-rhoidectomy when the necrotic mucosa overlying the vascular pedicle sloughs. While some of these patients may be safely observed, others will require an exam under anesthesia to ligate the bleeding vessel or to oversew the wounds if no specific site of bleeding is identified. Infection is uncommon after hemor-rhoidectomy; however, necrotizing soft tissue infection can occur with devastating consequences. Severe pain, fever, and urinary retention may be early signs of infection. If


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Surgery_Schwartz. is uncommon after hemor-rhoidectomy; however, necrotizing soft tissue infection can occur with devastating consequences. Severe pain, fever, and urinary retention may be early signs of infection. If infection is suspected, emergent examination under anesthesia, drainage of abscess, and/or debridement of all necrotic tissue are required.Long-term sequelae of hemorrhoidectomy include incon-tinence, anal stenosis, and ectropion (Whitehead’s deformity). Many patients experience transient incontinence to flatus, but these symptoms are usually short-lived, and few patients have ABCDEFFigure 29-32. Technique of closed submucosal hemorrhoidectomy. A. The patient is in prone jackknife position. B. A Fansler anoscope is used for exposure. C. A narrow ellipse of anoderm is excised. D. A submucosal dissection of the hemorrhoidal plexus from the underlying anal sphincter is performed. E. Redundant mucosa is anchored to the proximal anal canal, and the wound is closed with a running absorbable


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Surgery_Schwartz. dissection of the hemorrhoidal plexus from the underlying anal sphincter is performed. E. Redundant mucosa is anchored to the proximal anal canal, and the wound is closed with a running absorbable suture. F. Additional quadrants are excised to complete the procedure.Brunicardi_Ch29_p1259-p1330.indd 131223/02/19 2:29 PM 1313COLON, RECTUM, AND ANUSCHAPTER 29permanent fecal incontinence. Anal stenosis may result from scarring after extensive resection of perianal skin. Ectropion may occur after Whitehead’s hemorrhoidectomy.Anal FissureA fissure in ano is a tear in the anoderm distal to the dentate line. The pathophysiology of anal fissure is thought to be related to trauma from either the passage of hard stool or prolonged diarrhea. A tear in the anoderm causes spasm of the internal anal sphincter, which results in pain, increased tearing, and decreased blood supply to the anoderm. This cycle of pain, spasm, and ischemia contributes to development of a poorly healing wound that


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Surgery_Schwartz. anal sphincter, which results in pain, increased tearing, and decreased blood supply to the anoderm. This cycle of pain, spasm, and ischemia contributes to development of a poorly healing wound that becomes a chronic fissure. The vast major-ity of anal fissures occur in the posterior midline. Ten percent to 15% occur in the anterior midline. Less than 1% of fissures occur off midline.Symptoms and Findings. Anal fissure is extremely common. Characteristic symptoms include tearing pain with defecation and hematochezia (usually described as blood on the toilet paper). Patients may also complain of a sensation of intense and painful anal spasm lasting for several hours after a bowel move-ment. On physical examination, the fissure can often be seen in the anoderm by gently separating the buttocks. Patients are often too tender to tolerate digital rectal examination, anoscopy, or proctoscopy. An acute fissure is a superficial tear of the distal anoderm and almost always heals with medical


Surgery_Schwartz

Surgery_Schwartz. Patients are often too tender to tolerate digital rectal examination, anoscopy, or proctoscopy. An acute fissure is a superficial tear of the distal anoderm and almost always heals with medical management. Chronic fissures develop ulceration and heaped-up edges with the white fibers of the internal anal sphincter visible at the base of the ulcer. There often is an associated external skin tag and/or a hypertrophied anal papilla internally. These fissures are more challenging to treat and may require surgery. A lateral loca-tion of a chronic anal fissure may be evidence of an underlying disease such as Crohn’s disease, HIV, syphilis, tuberculosis, or leukemia. If the diagnosis is in doubt or there is suspicion of another cause for the perianal pain such as abscess or fistula, an examination under anesthesia may be necessary.Treatment. Therapy focuses on breaking the cycle of pain, spasm, and ischemia thought to be responsible for development of fissure in ano. First-line therapy to


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Surgery_Schwartz. under anesthesia may be necessary.Treatment. Therapy focuses on breaking the cycle of pain, spasm, and ischemia thought to be responsible for development of fissure in ano. First-line therapy to minimize anal trauma includes bulk agents, stool softeners, and warm sitz baths. The addition of 2% lidocaine jelly or other analgesic creams can provide additional symptomatic relief. Nitroglycerin ointment has been used locally to improve blood flow but often causes severe headaches. Both oral and topical calcium channel block-ers (diltiazem and nifedipine) have also been used to heal fis-sures and may have fewer side effects than topical nitrates.162 Newer agents, such as arginine (a nitric oxide donor) and topical bethanechol (a muscarinic agonist), have also been used to treat fissures. Medical therapy is effective in most acute fissures, but it will heal only approximately 50% of chronic fissures.162Botulinum toxin (Botox) causes temporary muscle paraly-sis by preventing acetylcholine


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Surgery_Schwartz. therapy is effective in most acute fissures, but it will heal only approximately 50% of chronic fissures.162Botulinum toxin (Botox) causes temporary muscle paraly-sis by preventing acetylcholine release from presynaptic nerve terminals. Injection of botulinum toxin is used in some centers as an alternative to surgical sphincterotomy for chronic fissure. Although there are few long-term complications from the use of botulinum toxin, healing appears to be equivalent to other medical therapies.163,164Surgical therapy has traditionally been recommended for chronic fissures that have failed medical therapy, and lateral internal sphincterotomy is the procedure of choice. The aim of this procedure is to decrease spasm of the internal sphincter by dividing a portion of the muscle. Approximately 30% of the internal sphincter fibers are divided laterally by using either an open (Fig. 29-33) or closed (Fig. 29-34) technique. Healing is achieved in more than 95% of patients using this technique,


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Surgery_Schwartz. of the internal sphincter fibers are divided laterally by using either an open (Fig. 29-33) or closed (Fig. 29-34) technique. Healing is achieved in more than 95% of patients using this technique, and most patients experience immediate pain relief. Recurrence occurs in less than 10% of patients, and the risk of incontinence (usually to flatus) ranges from 5% to 15%. Advancement flaps (VY) with or without sphincterotomy have also been reported to successfully treat chronic fissures.Anorectal Sepsis and Cryptoglandular AbscessRelevant Anatomy. The majority of anorectal suppurative disease results from infections of the anal glands (cryptoglan-dular infection) found in the intersphincteric plane. Their ducts traverse the internal sphincter and empty into the anal crypts at the level of the dentate line. Infection of an anal gland results in the formation of an abscess that enlarges and spreads along one of several planes in the perianal and perirectal spaces. The perianal space


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Surgery_Schwartz. of the dentate line. Infection of an anal gland results in the formation of an abscess that enlarges and spreads along one of several planes in the perianal and perirectal spaces. The perianal space surrounds the anus and laterally becomes con-tinuous with the fat of the buttocks. The intersphincteric space separates the internal and external anal sphincters. It is continu-ous with the perianal space distally and extends cephalad into the rectal wall. The ischiorectal space (ischiorectal fossa) is located lateral and posterior to the anus and is bounded medially by the external sphincter, laterally by the ischium, superiorly by the levator ani, and inferiorly by the transverse septum. The ischiorectal space contains the inferior rectal vessels and lym-phatics. The two ischiorectal spaces connect posteriorly above the anococcygeal ligament but below the levator ani muscle, forming the deep postanal space. The supralevator spaces lie above the levator ani on either side of the rectum


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Surgery_Schwartz. connect posteriorly above the anococcygeal ligament but below the levator ani muscle, forming the deep postanal space. The supralevator spaces lie above the levator ani on either side of the rectum and commu-nicate posteriorly. The anatomy of these spaces influences the location and spread of cryptoglandular infection (Fig. 29-35).As an abscess enlarges, it spreads in one of several direc-tions. A perianal abscess is the most common manifestation and appears as a painful swelling at the anal verge. Spread through the external sphincter below the level of the puborectalis pro-duces an ischiorectal abscess. These abscesses may become extremely large and may not be visible in the perianal region. ClosureInternal sphincterincisedExternalsphincter m.Internalsphincter m.FissureFissure-in-anoADCBFigure 29-33. A through D. Open lateral internal sphincterotomy for fissure in ano. m = muscle.Brunicardi_Ch29_p1259-p1330.indd 131323/02/19 2:29 PM 1314SPECIFIC CONSIDERATIONSPART IIDigital


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Surgery_Schwartz. 29-33. A through D. Open lateral internal sphincterotomy for fissure in ano. m = muscle.Brunicardi_Ch29_p1259-p1330.indd 131323/02/19 2:29 PM 1314SPECIFIC CONSIDERATIONSPART IIDigital rectal exam will reveal a painful swelling laterally in the ischiorectal fossa. Intersphincteric abscesses occur in the inter-sphincteric space and are notoriously difficult to diagnose, often requiring an examination under anesthesia. Pelvic and supralevator abscesses are uncommon and may result from extension of an intersphincteric or ischiorectal abscess upward or extension of an intraperitoneal abscess downward (Fig. 29-36).Diagnosis. Severe anal pain is the most common presenting complaint. A palpable mass is often detected by inspection of the perianal area or by digital rectal examination. Occasion-ally, patients will present with fever, urinary retention, or lifethreatening sepsis. The diagnosis of a perianal or ischiorectal abscess can usually be made with physical exam alone (either in the


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Surgery_Schwartz. patients will present with fever, urinary retention, or lifethreatening sepsis. The diagnosis of a perianal or ischiorectal abscess can usually be made with physical exam alone (either in the office or in the operating room). However, complex or atypical presentations may require imaging studies such as CT or MRI to fully delineate the anatomy of the abscess.Treatment. Anorectal abscesses should be treated by drain-age as soon as the diagnosis is established. If the diagnosis is in question, an examination and drainage under anesthesia are often the most expeditious ways both to confirm the diagnosis and to treat the problem. Delayed or inadequate treatment may occasionally cause extensive and life-threatening suppuration with massive tissue necrosis and septicemia. Antibiotics are only indicated if there is extensive overlying cellulitis or if the patient is immunocompromised, has diabetes mellitus, or has valvular heart disease. Antibiotics alone are ineffective at treat-ing


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Surgery_Schwartz. only indicated if there is extensive overlying cellulitis or if the patient is immunocompromised, has diabetes mellitus, or has valvular heart disease. Antibiotics alone are ineffective at treat-ing perianal or perirectal infection.Perianal AbscessMost perianal abscesses can be drained under local anesthesia in the office, clinic, or emergency department. Larger, more com-plicated abscesses may require drainage in the operating room. A skin incision is created, and a disk of skin excised to prevent premature closure. No packing is necessary, and sitz baths are started the next day (Fig. 29-37).Ischiorectal AbscessAn ischiorectal abscess causes diffuse swelling in the ischiorectal fossa that may involve one or both sides, forming a “horseshoe” abscess. Simple ischiorectal abscesses are drained through an incision in the overlying skin. Horseshoe abscesses require drainage of the deep postanal space and often require counterin-cisions over one or both ischiorectal spaces (Fig.


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Surgery_Schwartz. are drained through an incision in the overlying skin. Horseshoe abscesses require drainage of the deep postanal space and often require counterin-cisions over one or both ischiorectal spaces (Fig. 29-38).Intersphincteric AbscessIntersphincteric abscesses are notoriously difficult to diagnose because they produce little swelling and few perianal signs of infection. Pain is typically described as being deep and “up inside” the anal area and is usually exacerbated by coughing or sneezing. The pain is so intense that it usually precludes a digital rectal examination. The diagnosis is made based on a high index of suspicion and usually requires an examination Anal fissureSentinel pileADCBFigure 29-34. A through D. Closed lateral internal sphincterotomy for fissure in ano.Brunicardi_Ch29_p1259-p1330.indd 131423/02/19 2:29 PM 1315COLON, RECTUM, AND ANUSCHAPTER 29Levator ani m.Internal sphincter m.Puborectalis anddeep external sphincter m.Superficial externalsphincter


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Surgery_Schwartz. 131423/02/19 2:29 PM 1315COLON, RECTUM, AND ANUSCHAPTER 29Levator ani m.Internal sphincter m.Puborectalis anddeep external sphincter m.Superficial externalsphincter m.Subcutaneousexternal sphincter m.PeritoneumUreterSupralevator spaceIschiorectal spacePerianal spacePeritoneumRectorectal spaceRectosacral fasciaSupralevator spaceLevator ani m.Deep postanal spaceSuperficialpostanal spaceABFigure 29-35. Anatomy of perianorectal spaces. (A) Anterior view and (B) lateral view. m = muscle.Internalsphincter m.Perianal spaceabscessLevatorani m.Externalsphincter m.Longitudinal m.Pelvirectal spaceabscessIntersphincteric spaceabscessIschiorectal fossaabscessABFigure 29-36. A and B. Pathways of anorectal infection in perianal spaces. m = muscle.Brunicardi_Ch29_p1259-p1330.indd 131523/02/19 2:29 PM 1316SPECIFIC CONSIDERATIONSPART IIunder anesthesia. Once identified, an intersphincteric abscess can be drained through a limited, usually posterior, internal sphincterotomy.Supralevator


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Surgery_Schwartz. 2:29 PM 1316SPECIFIC CONSIDERATIONSPART IIunder anesthesia. Once identified, an intersphincteric abscess can be drained through a limited, usually posterior, internal sphincterotomy.Supralevator AbscessThis type of abscess is uncommon and can be difficult to diag-nose. Because of its proximity to the peritoneal cavity, supral-evator abscesses can mimic intra-abdominal conditions. Digital rectal examination may reveal an indurated, bulging mass above the anorectal ring. It is essential to identify the origin of a supralevator abscess prior to treatment. If the abscess is sec-ondary to an upward extension of an intersphincteric abscess, it should be drained through the rectum. If it is drained through the ischiorectal fossa, a complicated, suprasphincteric fistula may result. If a supralevator abscess arises from the upward extension of an ischiorectal abscess, it should be drained through the ischiorectal fossa. Drainage of this type of abscess through the rectum may result in an


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Surgery_Schwartz. abscess arises from the upward extension of an ischiorectal abscess, it should be drained through the ischiorectal fossa. Drainage of this type of abscess through the rectum may result in an extrasphincteric fistula. If the abscess is secondary to intra-abdominal disease, the pri-mary process requires treatment and the abscess is drained via the most direct route (transabdominally, rectally, or through the ischiorectal fossa).Perianal Sepsis in the Immunocompromised PatientThe immunocompromised patient with perianal pain presents a diagnostic dilemma. Because of leukopenia, these patients may develop serious perianal infection without any of the cardinal signs of inflammation. While broad-spectrum antibiotics may cure some of these patients, an exam under anesthesia should not be delayed because of neutropenia. An increase in pain or fever and/or clinical deterioration mandates an exam under anesthesia. Any indurated area should be incised and drained, biopsied to exclude a leukemic


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Surgery_Schwartz. because of neutropenia. An increase in pain or fever and/or clinical deterioration mandates an exam under anesthesia. Any indurated area should be incised and drained, biopsied to exclude a leukemic infiltrate, and cultured to aid in the selection of antimicrobial agents.165Necrotizing Soft Tissue Infection of the PerineumNecrotizing soft tissue infection of the perineum is a rare, but lethal, condition. Most of these infections are polymicrobial and synergistic. The source of sepsis is commonly an undrained or inadequately drained cryptoglandular abscess or a urogenital infection. Occasionally, these infections may be encountered postoperatively (e.g., after hemorrhoidectomy). Immunocom-promised patients and diabetic patients are at increased risk.Physical examination may reveal necrotic skin, bullae, or crepitus. Patients often have signs of systemic toxicity and may be hemodynamically unstable. A high index of suspicion is necessary because perineal signs of severe infection may be


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Surgery_Schwartz. skin, bullae, or crepitus. Patients often have signs of systemic toxicity and may be hemodynamically unstable. A high index of suspicion is necessary because perineal signs of severe infection may be minimal and prompt surgical intervention can be lifesaving.Surgical debridement of all nonviable tissue is required to treat all necrotizing soft tissue infections. Multiple operations may be necessary to ensure that all necrotic tissue has been resected. Broad-spectrum antibiotics are frequently employed, but adequate surgical debridement remains the mainstay of ther-apy. Colostomy may be required if extensive resection of the sphincter is required or if stool contamination of the perineum makes wound management difficult. Despite early recognition and adequate surgical therapy, the mortality of necrotizing peri-neal soft tissue infections remains approximately 50%.ABCFigure 29-37. A through C. Technique of drainage of perianal abscess.Figure 29-38. Drainage of horseshoe abscess. The