Improved Outcomes in

Colon and
Rectal Surgery

Edited by
Charles B Whitlow
David E Beck
David A Margolin
Terry C Hicks
Alan E Timmcke
Improved Outcomes in Colon
and Rectal Surgery

Edited by
Charles B Whitlow MD
Program Director
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA

David E Beck MD
Chairman
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA

David A Margolin MD
Research Director
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA

Terry C Hicks MD
Associate Chairman
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA

Alan E Timmcke MD
Staff Surgeon
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
© 2010 Informa UK
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Contents

List of Contributors v
Preface ix
Foreword xi
  1 Preexisting conditions 1
Eric L Marderstein, Siyamek Neragi-Miandoab, and Conor P Delaney
  2 Preoperative bowel preparation 14
David A Margolin and Sean Mayfield
  3 Anesthesia and intraoperative positioning 19
Lebron Cooper and Larry R Hutson
  4 Sepsis 27
Steven Mills and Michael J Stamos
  5 Intraoperative anastomotic challenges 33
David E Beck
  6 Other intraoperative challenges 44
James T McCormick and Sharon G Gregorcyk
  7 Postoperative anastomotic complications 56
Daniel L Feingold
  8 General postoperative complications 67
Scott R Steele and Clifford L Simmang
  9 Care paths and optimal postop management 79
Surya P M Nalamati and Eric J Szilagy
10 Limitations of anorectal physiology testing 87
Thomas E Cataldo and Syed G Husain
11 Limitations of colorectal imaging studies 97
Travis J Blanchard, Wilson B Altmeyer, and Charles C Matthews
12 Transanal endoscopy 132
Terry C Hicks
13 Laparoscopic colorectal surgery 140
James W Fleshman and Jonathan S Chun
14 Medical legal issues 148
Charles F Gay Jr and Terry C Hicks
15 Miscellanous conditions 154
M Benjamin Hopkins and Alan E Timmcke
16 Quality and outcome measures 159
Janak A Parikh, Sushma Jain, Marcia L McGory, and Clifford Y Ko
17 Hemorrhoidal surgery 168
Dan R Metcalf and Anthony J Senagore
18 Nonoperative therapy for hemorrhoid disease 178
Kerry Hammond and Charles B Whitlow


 contents

19 Surgery and nonoperative therapy of perirectal abscesses and anal fistulas 183
Brian R Kann and Charles B Whitlow
20 Surgery and nonoperative therapy of anal fissure 199
Jaime L Bohl and Alan J Herline
21 Surgery for pilonidal disease and hidradenitis suppurativa 215
Paula I Denoya and Eric G Weiss
22 Surgical treatment of fecal incontinence 226
Ann C Lowry and Dimitrios Christoforidis
23 Surgery for rectal prolapse 239
Steven R Hunt
24 Operative and nonoperative therapy for diverticular disease 249
R Scott Nelson and Alan G Thorson
25 Abdominal surgery for colorectal cancer 263
Jason Hall and Rocco Ricciardi
26 Transanal approaches to rectal cancer 271
Sachin S Kukreja and Theodore J Saclarides
27 Abdominoperineal resection 278
W Brian Perry, Fia Yi, Clarence Clark, and Danny Kim
28 Indications and outcomes for treatment of recurrent rectal cancer and colorectal
liver and lung metastasis 286
Harry L Reynolds Jr, Christopher T Siegel, and Jason Robke
29 Chemotherapy for colon and rectal cancer 300
Liliana Bordeianou and Judith L Trudel
30 Radiation therapy: Acute and late toxicity 306
Roland Hawkins
31 Surgery for ulcerative colitis 318
Patricia L Roberts
32 Surgery for Crohn’s disease 331
Jorge Canedo, Tolga Erim, and Steven D Wexner
33 Ostomies 349
Vance Y Sohn and Scott R Steele
34 Operative and nonoperative therapy for chronic constipation 361
Harry T Papaconstantinou
35 Colorectal trauma 375
S David Cho, Sharon L Wright, and Martin A Schreiber
36 Urologic complications of colorectal surgery 395
Scott Delacroix Jr and J Christian Winters
Index 405
List of Contributors

Wilson B Altmeyer MD Dimitrios Christoforidis MD

Department of Radiology Department of Visceral Surgery,
Ochsner Clinic Foundation CHUV-University of Lausanne
New Orleans, Louisiana Lausanne, Switzerland
USA
Jonathan S Chun MD
David E Beck MD Section of Colon and Rectal Surgery
Colon and Rectal Surgery Washington University School of Medicine
Ochsner Clinic Foundation St Louis, Missouri
New Orleans, Louisiana USA
USA
Clarence Clark MD
Department of General Surgery
Travis J Blanchard md
Wilford Hall Medical Center and the University of Texas Health
Department of Radiology
Science Center, San Antonio
Ochsner Clinic Foundation
Lackland AFB, Texas
New Orleans, Louisiana
USA
USA
Lebron Cooper MD
Jaime L Bohl MD Department of Anesthiology
Department of Surgery Ochsner Clinic Foundation
Vanderbilt University New Orleans, Louisiana
Nashville, Tennessee USA
USA
Scott E Delacroix, Jr., MD
Liliana Bordeianou MD Department of Urology
Department of Surgery Louisiana State University Health Sciences Center
Division of General and Gastrointestinal Surgery New Orleans, Louisiana
Massachusetts General Hospital University of Texas, MD Anderson Cancer Center
Boston, Massachusetts Houston, Texas
USA USA

Jorge Canedo MD Conor P Delaney MD MCh PhD

Department of Colorectal Surgery Department of Surgery
Cleveland Clinic Florida Division of Colorectal Surgery
Weston, Florida University Hospitals Case Medical Center
USA Cleveland, Ohio
USA
Thomas E Cataldo MD
Warren Alpert Medical School of Brown University Paula I Denoya MD
Brown Program in Colon and Rectal Surgery Department of Colorectal Surgery
Rhode Island Hospital/Lifespan Health System Cleveland Clinic Florida
Providence, Rhode Island Weston, Florida
USA USA

S David Cho MD Tolga Erim MD

Department of Surgery Department of Colorectal Surgery
Oregon Health and Science University Cleveland Clinic Florida
Portland, Oregon Weston, Florida
USA USA

 list of contributors

Daniel L Feingold MD Steven R Hunt MD

Section of Colorectal Surgery Colon and Rectal Surgery Section
Columbia University Division of General Surgery
New York, New York Washington University
USA St. Louis, Missouri
USA
James W Fleshman MD
Section of Colon and Rectal Surgery Syed G Husain MD
Washington University School of Medicine Brown Program in Colon and Rectal Surgery
St Louis, Missouri Warren Alpert Medical School of Brown University
USA Rhode Island Hospital/Lifespan Health System
Providence, Rhode Island
Charles F Gay Jr USA
Adams and Reeds Attorneys and Counselors at Law
New Orleans, Louisiana Larry R Hutson MD
USA Department of Anesthiology
Ochsner Clinic Foundation
Sharon G Gregorcyk MD New Orleans, Louisiana
Texas Colon and Rectal Specialists USA
Dallas, Texas
USA Sushma Jain MBBS MPH
David Geffen School of Medicine at UCLA
Jason Hall MD Department of Surgery
Department of Colon and Rectal Surgery Los Angeles, California
Lahey Clinic USA
Tufts University
Burlington, Massachusetts Brian R Kann MD
USA Cooper University Hospital
UMDNJ-Robert Wood Johnson Medical School-Camden
Roland Hawkins MD Department of Surgery
Radiation Oncology Camden, New Jersey
Ochsner Cancer Institute USA
New Orleans, Louisiana
USA Danny Kim MD
Department of General Surgery
Kerry Hammond MD Wilford Hall Medical Center and the University of Texas Health
Division of General Surgery Science Center, San Antonio
Medical University of South Carolina Lackland AFB, Texas
Charleston, South Carolina USA
USA
Clifford Y Ko MD MS MSHS
Alan J Herline MD David Geffen School of Medicine at UCLA
Department of Surgery Department of Surgery
Vanderbilt University Los Angeles, California
Nashville, Tennessee USA
USA
Sachin S Kukreja MD
Terry C Hicks MD Section of Colon and Rectal Surgery
Colon and Rectal Surgery Department of General Surgery
Ochsner Clinic Foundation Rush University Medical Center
New Orleans, Louisiana Chicago, Illinois
USA USA

M Benjamin Hopkins MD Ann C Lowry MD

Department of Colon and Rectal Surgery Colon & Rectal Surgery Associates Ltd
Ochsner Clinic Foundation St Paul, Minnesota
New Orleans, Louisiana USA
USA


 list of contributors

James T McCormick DO R Scott Nelson DO

Department of Surgery Colon & Rectal Surgery, Inc
Division of Colon and Rectal Surgery Omaha, Nebraska
Western Pennsylvania Hospital and the Forbes Regional Campus USA
Temple University School of Medicine
Philadelphia, Pennsylvania Siyamek Neragi-Miandoab MD
USA Division of Colorectal Surgery,
Department of Surgery,
Marcia L McGory MD PhD University Hospitals Case Medical Center,
David Geffen School of Medicine at UCLA Cleveland, Ohio
Department of Surgery USA
Los Angeles, California
USA Harry T Papaconstantinou MD
Department of Surgery
Eric L Marderstein MD MPH Scott & White Hospital and Clinic
Division of Colorectal Surgery, Texas A&M University System Health Science Center
Department of Surgery, Temple, Texas
University Hospitals Case Medical Center, USA
Cleveland, Ohio
USA Janak A Parikh MD
David Geffen School of Medicine at UCLA
David A Margolin MD Department of Surgery
Colon and Rectal Surgery Los Angeles, California
The Ochsner Clinic Foundation USA
New Orleans, Louisiana
USA W Brian Perry MD
Department of General Surgery
Charles C Matthews MD Wilford Hall Medical Center and the University
Department of Radiology of Texas Health Science Center, San Antonio
Ochsner Clinic Foundation Lackland AFB, Texas
New Orleans, Louisiana USA
USA
Harry L Reynolds Jr MD
Sean Mayfield MD University Hospital of Cleveland
Colon and Rectal Surgery Cleveland, Ohio
The Ochsner Clinic Foundation USA
New Orleans, Louisiana
USA Rocco Ricciardi MD MPH
Department of Colon and Rectal Surgery
Dan R Metcalf MD Lahey Clinic
SMDC Health System Tufts University
Department of Surgery Burlington, Massachusetts
Duluth, Minnesota USA
USA
Patricia L Roberts MD
Steven Mills MD Department of Colon and Rectal Surgery
University of California Lahey Clinic Medical Center
Irvine, California Burlington, and
USA Tufts University School of Medicine
Boston, Massachusetts
Surya PM Nalamati USA
Division of Colon and Rectal Surgery
Henry Ford Health System J Robke MD
Department of Surgery/Colon & Rectal Group University Hospital of Cleveland
Detroit, Michigan Cleveland, Ohio
USA USA


 list of contributors

Theodore J Saclarides MD Alan E Timmcke MD

Section of Colon and Rectal Surgery Colon and Rectal Surgery
Department of General Surgery Ochsner Clinic Foundation
Rush University Medical Center New Orleans, Louisiana
Chicago, Illinois USA
USA
Judith L Trudel MD, MSc, MHPE
Martin A Schreiber MD University of Minnesota
Division of Trauma and Critical Care St Paul, Minnesota
Oregon Health and Science University USA
Portland, Oregon
USA Eric G Weiss MD
Department of Colorectal Surgery
Christopher T Siegel MD Cleveland Clinic Florida
University Hospital of Cleveland Weston, Florida
Cleveland, Ohio USA
USA
Steven D Wexner MD
Anthony J Senagore MD MS MBA Department of Colorectal Surgery
Spectrum Health System Ohio State University and
Grand Rapids, Michigan Department of Surgery, Division of General Surgery
USA University of South Florida College of Medicine
Cleveland Clinic Florida
Clifford L Simmang MD Weston, Florida
Texas Colon and Rectal Surgeons USA
Dallas, Texas
USA Charles B Whitlow MD
Colon and Rectal Surgery
Vance Y Sohn MD Ochsner Clinic Foundation
Department of Surgery New Orleans, Louisiana
Madigan Army Medical Center USA
Tacoma, Washington
USA J Christian Winters MD FACS
Department of Urology
Michael J Stamos MD Female Pelvic Medicine and Reconstructive Surgery
University of California Louisiana State University Health Sciences Center
Irvine, California New Orleans, Louisiana
USA USA

Scott R Steele MD Sharon L Wright MD

Department of Surgery Department of Surgery
Madigan Army Medical Center Oregon Health and Science University
Tacoma, Washington Portland, Oregon
USA USA

Eric J Szilagy MD Fia Yi MD

Department of Surgery/Colon & Rectal Group Department of General Surgery
Division of Colon and Rectal Surgery Wilford Hall Medical Center and the University of Texas Health
Henry Ford Health System Science Center, San Antonio
Detroit, Michigan Lackland AFB, Texas
USA USA

Alan G Thorson MD
Colon & Rectal Surgery, Inc
Omaha, Nebraska
USA


Preface
Quality measures and outcomes are receiving greater attention
by the lay and medical communities. The occurrence or mis­
management of complications often results in poor outcomes,
increased cost, and significant morbidity. Answering the call for
transparency and improvement requires action by all involved
in the care of patients. Collection of objective data and quality
measures allows documentation of optimal care and desired out­
comes while identifying areas for improvement.
The goal of this text is to present the current knowledge of
outcomes, as well as the techniques for minimizing and managing
complications from the common diseases and procedures of this
specialty. This information will aid providers in optimizing care
and encourage research in outcome and quality measurement.
Improved Outcomes of Colon and Rectal Surgery represents
the collaborative efforts of many individuals. The contributing
authors were selected for their knowledge of colorectal surgery and
ability to present their surgical judgment and experience in written
form. They represent a spectrum of experienced providers who
have made significant contributions to younger individuals who
will shape the future of their specialty. In addition to reviewing the
available literature, they have described their personal approach
to complications in colorectal surgery. Numerous technical
descriptions and highlights from multiple discussions held in
surgical locker rooms, morbidity and mortality conferences, and
the hallways of conferences and symposiums have been included.
Using this approach, we hope this text will provide initial guidance
to the less experienced provider and stimulate additional thought
and research to the more experienced provider.
The editors gratefully acknowledge the efforts of the many
individuals who made this book possible. This text carries on
the vision of previous editors and contributors to the first two
editions of Complications in Colon and Rectal Surgery.
Charles B Whitlow, MD
David E Beck, MD
David A Margolin, MD
Terry C Hicks, MD
Alan E Timmcke, MD

Foreword
In Improved Outcomes in Colon and Rectal Surgery, Drs.
Whitlow, Beck, Margolin, Hicks, and Timmcke have assembled
a knowledgeable, expert, and distinguished group of contribu-
tors who additionally have flavored their contributions with their
practical experience and “how I do it” approaches. This volume
is the third in a series dealing with improving outcomes, avoid-
ing complications, and in general improving the lot of patients
who require surgery for conditions of the large bowel, rectum,
and anus.
The stated objective of guiding less experienced surgeons in
avoiding the pitfalls of both commonly encountered complica-
tions and those of rarer occurrence is well met in this volume. It
should be in the library of all neophyte surgeons and deserves to
be read even by experienced practitioners.
The field of colon and rectal surgery is a dynamic one with endo-
scopic and open surgery procedures at a mature stage. With con-
stantly improving laparoscopic techniques, robotic surgery and other
modalities only dreamed about in the past requiring every surgeon
to continue to learn and improve this book fills a visible need.
I congratulate the editors and contributors for assembling an
extremely useable and timely text.
J Byron Gathright, Jr. MD
Chairman Emeritus
Department of Colon and Rectal Surgery
Ochsner Clinic
New Orleans, Louisiana
USA

1 Preexisting conditions
Eric L Marderstein, Siyamek Neragi-Miandoab, and Conor P Delaney
challenging case
A 65-year-old hypertensive male smoker requires a low anterior
resection for treatment of an upper rectal cancer. A CT scan of
the chest, abdomen, and pelvis does not show any distant meta-
static spread and his carcinoembryonic antigen is normal. What
additional preoperative laboratory studies and adjunctive testing
are indicated?
case management
A complete history and physical examination is perhaps the
single most important step for guiding preoperative prepa-
ration. If a cardiac review of systems indicates no symptoms
of ischemia at a high workload, and an electrocardiogram is
­normal then no further cardiac testing is necessary. A complete
blood count is indicated because the underlying disease can
cause anemia and serum chemistries are indicated because of
the patient’s hypertension. Although routine laboratory test-
ing is not indicated for most procedures, for patients older
than 60 due to undergo major surgery, they are reasonable in
many situations. If there is no suggestion of bleeding abnor-
malities or liver disease on history and physical examination
then coagulation studies are not required. Pulmonary function
testing, unless the patient has significant pulmonary-attribut-
able shortness of breath or extreme oxygen dependence, is not
necessary. The patient should be counseled to stop smoking
because it may prevent postoperative pulmonary complica-
tions, although several weeks of smoking cessation is required
to obtain measurable benefit.
introduction
Part of the attraction of colorectal surgery is the diversity of dis-
eases, patients, and procedures that the surgeon sees on a routine
basis. On one day a surgeon can perform several small outpatient
anorectal procedures on relatively healthy patients, followed the
next day by several major complex intraabdominal operations on
frail elderly patient with significant comorbidities. Such variety
underscores the importance of the preoperative evaluation in
identifying preexisting medical conditions and determining their
effect of the proposed procedure. Knowledge of how preexisting
medical conditions can result in certain patterns of postoperative
complications helps to guide the preoperative evaluation. This
chapter’s recommendations regarding laboratory investigation
and additional testing are, when possible, based on published
evidence of their clinical efficacy and cost-effectiveness. As a
general rule, ordering a myriad of specialized tests or routine
laboratory batteries is expensive and provides low yield. Instead,
testing is designed to quantify the magnitude of the preexisting
medical conditions so they can be optimized in the pre-, intra-
and postoperative period to maximize the chance of a successful
outcome.
history and physical examination
A thorough history includes past and current medical and ­surgical
history, medications, allergies, family history, functional ­history,
and review of systems. History and physical examination are
generally more important than laboratory data in the develop-
ment of a treatment plan for anesthesia. Young healthy patients
with an unremarkable history and examination may not need any
anesthesia evaluation for moderate size procedures. The overall
risk of surgery is extremely low in healthy individuals and no
additional benefit is gained from more complex evaluations.(1)
If major surgery is planned, or if patients are elderly or have high
levels of comorbidity, a preoperative anesthesia consult is war-
ranted and appropriately required at many institutions. While the
surgeon needs to play an active role in preoperative risk assess-
ment, it is often very helpful to have an anesthesia consultation
to evaluate the patient solely from the standpoint of surgical risk.
Coordination and cooperation between surgeons and anesthe-
siologist is essential to avoid unnecessary delays and surprises
before the surgery. A patient self-administered questionnaire on
the complexity of their past medical history can act as an effective
primary screening tool to stratify patients for further assessment
before surgery.(2) Evaluation is performed with a combination
of history, physical examination, and selected investigations. In
a large prospective clinical-epidemiological study, Arvidsson and
colleagues found that a standardized assessment before surgery,
by a combination of questionnaires, interview, physical exami-
nation, and selected laboratory testing identified a high propor-
tion of patients who were likely to suffer an adverse event in the
­postoperative period.(3)
preoperative tests
Thorough preoperative assessment of patients can minimize
or prevent postoperative complications.(4) Selective labora-
tory studies can be useful, but routine laboratory tests are often
unnecessary.(5, 6) Ordering a battery of routine preoperative
laboratory studies leads to inefficient clinical practice and is not
cost-effective.(7). In one large study, only 0.22% of routine pre-
operative laboratory studies revealed abnormalities that might
influence peroperative management.(8) Tests ordered in screen-
ing panels are frequently not acted upon before surgery, thereby
creating additional medicolegal risk.(8) When laboratory tests are
felt to be necessary, it is probably safe to use test results that were
performed and were normal within the past 4 months as preop-
erative tests unless there has been an interim change in clinical
status. Anemia is present in approximately 1% of asymptomatic
patients.(8) However, anemia is common following major sur-
gery and the preoperative hemoglobin level predicts postopera-
tive mortality.(9) A baseline hemoglobin level in patients who are
undergoing major surgery that is expected to result in significant
blood loss is useful in postoperative management to differentiate

 improved outcomes in colon and rectal surgery

between acute or chronic blood loss. The frequency of significant
unsuspected white blood cell or platelet abnormalities is also low.
(10) Unexpected electrolyte abnormalities are uncommon and
routine electrolyte determinations are not recommended unless
the patient has a history that increases the likelihood of an abnor-
mality.(8) Premenopausal females at risk should undergo a urine
or blood test for beta-HCG to determine if they are pregnant so
that appropriate precautions are taken during surgery if still indi-
cated. This practice is codified at many institutions to improve
safety and reduce medical liability. Nonetheless, it is all too com-
mon for a lapse in obtaining a pregnancy test to result in a lengthy
delay in the start of ­surgery. Routine urinalysis to detect disease
(proteinuria, glucosuria, bacteruria), however, is not indicated.
preoperative risk assessment using
scoring systems
Scoring systems assess the patients’ risk for morbidity and mor-
tality taking into account the kind of planned surgical procedure
and the type of anesthesia.(11) These systems generally use data
acquired during prehospital and in-hospital care, while inclu-
sion of the severity of the planned procedure might improve the
predictive value of these systems.(12, 13) Others have tried to
predict the risk anecdotally, suggesting that a surgeon’s general
feeling and personal experience are a good indicator of subse-
quent outcome.(14) Scoring systems can be helpful in coun-
seling the patient and setting their expectations preoperatively
beyond clinical intuition. In addition, well-constructed scoring
systems can be used to compare hospitals and surgeons while
controlling for the known influence of preoperative risk factors
for poor outcome.(15)
American Society of Anesthesiologists (ASA) Classification
The ASA classification system (Table 1.1) has been developed by
anesthesiologists to evaluate patients’ preexisting morbidities
and operative risk. The system is easy to use and is based on his-
tory, physical examination, and the physician’s experience and
it requires no tests.(16, 17) ASA class has been shown to corre-
late with perioperative mortality and morbidity, as well as with
perioperative variables such as intraoperative blood loss, dura-
tion of postoperative ventilation, and duration of intensive care
unit stay.(18–20) The severity of operative ­procedure, higher
ASA class, symptoms of respiratory disease and malignancy
are ­predictive of postoperative morbidity.(13) Disadvantages
to use of the ASA score is that its accuracy depends on the
subjective clinical ­judgment and experience of the attending
anesthesiologist.
POSSUM (Physiologic and Operative Severity Score for
enUmeration of Mortality and morbidity)
POSSUM was developed through multivariate analysis prima-
rily to permit surgical audit for assessment of quality of care.(21)
It calculates expected death and expected morbidity rates based
on 12 physiological variables and six operative variables each of
which are scored 1, 2, 4, or 8 (Table 1.2).(22) POSSUM was devel-
oped as a scoring system for audit, so other factors may need to be
considered when using POSSUM for risk assessment of patients
for surgery.
One concern with POSSUM has been that it may over predict
mortality and morbidity rates by up to six times with a mini-
mum mortality of 1.1%. POSSUM was modified by Portsmouth
to P-POSSUM using a different calculation to reduce the over-
prediciting bias.(23) While some studies found that both
scoring systems overpredicted mortality rates for vascular sur-
gery patients (24, 25), others found that P-POSSUM was a bet-
ter predictor of mortality and morbidity than POSSUM for
vascular (26) gastrointestinal surgery (27), and laparoscopic
colorectal surgery (28).
The CR-POSSUM (Table 1.3) was a modification of POSSUM
designed to assess risk of colorectal procedures. A retrospec-
tive multivariate analysis was performed on more than 6,000
patients operated on in the United Kingdom between 1993 and
2001.(29) The overall mortality for the series was 5.7% and the
CR-POSSUM was more accurate than POSSUM in their valida-
tion patient set. The advent of laparoscopic colorectal proce-
dures may result in CR-POSSUM also overestimating mortality.
A recent report noted that CR-POSSUM overestimated mor-
tality in patients undergoing laparoscopic colectomy, but
accurately predicted mortality in the subset of patients requir-
ing conversion.(30) When these ­scoring systems were applied
Table 1.2  Parameters for calculation of the POSSUM score.
Physiological Parameters Operative Parameters
Age (years) Operative severity
Cardiac signs/chest x-ray Multiple procedures
Respiratory signs/chest x-ray Total blood loss (ml)
Pulse rate Peritoneal soiling
Systolic blood pressure (mm Hg) Presence of malignancy
Glasgow Coma Score Mode of surgery
Hemoglobin (g/dl)
White cell count (×1012/l)
Urea concentration (mmol/l)
Na+ and K+ levels (mmol/l)
Electrocardiogram

Table 1.1  American Society of Anesthesia (ASA) classification

scheme. Table 1.3  Parameters for calculation of the CR-POSSUM score.
Physiological Parameters Operative Parameters
I Normal healthy patient
II Mild systemic disease Age (years) Operative severity
III Severe, noncapacitating systemic disease Cardiac signs/ chest x-ray Urgency of surgery
IV Incapacitating systemic disease, threatening life Pulse rate Peritoneal soiling
V Moribund, not expected to survive 24 hours Systolic blood pressure (mm Hg) Presence of malignancy
‘E’ Emergency Urea concentration (mmol/l) Hemoglobin (g/dl)


 preexisting conditions
to data from a series of U.S. hospitals; the CR-POSSUM was
the most accurate variant, but overestimated mortality by more
than twofold.(31)
National Surgery Quality Improvement Project (NSQIP)
NSQIP was initially started as a way to measure quality of surgical
care at Veteran’s Administration hospitals but the methodology
has spread to the private sector and is embraced by the American
College of Surgeons (ACS-NSQIP). It is a nationally validated,
risk-adjusted, outcomes-based program to measure and improve
the quality of surgical care.(32) The program employs a pro-
spective, peer-controlled, validated database to quantify 30-day
­risk-adjusted surgical outcomes, which allows valid comparison of
outcomes among all hospitals in the program. Participating hos-
pitals and their surgical staff are provided with the tools, reports,
analysis, and support necessary to make informed decisions about
improving quality of care. A key lesson from NSQIP was deter-
mining what key preoperative variables influence morbidity and
mortality. By risk-adjusting the outcomes, morbidity and mortal-
ity can be compared between hospitals without the common argu-
ment “my patients are sicker.” The initial studies were performed
on huge numbers of patients with multivariate analysis ranking
certain preoperative conditions/variables as particularly influen-
tial on postoperative complications and mortality. Albumin, ASA
class, disseminated cancer, emergency surgery, age, blood urea
nitrogen, functional status, weight loss, and “do not resuscitate”
order are consistently the most important variables in the analysis.
(33) The program was initially validated using a range of surgi-
cal procedures, but subsequent publications have used the same
methodology to study particular types of operations. For example,
complications and mortality after colectomy for colorectal cancer
depends on identical preoperative variables as the initial validation
set.(34) The program is well respected because a great emphasis
is placed on data integrity and follow-up to identify preoperative
and postoperative events.
documentation
As an increased emphasis is placed on tracking and report-
ing of complications it is critically important to the surgeon
to document well. For risk-adjusted complications to be valid,
preoperative comorbidities must be identified and noted in the
medical record. Without this, the surgeon will not have justi-
fication for elevated complication rates based on preoperative
illness. This will become more important as DRG classification,
and therefore institutional technical reimbursement, becomes
dependent on diagnosis documented at the time of admission
in the near future.
cardiovascular disease
Perioperative cardiac complications are among the most feared
of surgical complications because they can result in death. Their
severity spans a wide range from asymptomatic increase in car-
diac enzymes to fatal massive myocardial infarctions. The goal of
preoperative cardiac evaluation is to quantify the likelihood of
a perioperative cardiac event taking into account patient factors
and the proposed operative procedure. The concept of “cardiac
clearance” is flawed and should not be used. In reality, a patient
with a very low cardiac risk is not immune to perioperative cardiac
events and a patient with known severe coronary artery disease
is by no means guaranteed to have a fatal myocardial infarction.
Even in the highest risk patients undergoing complex vascular
surgery, the risk of postoperative cardiac events is only 34%.(35)
The risk of the proposed procedure must be weighed against the
proposed benefit and urgency to be derived from the operation to
permit the surgeon and patient decide about the appropriateness
of proceeding with surgery.
Multiple models have been devised to estimate perioperative
cardiac risk. The Goldman risk model was an early and well-
­accepted model for pure determination of cardiac risk for ­surgery.
(36) The system is easy to use and utilizes relative weighting of
risk factors; however, it was designed several decades ago and has
not been updated for modern practice. Two more modern predic-
tive models include those proposed by Detsky et al. (37) and Lee
et al. (38). The Lee index identified six independent predictors of
cardiac complications: high-risk surgery (procedures with a 5%
or higher risk of cardiac complications—including prolonged
intraperitoneal operations), history of ischemic heart disease, his-
tory of congestive heart failure, history of cerebrovascular disease,
diabetes, and preoperative serum creatinine >2.0 mg/dL. Patients
with 0, 1, 2, or 3 or more criteria were found to have a rate of major
cardiac complications of 0.5%, 1.3%, 4%, and 9% respectively.
The receiver operating curve generated on a validation cohort of
patients was higher for the Lee index versus the Goldman index
and Detsky’s model, indicating higher predictive power.(38)
The American College of Cardiology (ACC) and American
Heart Association have issued evidence-based guidelines for the
evaluation of patients for noncardiac surgery. They are available at
their website (www.acc.org), the National Guideline Clearinghouse
(www.guidelines.gov), and in print.(39)
A cardiac history and physical exam is designed to identify unsta-
ble coronary syndromes, prior angina, recent or past myocardial
infarction, severe valvular disease, decompensated heart failure,
and significant arrhythmias. Presence of a pacemaker or implant-
able cardioverter defibrillator should be noted. Hypertension
should be identified and controlled pre-, intra-, and postopera-
tively. Elevated blood pressure increases myocardial work, stress
and oxygen demand. Interestingly, a randomized trial was unable
to demonstrate a benefit to delay of surgery for the purpose of con-
trol of severe hypertension.(40) Volatile anesthetics and intravenous
medications can remedy the hypertension quickly. Antihypertensive
medications should be taken with a sip of water on the morn-
ing of surgery and resumed postoperatively as soon as possible.
Symptomatic aortic or mitral stenosis should be identified and
evaluated preoperatively. In certain cases, a valve replacement or
percutaneous valvuloplasty will greatly reduce the risk of surgery.
A history of orthopnea, dyspnea on exertion, and paroxysmal noc-
turnal dyspnea are suggestive of congestive heart failure. Pitting
ankle edema, rales on auscultation of the chest, jugular venous dis-
tention, and an S3 gallop on physical examination all support the
diagnosis of heart failure. A chest radiograph showing cardiomegaly
and prominent pulmonary vascularity is supportive. Noninvasive
evaluation of ventricular function and optimization of the con-
gestive heart failure should be achieved before surgery in such
patients.

 improved outcomes in colon and rectal surgery
In patients with existing cardiac disease, recent changes in
symptoms must be identified. Assessment of functional status is
important to determination of preoperative risk. If the patient can-
not or does not achieve an adequate level of activity in their daily
life it may hide the angina or symptoms they would experience
should they reach that level. The surgical stress can cause cardiac
complications in these patients who would appear to be asymp-
tomatic based on preoperative questioning if their functional
­status is poor. The Duke Activity Status Index was developed as a
way to correlate a patient’s exercise tolerance with activities that
they can perform in daily life.(41) Peak oxygen uptake on exercise
­testing correlates very well with the determination by this self- or
physician-administered questions. The scale defines these daily
activities in terms of metabolic equivalents (METs). Patients who
cannot reach four METs (equivalent to light housework, climbing
a flight of stairs or walk on level ground at 4 mph) would require
additional investigation if it is necessary to determine whether
they are really asymptomatic or not. Patients who can exercise
at a very high MET without symptoms are less likely to harbor
significant cardiac disease.
The ACC has defined a stepwise algorithm to preoperative
evaluation of the patient requiring noncardiac surgery. Surgery
should be cancelled or delayed unless emergent in patients with
unstable or severe angina, myocardial infarction <1 month prior,
decompensated heart failure, significant arrhythmias or severe
valvular disease.(39) Risk stratification for the type of surgical
procedure includes high (>5% reported cardiac risk), intermedi-
ate (1–5%), or low risk. Intraperitoneal procedures are considered
intermediate risk while ambulatory procedures are considered low
risk. Laparoscopic intraperitoneal surgery, although associated
with less pain and postoperative fluid shifts, should be considered
intermediate risk because of the potential need for use of an open
approach depending on intraoperative circumstances. In patients
undergoing low-risk surgery, no further cardiac assessment is
necessary. For patients undergoing intermediate risk surgery, evi-
dence of good functional capacity without symptoms indicates
no further testing is neededbefore surgery. If the functional status
is poor or unknown, presence of one or more clinical risk factors
as defined by Lee (history of coronary artery disease, history of
heart failure, history of cerebrovascular disease, diabetes or renal
insufficiency) then options include noninvasive cardiac testing to
further stratify risk if it will change management. Alternatively,
the operation can proceed with heart rate control pre-, intra-, and
postoperatively. Patients without symptoms and with a normal
cardiac stress test within past 2 years or revascularization in the
past 5 years do not require further evaluation. If no clinical risk
factors are present, the operation can proceed.
The preoperative electrocardiogram (ECG) is not as indispen-
sable as it once was. The prevalence of abnormal ECGs increases
with age.(42) However, multiple studies seem to indicate that the
electrocardiogram alone is a poor independent predictor of post-
operative cardiac complications.(43–45) While ECG abnormalities
indicate an elevated cardiac risk, it loses its independent predictive
power when analyzed with patient clinical characteristics. One of
these studies did indicate particular risk for patients with left or
right bundle branch blocks on their ECG.(46) In certain cases, the
ECG may contribute to an incomplete history as previous silent

myocardial infarction is common.(47) A preoperative baseline ECG
can be important as a baseline, since it can be of significant impor-
tance in identifying postoperative ECG changes.(36) Preoperative
dysrhythmias (>5 premature ventricular contractions/min) and
P-wave abnormalities are predictive of postoperative dysrhythmias.
(48) The recommendations of the ACC are less clear on the value
of a preoperative ECG than other clinical issues. A preoperative
resting 12-lead ECG is recommended for patients with at least one
clinical risk factor who are undergoing intermediate risk proce-
dures or patients with no clinical risk factors who are undergoing
high-risk surgery. Additionally, a preoperative and postoperative
ECG is not recommended for asymptomatic patients undergoing
low risk ­surgery. The quandary lies with the asymptomatic patient
planned for intermediate risk surgery. If there is any question about
the functional status, an ECG is indicated. By contrast, if the func-
tional status is outstanding and no symptoms are present it could
be argued to omit the test. Lee’s Revised Cardiac Risk Index was
derived in patients 50 years and older so an arbitrary age cutoff here
may be reasonable.
Noninvasive evaluation of ventricular function with echocar-
diography is indicated in patients with dyspnea of unknown ori-
gin, current or prior heart failure with change in symptoms.(37)
Routine evaluation of ventricular function is not recommended.
Preoperative revascularization is generally not indicated before
surgery unless it would have been recommended for the patient
based on their cardiac evaluation, regardless of whether they had sur-
gery planned. The Coronary Artery Revascularization Prophylaxis
(CARP) trial randomized patients with known coronary artery
disease by cardiac catheterization to revascularization ­versus medi-
cal management before elective vascular surgery.(49) The Dutch
Echocardiographic Cardiac Risk Evaluation Applying Stress Echo­
cardio­graphy (DECREASE-V) trial also randomized patients to
revascularization or best medical therapy before ­vascular surgery.
(50) Both randomized trials failed to show a benefit to revasculari-
zation before surgery when optimal medical treatment was applied.
If percutanous coronary intervention is indicated and performed
before surgery, either angioplasty or bare-metal stents should be
used and drug-eluting stents avoided. Drug eluting stents have a
higher associated restenosis rate when anticoagulation is discontin-
ued early. If possible, waiting 4 to 6 weeks after stent placement is
beneficial because the stent with be at least partially endothelialized
and clopidogrel (Plavix) can be stopped. If possible, aspirin is to be
continued or resumed quickly after surgery.
Perioperative treatment with beta-blockers titrated to a heart
rate of <70 beats per minute to reduce cardiac risk has been studied
in multiple clinical trials. Although some more recent trials have
not demonstrated the pronounced benefit of earlier trials on the
subject, the aggregate conclusion of the multiple studies ­suggests
benefit with small risk. Preoperative beta-blockade is indicated in
patients having intermediate risk surgery with one or more clinical
risk factors or any patient having vascular surgery. It is not indi-
cated in patients for low-risk surgery or intermediate risk surgery
without clinical risk factors. Some authors argue that effective beta-
blockade obviates the need for additional ­cardiac testing in certain
intermediate risk patients.(51) Institution of statin-class medica-
tion for patients with one or more clinical risk factors undergoing
intermediate risk surgery should be considered.(52)
 preexisting conditions
pulmonary disease
Postoperative pulmonary complications (PPCs) are equally preva-
lent and contribute similarly to morbidity, mortality, and length
of stay as cardiac complications.(53) They include atelectasis,
pneumonia, bronchospasm, and respiratory failure (mechanical
ventilation for >48 hours). The American College of Physicians
(ACP) issued guidelines for pulmonary risk stratification avail-
able on their website www.acponline.org and www.guidelines.gov.
Several risk factors are known to increase the risk of pulmonary
complications. Even when controlling for other comorbid condi-
tions, evidence suggests that increasing age is a risk for pulmo-
nary complications.(51) Congestive heart failure, although not
a pulmonary condition, increases risk for postoperative pulmo-
nary complications. Functional dependence defined as need for
assistance from another person or devices to perform activities
of daily living was associated with pulmonary complications.(54)
Impaired sensorium is associated with an increased risk of pulmo-
nary complications. While obesity does not seem to be associated
with an increased risk of pulmonary complications, sleep apnea
does appear to confer increased risk.(53) Cigarette smoking greatly
increases the incidence of pulmonary complications compared to
nonsmokers.
Procedure-related risk factors increase the likelihood of pulmo-
nary complications. Incision location (thoracic, upper abdomen,
lower abdomen) has been shown in several heterogeneous studies
to correlate with pulmonary risk, as well duration of surgery (>2.5
hours in some studies and >4 in others).(53) General anesthesia
and emergency surgery have also been found to be associated
with increased postoperative pulmonary complications.
The ACP guidelines suggested that a preoperative chest radiograph
is indicated in patients with known cardiopulmonary ­disease or those
older than 50 years of age who are undergoing upper abdominal or
abdominal aortic aneurism surgery. Routine chest radiography in
all patients has been shown to be associated in many studies with a
very small number of abnormalities that influenced management
and an even smaller number in patients under the age of 50.(55,
56) It is reasonable however to have a low threshold to order the
test in those patients in whom it is more likely to be abnormal than
an unselected population. This includes patients with a positive
pulmonary review of systems for conditions such as cough, dys-
pnea on exertion, or recent pneumonia or the presence of chronic
lung conditions such as asthma or pulmonary fibrosis.
Pulmonary function testing is an expensive and tricky test to
administer. It has a well-established place in the preoperative
workup of lung resection patients, but there is no clear indica-
tion in the preoperative workup of abdominal surgery patients.
Evidence from several studies suggests that segregating patients
by forced expiratory volume in 1 s (FEV1) creates groups with
differing pulmonary complication rates from 14.6% up to 31%
in the highest and lowest group respectively.(53) What is lacking
from these studies is the correlation of the spirometry with clinical
­history, physical exam and other findings. The implication is that
poor preoperative spirometry can be inferred from these noninva-
sive means. The few studies that have compared spirometry data
with clinical data have not consistently shown spirometry to be
superior to history and physical examination.(53) The spirom-
etry data do not demonstrate a threshold below which surgery is
prohibitively dangerous. In a study of patients with FEV1 < 50%
predicted only <15% of patients died or experienced a major
­pulmonary complication.(57)
Control of acute and chronic pulmonary illness and cessa-
tion of smoking can help reduce pulmonary complications.(58)
Treatment and clearance of acute pulmonary infection before
­surgery is recommended. Smokers have a four-fold higher risk of
pulmonary complications compared to nonsmokers. Several stud-
ies demonstrate that a 4 to 8 week period of smoking cessation with
greatly decrease this risk.(59–61) Anecdotal evidence suggested
that stopping smoking too close to the time of surgery would have
a paradoxical increase in pulmonary complications. While the sal-
utary effect of stopping smoking is difficult to demonstrate until
4 weeks, these same studies do not report a higher complication
rate in those who have recently quit.(59, 61) Optimization of chronic
obstructive pulmonary disease (COPD) and treating any exacerba-
tion with steroids if necessary is advantageous.(56) Laparoscopic
surgery, if possible, is recommended as it was shown in meta-analysis
to have a trend toward lower pulmonary complications.(62)
Asthma can worsen after surgery. Patients with asthma should
be identified preoperatively and their medications reviewed. The
National Asthma Education and Prevention Program has issued
guidelines for management of asthmatics undergoing surgery
(available at www.guidelines.gov and in print).(63) Their pre-
operative lung function should be optimized to their predicted
­values or personal best using a short course of steroids if necessary
to achieve this. Patients who received >20 mg of prednisone per
day for more than 3 weeks in the 6 months before surgery should
be assumed to have suppression of hypothalamic—pituitary—
adrenal function and stress dose steroids are indicated. The stress
dose depends on physicians’ experience, the patient’s condition
requiring chronic steroids, the length and dose of preoperative
use of steroids. The stress dose can be tapered to preoperative
dose within 3 days postoperatively.
Postoperative care techniques can reduce pulmonary complica-
tions. Adequate pain control is essential for an effective deep breath-
ing program. Multiple studies have been performed evaluating
various techniques but the consensus guideline indicates that no
lung expansion intervention has been shown superior to another
but any type of prophylaxis is better than none.(58)
renal disease
The patient with preexisting renal disease presents a special chal-
lenge to the surgeon. In patients with preexisting renal dysfunction
is important to avoid additional intraoperative or postoperative
injury caused by dehydration or toxic agents. Adequate urine
output is an indication of adequate renal perfusion. Obtaining a
preoperative urinalysis may identify unsuspected urinary tract infec-
tion, diabetes, or renal insufficiency. However, routine ­urinalysis is
not recommended preoperatively for most surgical procedures.
(64) Careful questioning regarding symptoms of dysuria, hesi-
tancy, nocturia, and feelings of incomplete evacuation may diag-
nose prostatic disease and its complications including early stage
renal dysfunction. Normal renal function is necessary for the
excretion of the nondepolarizing muscle relaxants used for
anesthesia and surgery. Renal function is also a consideration when
choosing postoperative analgesic regimens including ­nonsteroidal

 improved outcomes in colon and rectal surgery
medications such as ketoralac. Age, hypertension, and diabetes
may be indications for preoperative selective renal function test-
ing. Once renal function is compromised, all medications cleared
by kidney must be dose adjusted in a timely ­manner and care-
fully monitored if needed. Nephrotoxic agents should be avoided
whenever possible. Angiotensin-converting enzyme inhibitors
reduce the renal perfusion and should probably be avoided if
possible.(65) Mild to moderate renal impairment is usually
asymptomatic; the prevalence of an elevated creatinine among
asymptomatic patients with no history of renal disease is only
0.2%.(66) However, it increases with age.(67) Dialysis is neces-
sary in 1% of patients who develop acute renal failure; the 30-day
mortality is high in those patients with acute renal failure com-
pared to those with normal renal function.(68, 69) Risk factors
for acute renal failure include advanced age, baseline renal dys-
function, left ventricular dysfunction, peripheral ­vascular ­disease,
and clinical signs of poor cardiac function such as ­pulmonary
rales.(38, 68)
Patients with end stage renal failure on dialysis require spe-
cial attention. Patients in with end stage renal disease often have
­concurrent hypoalbuminemia and anemia resulting in poor
wound healing and increased risk of complications. Krysa et al.
describe a high instance of anastamotic leak in these patients.
(70). Decreased leukocyte and immunologic function result in
increased risks of infection and impaired cellular immunity.(71)
Pulmonary edema and uremic pneumonitis may compromise res-
piratory function.(72) Postoperative ileus may be prolonged and
patients with diverticulosis are at increased risk for acute infection
and perforation.(73) Fluid and electrolyte abnormalities occur
rapidly and require intensified scrutiny to maintain balance. It is
important to know if the patients make any urine preoperatively,
otherwise alternative strategies from postoperative urine volume,
such as central venous pressure measurement, will be necessary
to ensure adequate tissue perfusion. Dialysis can be scheduled on
the preoperative day and again on postoperative day number one.
Acute postoperative dialysis can be provided at any time using
the same indications for acute dialysis in a nonpostoperative
patient. Dialysis can improve abnormalities of hemostasis that
are caused by platelet dysfunction. Abnormal bleeding in dialysis
patients can be improved by platelet transfusion or administra-
tion of desmopressin acetate (DDAVP) increasing the release of
von Willebrand factor from the endothelium.
hepatic disease
Operating on patients with significant liver disease is among the
most daunting tasks for the colorectal surgeon. Although the Child-
Pugh classification was originally described to assess the operative
risk in patients undergoing shunt surgery for portal hyperten-
sion, it has implications for other abdominal surgery. This classi-
fication is a scoring scale designed to quantify liver dysfunction. It
utilizes bilirubin, albumin, prothrombin time, presence of ascites,
and presence of encephalopathy to assign points and a subsequent
classification from A to a maximal dysfunction of C. In a classic
review of cirrhotic patients undergoing a variety of elective and
emergent general surgical procedures, Child’s A cirrhosis carried a
10% mortality, Child’s B cirrhosis had a 31% mortality, and Child’s
C cirrhosis was associated with a 76% mortality.(74) In a study of

cirrhotic patients undergoing colectomy, the in-­hospital mortality
was 24% with highest mortality for patients with encephalopathy,
ascites, hypoalbuminemia, and anemia.(75)
Suggestion of underlying cirrhosis can be detected at physical
examination. Scleral icterus, jaundice, spider telangiectasia, and
­palmar erythema may be present. Early cirrhosis is associated with
an enlarged liver while advanced disease will lead to a small shrunken
liver. Asterixis, or flapping tremor, is a sign of advanced disease.
Ascites can be detected by physical examination. Unexpected liver
enzyme abnormalities are uncommon, occurring in only 0.3% of
patients in one series.(76) In a pooled data analysis, only 0.1% of
all routine preoperative liver function tests changed preoperative
management.(77) Severe liver function test abnormalities among
patients with cirrhosis or acute liver disease are associated with
increased surgical morbidity and mortality, but it is not clear if mild
abnormalities among patients with no known liver disease have a
similar impact.(78) Clinically significant liver disease would most
likely be suspected on the basis of the history and physical exami-
nation; thus, routine liver enzyme testing is not recommended.(8)
In addition, the relationship between an abnormal result and the
risk of perioperative hemorrhage is not well defined.(77, 79)
Patients with liver disease often have disordered and abnormal
coagulation. Decreased production of clotting factors, especially
vitamin K-dependent ones, by the liver will often result in elevated
prothrombin times (PT) or partial thromboplastin times (PTT).
In some cases fresh frozen plasma or vitamin K administration
can correct these abnormalities, at other times the liver disease
is so severe that the coagulopathy cannot be corrected. In addi-
tion, patients with cirrhosis may have portal hypertension and
splenomegaly, resulting in sequestration and a very low platelet
count. It is mandatory to monitor platelet count as well as PT,
PTT preoperatively so that abnormalities can be corrected.
Portal hypertension can result in portosystemic varicies resulting
in significant intraoperative bleeding at sites which are technically
difficult to manage, such as the splenic flexure and the distal rec-
tum. Use of alternate energy sources (such as Liga-SureTM, Valleylab,
Boulder, CO or Enseal®, SurgRX, Redwood City, CA) may assist in
reducing intraoperative blood loss in these challenging patients.
Abnormal clotting factors may increase the risk of bleeding from
hemorrhoidal disease in these patients, or actual rectal varices may
be present.
Patients with liver disease are often nutritionally depleted and
have a very low albumin. They may also have ascites present at sur-
gery. Although the ascites can be drained at operation, it generally
reaccumulates rapidly. Our practice is to leave a drain in the abdo-
men perioperatively to assist the fascia to seal, so that the ascites
will not become tense and may be less likely to breach the incision.
Fluid and electrolyte disturbances are common in the patient with
liver disease including sodium retention, potassium losses, and the
development of edema. Fluid and sodium restriction, potassium
supplementation, and the judicious use of diuretics (spironolac-
tone and furosemide) may be necessary.
malnutrition
Malnutrition is a frequent preexisting condition in surgical
patients. Identification of malnourished patients is possible by
clinical history, physical examination, and laboratory parameters.
 preexisting conditions
Malnourished patients, who have lost more than 10% of their
bodyweight in the past 6 months, and have an albumin below 3 g/
dL, have increased complication rates after surgery.(80) A serum
albumin of <3 g/dL, transferrin of <200 mg/dL, and total lym-
phocyte count of <1,200 are consistent with at least some level of
nutritional depletion. The enteral route is the preferred route of
improving nutrition as long as there is a functioning gastrointes-
tinal tract. There is moderate evidence that improved preopera-
tive nutritional status can improve the postoperative outcome.
(81) Severely malnourished patients might benefit more from
nutritional support, although this needs to be provided for
approximately 2 weeks to achieve such benefit.(82) Low body
mass index (BMI) (<20 kg/m2) and hypoalbuminemia (<2.5 g/
dL) are ­independently associated with increased risk of morbidity
and mortality after surgery. Patients with decreased albumin lev-
els are also at increased risk for bleeding, renal failure, ­prolonged
ventilatory support, and reoperation.(83, 84)
immunocompromise
The sources of immunocompromise in potential surgical patients
are numerous and may be primary or acquired. Primary immu-
nodeficiencies are relatively rare (1/10,000) and will not be
encountered by most practicing surgeons.(85) Acquired immu-
nodeficiencies are very common and range from mild defects to
complete loss of immune function. Age, malnutrition, obesity,
malignancy, burns, sepsis, trauma, surgery, anesthesia, blood trans-
fusion, diabetes, renal failure, liver disease, splenectomy, radiation,
and foreign bodies all modify the body’s response to invasion.
Drugs including chemotherapeutic agents are probably the most
frequently encountered cause of severe immunocompromise in
surgical patients and are associated with profound neutropenia.
The use of filgrastim, a granulocyte colony-stimulating ­factor,
has been shown to decrease the duration of neutropenia and
the incidence of infection versus controls in patients undergo-
ing chemotherapy for small cell carcinoma of the lung and other
nonmyeloid malignancy (86, 87) Cook et al. (88) reported that
neutrophil—lymphocyte ratio (NLR) is an indicator of postoper-
ative complications in colorectal surgical patients in critical care
units. An elevated NLR on the first day after an elective colorectal
resection is associated with increased risk of subsequent compli-
cations. NLR calculation does not burden the hospital with addi-
tional cost and can be used to identify patients at high risk of
complications.(88)
hiv/aids
When evaluating a human immunodeficiency virus (HIV)
positive patient for surgery it is important to understand the
current state of their disease. This can be obtained by checking
for history of autoimmune deficiency syndrome (AIDS) defin-
ing illness and measuring a CD4 count and HIV viral load. An
absolute CD4 count of <200 or a decreasing ratio of CD4 to
CD8 (normal 1.8–2.2) is associated with severe immunocom-
promise and subsequent risk for viral, fungal, protozoal, and
bacterial infections as well as ­prolonged wound healing. Newer
drug regimens that include combinations of protease inhibitors
and nucleoside analogs have greatly improved the prognosis for
HIV-infected patients.(89)
metabolic disease
Metabolic diseases represent disorders where altered chemical
transformation processes have resulted in abnormal release, stor-
age, synthesis, or degradation of various protein, carbohydrate,
lipid, or other products of metabolic activity. Gout is a generic
term for a number of genetic and acquired conditions mani-
fested by hyperuricemia and the deposition of uric acid crystals
in joints precipitating an acute inflammatory arthritis. Acute
gouty arthritis often follows a precipitating event. Acute gout has
been commonly described in the postoperative setting.(90, 91)
It manifests most commonly on the third to fifth postoperative
day. Treatment consists of joint rest and administration of colchi-
cine or ­non-steroidal anti-inflammatory agents.(92) A thorough
past medical history including previous attacks of gout will alert
the clinician that the patient is at risk postoperatively. At the first
early signs of an attack it can be treated quickly. Significant delay
can result in impaired ambulation secondary to pain which has
the potential to prolong ileus and delay recovery.
obesity
Obesity has reached epidemic proportions in many areas of the
world and obese patients are requiring surgery more and more
commonly. The BMI is a commonly used relationship to measure
obesity and it represents the bodyweight in kilograms divided by
the height in meters squared. A BMI 18–25 is considered normal
while >30 is obese. Obesity has been demonstrated to be a risk
factor for abdominal surgical wound infection.(93) It has not
surprisingly been linked to increased incidence of wound dehis-
cence (94), hernia (95), stoma complications (96). Some studies
indicate a higher anastomotic leak rate for low colorectal or colo-
anal anastamosis in obese patient.(97) Cardiovascular, pulmonary,
and thromboembolic complications are more frequent in obese
patients, often attributable to their comorbid diseases.(98) Obesity
also causes technical difficulties for the surgeon; operative dura-
tion and likelihood for conversion were increased in obese patients
undergoing laparoscopic surgery.(99) It is reasonable as part of the
informed consent process to counsel patients about their elevated
operative risk due to obesity. If possible, they should be encouraged
to lose additional weight before certain types of surgery where a
delay is safe, and indeed may be beneficial (proctocolectomy with
pouch-anal anastamosis, some diverticular resections).
The extensive experience with bariatric surgery has taught us
that sleep apnea is very common in obese individuals. The patient
should be questioned for snoring, apneic episodes, arousals dur-
ing sleep, or daytime somnolence. Physical exam should focus
on evaluation of the airway, neck circumference, tonsil size and
tongue volume. The American Society of Anestheiologists Task
force recommends that if any of these characteristics are present
that suggest sleep apnea then the anesthesiologist and surgeon
should jointly decide whether to: manage the patient periop-
eratively based on clinical criteria alone or obtain sleep studies
during the conduct of a more extensive evaluation in advance
of surgery.(100) Postoperatively supplemental oxygen should
be administered continuously to all patients with sleep apnea
until they are able to maintain their baseline oxygen saturation
while breathing room air. Sleep apnea patients should have con-
tinuous pulse oximetry monitoring until they are no longer at

 improved outcomes in colon and rectal surgery
increased risk. Intermittent pulse oximetry with observation does
not provide the same level of safety.(100) Continuous positive
­airway pressure ventilation (CPAP) is given to all patients using
it preoperatively.
diabetes
The frequency of glucose abnormalities and type II diabetes
increases with age; almost 25% of patients aged more than 60 had
an abnormal value in one report.(66) The diabetic patient who is
recognized and well managed perioperatively can achieve a surgi-
cal mortality which is equal to the nondiabetic patient. Protein
catabolism after colorectal surgery is increased in patients with
type 2 diabetes mellitus.(101)
The preoperative assessment should include any complaints
of polyuria, polydypsia, or polyphagia. An associated weight loss
with any of these could be a sign of diabetes. A fasting blood
glucose >140 mg/dl confirms a diagnosis of diabetes. Control of
hyperglycemia should be started preoperatively and continued in
the postoperative phase. In contrast to past doctrine that mild
hyperglycemia is permissible in the perioperative period, newer
studies indicate that there is a benefit in tighter glucose control.
These intensive insulin strategies result in less hyperglycemia
and as a result appear to improve immune function and reduce
infectious complications.(102) These intensive strategies require
­frequent monitoring of blood glucose levels but may result in more
hypoglycemia which has serious potential adverse consequences,
causing two large scale studies of this method to be stopped.(103)
Close monitoring of glucose and avoidance of hyperglycemia has
clear benefit, but especially in difficult-to-control diabetics it can
be challenging to avoid dangerous hypoglycemia.
Renal and cardiovascular disease occurs commonly in diabet-
ics and is a major cause of death in these patients. Compared to
the nondiabetic population, cardiovascular disease occurs more
frequently at a younger age, and with more severe manifestations.
The reasons for this accelerated atherosclerosis are postulated to
include the high incidence of hyperlipoproteinemia in diabetic
patients, abnormalities of endothelial cell function, increased
platelet aggregation, and a high incidence of hypertension in
diabetics.
age
Despite advances in surgery, anesthesia, and perioperative care,
increasing age continues to be a risk factor for perioperative
­complications. There is an increased risk of surgery associated
with advancing age. In a 1982 review of 50,000 elderly patients,
the risk of mortality with elective surgery increased from 1.3%
for those under age 60, to 11.3% in the 80–89 year-old age group.
(104) A recent review nearly 20 years later demonstrates an in-
hospital mortality of 0.3% for patients 50–59 and increasing to
2.6% for those patients older than 80.(105) Major perioperative
complications increased by decade from 4.3% for 50–59, to 5.7%
for 60–69, to 9.6% for 70–79 and 12.5% for 80 or older.
Surgical procedures and surgery should not be restricted on
the basis of age alone.(106) There is clear evidence that age has
an effect on physiologic life processes.(107) Maximum heart rate
slowly decreases with age (108) and there is an increasing frequency
of arrhythmias (109). There is a decline in maximum oxygen

­consumption except in very active patients.(110) A decrease in ven-
tilatory threshold with age is predominantly due to an age-related
decline of skeletal muscle mass.(111, 112) Chronologic age does not
always correlate with the more important estimation of physiologic
age. Active athletic individuals can maintain lean body mass equal
to that of younger athletes well into their 8th decade.(113)
Aging is characterized by a decline in renal function and by a sus-
ceptibility to renal diseases. Renal function is preserved with aging
in healthy subjects at the expense of a complete reduction of renal
functional reserve. Proteinuria (114) and bacteriuria (115) increase
with the age. Aging is associated with insulin resistance often attrib-
utable to obesity and inactivity. Recent evidence suggests that skeletal
muscle insulin resistance in aging is associated with mitochondrial
alterations. Aging is associated with both whole body and myocar-
dial insulin resistance, independent of obesity and inactivity.(113)
The population is steadily aging and geriatric surgical care is
likely to increase. As patients enter their 9th decade it will not
be uncommon for them to be acceptable candidates for major
surgery. Extremely elderly patients are likely to be poorly toler-
ant of complications and difficult to salvage once complications
occur. “Failure to rescue” is a new quality of care indicator to
measure the inability to save a patient once a complication has
occurred.(116) It is likely that elderly patients will prove particu-
larly ­difficult to rescue once a problem has occurred, so it is up to
the surgeon to be fastidious in his preoperative preparation and
risk assessment, intraoperative technique and postoperative care
to avoid complications in this fragile patient population.
neurologic system
The prevalence of occult cerebrovascular disease in elderly patients
is a common problem. An asymptomatic carotid bruit indicates
the presence of peripheral vascular disease and is an indication
for further evaluation by duplex scanning. However, prophylactic
endarterectomy is not indicated usually, as the increased risk of a
perioperative stroke compared to the unselected population is
small.(118) Symptomatic disease should be treated before elective
interventions. Aspirin prophylaxis and occasionally endarterectomy
might be indicated to reduce the incidence of cerebrovascular acci-
dents (CVA).(119)
Patients who have had a stroke in the past are at an estimated
5–15% annual risk of a recurrent event if left untreated. Thus
these patients are often maintained on either aspirin or clopidog-
rel (Plavix) to reduce their risk. While clopidogrel is more effective
in high-risk patients, it is associated with a higher incidence of
bleeding events. The risk of stroke while stopping the anticoagu-
lation must be weighed against the adverse event of postsurgical
bleeding. The decision-making must be tailored to the stroke risk
of the individual patient based on their history and the magnitude
and bleeding risk of the proposed procedure. For most patients,
the interruption in their anticoagulation for 7 days to proceed
with surgery is not likely to result in harm.
Parkinson’s disease is a progressive degenerative neurologic
condition associated with tremor and gait disturbance. In its
later stages, aspiration pneumonia is common thus patients with
advanced disease having abdominal surgery must have particular
attention paid to their postoperative respiratory program. Most
anti-Parkinsonian medications are only orally administered so
 preexisting conditions
they must be withheld after abdominal surgery until oral medi-
cations can be given. This can result in rigidity and further wors-
ening of airway protection. One author describes use of rectally
administered domperidone to patients with Parkinson’s disease
having abdominal surgery in an effort to avoid such problems.
(120) We have little experience with this, but it may prove useful
in a particularly symptomatic patient.
hypercoaguable disorders
Management of patients with hypercoaguable syndromes can
be especially challenging in the setting where the need to con-
trol postoperative bleeding is crucial. Common (factor V Leiden
deficiency) and relatively uncommon (antithrombin deficiency,
protein C and protein S deficiency) causes of thrombosis have
­different risk associations. For example, the relative risk of venous
thrombosis in the Caucasian population can range from 2.5%
for the prothrombin gene mutation to 25% in the presence of
antithrombin deficiency.(121) Furthermore, approximately 50%
of cases of venous thrombosis associated with these hereditary
disorders are provoked by known risk factors such as surgery.
Therefore, aggressive prophylaxis with subcutaneous heparin or
low-molecular heparin is warranted peri- and postoperatively.
By contrast, for those on long-term anticoagulation, the decision
to continue treatment for thrombosis should be individualized.
In general, warfarin therapy can be switched to low-molecular
weight or intravenous heparin 3 to 5 days before surgery.(121)
Patients with antiphospholipid antibody syndrome (lupus anti-
coagulant/anticardiolipin antibodies, history of arterial or venous
thrombosis, and/or recurrent fetal loss) deserve special mention.
Currently available anticoagulants are effective in reducing the
recurrence rate of venous thromboembolism (VTE). VTE is a
common complication in cancer patients and can lead to delay in
cancer therapy and is predictive of a worse prognosis. Prophylaxis
with anticoagulants is recommended for patients hospitalized for
surgery or medical conditions, but is not routinely administered
in the ambulatory setting.(122) However, anticoagulant treatment
is associated with an increased risk for bleeding ­complications and
needs to be discontinued when benefit of treatment no longer
clearly outweigh its risks.(123) The incidence of recurrent VTE
can be estimated through a two-step decision algorithm. First, the
features of the patient (gender), of the initial event (proximal or
distal deep vein thrombosis or pulmonary embolism), and the
associated conditions (cancer, surgery, etc) provide essential infor-
mation on the risk for recurrence after anticoagulant treatment
discontinuation. Second, at time of anticoagulant treatment dis-
continuation, D-dimer levels and residual thrombosis have been
indicated as predictors of recurrent VTE. Current evidence sug-
gests that the risk of recurrence after stopping therapy is largely
determined by whether the acute episode of VTE has been effec-
tively treated and by the patient’s intrinsic risk of having a new
episode of VTE. All patients with acute VTE should receive oral
anticoagulant treatment for 3 months. At the end of this treat-
ment period, physicians should decide for withdrawal or indefi-
nite anticoagulation. Based on intrinsic patient’s risk for recurrent
VTE and for bleeding complications and on patient preference,
selected patients could be allocated to indefinite treatment with
scheduled periodic reassessment of the benefit from extending
anticoagulation. Cancer patients should receive low-molecular
weight heparin over warfarin in the long-term treatment of VTE.
These patients should be considered for extended anticoagulation
at least until resolution of underlying disease.(123)
conclusion
The history and physical examination is the most important part
of the preoperative evaluation and can be used to guide further
workup and testing. Multiple scoring systems are available to
quantify risk of postoperative complications and mortality based
on preoperative conditions. Optimization of these conditions
will increase the likelihood of a successful outcome.
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
2 Preoperative bowel preparation
David A Margolin and Sean Mayfield
challenging case
A 57-year-old gentleman with a sigmoid colon cancer found via
colonoscopy for a history of anemia and weight loss is awaiting
surgery. You stop by the pre-op holding area to see the patient
where he tells you, “I tried drinking that prep last night and after
only half a glass I got sick and threw up. I just couldn’t take it.” Do
you perform elective surgery?
case management
Yes. Multiple studies have demonstrated the safety of elective
bowel surgery in the absence of a mechanical bowel preparation.
INtRODUCTION
The objectives of preoperative bowel preparation in elective colon
and rectal surgery include decreasing the bacterial count in the colon,
decreasing the wound infection rate, decreasing the rate of anasto-
motic leaks, improving interoperative bowel handling, and facilitating
interoperative endoscopy if necessary. Aside from the medical reasons
for a patient undergoing a bowel prep, there is surgical tradition as
well as the medicolegal implications of deviations from the perceived
norm. We know that there are a variety of well-documented factors
that play a role in infectious compilations in colon and rectal surgery
most notably, increased American Society of Anesthesiologists (ASA)
classification, obesity, diabetes, prolonged surgical time, interopera-
tive hypotension, excessive blood loss, surgical intervention for bowel
obstruction, whether partial or complete, and emergency surgery.
(1–5) We as surgeons also try to adhere the dictum of primum non
nocere. With those thoughts in mind, preoperative bowl preparation
has become the standard before elective colon surgery.
Preoperative bowel preparation is divided into two parts: antibi-
otic prophylaxis and mechanical bowel preparation. The use of anti-
biotic prophylaxis in elective colon surgery is mandatory to minimize
infection complications. Unfortunately the choice antibiotic and
rout of antibiotic administration is not as clear. The first principle
in prophylactic use of antibiotic administration is to provide cover-
age for the normal bowel flora. This means choosing antibiotics that
cover both aerobic bacteria, especially Escherichia coli and anaerobic
species most notably bacteroides sp. Even with appropriately cho-
sen antibiotics the route of antibiotic administration is undergoing
a re-evaluation. Oral antibiotics as used in the traditional Nichols-
Condon antibiotic preparation have been shown to reduce intralu-
minal and mucosal bacterial count while parenteral antibiotics have
been shown to reduce systemic bacterial counts at the tissue level.
Colorectal surgery performed before 1970 was fraught with
infectious complications which occurred in more than 30–50%
of all operations. With a better understanding of bacteriology and
the availability of an increasing number of antibiotics, surgeons
attempted to improve their outcomes with regards to infections.
Garlock and Seley in 1939 gave patients sulfanilamides before sur-
gery; unfortunately, there was no real improvement in infectious

complications.(6) Dearing in 1951 and Poth in 1960 tied tetracycline
and neomycin respectively with only minimal improvement.(7, 8)
It was not till the 1970s that a significant improvement in mitigat-
ing infectious complications was seen. In a 1977 VA cooperative study,
Nichols and Condon showed that by using oral neomycin sulfate and
erythromycin base that they were able to decrease the wound infection
rate of elective colon resections from 35% to 9%. They also showed
that this regimen showed a significant decrease in all septic complica-
tions (wound infection, anastomotic leak, and abscess) from 43% to
9%.(9–11) The dosing of 1 g of oral neomycin sulfate and erythromy-
cin base at 2:00 pm, 3:00 pm, and 10:00 pm for an 8:00 am case became
and remains a standard oral antibiotic regime for elective surgery.
Unfortunately, the Nichols prep has its draw backs. While this antibi-
otic combination is efficacious, it can cause significant gastrointestinal
discomfort severely limiting patient compliance with the remainder of
the antibiotic prep and completion of their mechanical preparation.
These limitations, along with the significant increase in number
and spectrum of paranteral antibiotics, led many investigators to
utilize various IV antibiotic combinations to minimize infectious
complications. In 1969, Polk demonstrated that cephaloridine ver-
sus mechanical prep alone decreased the rate of wound infection
in elective colon resections from 30% to 7%.(12) Since that initial
study their have been numerous attempts to find the best parenteral
antibiotic. From 1983 to 1995 there were more than 150 randomized
controlled trials performed (Table 2.1 and 2.2). Finally in 1998, Song
and colleagues, in a landmark review in the British Journal of Surgery,
codified modern practice and confirmed that parenteral antibiotics
alone decrease the rate of wound infection and that no single regi-
men is superior as long as the antibiotics chosen cover both aerobic
and anaerobic bacteria and are given before incision.(13) In 2003,
the Surgical Infection Prevention Guideline Writers Workgroup
(SIPGWW), a project endorsed by both the American College of
Surgeons (ACS) and American Society of Colon and Rectal Surgeons
(ASCRS), submitted consensus positions for surgical antimicrobial
prophylaxis.(3) They stated that the standard for parenteral antibi-
otic prophylaxis in elective colon resections should include:
1. Timing: Infusion of the first antimicrobial dose should begin
within 60 minutes before surgical incision.
2. Duration: Prophylactic antimicrobials should be discontin-
ued within 24 hours following surgery.
3. Dosing: The initial dose should be adequate based on weight,
adjusted dosing weight, or BMI. An additional dose should
be administered if the operation continues over two half-
lives after the initial dose.
4. Selection (Colon Surgery): Cefotetan, cefoxitin, or cefazolin/
metronidazole.
– Options for β-lactam allergic patients:
– Clindamycin + gentamicin, ciprofloxacin, or aztreonam.
– Metronidazole + gentamycin or ciprofloxacin.
 preoperative bowel preparation

Table 2.1  Intravenous Antibiotics. believed to eliminate the proximal stool column, possibly reduc-
ing the chance of anastomotic disruption by the passing stool,
Wound
and the sequelae should a disruption occur. The merits of this
Author No. of Pts. Antibiotic Infections
practice however have lacked clear investigational proof and
Periti 1989 (14) 403 cefoxitin 11.0% have undergone continued scrutiny over the last decade. In 1973,
cefotetan 9.0% Hewitt et al. presented whole gut irrigation, using a large volume
Skipper 1992 (15)   cefotetan 14.7% of isotonic solution, administered via a nasogastric tube.(26) No
Zanella 2000 (16) 615 cefepime plus 7.2% change in the rate of infection was displayed, although the qual-
metronidazole ity of the prep was improved. A subsequent advance was whole
Mosimann 1998 (17) 440 amoxicillin/ 11.1% gut lavage using mannitol as an osmotic agent. Mannitol reduced
clavulanic
the absorption of water, but was associated with dehydration and
Hall 1989 (18) 237 gentamicin plus 14.8%
loss of electrolytes. Because mannitol is fermented by E. coli into
metronidazole
a potentially explosive gas, explosions while using electrocautery
Corman 1993 (19) 907 cefuroxime plus 7.3%
metronidazole
were reported.
There are two oral preparations routinely used today, polyeth-
ylene glycol (PEG) and sodium phosphate (NaP). PEG is an inert
osmotically active polymer that is mixed with an electrolyte solu-
Table 2.2  Effect of Intravenous Antibiotics. tion resulting in an isosomotic preparation that acts to lavage stool
from the colon lumen. The electrolyte content combined with the
Wound osmotic activity of PEG prevents net absorption or excretion or
Author Pts. No. Antibiotics Infections
water and electrolytes. Typically, 4 L of PEG is ingested over 2 to 3
Codon 1983 (20) 1082 neo/erythro 8.0 hours. This produces good to excellent cleansing in most patients
neo/erythro + cephalothin 6.0 without causing significant fluid or electrolyte derangements.
Coppa 1983 (21) 241 neo/erythro 18 These issues are of particular importance in elderly patients or
neo/erythro + cefoxitin 7 those with renal insufficiency or congestive heart failure. Nausea,
Portnoy 1983 (22) 104 neo/erythro 27 vomiting, and patient compliance are obstacles to achieving ade-
neo/erythro + cefazolin 4.7
quate results in some patients. This has been addressed by the
neo/erythro + ticarcillin 2.3
addition of flavor additives and a reduced volume prep in which
Lau 1988 (23) 194 neo/erythro 27.4
metronidazole + gentamicin 11.9 patients take 2–4 (10 mg) bisacodyl tablets and ½ the normal vol-
neo/erythro + metronidazole ume of PEG (2 L). Some surgeons also prescribe metoclopramide
  + gentamicin 12.3 to hasten gastric emptying, or an antiemetic such as promethaz-
Schoetz 1990 (24) 197 neo/erythro 14.6 ine. However, prospective, randomized trials have not confirmed
neo/erythro + cefoxitin 5 significant benefit from either of these adjuvant medications.
Stellato 1990 (25) 146 neo/erythro 11.4 NaP is a hypersomolar oral saline laxative. Smaller volumes of
cefoxitin only 11.7 hypertonic NaP can produce adequate bowel cleansing with bet-
neo/erythro +cefoxitin 7.8
ter patient compliance. Patients are instructed to consume 45 ml
of sodium phosphate diluted in clear liquids (15 ml NaP in 240
ml) in two doses separated by 10 hours. The timing of this should
Since 1887, when Halsted described intestinal anastomosis, the be such that the patient is not kept awake evacuating the entire
idea of mechanically preparing the bowel has become accepted night before the procedure. Sodium phosphate tablets are also
surgical practice. The rationale for mechanical bowel prep has available and are equally efficacious. Three to four tablets with
been to reduce the risk of infectious complications including 8 oz of clear liquid are taken every 15 minutes to a total of 28
wound infection and anastomotic leak. At the beginning of the tablets. In May 2006, the Federal Drug Administration issued a
20th century, morbidity and mortality secondary to septic com- warning regarding oral NaP for bowel preps in elderly patients or
plications following colon and rectal surgery was high. However, those with underlying kidney disease, dehydration, or those tak-
medical innovations including broad-spectrum oral and intrave- ing medication that affect renal perfusion (diuretics, ACE inhibi-
nous antibiotics, improved surgical techniques and instrumenta- tors, angiotensin receptor blockers, and NSAIDs).(27) These
tion, improved anesthetic and perioperative care, and presumably patients are at increased risk for developing acute renal failure
mechanical bowel preparation has resulted in decreased infec- and nephrocalcinosis due to the relatively large phosphate load,
tious complication rates making elective colorectal surgery safe. fluid shifts, and decreased intravascular volume associated with
Mechanical bowel preparation preceding elective colon and rec- NaP preps. However, both the avoidance of this complication as
tal surgery has become surgical dogma, and surgeons are trained well as improved efficacy can be achieved by appropriate patient
that primary colonic anastomosis is unsafe in the presence of an selection and consumption of large volumes (2–3 L) of clear liq-
unprepared bowel. Proponents argue that the “clean” bowel has uids as part of this prep.
a lower bacterial load and is easier to handle thus reducing the A 2003 survey by Zmora et al. of members of the American
chance of fecal spillage and contamination of the wound and Society of Colon & Rectum Surgeons displayed that 99%
peritoneal cavity during surgery. Mechanical bowel prep is also of respondents routinely use mechanical bowel preparation


 improved outcomes in colon and rectal surgery

although 10% questioned its use.(28) 47% of the surgeons used
sodium phosphate, 32% used polyethylene glycol, and 14% alter-
nated between these two options. These results are the same as
those reported by Beck et al. in 1990 and are most likely based on
surgical tradition rather than evidence-based science.(29)
Since 1992, several randomized controlled trials and meta-
analyses have studied the influence of mechanical bowel prepara-
tion on the outcome of colorectal surgery. Brownson et al. were
the first to perform a randomized trial which consisted of 179
patients. Patients were divided into preparation with polyethylene
glycol or no mechanical preparation.(30) Interestingly, patients
who received a mechanical prep had a higher rate of anastomotic
leak and intraabdominal infection. There was no statistically sig-
nificant difference in wound infection. Burke et al. and Santos
et al. in 1994 published similar studies. Neither study showed
a significant difference in intraabdominal infection; however,
Santos displayed a higher wound infection rate 24% vs. 12% in
patients who received mechanical bowel preparation.(31, 32)
Miettinen et al. reported the results of a prospective rand-
omized trial in 2000 including patients undergoing rectal surgery.
(33) Again, no significant differences in infectious complications
were found between the two groups 4% vs. 2% for both wound
infections and anastomotic leaks. It was difficult to determine the
effect on anastomotic leakage, as this study included patients who
did not undergo an anastomosis. Zmora et al. performed the larg-
est study thus far, a randomized prospective trial in 2003 which
included 415 patients separated into mechanical bowel prep with
polyethylene glycol vs. no bowel prep.(34) Once again surgical
infectious complications did not significantly differ between the
two groups with the wound infection rate 6.4% for patient who
underwent a mechanical bowel prep vs. 5.7 for those who did not.
Similar results were seen with regards to anastomotic leak rate
3.7% vs. 2.1%. Fa-Si-Oen et al. performed a well-designed mul-
ticenter randomized controlled trial published in 2005.(35) Left-
sided colonic resections accounted for approximately half of the
procedures. This was distinctive, given the current thinking that
right-sided anastomosis are generally safe. No significant differ-
ence in wound infection or anastomotic leak was detected, but the
method of determining a wound infection was performed incor-
rectly in 65 patients which might have therefore affected the valid-
ity of the results.
Bucher et al. published a randomized control study in 2005
which again compared the outcome of patients who underwent
left-sided colorectal surgery with or without mechanical bowel
prep.(36) 153 patients were randomized into mechanical bowel
preparation (MBP) with polyethylene glycol vs. no prep. The overall
rate of abdominal infectious complications was 22% in the prepped
group vs. 8% in the unprepped. Anastomotic leak occurred in 6% in
the prepped group vs. 1%. Interestingly hospital stay was longer for
patient who had MBP, 14.9 days vs. 9.9 in the nonprepped. This was
a multicenter trial which the authors agree may partially bias the
results. The conclusion was that left-sided colorectal surgery could
be performed safely without MBP and that MBP might have a nega-
tive impact on the complication rate and hospital stay.(Table 2.3)
Additional evidence against the use of mechanical bowel prep
has arisen from the literature regarding urgent surgery for trau-
matic colon injuries. A retrospective review by Conrad et al. was
performed in 2000 which evaluated 145 patients with penetrat-
ing colon injuries.(33) Two separate time periods were com-
pared, the latter of which included a significantly larger number
of primary repairs compared to proximal diversions. The colonic
injuries were distributed equally between the right and left colon.
Anastomosis of the unprepped bowel appeared safe with only
one anastomotic leak in the study. Other infectious complica-
tions showed no statistical difference between the two periods.
The main focus of this study was to evaluate the safety of primary
anastomosis vs. fecal diversion; however it also revealed the safety
of an anastomosis in unprepped bowel.
A Cochrane review was performed in 2004 as a meta-analysis
to analyze the effectiveness and safety of prophylactic mechanical
bowel preparation for morbidity and mortality rates in elective
colorectal surgery.(39) Out of 1159 patients with anastomoses, 576

Table 2.3  Mechanical Bowel Prep Randomized Controlled Trials.

Zmora 2003 (34) Fa-Si-Oen 2005 (35) Ram 2005 (37) Bucher 2005 (36) Miettinen 2000 (33)

Patients 415 250 329 153 267

Patients
  (MBP/no MBP) 187/193 125/125 164/165 78/75 138/129
Mean age
  (MBP/no MBP) 68/68 68/70 68/68 63/63 61/64
Cancer %
  (MBP/no MBP) 78/78 90/92 75/88 32/28 46/55
L colon surgery %
  (MBP/no MBP) 68/72 48/58 89/85 100/100 45/47
Type of prep PEG PEG NaPO4 PEG PEG
Anastomotic leak %
  (MBP/no MBP) 3.7/2.1 (NS) 5.6/4.8 (NS) 0.6/1.2 (NS) 6/1 (NS) 4/2 (NS)
Wound infection %
  (MBP/no MBP) 6.4/5.7 (NS) 7.2/5.6 (NS) 9.8/6.1 (NS) 13/4 (NS) 4/2 (NS)
Intraabdominal abscess %
  (MBP/no MBP) 1.1/1 (NS) Not given 0.6/0.6 (NS) 1/3 (NS) 2/3 (NS)


 preoperative bowel preparation
received mechanical bowel prep and 583 underwent no prep. There
was no difference in anastomotic leak rates for low anterior resec-
tion (12.5 vs. 12%), or colonic surgery (1.2 vs. 6%) in patients with
or without MBP. Anastomotic leak rates were significantly lower
overall without MBP (5.5 vs. 2.9%). Wound infection, peritonitis,
reoperation, mortality, and extra abdominal complications were
similar between groups. The authors’ conclusion was no convinc-
ing evidence exists that MBP is associated with reduced rates of
anastomotic leakage after elective colorectal surgery and that MBP
may be associated with an increased rate of anastomotic leakage
and wound complications. No definitive conclusion on compli-
cation rates was possible due to the clinical heterogeneity of trial
inclusion criteria, poor reporting of concealment and allocation,
potential performance biases, and failure-to-treat analyses.(39)
One other important consideration when evaluating MBP is
the patient’s experience. A 2007 study from Sweden performed by
Jung et al. evaluated 105 patients who underwent elective colon
surgery.(40) 60 patients received MBP with half receiving poly-
ethylene glycol and the remainder receiving sodium phosphate.
52% in the MBP group required assistance via hospital staff or a
relative with the prep. Only 30% of the MBP group would con-
sider undergoing the same preoperative procedure. There was no
significant difference in postoperative pain and nausea; however,
patients in the no MBP group had more pain on postoperative
day #4. This was thought to be due to patient’s regaining bowel
function earlier compared to the no MBP group.
Despite the growing evidence against MBP, there are sev-
eral benefits unrelated to the risk of infection. A prepped colon
is easier to palpate and manipulate, and allows the surgeon to
identify smaller tumors and perform intraoperative colonos-
copy if required. During laparoscopy, it may reduce the risk of
traumatic bowel injury of an otherwise heavy, fecal loaded colon
being manipulated by relatively traumatic laparoscopic grasping
instruments. However, the overall data from randomized tri-
als and meta-analyses clearly show the safety of performing an
anastomosis in unprepared bowel and the lack of benefit of MBP
toward infectious complications.
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tion after elective colorectal resection. Ann Surg 2004; 239:
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  2. National Academy of Science NRC. Postoperative wound
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  3. Bratzler DW, Houck PM. Antimicrobial prophylaxis for
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  4. Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic
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  7. Dearing WH, Needham GM. The effect of terramycin on the
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  9. Clarke JS, Condon RE, Bartlett JG et al. Preoperative oral
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10. Bartlett JG, Condon RE, Gorbach SL et al. Veterans admin-
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15. Skipper D, Karran SJ. A randomized prospective study to
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16. Zanella E, Rulli F. A multicenter randomized trial of prophy-
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J Antimicrob Chemother 1989; 24 (Suppl B): 195–202.
19. Corman M, Robertson W, Lewis T et al. A controlled clinical
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3 Anesthesia and intraoperative positioning
Lebron Cooper and Larry R Hutson

challenging case patient with a pulmonary history who uses supplemental oxy-
A 47-year-old male is undergoing a transanal excision of a rectal gen. Bear in mind that while the patient may only be receiving
­villous adenoma under intravenous sedation and local infiltration local anesthesia in an office setting, the patient may be under
of xylocaine. During the procedure the patient complains of light- self-administered mild sedation. Any degree of sedation blunts
headedness and numbness of the tongue. The anesthesiologist the body’s response to hypoxia and hypercarbia, and while a rest-
notices bradycardia and hypotension. less patient may ­simply be a restless patient, there is always the
possibility that the patient is agitated due to relative hypoxia or
case management hypercarbia.
Xylocaine toxicity is suspected. The patient should be moved to One must always keep in mind the possibility of local anesthetic
the supine position and supported with supplemental oxygen via toxicity when using these drugs. The typical doses used for local
mask. The patient’s blood pressure is supported with intravenous infiltration in colorectal procedures are far below the threshold
fluid and epinephrine. needed for systemic toxicity (Table 3.1). However, accidental intra-
venous or intraarterial injection could result in systemic toxicity.
introduction As such, it is important to recognize the signs and symptoms of
The American Society of Anesthesiologists (ASA) defines anesthe- systemic toxicity when they first appear, as toxicity progresses in a
siology as a discipline within the practice of medicine that special- dose-dependent fashion.
izes in the (1) medical management of patients who are rendered At lower plasma concentrations, the patient begins to experi-
unconscious and/or insensible to pain and emotional stress ­during ence central nervous system (CNS) toxicity characterized by light-
surgical, obstetric, and certain other medical procedures; (2) protec- headedness, tinnitus, and numbness of the tongue. As plasma
tion of life functions and vital organs under the stress of anesthetic, concentrations increase, the patient begins to experience CNS
surgical, and other medical procedures; and (3) management of excitation, resulting in seizures, followed by unconsciousness,
problems in pain relief (1). In this chapter, we will be discussing the coma, and ­respiratory arrest. At higher plasma concentrations,
various kinds of anesthesia used in the operating room for colorec- cardiovascular (CV) toxicity occurs, as the local anesthetic blocks
tal surgery, including their relative benefits and risks. Additionally, sodium channels of the myocardium.
we will be discussing new treatments for postoperative pain relief, Relative potency of the local anesthetic plays a role here.
as well as one of the more visible risks of anesthesia—awareness Lidocaine toxicity will result in bradycardia and hypoten-
under anesthesia. We will also discuss the new Surgical Care sion before cardiac arrest, while the longer acting, more potent
Improvement Project (SCIP), including prophylactic antibiotic bupivicaine often results in sudden cardiovascular collapse due to
administration within 1 hour of surgical incision, and the proper ventricular dysrhythmias. Maintenance of perfusion and venti-
positioning and padding of patients for colorectal surgery. lation through prolonged cardiopulmonary resuscitation (CPR)
is the key, as the patient will not convert into a life-sustaining
anesthesia cardiac rhythm until the local anesthetic has had a chance to
Local Anesthesia completely dissociate from the sodium channels of the conduct-
The earliest local anesthetic used was cocaine (prepared in weak ing system of the heart. Cardiopulmonary bypass may even be
solutions and injected in high volumes) for field block at the turn considered. Dissociation of local anesthetic from sodium chan-
of the 19th century.(2) However, the toxicity of cocaine, its irritant nels has been shown to take a considerable length of time, and
properties, and its strong potential for physical and psychological prolonged, intensive, and continuous support is warranted.
dependence led to the development of alternative local anesthetics.
Many of these—such as lidocaine—are still used today, as much as Table 3.1  Local anesthetic drugs.
half a century after their introduction.(3)
Maximum Maximum Dose
While there are relatively few instances in colorectal surgery
Agent Onset Duration Dose with Epinephrine
where it is used as the sole anesthetic, local anesthesia still has a
place. It requires, however, a cooperative patient who can remain Tetracaine 30 seconds 30–60 minutes 400 mg
immobile for both the infiltration of the local anesthetic, as well Lidocaine 2–5 minutes 30–45 minutes 5 mg/kg 7 mg/kg
as for the actual procedure itself. Mepivacaine 7–15 minutes 2.5 hours 400 mg
It is important to be cognizant of the patient’s underlying Prilocaine 2 minutes 2.5 hours 80 mg
health status and the position that the patient will be in for the Bupivicaine 30 minutes 2 hours 2 mg/kg 4 mg/kg
procedure. A healthy patient in their mid-20s can tolerate the Procaine 5–10 minutes 15–30 minutes 10 mg/kg
prone jack-knife position much better than an obese geriatric


 improved outcomes in colon and rectal surgery

Treatment of CNS toxicity, including the cessation of seizure (a)

activity, is with the use of benzodiazepines, propofol, or thiopental.
Treatment of CV toxicity is supportive in nature, and may require
electric cardioversion, epinephrine, and magnesium.(4)
Systemic toxicity following local anesthetic administration is
thankfully rare. More common, however, is inadequate analgesia
following local anesthetic infiltration. This can be multifactorial in
nature. Inadequate analgesia resulting from insufficient quantities
placed in the correct location is easily resolved with the addition
of further local anesthetic at the site. Inadequate analgesia can also
result from tachyphylaxis to local anesthetics, which is defined as
repeated injection of the same dose of local anesthetic leading to
diminishing efficacy. Additionally, inadequate analgesia can be a
consequence of the tissue pH into which the local anesthetic is
injected. Local anesthetics exist in both an ionized and nonion-
ized state; it is only in the nonionized state that local anesthetics
can penetrate the nerve sheath, thus producing analgesia. In an
acidic environment (i.e., an infected pilonidal cyst), more of the
anesthetic is converted into the ionized state, leading to far less
of the nonionized form available to produce analgesia. It is not
uncommon for infected tissues to prove nearly impossible to be
rendered totally insensitive despite more than adequate amounts
of local anesthetic infiltration.
A perianal block (Figure 3.1) can be performed with the
patient in either the prone or lithotomy position and provides (b)
relaxation of the sphincter as well as anesthesia. The anesthetic
solution of choice is infiltrated in a fan fashion from the lateral
positions to superficially encompass the anal margin. Emphasis
should be placed in the posterolateral positions where the greatest
concentration of nerves is found. A finger or retractor is placed
within the canal. At the anterior, posterior, and lateral positions
anesthetic is injected submucosally or intramuscularly through
the previously infiltrated tissue. The needle is held parallel to the
finger, with care to avoid entering the canal.

Monitored Anesthetic Care (MAC)

MAC is defined by the ASA as “a procedure in which an anesthe-
siologist is requested or required to provide anesthetic services,”
and includes (1) the diagnosis and treatment of clinical problems
during and immediately following the procedure; (2) the support
of vital functions; (3) the administration of sedatives, analgesics,
hypnotics, anesthetic drugs, or other medications necessary for
patient safety; (4) physical and psychological comfort; and (5)
the provision of other services as needed to complete the proce- Figure 3.1  Technique for anal block. (A) perianal view of submucosal injection.
dure safely (5). When it comes to the care of a patient undergoing (B) saggital view of injection of anal canal.
MAC, all of the precautions and equipment needed to perform
a safe general anesthetic must be present, as it is always possible
that an escalation of care will be needed. While uncommon, it is as well. While most patients will be able to tolerate a lithotomy
possible that a patient cannot safely undergo a MAC for a specific or prone position without problem, there are some patients who
procedure. Most commonly this is due to the inability to safely are unable to tolerate these positions without endotracheal intu-
prevent a patient from moving in response to painful stimuli bation, positive pressure ventilation, and high oxygen concen-
without producing oversedation and/or apnea. Some patients, trations. Additionally, there are those patients who are unable to
when undergoing MAC, tend to have no middle ground between understand or comply with the requirement that they must remain
moving in response to stimuli and airway obstruction or com- immobile. Young children, mentally challenged, or extremely ill
plete apnea, requiring intervention by the anesthesiologist. patients are prime examples of poor candidates for MAC.
The same limits of positioning and patient tolerance that were There is an erroneous perception on the part of patients—and
discussed with local anesthetics apply to procedures under MAC even physicians—that a patient undergoing MAC is at decreased


 anesthesia and intraoperative positioning
risk for serious anesthesia-related complications when compared
to general anesthesia, that MAC is safer. This can best be appre-
ciated by examining the ASA Closed Claims Project database.
The ASA Closed Claims Project is a structured evaluation of all
adverse anesthetic outcomes obtained from the closed claim files
of 35 professional liability insurance companies in the United
States. A 2006 review showed more than 40% of claims associ-
ated with MAC involved death or permanent brain damage,
which was similar to the percentage seen in claims associated with
­general anesthesia. Respiratory depression was the most common
(21%) damaging mechanism, nearly half of which were judged to
be preventable through better monitoring.
Cardiovascular events comprised another 14% of the claims
made in patients undergoing MAC, which was similar in frequency
to that seen following general anesthesia. The average payment
made to a plaintiff in these cases was $159,000 (U.S.).(6) So, while
we would like to think that MAC is safer than a general anesthetic
for patients, in fact the risk of significant injury and death are
­similar between the two anesthetic types.
­epidural anesthetic. While epidural anesthesia can be used as the
Regional Anesthesia
Central Neuraxial Blockade
Regional anesthesia encompasses a wide variety of peripheral and
central neuraxial blocks, many of which do not pertain to color-
ectal surgery. The most common regional anesthesia technique
applied in colorectal surgery is the spinal, or intrathecal, block-
ade. The spinal block is relatively easy to place, has a fast onset
of sensory and motor blockade, and has a predictable length of
efficacy. This is a very old technique, dating back to the late 1800s,
when it was performed using cocaine as the anesthetic agent, to
great amazement of surgeons of the day.(2)
With the advent of newer local anesthetics, we can now tailor
the duration of the spinal blockade to the projected length of the
surgery by varying the type and amount of local anesthetic used.
The goal is to provide adequate analgesia for the duration of the
procedure, yet allowing safe ambulation and encouraging urination
within a short time frame after cessation of surgery.
There are three different densities of the medications used:
hyperbaric, isobaric, and hypobaric. Hypobaric local anesthetics
are less dense than normal cerebrospinal fluid (CSF), which allows
these medications to rise in the CSF following injection. This is
commonly used for perineal procedures that will be performed
in the prone jack-knife position. The local anesthetic is injected
into the intrathecal space, and the patient is immediately placed
in the jack-knife position to allow the hypobaric solution to drift
upward, or caudad. After approximately 5 minutes, the spinal
anesthetic will have “set up”, meaning the uptake and distribution
of the local anesthetic across nerve membranes has occurred. No
further migration of the drug should occur at this point.
By adding a small amount of glucose to the local anesthetic used,
the solution will become hyperbaric. The density of the solution will
cause it to sink in relation to the CSF.(7) An alternative approach
to perineal analgesia performed in the prone jack-knife position is
performing the intrathecal block using a hyperbaric solution, then
keeping patients in the sitting position for 5 minutes to allow the
spinal anesthetic to sink caudad, thus blocking the ­lumbosacral
nerves. Once the block has “set up,” the patient is placed in the
prone jack-knife position. These two techniques have allowed the
use of significantly less local anesthetic for the spinal anesthesia,
compared to isobaric solutions, which have the same density as CSF.
Isobaric solutions require a higher dose of local anesthetic to evenly
distribute throughout the CSF, resulting in a larger volume needed
to achieve the same blockade of the lumbosacral nerves. The ben-
efits related to reducing the total amount of local anesthetic injected
are a decreased risk of toxicity, along with providing adequate
analgesia,and allowing faster recovery of motor function.
A caudal anesthetic is the placement of a local anesthetic and/
or narcotic into the epidural space from an approach through
the sacral hiatus. This is typically performed in either the prone
or lateral position. While uncommon in adults, this procedure is
used frequently in children, where the caudal space is more easily
accessible and a relatively safe and easy approach to infuse local
anesthetic and/or narcotic for postoperative analgesia while still
under general anesthesia.
The third and final type of central neuraxial block is the
sole anesthetic for colorectal procedures, it is more common to
place a catheter within the epidural space to provide analgesia
during and after the procedure. The location of the block is deter-
mined by the anesthesiologist based on several anatomic factors;
however, a thoracic approach has been shown to be more effec-
tive in reducing postoperative ileus and early return of bowel and
bladder function than a lumbar approach.(8)
Most commonly, patients will receive a postoperative continu-
ous infusion of a local anesthetic and narcotic mixture through the
epidural catheter. In addition, they may be given the opportunity
to provide themselves small amounts of analgesia through their
epidural catheter on demand. This is termed patient-controlled
epidural analgesia (PCEA), and it provides excellent pain control
while minimizing the undesirable side effects typically seen with
intravenous narcotics. Provided the patient does not manifest signs
of systemic infection, the epidural catheter can remain in place for
several days following surgery if needed to control pain. This ben-
efit must be weighed against the risk of withholding anticoagulant
prophylaxis and a possible resultant thromboembolic event.
While initial studies examining PCEA were performed using
lumbar epidural, more recent studies have examined the impact of
thoracic epidural analgesia on patients undergoing elective color-
ectal surgery. In a study in 2001, Carli et al. reported 42 patients
undergoing open large bowel resection, randomized to receive
either an intravenous Patient Controlled Analgesia (ivPCA) mor-
phine or a thoracic (T7-8) epidural with bupivicaine and fentanyl.
Patients who received thoracic epidural had distinctly superior
analgesia as compared to the ivPCA morphine group; time to first
flatus and first bowel movement occurred, on average, 36 hours
sooner in the epidural group, and time to readiness to discharge
was the same in both groups.(8) In 2007, Taqi et al. examined tho-
racic epidural analgesia compared to postoperative intravenous
morphine for laparoscopic colectomy. Recovery from postopera-
tive ileus occurred sooner in the epidural group by 1 or 2 days, and
a full diet was resumed earlier. The epidural group experienced
significantly less pain at rest, with coughing, and with ambula-
tion.(9) These studies demonstrate the effectiveness of thoracic
epidural analgesia and its superiority in allowing early return of

 improved outcomes in colon and rectal surgery
bowel function, ability to resume a full diet, and early ambulation,
as compared to intravenous narcotics.
All three of these techniques—spinal, caudal, and epidural—
have one thing in common: contraindications. Specifically, abso-
lute contraindications to neuraxial techniques include patient
refusal, infection at the planned site of needle puncture, elevated
intracranial pressure, and bleeding diathesis. There are also several
relative contraindications. Bacteremia raises the concern that the
needle puncture site of the neuraxial block might allow an epidural
abscess or meningitis to develop; however, a clinical scenario may
exist where the need to avoid a general anesthetic might outweigh
the small risk of such occurring.
While chronic back pain is not a contraindication to neuraxial
techniques, patients with underlying neurological disease should
be considered carefully, as neuraxial blockade might exacer-
bate their condition, such as in multiple sclerosis. The presence
of cardiac disease also indicates that caution should be applied,
as patients who receive a neuraxial block typically experience
a sudden decrease in lower extremity vascular tone, leading to
rapid vasodilation and a significant decrease in systemic vascular
resistance. The resultant precipitous drop in systolic and diastolic
blood pressure can be extremely dangerous, or even deadly, in
patients with severe coronary artery disease, aortic stenosis, and
idiopathic hypertrophic subaortic stenosis (IHSS). It is still argu-
able whether the presence of IHSS or aortic stenosis is an absolute
contraindication to neuraxial blockade, and many centers avoid
them in the presence of these coexisting morbidities.
The final relative contraindication is abnormal coagulation sta-
tus. Patients with abnormal coagulation—either due to endogenous
factors such as liver disease or thrombocytopenia, or due to the
administration of anticoagulants—must be considered carefully.
Additionally, patients who are receiving or will be receiving anti-
coagulants postoperatively have different needs than patients who
receive a general anesthetic alone. For spinal and caudal anesthesia,
the greatest risk of spinal hematoma (a neurosurgical emergency)
occurs at the time the block is placed. For epidural anesthesia, the
risk of hematoma formation is just as great at the time of epidural
catheter removal as during placement. As a result, certain guidelines
should be instituted in order to reduce the risk of spinal hematoma
formation upon removal of the epidural catheter.
Heparin is often administered perioperatively as prophylaxis
against deep vein thrombosis formation. While the effect of
intravenous heparin administration is immediate, subcutaneous
administration requires 1–2 hours to effect a change on coagula-
tion. Small doses of heparin administered before surgery for DVT
prophylaxis are not a concern in terms of risk of spinal hematoma
formation.(10) Postoperatively, subcutaneous DVT prophylaxis
dosing twice daily of heparin while an epidural catheter is in place
is acceptable. The catheter is removed 2 hours before the next
heparin dosing to maximize safety.
Therapeutic heparin, however, is a different matter. Ruff et al.
demonstrated that neuraxial procedures performed <1 hour after
heparin therapy is discontinued resulted in a 25-fold increase in
spinal hematoma.(11) The effect is even more pronounced if the
patient also received aspirin.
Low-molecular weight heparin (LMWH) was introduced in
1993 as an alternative to heparin prophylaxis for prevention of

DVT. There have been numerous reports of spinal hematoma in
patients receiving LMWH with a neuraxial blockade. For patients
receiving low-dose LMWH for thromboprophylaxis preopera-
tively, it is recommended that neuraxial anesthesia occur at least
12 hours after the last dose. In patients who are receiving high-
dose LMWH, neuraxial anesthesia should be delayed for 24 hours
after the last dose. Postoperatively, the typical prophylactic twice-
daily dosing of LMWH should only begin 24 hours after the neu-
raxial block, and any epidural catheter should be removed before
initiation of twice-daily dosing. Once-daily thromboprophylactic
dosing, however, can safely occur with an epidural catheter in
place, provided that the first dose occurs at least 8 hours follow-
ing the initial blockade and that any epidural catheter is removed
12 hours after the last dose before its removal.(12)
Warfarin therapy is another concern. Warfarin anticoagulation
must be stopped 4–5 days before surgery, and the PT/INR assessed
before surgery. Anticoagulation with warfarin can be used for
thromboprophylaxis in patients with an indwelling ­epidural
catheter, though the catheter should be removed while the INR is
still <1.5. Typically, this is approximately 36 hours following the
initial administration of warfarin. Neurologic and motor testing
should be routinely performed on these patients.(12)
All three of the neuraxial techniques have possible side effects.
Patients can become hypotensive, as their systemic vascular
resistance decreases. This is due to the sympathectomy caused
by blockade of sympathetic fibers along the thoracic sympathetic
chain. Rarely, patients can develop an unintentionally high spinal
anesthetic, leading to bradycardia, apnea, and even loss of con-
sciousness. This “high spinal” must be treated as a general anes-
thetic, with immediate securing of the airway with endotracheal
intubation and supportive therapy until the local anesthetic is
metabolized.
Some patients can experience mild back pain at the site of
needle placement, especially when multiple attempts are needed
to place the block. Post Dural Puncture Headache (PDPH) can
occur, typically following inadvertent dural puncture with an
­epidural needle—a ‘wet tap’. These headaches are characterized
by a slow leak of CSF from the puncture, leading to a headache
that is strongest when standing and lessened when lying. They
are often treated conservatively with oral fluid therapy, oral caf-
feine, and remaining recumbent. Should there be no relief after a
couple of days of conservative treatment, an epidural blood patch
can be performed. 20 mL of sterile, autologous blood is injected
into the epidural space, resulting in thrombus formation, sealing
of the dura, and cessation of CSF leak. If the diagnosis of PDPH is
correct, there is typically immediate relief of symptoms. Epidural
abscess and meningitis are possible if proper sterile technique is
not used, or if systemic infection is present.(7)
Transversus Abdominis Plane (TAP) Block
The TAP block is a relatively new procedure for blocking the
abdominal wall afferent nerves by way of the lumber trian-
gle of Petit. It can be performed using a landmark technique or
under ultrasound guidance; 20 mL of 0.375% of bupivicaine or
­levobupivicaine is then injected into the transversus abdominis
neurofascial plane.(13, 14, 15) In a prospective, randomized
controlled trial, McDonnell et al. reported patients undergoing
 anesthesia and intraoperative positioning
large bowel resection who received the TAP block required 75%
less morphine in the first 24 hours, and had significantly lower
pain scores at all time points over the first 24 hours. Additionally,
these patients experienced significantly less postoperative nausea
and vomiting.(13) This is an excellent block for patients having
smaller abdominal procedures, e.g., ventral hernia repair, on an
outpatient basis.
Ilioinguinal and Iliohypogastric Nerve Block
These are field blocks of the terminal branches of the lumbar plexus,
primarily from the L1 root. These blocks are relatively simple to
perform and provide anesthesia in the inguinal and genital region.
A 22-gauge needle is inserted 3 cm medial and 3 cm inferior to the
anterior superior iliac spine, in a cephalolateral direction through
the abdominal muscles until contact is made with the iliac bone. As
the needle is removed, local anesthetic solution is injected. This is
repeated 1–2 more times to cover a fan-shaped area, for a total of
approximately 10–20 mL of local anesthetic.(16)
Awareness Under Anesthesia
Awareness under anesthesia is a rare complication of anesthesia,
but one which has risen to prominence in the public eye recently.
Studies of large numbers of patients in Sweden demonstrated an
overall incidence of 0.16%.(17) One can imagine that this would
be a distressing event; the frequency of posttraumatic stress dis-
order (PTSD) in the 2 years following an incident of awareness
under anesthesia approached 50%, even if the patient was not
initially distressed by the incident. A similarly large study in
the United States found an overall incidence rate for confirmed
intraoperative awareness of 0.13%, and a rate of 0.24% of possi-
ble awareness.(18) It has long been known that awareness occurs
with greater frequency in emergent trauma surgery cases, cases
involving ­cardiopulmonary bypass, and emergency caesarean
sections. These are situations where patients may experience sig-
nificant hypotension, requiring a reduction in volatile anesthetic
agents below the level that ensures amnesia. If there is a ques-
tion whether a patient has had an episode of awareness under
anesthesia, it is imperative the anesthesiologist be contacted, and
the patient reassured. Psychiatric evaluation is usually necessary
to help the patient deal with the potentially ­distressing nature of
this complication.
A device available that attempts to determine the depth of
consciousness is the bispectral index (BIS), a monitor of anes-
thetic depth approved by the Food and Drug Administration in
the United States. The frontal EEG is measured, processed using
proven ­algorithms, and reported on an arbitrary scale of 0–100.
A total of 100 equates to completely awake and responsive, and
zero represents complete electrical silence of the brain. A BIS of
<60 is generally considered a safe level to ensure adequate depth
of anesthesia and lack of awareness under anesthesia. In the
B-Aware trial, patients at high risk for awareness under anesthe-
sia were randomized to two groups, either routine care or a
BIS-guided anesthetic. While the incidence of awareness among
even high-risk patients was very low, the BIS-guided group had a
reduced risk of awareness by 82%.(19)
However, there is controversy surrounding the reliability of the
BIS monitor. Use of the BIS monitor and maintenance within the
proper depth of anesthesia (as indicated by the BIS algorithm)
is still no assurance that the patient will not have an episode of
awareness, as there are numerous reports to the contrary.(20)
Additionally, there are numerous conditions that can influence
the BIS, causing BIS levels that are paradoxically high, such as
ketamine administration or the use of halothane, or paradoxi-
cally low, such as following nitrous oxide termination.(21) An
analysis of the ASA Close Claims Project database demonstrates
that between the years of 1961 and 1995 there were 79 claims for
awareness made in the United States; 18 claims for awake paraly-
sis, i.e., the inadvertent administration of a muscle relaxant to an
awake patient, and 61 claims for recall under general anesthesia,
i.e., recall of events while receiving general anesthesia. Most of
the claims for awake paralysis represented substandard care; less
than half of the claims for recall were the result of substandard
care. The majority of patients experienced temporary emotional
distress; 10% of patients were later diagnosed with PTSD. The
awareness of sound without pain was the most common intra-
operative event; 21% of patients experienced pain while aware
under anesthesia.(22)
positioning
Supine
This is the most common surgical position; it results in the least
hemodynamic and ventilatory changes and is frequently the best
position for surgical exposure. The supine position is not perfect,
of course, as it creates certain pressure points that, given time,
result in ischemia over certain bony prominences, such as the
heels, sacrum, and back of the head. The head should rest on a
soft support to spread the pressure, decreasing the incidence of
pressure points, thus preventing alopecia. Particular care must be
given to the arms, including careful padding of the elbows and
wrists. Abduction of the arms must not exceed 90 degrees from
the body to prevent compromising blood flow to the distal arm.
(23) Trendelenburg positioning while supine has several anes-
thetic implications, as it causes the diaphragm to move cephalad,
causing increased airway pressures and possibly advancing the
endotracheal tube into an endobronchial position.
Shoulder braces are sometimes used to prevent the patient from
sliding off the table during extreme Trendelenburg positioning,
though this can cause injury by compressing the brachial plexus.
(24) The most common upper extremity injury is to the ulnar
nerve, which is 3 times more likely in men who undergo general
anesthesia. This seems to occur despite padding of the extrem-
ity.(25) Other nerves at risk due to positioning are illustrated in
Figure 3.2.
Prone
Even when a procedure is planned in the prone position, induc-
tion of general anesthesia and intubation of the trachea should
occur in the supine position. The patient is then turned prone,
taking care to keep the cervical spine and head in-line with the
rest of the body. There are several different pillow types that allow
for proper positioning of the head in a neutral position with the
remainder of the body, while keeping the eyes, nose, and chin free
from pressure.

 improved outcomes in colon and rectal surgery
Figure 3.2  Nerves at risk for injury during positioning for a surgical procedure.
There is a low, but significant risk that pressure on the eye or
surrounding orbit will lead to increased intraocular pressure,
decreased retinal artery blood flow, and resultant blindness, if
the intraocular pressure exceeds systemic pressure. Although this
is a rare complication associated with the prone position, it is
­nevertheless, devastating. Extreme care must be taken to avoid
this life-changing occurrence.
The thorax should be supported with chest rolls that extend
from the clavicle to the iliac crest. The arms can be placed at the

side of the body in a neutral position, with careful padding of the
elbows to prevent injury. Alternatively, the arms can be positioned
along side the head, taking care that the arms are not abducted
>90 degrees to prevent injury to the brachial plexus.(23, 24) Great
care must be taken to not inadvertently dislodge the endotracheal
tube while prone, as it is exceedingly difficult to reintubate or mask
ventilate a patient in the prone position.
Lateral Decubitus
Just as with prone positioning, it is imperative that the head be kept
in a neutral positioning while turning the patient. Additionally,
extra cushioning is needed under the head to keep the cervical
and thoracic spines in line. An axillary roll needs to be placed
just caudad to the dependent axilla in order to prevent compres-
sion injuries to the brachial plexus. It should not be placed in the
axilla, as the purpose is for the weight of the thorax to be borne
by the chest wall. The dependent arm is extended perpendicular
to the body on a padded armboard, while the nondependent arm
is similarly extended on an armrest suspended in such a way that
the arm is not abducted >90 degrees from the body. Additionally,
the arm should not be raised superior to the level of the deltoid.
A pillow or cushion should be placed between the knees.(23, 24)
Lithotomy
The lithotomy position is very common in colorectal surgery. The
hips are flexed 80–100 degrees from the trunk, and the legs are
abducted 30–45 degrees from midline. It is important that the legs
always be moved simultaneously to prevent lumbar spine torsion,
and that the legs be carefully padded to reduce the risk of injury.
In a retrospective review of patients undergoing surgery in the
lithotomy position, Warner et al. found that the most common
lower extremity nerve injury was to the common peroneal nerve,
accounting for 78% of nerve injuries. It was postulated that the
cause was compression of the nerve between the leg support and
the lateral head of the fibula.(26)
While rare (1 in 8,720), the incidence of compartment ­syndrome
of the lower extremities is markedly higher in the lithotomy posi-
tion than all other surgical positions. Compartment syndrome
occurs when high tissue pressure builds within the closed space of
the anterior compartment. Ischemia of the tissue in the compart-
ment results in edema of the interstitium, thereby raising com-
partment pressure. Since perfusion is dependent on compartment
pressure being lower than mean arterial pressure to allow tissue
perfusion, any situation where increased compartment pressure
and/or decreased arterial flow into the tissue can result in ischemia.
The result is capillary endothelial damage and even greater inter-
stitial edema. Unfortunately, it is not completely understood why
some patients develop a compartment syndrome, while others
do not. As a result, no safe maximum time limit can be defined.
(27) Early diagnosis and treatment with fasciotomy is imperative.
Analysis of closed claims in cases of compartment syndrome due
to the lithotomy position during colorectal surgery demonstrated
an average indemnity payment of $426,000.
Great care must be taken in the positioning and padding,
as patients themselves cannot express any pain or discomfort
they may be experiencing while under general or regional
anesthesia.
 anesthesia and intraoperative positioning
surgical care improvement project
Process and Outcome Measures
The Surgical Care Improvement Project (SCIP) of the United
States is a national quality initiative involving the American
Society of Colorectal Surgeons, the American College of Surgeons,
the American Society of Anesthesiologists, the American Hospital
Association, the Association of Perioperative Registered Nurses,
and a host of governmental agencies dedicated to improvement
in healthcare.(28) The goals of the SCIP partnership are to reduce
the incidence of surgical complications by 25% by the year 2010,
and to promote the use of evidence-based care processes known
to reduce surgical complications.
Out of approximately 40 million major operations each year,
postoperative complications account for up to 22% of preventable
deaths among patients, depending on the complication. These
complications accounted for 2.4 million additional hospital days
and $9.3 billion (USD) in additional charges each year.(29)
SCIP focuses on areas where the incidence and cost of the most
common and preventable complications are high:
Surgical Site Infections (SSIs)
Adverse Cardiac Events
Venous Thromboembolism
Postoperative Pneumonia
Although not limited to anesthesia care, the anesthesiologist and
colorectal surgeon must partner in attempts to meet the expecta-
tions set by the national SCIP initiative.
One such initiative is the administration of prophylactic anti-
biotics within 1 hour of surgical incision. Although not typically
considered “anesthetic agents”, antibiotics may best be given
within 1 hour of incision if administered by the anesthesia pro-
vider. Frequent operating room and turnover delays may result
in an antibiotic administration well-before the 1 hour limit if
given by in the preoperative holding area. Late patient arrivals for
same-day admit surgery or administrative paperwork delays may
result in inadequate or insufficient time to infuse the antibiotic
before going to the operating room (OR), with the result of no
antibiotic being given or being given only if the “missed dose” is
noticed by someone in the OR.
Although no longer reportable as public information, prophy-
lactic antibiotic selection for surgical patients is monitored, as is
discontinuation of the antibiotic within 24 hours after the surgery
end time (48 hours for cardiac surgery patients). If an antibiotic
if felt to be needed beyond the allowed 24 hours, the colorectal
surgeon must document, in the medical record, the reason for the
continuation of the antibiotic.
Another SCIP initiative that is frequently met or monitored
by the anesthesiologist is perioperative beta blockade. By having
patients see an anesthesiologist preoperatively for assessment
and clearance for anesthesia, the anesthesiologist can begin beta
blockers on all patients who are not already on them.
Venous thromboembolism was discussed above, and involve-
ment of the anesthesiologist and associated regional anesthesia
play a significant role here. As previously mentioned, an epidural
catheter must be removed at an appropriate time surrounding the
initiation and discontinuation of heparin, LMWH, or warfarin.
The risks of inadequate venous thromboembolism prophylaxis
must be weighed against the benefits of regional anesthesia for
colorectal surgical patients.
Postoperative pneumonia is a complication where the cause is
multi-factorial. Ventilator management and weaning protocols
for patients requiring postoperative mechanical ventilation may
fall under the purview of the anesthesiologist.
conclusion
Although the sum total of anesthesia practice can hardly be related
in a textbook chapter, we have attempted in the preceding pages
to highlight areas in anesthesia practice of which the colorectal
surgeon should be aware. Improved patient satisfaction through
reduction of postoperative pain, earlier ambulation, and quicker
return of bowel function and diet will have a marked impact
on surgical outcomes. Thoracic epidural anesthesia/analgesia is
becoming a standard for many colorectal surgical procedures,
whether as the sole anesthetic, or in conjunction with general
anesthesia.
Awareness under anesthesia is a rare, but serious concern, high-
lighted more recently in the media and receiving much greater
appreciation among surgical patients. Supportive care, including
psychological counseling may improve outcome and reduce the
incidence of posttraumatic stress disorder.
Oversedation resulting in hypoventilation, hypoxemia, and
hypercarbia can produce devastating results. Extreme caution must
be given to the patient who is restless, but sedated. Loss of airway is
the ultimate disaster under general anesthesia, and is a surgical, as
well as anesthetic, emergency.
Proper positioning requires the vigilance of the anesthesia
provider, the colorectal surgeon, and the operating room nurses.
Severe nerve injuries can generally be avoided with the use of
padding. Although even with appropriate padding, there is an
increased incidence of neurologic injury with the use of stirrups
in the lithotomy position.
Extra care must be taken of the patient in the prone position,
as neck injuries from improper turning, endotracheal tube dis-
lodgement, or perioperative blindness from periorbital pressure
can all result in devastating outcomes.
Partnership of the surgeon and the anesthesiologist may help
improve outcomes, reduce surgical site infections, improve periop-
erative cardiac morbidity and mortality, and reduce the incidence of
venous thromboembolism. Whether in the office setting, outpatient
center, or surgical hospital, safe anesthesia practice is paramount.
references
  1. Stoelting RK, Miller RD. Scope of Anesthesia Practice in
Basics of Anesthesia. Fifth Edition. Philadelphia: Churchill
Livingstone Elsevier, 2007: 11.
  2. Hutson LR, Vachon CA, Dr. Rudolph M. Innovator and pio-
neer in anesthesiology. Anesthesiology 2005; 103(4): 885–9.
  3. Stoelting RK, Miller RD. Local Anesthetics in Basics of
Anesthesia. Fifth Edition. Philadelphia: Churchill Livingstone
Elsevier, 2007: 123–34.
  4. Barash PG, Cullen BF, Stoelting RK et al. Local Anesthetics in
Clinical Anesthesia. Fifth Edition. Philadelphia: Lippincott
Williams & Williams, 2006: 449–67.

 improved outcomes in colon and rectal surgery
  5. Stoelting RK, Miller RD. Choice of Anesthetic Technique in
Basics of Anesthesia. Fifth Edition. Philadelphia: Churchill
Livingstone Elsevier, 2007: 178–84.
  6. Bhananker SM, Posner KL, Cheney FW et al. Injury and
liability associated with monitored anesthesia care: a closed
claims analysis. Anesthesiology 2006; 104: 228–34.
  7. Stoelting RK, Miller RD. Spinal and Epidural Anesthesia in
Basics of Anesthesia. Fifth Edition. Philadelphia: Churchill
Livingstone Elsevier, 2007: 241–71.
  8. Carli F, Phil M, Trudel JL et al. The effect of intraoperative
thoracic epidural anesthesia and postoperative analgesia on
bowel function after colorectal surgery. Dis Colon Rectum
2001; 44(8): 1083–9.
  9. Taqi A, Hong X, Mistraletti G et al. Thoracic epidural analgesia
facilitates the restoration of bowel function and dietary intake
in patients undergoing laparoscopic colon resection using a
traditional, nonaccelerated, perioperative care program. Surg
Endoscopy 2007; 21: 247–52.
10. Liu SS, Mulroy MF. Neuraxial anesthesia and analgesia in the
presence of standard heparin. Reg Anesth Pain Med 1998; 23:
157–63.
11. Ruff RL, Dougherty JH. Complications of anticoagulation
followed by anticoagulation. Stroke 1981; 12: 879–81.
12. Horlocker TT, Wedel DJ, Benzon H et al. Regional Anesthesia
in the Anticoagulated Patient: Defining the Risks (The Second
ASRA Consensus Conference on Neuraxial Anesthesia and
Anticoagulation) http://www.asra.com/consensus-statements/
RAPM-Anticoagulation.pdf.
13. McDonnell JG, O’Donnell B, Curley G. The analgesic effi-
cacy of transversus abdominis plane block after abdominal
surgery: a prospective randomized controlled trial. Anesth
Analg 2007; 104(1): 193–7.
14. Rafi AN. Abdominal field block: a new approach via the
­lumbar triangle. Anaesthesia 2001; 56(10): 1021–6.
15. El-dawlatly AA, Thallaj A, Aldohayan A et al. Unilateral
US guided TAP block for abdominal surgery. The Internet
J Anesthesiology 2006; 16(2).
16. Stoelting RK, Miller RD. Peripheral Nerve Blocks in Basics of
Anesthesia. Fifth Edition. Philadelphia: Churchill Livingstone
Elsevier, 2007: 273–90.

17. Sandin RH, Enlund G, Samuelsson P, Lannmarken C. Awareness
during anesthesia: a prospective case study. Lancet 2000; 355:
707–11.
18. Sebel PS, Bowdle TA, Ghoneim MM et al. The incidence of
awareness during anesthesia: a multicenter United States
study. Anesth Analg 2004; 99: 833–9.
19. Myles P, Leslie K, McNeil J, Forbes A, Chan M. Bispectral
index monitoring to prevent awareness during anaesthesia:
the B-Aware randomised controlled trial. Lancet 2004; 363:
1757–63.
20. Rampersad SE, Mulroy MF. A case of awareness despite an
“adequate depth of anesthesia” as indicated by a bispectral
index monitor. Anesth Analg 2005; 100: 1363–4.
21. Dahaba AA. Different conditions that could result in the
bispectral index indicating an incorrect hypnotic state.
Anesth Analg 2005; 101: 765–73.
22. Domino K, Posner KL, Caplain RA, Cheney FW. Awareness
during anesthesia: a closed claims analysis. Anesthesiology
1999; 90(4): 1053–61.
23. Barash PG, Cullen BF, Stoelting RK et al. Patient Positioning
in Clinical Anesthesia. Fifth Edition. Philadelphia: Lippincott
Williams & Williams, 2006: 643–65.
24. Stoelting RK, Miller RD. Positioning and Associated Risks in
Basics of Anesthesia. Fifth Edition. Philadelphia: Churchill
Livingstone Elsevier, 2007: 291–303.
25. Cheney FW, Domino KB, Caplan RA, Posner KL. Nerve
injury associated with anesthesia: a closed claims analysis.
Anesthesiology 1999; 90(4): 1062–9.
26. Warner MA, Martin JT, Schroeder DR et al. Lower-extremity
motor neuropahty associated with surgery performed on
patients in a lithotomy position. Anesthesiology 1994; 81:
6–12.
27. Beraldo S, Dodds SR. Lower limb acute compartment
syndrome after colorectal surgery in prolonged lithotomy
position. Dis Colon Rectum 2006; 49: 1772–80.
28. “Medicare Quality Improvement Community” website.
http://www.medqic.org accessed March 31, 2008.
29. Zhan C, Miller MR. Excess length of stay, charges, and mor-
tality attributable to medical injuries during hospitalization.
JAMA 2003; 290: 1868–74.
4 Sepsis
Steven Mills and Michael J Stamos
Challenging Case
Six days after a low anterior resection with diverting loop ileos-
tomy for rectal cancer, the patient is febrile and has a leukocytosis
with a left shift. His vital signs remain stable, but he had a border-
line low urine output overnight.
case management
You increase the patient’s intravenous fluids, start him on broad
spectrum antibiotics and obtain a computed tomography scan of the
abdomen and pelvis. The study reveals evidence of an anastomotic
leak with an associated collection of fluid and gas in the pelvis. After
consultation with interventional radiology, the patient undergoes
percutaneous drainage with a 7-French pig tail catheter.
INTRODUCTION
The postoperative patient with sepsis is concerning to any sur-
geon. There are different causes of sepsis following an operation,
from soft tissue infections to intraabdominal infections and pel-
vic sepsis, not to mention those causes not directly related to the
surgical procedure, such as line sepsis, urinary tract infection, or
pneumonia. Each can produce a response along a physiologic
spectrum, from minimal systemic effects to multisystem organ
dysfunction. For the surgeon, knowledge of prevention, identi-
fication, and treatment of each type and cause of postoperative
sepsis is necessary.
Recognizing a postoperative patient in trouble is critical for any
surgeon. Changes in certain physiologic parameters may indicate a
problem, or may be a normal response to surgery (e.g., tachycardia
due to pain). The systemic inflammatory response syndrome (SIRS)
is a constellation of findings suggestive of “systemic inflammation”
without a defined cause (i.e., either infectious or noninfectious). In
contrast, sepsis is this same physiologic response with an identified
infectious etiology. A patient with SIRS exhibits two or more of the
following: tachycardia, tachypnea, fever, and a leukocytosis.(1) Any
patient who qualifies for SIRS by this definition should be carefully
evaluated to search for infectious causes of the systemic response,
including wound infections, urinary tract infections, pneumonia,
abdominal, or pelvic abscesses, etc. As each of these may be treated
differently, or indeed, there may be another cause for the patient’s
systemic inflammatory response, the surgeon needs to evaluate sys-
tematically the patient to determine whether or not any interven-
tions are required.
surgical site infections
Skin and soft tissue infections are a risk of any operation. The
skin functions as a natural barrier to protect our body from inva-
sion by bacteria in the environment. As we violate this protective
shield during surgery, a bacterial inoculum occurs at the surgical
site, and the host defenses must fight to overcome this bacterial
load. Over the past century, surgeons have worked diligently on
methods to decrease the risk of surgical site infections, includ-
ing improved surgical technique and antimicrobial prophylaxis.
If a wound infection does occur, decisions must be made on how
appropriately to manage the complication.
In an effort to predict the expected risks of infection for a patient
before surgery, various scales have been devised to categorize and
risk stratify. More recently, some of these same scales have been
used to “grade” or trend outcomes. Many of these are based upon
a wound classification scale which divides wounds into categories:
clean, clean-contaminated, contaminated, and dirty. Predictions
of wound infection risk have been based upon this classification.
An inclusive classification scheme was devised in 1985 by Haley
et al. (2) They described additive factors for wound infection risk
which include (in order of importance): abdominal operations,
operations >2 hours, contaminated or dirty wounds, and three
or more associated medical diagnoses (complicated patients).
The lowest risk operations had infection rates of <1% whereas
the riskiest procedures carried up to 27% risk of surgical site
infection. The National Healthcare Safety Network (NHSN) (for-
merly known as the National Nosocomial Infections Surveillance
(NNIS) System) is regarded as one of the strongest predictors of
surgical site infections (SSI).(3) To predict SSI, ASA score, wound
class, and surgery duration were evaluated. A “point” is added for
each positive category, with cutoffs based upon specific type of
surgery being performed (e.g., colon, hepatobiliary, etc.). More
recently, the surgical approach has been factored in, with laparo-
scopic operations having a “point” deducted due to lower risk of
infection observed in NHSN’s database.
Prophylactic antibiotics given before surgical incision have
become standard of care for colon and rectal operations. Most
surgeons agree that prophylactic antibiotics will decrease the risk
of surgical site infections, though specific choice of agent(s), and
their timing and length of use are somewhat more controversial.
Nichols et al. described the use of oral antibiotics to decrease the
levels of intracolonic bacteria (4) in patients without any intes-
tinal pathology. The same investigative group then followed this
with a look at colonic resection and a comparison of mechanical
prep alone versus mechanical and oral erythromycin base/neomy-
cin preparation.(5) This study showed a dramatic drop in wound
infection rate in the group receiving the oral antibiotics. A follow-
up Veteran’s Administration study (6) showed an improvement
from 43% overall septic complications with mechanical bowel
prep to 9% with mechanical prep and oral antibiotics. However,
with improvements in intravenous antibiotics, the routine use of
oral antibiotics has been called into question. In a 2003 survey of
members of the American Society of Colon and Rectal Surgeons,
49% felt prophylactic oral antibiotic to be essential, 41% deemed
them doubtful and 10% considered oral prophylaxis unneces-
sary; however, 75% of the surgeons routinely used oral antibiot-
ics, 11% used them selectively and 13% omitted oral prophylaxis.
(7) A more recent randomized trial evaluating the efficacy of

 improved outcomes in colon and rectal surgery
oral antibiotic prophylaxis in colon surgery (8) compared three
oral doses to one oral dose to no oral antibiotics. Patients in all
three groups received intravenous cefoxitin before incision and
two doses after surgery ended. They found no benefit to the oral
antibiotics and indeed found that patients randomized to three
doses of oral medications had lower tolerance of the prep. They
concluded that there is no benefit to oral antibiotics assuming
that appropriate intravenous antibiotics are given.
The long-standing practice of mechanical bowel prepara-
tions before surgery to decrease the fecal load has also come
under closer scrutiny in the past decade. Multiple case series were
reported which led to randomized trials in the 1990s and early
2000s. A meta-analysis in 2004 (9) demonstrated in an evalua-
tion of five such randomized trials that mechanical bowel prepa-
ration did not improve outcome or decrease the risk of surgical
site infection. They concluded that mechanical bowel preparation
might be omitted, but that further studies should be performed.
A recently published Cochrane Database Review (10) further
concluded that there is not good evidence that mechanical bowel
preparation reduces the risk of anastomotic and infectious com-
plications. Furthermore, although the data does not support con-
clusively that mechanical bowel preparation can be deleterious,
there is some evidence to that point. All in all, the authors felt that
routine mechanical bowel preparation should be reconsidered.
A recent multiinstitutional randomized trial also showed similar
results, leading the authors to conclude that routine mechanical
bowel preparation is unnecessary.(11) Two large multiinstitu-
tional randomized trials recently published also showed simi-
lar outcomes between patients receiving bowel preparation and
those not receiving one.(12, 13) Close evaluation of the data
from these two trials does however raise concern that the lack
of a bowel preparation may be deleterious as the rate of abscess
and leak (when combined) was higher in the patient group who
did not undergo mechanical bowel prep.(14) Further details on
bowel preparation are discussed in chapter 2.
Some clinicians have advocated using incision protectors to pre-
vent or decrease the amount of contamination of the subcutane-
ous tissues from both the surrounding skin as well as from enteric
organisms during anastomosis formation. One study in the late
1960s gave some hope that draping of the incision with a plastic
barrier would decrease wound infection (2.4% vs. 15% without
the wound drape).(15) However, subsequent studies over the next
decades did not fully support these findings. Nystrom reported
a randomized, controlled trial comparing a plastic wound drape
to no drape in colorectal surgery patients.(16) They found no
improvement in infection rate (9% vs. 10%) by using the wound
drape. Indeed, they performed culture swabs of the subcutaneous
tissues at the time of surgery in most cases and did not notice any
difference in rates of contamination with enteric organisms.
Beside preoperative antibiotics and bowel preparation, body
temperature and oxygenation may be important in prevent-
ing surgical site infection. Kurz et al. showed that in a group of
patients undergoing colorectal surgery, there was a higher risk
of surgical site infection in patients with lower body tempera-
ture (34.7 degrees vs. 36.6 degrees C).(17) However, these find-
ings are somewhat controversial as another group found that
there was no relationship between hypothermia and surgical site

infection in patients undergoing colonic surgery.(18) In terms
of tissue oxygenation, many studies have demonstrated lower
rates of surgical site infection following colon and rectal sur-
gery in patients receiving inspired oxygen peri- and immediately
postoperatively.(19–21) Indeed, in a meta-analysis of random-
ized trials of immediate postoperative oxygen usage, Chura et al.
determined that postoperative oxygen did lower rates of surgical
site infection.(22)
Despite our best techniques and proper antibiotic prophylaxis,
wound infections do still occur. Their exact incidence is hard
to gauge given that studies on wound infection incidence have
a wide range of results.(6, 23–27) Managing a wound infection
properly is important to prevent a relatively small problem from
becoming a large, life-threatening problem.
Laparoscopic surgery has been postulated by some to result in
a lower risk of surgical site infection than does the corresponding
open procedure. This has not been shown to be true of all types
of surgery. However, it does seem to hold true at least for chole-
cystectomy and for colonic surgery; laparoscopic colectomy has a
lower risk of surgical site infection than does open colectomy.(3)
Case selection bias may have affected this result however, as this
was an observational study without randomization.
Erythema at the surgical incision is often the first sign of a sur-
gical site infection. The incision site should be carefully examined
to see if there is any evidence of abscess deep to the skin (e.g.,
fluctuance). In cases of suspected abscess, the incision should
be opened over the area of concern, draining any infection. The
rest of the superficial incision should be examined to make sure
that all areas of abscess are adequately drained. Routine wound
care is then employed, often amounting to “wet-to-dry” dressing
changes or negative-pressure dressing device placement. In cases
of surrounding skin erythema and in immunocompromised
patients, appropriate antibiotics should be employed.
The management of open skin and subcutaneous tissue is
important. Once nonviable tissue has been debrided and any
abscesses drained, the tissue needs to be cared for to promote
healing. This often occurs with “wet-to-dry” dressings consist-
ing of gauze dampened with water or saline. Dressing changes
occur once or twice daily and the wound closes by secondary
intention over time. Another option for closure of a re-opened
abdominal incision is with a negative-pressure dressing, for
example, the Wound-Vac (KCI). Even in complex wounds, the
negative-pressure dressing is a good adjunct for subcutaneous
tissue closure.(28)
Though uncommon in the postoperative setting, soft tis-
sue necrotizing infections can occur at a surgical site and can
be disastrous if not treated aggressively. Wide debridement to
healthy, bleeding tissue should be performed urgently and is the
mainstay of treatment, along with appropriate antibiotic therapy.
The surgeon should have a low threshold to return to the operat-
ing room for re-evaluation of the surgical site. Adjunctive treat-
ments of necrotizing soft tissue infections (including Fournier’s
gangrene and postoperative soft tissue necrotizing infections)
include hyperbaric oxygen (29, 30) and intravenous immuno-
globulin administration (31). However, their application is con-
troversial and adherence to surgical treatment at this point is
standard of care.
 sepsis

intraabdominal infections
Intraperitoneal anastomoses have a relatively low risk of disrup-
tion; nevertheless, abdominal abscess is an all too common com-
plication of abdominal surgery. An abdominal abscess can lead
to sepsis and needs to be dealt with in a timely fashion. Again,
a spectrum of severity of sepsis and physiologic effect exists.
Abscess associated with anastomotic failure can be devastating.
Studies have shown mortality rates >20% (32) as well as worse
cancer survival (33, 34).
In most cases, the intraabdominal abscess is discovered on a
CT scan ordered for fever, persistent ileus, leukocytosis, abdom-
inal pain, or other complaint. The surgeon must now decide
what steps to take in managing the abscess. One retrospective
review showed that many intraabdominal abscesses can be
managed with antibiotics alone.(35) Kumar et al. showed a high
level of success (55%) with antibiotic treatment alone. There
were only two patients who initially succeeded but ultimately
required intervention. Most of the abscesses in this study were
diverticular or periappendicular, although 11% were postopera-
tive. All patients diagnosed with an abscess were started on par-
Figure 4.1  Computerized tomography of the pelvis showing a large presacral
enteral antibiotics. They showed that patients with an abscess space abscess. Note that staple-line is visible anterior to the large collection.
>6.5 cm in greatest diameter or in patients presenting with a
temperature more than 101.2 were likely to require percutane-
ous drainage. These authors treated initially with appropriate
intravenous antibiotics, and 54% of patients improved with that
treatment alone. 44% of patients required percutaneous drain-
age after 48–72 hours of intravenous antibiotic treatment for
failure to improve significantly.
Percutaneous drainage of intraabdominal abscesses has
become the treatment of choice for intraabdominal abscesses
(see Figures 4.1 and 4.2). However, percutaneous drainage is
not successful in 100% of patients.(35–37) A patient who is
not stable for an attempt of nonoperative management, or one
who fails to improve without operation will need to go to the
operating room for therapy. Of important note, some studies
have indicated a higher mortality for surgical management of
intraabdominal abscess after failed percutaneous drainage.(38,
39) Therefore, it is imperative that a surgeon knows the fac-
tors which predict failure with nonoperative management. One
group looked at 73 patients with abscess in whom attempted
percutaneous drainage was performed. They experienced a 19%
failure of nonoperative treatment. Using multivariate analysis,
they showed that only abscess diameter <5 cm or failure to start
the patient on antibiotic therapy before drainage were predictive Figure 4.2  Computerized tomography of pelvic abscess resolved after percutaneous
of failure of percutaneous drainage.(36) drainage. Note the drain remains in place just anterior and left of the coccyx.
Another study examined factors that would predict which
patients would fail versus succeed with percutaneous manage-
ment of intraabdominal abscesses.(40) Of 96 patients pro-
spectively evaluated, they found that 70% of patients were Pelvic Sepsis Postoperatively
successfully managed with a single percutaneous drainage and A surgeon who operates on the rectum needs to know how to
that an additional 12% were successful with a second attempt. deal with pelvic sepsis as the result of an anastomotic leak associ-
Further attempts were not often successful. Only 16% of the ated with rectal resection, regardless of the level of anastomosis.
patients ultimately required surgery. In evaluating their results, One comprehensive study from 2004 looking at which factors
success was predicted in postoperative abscess, whereas failure related to rectal resection were associated with an increased risk
was predicted with pancreatic source of abscess and when yeast of anastomotic leak showed interesting results.(41) Multivariate
was present in the abscess cavity. analysis of 432 rectal resection patients showed that anastomo-
The following algorithm can be used as a guideline: (Figure 4.3) sis <6 cm from the anal verge, history of preoperative radiation


 improved outcomes in colon and rectal surgery
Figure 4.3  Treatment algorithm for dealing with intraabdominal and pelvic abscesses.
therapy, the presence of adverse intraoperative events, and male
sex were independent risk factors for anastomotic leak. Their
overall symptomatic leak rate was 12%.
In a hemodynamically stable patient with a pelvic abscess
(obviously, hemodynamically unstable patients need to be dealt
with urgently, often surgically), broad-spectrum antibiotics
should be started and a decision about drainage of the abscess
needs to be made. In general, the guidelines above for intraab-
dominal abscesses can be extrapolated to pelvic abscesses. The
algorithm above (Figure 4.3) can likewise be used as a guide in
management.
One common CT-guided approach for pelvic abscesses is
via the transgluteal approach. Harisinghani performed a study
examining 154 cases of pelvic abscess treated in this manner (42),
showing a 96% success rate in completely resolving the abscess via
this approach. Complications were uncommon, but did include
hemorrhage in 2% (though all had transpiriformis approaches to
their abscesses). Two of these patients required angio-emboliza-
tion for pseudoaneurysm of the inferior gluteal artery while the
third patient resolved spontaneously.
Endoscopic ultrasound guidance with aspiration and drainage
has also been described in treating deep pelvic abscess.(43) They
described their first 12 patients in this fashion. 25% of patients
required surgical drainage, though eight of nine patients who

were able to have a stent placed into the cavity were completely
treated via this approach.
Duration of antibiotic therapy for treating intraabdominal
infections is controversial. There is a paucity of good data on
length of treatment, and much of the decision is based upon
“because that’s how we always do it” logic. Current data and
trends are leaning toward shorter duration of treatment. In a
review of antibiotic treatment for intraabdominal infections,
Mazuski et al. (44) state that two current approaches to dura-
tion exist: making decisions based upon intraoperative findings
versus tailoring treatment based upon clinical condition and
improvement of the patient. One prospective randomized trial
looked at minimum length of antibiotic treatment after compli-
cated appendicitis.(45) Appropriate patients were divided into
two groups and given IV antibiotics. One group had a minimum
of 5 days of antibiotics whereas the other group did not have a
minimum number of treatment days. Antibiotic treatment was
terminated based upon clinical findings: resolution of fever,
improved physical examination, and return of GI function. The
group with no minimum number of days of treatment received
less doses of antibiotics overall. The authors also determined that
stopping antibiotic treatment based upon clinical indices resulted
in the same amount of recurrent infections as having a minimum
number of days of treatment (i.e., 5 days).
 sepsis
The decision that nonoperative management has been unsuc-
cessful can be difficult to make. Any hemodynamically unstable
patient should return to the operating room. Further, patients who
fail to respond to nonoperative management may need surgery.
When operating for sepsis secondary to a failed anastomosis, there
is some controversy as to whether diversion and washout is ade-
quate or if the anastomosis needs to be resected. One retrospective
study of 27 leaks showed that proximal diversion with drainage is
adequate and results in a high chance of anastomotic salvage.(46)
Knowledge of appropriate treatment of the septic patient follow-
ing colon and rectal surgery is mandatory for any surgeon operating
on these organs. Some patients can be successfully managed with
nonoperative techniques. Timely identification of which patients
will require intervention, whether it is percutaneous or surgical, is
essential as is choosing the most effective treatment plan. Finally,
the surgeon must appropriately carry out that plan and know when
to switch to another course if failure occurs.
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18. Barone JE, Tucker JB, Cecere J et al. Hypothermia does not
result in more complications after colon surgery. Am Surg
1999; 65(4): 356–9.
19. Greif R, Akca O, Horn EP et al. Supplemental perioperative
oxygen to reduce the incidence of surgical wound infec-
tion. Outcomes Research Group. N Engl J Med 2000; 342(3):
161–7.
20. Belda FJ, Aguilera L, Garica de la Asuncion J et al. Spanish
Reduccion de la Tasa de Infeccion Qirirgica Group.
Supplemental perioperative oxygen and the risk of surgical
wound infection: a randomized controlled trial. JAMA 2005;
294(16): 2035–42.
21. Brasel K, McRitchie D, Dellinger P. EBRS Group. Canadian
association of general surgeons and American college of sur-
geons evidence based reviews in surgery. 21: the risk of surgi-
cal site infection is reduced with perioperative oxygen. Can J
Surg 2007; 50(3): 214–6.
22. Chura JC, Boyd A, Argenta PA. Surgical site infections and
supplemental perioperative oxygen in colorectal surgery
patients: a systematic review. Surg Infect (Larchmt) 2007;
8(4): 455–61.
23. Stone HH, Hooper CA, Kolb LD et al. Antibiotic prophylaxis
in gastric, biliary and colonic surgery. Ann Surg 1976; 184(4):
443–52.
24. Coppa GF, Eng K, Gouge TH et al. Parenteral and oral antibi-
otics in elective colon and rectal surgery. A prospective, ran-
domized trial. Am J Surg 1983; 145(1): 62–5.
25. Kaiser AB, Herrington JL Jr, Jacobs JK et al. Cefoxitin versus
erythromycin, neomycin, and cefazolin in colorectal opera-
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Ann Surg 1983; 198(4): 525–30.
26. Schoetz DJ Jr, Roberts PL, Murray JJ et al. Addition of par-
enteral cefoxitin to regimen of oral antibiotics for elective
colorectal operations. A randomized prospective study. Ann
Surg 1990; 212(2): 209–12.
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27. Itani KM, Wilson SE, Awad SS et al. Ertapenem versus cefo-
tetan prophylaxis in elective colorectal surgery. N Engl J Med
2006; 355(25): 2640–51.
28. Heller L, Levin SL, Butler CE. Management of abdominal
wound dehiscence using vacuum assisted closure in patients
with compromised healing. Am J Surg 2006; 191(2): 165–72.
29. Riseman JA, Zamboni WA, Curtis A et al. Hyperbaric oxygen
therapy for necrotizing fasciitis reduces mortality and the
need for debridements. Surgery 1990; 108(5): 847–50.
30. Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adju-
vant therapy in the management of necrotizing fasciitis. Am
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31. Norrby-Teglund A, Muller MP, Mcgeer A et al. Successful man-
agement of Sever Group A streptococcal soft tissue infections
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intaperitoneal colon anastomosis after colon surgery. Tech
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is predictive of diminished survival after potentially curative
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associated with poor long-term outcome in patients after
curative colorectal resection for malignancy. J Gastrointest
Surg 2007; 11(1): 8–15.
35. Kumar RR, Kim JT, Haukoos JS et al. Factors affecting the
successful management of intra-abdominal abscesses with
antibiotics and the need for percutaneous drainage. Dis
Colon Rectum 2006; 49(2): 183–9.
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taneous drainage of postoperative abdominal abscesses be
predicted? Am J Surg 2002; 184(2): 148–53.
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37. Shuler FW, Newman CN, Angood PB et al. Nonoperative
management for intra-abdominal abscesses. Am Surg 1996;
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38. Brolin RE, Flancbaum L, Ercoli FR et al. Limitations of per-
cutaneous catheter drainage of abdominal abscesses. Surg
Gynecol Obstet 1991; 173(3): 203–10.
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ful percutaneous image-guided drainage of intra-abdominal
abscess. Arch Surg 2002; 137(7): 845–9.
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for anastomotic leakage after anterior resection of the rec-
tum. Colorectal Dis 2004; 6(6): 462–9.
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approach for percutaneous drainage of deep pelvic abscesses:
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deep pelvic abscesses using therapeutic echo endoscopy.
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5 Intraoperative anastomotic challenges
David E Beck
Challenging Case
A 28-year-old man is undergoing a restorative proctocolectomy
using a double-stapled technique for the ileoanal anastomosis.
During insertion of the stapler into the anus, the anal canal distal
linear staple line is disrupted. What are your options?
case management
Initial action is to visualize the distal staple line using retractors. If
the ends of the partially closed distal bowel can be visualized and
grasped with clamps or traction sutures, the amount of residual
bowel can be assessed. If adequate length is present, one option is
to reclose the bowel with a linear stapler placed below the disrupted
staple line. After the stapler is fired, the residual bowel end can be
resected with scissors or a scalpel. A second option is to reclose the
disrupted staple line with sutures placed from the abdominal side
or placed intralumenally via a retractor (lighted Chelsea-Eaton,
Hill-Ferguson, etc.,) placed into the anal canal. If the defect and
bowel are successfully closed, the anastomosis can proceed.
If the distal segment of bowel is impossible to visualize or close,
a musectomy can be performed via the anus and a hand sewn ileo
anal anastomosis can be performed, as described in chapter 31.
Most surgeons will create a diverting loop ileostomy when the
anastomosis has been this challenging.
Colon and rectal Surgery is a technique-oriented specialty with
many procedures requiring an anastomosis to reestablish bowel
continuity. Achievement of a successful anastomosis is related to
a number of surgical principles, which can be divided into patient
factors and surgeon factors.(1–3) Patient-related factors, such as the
patient’s nutritional status and associated medical conditions or
medications, are not under the operating surgeon’s control and are
discussed in other chapters. This chapter focuses on anastomotic
principles and problems (e.g., leakage, ischemia, stenosis, and hem-
orrhage) that can be identified and managed during the procedure.
Preanastomotic Considerations
Preoperative Discussion and Planning
Before surgery the surgeon should have a plan which includes
the expected operative findings or pathology and restoration of
intestinal continuity if possible. If the preoperative findings are
confirmed, the operation should proceed along an organized
pathway. Unexpected findings will obviously require modifica-
tions. Before the procedure, the surgeon should also have a dis-
cussion with the patient, which includes these considerations with
special emphasis on aspects of the anastomosis and the possible
need for a temporary or permanent stoma should restoration of
intestinal continuity be impossible or ill advised.(4) Proximal
diversion will reduce the clinical sequalae from an anastomotic
dehiscence. This is more likely in patients receiving preoperative
chemotherapy and/or radiation, with poor nutrition, associated
infection, or comorbid conditions (steroid use, hypotension,
etc.,). The appropriate site for a potential stoma should be cho-
sen preoperatively, with the assistance of an enterostomal thera-
pist. The selection and marking of a stoma site provides another
opportunity for dialogue between the surgeon and patient.
Operative Principles
The key to uncomplicated healing of an intestinal anastomosis
depends on adherence to well-established principles as well as the
specifics of the technique. The principles of intestinal anastomo-
sis include: (1) appropriate access and exposure to the two ends
of bowel, (2) healthy bowel to be joined, (3) good blood supply,
(4) gentle handling of the bowel, and (5) good apposition of ends
with no tension on the anastomosis (5). Any compromise of these
principles places the anastomosis at risk for complications.
Exposure and access to bowel ends can be maximized by tak-
ing the time to set up and position retractors and intraabdominal
packs. Headlights and lighted retractors minimize the frustration
of inadequate overhead lights. Deep pelvic retractors such as the
St. Marks retractor or Wiley vein retractors assist the visualization
of the distal rectum prior to anastomosis. Extending the mid-line
incision to the symphysis pubis likewise, allows maximum expo-
sure of the distal rectum. Operating with poor lighting and inad-
equate exposure not only jeopardizes the anastomosis but also
increases operating room time.
Techniques of intestinal anastomosis should also be performed
following the principle of gentle bowel handling. Clamps should be
used only when absolutely necessary with the least amount of clo-
sure required to occlude the lumen. Care should be taken to exclude
mesenteric blood vessels within the intestinal clamp. Gingerly
inserting appropriately sized intraluminal staplers prevents inad-
vertent splitting and tearing of bowel ends to be anastomosed.
Excessive use of electrocautery at the anastomosis can cause unap-
preciated tissue necrosis with potential for disruption. Mobilization
of intestinal ends is required for exposure, access, and freedom of
tension on the anastomosis. However, during mobilization it is
important to preserve those blood vessels required for adequate
anastomotic healing. For example, excessive skeletonization of the
cut intestinal ends may compromise their blood supply.
Having two healthy ends of bowel to anastomose is ideal. In
some cases (bowel obstruction, diverticular disease, radiation
enteritis, Crohn’s disease), this situation may not be possible and
the plan to anastomose may be questioned. Optimizing patient
nutrition, treating infection, and minimizing inflammation in
the preoperative period may improve the bowel status. At opera-
tion, all diseased bowel is resected whenever possible to provide
soft, pliable bowel ends for anastomosis.
Bowel Preparation
As described in chapter 2, bowel preparation has undergone major
changes over the past 70 years. Until the past decade, mechanical

 improved outcomes in colon and rectal surgery
bowel preparation was a standard feature of elective bowel surgery
and the lack of a bowel preparation or poor results with a mechani-
cal preparation was in many surgeons view a contraindication to
a primary anastomosis. Recent studies have failed to support the
accepted view that bowel cleansing, in the presence of appropri-
ate antibiotics, reduced the risk of anastomotic leak or wound
infection.(6) Case series and reports from the trauma literature
suggested that good or better outcomes could be achieved in unpre-
pared bowel with an anastomosis.(7, 8) A Cochrane review of five
randomized trials showed equal or better morbidity or mortality in
576 patients with a mechanical bowel preparation and 583 patients
without a mechanical preparation.(9) An additional meta-analysis
of seven randomized trials containing 1,454 patients showed no
significant differences for wound infection and septic and nonsep-
tic conditions.(10) Certain situations, such as laparoscopic proce-
dures, potential need for intraoperative colonoscopy, or avoidance
of spillage from proximal stool loading after a low colorectal anas-
tomosis, still require adequate mechanical bowel preparation. For
other situations, many surgeons are minimizing or eliminating a
mechanical bowel preparation in elective situations. The current
evidence suggests that intralumal contents should not be the pri-
mary factor in deciding if an anastomosis should be performed.
Other options to consider with unprepareed bowel are to perform a
subtotal colectomy with ileocolonic or ileorectal anastomosis. This
option has been shown to be a safe option for avoiding a stoma
in left colon obstruction.(11) Alternatively, intraoperative colonic
lavage in some hands offers the ability to construct an anastomosis
in patients with this condition.(11–13)
Whatever the bowel preparation used, it is critical that spillage
of intralumenal contents be avoided to minimize complications
and neoplastic dissemination. Most surgeons agree that a clean,
empty colon has less potential for spillage, but cannot compen-
sate for poor technique. An additional protection against spillage
of residual intestinal contents is provided by controlling the ends
of bowel used in the anastomosis. This can be accomplished by
elevating of the ends (with traction sutures) or by occluding the
bowel proximal and distal to the anastomosis with tapes or non-
crushing clamps.(14)
Bowel Status
When intestinal surgery is being performed for urgent situa-
tions or even during certain elective operations, the first decision
is whether or not an anastomosis is appropriate. Healing of an
anastomosis is at risk in certain clinical situations. Traditionally,
intestine that is unprepared, obstructed, irradiated, inflamed, or
ischemic may not be suitable for anastomosis.(15–17) However,
other than ischemia, current evidence suggests that constructing
an anastomosis is safe in selected cases of obstruction, irradia-
tion, inflammation, and without bowel preparation.(5, 11, 18, 19)
In addition to these local factors, patient factors such as malnu-
trition, diabetes, renal failure, chronic hepatic disease, anemia,
shock, steroid use, and other immunocomprised states may place
an anastomosis at risk for failure.(4, 5, 6)
The safety of intestinal anastomosis in any particular clinical
scenario thus depends upon patient and intestinal factors that
must be carefully weighed by the operating surgeon.(5) Optimally,
the bowel will have a good blood supply, (documented by pink

color, parastalysis and pulsitile bleeding from the cut edge), lack
edema, be free of tension (see later section), and have adequate
lumen for the type of anastomosis. The ultimate decision to per-
form an intestinal anastomosis ultimately depends on surgical
judgment derived from an understanding of documented risks as
well as knowledge of one’s own ability and experience.
Exposure
The importance of adequate exposure cannot be overempha-
sized. Exposure is facilitated by patient position, adequate length
of incision, appropriate choice of retractors, and lighting. If the
possibility of a left-sided anastamosis exists, the patient should be
placed in lithotomy position, using either Lloyd-Davies, Allen or
yellow-fin stirrups, after anesthesia is induced. (Figure 5.1) Great
care is taken to avoid pressure on the peroneal nerves and hips.
(20) The perineum should extend slightly over the end of the
operating table to allow easy access for transanal stapled anasta-
mosis, upward pressure on the perineum for exposure of the dis-
tal rectum, or a two-surgeon combined approach to hand sewn
coloanal anastamosis or abdominoperineal resection. Once the
patient is correctly positioned, irrigation of the rectum should be
performed to ensure the quality of the bowel preparation and to
evacuate any remaining fecal residue. Leaving a large mushroom-
shaped or Foley catheter in the rectum alerts the surgeon to the
level of dissection in the low pelvis, prevents rectal distension and
possible enterotomy during mobilization, and allows drainage of
rectal contents which minimizes luminal spillage.
The trend toward smaller incisions should be critically evalu-
ated when planning a colorectal anastamosis.(4) Pelvic expo-
sure is greatly facilitated by incisions that extend to the pubic
bone. The incision may require proximal extension if mobiliza-
tion of the splenic flexure is required. The extent of this exten-
sion will depend on factors such as the patient’s body habitus,
disease process, and surgical technique. Adequate exposure with
less generous incisions is often possible in thin patients or those
with low splenic flexures, mobile colons, or left-sided Crohn’s
disease (the splenic flexure that is contracted down into the
abdominal cavity). Placement of the operating surgeon between
the patient’s legs often improves visualization during splenic
flexure mobilization. Adequate visualization is imperative for
safe splenic flexure mobilization, and additional retraction or
incision extension should be one of the first considerations if
mobilization is difficult.
Different retractors are available to improve exposure. Those
that are fixed to the bed, such as the Bookwalter, “upper hand,”
omnitract, or polytract, make life easier for surgical assistants and
provide a consistent view throughout the operation.(4) When
placing retractor attachments, the surgeon must be aware of the
relation of the retractor to the femoral vessels, nerves, and iliac
crests. Prolonged constant traction on the bowel may also be a
problem, and consideration of relieving the pressure intermit-
tently during long cases may be appropriate.
Finally, adequate lighting is extremely important during pelvic
dissection as well as to provide a view of the anastomosis, deep
in the pelvis. Equipment available to enhance vision includes
headlights, lighted retractors, cautery instruments, and suction
devices.
 intraoperative anastomotic challenges

Figure 5.1  Stirrups for modified lithotomy position.

Obtaining Adequate Length

After the appropriate resectional procedure is completed, suf-
ficient proximal and distal mobilization provides tension-free
bowel ends for a secure anastomosis. Tension is rarely a problem
for small bowel or ileocoioc anastomosis. The small bowel mes-
entery has an avascular plane anterior to the aorta to the takeoff
of the superior mesenteric artery. The right and left colon have a
posteriolateral fusion plane anterior to Geroda’a fascia. This avas-
cular plane can be opened using a lateral or medial approach.
Difficulty in obtaining tension-free bowel occurs more com-
monly with a left-sided (e.g., colorectal) anastomosis. Additional
left colon length is obtained using the following maneuvers in
this order: division of the lateral colonic attachments, division of
the splenic flexure, division of the inferior mesenteric artery at its
aortic takeoff, and division of the inferior mesenteric vein at the
inferior border of the pancreas (Figure 5.2).(4) If these maneu-
vers do not provide adequate bowel length, branches of the distal
middle colic artery and veins may need division. Unfortunately
this last action may compromise the blood supply to the remain-
ing colonic end. If this occurs, the ischemic bowel must be
resected and additional vessels will need to be divided to provide
the required bowel length. In some cases the middle colic vessels
will have to be divided proximally and the blood supply of the
residual colon will need to be based on the right and/or ileocolic
artery. In most patients these vessels will provide adequate blood
supply to the proximal transverse colon or hepatic flexure which
can be made to reach the rectum with one of two techniques.
One method is to open a window in the ileal mesentery medial
to the ileocolic artery and vein. The proximal transverse colon
is brought through this window to reach the pelvis (Figure 5.3).
(21) Another option is to completely mobilize the right colon and Figure 5.2  Operative techniques to obtain left colon length. (1) division of lateral colonic
then derotate it to the right. This rotates the cecal tip to the right attachments. (2) division of the splenic flexure. (3) division of the inferior mesenteric
artery at its aortic takeoff and the inferior mesenteric vein. (4) second division of the
middle abdomen (pointed toward the liver), reverses the direc- inferior mesenteric vein at the inferior border of the pancreas. (5) incision of splenic
tion of the colon, and provides enough length for the hepatic flexure mesentary. (From Rafferty JF. Obtaining adequate bowel length for colorectal
flexure to reach the pelvis (Figure 5.4). As this maneuver moves anastomosis. Clin Colon Rectal Surg 2001; 14: 25–31. With permission.)


 improved outcomes in colon and rectal surgery
(a) (b)
(a) (b)
the cecum to an abnormal position, it is important to remove the
appendix. Development of appendicitis would produce confus-
ing signs and symptoms.
In addition to a lack of tension, it is also critically impor-
tant that the anastomotic site have a good blood supply. Before
the anastomosis is constructed, the bowel should be routinely
checked for viability (normal color and peristalsis and a pulsa-
tile blood supply). Well-perfused bowel and its appendages (e.g.,
appendices epiploicae) will bleed when cut. Dividing an appendi-
ces epiploicae at the proximal bowel end intended for the anasto-
mosis is frequently used by the author to objectively confirm an
adequate blood supply.

Figure 5.3  (A) Window in mesentary is created medial
to the ileocolic atrery and vein. (B) Transverse is brought
through ileal mesenteric window to reach the pelvis.
Figure 5.4  (A) Right colon is mobilized, right colic
vessels are divided, and appendix is removed. (B) The
right colon is derotated to allow the hepatic flexure to
reach the pelvis.
In addition to the factors described previously, bowel used for
an anastomosis must not be edematous, radiated, or ischemic. An
appropriate resection should remove ischemic or radiated bowel,
while edema of the residual bowel (e.g., associated with peritonitis)
may mandate forgoing an anastomosis in favor of a diverting stoma.
Anastomotic Technique
In performing an anastomosis, surgeons have multiple options.
Each technique has associated advantages and disadvantages, and
the specific one favored by an individual surgeon depends more
on training, personal experience, and perhaps blind faith than on
the results of randomized, prospective studies. There has been no
 intraoperative anastomotic challenges
(a)
(b)
(c)
Figure 5.5  Types of anastomoses. (A) End-to-end anastomosis. (B) Side-to-side
functional end-to-end anastomosis. (C) End-to-side anastomosis. (From Beck
DE. Malignant lesions. In Beck DE, ed. Handbook of Colorectal Surgery. Quality
Medical Publishing, St Louis, MO. 1997, pp 400–430. With permission.).
consistent scientific proof that one intestinal anastomotic technique
is superior. Options range from the physical configuration of the
anastomosis (end-to-end, side-to-side, end-to-side, side-to-end, etc.
Figure 5.5) and the method used to construct it: sutures, staples, a
combination of these, and experimental methods such as compres-
sion devices or adhesives. Several of these merit discussion.
Staples versus Sutures
Suturing has been used since the beginning of intestinal surgery.
Different suture materials have shown some experimental differ-
ences, but the clinical difference is arguable. In general a stapled
anastomosis usually takes less time but is more expensive.(22, 23)
Blood flow may be higher with a stapled anastomosis, and in cer-
tain situations, such as a low colorectal anastomosis, the use of
staples is technically easier.(24) A final consideration is that any
device can malfunction and lead to the need for use of additional
staplers or conversion to a sutured anastomosis.(5)
A meta-analysis of 13 trials comparing hand-sewn with stapled
anstomosis showed similar mortality, leak rates, local cancer recur-
rences, and wound infections.(25) This review did reveal a higher
rate of postoperative stricture with the stapled anastomosis, most
of which were asymptomatic and easily managed with diltation.
Suture techniques such as the number of layers or use of inter-
rupted versus running sutures, have shown some clinical differ-
ences. An inverting anastomosis is superior to an everting technique.
A number of investigators advocate a single layer anastomosis
because they believe it causes less narrowing of the lumen since
a smaller amount of tissue is strangulated.(26, 27) A single layer
anastomosis is also felt to cause less devascularization, infection,
and necrosis, while the continuous suture distributes tension more
evenly around the lumen.(27, 28) In clinical practice, however, tech-
nical factors such as the correct placement of sutures, correct ten-
sion of the suture, and secure knots appear to be more important
than the experimental findings discussed previously. Experience,
training, clinical judgment, and ability are major factors in a sur-
geon’s choice of anastomotic technique; however, some of the
reported experience with suturing merits additional comment.
An extensive experience using a running monofilament tech-
nique has been described by Max and colleagues.(28) In a ret-
rospective report of 1,000 single layer continuous polypropylene
intestinal anastomoses, the authors believed that this technique
was quick, simple, economical, and safe. Although an intraopera-
tive leak rate was not reported, their postoperative leak rate of 1%
with the technique compares very favorably with other that in
reports using alternate techniques.(28)
A Cochrane Database Systemic reviewed six trials with 955
ileocolic participants.(29) The three largest prospective random-
ized trials comparing stapled versus hand-sewn methods for ile-
ocolic anastomoses conducted between 1970 and 2005 showed
fewer leaks with stapled anastomosis. All other outcomes: stric-
ture, anastomotic hemorrhage, anastomotic time, re-operation,
mortality, intraabdominal abscess, wound infection, and length
of stay, showed no significant difference.
End-To-End
The use of surgical staplers has advantages in certain situations
(e.g., the very low colorectal anastomosis), and they have enjoyed
widespread clinical usage. These mechanical devices, however, do
not compensate for improper or poor technique.
In an early survey of stapler complications by the American
Society of Colon and Rectal Surgeons (ASCRS) published in
1981, 243 surgeons responded that they had performed 3,594
end-to-end anastomoses (EEA).(30) Intraoperative complica-
tions were reported in 15.1% of patients. These complications

 improved outcomes in colon and rectal surgery

included anastomotic leak (9.8%), tear during extraction (1.9%), (a)

anvil not extractable (1.2%), complete anastomotic failure that
required conversion to another technique (0.9%), instrument
failure (0.8%), and bleeding (0.5%). This report represents sur-
geons’ early experience with the use of staplers, and therefore the
results must be evaluated in the proper context. Improvements in
the instruments, anastomotic technique, and surgeon experience
have resulted in fewer complications.
An early experience with 73 consecutive stapled end-to-end
colorectal anastomoses by Gordon and Vasilevsky identified intra-
operative complications in 19 patients (26%).(31) These included
instrument failure (4), incomplete or inadequate doughnuts (5),
bleeding (3), bowel injury associated with use of sizers (1), anvil
extraction (1), anvil insertion (3), difficulty with stapler extrac-
tion (1), and anvil not extractable (1). The relative high incidence
of these problems reflects the early learning curve with stapling
instruments and the early developmental nature of the instru-
ments used. Increased experience and advances in instruments
have minimized the occurrence of these problems.
A prospective randomized multicenter study by Dochetry and
colleagues described 652 patients who were randomized to a
sutured (n = 321) or stapled large bowel anastomosis (n = 331)
between 1985 and 1989.(32) During the study, 5 of the 331 patients
(b)
(1.5%) randomized to a stapled anastomosis had an instrument
or technical failure. Intraoperative anastomotic testing was not
routinely performed, but postoperative radiologic leaks were iden-
tified in 14.4% of the sutured and 5.2% of the stapled colorectal
anastomoses. Clinical anastomotic leakage was evident in 4.4% of
the sutured patients and 4.5% of the stapled patients.
Proper technique is a critical component to obtaining a good
anastomosis with a circular intraluminal stapler. To minimize
problems, the largest diameter stapler that can be accommodated
by both bowel ends should be used.(33) As originally described,
an intraluminal stapler entails usage of purse-string sutures to
hold the bowel over the stapler cartridge and anvil during stapler
closure. This purse-string suture can be placed by hand (with a
baseball or in-and-out technique), with a fenestrated purse-string
clamp (Purse String Device, Davis & Geck, Wayne, NJ), or with a
stapling device (Purse String Instrument-65, U. S Surgical Corp.,
Norwalk, CT). To work properly, the sutures must be placed cor-
rectly (approximately 1–2 mm back from the bowel ends and 2–3
mm apart). If the sutures are placed too close, the bowel will not
close tightly around the stapler shaft. This nonconstricting purse-
string may be corrected by carefully cutting the bowel overlying
the suture in two or more places to release additional suture to Figure 5.6  Repair of pursestring stitch. (A) Gap is identified in pursestring suture.
bunch up more of the bowel end. If the sutures are placed too far (B) Gap is closed with «pulley» sutures.
apart or some tear through, gaps in the bowel ends will appear
when the suture is tightened. This can be repaired by use of a excess tissue adjacent to the clamp may result in too much tis-
“Pulley Stitch” (Figure 5.6).(1, 34) These interrupted 4-0 or 3-0 sue at the purse-string which may prevent the stapler from clos-
braided sutures (e.g., silk or braided polyester) hold the purse- ing and firing properly. Releasing the clamp before dividing the
string suture to the bowel ends and assist in pulling it tightly bowel may result in inadequate tissue to hold the purse-string.
around the shaft. Finally, placement of sutures, too near the bowel Difficulties in using the purse-string clamp low in the pelvis are
end results in their tearing through the bowel, while placing the minimized by the use of a double armed suture (e.g., 2–0 mono-
sutures too far back from the bowel ends will produce an exces- filament polypropylene, double-armed TS-9, David & Geck,
sive bulk of tissue around the shaft. Wayne, NJ). Both needles are placed through the clamp and the
If a purse-string clamp is used, it is important that the bowel needles can be bent several times while the needle is withdrawn to
be divided close to the clamp before the clamp is released. Leaving allow the needles to be removed in the confined pelvis.


 intraoperative anastomotic challenges
Many surgeons use clamps to hold the bowel ends while plac-
ing the purse-string or to hold the bowel open to assist place-
ment of the anvil or stapler. Several problems can occur with use
of these clamps. If the clamps are placed too far back from the
bowel end and placed too tightly, an injury to the bowel wall can
occur which can produce a leak despite a secure anastomosis. If
open ended clamps (e.g., Babcock clamps) are used, it is possible
for the purse-string to go through the end of the clamp. If this
occurs, the clamp or the purse-string suture will need to be cut.
Use of solid ended clamps eliminates the chance of this happen-
ing. Large clamps increase the difficulty in inserting an anvil in
bowel diameter close to the diameter of the anvol.
Double Staple
Another end-to-end stapling option involves a double staple
technique.(35, 36) With this method a linear staple line is placed
across the distal bowel and a circular stapler is inserted into this
bowel (via the anus for a left-sided anastomosis). To avoid creat-
ing an ischemic area, the trocar of the circular stapler should exit
adjacent or as close as possible to the linear staples. The anvil is
placed in the proximal bowel and secured with a purse-string as
described previously. When closed and fired, the circular stapler
removes a portion of the crossed linear staple line to create the
anastomosis. Concern was initially expressed about these cross-
ing staple lines. However, subsequent experimental and clinical
evidence has confirmed the relative safety of this method.(37, 38)
The double staple technique is helpful in anastomosing bowel
ends of dissimilar size and in ultralow colorectal or coloanal
anastomoses. Outside of these situations, the extra cost of using
a stapler rather than a sutured purse-string argues more for the
use of a purse-string.
With low distal staple lines, it can be challenging to insert the
stapler into the anus and not disrupt the staple line. Distal staple
line disruption can occur if the distal bowel is tenous or under
too much traction. It has anecdotically seemed to occur more fre-
quently with the use of a contour stapler (Ethicon). If this occurs,
several options are available. Initial action is to visualize the distal
staple line. If the ends of the partially closed bowel can be grasped
with clamps or traction sutures, the amount of residual bowel can
be assessed. If adequate length is present the bowel can be closed
with a linear stapler placed below the disrupted staple line. After
the stapler is fired, the residual bowel end can be resected with
scissors or a scalpel. A second option is to recluse the disrupted
staple line with sutures placed from the abdominal side or placed
intralumenally via a retractor placed into the anal canal.(39) If the
bowel is successfully closed, the anastomosis can proceed. If the
distal segment of bowel is impossible to close, a musectomy can
be performed via the anus and a hand-sewn coloanal or ileoanal
anastomosis can be performed.
A serious problem associated with double stapling of the low
rectum is the inadvertent creation of a recto-vaginal fistula. This
unfortunate complication results from incorporating the poste-
rior wall of the vagina into the staple lines. Maneuvers to reduce
this occurrence include an adequate dissection of the rectum off
the posterior vagina, careful visualization of the bowel ends dur-
ing closure of the stapler, and intravaginal palpation of the poste-
rior vaginal wall before firing the stapler.(1)
A variation of double stapling is triple stapling. In this anasto-
motic method, an extra linear stapler is used to close the bowel
end after placement of the anvil into the proximal bowel.
The anvil trocar is then advanced through the closed bowel.
This technique has been suggested for intracorporeal laparoscopic
techniques; however, it is costly and produces another linear
suture line that must be incorporated into the final anastomotic
staple line. The technique has not gained widespread acceptance
due to the relative ease in placing the proximal purse-string.
Difficulty with anvil insertion in the proximal bowel lumen
usually occurs when the stapler is too large for the diameter
of the bowel. Experience or the use of scissors allows accurate
selection of the correct size of circular stapler. Additional helpful
techniques include the use of dilators to overcome bowel spasm,
lubrication of the anvil head (with betadine, saline, or blood),
and distraction of the bowel ends with three small-ended forceps
or clamps. Use of a recently developed low profile anvil (CDH
Ethicon-Endosurgery, Inc. Cincinnati, Ohio) has diminished this
occurrence.
Detachable Staplers
For colorectal anastomosis, the circular stapler is usually placed
through the anus. With currently available detachable head sta-
plers, the flat stapler shaft may be difficult to pass atraumatically
through the anal sphincter muscles. Khoury and Opelka, in 1995,
described a technique to facilitate this maneuver.(40) A Faensler
or Chelsey-Eaton anoscope allows a gradual controlled dilation of
the sphincters. After removal of the obturator, the stapler shaft can
easily be passed through the anoscope (Figure 5.7). Once through
the sphincter, the stapler must be inserted up to the resected end of
the rectum. Knowledge of rectal anatomy, adequate mobilization
of the posterior rectum, and selection of an appropriate size of sta-
pler assist in accomplishing this advancement. Incorrect insertion
can tear or split the rectum. Such an injury to the rectum man-
dates a very low or coloanal anastomosis to reestablish intestinal
continuity. A proctoscopic examination of the rectum insures an
adequate lumen, confirms an adequate preparation and mobiliza-
tion, and assists in identifying the apex of a Hartman’s pouch.
Once the stapler is closed and fired it must be removed. Stapler
extraction from the anastomotic area may be aided with a trac-
tion stitch. Bowel spasm or a stapler misfire may cause extrac-
tion difficulty. Gentle traction and careful stapler manipulation
usually allow it to be removed. If a misfire results in inability to
remove the stapler, it may be necessary to excise and reaccomplish
the anastomosis.
End-To-Side and Side-To-Side (Functional End-To-End)
An end-to-side or side-to-end (the proximal bowel is usually listed
first) is useful for joining bowel of different diameter. The size of
the anastomosis is not limited by the bowel diameter. This con-
figuration is often used for ileocolic or ileorectal anastomoses.
A side-to-side anastomosis is frequently used to join bowel with
a linear cutting stapler. Use of the bowel ends for a side-to-side
anastomosis, serves as a functional end-to-end anastomosis. A
surgical atlas should be consulted for additional technical details.
A meta-analysis of studies published between 1992 and
2005 of end-to-end versus other anastomotic configurations in

 improved outcomes in colon and rectal surgery

(a)
Crohn’s disease used eight studies including 661 patients.(41)
The authors conclude that a side-to-side anastomosis led to fewer
anastomotic leaks and overall complications, a shorter hospital
stay, and a perianastomotic recurrence rate comparable to end-
to-end anastomoses.

Anastomotic Testing
All surgeons test their anastomoses in some way. At a minimum,
the anastomotic site is inspected and in some cases palpated.
A visual inspection of a side-to-side anastomosis may be per-
formed before closing the ends of the bowel. Gentle constriction
of the bowel proximal or distal to the anastomosis will confirm
a patent lumen and the absence of a gross leak. A more sensitive
test can easily be performed in the colorectal anastomosis (which
is at higher risk for a leak).(42–45)
The author prefers to test low colorectal anastomosis with
intraluminal instillation of a dilute solution of povidine-iodine
(Betadine, Purdue Frederick Co, Norwalk, CT). After the bowel
is occluded above the anastomosis with finger pressure, the
(b) testing solution is instilled gently with a bulb syringe inserted
into the anus. Any leak is readily apparent. Irrigation with this
dilute providine-iodine solution also provides antimicrobial and
tumorcidal activity. Others have suggested testing with a dilute
solution of methylene blue.(46) Larger volumes are infused via
a rectal tube, and with care even ileocolic anastomosis can be
tested for leaks with this technique. The optimal pressure recom-
mended for detecting intraopeartive leaks with air/water testing is
25–30 cm H2O.(47, 48) If an infusion system is used, the pressure
can be controlled by the height of the infusion bag.
Some surgeons prefer to test their anastomosis with air.(45) The
pelvis is first filled with saline and the distal bowel (containing the
anastomosis) is distended with air (instilled transanally). Any anas-
tomotic defect will produce air bubbles. Unfortunately, with this
method it is often difficult to accurately identify the location of the
leak if any blood has mixed with the saline. The saline must also be
removed before any identified leak can be repaired. Testing with
air may be preferable for higher colorectal anastomosis as infused
(c)
intralumenal fluid may not reach a higher anastomosis.
A proctoscope can also be used to inspect the colorectal anas-
tomosis. Sufficient lumen size is usually confirmed by the lack
of stenosis, hemostasis is confirmed, and the bowel can easily be
distended with air.
Finally, some surgeons inspect the intraluminal stapler “dough-
nuts.” The author has not found this to be helpful as complete
“dough-nuts” do not ensure the absence of a leak at the anas-
tomotic site (e.g., due to a tear of the bowel or staple lines dur-
ing stapler removal). Also, an incomplete “dough-nut” may be
produced with an intact anastomosis. Intraoperative testing as
described above is more sensitive and specific.
Whatever method is used to inspect or test an anastomosis, it is
important to act on any defect or leak identified. Options include
suture reinforcement, reconstruction, or proximal diversion.

Figure 5.7  Anoscopic assisted stapler insertion. (A) Faensler anoscope is inserted
after gentle anal dilation. (B) The anoscope obturator is removed and the circular
stapler is inserted through the anoscope. (C) The anoscope is withdrawn and
taken off the shaft of the stapler.
Challenges
Inadequate Anastomotic Lumen
Adequate lumenal patency is important for several reasons. Bowel
edema occurs in the perioperative period, and a marginal lumen


 intraoperative anastomotic challenges
Figure 5.8  Isoparastaltic side-to-side functional end-to-end anastomotic technique.
may lead to a partial obstruction. The anastomotic lumen can be
sized by palpation or visually inspected. The ability to remove the
anvil of a circular stapler confirms a lumen corresponding to the
size of the stapler, while distal rectal anastomosis can be evaluated
by a proctoscope. An alternative technique for colorectral anasto-
mosis is an isoparastaltic side-to-side anastomosis (Figure 5.8).
Leakage
An accurate incidence of anastomotic leakage is difficult to deter-
mine. Few studies have reported the incidence of intraoperatively
identified anastomotic problems. The incidence of leaks identi-
fied in the postoperative period is described in chapter 6.
If a defective anastomosis is identified, it may be repaired in
several ways. Additional sutures can approximate a small gap, or
the anastomosis can be resected and completely redone using
a stapler or hand-sewn technique. Another option is to replace
purse-string sutures around the defective anastomosis and rein-
sert a new stapler through the lumen. The purse-string sutures are
tightened, which should close the defect and hold the previously
placed staples toward the stapler shaft. After closure and firing of
the new stapler, the new donuts (which should also contain the
old staples) are removed with the stapler.(49) If the anastomosis
is very low, the defect may also be repaired transanally.
Anastomotic Hemorrhage
Hemorrhage can occur at both a staple and a suture line. Proper
size staple height and correct tension of sutures minimize the
occurrence of this problem. Techniques to stop hemorrhage
include cautery of the bleeding vessels or placement of a suture at
the site of bleeding. Excessive cautery is to be avoided as the staple
line has the potential to transfer the electrical energy to adjacent
portions of the bowel. Reduction or stoppage of the bleeding may
also be helped by digital compression or intraluminal instillation
of an epinephrine solution (1 to 100,000 or 1 to 200,000 u/mL).
Another option is submucosal injection of an epinephrine solu-
tion.(50)
Proximal Protection (Stomas)
For high-risk anastomosis, a proximal diverting stoma is often
used. A diverting stoma will not prevent an anastomotic leak but
will reduce the septic morbidity and mortality associated with
the leakage. A properly constructed loop stoma is almost totally
diverting.(51) However, if absolute total diversion is desired, a
Prasad type of end loop stoma may be constructed.(52)
If diversion is needed, the author and editors prefer an ileos-
tomy over a colostomy. A diverting colostomy following a colonic
resection has several problems. A colostomy includes a larger
stoma, and due to its proximal location, the ostomy output is
loose or liquid and very odorous. If a significant colonic resection
has been performed, the remaining colon length is often insuf-
ficient to easily reach the abdominal wall at a preferred stomal
location.
A loop ileostomy has several advantages.(53) First, it is easy
to construct and close. As it is usually created in bowel removed
from the anastomotic site, tension and blood supply are rarely a
problem. Ileostomy output is liquid, has little odor, and unless
the mesentery is abnormally shortened, an ileostomy will reach
almost any site on the abdominal wall.
Adjuvants and Drains
Due to the morbidity associated with leaks, several adjuvants have
been used in high risk of potential compromised anastomoses.
Wrapping the anastomosis with omentum is a popular adjunct
that is felt by many surgeons to prevent disruption. Unfortunately,
there is no evidence to support this practice in humans.(54, 55)
The use of foreign materials around the anastomosis has been
shown to be harmful.(56, 57) Reinforcing sutures positioned
around a stapled anastomosis, while not routinely necessary, may
provide security especially for low rectal anastomoses.
Controversy continues regarding the use of drains as an
adjunct to intestinal anastomosis. The abdominal cavity cannot
be adequately drained, but in cavities like the low pelvis it is pos-
sible. Proponents believe that the drain removes contaminated
fluid and blood and, should a leak occur, it would be controlled.
Opponents argue that the drain is dangerous as it allows bacteria
a portal of entry and it may erode the anastomosis. Trials have
clearly shown no benefit from drainage of intestinal anastomoses.
(58, 59) Despite evidence to the contrary, the practice of closed
suction drainage for low pelvic anastomoses the first few days
postoperatively continues due to individual surgeon’s beliefs.(5)
Summary
Adherence to established surgical principles and techniques
should minimize anastomotic problems. Mechanical devices
cannot overcome limitations in experience, skill, or judgment.
Intraoperative identification of problems that occur permits cor-
rection with minimal morbidity.

 improved outcomes in colon and rectal surgery
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
6 Other intraoperative challenges
James T McCormick and Sharon G Gregorcyk
challenging case
You are operating on 64-year-old man with a locally advanced
rectal cancer that has been treated with neoadjuvant chemora-
diation. The mass is large, the dissection is difficult and the tissue
is edematous and friable. As you are dissecting along the right
pelvic sidewall your assistant adjusts the retractor and there is an
immediate, brisk rush of blood into the field. You attempt to pack
the area but the blood soaks the lap immediately. Your patient
is bleeding. You also note significant edema and are already
­concerned about closing the abdomen.
case management
You alert the anesthesia personnel of the occurrence of ongoing
blood loss. Various intraoperative challenges exist and can occur
on any given case. Some challenges may be predictable while
­others may not. One must be prepared to address any number
of events during any given case. All of these challenges should be
approached with calm reason and sound surgical principles to
optimize the outcome.
preoperative evaluation
The preoperative evaluation is useful to anticipate and in some
cases minimize intraoperative challenges. As always, one should
start with a thorough history and physical examination. The surgi-
cal history including indications and complications is important
in predicting intraabdominal adhesive disease. Multiple abdomi-
nal surgeries, intraabdominal abscess, perforation, hernia repairs
with mesh, and enterocutaneous fistulae are all concerning for sig-
nificant adhesive disease. On examination, a stiff, noncompliant,
scarred abdominal wall adds to the concern.
With regards to bleeding risk, you should question the patient
about any prior bleeding problems with surgery, easy bruising,
bleeding gums when brushing teeth, heavy menses, or a family
history of hemorrhagic complications. Any of these may indi-
cate an underlying coagulation disorder. Medical problems such
as renal failure, hepatic failure, and portal hypertension should
likewise raise a red flag with regards to bleeding risk. If there is no
indication by history of a bleeding problem, routine blood work
to further assess this issue is not indicated as the yield is very low.
(1) When further evaluation is needed, a bleeding time is the
most effective single test covering all aspects of the coagulation
system. If it is prolonged, then further testing is necessary.
Another important component of the history is the patient’s
medication list. Easy to identify medications that increase the risk
for bleeding are warfarin, aspirin, non-steroidal anti-inflammatory
drugs (NSAIDs), clopidogrel bisulfate, and ticlopidine hydrochlo-
ride. More subtle, often missed and increasingly popular are herbs,
vitamins, and dietary supplements. Some of the more common
agents that can prolong bleeding time include garlic, ginkgo, ginseng,
capsaicin, fish oil, ginger, and vitamin E.(2) In general, these agents

should be stopped 1 week before surgery. The same is true for aspi-
rin, NSAIDs, and clopidogrel bisulfate, while warfarin is held 3 to
5 days before surgery.(3) For patients at a higher risk for a throm-
boembolic event, such as those with recent coronary stent, a recent
(<3 mo) history of venous thromboembolism, or mechanical
­cardiac valve in the mitral position, a discussion with the patients
treating physician or cardiologist is advised and the risks and
benefits weighed.(4) In the emergency setting, platelets and fresh
frozen plasma may be necessary to immediately address bleeding
disorders, iatrogenic or otherwise.
intraoperative hemorrhage
Intraoperative bleeding ranges from a small amount of oozing
to major hemorrhage. Even small, pesky bleeding can be an issue
laparoscopically by absorbing light and obscuring the view. Using
cautery or devices such as the Harmonic scalpel™ (Johnson and
Johnson) or Ligasure™ (Covidien) may help minimize this obsta-
cle. Dividing major vessels can always result in significant bleeding
if the vessel is not adequately ligated. For the open case, simply
regrasping the vessel and tying it off takes care of the problem.
Laparoscopically, one can quickly lose visualization and lose
track of the vessel. Being prepared can help avert this problem.
One technique is to hold on to the proximal portion of the ves-
sel being divided so it can be quickly occluded. A surgical clip
or Endoloop™ (Johnson and Johnson) can then be applied if
needed. Having those supplies in the room where they can be eas-
ily and quickly accessed is advantageous. Most important is wisely
choosing the device with which to divide the vessel. Older patients
may have atherosclerotic disease in their vessels with calcification,
which may cause devices such as the Ligasure™ (Covidien) to be
less effective. In these cases, stapling, clipping, or tying the vessels
may be more prudent.
The spleen can be a source of profound bleeding. Its anatomic
relationship to the colon and omentum makes it vulnerable
to injury, especially during mobilization of the splenic flexure.
Dividing these attachments without retracting too vigorously is
key to avoid a splenic capsular tear/avulsion. This can be achieved
by approaching the splenic flexure from different angles—medially
through the lesser sac, inferiorly coming over top of Gerota’s fascia,
and laterally by dissecting along the white line of Toldt.
If an injury does occur to the spleen, it is most commonly a cap-
sular tear that can be controlled by electrocautery. If the bleeding
is brisk, the spleen should be packed off and preparations made
to address the bleeding. The anesthesiologist should be alerted
to the potential ensuing blood loss. Once the anesthesiologist is
prepared, having given adequate fluids, and with blood products
available, the packs can be removed. Topical hemostatic agents,
such as microfibular collagen, methylcellulose, or fibrin glue may
be necessary and should be available. An argon beam coagulator
can also be beneficial in this setting. Other key preparatory points
 other intraoperative challenges
are adequate exposure, working suction, and appropriate length
instruments. Laparoscopic splenic injuries may require conversion
to an open procedure to control the bleeding. However, the risk
of splenic injury is actually reported to be lower in laparoscopic
versus open cases with one series revealing no splenic injuries in
almost 2,000 laparoscopic colectomies compared to 0.24% in over
5,000 open colectomies.(5)
Once the packs are removed, if the bleeding cannot swiftly be
stopped by simple means, the spleen should be mobilized into the
operative field dividing its avascular ligaments with electrocautery.
While mobilizing the spleen, pressure is held directly on the spleen
or the splenic hilum to slow down the bleeding. The decision now
must be made as to whether splenic salvage or splenectomy should
be performed.
While one should be aggressive in attempting to save the spleen,
these attempts should not continue in the face of ongoing bleed-
ing or if the patient is unstable. A splenectomy may be necessary
and is very affective in stopping the bleeding. Splenectomy carries
a 5% lifetime risk of postsplenectomy sepsis syndrome, primar-
ily from encapsulated bacteria such as Streptococcus pneumoniae,
Haemophilus influenzae, and Neisseria meningitidis. Vaccinations for
pneumococcal, meningococcal and H. influenza are recommended
following splenectomy to curtail this incidence.(6–8) Additionally,
antibiotic prophylaxis and aggressive treatment of infections may
be advocated. Early complications associated with a splenectomy
include pneumonia, pancreatitis, and subphrenic abscess.
Attempts to preserve the spleen include partial splenectomy,
mattress suture repair, and mesh wrap. The mesh wrap is per-
formed with a polyglycolic mesh. A keyhole is cut in the mesh and
the spleen is passed through the defect such that the hole is encircl-
ing the splenic hilum. The mesh is then wrapped around the spleen
and sutured to itself resulting in compression on the spleen.(9)
Hemorrhage in the pelvis is a particularly difficult challenge.
In addition to the vessels themselves being difficult to control, the
­confines of the pelvis limit the exposure and space in which to work.
A bulky tumor, inflammation, or radiation changes can magnify
the complexity. Portal hypertension which results in enlargement
of numerous pelvic collaterals can complicate matters further.
While bleeding associated with the posterior vaginal wall or
prostate can be frustrating, it does not compare to the potentially
exsanguinating hemorrhage that can occur from the pelvic side
wall or presacral region. Once again, immediate packing of the
region should be performed in an attempt to slow bleeding while
preparing to definitively control it. Long instruments, an extra
suction device, and any necessary equipment should be gathered.
Anesthesiologists should adequately resuscitate the patient and
be ready to give blood products.
The walls and floor of the pelvis are lined by the endopelvic
fascia. If this fascia is not violated, then bleeding is not typically
an issue. Deep to this endopelvic fascia on the side walls are the
internal iliac veins. Injury to one of these veins results in profuse
bleeding. The vessels are large and thin walled which can make
suturing difficult. Suture ligation is the best option. Compressing
the iliac artery to decrease the inflow may be of benefit but will
not stop the bleeding. If a vascular surgeon is readily available, this
expertise can prove very helpful. They routinely suture vessels and
are less likely to tear thin-walled vessel while attempting repair.
They will need assistance with exposure and help keeping the
blood suctioned out. This double-team approach with two skilled
surgeons is most advantageous. Other tools that may be useful are
clip appliers. The laparoscopic instruments, even in an open case,
can give extra length that may be necessary deep in the pelvis.
Presacral hemorrhage can also result from violation of the
endopelvic fascia over the sacrum and injuring the underlying pre-
sacral vein. These avalvular veins communicate with the internal
vertebral venous system through the basivertebral vein. This system
can attain high pressures and result in profuse bleeding. The veins
retract into the sacral foramen, which is problematic. In contrast
to injury to the iliac vein, packing the pelvis in the case of presacral
vein injury may be sufficient to stop the bleeding. When possible,
the specimen should be resected to optimize access. The packing
may need to be left in place for 10 minutes or more to be effec-
tive and patience is needed. Once again, having resources ready
to control the bleeding once the packs are removed is paramount.
The electrocautery should be turned up to high levels (up to 60–80
watts) and at times it alone can control the bleeding. Clips or suture
ligation can work, but are limited secondary to the retraction of the
vessels and the lack of mobility of the presacral tissue. Titanium
thumb tacks are commercially available and can be placed directly
into the sacrum to occlude the vessels. Multiple thumb tacks may
have to be placed. If the bleeding does not stop but is sufficiently
retarded, then topical agents or repacking the pelvis may achieve
complete hemostasis.
In severe cases of pelvic hemorrhage, when all else fails, the pelvis
should be tightly packed and the patient taken to the ICU for resus-
citation and correction of any coagulopathies. In the rare case of an
arterial injury, angiographic embolization may be useful. Typically,
the patient is taken back to the operating room in 24–36 hours
after having been optimized. At this time, most bleeding will have
stopped or at least become manageable. With any massive hemor-
rhage, consideration should be given to using a cell-saver to allow
autotransfusion. In addition to transfusing blood, FFP and plate-
lets may be necessary. The patient should be warmed to ­further
improve their clotting ability. Another issue to be addressed, in the
pelvis especially, is to whether to proceed with an anastomosis. The
patient’s hemodynamic status dictates this decision. Poor perfu-
sion to an anastomosis would result in a high risk of a leak, while a
pelvis full of blood clots would increase the risk of infection. Both
are deterrent to a successful anastomosis. Additionally, the actual
time to do the anastomosis may be a consideration, as this may
contribute to hypothermia and blood loss.
With laparoscopic surgery, an additional bleeding risk occurs at
each trocar site. A vessel can be injured during placement of the port
within the abdominal wall. The most commonly injured abdominal
wall vessels during laparoscopy are the inferior epigastric vessels,
with an average incidence of approximately 0.1%.(10) As the ports
themselves will often tamponade a vessel injured during insertion,
it is wise to remove as many ports as possible under direct laparo-
scopic visualization. Recognizing and dealing with the injury at this
point will prevent an untimely return the operating room and/or the
morbidity related to hematoma. The majority of time this is a small
vessel and can be controlled with pressure or cautery alone. In the
case of continued bleeding, the incisions may need to be extended
and suture ligation of the vessel performed. Alternatively, bleeding

 improved outcomes in colon and rectal surgery
from the abdominal wall can be addressed by placing a stitch across
the port site defect. This can be accomplished with use of a Keith
needle or an Endo Close™ (Covidien) device. The stitch is passed
externally through full thickness abdominal wall into the peritoneal
cavity, grasped within the peritoneum, and laparoscopically passed
back out and tied. This can repeated as necessary.
damage control
The term damage-control laparotomy refers to a management
strategy first described for use in the unstable multiple organ
trauma patient.(11–14) The goal is to stop hemorrhage, cur-
tail contamination, and remove or debride any frankly necrotic
tissue. Reconstruction, definitive therapy, and abdominal wall
closure are deferred in favor of correction of metabolic derange-
ments, hypothermia, and coagulopathy, with the plan, ultimately,
to return to the operating room for completion of surgical ther-
apy and abdominal wall closure. This usually involves some sort
of temporary containment of the viscera and packing of the
open wound. It is not hard to imagine that these basic concepts
and principles may be applied to any patient who may benefit
from an abbreviated initial operation followed by stabilization
and optimization before definitive management.(15, 16)
As there is potential morbidity associated with leaving the
abdominal wall open and multiple trips to the operating room, indi-
cations must be carefully considered and proper patient selection
is critical. Patients with poorly controlled metabolic derangements
and acidosis, significant hypothermia, and clinical evidence of
coagulopathy may be considered appropriate candidates. Selection
criteria have been summarized as follows: inability to achieve
hemostasis due to coagulopathy, time-consuming procedure in an
appropriate patient (>90 min), inaccessible major venous injury,
associated life-threatening injury in a second anatomical location,
planned reassessment (in 24–72 hours) of abdominal contents (as
in a patient with questionable bowel viability), inability to close fas-
cia due to visceral edema, or concern for development of abdomi-
nal compartment syndrome.(17, 18)
The most common indication is related to hemorrhage and
massive resuscitation. This may be accompanied by hemodynamic
instability, coagulopathy, cardiac ischemia and often, massive
bowel edema. In the nontrauma venue this may be the patient who
has received large volume resuscitation for lower gastrointestinal
or intraoperative hemorrhage or who has returned to the operat-
ing room for postoperative hemorrhage. During the course of the
operation previously hemostatic sites may begin to bleed signal-
ing coagulopathy—dilutional, consumptive, and/or hypothermia
related. In this bleak scenario, it may be reasonable to pack the
abdomen, apply an occlusive dressing, and take the patient to ICU
for aggressive rewarming, ongoing resuscitation, and optimiza-
tion, followed by a return to the operating room in 24–72 hours
when these variables have been minimized. Likewise, a patient may
escape the coagulopathic and hypothermic effects of large volume
resuscitation but massive edema may manifest as increased pul-
monary pressures or hemodynamic compromise from abdominal
compartment syndrome when the fascia is closed.(19)
Occasionally, massive bowel edema can preclude closure of
the fascia and forcing the issue can lead to abdominal compart-
ment syndrome or at the very least compromise pulmonary

function. This can be seen when operating for bowel obstruction
but can be worsened further when septic complications accompany
the obstruction. Even after the obstruction is relieved, the bowel
remains edematous from both the obstruction and from the resus-
citation. Serosal compromise is not uncommon, in sometimes-
dramatic fashion, when longitudinal tears occur secondary to
massive dilation. The integrity of the bowel is in question but resec-
tion would be too extensive and anastomosis dubious. Protecting
the bowel and applying a suction dressing would allow for resolu-
tion of the systemic inflammatory response and diuresis, followed
by reoperation, reassessment, and definitive abdominal closure.
Abdominal compartment syndrome can be caused by increased
retroperitoneal volume, increased intraabdominal volume, and/
or restriction of abdominal wall expansion. When intraabdominal
pressure (IAP) increases rapidly, physiologic derangement can be
seen. This pressure can be measured directly by intraabdominal
catheter or indirectly by gastric, urinary, or inferior vena cava cath-
eterization, but urinary bladder pressure has been shown to best
correlate with IAP. Physiologic derangements seen in the course
of abdominal compartment syndrome occur in multiple systems.
Pulmonary changes are usually the most prominent with diaphrag-
matic elevation leading to decreased pulmonary compliance with
decreased lung capacity, decreased residual capacity, and decreased
volumes. Cardiovascular changes include decreased filling second-
ary to venous compression, decreased ventricular end-diastolic
volumes, increased afterload, decreased contractility, and loss of
cardiac output. Prerenal azotemia unresponsive to volume is a char-
acteristic finding, with oliguria leading to anuria due to decreased
renal perfusion, decreased glomerular filtration rate, and increased
retention of sodium and water with renin production. Compression
of splanchnic vasculature leads to ischemia and translocation of
bacteria. Hepatic insufficiency can also result. Intracranial pressure
is seen to increase with decreased cerebral perfusion and decreased
venous outflow.(20) Abdominal compartment syndrome is gener-
ally noted in patients with a urinary bladder pressure of more than
20 mmHg. Patients with high pressure will require decompression
if any of the aforementioned signs are noted. If when attempting
to close the abdomen pressure becomes unacceptably high, as evi-
denced by impairment of respiratory mechanics and an increase in
the peak airway pressures, the diagnosis should be considered and
routine closure should be avoided.
The objectives of the temporary closure are containment of vis-
cera, control of abdominal secretions, maintenance of tamponade,
and facilitation of future closure.(21)
A polyethylene sheet (or a large occlusive dressing folded in half
on itself) is perforated multiple times and placed over the perito-
neal viscera but beneath the abdominal wall peritoneum. Then,
sterile surgical towels are placed atop the protective sheet and the
edges tucked below the skin, fascia, and peritoneum. Jackson-Pratt
or similar suction drains are positioned on the towels and tunneled
beneath the skin to exit away from the wound edge. The skin is
prepared with tincture of benzoin and covered with a plastic drape
backed with iodophor-impregnated adhesive.(22) The drains are
kept to continuous wall suction. Alternatively, a vacuum-assisted
closure device, such as V.A.C.® (KCI) may be applied over the poly-
ethylene sheet and may be associated with a higher rate of primary
delayed fascial closure (23) (See Figures 6.1 and 6.2).
 other intraoperative challenges
Figures 6.1  Example of a damage control laparotomy: before placement of
temporary closure device.
Figure 6.2  Example of a damage control laparotomy: after placement of temporary
closure device, with application of the V.A.C.® (KCI) system. (Courtesy of Richard
Fortunato, DO, Pittsburgh, PA).
Optimal timing of return to the OR is poorly defined but it is felt
that patients who are returned to the OR after more than 72 hours
experience greater morbidity and mortality.(24)
Careful planning, technique, and patient selection should mini-
mize the colorectal surgeon’s encounters with damage control
situations. However, when confronted by a scenario with suspect
options and dubious outcome, a damage-control laparotomy
can turn an uncontrolled situation into a controlled second-look
operation with potentially more desirable options and outcomes.
adhesive disease
Adhesions result from prior abdominal surgeries or infections. One
would expect adhesions to be worse in a patient with multiple prior
abdominal surgeries or a history of a bowel perforation. Particularly
concerning for adhesions are those patients with enterocutaneous
fistulas and a history of intraperitoneally placed mesh.
Sometimes the adhesions encountered are much less than antic-
ipated and other times they are, without warning, much worse
than anticipated. Adhesions can be categorized as demonstrated
in the grading system in Table 6.1. With surgery, one of the first
objectives is to enter the peritoneal cavity without causing a bowel
injury. With heightened concern about adhesions, more caution
is exercised and, if possible, the abdomen is entered in virgin ter-
ritory. With laparoscopic surgery, adhesions can be prohibitive.
Some patients are obviously not laparoscopic candidates, such as
the patient with a stiff abdominal wall with extensive scarring and/
or multiple enterocutaneous fistulas. Other patients may be bor-
derline candidates for laparoscopy. In these cases, an attempt can
be made to look in the abdomen with the laparoscope and then
make a decision whether to proceed laparoscopically or not. A lim-
ited number of laparoscopic instruments can initially be opened
to save resources until this decision is made. One may access the
peritoneal cavity using the Hasson technique. Alternatively, pneu-
moperitoneum can be established with a veress needle at a site
remote from previous surgery and the insufflated peritoneal cavity
accessed using a Visiport™ (USS/TYCO) or a clear optic tip port
(Ethicon). The author prefers the later technique most commonly
at a left upper quadrant site.(25, 26) Others have advocated the use
of a “peek-port” where an approximately 7 cm incision is made
and the abdomen assessed. If the abdomen appears hostile, the
incision is lengthened and a laparotomy preformed. If favorable,
hand-assisted laparoscopic surgery (HALS) can be employed.(27)
For open cases, again, entering the abdomen in virgin terri-
tory is advantageous. Exposure and visualization are important
to avoid bowel injury, so frequent suctioning or dabbing with a
laparotomy sponge is used. Different techniques for dividing adhe-
sions exist, but most will be taken sharply with scissors or scalpel.
Electrocautery is employed cautiously and judiciously, as collateral
damage may occur to adjacent bowel and go unrecognized until
the patient becomes sick postoperatively. A scalpel is especially
­useful in the very dense adhesions of bowel to the abdominal wall.
Table 6.1  Grading system for bowel adhesions.
Grade Description
1 Thin filmy adhesions.
2 Adhesions that can be divided by blunt dissection.
3 Dense adhesions that require sharp division.
4 Dense adhesions, the division of which results in bowel injury.
Source: Adapted from Fazio VW. Personal communication, 1998.

 improved outcomes in colon and rectal surgery

A more difficult or dense adhesion can be approached from differ-

ent angles to help define the appropriate plane. Oftentimes, ­simpler
adhesions can be taken down on either side or even behind the
dense adhesion to help delineate the proper path of dissection.
Placing one’s fingers on either side of the adhesion and palpating
can be of assistance to feel the plane and also sometimes stretch out
the adhesion for easier division. Of course, one of the biggest keys
to success is proper traction and counter-traction. If the traction is
too forceful though, tearing of the bowel may occur.
If an enterotomy does occur, it should be repaired immediately
with absorbable sutures to minimize contamination. If the case
is difficult and more injuries are predicted, temporary closure
can be employed until all adhesiolysis is complete. A segment of
bowel with extensive injuries may be best resected. Waiting until
all injuries have been identified and a plan made can save sig-
nificant time on unnecessary repairs. Sometimes dissection can
be performed in an extraperitoneal plane to avoid bowel injury,
leaving peritoneum adherent to the bowel wall. Other times a
small piece of bowel wall may be left behind, adherent to a more
critical structure, such as the ureter or iliac vessels, in order to
avoid morbid injury at these crucial sites. Leaving devascularized
bowel serosa or muscularis in-situ is not a problem. Any mucosa
left behind, however, should be desiccated with electrocautery to
prevent formation of mucoceles or malignancy.
Consideration should be given in each case to preventing adhe-
sions, which lowers the risk of bowel obstruction and makes any
future surgeries easier. Adhesion formation is a local response of the
peritoneum and pertonealized structures to ischemia, ­desiccation,
or trauma and may form as result of the primary ­disease process
or due to contact with surgical instruments, staples, suture, gloves,
sponges, and other irritants introduced at the time of surgery. It
is assumed that laparoscopy can minimize some of these insults
by limiting bowel manipulation and exposure of the peritoneal
surface to potential irritants.(28–30) Preliminary evidence in this
Figure 6.3  Laparoscopic images demonstrating lack of adhesions in a patient
regard can be found by noting that laparoscopic assisted ileocolic
undergoing laparoscopic appendectomy for appendicitis 2 years after hand-assisted
resection is associated with reduced rate of bowel obstruction laparoscopic anterior resection for recurrent sigmoid diverticulitis. (Courtesy of
when compared to open surgery.(31, 32) Adhesions to the anterior Thomas E. Read, MD, Pittsburgh, PA).
abdominal wall are minimal or absent.(33) (See Figures 6.3 and
6.4) (34) Additionally, the CO2 pneumoperitoneum is felt to be this is assumed to be the result of a laparoscopy-related decrease in
protective of certain types of injury.(35, 36) Initial hope for elimi- scar formation between newly apposed peritoneal surfaces which
nation of adhesive disease with the advent of laparoscopy (37) has leaves defects open.(41) One can imagine this same phenomenon
been replaced by the realization that adhesions do indeed form and following laparoscopic colon resection. Obstructions due to inter-
reform after laparoscopy, ­primarily in the operative field, (38, 39) nal hernias are associated with a high incidence of bowel threatening
but to a lesser extent than with open surgery. ischemia and therefore require a high index of suspicion and prompt
Despite these advantages, bowel obstruction continues to surgical management. The authors’ experience is that relaparoscopy,
occur frequently in patients following laparoscopic surgery. The in this patient population, is an excellent technique for diagnosing
mechanism, severity, and risk of obstruction have shifted how- and managing these obstructions and other complications.(40)
ever. In a report for the French Association for Surgical Research, General principles to minimize adhesions include gentle han-
Duron (39) and colleagues noted that only 33% of postoperative dling of the tissue, hemostasis, and avoidance of infection and
bowel obstructions following various laparoscopic surgeries were ischemia. Products such as SeprafilmTM (Genzyme), a bioabsorb-
due to multiple adhesions, while an additional 17% were due to able membrane of sodium hyaluronate, and carboxymethylcellu-
a single band. Intestinal incarceration (in abdominal wall defect lose, can be placed at the time of surgery to reduce the incidence
or port site) (See Figures 6.5 and 6.6) was responsible for another of adhesions.(42–44) It should be noted that these products
46%. All told, 25% of patients required resection. should not be placed adjacent to a fresh anastomosis.(45)
A report from the Western Pennsylvania Hospital describes A qualification must be maintained in the case of adhesions
unique mechanisms of bowel obstruction, such as internal hernia, encountered when operating on a patient with a malignancy. If
are common after laparoscopic bariatric surgery.(40) The reason for the adhesions are between a cancer and another structure, they


 other intraoperative challenges
Figure 6.4  Laparoscopic images demonstrating lack of adhesions in a patient
undergoing laparoscopic appendectomy for appendicitis 2 years after hand-assisted
laparoscopic anterior resection for recurrent sigmoid diverticulitis. (Courtesy of
Thomas E. Read, MD, Pittsburgh, PA).
Figure 6.5   A port site hernia causing a bowel obstruction and injury to the bowel.
Figure 6.6  A port site hernia causing a bowel obstruction and injury to the bowel.
should be treated as an extension of the malignancy. In other
words, they should not be divided, but instead resected with the
specimen. This process might require partial resection of another
structure such as another limb of bowel or abdominal wall. Not all
adhesions encountered during surgery for malignancy are malig-
nant adhesions however. Attention should be paid to the extent of
the tumor such as growth through the full-thickness bowel wall
and its relationship to the adhesions as well as the characteristic
of the adhesion.
lesion localization
Up to 22% of endoscopically unresectable colorectal neoplasms
with benign histology on initial biopsy harbor invasive adeno-
carcinoma. Adhering to oncologically sound principles for these
neoplasms is advised.(46) Many of these will not be easily palpable
during surgery and even more difficult to localize laparoscopically.
For operative planning, particularly when considering a laparo-
scopic approach, accurate localization of the tumor is imperative to
avoid removal of the wrong segment of intestine.(47) Colonoscopy
alone as a localizing technique is inaccurate (48) unless the tumor
is clearly noted to be in the direct proximity of to an unmistakable
landmark such as the rectum or cecum. As such, localization should
be more definitively accomplished preoperatively. Endoscopic
injection of India ink in three or four quadrants of bowel adjacent
to and distal to, but not through the tumor, is safe and reliable, and
preferred in most centers (49, 50) (See Figure 6.7).
Other adjuncts for localization include endoscopic placement of
clips and subsequent plain film of the abdomen (See Figure 6.8).
Alternatively, barium enema or CT colography can be employed.
(51) Though more costly than India ink injection and associated
with radiation exposure, these modalities offer the additional
advantage of preoperative planning for room set up and patient
positioning for left vs. transverse vs. right colectomy. One disad-
vantage of these approaches is they offer no direct intraoperative
evidence of the lesion localization. Therefore they may be most
effectively used in conjunction with India ink marking.
Some centers have reported success with preoperative endo-
scopic clip placement followed by intraoperative laparoscopic

 improved outcomes in colon and rectal surgery
Figure 6.7  India ink injected endoscopically before laparoscopy provides excellent
lesion localization.
Figure 6.8  A plain film of the abdomen after endoscopic placement of clip
(arrow) can provide valuable information about the location of the lesion and aid
in preoperative planning.
ultrasonography or intraoperative fluoroscopy.(52) These intra-
operative imaging modalities, though effective, tend to be cum-
bersome, resource intensive, and operator dependent.
Due to the flexible nature of the colonoscope, the distance of
the tumor from the anal verge cannot be accurately measured on
colonoscopy. When the tumor is obviously within the colon or is
palpable within the rectum, this limitation of the colonoscope is
not an issue. Unfortunately, not uncommonly, a tumor reported
to be in the sigmoid colon by colonoscopy is actually much lower
and represents rectal cancer. A rigid proctoscope is very useful to
accurately measure the distance of the tumor from the anal verge,
which not only helps in planning surgery but also determines if
the tumor is in a location that its stage might warrant preoperative
neoadjuvant therapy.(53)

Careful preoperative assessment and planning is the best way to
ensure that the appropriate segment of the intestine is removed.
The most notable preventable cause includes assumptions made
based on colonoscopic determination of a site that is not within
the direct proximity to an unmistakable landmark such as the
rectum or cecum. Occasionally, however, despite our best efforts,
localization attempts fail to identify lesions intraoperatively in
up to 12% of cases.(54) Failure to visualize a tattoo can result
from disappearance of the tattoo compound, particularly when
products other than India ink are used.(55) Additionally, failure
to inject the ink compound into the submucosal tissue plane can
result in dissemination of the ink and imprecise localization or
intraperitoneal injection. Although this presents little direct risk
to the patient, it does present a problem with definitive intra-
operative localization. Techniques that have been described to
minimize this occurrence include injecting saline to develop the
submucosal plane before injection of ink.(56)
The surgeon must be prepared to deal with the case where local-
ization efforts have failed. Blind resection is not advised unless
confidently guided by preoperative imaging. Mobilization of the
flexures and dissection of the omentum off the transverse colon
may reveal a hidden tattoo mark. During laparoscopy, palpation
cannot be performed well but a hand assist device can be used to
overcome this limitation. Still there are cases where the lesion is too
small to palpate and remains unfound. Under such circumstances,
intraoperative colonoscopy can permit localization.(57) Use of
CO2 insufflation during the colonoscopy will minimize bowel dis-
tention. This is critical if laparoscopic assisted surgery is planned.
Requiring equipment, expertise, and time, this is best reserved as a
back-up rather than a primary localization modality. Regardless of
the technique of localization, opening the specimen after resection
to confirm the presence of the lesion is recommended.
abdominal wall closure
Abdominal wall closure is required following laparotomy and at
the specimen retrieval site for laparoscopic colectomy. Wound-
related complications such as acute wound failure (dehiscence),
infection, and incisional hernia can result in significant morbid-
ity. Malnutrition, tobacco abuse, and/or requirement for systemic
corticosteroids or chemotherapy will increase risk. Ideally, these
factors should be modified preoperatively whenever possible.
Intraoperatively, proper technique minimizes the risk of wound
complication and will be the focus of this discussion.
Acute wound failure, defined as an early separation of the
abdominal musculoaponeurotic layers, occurs at an incidence of
approximately 1.2% (range 0–2.3%), (58–62) with the majority
occurring between the 6th and 9th postoperative days.(63, 64)
The most common cause is felt to be suture tearing through the
fascia but may also occur as a result of abdominal wall rupture
away from the incision or excessive suture interval. Suture break-
age and knot slippage are rare.(58, 6, 65–70)
An incisional hernia is failure of complete abdominal wall heal-
ing following abdominal surgery, resulting in a myofascial defect.
The reported incidence of incisional hernias in the literature varies
from 9–19%. They often require repair, with recurrence rates as
high as 45%, causing further complications. The ideal abdominal
wound closure should minimize this complication.
 other intraoperative challenges
technique
Numerous studies have demonstrated mass closure to be superior
to layered closure in clinical practice (71–73), since incorporating
large bites of tissue reduces the pressure per unit area caused by
the suture and decreases the risk of suture cut-through (74, 75).
Although a randomized trial of mass versus layered closure showed
no significant difference in wound rupture, (76) and most clini-
cal studies comparing mass closure to layered abdominal closure
have not revealed a difference in the incidence of incisional hernia
formation, (73, 77) mass closure of the abdominal wall is currently
favored because of its safety, efficacy, and speed. It is important to
note that peritoneum heals by regeneration of the layer over the
entire defect, and not in incremental advancement from the wound
edge.(78, 79) Randomized studies revealed no difference between
a one-layered closure (peritoneum not sutured) and a two-layered
closure (peritoneum sutured) in midline and paramedian inci-
sions.(73, 80) Peritoneal closure is therefore not vital in abdominal
closures and may contribute to adhesion formation.
Experimental models and cadaveric studies have shown that
continuous abdominal wall closure provides the greatest wound
security in terms of abdominal dehiscence.(81, 82) Continuous
suturing is thought to equalize the tension differences between
individual stitches and distributes the tension along the suture
line, thus reducing the risk of tissue strangulation and late cut-
through.(65, 81, 83, 84) The number of knots and therefore the
likelihood of knot slippage may be minimized. A meta-analysis
comparing six randomized controlled trials of continuous versus
interrupted closure (irrespective of suture type) found the inci-
dence of incisional hernias to be significantly less with continuous
closure.(85)
There is a zone of collagenolysis and matrix degradation that
extends out 0.75 cm from each wound edge.(86, 87) Further, fascia
strength near its cut edge decreases by 50% during the first 48 hours
after an operation.(88) Experimental models have demonstrated
a continuous closure while maintaining a 1 cm stitch interval and
a 1 cm tissue bite reduces dehiscence rate as compared to smaller
tissue bites by minimizing the risk of suture cut-through.(89)
suture material
Slowly resorbed monofilaments (polydioxanone: PDS® and polygly-
conate: Maxon®) are the strongest sutures in the fresh state, ­followed
by the nonresorbable monofilaments (nylon: Ethilon® and polypro-
pylene: Prolene®), and then the braided sutures (polyglactin: Vicryl®,
polyglycolic acid: Dexon®).(90) Silk and chromic catgut, are not
appropriate.(91, 66, 92, 93)
With regard to incisional hernia formation, it is known from
experimental studies that the abdominal fascia continues to gain
strength up to 3 months after surgery.(94) Nylon (Ethilon®)
loses approximately 20% strength per year while Polypropylene,
Surgilene®, Ethibond®, Tevdek®, and polybutester (Novafil®) seem
to retain their strength indefinitely.(95) Catgut, Dexon®, and
Vicryl® have tensile strength half-lives in the range of 1–4 weeks,
and are not suitable for fascial closure. Vicryl®, compared with
­nonresorbable sutures (Prolene®), is associated with an increased
rate of wound failure and incisional hernias (85). This is in con-
tradistinction to more slowly resorbed materials, such as poly-
dioxanone (PDS®), that do not appear to increase the rate of
incisional hernia (85). Multiple randomized trials have failed to
demonstrate a difference in dehiscence rates between resorbable
and nonresorbable sutures.(58, 96, 97) Additionally, persistent
sinus formation and chronic wound infection can be virtually
eliminated with the use of resorbable suture.(73, 98)
Multiple clinical studies implicate wound sepsis as the
most important factor associated with incisional herniation.
Multifilament sutures provide a better growth environment for
bacteria and are associated with a higher incidence of wound
infection compared to monofilament sutures.(77, 99, 100)
In summary, a continuous, mass closure using slowly-resorbable
monofilament suture with a 1 cm tissue bite and a 1 cm interval is
likely the best technique for primary abdominal wall closure.(101)
It is assumed that minimizing abdominal wall trauma vis-à-vis
laparoscopic approaches may minimize wound related morbidity.
retention sutures
Retention sutures are thought to aid abdominal closure by prevent-
ing wound necrosis and avoiding evisceration. However, problems
associated with retention sutures are several and include exacer-
bation of the intraabdominal hypertension when the ­viscera are
forcibly contained, and abdominal wall ischemia when the sutures
become too tight. Furthermore, several studies have implicated
retention sutures in the development of enterocutaneous fistu-
lae even when they are placed extraperitoneally. With caution,
retention sutures may be considered in abdominal wall closure in
the patient with multiple risk factors for delayed wound healing;
they are not recommended for those at risk for development of
abdominal compartment syndrome.
If loss of abdominal domain does not permit a tension free
­fascial closure, one can consider relaxing incisions to permit
medial mobilization of the rectus. This requires dissection above
the fascia laterally to the lateral edge of the anterior rectus sheath,
which is then incised in the sagittal plane, similar to the technique
for separation of parts. This technique should be used cautiously
in patients at risk for abdominal compartment syndrome and
those at above average risk for wound infection.
synthetic prostheses
The use of synthetic mesh has been a popular technique in
abdominal wall closures and reconstructions for many years
and the most extensive experience is with polypropylene mesh
(Prolene® and Marlex®).(102) Multiple reports in the literature
cite the advantages of this permanent material, which include
availability, ease of use, high tensile strength and durability,
maintenance of abdominal wall compliance, potential avoid-
ance of future reconstruction, and permeability allowing for
peritoneal drainage. However, several investigators have pointed
out the many long-term complications related to polypropylene
mesh. Most notably, the mesh acts as a nidus of infection and
is associated with severe foreign body reactions leading to mesh
extrusion and enterocutaneous fistulae with an incidence on the
order of 23%.(103) The placement of omentum between the
mesh and the viscera has been shown to reduce the early fistula
rate to 1–4%.(104) Recently mesh with an adhesion preventative
film bonded to it (e.g., Sepramesh® (Genzyme)) has been intro-
duced. The adhesive reductive film may reduce the problem of

 improved outcomes in colon and rectal surgery
small bowel adherence to the underside of the mesh, which may   
reduce complications such as enterocutaneous fistulae and allow
for an easier re-exploration or mesh removal.
Use of polytetrafluoroethylene mesh (PTFE, Gore-Tex®) decreases
the incidence of fistulization and mesh extrusion. However, PTFE   
impedes the free egress of abdominal fluid and may contribute to
abdominal compartment syndrome and seroma formation. After
appropriate consideration, polypropylene, or polytetrafluoroeth-
ylene mesh may be considered for abdominal wall reconstruction
when there is tissue loss.
Resorbable meshes, polyglactin acid (Vicryl®) and polyglycolic   
acid (Dexon®), may provide a temporary solution in the man-
agement of the difficult abdominal wall. In experimental studies,
Dexon® is 50–70% absorbed and Vicryl® is almost fully absorbed by
10 weeks. Resorbable mesh offers the early advantages of permanent
mesh without the late complications and allows for egress of fluid   
reducing the chances of intraabdominal hypertension. However,
not surprisingly, the reported incidence of hernia is unacceptably
high with the use of resorbable synthetic mesh.(105)   
biologic meshes
There are several commercially available meshes (either allografts  
or xenografts) that are derived from naturally occurring sources
of collagen and related connective tissues. The most extensively
studied of these is Alloderm (Lifecell) (acellular dermal matrix
derived from donated human skin) (106–109) and Permacol
(Tissue Science Laboratories) (intact porcine dermal collagen)  
(110). Other variations on the theme include Collamend (Bard)
(cross-linked acellular porcine dermal collagen and its constitu-
ent elastin fibers), Allomax® (Bard) (human dermal collagen), and  
Strattice® (Lifecell) (acellular dermal matrix derived from porcine
skin). The purported advantage of all of these agents is a low risk of
mesh infectious complication in contaminated fields. In the case  
of acellular dermal matrix, extracellular material provides a sig-
nal for fibroblast incorporation, collagen deposition, and matu-
ration resulting in tissue that cannot be differentiated from fascia.
(111–113) Long-term data are lacking.  
conclusions
The colorectal surgeon can be faced with any number of potential  
disasters. Proper preparation and maintenance of a diverse tool-
box of solutions can help avert or salvage even the most dramatic  
of these.
 
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
7 Postoperative anastomotic complications
Daniel L Feingold
challenging case
A 64-year-old man is 10 days status postlow anterior resection. He
complains of pelvic pressure and pain. His abdominal exam dem-
onstrates mild suprapubic tenderness, but no peritoneal signs. He
has a low-grade fever and a white blood count of 15,000.
case management
A CT scan with oral, rectal, and intravenous contrast demon-
strates a contained anastomotic leak. The patient is managed with
pecutaneous drainage and intravenous antibiotics.
INTRODUCTION
Surgical research over the past three decades has vastly enhanced
our technical abilities and knowledge with respect to creating col-
orectal anastomoses. The Miles operation, considered state of the
art for many years after its description in 1908, has been supplanted
by sphincter-saving operations which are now considered the gold
standard for the majority of patients with rectal cancer. The era of
anal sphincter salvage was ushered in with the commercialization of
mechanical staplers that permitted colorectal surgeons to resect can-
cers even in the distal rectum and maintain intestinal continuity.(1)
In 1979, Heald articulated the concept of total mesorectal exci-
sion for rectal cancer resection which was subsequently validated and
popularized adding a new dimension to our understanding of curative
rectal cancer surgery.(2) In addition, appreciation of the distal mural
spread of rectal cancer allowed for closer distal margins without com-
promising oncologic adequacy. Concomitantly, chemoradiation was
demonstrated to be an effective adjuvant therapy and became part of
the armamentarium routinely used to treat patients with rectal cancer.
With the ushering in of the era of low, stapled colorectal anastomo-
ses, and sphincter preservation, experience was gained diagnosing and
treating patients in whom complications of these operations arise.
The most common complications related to colorectal anasto-
mosis are dehiscence and stricture. The following chapter reviews
the relevant surgical literature with emphasis on diagnosis, treat-
ment, and prevention of these complications. Less-common
complications such as anastomotic cancer recurrence and anas-
tomotic hemorrhage and other forms of intestinal anastomoses
(ileorectal, ileal pouch anal) will not be reviewed.
Leaks and strictures are uncommon events and many of the
studies describing these complications present conflicting results,
are not definitive, or are statistically under-powered. For a more
thorough understanding of the literature, this chapter relies fre-
quently on meta-analysis that combines independent clinical tri-
als to come to a statistical consensus supporting evidence-based
practice. While meta-analysis is not an infallible tool, a well con-
ducted meta-analysis can allow for more objective appraisal of
the evidence, which may lead to resolution of uncertainty and
disagreement and may reduce the probability of false negative
results (i.e., lower the rate of a type II error).

anastomotic dehiscence
Anastomotic leak is the most serious complication of colorectal
operations as the clinical outcome due to anastomotic disruption
can be catastrophic. The risk of death within 30 days of colorectal
resection is significantly higher in patients who suffered a leak and
mortality has been reported as high as 36% in some series.(3, 4)
For patients who survive the acute physiologic trespass of an anas-
tomotic leak, there may be formidable, far-reaching implications in
terms of long-term survival, quality of life, and function.(5–7)
general considerations
The incidence of anastomotic dehiscence is about 10% for col-
orectal anastomoses within 7 cm of the anal verge.(8) The lack
of a standardized definition of what actually constitutes a leak
makes it difficult to compare series and draw meaningful conclu-
sions.(9) Absence of a universal definition and the low frequency
of leak events may explain why the surgical literature has so many
similarly constructed trials with contradictory results supporting
conflicting conclusions with regard to leaks.
Common definitions include leaks identified by reoperation
for peritonitis, demonstration of extraluminal contrast during an
imaging study or observation of colonic contents through a pel-
vic drain or through the vagina. When reviewing the literature, it
is important to differentiate between patients with clinically rel-
evant leaks and asymptomatic patients who have only radiologic
evidence of leak as they have different clinical consequences and
are treated differently.
Due to the potentially devastating consequences of anasto-
motic leak, there has been significant research investigating the
causes of leaks as well as techniques to reduce the likelihood of
anastomotic failure. A number of technical factors considered to
contribute to the occurrence of anastomotic leak are subjective
assessments made at the time of surgery and are difficult, if not
impossible, to quantify objectively.
Adequate blood supply to the ends of the bowel to be anas-
tomosed is of critical importance. The mesentery and epiploic
appendages should be stripped only enough to allow adequate
visualization to permit anastomosis. Overzealous cleaning of the
bowel compromises the blood supply to the anastomosis and
must be avoided.
In terms of the blood supply to the colon proximal to the anas-
tomosis, preserving the left colic artery by transecting the main
sigmoidal artery versus ligating the actual inferior mesenteric
artery before the takeoff of the left colic (i.e., a high ligation) is
oncologically sound but has not been shown to decrease the risk
of leak.(8, 10) Rather than dogmatically coming across a specific
named blood vessel, the level of transection along the mesenteric
blood supply in a particular operation should be chosen to allow
a tension-free anastomosis.(11) In cases where a colostomy is cre-
ated for proximal diversion, care should be taken to preserve the
 postoperative anastomotic complications
marginal artery blood supply to the distal colon; this is especially
important if the inferior mesenteric artery is transected. Although
a variety of methods can be used to assess the blood supply to
the anastomosis including Doppler ultrasound and intravenous
fluorescein visualized with a Wood’s lamp, in the vast majority of
cases, straightforward clinical assessment by inspection and pal-
pation is sufficient for this determination.
In an effort to improve the blood supply to the rectal side of
the anastomosis (and to potentially better protect the hypogastric
nerves), it is possible to spare the superior hemorrhoidal artery.
Preserving the inferior mesenteric arterial supply to the rectum
by transecting the individual sigmoidal branches mid-mesentery
may be useful in cases of diverticulitis but would be wholly inap-
propriate in cancer cases where mesenteric clearance and lymph
node harvest are paramount. While sparing the superior hemor-
rhoidal artery, there may be a tendency to avoid dissecting out
the proximal presacral space in order to prevent injury to the
artery. In operations for diverticulitis, the proximal rectum must
be mobilized in order to ensure complete resection of the sigmoid
colon and to facilitate passage of the trans-anal circular stapler
to the stapled end of the rectum. In theory, sparing the superior
hemorrhoidal artery may preserve blood supply to a colorectal
anastomosis but data regarding a potential reduction in the leak
rate is lacking.
Tension across the anastomosis can decrease blood supply and
physically disrupt the anastomosis. Care must be taken to suffi-
ciently mobilize the bowel to eliminate or minimize any tension
at the anastomosis. Technically, this may require division of the
inferior mesenteric vein at the level of the pancreas to adequately
release the descending colon mesentery to permit the colon to
reach to the low pelvis. Similarly, the inferior mesenteric artery
may be divided proximal to the takeoff of the left colic artery so
that the left colic does not tether the colon up in the abdomen.
In addition, splenic flexure release should be performed to afford
tension-free reach of the colon to the pelvis when required, as
is most commonly the case. Although not mandatory from an
oncologic perspective, splenic flexure takedown is only omitted
from curative resections when patient anatomy and tumor loca-
tion permit.(12)
To further reduce the chance of leak, the bowel to be anas-
tomosed should be healthy. Inflammation, edema, radiation
changes, and thickened bowel wall due to chronic obstruction
each influence the risk of leak. Under these suboptimal condi-
tions, the bowel should be resected to normal, healthy tissue to
allow safe anastomosis; otherwise, a primary anastomosis should
be avoided. If unhealthy tissue precludes safe stapled anastomo-
sis, then the anastomosis should not be handsewn; tissue unfit for
staples is unfit for sutures.
When preparing the colon for anastomosis, it is important to
note the presence of any diverticula as incorporating a divertic-
ulum into the staple line jeopardizes the anastomosis. To avoid
this, it is helpful to suture the diverticulum in toward the anvil of
the stapler so that the diverticulum ends up in the tissue donuts.
Alternatively, the diverticulum can be eliminated by resecting
additional colon.
When marrying the circular stapler, it is important to pre-
vent any extraneous tissue (i.e., vagina, adnexa, bladder, epiploic
appendages, etc.) from catching in the stapler. This tissue can
interfere with the firing mechanism of the stapler and increases
the risk of anastomotic failure. Once the anastomosis is created,
air testing with the pelvis under saline should be performed rou-
tinely to identify occult defects requiring repair. Once a defect
demonstrated by a leak test has been repaired, as evidenced by a
negative repeat on-table leak test, the risk of postoperative anas-
tomotic leak is not increased.(13) Similarly, in situations where
the anastomotic donuts are incomplete but the leak test is nega-
tive, the risk of anastomotic leak is not increased.(14)
proximal diversion
Many surgeons divert patients undergoing low anterior resection
with total mesorectal excision in the hopes of influencing the
leak rate and/or the clinical consequences of a leak.(15, 16) Given
the low frequency of anastomotic leak, in order to determine
whether fecal diversion protects patients from leaking, large, well-
designed, multiinstitution trials with homogenous study popula-
tions are required. Nonrandomized studies testing the hypothesis
that diversion decreases anastomotic failure are inherently biased
because of patient selection as surgeons are more likely to divert
patients in whom complications are anticipated.
The Rectal Cancer Trial On Defunctioning Stoma in Sweden, a
large, prospective trial including 234 patients, randomly assigned
patients undergoing stapled colorectal anastomosis within 7 cm
of the anal verge to have proximal fecal diversion.(17) The clinical
leak rate in the diverted and nondiverted groups was 10.3% and
28%, respectively (p < 0.001). In addition, the need for urgent
re-operation in the diverted and nondiverted groups was 8.6%
and 25.4%, respectively (p < 0.0001). To further evaluate the pos-
sible utility of a proximal stoma, a meta-analysis was performed
evaluating the role of a defunctioning stoma in low rectal cancer
surgery including the Swedish trial and three other smaller ran-
domized, controlled trials.(18) The odds ratios for clinical leak
and for re-operation due to a leak in diverted patients were 0.32
and 0.27, respectively (p < 0.001). While this meta-analysis and
a few other studies demonstrate significant benefits in terms of
decreasing the occurrence of leak, much of the remaining litera-
ture only supports the concept that proximal diversion amelio-
rates the septic consequences of leak but does not influence the
actual rate of leak.(14, 19–22)
Temporary fecal diversion is not without its own ramifications.
It is difficult to predict which individual patients will develop a
leak and routine stoma creation will reduce the quality of life
in patients in whom no anastomotic complication would have
occurred. Moreover, a certain percentage of diverted patients will,
inevitably, never have intestinal continuity restored; although,
a “temporary” diversion is more likely to become permanent
in patients who have experienced a leak.(17, 23) Finally, stoma
creation carries its own morbidity rate (i.e., increased wound
infection rate at the original operation, stoma complications,
morbidity of the reversal operation, etc.) and consumes signifi-
cant healthcare resources.(20)
Although there is no consensus regarding which patients should
undergo proximal fecal diversion at the time of colorectal anasto-
mosis, many surgeons routinely consider diversion in the setting
of low pelvic anastomoses as these are more likely to leak.(5, 24)

 improved outcomes in colon and rectal surgery
The specific type of fecal diversion, ileostomy versus colostomy,
does not influence anastomotic related outcomes.(25)
mechanical bowel preparation
Mechanical bowel preparation before elective resection has been
surgical dogma since Halsted’s description of intestinal anasto-
mosis in 1887. Empiric-based practice relies on mechanical bowel
preparation together with oral antibiotics to reduce the bacterial
load of the bowel and, in theory, to decrease the risks of anas-
tomotic leak and surgical site infection. Bowel preparation, far
from innocuous, is inconvenient and unpleasant for patients and
is associated with potentially harmful metabolic and fluid distur-
bances. For these reasons, and because the purported benefits of
bowel preparation remain unproven, the utility of mechanical
preparation has been questioned.
A Cochrane review evaluating the efficacy of bowel prepara-
tion in its ability to reduce postoperative complications included
1,592 patients from nine randomized, controlled trials stratified
to a colectomy group and a low anterior resection group.(26) The
clinical leak rate in the colectomy group with and without bowel
preparation was 2.9% and 1.6%, respectively (p value not signifi-
cant). The clinical leak rate in the low anterior resection group
with and without bowel preparation was 9.8% and 7.5%, respec-
tively (p value not significant). When the surgical groups were
combined, the 6.2% clinical leak rate in the prepared group was
significantly higher than the 3.2% rate in the unprepared group
(p = 0.003). Meta-analysis of all other infectious complication
rates, including surgical site infection, demonstrated no protec-
tive effect of mechanical bowel preparation.
Despite significant evidence that bowel preparation before
elective colorectal resection does not influence infectious com-
plications (and may actually increase the anastomotic leak rate)
surgical tradition and medico-legal pressure continue to heav-
ily influence the practice of colorectal surgery with respect to
mechanical bowel preparation.
anastomotic technique
Stapled techniques for low pelvic anastomosis have been rigor-
ously evaluated since their introduction into the armamentarium
of colorectal surgery. A systematic Cochrane review comparing
the outcomes of straight, end-to-end stapled and handsewn col-
orectal anastomoses pooled data on 1,233 patients from nine ran-
domized, controlled trials.(27) This comprehensive meta-analysis
found no statistically significant difference with regard to clinical
leaks (stapled 6.3% vs. handsewn 7.1%, p value not significant)
or radiologic anastomotic dehiscence (stapled 7.8% vs. handsewn
7.2%, p value not significant).
A similarly conducted Cochrane review of four randomized,
controlled trials comparing stapled versus handsewn ileocolic
anastomoses during colon cancer resection demonstrated signifi-
cantly fewer clinical leaks in the stapled group (1%) compared to
the handsewn group (4.2%, p = 0.04).(28) Given the fundamen-
tal differences between ileocolic and colorectal anastomoses, it is
not surprising that they each may have unique technical require-
ments to reduce the risks of complications.
In addition to evaluating the mechanics of forming the anas-
tomosis, the configuration of the anastomosis has been studied

with regard to possible reduction in the risk of leak. Of the most
common stapled colorectal anastomotic configurations (end-to-
end, side-to-end Baker, colonic “J” pouch) there is no optimal
configuration that consistently confers a risk reduction benefit.
(8, 10, 15, 17, 19, 29) It has also been shown that the size of the
circular stapler does not contribute to the leak rate.(14)
omental pedicle
In an effort to quarantine an anastomosis in the event of a leak and
to mitigate the consequences of a leak, many surgeons utilize an
omental pedicle. To reach a pelvic anastomosis, the omentum is
typically mobilized to survive off the left gastroepiploic artery. The
influence of an omental pedicle on anastomotic outcomes was eval-
uated in a prospective, randomized study of 705 patients undergo-
ing bowel anastomosis and no statistically significant influence on
the rate or severity of leak was observed.(30) Another smaller, ran-
domized, controlled trial of 126 patients demonstrated a protective
effect of an omental pedicle; though, this study could be criticized
for a rather high leak rate (22%) in the group of patients without
an omentoplasty.(31) Both of these studies reported overall leak
rates including clinical and radiologic leaks.
The discrepancy between these two trials is characteristic of
many of the studies investigating anastomotic complications.
Leaks are low frequency events requiring large, homogenous study
populations for accurate evaluation. No firm evidence-based rec-
ommendation can be made with regard to omentoplasty and its
potential effects on colorectal anastomotic outcomes; bringing an
omental pedicle to the pelvis should be done according to the
surgeon’s preference.
radiation
Neoadjuvant radiotherapy has been evaluated in terms of poten-
tially increasing the risk of dehiscence of pelvic anastomoses.
The proposed mechanism of increasing the leak rate is that pel-
vic radiation may interfere with healing of the anastomosis due
to toxicity in the pelvis. Radiation changes to the colon side of
the anastomosis are usually not an issue as the irradiated colon
is resected at the time of the proctectomy to ensure that healthy
colon is used to form the anastomosis.
The Dutch Total Mesorectal Excision (TME) trial randomized
1,414 rectal cancer patients to neoadjuvant short-course radia-
tion therapy followed by low anterior resection versus resection
alone and demonstrated no significant difference between the
two groups with respect to clinical anastomotic leak (neoadju-
vant group leak rate 11% versus surgery alone leak rate 12%,
p value not significant). However, these results were difficult to
interpret because patients in the radiotherapy group were more
likely to have a diverting stoma.(19, 22) The Swedish rectal can-
cer trial randomized 1,168 patients to short-course neoadjuvant
radiation followed by surgery versus surgery alone and also dem-
onstrated no significant difference in leak rates between the two
study arms.(32) A nonrandomized study comparing 150 patients
who received long-course chemoradiation (5,040 cGy) followed
by surgery to 531 patients who underwent surgery alone dem-
onstrated similar results with 4% overall leak rate in each group
(p = 0.86).(10) The notion that neoadjuvant radiotherapy
increases the risk of leak is not supported by the majority of the
 postoperative anastomotic complications
literature and may be incorrectly based on the fact that low pelvic
anastomoses in the setting of total mesorectal excision are more
likely to leak.(33, 34)
pelvic drains
Pelvic drains are placed by some surgeons to prevent colorectal
anastomotic leaks and to diagnose leaks sooner with the hope of
initiating treatment before leaking patients clinically decompen-
sate. The possible mechanism whereby pelvic drains, theoreti-
cally, may protect against colorectal anastomotic leak relies on the
characteristics of the extra-peritoneal low pelvis in that the peri-
toneum is absent. Violation of the presacral space during proctec-
tomy leaves a significant raw surface and without the absorptive
abilities of the peritoneum fluid can collect in the dependent dead
space created by total excision of the mesorectum. Further com-
plicating the matter is the potential for negative pressure in the
low pelvis that promotes the accumulation of fluid that can possi-
bly disrupt the anastomosis. A pelvic drain can, possibly, prevent
accumulation of fluid behind the anastomosis. These theoretical
benefits of pelvic drainage together with results of statistically
under-powered trials may explain why many surgeons continue
to drain pelvic anastomoses.
Routine pelvic drainage has been evaluated in retrospective
fashion as well as with randomized, controlled trials with regard
to a possible influence on the occurrence and diagnosis of col-
orectal anastomotic leak. For example, the data collected in the
prospective, randomized Dutch TME trial was studied after-the-
fact in retrospective fashion to determine the utility of pelvic
drainage during low anterior resection.(19) Patients in this trial
were randomly assigned whether or not to receive neoadjuvant
radiation therapy before TME. At the time of operation, place-
ment of pelvic drains was decided at the discretion of the oper-
ating surgeon. Multiple regression analysis demonstrated that
pelvic drainage was strongly associated with a lower clinical leak
rate (leaks occurred in 9.6% of patients with drains compared
with 23.5% of patients without drains, p < 0.001). Moreover, the
need for re-operation in leaking patients was significantly more
likely in patients without preexisting pelvic drainage (97% of
leaking patients without drains were re-operated versus 74% of
leaking patients with drains, p = 0.006). Other reviews and ran-
domized trials regarding the use of drains have been published
with contradicting results and conclusions; some attributed an
increase in the leak rate to pelvic drainage.(14, 29, 35, 36) Like
the retrospective study reviewed above, many of these papers may
not have accurately evaluated the utility of drains due to lack of
statistical power or suboptimal methodology.
To better evaluate the utility of pelvic drainage after colorec-
tal anastomosis, a Cochrane review tested the hypothesis that
anastomotic drainage after elective colorectal surgery does not
prevent the development of complications.(37) This exhaus-
tive meta-analysis pooled data on 1,140 patients from six ran-
domized, controlled trials. The clinical anastomotic leak rate
for patients with drains versus without drains was 2% and 1%,
respectively (p value not significant). Stratification of the data
according to the height of the anastomosis also showed no ben-
efit of drainage even for low pelvic anastomoses. In addition,
the re-operation rates between patient groups with and without
drains were comparable. This review does not support the prac-
tice of routinely draining colorectal anastomoses.
The practice of routinely draining colorectal anastomoses is
not supported by strong scientific evidence. In addition, there is
no compelling literature supporting the notion that pelvic drains
facilitate earlier diagnosis of a leak.
miscellaneous
Other factors shown to increase the colorectal anastomotic leak
rate include total mesorectal excision (8, 15, 16), height of the
anastomosis from the anal verge (5, 20, 33), male gender (5, 20),
and prolonged operating time (20). Each of these factors is either
difficult or impossible to influence. Due to the large numbers
of patients required to study anastomotic complications, many
variables may never be studied sufficiently in terms of possibly
contributing to anastomotic leak (Table 7.1).
Total mesorectal excision, as it was originally described, left a
relatively ischemic distal rectum after resection for proximal rec-
tal cancer. Tumor specific mesorectal excision for proximal rectal
cancer has become popular as it preserves the distal mesorectum
without compromising oncologic adequacy and decreases the
risk of leak compared with total mesorectal excision.(10, 15, 33,
38) The height of an anastomosis can influence tension across
the tissues and, together with prolonged operating time, is likely
a surrogate marker for more difficult operations especially in the
narrow, male pelvis. It is also postulated that, in low pelvic anas-
tomoses, the proximate anal sphincter increases the intraluminal
pressure across the anastomosis jeopardizing its integrity.
In terms of the surgical approach, the Clinical Outcomes of
Surgical Therapy (COST) trial and others have not demonstrated
an increased anastomotic failure rate with regard to laparoscopic
versus conventional open colectomy.(39–41) Trials evaluating
laparoscopic versus open rectal cancer resection with colorectal
anastomosis are underway.
clinical presentation
The clinical manifestations of anastomotic dehiscence vary
depending on the location of the leaking anastomosis, the
severity of the leak and whether or not the leak is contained or
walled-off. For these reasons, while many patients with anasto-
motic dehiscence present acutely with signs and symptoms of
sepsis and an abdominal catastrophe, a subset of patients have
Table 7.1  Factors with conflicting evidence in the literature that
may or may not impact anastomotic leak rates.
Smoking or alcohol abuse (33, 46, 59)
Obesity (8)
Hospital operative caseload (24)
Surgeon subspecialty training and volume (33, 60, 61)
Diabetes (48)
Cardiovascular disease (48)
Steroid use (46, 48)
Malnutrition (46, 62)
Anemia (48)
Blood transfusions (46)
Intraoperative rectal irrigation
ASA score (33)
Field contamination

 improved outcomes in colon and rectal surgery
Table 7.2  The time interval between colorectal anastomosis and
diagnosis of a leak.
Post Op Day
Study N of Diagnosisa Range (days)
Rullier 1998 (8) 32 11 2–41
Carlsen 1998 (16) 11 8 4–15
Alves 2002 (47) 43 8.1 4–25
Mäkelä 2003 (46) 44 8 3–25
Hedrick 2006 (4) 14 9b 3–137
Matthiessen 2007 (17) 27 8b 3–18
Nicksa 2007 (45) 36 10.1 2–50
Jung 2008 (6) 35 5.5b 2–15
a. Mean.
b. Median.
a more sub-acute, insidious presentation. This is more typical
of walled-off infections and leaks that have sealed on their own.
Possibly contributing to a sub-acute presentation of a leak is the
use of antibiotics during recovery from colorectal surgery (for
pneumonia, urinary tract infection, etc.) that can mask the signs
and symptoms of an occult leak. While the majority of patients
with colorectal anastomotic leak are diagnosed within a week of
operation, a significant proportion of patients are diagnosed well
beyond this timeframe (Table 7.2). Patients with a more delayed
presentation of a leak have often been released from the hospital
only to be diagnosed upon re-admission.(42)
Patients with feculent peritonitis or diffuse purulent peritonitis
typically become acutely ill, often in dramatic fashion, with classic
signs and symptoms of peritonitis, hemodynamic instability and
rapid progression to multisystem organ dysfunction. Meanwhile,
in a considerable number of patients, recognition of an anasto-
motic leak may be difficult due to the significant overlap between
the signs and symptoms of a leaking patient and those of a typi-
cal patient recovering from major abdominal surgery. Patients
may present with any combination of fever, tachycardia, varying
degrees of abdominal pain and distension, ileus, diarrhea, mal-
aise, failure to thrive, bowel obstruction, and septic shock. Some
patients present with symptoms mimicking cardiac complications
such as respiratory failure and chest pain. Leaking patients may
also fail to clinically progress or recover within a usual timeframe,
have increasing narcotic demands, or have decreased urine output
requiring fluid boluses. The physical exam of a leaking patient may
include focal or diffuse abdominal tenderness, rigidity, guarding,
abdominal distension, and evidence of varying degrees of hemo-
dynamic collapse. Patients may have leukocytosis, typically with a
left shift, leukopenia, metabolic acidosis, or thrombocytopenia.
After any intestinal anastomosis, the surgeon must maintain a
high index of suspicion when evaluating patients with unusual
signs of sepsis or patients who fail to meet the clinical milestones
of normal recovery within a typical timeframe. The potential for
delay in diagnosis is significant; delays may impact patient out-
comes and have medicolegal ramifications.
diagnosis
Patients with generalized peritonitis consistent with a leak require
urgent return to the operating room with concomitant intrave-
nous fluid resuscitation and broad-spectrum antibiotics. In this

setting, the time to re-operation is critical and a diagnostic jour-
ney with imaging studies will only delay potentially life-saving
abdominal exploration. Meanwhile, patients with a more subtle
clinical presentation do not mandate immediate exploration and
may benefit from imaging studies to confirm the diagnosis and
direct appropriate management.
Although no single radiologic study is ideal for investigating a
possible leak, computed tomography (CT) and contrast enemas
are the tests of choice in this setting. The advantage of triple con-
trast CT scanning with intravenous, oral, and rectal contrast is
that it may identify other potential underlying pathologies like
ileus, abscess, hematoma, and bowel obstruction. CT scan find-
ings consistent with anastomotic leak include extravasation of
luminal contrast, perianastomotic fluid, ascites, and varying
amounts of extra-luminal gas. With the exception of contrast
extravasation, many of the CT findings in leaking patients are not
specific and overlap considerably with CT scans of nonleaking
patients in the postoperative setting. The mere presence of free air
in the postoperative period is not specific for a leak and has been
demonstrated by CT in control patients without anastomoses up
to 9 days after operation and even later.(43, 44) Depending on the
clinical circumstances, inconclusive CT findings can be followed
up with a contrast enema study, repeat CT or abdominal explora-
tion to exclude anastomotic leak.
According to some of the literature, CT may be superior to
contrast enema when determining the integrity of an anastomo-
sis.(42) Potential shortcomings of enema studies in this setting
are that the water-soluble contrast can dilute out and compro-
mise resolution of a contrast enema and that clinicians may be
reluctant, in the early postoperative period, to introduce a suf-
ficient column of enema contrast to adequately fill the rectum.
On the other hand, some of the retrospective literature strongly
favors contrast enema over CT in terms of diagnosing a pelvic
anastomotic leak outright as well as after a CT scan fails to dem-
onstrate a leak.(9, 45) Extravasation or pooling of rectal contrast
outside of the bowel lumen during an enema study is pathogno-
monic of leak (Figures 7.1 and 7.2). Water-soluble contrast must
be used when evaluating for a possible anastomotic dehiscence as
extravasated barium increases the severity of a leak by adding to
the inflammatory response in the abdomen. In reality, the choice
of imaging study in a particular patient is influenced by the clini-
cal presentation, institutional expertise, and available resources.
management
The management of anastomotic dehiscence in a particular
patient depends on the clinical manifestations of the leak and
the condition of the patient (Figure 7.3). Common manifesta-
tions of a leak from a colorectal anastomosis are asymptomatic,
leak without abscess, leak with associated abscess, peritonitis, and
colocutaneous fistula.
Asymptomatic
Early in the experience with circular staplers, routine water-
soluble contrast enemas demonstrated that as many as half of
patients with pelvic anastomoses demonstrated a radiologic leak
during the first postoperative week. Often these are short, sim-
ple sinus tracts originating from the anastomosis. In otherwise
 postoperative anastomotic complications

Figure 7.1  Gastrografin enema demonstrating anastomotic leak (black arrows) Figure 7.2  Gastrografin enema demonstrating leak with contained abscess (white
from colorectal anastomosis (anterior-posterior view). arrows) from colorectal anastomosis (lateral view).

Anastomotic Leak

Peritonitis Colocutaneous Abscess No abscess

Fistula No peritonitis

Laparotomy Address any Drainage Antibiotics

Antibiotics collections Antibiotics Bowel rest
Resuscitation

Antibiotics Fistula Worsens Leak resolves No resolution

Bowel rest or
Nutrition Patient worsens

No further
treatment
Resolution No resolution

Laparotomy
No further
treatment

Figure 7.3  Management algorithm for patients with anastomotic leak.

asymptomatic patients with an anastomotic leak discovered inci-
dentally, no intervention is required as the leak is not likely of
clinical consequence and will seal spontaneously.
Leak without abscess
Stable patients with mild symptoms, focal abdominal tenderness,
and radiologic evidence of anastomotic leak without abscess may
be initially treated nonoperatively with bowel rest and intrave-
nous fluids and broad-spectrum antibiotics. These are often
minor leaks that can, potentially, seal spontaneously. The dura-
tion of treatment is empiric and is based on the clinical response,
the patient’s condition, and the surgeon’s judgment. An initial
treatment period of several days is reasonable after which par-
enteral nutrition or re-operation often need to be addressed.
Clearly, failure to improve or clinical deterioration requires sur-
gical intervention. It is difficult to predict which patients will suc-
cessfully recover without re-operation in the setting of a leak; this
treatment pathway requires dedicated attention on the part of the
surgeon with frequent hands-on re-evaluation.
Leak with associated abscess
Stable patients with CT evidence of a contained leak with an
abdominopelvic abscess should, initially, be treated with drainage
and appropriate antibiotic therapy (Figures 7.4 and 7.5). Drainage


 improved outcomes in colon and rectal surgery
Figure 7.4  Abdominal CT scan demonstrating a large abdominal abscess (arrows
mark cavity).
is usually performed percutaneously or trans-anally through the
anastomotic defect. There are situations where operative drain-
age is required due to inaccessibility of an abscess by less invasive
routes, but these are quite uncommon. As before, patients who
fail nonoperative treatment require exploration. A contained leak
can rupture freely into the abdomen; depending on the clinical
circumstances, repeat imaging, or urgent exploration would be
required in this situation.
Peritonitis
Patients with generalized peritonitis consistent with a leak require
urgent exploration with aggressive fluid resuscitation and intrave-
nous antibiotic administration on the way to the operating room.
Typically, these patients decompensate quickly and become unstable
and must be treated in urgent fashion. As reviewed earlier, in these
situations, there is no benefit to pursuing diagnostic studies as the
consequences of delaying operative intervention may be dire.
Colocutaneous fistula
Fistulization to the skin, typically through a drain site or skin
incision, may be a late manifestation of anastomotic leak. Once
a fistula is observed clinically, a CT scan is helpful to evaluate for
any undrained collection which would need to be addressed. In
general, once the local sepsis has been controlled, most anasto-
motic fistulae will close with bowel rest. Optimizing nutritional
status and attention to wound care are important in these patients.
Specific circumstances that may preclude spontaneous resolution
of a fistula are distal obstruction, associated anastomotic stric-
ture, radiation, and steroid therapy. Patients who fail nonopera-
tive treatment may benefit from operative intervention.
operative intervention
The goals of re-operation for anastomotic leak are to control the
source of sepsis, remove any purulence or contamination and
prevent ongoing leak. While preservation of function is impor-
tant, it must be emphasized that these are life-saving operations.

Figure 7.5  CT scan of a percutaneous drain in an abscess.
There are a number of options available to the surgeon returning
a patient to the operating room to address a leaking anastomosis
and the particular procedure performed is decided at the time of
exploration based on clinical judgment and the unique presenta-
tion of the patient on the table.
As most patients undergoing reoperation for suspected leak
require some form of fecal diversion that may be permanent,
potential sites for stoma formation should be marked preopera-
tively. In the operating room, it is helpful to have the patient in
either split leg position or in lithotomy stirrups to facilitate access
in case proctoscopy is required. In terms of the surgical approach
to re-operation in the setting of a leak, the quickest approach is
likely conventional laparotomy. Laparoscopic exploration has
potential benefits, especially if the original operation was per-
formed laparoscopically or if the diagnosis of anastomotic leak
is not clear, but a minimal-access approach to anastomotic leak
should only be performed by surgeons with expertise in advanced
laparoscopic techniques. Microbial cultures of the peritoneal
fluid encountered during re-operation for anastomotic leak most
often demonstrate polymicrobial flora and are of questionable
benefit in terms of directing patient management.(23)
Resection of the leaking anastomosis and colostomy creation
Traditionally, the surgical approach for a colorectal anastomotic
leak has been to dismantle the anastomosis, bring out the colon
as an end stoma, close the rectum as a Hartmann pouch, washout
the abdomen, and place drains.(12) This modified Hartmann
procedure is very effective at removing the septic source and
alleviating the abdominal sepsis. A major drawback of this oper-
ation is that end colostomy reversal is technically challenging
and carries its own risk of morbidity. It is not surprising that
these end colostomies become permanent in a substantial pro-
portion of patients.(4, 23, 46) Exteriorization of the rectal stump
as a mucus fistula (typically described in staged resections for
fulminant proctocolitis) can be considered in the rare circum-
stance of a difficult to control rectum.(47)
 postoperative anastomotic complications

Leaving the leaking anastomosis in place
An alternative to end stoma creation in many instances consists of
abdominal washout, proximal fecal diversion via loop stoma, and
drainage of the anastomotic leak.(19, 23, 45, 46) The benefits of this
approach are that it effectively controls the septic source and allows
the majority of patients to undergo stoma reversal in the future.(4,
6, 17) The main criticism of leaving a leaking anastomosis in place is
that luminal contents proximal to the anastomosis may provide an
ongoing source of contamination and that the anastomosis may stric-
ture or fistulize.(23) Review of the literature does not substantiate the
concern of ongoing contamination and demonstrates that proximal
diversion is safe and has a high rate of anastomotic salvage.
The use of a colostomy versus ileostomy for diversion does not
impact anastomotic outcomes but meta-analysis of 1,204 patients
demonstrated significantly fewer stoma related complications and
postreversal hernias with loop ileostomy.(25) Some advocate lavage
of the proximal colon to eliminate whatever stool is proximal to the
anastomosis and some surgeons describe suturing closed the anas-
tomotic defect in an effort to contain the leak; the utility of these
maneuvers remains empiric. Deciding whether or not to resect or
preserve a leaking anastomosis depends on the surgeon’s experience,
the size of the anastomotic defect, and the viability of the colon.
Repeat anastomosis after resection of the leaking anastomosis
In certain situations, it may be possible to resect a leaking anasto-
mosis and perform a new anastomosis with or without proximal
diversion. This may be technically possible when dealing with a
leak from an ileocolic anastomosis. Colorectal anastomoses are
unlikely to be amenable to immediate reconstruction given the
limitations of reach, especially in a hostile abdomen.
Exteriorization of the leaking anastomosis
Another surgical option for treating a patient with anastomotic
dehiscence is to exteriorize the leaking anastomosis as a stoma. This
removes the septic source from the abdomen and may be performed
rapidly. The potential problems with this damage control approach
are that the anastomosis rarely can reach out to allow exterioriza-
tion and that even if the leaking segment can reach out, it will make
for a very bulky and difficult to manage stoma. In addition, this
form of stoma may be fraught with wound-related complications.
The utility and practicality of this approach are questionable.
these reasons that anastomotic leak is the most dreaded complica-
tion of colorectal surgery.
Anastomotic leak also carries significant long-term conse-
quences. The quality of life of patients with permanent fecal diver-
sion after a leak and bowel function after experiencing a leak are
significantly impaired.(49) In comparison with patients who did
not leak, patients who undergo stoma reversal after resolution of a
leak have decreased rectal capacity and compliance and more diffi-
culties evacuating.(7) In addition, in a review of nearly 1,400 surgi-
cal patients treated for rectal cancer, patients who leaked were less
likely to receive adjuvant chemotherapy and when they did receive
chemotherapy, it was more likely after a substantial delay.(6)
In a multicenter Scottish study of 2,235 patients who under-
went curative resection for colorectal cancer, the 5-year overall
survival rate, excluding mortalities within 30-days of operation,
for patients who leaked compared with patients who did not
leak was 42% and 55%, respectively (p < 0.01) (3). The 5-year
cancer-specific survival rate, also excluding postoperative deaths,
for patients who leaked compared with patients who did not leak
was 50% and 68%, respectively (p < 0.001). The increased risk of
cancer-specific death in patients with an anastomotic leak was
most apparent between 2 and 4 years after surgery. Similarly,
other studies have demonstrated increased local recurrence rates
(5) as well as decreased overall and cancer-specific survival (50)
after anastomotic leak. The etiology of these inferior long-term
outcomes in patients who suffer a leak remains speculative.
anastomotic stricture
Colorectal anastomotic stricture may occur in up to 10% of patients
depending on how a stricture is defined.(51, 52) From a clinical
standpoint, stricture may be defined as a symptomatic narrowing
of the anastomosis that obstructs the flow of intestinal contents.
(53) Alternatively, a stricture may be defined by the inability to pass
a particular size of proctoscope through an anastomotic narrow-
ing. The vast majority of anastomotic strictures tend to be short
segment stenoses less than a centimeter in length (Figure 7.6).

short and long-term implications of leak

The short-term consequences of an anastomotic leak requiring
operative intervention are substantial. The 30-day mortality rate
associated with anastomotic leak is typically documented in the
10% to 15% range and has been reported to be as high as 36% (3, 5,
42, 46, 47). Indeed, the most common cause of death after colorec-
tal cancer resection is due to anastomotic leak.(4) In comparison to
patients who recover uneventfully, patients who suffer anastomotic
leak consume significantly more healthcare resources. After re-
operation for leak, roughly 50% of patients require intensive care
and a number of patients go on to require additional percutaneous
drainage procedures or operations.(4, 17) Also, the average length
of stay of patients with anastomotic leak is considerably prolonged
compared with patients who recover normally from colorectal
resection.(3, 48) In terms of overall morbidity rates, patients who
experience an anastomotic leak are much more likely to experience
further complications than patients who did not leak.(47) It is for Figure 7.6  Contrast enema demonstrating colorectal anastomotic stricture.


 improved outcomes in colon and rectal surgery
(a)
(c)
Figure 7.7  (A) Colonoscopic view of a strictured colorectal anastomosis. (B) Passage of a through-the-scope balloon dilator. (C) Hydrostatic dilation of the stricture.
(D) The dilated anastomosis.
Factors predisposing to anastomotic stricture include anasto-
motic leak, postoperative pelvic infection, and proximal diversion.
In addition, two meta-analyses concluded that stapling the col-
orectal anastomosis increases the risk of stricture formation com-
pared with hand sewing the anastomosis.(27, 54) It is hypothesized
that strictures develop due to an inflammatory response or, possi-
bly, from mucosal gaps within a staple line that heal by secondary
intention. Although ischemia is commonly included as a poten-
tial etiology of stricture formation, the pathophysiology remains
speculative. Whether or not a smaller diameter circular stapler
increases the risk of stricture formation is not clear; nonetheless,
the convention remains to use the largest diameter stapler that the
bowel can accommodate. Late anastomotic stricture formation is
associated with recurrent cancer, inflammatory bowel disease, and
radiation injury and must be thoroughly investigated.

(b)
(d)
diagnosis and treatment
While most strictures are likely incidental findings, certain patients
have symptoms such as mechanical obstruction or impaction at
the level of the stricture, constipation, tenesmus, frequent bowel
movements, or diarrhea. In general, asymptomatic strictures in
patients with intestinal continuity are not clinically relevant and
do not require treatment. Meanwhile, symptomatic patients and
asymptomatic patients undergoing evaluation before reversal of
a diverting stoma who demonstrate stenosis require intervention.
Stoma reversal in the face of a stricture risks anastomotic disrup-
tion at the site of the stoma takedown and should be avoided.
The majority of colorectal anastomotic strictures that require
intervention are readily salvaged using endoluminal dilating
techniques.(55) Typically, dilation is postponed until the anas-
tomosis has healed and become more pliable; waiting over 4–6
 postoperative anastomotic complications
weeks is prudent. Simple methods used to dilate a low anastomo-
sis include gentle digital rectal exam or sequentially sized dilators
(i.e., bougie, Hegar, etc.).
Strictures out of reach for these modalities or that require con-
trolled dilation under direct observation are usually treated with
commercially available through-the-scope (TTS) hydrostatic bal-
loon dilators that control radial expansion using a pressure gauge
(Figure 7.7). Sequential dilation to a diameter >20 mm is usually
accomplished under conscious sedation with or without empiric
antibiotic coverage and has a low complication rate.(56) Balloon
dilation is successful in the majority of cases although repeat dila-
tions may be required. Injecting triamcinolone, a long-acting
corticosteroid, into the stricture or releasing the stricture using
electrocautery or laser in combination with balloon dilation may
decrease the need for repeat dilations without significantly increas-
ing the complication rate.(57) Larger diameter, over-the-wire bal-
loons may require fewer repeat dilations than TTS devices.(55)
The few patients with short anastomotic strictures who do not
respond to repeated dilation and patients with long, irregular
strictures may be candidates for resection with repeat anasto-
mosis. Depending on the height of the stricture, the anastomosis
can be resected and intestinal continuity may be restored with
either colorectal or coloanal anastomosis. To avoid dissecting out
the distal rectum in a reoperative pelvis consideration could be
given to resecting the anastomosis and reconstructing with rectal
mucosectomy and a pull-through operation.(51, 53)
Alternatives to resection to correct an anastomotic stricture
include a number of creative stricturoplasty techniques using tran-
sanal endoscopic microsurgery, conventional staplers, or a special
mechanical anastomotic staple cutting device.(58) Individual cases
of endorectal stenting have been reported in the literature but the
utility and long-term outcomes of stenting in the setting of a benign
stricture remain questionable and require further evaluation.
conclusion
Anastomotic complications are difficult to predict and carry sig-
nificant risks of morbidity and mortality. Attention to detail while
forming a colorectal anastomosis is paramount to reducing the
risk of complications. Tissue sealants, novel compression anasto-
mosis devices, anastomotic buttressing materials, and alternatives
to conventional fecal diversion may each contribute to reducing
anastomotic complications in the future.
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8 General postoperative complications
Scott R Steele and Clifford L Simmang
Financial Disclosure: No outside financial support or provision
of supplies was solicited or received in connection with this work.
Disclosure and Proprietary Statement: This is an original work
by the above author. The opinions expressed are the author’s and
author’s alone. They do not necessarily reflect the opinion of the
U.S. Government, the U.S. Department of Defense, or Madigan
Army Medical Center.
challenging case
A 72-year-old female is scheduled to undergo a low anterior
resection for T3N0M0 rectal cancer. She has been confined to a
wheelchair for the last month due to a fibular fracture. Her co-
morbidities include diabetes, hypertension, hyperlipidemia, and
she has a 50 pack-year smoking history. Describe the optimal
management for deep venous thrombosis prophylaxis.
case management
The patient falls into a high risk classification as evidenced by
her older age, recent immobility, smoking history, comorbidi-
ties, malignancy, and need for pelvic surgery. In addition to the
mechanical measures (e.g., graduated compression stockings or
intermittent pneumatic compression devices and early ambula-
tion) this patient should receive either subcutaneous unfraction-
ated heparin (typically 5,000 IU two or three times per day) or
low molecular weight heparin (~0.5 IU/kg), with higher doses
reserved for those patients within the most at risk group. The first
dose of unfractionated subcutaneous heparin should be given
before induction, preferably 1–2 hours before incision, as some
evidence indicates that venous thrombotic events occur more
commonly during the time of anesthesia induction. Perioperative
use should continue until the patient is fully ambulatory. This
may require patient education on self-injection to continue after
discharge, for up to 10–14 days.
introduction
Despite ever-evolving advancements aimed at improving surgical
outcomes, which have included technological innovations, compre-
hension of perioperative physiology, and implementation of clini-
cal pathways, postoperative complications continue to account for
significant health care costs. Highlighting this, in a study evaluating
the financial impact on surgical site infections alone, development
of one single preventable surgical site infection was associated with
an increased length of stay of almost 11 days, at a resultant cost of
$27,000 for each patient.(1) In addition, lost work days, delayed
functional recovery, and resultant physical deficits are oftentimes
not as easily quantifiable in monetary amounts, yet create an even
larger impact on both patient and society alike. Thus, emphasis
needs to be placed not only on the identification and treatment of
these complications, but also prevention as a major focus in order
to optimize outcomes. In this chapter we will review the ­current
status of a variety of perioperative parameters surrounding com-
plications encountered with colon and rectal surgery as well as
explore the most recent measures employed for prevention. More
detailed treatment options are found in specific chapters elsewhere
within this text.
pain
Although it may seem intuitive that adequate control of postop-
erative pain is a mandatory and rather easy standard to achieve,
in practice this oftentimes remains a far more difficult objective
to attain. In part, this may be secondary to the lack of having an
accurate way to predict those patients that will have difficulty with
postoperative pain control. In addition, we frequently use primi-
tive measures to quantify pain, relying heavily on devices such as
visual analogue scales and verbal pain scales commonly employed
in the recovery phase, which, due to language and cultural barri-
ers, often do not have adequate correlation amongst patients. This
is especially evident when trying to accurately detect and record
changes in pain level over time, evaluate which pain dimension
the patient is being asked to report (i.e., intensity versus relief), or
to which interval does the pain level correspond (i.e., current level
versus average over a time period).(2) Despite these difficulties,
adequate pain control remains such an important component to
the overall care of the postoperative patient, it is often referred to
as the fifth vital sign. Optimal control of pain continues to be pur-
sued through a multifactorial and multifaceted approach.
Emphasis in recent years has been toward adequate preoperative
and thus preemptive pain control. Medications such as ketorolac,
COX-2 inhibitors, and local anesthesia before the incision have all
been used in attempt to lessen postoperative pain, as well as decrease
reliance on more traditional methods such as narcotics. Sim and
colleagues in a prospective randomized blinded study of 40 patients
undergoing elective colorectal surgery found the perioperative use
of COX-2 inhibitors, which included a single dose 1 hour before
surgery, was associated with a significant decrease in both postop-
erative narcotic use as well as shorter recovery of bowel function
and earlier discharge.(3) Lack of widespread use of these agents has,
in part, been centered on surgeon concerns regarding the potential
for increased bleeding felt to be associated with use of these medica-
tions. Yet this appears to be unfounded. As narcotics are plagued by
side effects such as respiratory depression, constipation, and ileus,
which hinder gastrointestinal recovery following colorectal sur-
gery, methods to decrease their usage seem beneficial in this patient
population. This is not to say that patients following both colorectal
and anal surgery do not require narcotics; However, other classes
of medications may improve pain control, while minimizing the
dependency on them. Other Nonsteroidal Antiinflammatory Drugs
(NSAIDS) have also been evaluated in the postoperative period as
independent pain-controlling agents, yet appear to work better in

 improved outcomes in colon and rectal surgery

a narcotic-sparing role. In a study of over 1,000 patients, the addi-

tion of ketorolac to standard intravenous morphine significantly
reduced the overall postoperative morphine requirements, and low-
ered side effects both directly attributable to the narcotic (mental
status, pulmonary) as well as gastrointestinal function (ileus, nau-
sea, vomiting).(4) The anti-inflammatory action of these agents,
especially when used on a set schedule, may be most beneficial for
the pain associated with the musculoskeletal trauma of the incision,
allowing a significant reduction in pain without the untoward side
effects associated with narcotic use.
Pain following anorectal surgery can be quite debilitating and
is often cited by patients as a primary deterrent toward undergo-
ing needed procedures such as hemorrhoidectomy.(5) In addition
to the local trauma associated with resection, pain following anal
canal procedures is often attributed to anal sphincter spasm. This,
in combination with the constipation and hard stools often asso-
ciated with narcotic use, results in additional pain and suffering
once return of bowel function commences. As in the laparotomy
literature, recent trials have shown a marked decrease in the nar-
cotic requirements using ketorolac and other NSAIDs periopera-
tively for anorectal surgery.(6)
Local anesthesia, which has been commonly employed in the
field of anorectal surgery, has recently been expanded to continued
use postoperatively following abdominal procedures. As a primary
modality during anorectal procedures, it has been shown to be effec-
tive and safe, with or without the addition of deep intravenous seda- Figure 8.1  Thumbtack occlusion of a bleeding basivertebral vein.
tion, and provides the additional benefit of less time in the recovery
room.(7, 8) As an adjunct following laparotomy, a local anesthetic and epidural placement/removal must be coordinated between
agent is applied via continuous infusion to the midline wound the surgeon and anesthesiologist. Downsides to epidurals have
through a set of subcutaneous catheters placed at the time of surgery. consistently been their potential for increasing urinary retention
(9) Despite mixed results, some prospective data does demonstrate and hypotension, higher costs, and perhaps decreased patient sat-
a decreased narcotic requirement and improved perioperative recov- isfaction, with no change in length of stay.(14) Despite these nega-
ery, including earlier ambulation, in the absence of significant overall tive attributes, epidural use for colorectal surgery provides the
postoperative pain score differences.(10, 11) As increased experi- potential for outcome improvement in analgesia and functional
ence is gathered using this modality, further data may determine its recovery, and is a very useful alternative for pain control following
appropriate place in the analgesia armamentarium. abdominal and large pelvic procedures.
Another method commonly employed is epidural anesthesia, Furthermore, gabapentin, a medication that was originally
which works through inhibiting ascending neural pathways as well designed for the treatment of epilepsy, has evolved as a treatment
as the sympathetic output from the spinal cord. This dual action for mainly neuropathic pain, and has been studied extensively in
provides the beneficial effects of not only improved pain control, both the pre- and postoperative settings. Although the exact mecha-
but also has been shown to aid with earlier return of bowel function nism of action is unknown, it is believed to act through N-gated
through its sympathectomy. Various agents have been described calcium channels, and focus has been on both providing improved
for use in epidurals, with the mainstays being local anesthetics and perioperative analgesia as well as narcotic-reducing effects.(15)
narcotics. In a meta-analysis of sixteen randomized controlled tri- Unfortunately, its use as an independent entity has been less effica-
als from 1987 to 2005 comparing the use of epidurals to paren- cious, and it has not been extensively studied for either colorectal
teral controlled analgesia, Marret and colleagues found epidurals or anorectal surgery.(16) Both it, and a newer analog pregabalin,
were associated with improved analgesia and overall decreased have been shown to decrease the need for opioids and thus reduce
ileus, with only side effects such as pruritis and labile blood pres- side effects such as nausea, vomiting, and urinary retention in other
sure significantly associated with epidural use.(12) Gendall and surgical arenas. While further study awaits recommendations spe-
colleagues confirmed these findings in a recent review of the lit- cifically for use in the realm of colon and rectal surgery, these medi-
erature, again demonstrating that epidural anesthesia improves cations, along with standard postoperative regimen of increased
functional recovery and pain relief, while potentially decreasing oral fluid intake, fiber, stool softeners, sitz baths, and avoidance of
pulmonary complications.(13) While the epidural is in place, the constipation all aid in recovery from anorectal surgery.
anesthesiologist often manages all of the pain medications, per- Most importantly, these varying agents all operating through
forming comprehensive pain management. When the epidural different mechanisms convey the needed concept for the surgeon
is removed, the management returns to the surgeon. The use of to use a multimodality approach to ensure successful perioperative
anticoagulation for deep venous thrombosis (DVT) prophylaxis pain management.


 general postoperative complications
bleeding
Bleeding complications with any operation can be categorized
by many different methods including intraoperative, postopera-
tive, anastomotic bleeding, and gastrointestinal bleeding, such
as stress-related ulcers. One of the most important factors for
the surgeon is to preoperatively assess and determine the risk
of bleeding. A thorough history and physical examination with
emphasis on a personal or family history of bleeding tendency
is crucial to identification and subsequent evaluation of those
patients at risk, and should be completed before embarking on
surgery. Questions should focus on any predisposition for easy
bleeding or bruising, inability to clot even with mild cuts, or his-
tory of prior transfusions following surgeries, to identify certain
patients that require further evaluation. Preoperative laboratory
evaluation should include a complete blood count, coagulation
panel (PT, PTT, INR), and platelet count. For those patients at
increased risk, a more detailed analysis of platelet and clotting
cascade function to include bleeding times, mixing studies, or
evaluation by a hematologist may be appropriate.
Perioperative bleeding with colorectal surgery depends in many
aspects on the surgical procedure performed. Whereas bleeding
rates following hemorrhoidectomy range from 2% to 6%, those fol-
lowing major abdominal operations such as total mesorectal exci-
sion (TME) for rectal cancer have been shown to have much higher
blood loss estimates, with transfusion requirements reported in
up to 43–73% of patients.(17–20) The most common causes for
postoperative hemorrhoidal bleeding are technical failure (failed
knot) within the first 24 hours, and infection with erosion at
7 days. Despite this, bleeding following hemorrhoidectomy is
often able to be controlled either without surgical intervention or
with simple suture ligation in the outpatient setting.
In contrast, bleeding following major abdominal or pelvic
procedures can mandate return to the operating room with
corresponding physiological changes that may lead to cardio-
pulmonary complications. Yet, with the emergence of emphasis
on decreased mandatory transfusion requirements, and techno-
logical advancements such as improved minimally invasive tech-
niques, transfusion rates are decreasing and blood loss has also
decreased. In a study of 147 patients in a case-matched compara-
tive analysis between open and laparoscopic colectomies, Kiran
and colleagues found that both estimated blood loss and peri-
operative transfusion rates were significantly higher in the open
group.(21) Timing of the onset of bleeding also provides some
insight as to its etiology. Early postoperative bleeding is typically
from a technical error at the time of operation.(22) Late bleed-
ing, which tends to present days to weeks after surgery, (though
not outside the realm of technical problems) is more commonly
secondary to patient factors such as an underlying bleeding ten-
dency, concomitant coagulopathy, or spontaneous rupture or
hemorrhage. It is worth noting that the risk of severe bleeding
such as after a two or three quadrant hemorrhoidectomy, despite
being small (2–6%), can be catastrophic.(5, 19) Therefore, it is
imperative that the possibility of bleeding is discussed with all
patients preoperatively, no matter how minor of a surgical proce-
dure the patient is undergoing.
Although uncommon, massive presacral bleeding during ­pelvic
dissection can result in hemodynamic instability and even death.
Injury is secondary to dissection outside the avascular plane. Initial
management includes packing and leveling the patient on the oper-
ating room table, along with continued resuscitation. This is effective
for most patients within 20–30 minutes. Multiple other methods have
described including electrocautery, suture ligation, sacral thumbtacks
(Figure 8-1), muscle fragment welding, placement of tissue expand-
ers or cyanoacrylate adhesives, topical hemostatic agents, and endo-
scopic tacking devices.(23–28) Although the presacral veins may be
injured, continued bleeding nonresponsive to initial management
is most commonly from the basivertebral veins through the sacral
foramina.(24, 29, 30) When all else fails, pelvic packing, peritoneal
closure, warming, and resuscitation in the ICU with return to the
operating room 24–48 hours later may be required. Thus, emphasis
on proper technique, knowledge of the pertinent anatomy, and com-
prehension of options to immediately consider when things do go
awry are all important to decrease perioperative bleeding complica-
tions and subsequent clinical complications.
infection
Surgical-Site Infection (SSI)
Surgical site infections continue to be a major source of cost and
morbidity despite a strong emphasis on proper selection, timing
and duration of perioperative antibiotics. Infections can be clas-
sified as surgical site infections, general postoperative infections
such as pneumonia and urinary tract (which will be covered in
separate sections), and infectious processes that deal specifi-
cally with the operation itself (i.e., anastomotic leaks, abscesses).
Although multiple different patient and surgical factors contrib-
ute to the development of postoperative infections, development
of any infectious complication results in increased patient suf-
fering, length of stay, and delayed recovery. Additionally, hospital
costs encompassing antibiotics, interventional procedures, nurs-
ing support, and surgical intervention contribute to driving up
overall healthcare system costs.
In simple terms, our skin and mucosal lining remain the
­primary defense mechanisms against infectious sources. With
surgery, the breach in these protective layers, along with manipu-
lation of the bowel and potential spillage of stool from various
colorectal procedures lead to increased rate of infections. Those
patients with an extensive component of cellulitis, characterized
by leukocytic infiltration of the dermis, bacterial presence, and
localized inflammatory response, typically require the addition of
antibiotics, especially in patients with immunosuppresion, diabe-
tes mellitus and the elderly. With the emergence of methicillin-
resistant Staphylococcus aureus (MRSA) and other multiresistant
bacteria, it is imperative for the surgeon to help control the emer-
gence of these more virulent pathogens by avoiding prolonged
usage of antibiotics and changing antibiotics once the pathogens
are cultured and appropriate sensitivity to antibiotics is known.
With such a drastic rise in the incidence of MRSA, some hospitals
are performing preadmission screening cultures for this patho-
gen. Thus, if there is an emergence of an active MRSA infection
in the postoperative period, the patient most likely brought the
infection into the hospital with them. Its presence then is not a
result of failure of the surgeon or hospital personnel to follow
protocol prevention. From a surgical perspective, proper wound

 improved outcomes in colon and rectal surgery
care, drainage of abscesses, and debridement of any necrotic tis-
sue, where appropriate, remain important adjuncts to the medi-
cal management of infections. Aspiration and drainage under
imaging can often be used to convert an urgent reexploration to
either an elective procedure or provide the ability to avoid a reop-
eration altogether.
In addition to proper surgical technique that avoids con-
verting a clean contaminated to a dirty case, identification of
at-risk patients can aid in early identification and treatment of
infectious complications. In a review of 428 patients specifi-
cally undergoing colorectal operations, surgical site infections
were independently associated with increased body mass index
(BMI) (odds ratio [OR] 1.07), and those in which a revision/
creation/or takedown of a stoma was involved (OR = 2.2).(31)
In addition, with the emerging pandemic of obesity through-
out the world, increased BMI has been found to be associated
with not only higher rate of surgical site infections, but also is
an independent predictor of wound dehiscence, herniation, and
anastomotic leak.(32)
Different methods have been employed to attempt to decrease
the incidence of surgical site infections. There is some debate in
the literature regarding the duration of antibiotic use for elective
colon and rectal surgery. Although preoperative use of intrave-
nous antibiotics to ensure adequate tissue concentrations at the
time of incision has become standard of care, there is some con-
troversy regarding the use of a single dose versus multiple doses.
Fujita and colleagues performed a study including almost 400
patients undergoing elective resection of colorectal cancer and
found that the three dose regimen of an every 8 hour, second
generation cephalosporin (i.e., 24-hour perioperative ­coverage)
significantly decreased the incidence of surgical site infections
over a single preoperative dose (4.3% vs. 14.2%, p = 0.009).(33)
However, organ or space SSI and other postoperative infectious
­complications did not differ between the two groups, and has
similarly been not significantly different in many other studies.
The practice of adding oral antibiotics has similarly contradic-
tory evidence, with large prospective randomized trials demon-
strating no decrease in infectious complications, while increasing
the rates of nausea, pain, and noncompliance.(34, 35) Yet, other
authors including a large prospective randomized trial and meta-
analysis of 13 studies demonstrated the addition of oral antibiot-
ics to systemic antibiotics was associated with a higher rate of
prevention of surgical site infections.(36, 37) Proponents cite
the ability of the oral antibiotics to decrease the bacterial load
in the colon, as well as the marked increase of colonic bacterial
isolates from the infected surgical wounds as evidence and ratio-
nale for its use. With such varying opinions, it is up to the indi-
vidual ­surgeon to evaluate the literature and determine the best
approach as it applies to their patient population. Finally, besides
the proper use and timing of preoperative antibiotics, supple-
mental postoperative high dose oxygen (80%) has been shown
to reduce ­surgical site infections by approximately 6–40%.(38, 39)
Through ­suggested mechanisms, including more efficient electron-
transport chain off-loading and improved neutrophil function,
postoperative high-flow oxygen in the immediate recovery period
has become part of a standardized postoperative pathway for many
institutions. Finally, fewer complications may be associated with

maintaining perioperative normothermia in patients undergo-
ing colorectal surgery. Employing methods such as preoperative
warming with bear-hugger devices, use of warm blankets and
fluids, and avoiding prolonged or unnecessary exposure, may all
result in less SSI.
urinary tract infection and retention
Urinary tract infections are the leading cause of nosocomial
infections, accounting for ~40% of all infections, of which 80%
are associated with transurethral catheter placement.(40) The
dilemma remains how to significantly reduce this rate, especially
in light of the chronic use of urinary catheters during colorectal
procedures. A recent Cochrane review evaluating the use of anti-
biotics during short-term catheter use demonstrated there was
a paucity of evidence that antibiotic prophylaxis was any better
than treating patients when clinically symptomatic. While it did
show some weaker evidence that bacteriuria, pyuria, and gram-
negative bacteria are all reduced following antibiotic use over 24
hours or until catheter removal, none of these studies specifically
focused on the colon and rectal patient. In addition, there was
limited data on cost or subsequent development of multiresis-
tant organisms, and most patients undergoing colorectal sur-
gery receive perioperative antibiotics to cover bowel flora. Thus,
caution needs to be taken when determining the applicability of
these results to colorectal surgical patients. Following rectal sur-
gery, urinary tract infection in part depends on the clinical prac-
tice of the surgeon regarding length of time of bladder catheter
drainage. In a study comparing catheter removal at 1 and 5 days
following rectal resection, Benoist and colleagues found urinary
tract infections to be increased in those patients with catheters in
for 5 days versus those who removed after 1 day (42% vs. 20%, p
< 0.01).(41) Increases in urinary tract infection with prolonged
drainage must be balanced with voiding dysfunction with early
catheter removal.
Unfortunately, urinary retention remains a well-known com-
plication of colorectal and anorectal surgery, as well as a result of
the spinal anesthesia commonly used during these operations.(42)
In the Benoist study, urinary retention was significantly increased
in those with the catheter present for only 1 day of postoperative
drainage over the 5-day cohort (25% vs. 10%, p < 0.05), especially
amongst those with tumors of the low rectum.(41) Following pel-
vic surgery, this may be, in part, secondary to third spacing and
edema around the urethra following disruption of these tissue
planes. Thus, in abdominal surgery, where the dissection does not
proceed below the peritoneal reflection, this may lower the rate
of dysfunction. The authors concluded that 1 day of drainage is
adequate for most patients, although for patients undergoing lower
resections, longer periods of drainage may be optimal. Changchien
and associates in a review of 2,355 patients with colorectal cancer
found urinary retention to be significantly associated with mul-
tiple factors to include older age, history of lung disease, rectal
cancer, longer operations, and additional pelvic procedures such
as hysterectomy or cystectomy.(43) Additionally, male gender,
American Society of Anesthesiologists’ (ASA) score of 2 or 3, rectal
cancer, use of a pelvic drain, and pelvic infection were indepen-
dently associated with prolonged urinary dysfunction, defined as
continued problems over one month postoperatively. To lessen
 general postoperative complications
the higher rates associated with transurethral catheter placement,
some authors have also advocated suprapubic catheter drainage. In
patients undergoing pelvic surgery, this has been associated with
similar voiding dysfunction rates, but fewer infectious complica-
tions than the traditional transurethral route.(44, 45)
Following anorectal surgery, urinary retention rates have
been reported to be up to 50%.(46) Multiple methods that have
attempted to decrease this rate have limited perioperative fluid, use
of local versus spinal anesthesia, and even use of alpha-adrenergic
blockade preemptively.(46) Although the latter did not seem to sig-
nificantly affect rates of voiding dysfunction, both fluid restriction
and adequate pain control have consistently been shown to have a
positive effect at decreasing this difficult problem.(47, 48) Toyonaga
and associates, in a prospective study of over 2000, patients found
independent predictors significantly associated with the develop-
ment of urinary retention following anorectal surgery were female
sex, prior urinary difficulties, diabetes mellitus, intraoperative flu-
ids over 1 L, and prolonged need for postoperative analgesics.(48)
Although ­urinary retention is known to increase overall length of
hospital stay, (42) careful patient education and strict fluid control
have allowed most anorectal surgeries to be performed in an ambu-
latory setting with a low rate of return for urinary catheterization.
(49) Additional use of agents such as NSAIDs and Ketorolac may
minimize narcotic use and increase the success rate by avoiding this
complication in an outpatient setting.(6) Surgeons therefore need
to be in constant ­communication with their anesthesia counter-
parts to discuss excessive fluids and proper analgesia, as many are
unaware of the potential downfall of these common practices.
atelectasis
Prevention
Basic principles of airway clearance, avoidance of splinting and
alveolar collapse, while preserving functional residual capacity
and pulmonary reserve remain important components of proper
postoperative pulmonary toilet. As a part of the “5 W’s” of the
postoperative fever, “wind” as it relates to atelectasis reminds phy-
sicians that optimizing ventilation and oxygenation are keys to
successful recovery, and are subsequently passed down to succes-
sive generations of training surgeons (as much as absolute truth
as ancient lore). The fundamental principle behind avoidance of
atelectasis has been shown to be successful in pulmonary processes
ranging from cystic fibrosis and acute spinal cord injury to post-
operative esophagectomy.(50–52) As such, factors such as head of
bed elevation, early ambulation, and the ever-present incentive
spirometer have become the mainstays of postoperative inpatient
care. However, a recent Cochrane review of incentive spirometry
use in the postcoronary artery bypass graft population with 443
participants in 4 trials found no difference in pulmonary compli-
cations amongst incentive spirometry, positive pressure use con-
tinuous positive airway pressure (CPAP), bilevel positive airway
pressure (BIPAP), or simple preoperative patient education.(53)
Furthermore, a meta-analysis with 14 trials over a 26-year period
evaluating the use of incentive spirometry, positive pressure, and
deep breathing following upper abdominal surgery to prevent
postoperative pulmonary complications, also demonstrated no
statistically significant difference between these modalities and no
therapy alone.(54) Pasquina and colleagues performed a review
of 35 ­trials evaluating the use of respiratory physiotherapy after
abdominal surgery and found that only in one study was the
incidence of pneumonia decreased. In another study atelectasis
decreased from 77% to 59% using pulmonary toilet methods of
deep breathing, cough, and postural drainage.(55) They concluded
that there are only a few trials that support its use, and the routine
use of respiratory physiotherapy does not seem warranted based
on data alone. Despite these large reviews, atelectasis is known
to be present in anesthetized patients in the dependent portions
of the lungs and has been shown to contribute to decreased lung
compliance, worse oxygenation, increased pulmonary vascular
resistance, and shunting.(56) It seems at worst that the practice of
employing methods to decrease atelectasis is not harmful, and at
best, may help out to a small degree with avoidance of pulmonary
complications, and therefore, it is our continued practice.
Pneumonia
There is little data in the literature that directly addresses the
development of pneumonia following colorectal or anorectal sur-
gery. As stated above, the degree to which atelectasis and proper
pulmonary toilet corresponds to the development of pneumo-
nia is debatable. One thing that is clear is that development of
postoperative pneumonia is independently associated with worse
outcomes. Therefore, both prevention and early ­recognition and
treatment, are key components to ensuring optimal outcomes.
Johnson and colleagues found in a study of 180,359 patients that
postoperative respiratory failure (defined as mechanical ventila-
tion for longer than 48 hours after ­initial surgery or unantici-
pated reintubation) was found in 5,389 (3.0%) of patients and
was associated with an increased in hospital morbidity, cost,
and late mortality.(57) Additionally, factors that were found to
be independently associated with the development of this was
higher ASA classification, emergency operations, more complex
surgery, sepsis, older age, congestive heart failure (CHF), chronic
obstructive pulmonary disease (COPD), and smoking. These,
along with a history of obesity and obstructive sleep apnea, man-
date a need for careful postoperative monitoring and aggressive
pulmonary toilet. Many of the patients, especially with underly-
ing malignancy, have these comorbidities, and speak to the com-
plexity of operations and need for close surveillance to avoid this
feared complication.
deep venous thrombosis
Deep venous thrombosis (DVT) and its embolic corollary, pul-
monary embolism (PE), are a significant source of morbidity and
mortality in the perioperative period. Due to the predominance of
abdominal and pelvic surgery, colorectal surgery carries a higher risk
of these postoperative complications than other ­general ­surgical pro-
cedures. Yet, despite so much emphasis, DVT and PE continue to be
the most common cause of preventable deaths during in-hospital
admission, accounting for 1 out of every 4 hospitalized patients
deaths.(58, 59) More concerning, over 50% of all DVTs are asymp-
tomatic, while the vast majority of PEs are detected only after death
(58). Since Virchow’s original description of stasis, hypercoaguability,
and endothelial damage as risk factors, large epidemiological studies
have found an increase in the development of symptomatic venous

 improved outcomes in colon and rectal surgery
thromboembolism in the perioperative period to be associated with
male gender, malignancy, trauma, immobility, COPD, sepsis, low
hematocrit, low albumin, and major surgery.(60)
One of the major problems with development of a DVT is the lack
of initial clinical signs. Patient complaints of pain, swelling, edema,
warmth, and tenderness of the affected limb are often absent.(61)
Those patients that progress onto pulmonary embolism present
many times in the late stages with cardiopulmonary shock and col-
lapse, though often heralded by symptoms such as acute shortness
of breath, dyspnea, pleuritic chest pain, along with tachycardia and
an increasing oxygen requirement. Thus, emphasis has been placed
on both prevention and screening. Despite its very high sensitiv-
ity and specificity of over 95%, screening with duplex and color
Doppler sonography, even in high risk patients, in the absence of
symptoms, has been questioned as to its cost-effectiveness.(62, 63)
Part of this may be that although the lower extremities are the most
common site of origin, approximately one-third of patients have
proximal (above popliteal) veins as the site of origin, which are not
visualized well by duplex.(59) Venous ultrasonography remains the
mainstay for diagnosis of deep venous thrombosis, especially when
combined with elevated d-dimer levels. The hallmarks of DVT via
ultrasound are both visualization of the clot and more commonly
the inability to compress the venous system under direct pressure.
(64) Similarly with the advent of multidetector row helical CT scan-
ners, this has essentially ­supplanted the pulmonary angiogram as
the procedure of choice for diagnosis of pulmonary embolism, with
sensitivity, specificity, and negative predictive value over 90%, even
for subsegmental ­pulmonary emboli.(65)
Prophylaxis of venous thrombotic events centers on both
mechanical and medical means. The current mainstays for chemi-
cal thromboprophylaxis are unfractionated and low-­molecular
weight heparin. Unfractionated heparin works through anti-
thrombin III to deactivate thrombin and other factors in the
­clotting cascade. Concerns about increased bleeding events as well
as its dose-effect relationship have led many to be wary of its use.
Low-molecular weight heparin has enhanced antifactor Xa activ-
ity and more predictable dose-effect relationships.(66) In a recent
Cochrane review addressing the prevention of thromboembolic
complications, the combined use of mechanical graduated stock-
ings with either unfractionated or low molecular heparin was
identified as the optimal prophylaxis.(67) Interestingly, despite the
extensive search, only 3 studies meeting inclusion criteria focused
specifically on colon and rectal surgery. That same group evalu-
ated 558 studies, of which 19 met the inclusion criteria, and again
found that unfractionated and fractionated heparin were equally
effective, and the addition of either to compression stockings was
superior to either alone.(68)
As pointed out in the opening challenging case, risk stratifi-
cation continues to be a mainstay for determining the extent of
prophylaxis in these patients. Young, healthy patients undergoing
routine anorectal surgery, with minimal patient-specific risk fac-
tors, do not require any therapy other than mechanical means
via graduated compression stockings and/or intermittent pneu-
matic compression boots and early ambulation. Those patients
with multiple risk factors and undergoing high risk surgery, such
as pelvic operations, warrant more aggressive means like unfrac-
tionated or low-molecular weight heparin, in addition to the

mechanical devices. Timing has been somewhat controversial
with some studies demonstrating higher bleeding without undue
increase in thrombotic events when given after the surgery and
others stating that dosing should begin preoperatively. Although
this question has yet to be definitively answered based on cur-
rent literature, it is well accepted that some form of perioperative,
including intraoperative means, has become the standard of care.
The risk of bleeding with thromboprophylaxis dosing is small,
with the majority revolving around injection site ecchymoses or
hematoma in up to 7% of cases.(69) More clinically significant
bleeding, such as gastrointestinal or intraabdominal bleeding,
occurs in <0.5%, and is rarely the cause for cessation of therapy.
One potential concern that arises frequently in the realm of
colorectal surgery is how to treat the patient receiving anticoagu-
lation for colonoscopy. Recent guidelines have shown that aspirin
and other NSAIDs do not need to be withheld, with the rate of
postpolypectomy bleeding around 2%.(70) On the other hand,
coumadin and other more potent antiplatelet medications (i.e.,
clopidogrel) are commonly held for 5 to 7 days before the pro-
cedure, especially when it is known that a polypectomy or other
procedure is likely. There is some evidence that the application
of endoclips with polypectomy in anticoagulated patients is safe;
however, small sample sizes hinder ability to make broad recom-
mendations.(71) Thus, most of the practice is based on guide-
lines and less on an abundance of available evidence ­supporting
or dissuading this practice.(72, 73)
nausea and vomiting
Though often not deemed as significant or crucial to overall ­success
of an operation by surgeons, postoperative nausea and vomiting
(PONV) can be extremely bothersome for the patient. Clearly, the
etiology is multifactorial—with surgical, anesthetic, medication,
and patient-related factors all contributing significantly. Head of
bed elevation and early ambulation are minor modifications that
may be somewhat helpful. More useful, anesthesia providers have
found increasing success through prophylaxis for this phenom-
enon. As a part of that process, identification of those patients at
risk is imperative, as universal prophylaxis has not been shown
to be cost-effective.(74) A thorough review of prior surgeries and
response to anesthetics may help in identification of these individ-
uals. Intravenous use of ondansetron, a selective serotonin 5HT3
receptor antagonist, has been shown in multiple randomized trials
to be effective in complete prevention of postoperative emesis in up
to 60–85%, when given before the induction of general anesthesia.
(75–77) Finally, routine decompression with nasogastric tubes has
demonstrated no impact on PONV and has fallen out of favor.(78)
prolonged ileus
In general, postoperative obstruction can be divided into two broad
categories—early and late. Early postoperative bowel obstruction is
defined as onset of symptoms within thirty days of surgery. The
majority of early postoperative bowel obstructions are due to para-
lytic ileus or adhesions—up to 90 percent in some series, with the
remaining possible etiologies including phlegmon, intraabdomi-
nal abscess, Crohn’s disease, hernia, volvulus, intussusceptions,
and malignancy.(79, 80) Late obstructions are those presenting at
any point >30 days following surgery. The management of bowel
 general postoperative complications
obstruction including ileus remains a significant burden to health-
care costs. In 1994, according to Beck and colleagues, there were
303,836 hospitalizations during which adhesiolysis was performed,
accounting for 846,415 inpatient days and an estimated $1.3 billion
in expenditures.(81) In addition, reoperative surgery in the setting
of early bowel obstruction can prove to be significantly challeng-
ing, as abdominal inflammation and early adhesions create a hostile
environment marked by densely adhered bowel and ­friable tissues.
In order to safely and effectively manage these patients, one must
have an extensive understanding of the various conditions which
may result in prolonged ileus.
Like many of the complications discussed in this chapter,
the development of a prolonged ileus has multiple potential
causative factors including hormones, medications and sur-
gical stress. Postoperative ileus clinically manifests itself with
abdominal distension, bloating, failure to pass stool or gas, nau-
sea, emesis, and pain. Even more concerning, Senagore found
that in addition to the symptoms experienced as a result of the
ileus, delayed surgical wound healing and ambulation, atelecta-
sis, pneumonia, and deep vein thrombosis are all potentially
increased by the development of a postoperative ileus, which
increases ­hospitalization length of stay and overall costs.(82) The
definition of what constitutes a prolonged ileus widely varies in
the literature and contributes to discrepancies between different
studies. In general, when the symptom complex continues for over
7 days following abdominal surgery, most consider this ­prolonged
and should raise concern for more extensive evaluation.
Return of bowel function has multiple parameters that can be
controlled by the provider in the perioperative period. For exam-
ple, limiting the amount of intraoperative and postoperative fluid
and sodium has been shown to improve time to passage of flatus
and stool, and result in earlier hospital discharge.(83) In addition,
clinical pathways that include the use of restricted perioperative
intravenous fluids, early oral intake, early ambulation, and epidu-
ral anesthesia, have been shown to significantly decrease length of
stay and perioperative cardiopulmonary complications, although
readmissions are slightly higher.(84) Thus, working through
optimization of all components of postoperative care may con-
tribute more to a successful recovery than primary emphasis on
one factor alone. Through entry into a standardized program,
the avoidance of certain variables that negatively affect recovery
for both the intraoperative and postoperative settings can pro-
vide improved reproducible results.(85) A bonus of implemen-
tation of pathways is the ability to help all healthcare providers,
including nursing personnel, to become accustomed to a routine
postbowel resection course. Therefore, any deviations from this
can be ­recognized more readily, allowing intervention before the
patient enters a more severe or septic state.
A thorough history and physical examination help distinguish
some of the benign causes of obstruction and aid in differentiating
this from a prolonged ileus. For example, the history in a patient
with Crohn’s disease or prior radiation therapy can ­provide just
as many clues as to the etiology of the obstruction, such as pos-
sible stricture, or an obvious hernia detected on physical exami-
nation. As patients often present with concomitant dehydration
and electrolyte abnormalities, placement of a nasogastric tube,
with appropriate fluid resuscitation, and correction of electrolyte
abnormalities should occur while the work-up is in progress. Plain
film radiographs may confirm dilated small bowel loops with
stair-stepping air-fluid levels, but usually do not assist in defin-
ing the underlying etiology. Despite their frequent use, numerous
studies quote a poor sensitivity for plain abdominal radiographs
in diagnosis of small bowel obstruction, ranging from 13% for
low grade obstruction to 50–60% for high grade obstructions.
(86) CT may give anatomical information outside of the bowel
wall itself that may help with accurate diagnosis. Caution should
be used in giving oral contrast for the patient with high grade
ileus or obstruction, and in general, should be avoided.
Newer pharmacotherapeutic endeavors, such as the peripher-
ally acting mu-opioid receptor antagonist, alvimopan, have been
shown to reduce the incidence of postoperative ileus, nasogas-
tric tube insertion, time to gastrointestinal recovery, and overall
hospital length of stay.(87–89) Further studies are still ongoing
to evaluate whether its safety profile is acceptable for wide-scale
clinical use. Other methods that have been studied in attempt to
shorten bowel function return include prokinetic agents such as
erythromycin and cisapride, although the results have been mixed.
Erythromycin, a motilin agonist, has been shown in the past to be
effective for upper gastric and pancreatic surgery, especially with
regard to promotion of gastric emptying. In a randomized double-
blind placebo study of 134 patients, erythromycin was not shown
to affect clinically relevant outcomes such as time to intake of solid
foods, nausea rate, or length of stay.(90, 91) Similarly, cisapride,
before its removal from the market secondary to cardiac toxicity,
did show some, albeit limited, clinically significant improvements.
(92–94) Thus, for hindgut surgery, prokinetic agents have not yet
been shown to make a clinically relevant difference.
Probably the most important factor that has been shown to
make a difference in reducing ileus is postoperative clinical
pathways that include early oral feeding.(95) A recent Cochrane
review by Andersen et al. including 13 randomized controlled
­trials and over 1,100 patients, evaluated the use of early feeding
and the development of complications and found early feeding
is safe, may reduce postsurgical complications, and concluded
there is no advantage to withholding oral intake.(96) Opponents
of this practice cite a lack of a consistent definition of what early
feeding encompasses. As such, although many surgeons prefer to
advance the postoperative diet slowly, it does seem clear that the
recovery of gastrointestinal function as evidenced by first bowel
movement or flatus and tolerance of an oral diet in the early post-
operative setting are independent of each other, and the practice
of early resumption of diet is safe.(97)
retained foreign bodies
In any complex surgical procedure there exists a potential for items
to be unknowingly left in body cavities.(98) To minimize this risk,
current standards require all sponges, needles, surgical instru-
ments, equipment, and items small enough to be misplaced be
counted before the procedure and one or two times after the com-
pletion of the procedure to confirm that all items are accounted
for. These activities are usually performed and documented by the
operating room nurses and technicians; however, the surgeon is
ultimately responsible and should conduct each operation so as to
minimize the risk of misplaced foreign bodies. In accordance with

 improved outcomes in colon and rectal surgery
Figure 8.2  Radiograph demonstrating radoopaque markers. Left to right.
Laparotomy sponge, Ray-tec sponge. The upper image is flattened, whereas the
lower image demonstrates the radiologic view when the item is crumpled.
Figure 8.3  Radiograph of (left to right) Jackson-Pratt drain, Penrose drain,
nasogastric tube.

(A)
(B)
Figure 8.4  (A) CT scan of patient with a retained Ray-tec sponge. Image is the
inferior cut of the study. The upper edge of the Ray-tec marker is demonstrated
as white dots lines between the bladder (filled with contrast) and the sacrum. (B)
Pelvic radiograph of the same patient demonstrating Ray-tec marker in pelvis.
this goal, most surgeons, avoid using small Ray-tec sponges in the
abdomen and avoid placing laparotomy sponges in areas that are
hard to visualize. If sponges must be used to pack areas, the sponge
marker should be left in an obvious area, or a ring or clamp may
be attached to the sponge. Most important is a through explo-
ration of the entire operative field, which should be performed
­routinely before closing the incision. Items used during the opera-
tion that have the potential to be easily lost should be radiopaque
or contain a radiopaque marker (e.g., Ray-tec sponges and Silastic
drains). Figures 8.2 and 8.3 demonstrate the radiologic view of
several common surgical items. Plain radiographs are often the
best for identifying the radiopaque markers incorporated into
these items; The markers may be much less obvious on studies
such as CT scans (Figures 8.4a and b).
If an instrument, sponge, or needle count is not correct, several
actions are indicated. All the sponge wrappers and suture pack-
ages should be counted to confirm the accuracy of the original
count. The entire operating room, and especially the trash bags
and floor under the operating table, should be searched for the
misplaced item. Simultaneously, the surgeon should inspect the
operative field thoroughly for the missing item. If the missing
item cannot be located, a radiograph of the entire operating field
 general postoperative complications
should be obtained before closure of the body cavity to identify
any radiopaque object and minimize the morbidity of locating
the missing item. Because of the potential for human error, a
“correct” instrument, needle, or sponge count does not absolutely
exclude the presence of a foreign body. Therefore, each member
of the team must maintain a high index of suspicion.
A sponge or other foreign body left in a body cavity can pres-
ent or be identified in a number of ways. The foreign body may
be seen on a radiograph obtained for other reasons, or the patient
may develop symptoms that lead to the need for radiographs or
an exploratory procedure. Symptoms may be infectious (fever,
elevated white cell count, wound infection, or abscess) or inflam-
matory (ileus, tenderness, mass effect). For any postoperative
patient with unusual or unexplained symptoms, radiographs
should be included in the evaluation.
Finding a retained foreign body is unusually an indication for
an urgent exploratory procedure. The exception may be asymp-
tomatic patient with a retained small needle. The morbidity associ-
ated with localizing and removing a small needle must be weighed
against the potential risk of leaving it alone, and the patient can
assist in this decision. Review of biplanar radiographs may assist
in localizing a retained item, and early identification will minimize
the morbidity associated with the object’s removal. Retention of
operative foreign bodies is uncommon, and a surgical team that
adheres to careful practices should avert its occurrence.
“time out” and sided surgery concerns
Wrong-side/wrong site, wrong-procedure, wrong-patient adverse
events (WSPEs) constitute some of the worst medical errors that cli-
nicians and patients experience. These events often result in patient
harm and litigation, but literature on frequency and root causes
is limited.(99) The Institute of Medicine report To Err Is Human
painted a broad picture of the magnitude of medical errors in the
United States and gave directions for safety improvements.(100)
While, sided surgery is less of a concern in colorectal patients, incor-
rect surgery due to inadequate lesion location remains a challenge. In
July 2004, the Joint Commission on the Accreditation of Healthcare
Organizations (JCAHO) implemented the universal protocol for the
prevention of WSPEs.(101) The protocol uses preoperative verifica-
tion of patient, site, and procedure, marking the operative site, and
a time-out immediately before starting the procedure. Prevention of
WSPEs requires new and innovative technologies, reporting of case
occurrence, and learning from successful safety initiatives (such as
in transfusion medicine and other high-risk nonmedical industries),
while reducing the shame associated with these events.
future directions
As the push to not only prevent complications but detect them
earlier continues to expand, molecular markers may become an
increasingly utilized component. Welsch and associates evaluated
the use of C-reactive protein (CRP) in the postoperative course
of 383 rectal resections with primary anastomosis in patients
with rectal cancer and found that using a cutoff of levels above
140 mg/dl on postoperative days 3 and 4 was associated with a
sensitivity of 80 and 54% respectively and specificities of 81 and
92%, respectively, for the presence of all infectious complications.
(102) Although this is just one example of a vast field, it highlights
a growing trend toward bridging the gap between molecular and
bench research with clinical application in attempt to change the
way surgeons approach patients and improve outcomes.
conclusion
As the field of colon and rectal surgery continues to evolve as a
specialty, emphasis on optimization of outcomes through pre-
vention and early identification, and treatment of complications
is imperative. As many complications are a result of multiple dif-
ferent components, sometimes all working in concert to lead to
untoward results, surgeons must also use a multifaceted approach
to ensure a successful perioperative course.
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double-blind study. Dis Colon Rectum 2000; 43(3): 333–7.

  91. Bonacini M, Quiason S, Reynolds M et al. Effect of intrave-
nous erythromycin on postoperative ileus. Am J Gastroenterol
1993; 88(2): 208–11.
  92. Roberts JP, Benson MJ, Rogers J et al. Effect of cisapride
on distal colonic motility in the early postoperative period
­following left colonic anastomosis. Dis Colon Rectum 1995;
38(2): 139–45.
  93. Tollesson PO, Cassuto J, Rimbäck G et al. Treatment
of postoperative paralytic ileus with cisapride. Scand
J Gastroenterol 1991; 26(5): 477–82.
  94. Brown TA, McDonald J, Williard W. A prospective, ran-
domized, double-blinded, placebo-controlled trial of
cisapride after colorectal surgery. Am J Surg 1999; 177(5):
399–401.
  95. Reissman P, Teoh TA, Cohen SM et al. Is early oral feeding
safe after elective colorectal surgery? A prospective random-
ized trial. Ann Surg 1995; 222(1): 73–7.
  96. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition
within 24 hours of colorectal surgery versus later commence-
ment of feeding for postoperative complications. Cochrane
Database Syst Rev 2006; (4): CD004080.
  97. Han-Geurts IJ, Hop WC, Kok NF et al. Randomized clinical
trial of the impact of early enteral feeding on postoperative
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  98. Stamos MJ, Theuer CP, Headrick CN. General postop-
erative complications. In Hicks TC, Beck DE, Opelka FG,
Timmcke AE. eds, Complications of Colon & Rectal Surgery.
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  99. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human:
Building a Safer Health System. Washington, DC: Institute
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100. Seiden SC, Barach P. Wrong-side/wrong site, wrong-
­procedure, wrong-patient adverse events. Are they pre-
ventable? Arch Surg 2006; 141: 931–9.
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102. Welsch T, Muller SA, Ulrich A et al. C-reactive protein
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1499–507.
9 Care paths and optimal postop management
Surya P M Nalamati and Eric J Szilagy
challenging case
A 45-year-old man undergoes an open sigmoid colectomy for
diverticular disease and is placed on a postoperative care path.
On postoperative day three, the patient is ambulating, has mild
nausea, and has not passed flatus.
case management
The care path is modified to continue intravenous fluids. The
patient-controlled analgesia is stopped and the patient is started on
small doses of intravenous narcotics. Ambulation is continued.
INTRODUCTION
The constant endeavor of modern medicine has been to improve
the quality of patient care. Over the past century there have
been tremendous technological advances in medicine and sur-
gery. The pattern of care has evolved from being a single physi-
cian managing one patient’s care to team care involving one or
more physicians from same or different fields of specialization,
residents, nurses, physician assistants, social workers, and case
managers. However, these advances have increased health care
delivery costs, which in turn demanded a system of care to be
developed that is more efficient without compromising patient
safety and the quality of health care. Care paths are one of the
most wide spread tools used to enhance outcomes and contain
costs.(1) Introduced in early1990s in the United Kingdom and
United States, they have rapidly gained acceptance and are now
being used all over the world.
Care paths are structured, multidisciplinary plans of anticipated
care, set in an appropriate time frame, to help patients with spe-
cific conditions or sets of symptoms, move progressively through
a clinical experience to a positive outcome. Numerous synonyms
exist for care paths including clinical pathways, critical care path-
ways, integrated care pathways, critical paths, multidisciplinary
pathways of care, and care maps.(2, 3) Fast-track surgery and ERAS
(enhanced recovery after surgery) programs are recent evolutions of
the care paths concept.(4–6) Critical pathways, successfully utilized
in several different business sectors, including construction and
automotive industries, have been adapted and applied to medical
field.(7–11) They are designed to support the implementation and
translation of national guidelines, or an evidence-based standard of
care, into local protocols. The anticipated result is the subsequent
application of pathways to clinical practice, clinical and nonclinical
resource management, clinical audit, and financial management.(2)
They provide detailed guidance for each stage in the management
of a patient (diagnosis, treatment, interventions etc.,) for a specific,
given condition over a period of time. They encompass the progress
of patient care and document details of outcome.(12)
Clinical pathways have four main components: a time line, the
categories of care or activities and their interventions, interme-
diate and long-term outcome criteria, and the variance records,
which allows deviations to be documented and analyzed.(2)
Care paths differ substantially from clinical guidelines, proto-
cols, and algorithms. Clinical guidelines are consensus state-
ments that are systemically developed to assist practitioners
in making patient management decisions related to particular
clinical circumstance.(13) Protocols are treatment guidelines
that are developed based on clinical guidelines.(14) Although
anchored in clinical guidelines, care paths are designed to be
used by multidisciplinary teams and focus on details of the
process of care and highlight inefficiencies. Care paths in con-
trast to guidelines contain a continuous monitoring and data
evaluation component. This helps in identifying the rate limit-
ing steps and to make any evidence-based changes in the care
path to improve the overall process of care.
care paths in colon and rectal surgery
Care paths in surgery are used in the management of patients under-
going commonly performed surgical procedures.(15) In colon and
rectal surgery, care paths have been successfully initiated since the
early1990s. Care paths have been used in the management of peri-
operative care where they were more procedure specific. They have
been successfully used in management of standard colon resection,
laparoscopic colon resections, complex cases such as restorative
proctocolectomy, and complex anorectal reconstructions.(16–20)
The objectives of care paths, as reviewed by Pearson et al., were to
select the best demonstrated practice when practice varied unneces-
sarily.(21) He outlined the process guidelines as follows:
Define the standards for the expected duration of hospital
stay and for the use of tests and treatments. These standards are
evidence-based or based on guidelines for the specific clinical cir-
cumstance. For example, Stephen et al. noted in their article, that
before implementation of pathways patients had their nasogastric
tubes removed after they passed flatus.(22) During development
of their care path for colonic resection, evidence for the routine
use of nasogastric tube which was a rate-limiting step for early
recovery was reviewed. Evidence showed that routine prophylac-
tic decompression with nasogastric tube decompression is of no
use and should be abandoned.(23) This led to incorporating the
step to remove the nasogastric tube on the day of the surgery,
which has become now widely accepted clinical practice.
•• To examine the interrelations among the different steps in the
care process and find ways to coordinate or decrease the time
in the rate-limiting step.
•• To give all the care providers a common plan from which to view
and understand their various roles in overall care process.
•• To provide a framework for collecting data on the care pro-
cess so that providers can learn and analyze how often and why
patients do not follow an expected course.
•• To decrease documentation burdens and improve patient satis-
faction with care by educating patients and their families about
the plan of care.

 improved outcomes in colon and rectal surgery
defining and improving outcome measures
Surgical care outcomes have been defined by a variety of measures.
Complication rates relating to abnormal outcomes, such as infection,
hemorrhage, organ system dysfunction, and reconstruction failure,
are common benchmarks for surgical performance. These rates have
been the targets of quality improvement because they have impact
not only on morbidity but also mortality. However, these outcome
measures, although significant, do not necessarily reflect the effort of
the entire surgical team or the efficiency of the care process.
Length of stay, rate of return of physiologic function, and quality
of life measures are cumulative standards that also take into account
the impact of multiple caregivers. They may not only correlate with
lower morbidity and mortality, but provide additional metrics for
the result of a multidisciplinary team approach.(24) The cumula-
tive effect of introducing efficiency in the multidisciplinary effort is
improved utilization of resources, with higher quality, using fewer
resources at a lower cost.
Traditionally, the hospital stay after colonic resection varied be­­
tween 5 and 10 days with a median of 7 days and a complication
rate of 10–20%.(25, 26) Implementation of care paths has signifi-
cantly reduced this number. Archer et al. reported a mean length of
stay decrease from 10.3 to 7.5 days, and average hospital charges from
$21,650 to $17,958 (20) whereas Billingham et al., in their series of 263
patients, reported stay of 5.5 vs. 8.2 days and hospital charges $12,672
vs. $16,665 (19). Even though the decreased length of stay and cost
benefits appear to be obvious, it is not clear in these studies if there is
significant shifting of costs from hospital care to home care.
benefits of care paths
Care paths provide explicit and well-defined standards for care. They
support introduction of evidence-based medicine and use of clini-
cal guidelines thus reducing variations in patient care and improving
clinical outcomes.(27) They improve multidisciplinary communica-
tion, interprofessional collaboration, teamwork, and care planning.
(28) Care paths implement continuous clinical audit, providing a
means of continuous quality improvement, thus providing a base-
line for future initiatives to modify the pathway. Care paths reduce
risk, support training, optimize resources, and reduce costs, which
contribute to shortening the hospital stay. Care paths are not pre-
scriptive; they do not override clinical judgment. On the contrary, the
surgeon can at any time elect not to follow the pathway based on his
clinical judgment. One of the most useful characteristic of care paths
is that they provide a visual overview of each patient’s care with spe-
cific outcomes stated. This can be reviewed and acted on by every one
caring for the patients, as well as by patients themselves.(20) Using
care paths designed around evidence-based data and standards of
practice, one could expect a decrease in overall malpractice risk.(29)
development of care path
The development and implementation of care paths consist of
the following steps as reviewed in numerous publications.(1, 14,
19, 21, 22, 30, 31)
Select a Topic
Topic selection for formulating a care path could be either disease
or procedure specific. High volume, high-cost diagnoses or proce-
dures are ideal. Critical pathways development in colorectal ­surgery

concentrated on high volume and high cost procedures like colec-
tomies, restorative total proctocolectomies, and complex anorectal
reconstructions.(5, 16, 19, 20, 22) Most of the care paths developed
in colon and rectal surgery are procedure specific and aimed at
perioperative management. These procedures are more suitable for
pathway development because of the predictable course of events
before and after hospitalization, and variations in care associated
with them. Development of care paths makes the goal of decreased
variation and improved resource utilization possible.
Select a Team
A multidisciplinary team is the most critical element of any care
path. Historically, care paths were developed by and for nurses
and other nonphysician hospital-based workers. However, the
lack of physician participation led to failure of that model of care
pathway.(32, 33) The active role of surgeons in a leadership role
is crucial to development and implementation of pathways. In
addition, it is vital to involve representatives from all groups that
will play a role in implementation of pathway. The team should
discuss all the elements of the pathways. The team should meet
regularly to develop the pathway and after implementation to dis-
cuss variances and make appropriate revisions to it.
Colon and rectal care path teams consist of surgeons, house
staff, physician assistants, stoma nurses, office nurses for preop-
erative care planning, ward nurses, physical therapists, and social
workers to plan the home care needs and arrange them in a
timely fashion. Timely intervention by each of the team members
is essential for success of the care path.
Evaluate the Current Process of Care
A careful review of the medical records should be performed to
identify the critical intermediate outcome, rate limiting steps, and
high cost areas on which to focus. Evaluation can be automated
where electronic medical systems are available. This should
include review of the preop process (preanesthesia work up,
obtaining necessary consults, stoma training if needed, antibiot-
ics, anti coagulation) and the postop process. In our initial review
process, during the development of care pathways, we found that
nasogastric intubation, postoperative feeding, GI function recov-
ery time, and mobilization to be the important rate limiting steps.
Further development will be based on intraoperative anesthesia
care, and postoperative pain management.
Evaluate Medical Evidence and External Practices
After defining the rate limiting steps, the team should evaluate lit-
erature for evidence of the best-demonstrated practice. For most
of the rate limiting steps in colon rectal surgery there is data avail-
able. In the absence of evidence, comparison with other institutes
to set up a benchmark is the most reliable method. These steps
should be then incorporated into the care path.
Establish Goals and Endpoints
A reasonable objective should be established as a goal, which
serves as an endpoint for the care path. Multiple goals can be
established involving each aspect of care in the pathway, and the
successful achievement of each of these landmarks would define
the success of care path. For example, in our care path for colon
surgery (see Figures 9.1 and 9.2), the goal of the pathway is to
 Aspect of Care PRE-HOSPITAL PRE-OP/DAY OF POST_OP/DAY OF POST_OP/DAY 1 POST_OP/DAY 2
SURGERY Date_____ SURGERY Date_____ Date________ Date________

CONSULTS Surgery/PCP
Anesthesia class3 Anesthesia ostomy/ET consult
ET for elective stoma

TESTS CBS,chem 7, Platelets CBS,chem 7 (only if blood

EKG & CXR, as Type and Screen loss or metabolic issue)
needed only

Ambuiate X 4 Ambuiate X 4
Bed rest, Reposition q 2-4 hr
ACTIVITY Increase 1. 2. 3. 4 1. 2. 3. 4
Dangle Post-op eve______
Increase freq & distance Increase freq &
Ankle Pumps, C&DB
50ft to 100ft distance 50ft to 100ft

Spirometry No NG unless obstructed. NG_______

NG_____ IV, Dressing SED
NG_______ IV, de dressing, SED
TREATMENTS Incentive spirometry
IV, Dressing, Spirometry
Pulse Ok Wean O2
Incentive spirometry, Pulse Ok Incentive

Bowel prep day Analgesia: PCA____ Analgesia: PCA____ Analgesia: PCA____

before surgery Epidural_____ Epidural_____ Epidural_____ dc___
Routine meds as DVT prophylaxis Other_____ Other_____ Other_____ All routine meds
indicated by MD Resume pre-hospitalization Resume meds PO if tolerated
meds

I&O dc Foley______ (leave
Bowel prep day

ELIMINATION in if fluid status problem
before surgery Confirm bowel prep Monitor I & O Foley Monitor I & O Foley
or Epidural Bladder scan
post vaid straight cath

Clear Liquids when

DIET Clear fluids per MD NPO after midnight NPO/Ice chips Sips of clear liquids tolerating 800cc clear liquid
advance to PO#1 diet_____
care paths and optimal postop management

Consult CRM if Consult CRM: estabilish Consult CRM: confirm

DISCHARGE PLAN needs identified Consult CRM discharge dispositional discharge plan
by nurse screen or MD needs

Pre-op education Post-op education, C&DB, SED,

TEACHING re:bowel prep, post op pre-op teaching Incentive spirometry, early Introduce ostomy Ostomy education
activities, pain ambulation education
management_____

REVIEW Days Initials_______ Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____

Eves Sign/title_______ Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____
PATH
WAY Nights Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____

Figure 9.1 Care Path for Colon Surgery.



Aspect of Care POST-OP/DAY 3 POSTE-OP/DAY 4 COMMENTS OUTCOMES
Date____________ Date____________

CONSULTS Clear discharge with consulting MD Appropriate referrais pre-op

TESTS

Ambulate in atleast
4 times(50 ft —100 ft) Ambulate independently, Elimination of post-op complications
ACTIVITY Progressively increase or with aids as required related to immobility
distance/frequency

TREATMENTS Transfer IV to saline lock Monitor No post-op infections

Analgesia: change to PO pain PO analgesia Effective pain management

medication if tolerating fluids

Monitor I&O Monitor I&O

Monitor bowel function: Monitor bowel function: Effective bowel and bladder functon
ELIMINATION Flatus__________ Flatus__________ re-estabilished

PO # 1 diet
DIET Diet/Low Residue Adequate nutritional intake
Dietary consult if needed

Consult CRM: Finalize discharge plan

obtain supplies and equipment.
Complete discharge, W-10. Consult CRM: review
DISCHARGE PLAN Discharge by post-op day #4
Consider discharge if tolerating PO & finalize Discharge plan
Passing flatus if needs identified by nurse
screen or MD

Reinforce ostomy education. Incerase Patient/Family will

Review diet, activity
TEACHING patient participation. Review diet, understand and participate
improved outcomes in colon and rectal surgery

meicaton and home care

activity and medication. in plan

REVIEW Days Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____

PATH Eves Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____
WAY Nights Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____

Figure 9.2  Care Path for Colon Surgery (Continued).

 care paths and optimal postop management
­discharge the patient on postoperative day 4, and if possible on
day 3. The subgoals that were established were based on the aspect
of care such as to ambulate on day 1 after surgery, remove the
Foley catheter on day 2, etc. Goals should also be established for
achieving patient satisfaction, as measured by survey tools such as
those used by Press Ganey Associates.(34)
Determine Critical Pathway Format
There are multiple formats, which can be used; most of them
have a task-time matrix in which specific tasks are specified
along a time line. Care paths range from different kinds of man-
ual ­formats to electronic format, where electronic charting, and
pathway compliance are obtained simultaneously.(31, 35)
Implement the Care Path
Education of all the involved caregivers, patients, and their families
is the key to successful implementation of a care path. In-service
education should be given to all the involved groups, especially
if electronic care paths are used.(36) Different individuals in the
care path should be assigned specific functions such as collection
of data, analyzing variance etc.
Document and Analyze Variance
Implementation of the pathway is only the first action of care
path. This must be followed by data collection analysis and then
process improvement to achieve the set goals. A good tool suited
for this purpose is the analysis of variance grids.(27) By examin-
ing the variance sheets that record variances in implementation of
pathway regularly, it will be easier to identify common reasons for
noncompliance. These issues can be discussed with the team to see
if any changes can be made for full implementation of care path.
our institutional experience
Care pathways for colon surgery were initiated in 1995 at our
institute. This was used for both standard and laparoscopic colon
resections. The care path was designed with an aim of providing
optimal care in a cost effective manner. The goal of the pathway
is to discharge patients by postoperative day 4 and when possible
on day 3. The endpoint of the pathway is to discharge the patient
home when tolerating diet and passing flatus. The documenta-
tion for the pathways was of paper format and had boxes to check
and spaces for writing notes to document the progress.
The pathway starts with preoperative patient teaching during
their office visit. Patients are informed about the procedure, the
length of stay and anticipated days for landmarks of progress, such
as ambulation, advancement of diet and return of bowel func-
tion, and discharge. They are also provided with a printed copy
of the care path guide, which is especially designed for patients,
that details preoperative preparation, what to expect on arrival
to hospital, and postoperative care scenario. Patients are encour-
aged to call if they have any doubts regarding the care path. A
complete blood count, chemistries are ordered for every patient.
Electrocardiogram and chest x-rays are ordered for patients if
needed. Patients undergo bowel preparation at home the day
before surgery, using Golytely.
On the day of surgery the patients receive Heparin 5000 units
subcutaneously, and antibiotics in the preoperative period.
Antibiotics are administered for 24 hours and heparin is given
throughout their hospital stay. Antiembolism devices such as
Venodynes are put on preoperatively. The anesthesiologist places
an epidural catheter if the patient consents to it.
Postoperatively, the patient is admitted to a regular surgical
unit, and vitals monitored every 4 hours during the entire length
of hospitalization. The patient is given an incentive spirometer
and its use demonstrated. On postoperative day 1 they are ambu-
lated. Patients are given sips of clear liquids and if tolerated given
a clear liquid tray. Stoma education is introduced on day 2 if
indicated. Patients on postop day 2 are given unrestricted clear
liquids and advanced to regular diet if tolerating 800 cc of clear
liquids. Foley catheter is also removed. In addition, the epidural
or patient controlled anesthesia (PCA) are discontinued and the
patient is started on oral pain medications. Discharge disposition
needs are established. On postoperative day 3, patients are given
a regular diet; discharge paperwork is completed and kept ready.
If the patient tolerates diet and passes flatus they are discharged;
if not, the patient is discharged on postoperative day 4 after
meeting the discharge criteria. Before discharge, the diet, activ-
ity, medication, and homecare instructions are reviewed with the
patient and follow up appointments are set up. The Care path
was routinely analyzed at interdisciplinary conferences. (Refer to
Figures 9.1 & 9.2).
challenges and concerns
Many surgeons believe that their responsibility to practice medi-
cine economically is becoming secondary to their responsibility
of practicing medicine effectively.(37)
Common reluctance to accept care paths arises from a preju-
dice in viewing them as a form of “cookbook” medicine.(38, 39)
Some consider them to be intrusive, decreasing the physician’s
autonomy, and lack the element of individualized care for each
patient. However, although care paths encourage standardiza-
tion as a strategy to improve quality and efficiency, physicians,
by helping define these standards, actually would gain greater
control over the patient care rather than losing their autonomy.
Physicians also need to be free to write orders to change the
pathway or to remove the patient from the pathway if needed.
Documenting the reasons to do so would help in analyzing the
pathway processes and lead to improvement in the pathway. This
would increase the acceptance of care paths and also counter the
criticism of deficiency of individual care.
Although many studies report cost savings in implementa-
tion of care paths, most of these do not address the issue of cost
of development of care paths. Macario et al. estimated the cost
of development of the care path for patients undergoing knee
replacement surgery at $21,000.(40) However these did not take
into account the time staff physicians spent on the project.
There is a concern among the academic faculty that the care
paths when used in resident training environments may discourage
experimentation, independent thinking, and application of appro-
priate clinical judgment to individual cases. Those responsible for
house staff education may feel care paths might stifle the question-
ing through which residents learn. However medical training might
be well served by incorporating methods such as critical pathways
to teach students evidence-based and cost-effective practice.(21)

 improved outcomes in colon and rectal surgery
Care pathways may serve to frame the educational process. They
are based on expected physiological outcomes, but are monitored
so that variances (i.e., complications) can be addressed with the use
of clinical judgment. The clinical judgment is, in effect, the imple-
mentation of an expanded path or alternate pathway. The alternate
pathway, for example, may be for postoperative myocardial infarc-
tion management. Pathways are structured but dynamic.
There is also a concern that care paths might create an atmos-
phere in which patients will be steered away from clinical research
studies into treatment according to critical pathways. Including
a step in the care path can offset this. If set criteria are met, the
patient should be considered for the appropriate clinical trial
and the research team would be contacted. This would actually
yield in improved recruitment to clinical studies. Research ques-
tions can themselves be embedded in care paths and answers be
obtained on analysis of the care paths.
Another frequently voiced concern is that physicians may be
more vulnerable to malpractice suits if they do not comply with
a care path and a patient has a complication. In essence, litigation
is more likely to occur when there is a failure to follow a pathway
based on standards of care. Careful documentation as to reason
for deviation from the pathway could potentially decrease the
chance of litigation.
realistic expectations
Despite the successful use of care paths for optimal management
of postoperative patients undergoing colon and rectal surgeries,
it should be noted that the pathways are oriented towards ideal
patients with predictable course of care. Enthusiasm to man-
age every patient with the care path without paying attention
to individual circumstance could be counterproductive. Hence,
care paths should be designed to recognize patients with special
needs or comorbidities. Perioperative pathways that consider the
needs of diabetics, cardiac patients, pulmonary patients, or stroke
patients for example, would be a proactive way to institute risk-
reducing strategies that would have a positive impact in reducing
perioperative morbidity and mortality.
Tremendous scope for improvement still exists in implementa-
tion of evidence-based management. In a recent article, Kehlet
et al. reviewed the care after colonic surgery in Europe and the
United states and analyzed the use of evidence-based care in the
perioperative period.(41) They identified mechanical bowel prep-
aration, operative techniques, nasogastric intubation, time frame
for postoperative food, and fluid intake, time to recovery from
GI function, and mobilization as the important variables, which
have positive evidence-based practices. They noted preoperative
bowel preparation was used in >85% of patients. The nasogastric
tube was left in situ postoperatively in 40% vs. 66% of patients
in the United States and Europe, respectively. It took 3–4 days
for 50% of patients tolerating liquids. This suggests that clinical
practice does not optimally reflect published evidence and indi-
cates a potential for major improvement.
fast track colon and rectal surgery
Fast track surgery is an evolution in the care path approach that
involves rapid progress from perioperative preparation, through
surgery, and discharge from hospital. Synonyms used for this

include accelerated postoperative recovery programs and enhanced
recovery programs. Critical elements of fast track colon surgery
paths include use of the following: extensive preoperative coun-
seling, no bowel preparation, no premedication, administration
of short acting anesthetic drugs, standardized surgical procedure,
minimal access techniques, restriction of drains, and catheters,
early extubation, rewarming and sustained postoperative normo-
thermia, optimal pain control, avoiding opiates for pain control,
early ambulation and discharge, and follow up after discharge.
(2, 5, 16, 17, 42–44)
Factors that limit early discharge include pain, nausea, vomit-
ing, prolonged ileus, mechanical factors such as drains, indwell-
ing catheters, and stress-induced organ dysfunction.(6, 45) Kehlet
and Mogensen, in their study involving 18 patients who under-
went open sigmoid colectomy, addressed these factors by imple-
menting a multimodal rehabilitation program.(43) It involved a
highly scripted preoperative and postoperative care path regu-
lating the introduction of epidural analgesia, diet, and ambula-
tion. The pathway involved mobilization of patients on the day
of surgery, administering cisapride and magnesium, and allowing
free fluid intake on evening of surgery, among numerous other
inter­ventions instituted. They described a median postoperative
stay of 2 days, mobilization of patients for 5 hours on second post-
operative day and 10 hours on third postoperative day. They also
showed decreased pain and fatigue scores.(43) Delaney et al. stud-
ied 60 patients undergoing major abdominal and pelvic surgeries
without administration of preemptive epidurals, oral cathartics,
and prokinetic agents. They have described shorter length of stay
than patients having traditional care.(46)
Recent developments of laparoscopic colon surgery showed
significant improvements in average length of stay after colec-
tomy and also better patient satisfaction in terms of pain control.
This further catalyzed the interest in fast track pathways in colon
and rectal surgery. Several authors described in their studies,
multimodal care plans involving different strategies to optimize
preoperative, intraoperative, and postoperative limiting factors,
to achieve an early discharge with no difference in readmission
rate or mortality.(16, 17, 24, 42, 46–48) Wind et al. published a
review of all randomized controlled and controlled clinical trial
on fast track colon surgery. This meta-analysis showed that the
average hospital stay (2.61 days) and morbidity were signifi-
cantly lower for fast track programs.(44) The strategies adapted
in these studies included the following: extensive preoperative
counseling, no bowel preparation, no premedication, antibiotics
administration before surgery, no preoperative fasting, adminis-
tration of carbohydrate loaded liquids until 2 hrs before surgery,
tailored anesthesia encompassing thoracic epidural anesthesia,
and short-acting anesthetics, perioperative high inspired oxygen
concentrations, avoidance of perioperative fluid load, short inci-
sions, minimally invasive surgery, nonopiod pain management,
no ­routine use of drains and nasogastric tubes, early removal of
bladder catheters, standard laxatives and prokinetics, and early
and enhanced postoperative feeding and mobilization.
There are no randomized controlled trails comparing laparo-
scopic, fast track, and standard approaches. However, recently
LAFA (laparoscopic and or fast track multimodal management
versus standard care) trial was instituted, which was conceived
 care paths and optimal postop management
to determine whether laparoscopic surgery, fast track surgery, or
a combination of both is to be preferred over open surgery with
standard care in patients having segmental colectomy for malignant
disease.(49)
summary
Care paths are tools which promote evidence-based standard
care, improve efficiency, and reduce hospital stay without com-
promising the quality of final outcome of care.
Care paths can be used as either disease specific or process-
specific tools to manage patients throughout the complete ­disease
cycle. Care path development requires a dedicated multidisci-
plinary team. With increasing popularity of laparoscopic colon
surgeries and other techniques to decrease perioperative stress
response, care paths in colon and rectal surgery are evolving
­continuously, into new programs, such as fast-track surgery.
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10 Limitations of anorectal physiology testing
Thomas E Cataldo and Syed G Husain
challenging case
A 65-year-old woman and her 30-year-old daughter both present to
your office with complaints of fecal incontinence. Both are G3 P3,
all vaginal deliveries, and have had at least one delivery of a child
of 8 pounds or more. Both have required an assistance device for
delivery of one child. Both report fecal soiling for the last year. The
older woman reports progressive uncontrolled passage of flatus and
occasional identification of stool in her undergarments that she
was unaware of having passed. The daughter reports incontinence
to moderate amounts of stool despite attempts to delay defecation.
There is additional incontinence associated with athletic activity.
case management
Normal function of the anus and rectum resulting in comforta-
ble passage of stool under voluntary control is a complex balance
of a number of competing factors and requires intricate correct
­performance of enteric and colonic physiology, rectal, anal and
pelvic sensory and motor nerves, as well as anatomically intact
and functioning anal and pelvic musculature. Disruption of any
of these factors may result in fecal incontinence. On the other
end of the spectrum, the patient may suffer difficult, painful, or
incomplete evacuation. Anorectal dysfunction is often devastating
to the patient resulting in emotional distress and social isolation.
Fecal continence is defined as the ability to defer defecation
until a socially appropriate time and place. Incontinence has a
number of definitions from simply involuntary passage of stool
to inability to control passage of solid, liquid, or gas. In a 2001
­consensus conference report fecal incontinence is defined as,
“recurrent uncontrolled passage of fecal material for at least one
month in an individual with a developmental age of at least four
years”.(1) Reported prevalence varies from 1.4% to 18%, with rates
as high as 45% in elderly, debilitated, or psychiatrically impaired
institutionalized adults. These numbers are generally accepted as
under reported due to patients’ unwillingness to come forward
due to associated social and cultural stigma.(1–3)
Constipation is as difficult to define. It may be as subjective as
any difficulty or infrequency in passing stool as perceived by the
patient. The Rome II criteria define constipation as two or more
of the following for at least 3 months: straining more than 25%
of the time, hard stools more than 25% of the time, incomplete
evacuation more than 25% of the time, two or fewer bowel move-
ments in a 7 day period.(4)
A problem inherent to all anorectal physiology testing is the
scarcity of “normal” values for comparison. There is relative
paucity of literature describing anorectal physiology testing on
normal population and almost all of the available studies are
comprised of small group of subjects.
physiology of fecal continence
Normal fecal continence relies on a number of mechanisms.
The first of which is normal enteral and colonic motility and fluid
transport physiology resulting in manageable stool consistency.
Stool consistency may be the most important characteristic that
influences fecal continence.(5) Some patients may be continent to
solid stool but not to liquid or gas. The rectum needs to maintain
adequate reservoir capacity. In addition the rectum, anus, and pelvic
musculature must have adequate ability to sense and differentiate
the presence, of solid, liquid, and gas. Additionally, it is postulated
that the vascular cushions or hemorrhoids ­create a controllable seal
as a rectal “corpus cavernosum”. This is supported by the identifi-
cation of leakage in some patients after otherwise uncomplicated
hemorrhoidectomy.(5) On a mechanical level, defecation occurs
when the pressure within the rectum exceeds the pressure or resist-
ance provided by the anus. For normal defecation this relies on the
controlled increase in rectal pressure combined with simultaneous
relaxation of the anus and straightening of the rectum through
relaxation of the pelvic muscles. The rectum must also possess cor-
rect mechanical properties of capacity and distensibility. It must be
able to sense the need to empty and the qualities of the contents
within it. Disease processes or injuries that limit the ability of the
rectum to distend to accept stool and air from the sigmoid colon
will alter the urge to defecate, and the ability to defer defecation.
Conversely, a chronically distended capacious rectum may lose the
ability to sense when it is full and thereby overflow. Both cases might
present as incontinence. Alternatively, if the body cannot differenti-
ate between solid, liquid, or gas or if the mechanism by which this is
sampled is altered, the result is often fecal soiling.
the anorectal physiology lab
A battery of devices and tests has been developed to investigate
many aspects of normal and altered defecation. Many centers have
collected the equipment to accomplish these tests. (Figure 10.1).
Much work remains to fully elucidate the source and thereby the
solutions to disordered defecation.
investigations for incontinence
Manometry
Manometry is a technique to measure the pressures which exist
within the anal canal and the pressures that the anus is capable
of achieving voluntarily. Over many years a variety of catheters,
pressure detectors, and recording apparatuses have been devel-
oped. In addition, different operator techniques have been devel-
oped making standardization of results difficult. Throughout the
1960s a variety of catheters were developed with different num-
bers of open tipped channels and microballoons. The number
of channels varied and they were arranged radially or in a spi-
ral orientation. Water within the channels was either static or
continuously perfused. Initial continuous recordings were made
with pen and ink on polygraph devices. Currently, the state of
the art manometers contain solid state micropressure transducers
mounted within the catheter itself (Figure 10.2a,b). In addition

 improved outcomes in colon and rectal surgery

to more reliable and reproducible data, these catheters are more

easily and reliably cleaned from patient to patient. Pressure data
is recorded continuously to computer based software that assists
in creating the interpretation and the report. One critical obser-
vation of the water perfused systems is that the patient may react
to the sensation of water dripping from the anus with increased
tone. Scrupulous technique may avoid this.
Because various technologies and methods exist for measur-
ing anal canal pressures, no universally accepted set of normal
values exist. Simpson et al. addressed this issue in a study com-
paring five different catheters and techniques of manometry in
both normal and incontinent patients.(6) Although their sample
size was small, 10 normal and 11 patients with incontinence, the
authors found no significant difference between five commonly
employed devices. They were; a water perfused end-hole catheter,
a catheter water perfused with four radially arranged side holes,
water filled microballoon, microtransducer, and an air-filled port-
Figure 10.1 Typical Anorectal Physiology Lab with Manometry, Transanal able microprocessor controlled device.
ultrasound, Pudendal Nerve Terminal Motor Latency testing, Biofeedback, storage
and equipment for sterilization. sphincter pressure measurement
Although written consent is not required as the patient is fully
awake, at our institution we obtain full informed consent and con-
(a) firmation of patient identity, condition being evaluated, and their
understanding of the tests they are about to undergo. The patients
take one or two small volume cleansing enemas at home before
the exam. Anal canal pressures are measured with the patient lying
comfortably in the left lateral decubitus position with knees as hips
flexed 90°. Some emphasis is placed on comfort and relaxation as
anxiety, talking and anything that increases the intraabdominal
pressure may affect the results. We employ a stationary pull through
technique. The catheter is placed transanally with the measuring
points (balloons, holes or microtransducers) to a distance of 6 cm
above the anal verge. Measurements are taken in the anterior, pos-
terior, left, and right lateral positions. (Figure 10.2c) Pressures are
recorded at relaxation and at maximum “squeeze” for 10 seconds.
The patient must be instructed to try to isolate squeeze of the anus
and not employ the gluteal or any other accessory muscles. The
(C)
(b)

Figure 10.2 (A) Manometry Catheter, with balloon. (B) Manometry Catheter, detail microtransducers. (C) Manometry tracing, computer display.


 limitations of anorectal physiology testing
catheter is repositioned 1 cm distally and the process is repeated.
The process is repeated in step-wise fashion until the entire canal
had been tested. An alternative to this “station pull out” technique
is recording pressures during a continuous pullout of the catheter
at a controlled steady rate. The following parameters are recorded:
length of the anal high pressure zone, mean resting tone, maximum
squeeze pressure.
In an effort to study the symmetry and detailed overall ­pressure
profile of the anal sphincter, pressure vectography, a technique
that provides graphical representation of radial pressure profile
of anal canal, was developed.
the recto-anal inhibitory reflex
The presence or absence of the Recto-Anal inhibitory reflex
(RAIR) is identified by rapid distention of the rectum by insuf-
flation of the balloon at the tip of the catheter with 10 cc of air.
Simultaneous recording taken in the middle of the anal canal high
pressure zone are made for 10 seconds. If the RAIR is present, a
reflex relaxation of internal sphincter and resultant decrease in
anal canal pressure should be observed. Balloon insufflation may
be repeated with more air at 10 cc increments up to 60 cc until a
reflex is observed.
rectal capacity and sensation
The balloon at the end of the catheter may also be filled with
water in an incremental fashion to assess rectal sensation and
compliance. Measurements are made at the minimum volume of
first rectal sensation, the volume required to produce a sustained
feeling of the need to defecate and a maximum volume that cre-
ates significant discomfort or an irresistible need to defecate.
value and limitations of
manometry for incontinence
Anal manometry has become a staple in the evaluation of fecal
incontinence. Though routinely performed in many centers, man-
ometry lacks standardization of technique, data collection, and
methods of interpretation. This makes it extremely difficult to
compare data obtained at different centers. The range of accepted
normal values is wide varying for gender, parity, age, and numer-
ous other factors. Despite the fact that the newer catheters are
more comfortable and easier to maintain, the test remains mildly
invasive and uncomfortable for the patient.
There are several technical caveats that may lead to consider-
able alteration in results. Patients with megarectum may require
a higher volume to illicit RAIR and may be falsely labeled as
RAIR negative if the usual volume of 30–40 cc is used to illicit
RAIR.(7) The balloon material can influence the results as latex
­balloons tend to deform along their axis, resulting in a falsely
elevated rectal compliance.(8) Rectal compliance testing depends
entirely upon patient’s input, thus patient’s psychological status
plays a very important role in data acquisition during this test.
(7) Furthermore the results of rectal compliance may differ if the
test is performed on “prepared”, i.e., after enema evacuation vs.
unprepared rectum.(7) The rate at which water is injected into
the balloon may also affect the rectal sensitivity testing.(9) Thus,
it is recommended that slow filling should be accomplished at
a rate of 1 ml/second.(7) Whatever the method used, the same
technique should be applied to all patients in order to obtain
reproducible and comparable results.
Caution should be exercised while making treatment decisions
based on manometric findings as normal or abnormal values in
incontinent patients do not necessarily correlate with severity of
symptoms. In a large prospective study Lieberman et al. evaluated
90 incontinent patients, including 6 males with a specific goal at
determining what impact physiology testing including manom-
etry had on treatment and outcome. After appropriate history
and physical exam patients were selected for medical or surgical
management. Following this determination they underwent anal
physiology testing including manometry, pudendal nerve termi-
nal motor latency (PNTML), and anal ultrasound (AUS). Overall
only 9 (10%) had a change in their management plan. Based on the
results of these tests, 5 of 45 patients initially assigned to medical
management were offered surgery instead. On the other hand, 3 of
45 patients assigned to undergo surgical treatment were switched
to the medical group. Almost all of these alterations in manage-
ment were based on AUS. Manometry was found to be abnormal
in one-third of both management groups and there was no correla-
tion between manometric results and change in management plan.
There did not appear to be an association between manometry,
AUS and PNTML results.(10) In an elaborate study of 350 patients
including 80 controls, Felt-Bersma et al. found that the most sig-
nificant difference between continent and incontinent patients was
maximum squeeze pressure.(11) However, the authors surmised
that continent function could not be predicted based on anal man-
ometry alone and ­suggested that these results should only be inter-
preted in conjunction with other tests.
Although it creates a rather striking and impressive graphical
representation of anal canal pressure profile, pressure vector dia-
grams have been shown to be of questionable clinical value for
sphincter evaluation.(12) A study by Yang et al. could not demon-
strate any correlation when vectoral analysis was compared to nee-
dle electromyography (EMG) and ultrasonography.(12) With the
increased use of AUS the utility of vectogrpahy has been negated.
Anorectal manometry remains of value for objective preopera-
tive documentation of anal tone function or muscle weakness. It
is also helpful in excluding patients from surgery.(2) Perhaps the
biggest merit of manometry is its role as the initial diagnostic
test for short segment Hirschsprung’s disease where the presence
of an RAIR effectively rules out the disease.
electromyography
EMG is the measurement of the electrical activity generated by mus-
cle fibers during contraction or at rest. In 1930 Beck first described
anal sphincter EMG.(13) Specifically, the EMG measures activity
in a motor group or those muscle cells innervated by a single axon.
Muscles whose nerves have been damaged will demonstrate altered
activity. Myography has been used to map the perianal area for
muscular activity and thereby detect sphincter defects. EMG is also
used to demonstrate nerve conduction and appropriate activation
and relaxation used in biofeedback therapy.
Concentric Needle EMG
A concentric needle electrode is two insulated electrodes, one
within the other. With the needle inserted into the muscle to

 improved outcomes in colon and rectal surgery

be observed, in this case the external sphincter or the pelvic

floor, the electrical potential from one electrode to the other
is recorded. Information collected includes amplitude, duration
and frequency, as well as the number of phases. Amplitude is
proportional to the number of muscle fibers activated. Normal
values are an amplitude of <600 μV and duration <6 μs.(14,
15) Longer duration or spreading of the signal can indicate dis-
persion of the motor unit potential (MUP). This may repre-
sent denervation or demyelination, or simply aging. The sum
of the activity of many muscle cells creates a shape to the MUP.
Normal MUPs are bi- or triphasic. In general, more phases
within the action potential indicated denervation and rein-
nervation. However four or more phases have been reported in
normal muscle in up to ¼ of the time.

Single Fiber EMG

Individual muscle fiber action potentials can be recorded with
a single fiber EMG. The recording area of the needle is much Figure 10.3  Surface EMG electrode.
smaller, 25 μm. In normally innervated external anal sphinc-
ter muscle only a few fibers will be activated by a single motor
group axon. However, when damage occurs denervated muscle
fibers are recruited by surviving axons. The number of muscle
fibers and thereby signal density within the recording area of the (a)
­needle increases, resulting in a more polyphasic signal. The test
is performed by taking multiple readings requiring multiple skin
punctures around the anus.

Surface EMG/biofeedback
Measurement of muscular activity through the insulation of the
skin is far more imprecise but less painful than needle EMG.
Surface EMG is valuable for documentation of overall activity,
especially during attempted voluntary rest, inhibition, or contrac-
tion of a muscle. Surface EMG is helpful to document paradoxical
sphincter activity as part of the diagnosis of disordered defecation.
Two self-adhering surface electrodes can be applied on opposite
sides of the anus over the subcutaneous portion of the external
sphincter, with a grounding electrode placed at a distance on the
patient. Alternatively, a plug electrode is employed within the anal
canal (Figure 10.3). Surface measurement of muscle activity is
more valuable if the muscle is being artificially activated by stimu- (b)
lating the nerve. When the time of nerve stimulation is known and
time of muscle activity measured, nerve conduction velocity can
be assessed. A specific application of nerve stimulation and surface
EMG is measurement of the PNTML.

pudendal nerve terminal motor latency

The pudendal nerve arises from the second, third and fourth sac-
ral nerve roots bilaterally and passes along the inferior pubic rami
through Alcock’s canal. Prolonged labor or the use of forceps for
delivery may injure the pudendal nerve as it exits from the canal.
The conduction time of the nerve can be measured by stimu-
lating the nerve transrectally and observing the time to electri-
cal activity of the external anal sphincter. A St. Marks electrode
attached to a gloved finger provides both stimulation and meas-
urement (Figure 10.4a,b). An absent trace may indicate injury to
the nerve whereas a prolonged PNTML is interpreted to indicate
nerve injury and repair. Figure 10.4  St. Marks electrode.


 limitations of anorectal physiology testing

limitations of electomyography in
incontinence
The EMG delineation of anatomic sphincter defect has been largely
supplanted by imaging studies such as ultrasound and pelvic mag-
netic resonance imaging (MRI). Concentric needle EMG and single
fiber EMG testing is uncomfortable, or in some cases, frankly pain-
ful for the patient. The equipment is expensive and difficult to mas-
ter. Results are variable based on the cooperation of the patient, the
experience of the examiner, and the patience of both.(16) Surface
EMG is mildly uncomfortable to the patient and technically chal-
lenging to perform. Identification of the nerve tracing can be sub-
jective. Pudendal nerve latency testing is operator dependent. Since
PNTML measures the fastest remaining fibers, a normal latency
time does not exclude injury. The latency values obtained are also
affected by the distance between the electrode and the pudendal
nerve; shortest latencies being obtained by placing the electrode as
close to the nerve as possible.(9) This is usually accomplished with
subtle movements of the electrode bearing finger inside the anal
canal while observing waveforms for the shortest latency thus gen-
erated in response to repeated electrical stimuli. This method may
result in significant patient discomfort in some cases. There is some
bilateral crossover innervation of the sphincter therefore a unilat-
erally abnormal test does not preclude normal function. Earlier
studies indicated that significantly abnormal bilateral results were
predictive of poor outcome with sphincter repair.(17–19) However,
other authors have not found PNTML to be helpful in this regard.
(10, 20) Increased pudendal nerve terminal velocities have been
previously associated with patients with idiopathic incontinence.
(21) Newer literature, however, suggests that this association might
not be entirely true. Ricciardi et al. showed that only a small per-
centage of patients with idiopathic fecal incontinence had associ- Figure 10.5  St. Marks electrode attached to glove.
ated pudendal neuropathy.(22)

Anal Ultrasonography
High quality circumferential images of the anal sphincter complex
can be obtained using anal ultrasonography (AUS). Although a
number of probes are available, the most commonly used for evalu-
ation of the anal sphincter is a rotating probe that creates a 360°,
two-dimensional transverse image. The transducer generally used is
a combined 7 or 10 MHz transducer, rotating within a water-filled
rigid cap covered with a balloon or condom. Newer probes are fully
self-contained. They still require protection with a condom and
some type of interface media such as gel or water.(Figure 10.5)
In many outpatient anorectal physiology labs the procedure
is performed in the left lateral decubitus position in conjunc-
tion with anal manometry. For a patient scheduled to undergo
multiple anorectal physiology studies the same day, we follow
a policy of performing manometry initially followed by other
investigations as the sphincter stretch induced by 12 mm son-
ogram probe may produce erroneous manometric findings.
As such, the patient may have had limited preparation with a
small volume enema. This is not required for AUS alone. Some
authors prefer the prone or lithotomy positions feeling that the
lateral position deforms the anatomy.(23) The clinical signifi-
cance of this is unclear. AUS can distinguish the internal and
external sphincters individually, with an intact internal sphinc-
ter representing a continuous hypoechoic band. The external
sphincter is more heterogenous but distinctly more hyperechoic.
Although images can be taken throughout the anal canal, images
are traditionally documented and preserved at proximal, mid
and, distal anal canal. Defects in either the internal or external
sphincters are identified as a disruption in the continuous ring.
The external sphincter naturally splits proximally as it extends
to the levator sling and the pelvic floor musculature. Disrupted
tissue heals with a scar which appears amorphous, more echo-
genic than internal sphincter, but less so than external. It is seen
bridging the gap in the defect between the disrupted ends of
the sphincters. The presence of a sphincter defect on AUS cor-
relates well with a history of obstetrical trauma, as well as with
physical exam findings and manometric findings.(10, 20, 24)
Interobserver agreement is excellent and when an anatomic
defect is present AUS sensitivity approaches 100%, specifically
for internal anal sphincter defects in the mid anal canal.(25)
Different techniques have been employed to either improve or
make easier definition of the anal anatomy. Some authors claim
anal squeeze, and relaxation improves the yield of sonographic
exam while others have no benefit.(23) A finger placed in the
posterior wall of the vagina used to measure the thickness of
the perineal body has been shown to aid in the evaluation of
anterior sphincter defects.(25)


 improved outcomes in colon and rectal surgery
Global deficiencies or thinning of the sphincters rather than
defects are more difficult to define with AUS. The internal
sphincter is normally between 2 to 4 mm. Since it is more distinct
on AUS, excessive thickness or thinness can be identified. One
elusive objective is to identify atrophy of the external sphincter as
this correlates with poor outcome from sphincter repair.(26)
Three dimensional axial endosonography is now available.
The probe spirals and moves through the sphincter at a fixed
rate ­collecting a three dimensional block of echo-data that can
be ­represented on a computer screen and evaluated through any
plane through the block. In a study involving 33 women with sus-
pected sphincter injury, two different observers compared 2-D
AUS with 3-D evaluation. There was an identifiable improvement
in the confidence of the examiner in detecting sphincter defects
with 3-D evaluation over 2-D images. Interobserver correlation
was also improved by 3-D evaluation but not to a significant
degree.(27) Nevertheless, 3-D AUS has not been indisputably
demonstrated to be more sensitive or specific, than transverse
planar AUS.
limitations of ultrasound in incontinence
Ultrasound is the most important test in the evaluation of fecal
incontinence with few limitations. Anorectal ultrasound entails a
significant learning curve (28) and results are operator and experi-
ence dependent. The external sphincter is less distinct than internal
sphincter and smaller, <90°, defects are harder to demonstrate.
(29) Patients with minimal symptoms and limited defects may
not require surgery; therefore the clinical significance of a defect
is determined by the combination of physical exam, anorectal
physiology (ARP) testing, and AUS (Figure 10.4). The presence of
atrophy of the external sphincter is similarly hard to prove. This is
due to the fact that atrophic external sphincter becomes replaced
with fat making sonographic delineation of the sphincter from
the surrounding fat tissue more difficult.(30) Many investigators
believed that 3-D ultrasound, by virtue of its superior resolu-
tion, may result in improved identification of external sphincter
atrophy. However a comparative study showed no correlation
between 3-d AUS and MRI in 18 incontinent women with MRI
evidence of sphincter atrophy.(31)
Biofeedback for fecal incontinence
Biofeedback is a process by which the patient is given an audi-
tory or visual representation of anorectal information, pres-
sure or muscle activity, which they cannot otherwise perceive or
correctly interpret. Techniques of biofeedback have successfully
used in the treatment of fecal incontinence for over 25 years. The
practice parameters of the American Society of Colon and Rectal
Surgeons (ASCRS) give a grade “B” recommendation for its use
as a first line therapy and in patients that have incomplete success
after sphincter repair.(2)
limitations of biofeedback for incontinence
Despite some encouraging earlier reports describing success of
biofeedback in the management of incontinence, the Cochrane
system review of treatments for incontinence in 2006 did not
support its use.(32) The authors reported, “The 11 trials reviewed
were of very limited value because they were generally small, of

poor or uncertain quality, and compare different combinations
of treatments”. Overall success with biofeedback varies from 65%
to 89%.(2, 33, 34) Two large randomised controlled trials include
more than 100 subjects. Both concluded that biofeedback pro-
vided no additional benefit over office counseling therapy such
as advice, education, dietary modification, digital guidance, and
medication. Despite the lack of demonstrated benefit, both ­trials
showed improvement in severity of symptoms, fecal incontinence
scores, and quality of life.(35–37) These benefits were seen in both
the treatment and control groups indicating the role of patient
motivation and ongoing medical involvement in the treatment
of fecal incontinence. The most important predictors of success
were completion of the program, and age over 60 years. Higher
body mass index was associated with a worse outcome.
Summary: Value and limitations of ARP
testing for evaluation of fecal incontinence
The perceived value of ARP testing in the evaluation and man-
agement of fecal incontinence varies greatly on the perspective of
the examiner and the expectations of the patient. The most fre-
quently employed test include anal manometry, transanal ultra-
sound, and pudendal nerve terminal motor latency. Techniques
and normal values are not universally accepted. Abnormal results
do not equate with specific disease, injury, or symptomatology.
Transanal ultrasonography and MRI provide excellent anatomic
definition to aid in the planning of surgical intervention. At best
manometry serves for documentation of preoperative function
and may assist in patient selection for surgery. PNTML is still
controversial as to its role in the treatment of fecal incontinence.
Investigations for constipation and
disordered defecation
Constipation is one of the common ailments presented to the color-
ectal surgeon. It usually entails unsatisfactory defecation resulting
from decreased frequency of defecation of difficulty in passing
stools or both. Prevalence in the general population in United
States has been reported to be as high as 2–15%.(38, 39) Women
are affected 2–3 times more commonly with incidence increasing
with age. As with incontinence, the etiology is multifactorial and
complex. Etiological factors associated with constipation include
lifestyle issues and medications; especially narcotics, antidepres-
sants, and calcium channel blockers. Pelvic outlet obstruction
(puborectalis dysfunction, rectocele) is also a common underlying
abnormality. Other causes include neurological or endocrine dys-
function for example, Parkinson’s disease, diabetes mellitus, and
hypothyroidism. Finally, dysfunction of enteric nervous ­system
seen in Hirschsprung’s and Chagas disease and psychological
­factors may also play an important role in the pathogenesis.
Refractory constipation that fails to respond to dietary modifi-
cation and conservative management warrants a formal work-up.
From management perspective, constipation is usually referred
to as either slow transit constipation or obstructed defecation.
The initial history and physical examination, in most cases, is
able to indicate if the patient is experiencing slow transit con-
stipation vs. obstructed defecation. Colonic transit studies are
usually the first tests to be ordered in cases where slow transit
is suspected to be the underlying etiology whereas in patients
 limitations of anorectal physiology testing
with obstructed defecation, a defecogram should be offered as
the initial diagnostic study. However, studies have shown that
there is little, if any, correlation between these two diagnostic
modalities and clinical picture does not necessarily reciprocate
the radiological findings.(40)
defecography
Since the 1960s, continuously recorded fluoroscopy has been used
to evaluate the dynamic function of the pelvic floor. Defecating
proctography or ciné defecography is a method whereby semi-solid
radiopaque contrast material is placed retrograde into the rectum
and lateral images are obtained in real time. Creating a realistic
“pseudo stool” has been a challenge. A commercially available prod-
uct was available but was transiently taken off the market. Many
institutions create there own contrast as needed using a combina-
tion of barium and potato starch. At the authors institution we use
a unique recipe based on breadcrumbs. The material must be thick
enough to simulate stool but able to be passed transanally.
Once the enema is administered the subject is seated in a lat-
eral orientation on a radiolucent commode. Before defecation
measurements are made of the angles of the proximal and distal
rectum. In women the vagina may be delineated with a tampon
soaked with water soluble contrast, and in certain circumstances
the small bowel is opacified with oral contrast. If further deline-
ation is required sterile water soluble contrast can be placed
intraperitoneally to define the lower peritoneal reflection, fur-
thermore, in patients with suspected cystocele, instillation of dye
into the bladder may increase the diagnostic yield of the study.
The anorectal angle is created in part by the tone and function of
the puborectalis muscle. Measurements are taken as the patient is sit-
ting at rest, during forced contraction, straining without ­defecation
(Valsalva maneuver), and during defecation. Perineal decent is
defined as the change in distance of the line drawn perpendicularly
from the anorectal junction to the pubococcygeal line. This line is
drawn from the tip of the coccyx to the posterior-inferior margin
of the pubic ramus. In addition perianal skin can be marked with a
metal marker and the motion or decent of the perineum measured.
Normal reported values vary widely. One author offers a broad
range, 70°–140° at rest, 100° to 180° defecating, and 75° to 90°
squeezing (41, 42), where another is more specific 92° +/- 1.5°
resting and 137° +/- 1.5° straining (5). The change in the angle
may be more important than the absolute numbers. In our prac-
tice the test is of most value if the surgeon reviews the study with
the radiologist while the test is being performed.
Abnormal findings include perineal descent of more than 3 cm
while resting or more than 3 cm while straining. Paradoxical con-
traction of the puborectalis and disordered defecation is indicated
by an observed ascent of the perineum or a static or more acute
anorectal angle during attempted defecation. Additional findings
may include internal intussusception to frank prolapse, rectocele,
or enterocele. Small, <2 cm rectoceles, are commonly seen in
asymptomatic patients and are regarded as a normal finding.
limitations of defecography in constipation
It must be remembered that defecography is not a “physiological”
study as the study is not performed in response to a natural desire
to defecate, instead patients are asked to evacuate in a rather alien,
uncomfortable environment. Amongst other criticisms regarding
defecography are poor interobserver agreement.(43, 44) To com-
plicate issues further, abnormal defecographic findings are com-
mon in asymptomatic patients.(45, 46) The significant degree
of overlap between defecographic findings in patients with con-
stipation and asymptomatic controls raises questions regarding
the cause and effect relationship between clinical symptoms and
defecographic findings. One of the radiological signs frequently
documented during these studies is contrast retention within the
rectoceles. The clinical significance of this “Barium trapping”
seen has also been questioned.(47)
In a study by Shorvon et al. one half of asymptomatic subjects
had some aspect of mucosal prolapse and intussusception, 17 of 21
women demonstrated some degree of rectocele.(48) In addition,
before that work, no work had employed normal, healthy volun-
teers as controls and “normal” was determined retrospectively by
lack of anatomic abnormality. Other studies were performed in
patients undergoing barium enemas for other, nonanorectal condi-
tions.(48, 45, 49) Anorectal angle assessment and its interpretation
should be performed with utmost caution. As alluded to earlier,
there is a wide variation in normal values for anorectal angle and
many investigators believe that it is the change in angle rather than
the absolute values that serves as a useful guide to therapy.(7)
Patients with urge incontinence may frequently show increased
threshold for urge to defecate. It is unclear if this finding is the
result rather than the cause of constipation (9) and the clinical
implication of this finding remains uncertain. Abnormal pub-
orectalis function noted at defecography has also been a topic of
considerable debate. Many normal individuals have been shown
to have puborectalis abnormalities on defecograms (50), thus the
clinical relevance of these findings are questionable and thera-
peutic decisions should be based on clinical rather than mere
abnormal findings on radiological studies.
colonic transit studies (sitz marker®)
Colonic transit studies play a pivotal role in the assessment of con-
stipation. Majority of colorectal surgeons agree that transit studies
supply the most pertinent information out of all the physiology
testing modalities available for constipation.(51) The most widely
accepted technique involves ingestion of 24 radio-opaque rings
followed by X-ray at days 1,3 and 5. A normal study entails passage
of more than 80% of the rings. A quick way to help evaluate the
patient for the presence of gastroparisis as well as small dysmotily
is to make sure that they take the sitzmaker pill right before bed
and have the day one x-ray as early in the morning as possible.
While not useful in evaluating colonic transit, all of the makers
should be out of the upper GI tract. The mean colonic time has
been shown to 31 hours in males and 39 hours in females.(15)
Based on the location of retained rings, abnormal studies may be
labeled as “outlet obstruction” if 20% or more rings are retained at
day 5 in the rectosigmoid region or “colonic inertia” if more than
20% rings are dispersed throughout entire colon. Clinical effi-
cacy of colonic transit studies to detect segmental bowel motility
remains controversial.(9) No bowel prep is administered before
the study and patients are directed to avoid using laxatives and
promotility agents including dietary fiber for at least a week before
the study and during the duration of the study.

 improved outcomes in colon and rectal surgery
small bowel transit studies
Since it is generally accepted that slow transit constipation is over-
whelmingly attributed to colonic dysfunction, small bowel transit
studies are infrequently requested. However when clinical suspicion
exists, such as patients with gastroparesis and dilated small bowel
on plain x-rays, small bowel motility studies should be undertaken
before undertaking a surgical intervention. Several techniques are
available to assess small bowel transit. Nondigestible carbohy-
drates are broken down into hydrogen and fatty acids upon reach-
ing the colon. Hydrogen and fatty acids are then absorbed into the
blood stream. Therefore interval between ingestion of substrate
and increments in exhaled hydrogen levels estimate small bowel
transit. Similarly, orally administered sulfasalazine is broken down
by colonic bacteria into mesalazine and sulfapyridine and then
absorbed. Colonic transit can be measured by serum detection of
sulfapyridine. Radio nucleotide scintigraphy has also been used to
assess small bowel transit function. However, the clinical applica-
tion of these tests is limited by their complexity and variation in
bacterial flora in different subjects.
mri
Magnetic Resonance Imaging (MRI) of the pelvic floor is the
newest addition to the diagnostic armamentarium available for
pelvic floor evaluation. MRI obviates the exposure to radiation.
Technique involves filling rectum with ultrasound gel. Images can
be obtained in “static” manner or in the form of dynamic pelvic
MRI which involves patient to perform maneuvers that are simi-
lar to those performed during conventional defecography. During
these maneuvers, multiple images are obtained which are then
viewed as a cine loop. MRI provides excellent spatial orientation
of the sphincter complex and provides superior delineation of
the surrounding structures. MRI appears to be superior to ultra-
sonography in discerning external sphincter abnormalities.(30)
Additionally, dynamic MRI defecography appears to be supe-
rior to conventional defecography in the evaluation descending
perineum syndrome as it provides excellent spatial assessment of
­pelvic floor musculature.(52)
Limitations of mri in constipation
Dynamic pelvic floor MRI shares similar limitations as conven-
tional MRI: cost, claustrophobia, and availability. There are how-
ever, some specific limitations related to the diagnostic modality.
Studies comparing dynamic MRI with conventional defecography
have yielded conflicting results. Healy et al. (53) found significant
correlation between dynamic MRI findings and defecography in
ten patients examined employing both techniques. On the con-
trary, Matsouka et al. (54), in their study of 22 patients, reported
defecography to be more sensitive than dynamic MRI and recom-
mended against the routine use of this expensive modality. Most
centers perform pelvic floor imaging with patient in supine posi-
tion. Patients are asked to strain in a position which is far from
physiologic and raises concerns regarding the reliability of the
test. The influence of patient positioning has been investigated.
Bertschinger et al. (55) performed a prospective comparison of
38 patients who underwent closed MRI in supine position fol-
lowed by open MRI in a sitting position. Four rectal descents,
two enteroceles, four small cystoceles, and four small anterior

rectoceles were missed at supine MRI. The clinical significance
of these findings, however, remains questionable. As mentioned
earlier, the lack of “normal controls” makes it difficult to assess
the efficacy of this test.
Balloon Expulsion Test
Balloon expulsion test is an infrequently used method to test
motor defecatory function of the rectum. There is complete lack
of standardization of methods used in various anorectal manom-
etry laboratories.(55A) Various size balloons have been used for
this purpose. Commonly 50–100 cc deformable balloons are used.
Alternatively, smaller, more rigid balloons may also be employed.
The impact of size and compliance of balloon on the final inter-
pretation of test is unclear. In general, it is easier to evacuate larger
balloons.(56) Many investigators believe that volume of balloon
should be individualized to induce a constant desire to defecate.
Consequently, use of lower volumes may result in false positive
results.(57) There is a wide variation in what is considered to be a
normal test. Inability to expel balloon in a sitting position within
30–60 seconds is considered abnormal in most centers. Balloon
expulsion has been shown to be of importance in differentiating
between constipation caused by slow transit from that caused by
pelvic floor dyssynergia.(57)
biofeedback for constipation
Biofeedback training is widely utilized to teach relaxation of the
pelvic floor in patients with pelvic floor dyssynergia. A critical
review of the available literature by Heymen et al. (58) includ-
ing thirty eight studies showed that mean success rate with pres-
sure biofeedback was 78% compared to mean success rate of 70%
seen with electromyography feedback. The authors surmised that
despite the reported success rates, quality research is lacking.
The most controversial area involving biofeedback training
for constipation is questionable longevity/sustainability of the
results. Ferrara et al. (59) reported a clear loss of benefits over
time despite initial success.
patients perspective
Inherent to the evaluation of fecal incontinence is patients’ feel-
ings of shame, embarrassment and discomfort. These sensations
are felt by the incontinent patient resulting in depression and
social isolation. A number of quality of life tools have been devel-
oped to quantify the results of evaluation and treatment of fecal
incontinence. No one tool is universally accepted and these tools
have been difficult to validate.(60, 61)
In addition the testing incontinent patients are subjected to
may be embarrassing and uncomfortable. Deutekom et al. con-
ducted a cohort study of 240 consecutive patients undergoing
evaluation of fecal incontinence in 16 Dutch centers. Each patient
underwent manometry, defecography, AUS, PNTML, and MRI.
Two hundred forty of the 270 self-administered questionnaires
were returned. Patients were asked to evaluate anxiety, discom-
fort, embarrassment, and pain. Answers were scaled from 1(not
0), none to 5, severe. Results were also summarized as total test
burden. Overall test results were surprisingly low, with aver-
age scores in each category not exceeding 2. Overall MRI was
the most preferred and least uncomfortable test. Defecography
 limitations of anorectal physiology testing
was the most inconvenient and uncomfortable. Anorectal com-
bined testing; manometry, PNTML, and AUS, also scored low for
­discomfort and overall test burden but more so than MRI.(62)
conclusion
Physiological studies of anorectal function can provide valuable
information in carefully selected cases. While performing these
studies, one should be cognizant of the fact that these procedures
can be embarrassing, and at best are far from patient’s usual habits.
It is unnerving for many patients to perform the act of ­defecation
in the presence of an audience and it is conceivable that “perform-
ance anxiety” may lead to results which may not be truly repre-
sentative of actual patient status. Thus, these studies should be
interpreted with a grain of salt. Despite the plethora of literature
available, the clinical usefulness of these tests remains vague and
there is limited evidence that anorectal imagining guides man-
agement in pelvic floor disorders.(63) There are multiple well-
designed studies, which unfortunately report conflicting results.
We therefore recommend that the most decisive factor govern-
ing treatment decisions is history and physical exam. Physiology
­testing should always be used as an adjunct rather than a primary
determinant.
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Rectum 1992; 35: 597–8.
56. Azpiroz F, Enck P, Whitehead WE. Anorectal functional test-
ing: review of collective experience. Am J Gastroenterol 2002;
97(2): 232–40.
57. Minguez M, Herreros B, Sanchiz V et al. Predictive value of
the balloon expulsion test for excluding the diagnosis of pel-
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126(1): 57–62.
58. Heymen S, Jones KR, Scarlett Y, Whitehead WE. Biofeedback
treatment of constipation: a critical review. Dis Colon
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of fecal incontinence. Dis Colon Rectum 1993; 36: 139–45.
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nence quality of life scale: quality of life instrument for patients
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ception of tests in the assessment of faecal incontinence. Brit
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63. Bharucha AE, Fletcher JG. Recent advances in assessing
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133(4): 1069–74.
11 Limitations of colorectal imaging studies
Travis J Blanchard, Wilson B Altmeyer, and Charles C Matthews

challenging case
A 53 year-old woman presents to the emergency room with fever,
left lower quadrant abdominal pain, and tenderness. Her tem-
perature is 39 degrees Centigrad and her white blood cell count is
17,000 cells per cubic milliliter. What is the best radiologic test to
confirm her diagnosis?

case management
A CT scan of the abdomen and pelvis will evaluate her to con-
firm the diagnosis of acute diverticulitis. In the absence of acute
diverticulitis it may very well provide anothe explanation for her
symptoms.

Introduction
Years of technical developments, organizational changes, and
educational advances have inexorably altered the nature and com-
position of colorectal imaging. Conventional radiology or “plain
films” and barium fluoroscopy studies are still important, but the
developments of CT, US, MRI, nuclear medicine, and interven-
tional radiology have greatly expanded the scope of radiology.
This chapter will discuss the various imaging modalities, focusing Figure 11.1  Pneumoperitoneum. Upright radiograph of the abdomen demonstrates a
on the capabilities and limitations of each modality to diagnose collection of air within the peritoneal space between the liver and the diaphragm.
various disease processes important to the colorectal surgeon.

abdominal radiography (plain films)

Abdominal radiography typically consists of a single-view abdom-
inal x-ray of the kidneys, ureters, and bladder (KUB) or an
acute abdominal series (AAS). An AAS includes an upright chest
radiograph, as well as upright and supine radiographs of the
abdomen. An AAS can identify large masses, radiopaque for-
eign bodies, and radiopaque densities (including gallstones and
kidney stones).

Pneumoperitoneum
As little as 1–2 cc of pneumoperitoneum (free intraperitoneal air)
can be seen on an upright chest (Figure 11.1) or lateral decubitus
film.(1) Postoperative pneumoperitoneum usually resolves in 3 to 7
days. Failure of progressive resolution or an increase in the amount
of air present suggests a bowel anastomosis leak or abscess/sepsis.
Signs of pneumoperitoneum (Figure 11.2) on supine radiographs
include the “Rigler” sign or “double lumen” sign (gas on both sides
of the bowel wall), and gas outlining the falciform ligament.(2)

Bowel Obstruction and Dilatation

The 3, 6, 9 rule can be used to identify bowel dilatation. The small
bowel is dilated when its diameter is 3 cm; the colon when it is
6 cm, and the cecum when it is 9 cm. Abdominal plain films can
diagnose small bowel obstruction (SBO), in 50–60% of cases
with approximately 20% false-negative rate.(3) SBO can be com- Figure 11.2  Pneumoperitoneum. Plain radiograph demonstrates the “Rigler”
plete/high grade or partial. Dilated loops of small bowel, air-fluid sign or “double lumen” sign (gas on both sides of the bowel wall).


 improved outcomes in colon and rectal surgery

Figure 11.4  Large Bowel Obstruction. Supine radiograph demonstrates dilated

colon as well as dilated small bowel in the right lower quadrant, indicating a large
bowel obstruction with incompetent ileocecal valve.

Figure 11.3  Small Bowel Obstruction. Plain radiograph demonstrates dilated

loops of small bowel with absence of colonic gas indicating a complete/high grade
small bowel obstruction. There is air in the right inguinal canal. This patient had
a surgery proven incarcerated right inguinal hernia.

levels, and absence of colonic gas indicate a complete/high grade

small bowel obstruction. SBO can be simple (blood supply not
impaired) or strangulating (blood supply impaired). Most stran-
gulating obstructions are closed-loop obstructions (blocked at
both ends), and this occurs typically with incarcerated hernias
(Figure 11.3) and volvulus.(4) Plain films are not able to reliably
differentiate simple from strangulating obstruction. However,
extensive mucosal thickening or edema, portal venous gas, or
a closed loop obstruction indicates high risk for strangulating
obstruction.(5)
Large bowel obstructions (LBO) occur commonly in the sigmoid
colon, where stool is more formed and the colon is narrower. Air fluid
levels distal to the hepatic flexure are strong evidence of obstruction
unless the patient has had an enema. When the ileocecal valve is com-
petent, the small bowel usually contains little gas. When the ileocecal
valve is incompetent (Figure 11.4), gaseous distention of the small
bowel is often present as the colon decompresses into the ileum.(6)
Toxic Megacolon
Toxic megacolon is a manifestation of sever colitis with absent
peristalsis, and extreme dilation of all or a portions of the colon.
A markedly dilated (>6 cm) colon with “thumbprinting” (thick-
ened mucosal folds projecting into the lumen caused by bowel
wall edema) is ­concerning for toxic megacolon (Figure 11.5).
Figure 11.5  Toxic Megacolon. Plain radiograph demonstrates a markedly dilated
transverse colon with “thumbprinting” (thickened folds projecting into the lumen
caused by bowel wall edema – see arrows) in a patient with ulcerative colitis and
toxic megacolon.
When the cecum exceeds 10 cm in diameter, it is at risk for
perforation. Ulcerative colitis is the most common cause of toxic
megacolon and other causes include: Crohn’s colitis and infec-
tious colitis. Barium enema is ­contraindicated because of the per-
foration risk.(4)
Sigmoid and Cecal Volvulus
Sigmoid volvulus is a closed loop obstruction that occurs most
common in the elderly. On plain films, the sigmoid colon appears
as a large gas-filled loop without haustral makings, arising from
the pelvis and extending high into the abdomen. The three white


 limitations of colorectal imaging studies
Figure 11.6  Sigmoid Volvulus. Radiograph of the abdomen demonstrates the
characteristic massive dilation of the sigmoid colon arising from the pelvis and
extending to the right diaphragm. Three lines representing the twisted walls of the
sigmoid colon converge in the left lower quadrant.
Figure 11.7  Cecal Volvulus. Abdominal radiograph demonstrates a massively
dilated cecum folded over into the left upper quadrant with distended small bowel.
Figure 11.8  Limitations of Plain Films. CT of the same patient in Figure 11.I-
B-2 shows the cause of the large bowel obstruction is an annular constricting
sigmoid carcinoma. A dilated loop of small bowel is seen adjacent to the sigmoid
colon.
lines formed by the lateral walls of the loop and the summation
of the two opposed medial walls of the loop usually converge
inferiorly into the left iliac fossa (Figure 11.6). Cecal volvulus
on plain films is characterized by a massively dilated cecum
folded over into the left upper quadrant (Figure 11.7), usually
with distended small bowel.(6) Confirmation of a volvulus can
be obtained with CT or contrast enema (See CT scan [sigmoid
volvulus] and fluoroscopy [water soluble enemas]).
Benefits and Limitations of Acute Abdominal Series (AAS)
Plain Films
AAS are relatively inexpensive, and can be performed with porta-
ble equipment. However, AAS is insensitive, results are often not
specific, and other imaging modalities (e.g. CT) (Figure 11.8) are
often needed for definitive evaluation.(2–5)
computed tomography (ct scan)
Unenhanced Multidector Computed
Tomography vs. Plain Films
Unenhanced spiral/helical Multidetector Computed Tomography
(MDCT) is an accurate technique in the evaluation of patients
with traumatic or nontraumatic abdominal pain and should be
considered as an alternative to plain films as the initial imaging
modality.(7–10) MDCT is more expensive and exposes the patient
to more radiation. However, given the poor sensitivity of plain
films; the radiation, time, and money spent pursuing a plain film
examination in all patients may be unnecessary.(10) Additionally,
MDCT provides more information to the surgeon for preopera-
tive planning. With the advent of the new 16, 32, and 64 MDCT
fast speed scanners, a high quality MDCT can be obtained almost
as rapidly as a plain film, but it is not portable.

 improved outcomes in colon and rectal surgery

Table 11.1  Premedication for Contrast Allergy.

Oral Premedication for Contrast Allergy
Prednisone 50 mg orally at 13, 6, and 1 hour prior to IV contrast
administration
Diphenhydramine 50 mg orally 1 hour prior to IV contrast administration.
Emergency Stat Premedication for Contrast Allergy
30 minutes prior to IV contrast: Hydrocortisone 100 mg IV or Solucortef
200 mg IV and Diphenhydramine 50 mg IV.

Figure 11.10  CT Signs of Bowel Injury. MDCT axial section demonstrates

pneumoperitoneum, free intraabdominal fluid, an air fluid level, and extravasation
of oral contrast material in a patient with blunt abdominal trauma.

Table 11.2  Bowel wall thickening.

Benign Neoplastic

Circumferential thickening Eccentric thickening

Figure 11.9  Pneumoperitoneum. When viewed on lung windows, free air can be
seen in the subdiaphragmatic area, along the anterior peritoneal surfaces of the liver.
Contrast Enhanced Multidector Computed Tomography
If the patient has no contraindications to oral and IV contrast
(allergy, renal insufficiency), a contrast enhanced MDCT has
been shown to be sensitive in diagnosing patients with bowel
obstruction; as well as inflammatory, infectious, and neoplas-
tic processes.(9, 11–27) Low osmolar, “nonionic,” iodine-based
agents are more expensive than the older “ionic” contrast agents,
but provide a decreased risk of adverse reactions and renal dam-
age. If the patient has a simple allergy to IV contrast, such as
hives; a low osmolar, “nonionic” contrast should be used and the
patient can be premedicated with steroids and diphenhydramine
(Table 11.1). Prior anaphylaxis to IV contrast is a complete con-
traindication. Orally administered water soluble contrast and rec-
tal contrast add significant additional diagnostic information as
accurate interpretation requires optimal opacification of the GI
tract. However, to allow appropriate intraluminal distention with
contrast, the patient has to drink contrast 1–2 hours before the
CT scan can be performed. Diluted 2% barium mixture can also
be used for oral contrast, but if bowel perforation is suspected,
barium should be avoided as it can cause severe peritonitis.
Pneumatosis, Pneumoperitoneum, and Bowel Trauma
Pneumatosis (air in the bowel wall due to ischemia) and pneu-
moperitoneum from a traumatic or nontraumatic perforated
Symmetric thickening Asymmetric thickening
Thickening <1–2 cm Thickening >2 cm
Segmental or diffuse involvement Focal soft tissue mass
Mesenteric fat thickening Abrupt transition and lobulated
contour
Long segments of involvement Short segments of involvement
except lymphoma
Wall is homogeneous soft tissue Spiculated outer contour
density
Stratified enhancement “double halo” Luminal narrowing, adenopathy, or
or “target” appearance liver metastasis.
abdominal viscus, can be identified on MDCT when examined
on “lung ­windows” (window level – 400 to -600 H; window width
1000 to 2000 H). Pneumoperitoneum can be seen in the subdia-
phragmatic area, along the anterior surfaces of the liver (Figure
11.9). The accuracy of CT in the diagnosis of blunt abdominal
trauma has been reported to be as high as 97%.(28–33) The
routine use of oral contrast in CT examination of abdomi-
nal trauma is controversial. Oral contrast material can aid in
the identification of bowel loops, and differentiation of bowel
from hematoma or hemorrhage. Disadvantages of oral contrast
include risk of aspiration, and additional time requirements
which may delay diagnosis.(33–35) Posttraumatic abdomi-
nal CT examinations should be performed using IV contrast,
which maximizes the difference between contrast-enhancing
bowel and nonenhancing hematomas.(36) CT signs of bowel
and mesenteric injury include: (1) pneumoperitoneum; (2)
extravasation of oral contrast material; (3) free intraabdominal
fluid (Figure 11.10); (4) intramural hemorrhage, manifested as
luminal narrowing with thickened and/or discontinuous bowel

This section will focus on abdominal trauma to the bowel and mesentery that a colorectal surgeon may encounter. Trauma to the other intraabdominal organs (e.g.
liver, spleen, bones) will be omitted.


 limitations of colorectal imaging studies

Figure 11.13  Neoplastic Wall Thickening. MDCT axial image demonstrates

abnormal colon wall thickening (>3 cm) that is asymmetric, nodular, and
lobulated in contour with narrowing of the intestinal lumen. The combination
of a paucity of pericolonic fat stranding with the short segment of involvement is
worrisome for malignancy. Surgery confirmed adenocarcinoma.

Table 11.3  Ulcerative colitis versus Crohn Colitis.

Ulcerative Colitis Crohn Colitis

Figure 11.11  Benign, Pathologic Wall Thickening. MDCT coronal reformatted Circumferential disease Eccentric disease
image demonstrates colonic wall thickening (<1 cm) that is homogenous, circum­ Continuous disease Skip lesions
ferential, symmetric, and segmental in distribution. The long segment of involvement Predominantly left-sided Predominantly right-sided
suggests a benign condition.
Rectum usually involved Rectum normal in 50%
Confluent shallow ulcers Confluent deep ulcers
No aphthous ulcers Aphthous ulcer early
Collar button ulcers Transverse and longitudinal
ulcers
Terminal ileum usually normal Terminal ileum usually
diseased
Terminal ileum patulous in backwash ileitis Terminal ileum narrowed
No pseudodiverticula Pseudodiverticula
Inflammatory polyps and pseudopolyps No polyps or pseudopolyps
No fistulas Fistulas common
High risk of cancer Low risk of cancer
Risk of toxic megacolon No toxic megacolon

11.2). Benign, pathologic wall thickening (Figure 11.11) is seen

Figure 11.12  “Double Halo” or “Target” Sign. MDCT axial image of the same
patient in Figure 11.II-D-1, demonstrates a stratified enhancement pattern in a
thickened segment of descending colon bowel wall.
wall; (5) intense enhancement or high-attenuation clot (senti-
nel clot) ­adjacent to the involved bowel (30, 37–48).
Bowel Wall Thickening
When fully distended the bowel wall is 1–2 mm in thickness, and
the collapsed bowel wall should not exceed 3–4 mm. MDCT can
often differentiate benign from malignant wall thickening (Table
in infectious, inflammatory, and ischemic processes; usually does
not exceed 1–2 cm; is homogenous in attenuation; and is circum-
ferential, symmetric, and segmental in distribution.(49) A strati-
fied enhancement pattern in a thickened segment of bowel wall
is used to exclude malignant conditions. Such a pattern may have
a “double halo” or “target” appearance of the intestine in cross
section which is caused by inflammation, edema, and hyperemia
(Figure 11.12). Neoplastic wall thickening is thicker (2–3 cm),
asymmetric, nodular, lobulated, or spiculated in contour and
tends to narrow the intestinal lumen (Figure 11.13). The extent
or length of bowel wall involvement aids in narrowing the differ-
ential diagnosis. With few exceptions (mainly lymphoma), long
segments of involvement indicate a benign condition. When the
perienteric fat adjacent to a thickened bowel segment is normal,

 improved outcomes in colon and rectal surgery
Figure 11.14  Crohn’s Disease. Axial MDCT demonstrates circumferential wall
thickening of the terminal ileum that results in narrowing of the bowel lumen
and formation of a stricture.
Figure 11.15  “Comb Sign”. Swollen blood vessels produce an appearance like the
teeth of a comb extending from the thickened bowel wall into the mesenteric fat.
Note the irregular outer wall of the cecum indicating Crohn’s colitis.
Figure 11.16  Crohn’s Abscess. Axial MDCT image demonstrates extraluminal
abscess in this patient with Crohn’s disease/colitis.

Figure 11.17  Ulcerative Colitis. Coronal reformatted CT image of the abdomen
and pelvis shows wall thickening and marked irregularity of the remaining mucosa
in the ascending and descending colon (arrows).
an acute inflammatory condition is less likely. Fat stranding that
is disproportionately more severe than the degree of wall thick-
ening suggests an infectious or inflammatory process.(50)
Inflammatory Bowel Disease (IBD)
Benign, circumferential thickening of the bowel wall is a hallmark
of Crohn’s Disease (Table 11.3). Wall thickening (Figure 11.14)
can result in strictures that narrow the bowel lumen in advanced
disease.(51–52) CT is excellent in documenting the extralumi-
nal manifestations of the disease such as the “comb sign” (Figure
11.15), which is produced by hyperemic thickening of the vasa
recta due to active disease. The swollen blood vessels produce an
appearance like the teeth of a comb extending from the thickened
bowel wall into the mesenteric fat.(53) “Skip areas” of normal
bowel intervened between diseased segments are characteristic.
Mesenteric abscesses are characteristic and may can contain fluid,
air, or contrast material (54–57) (Figure 11.16). Crohn’s Colitis is
characterized by transmural inflammation that usually affects the
terminal ileum (80%) and proximal colon (50%).(51–52) Bowel
wall thickening in Crohn’s colitis is typically 10 to 20 mm com-
pared with the 7 to 8 mm for Ulcerative Colitis (UC). With Crohn’s
colitis (Figure 11.15), the outer wall is irregular, whereas with UC
the outer wall is smooth.(58) Acute active disease shows layering
of the colon wall (“target and halo” signs), whereas chronic dis-
ease with fibrosis shows homogeneous enhancement of the colon
wall. Fibrous and fat proliferation in the mesentery (“creeping
 limitations of colorectal imaging studies
Figure 11.18  Ulcerative Colitis. Coronal reformatted CT image of the abdomen
and pelvis shows pseudopolyps (arrow) that extend into the lumen of the
transverse colon.
Figure 11.19  Psuedomembranous Colitis. Axial MDCT demonstrates pancolitis
with irregular wall thickening and submucoal edema resulting in a characteristic
“accordion pattern” of disease.
fat”) separates bowel loops with extensive fat-containing fibrous
strands. Sinus tracts between bowel loops, enterocutaneous fis-
tulas, and enterovesicular fistulas are also characteristic findings.
Ulcerative Colitis (UC) is characterized by inflammation and dif-
fuse ulceration of the colon mucosa (Figure 11.17). The disease
Figure 11.20  Typhilitis. MDCT axial image demonstrates marked wall thickening,
low-density edema within the cecal wall, and pericecal fluid and inflammation in
a patient with HIV. The wall thickening and inflammation extended from the
cecum to the hepatic flexure.
Figure 11.21  Radiation Colitis. Axial MDCT image demonstrates mucosal
thickening with prominent stranding in the expanded pericolic fat confined to
the radiation port distribution. A lymphomatous mass is noted adjacent to the
radiation colitis (large arrow).
starts in the rectum and extends proximally to involve part or
the entire colon. Wall thickening with luminal narrowing and the
inflammatory pseudopolyps, that result from mucosal ulceration,
are sometimes seen on CT (Figure 11.18). Narrowing of the rectal
lumen with thickening of the rectal wall and widening of the pre-
sacral space are often seen (51–53, 58). Similar to Crohn’s disease,
mesenteric adenopathy can be seen, but it is not specific for IBD.
Other Colitides
Psuedomembranous colitis results from overgrowth of Clostri­
dium difficile and its enterotoxin, as a complication of antibiotic
therapy. A pancolitis with irregular wall thickening (up to 30 mm)

 improved outcomes in colon and rectal surgery

and submucoal edema results in the “accordion pattern” of dis- intestinal obstruction and visualization of a normal appendix aid
ease that is characteristic.(58) The edema and thickening of the in diagnosis.(63–64)
colon may be greater than that seen with other colitides, and a
pancolitis ­suggests pseudomembranous colitis (Figure 11.19). Diverticulitis
Typhilitis or neutropenic colitis refers to a potentially fatal infection Acute diverticulitis is characterized by benign wall thickening,
of the cecum and ascending colon in patients who are immuno- hyperemic contrast enhancement, inflammatory pericolic fat
compromised. CT is the study of choice for making the diagno- stranding, and diverticula in the involved segment (Figure 11.22).
sis. Typhilitis is characterized by marked wall thickening (10–30 Perforation or abscess may form, and CT is better suited to dem-
mm), low-density edema in the cecal wall, pericecal fluid, and onstrate extraluminal disease than barium enema (Figure 11.23).
inflammation (Figure 11.20), which may be confused with the Sinus tracts and fistulas may extend to adjacent organs or the skin
reactive changes of appendicitis.(58–59) The length of the cecum and are represented by linear fluid or air collections. Air in the
and right colon involved is generally much greater with typhlitis, bladder suggests a colovesicular fistula, unless the patient has had
and the thickening is more asymmetric in appendicitis.(60) The
presence of known risk factors favors the diagnosis of typhilitis.
Ischemic colitis features include benign, pathologic wall thicken-
ing in a vascular distribution watershed segment of colon, usually
at the splenic flexure (Figure 11.12). Radiation colitis in the acute
phase demonstrates mild wall thickening and pericolic fat strand-
ing confined to the radiation port area. Chronic radiation injury
6 to 24 months after treatment appears as mucosal thickening with
prominent stranding in expanded pericolic fat (Figure 11.21).
Infectious colitis differentiation is based on clinical findings
because CT findings are nonspecific. Infectious terminal ileitis
is usually caused by Yersinia, Tuberculosis, Campylobacter, or
Salmonella organisms.(61) The diagnosis is made clinically with
stool cultures. CT features are benign wall thickening of the ter-
minal ileum and cecum, and moderate or marked enlargement
of the mesenteric lymph nodes in the right lower quadrant.
(62)
Although a Meckel’s diverticulum occurs at some distance
(60–100 cm) from the cecum, it may cause complications such as
inflammation, whose differential diagnosis includes appendicitis
and IBD.(63) The CT diagnosis of an inflamed Meckel’s diver-
ticulum relies on the identification of a blind-ending, tubular, or Figure 11.23  Perforated Diverticulitis. Axial MDCT image demonstrates colon
round pouch-like structure in the right lower quadrant attached wall thickening and extravasation of oral contrast (small arrows), as well as free
to the small intestine with surrounding inflammation. Small peritoneal air anteriorly (large arrow).

Figure 11.22  Diverticulitis. Axial MDCT demonstrates benign wall thickening, Figure 11.24  Colon Cancer. Axial MDCT demonstrates a large colonic mass in
hyperemic contrast enhancement, and inflammatory change that extend into the the descending colon that narrows the lumen. CT cannot differentiate tumor
pericolic fat, with diverticula in the involved segment. extension through the wall from pericolonic edema or desmoplastic reaction.


 limitations of colorectal imaging studies

bladder catheterization. Obstruction of the colon or urinary tract
from the inflammatory process can be seen on CT. Diverticulitis
of the right colon may be confused with acute appendicitis or
IBD. Visualization of a normal appendix or inflammatory changes
involving the ascending colon distal to the ileocecal valve favor
the diagnosis of diverticulitis over appendicitis.(58) The extrin-
sic inflammation from a tubo-ovarian abscess may cause serosal
edema and mural thickening of the cecum or sigmoid colon wall.
Recognizing that the inflammation is centered in the adnexa and
appropriate distention of the colon with oral and rectal contrast
agents assist in making the correct diagnosis.(65–66)
Colorectal Cancer
Detection and Differentiation from Diverticulitis
The CT appearance of diverticulitis overlaps that of colon cancer,
as bowel wall thickening and pericolonic fat stranding occur in
both. Fluid in the sigmoid mesentery and engorgement of mes-
enteric vessels favors diverticulitis (Table 11.2). Enlarged lymph
nodes, asymmetric wall thickening, and the presence of an intralu-
minal mass (Figure 11.24) favors cancer.(67–73) Prior recent films
showing no colonic wall thickening can aid in diagnosis. A biopsy
may be required in equivocal cases.
from the inability to distinguish tumor from peritumoral desmo-
plastic reaction or edema, and the inability to detect microscopic
extramural tumor extension (Figure 11.24). A major advantage
of CT is the ability to demonstrate the local extent of tumor and
involvement of adjacent organs, such as the bladder, vagina, peri-
toneum, and abdominal or pelvic musculature.(84) Also, MDCT
can reliably detect enlarged lymph nodes for staging of colorectal
cancer.(83) Although the presence of lymph nodes larger than
1–1.5 cm in short-axis diameter is considered pathologic, not all
enlarged nodes contain tumor. Conversely, normal-sized nodes
may have microscopic tumor involvement.(80) Another factor
that poses problems in staging is ischemic bowel associated with
an obstructing colon cancer.(85–87) Detecting ischemic change
proximal to colonic carcinoma is important because 25% of cases

Colorectal Cancer Staging

Preoperative CT for staging colorectal cancer is performed to
detect invasion of adjacent organs, enlargement of local nodes,
or evidence of distant metastases. The Tumor, Nodes, Metastasis
(TNM) and Dukes classification are both used for preoperative
staging (Table 11.4). Squamous cell carcinoma can occur in the
anal canal, and it does not have any ­discriminating imaging fea-
tures from adenocarcinoma. The primary adenocarcinoma may
be seen as a polyp larger than 1 cm, or a soft-tissue cancer mass
that narrows the lumen of the colon.(74) Flat lesions appear as Figure 11.25  Colon cancer liver metastasis. MDCT performed with IV contrast
material during the portal vein phase of enhancement shows heterogeneous, ring-
focal, lobulated thickening of the bowel wall (>3 mm). “Apple enhancing metastases that are hypodense to the liver.
core” lesions demonstrate irregular bulky circumferential wall
thickening with marked and irregular narrowing of the bowel
lumen.(74–75) Adequate luminal distention is essential, and may
be achieved with oral and rectal water soluble contrast or water as
a negative contrast agent.(76–77) The accuracy of CT in preoper-
ative staging varies from 48% to 77%, and this variability depends
on the actual stage of the cancer.(78–82) The accuracy of CT stag-
ing ranges from 17% for early lesions (Dukes stage B) to 81% for
advanced lesions (Dukes stage D) (75, 80, 83). Inaccuracies arise

Table 11.4  TNM compared to modified Dukes staging for

colorectal carcinoma.
TNM Stage Modified Dukes Stage

I: Submucosa T1, Muscularis, T2 N0M0 A: Limited to wall mucosa or

II: Muscularis T3, Perirectal T4 N0M0
IIIA: T1–4N1M0 IIIB: T1–4N2–3M0
IV: T1–4 N1–3 M1
submucosa
B: Extension into or through
serosa
C: Cancer that extends to lymph
nodes Figure 11.26  Mucinous Adenocarcinoma Metastatic Disease. MDCT axial
D: Distant Metastasis image shows necrosis and calcification of meatastatic mucinous adenocarcinoma
to the liver.


 improved outcomes in colon and rectal surgery
Figure 11.27  Colon Cancer Peritoneal Metastasis. Axial MDCT demonstrates
thickening of the peritoneal surfaces, ascities, and two large peritoneal nodules in
a patient with colon cancer.
with proximal ischemic colitis have been reported to cause post-
operative complications such as suture-line disruption.(86–89)
Also, an ischemic segment in colonic carcinoma may give a false
radiologic impression regarding tumor length or depth of tumor
invasion.(85) Ischemia can develop at sites remote from the
obstructing cancer, such as the terminal ileum, mimicking syn-
chronous lesions.(85, 89–93) CT can usually distinguish an isch-
emic segment from a tumoral segment in approximately 75% of
the cases by applying the criteria for benign (ischemic) bowel wall
thickening, and the “target” or “double halo” sign is the most spe-
cific sign.(88–93) This finding must be interpreted with ­caution,
as signet ring cell adenocarcinoma can have low-density mural
thickening.
Colorectal Cancer Metastasis
The liver is the predominant organ to be involved with metas-
tases from colorectal cancer, and MDCT has an established role
in detection. Hepatic metastases are supplied by the hepatic
artery, and two thirds of the liver is supplied by the portal vein.
MDCT (performed with IV contrast material during the portal
vein phase of enhancement, 60–70 sec after the start of the bolus)
typically shows heterogeneous, ring-enhancing metastases that
are hypodense to the liver (Figure 11.25). Images obtained after
a longer delay may not reveal evidence of disease because lesions
become isodense to the liver.(94–95) Small lesions (<1 cm) do
not have adequate enhancing properties to be differentiated and
are named indeterminate lesions. Necrosis and calcification of
metastatic mucinous adenocarcinoma to the liver can be seen on
MDCT (Figure 11.26). CT can detect intraperitoneal metastases,
which appear as thickening of the peritoneal surfaces or perito-
neal nodules (Figure 11.27), but microscopic seeding will not be
detected. Careful attention to the peritoneal surfaces and omen-
tum is needed in the setting of unexplained ascites to identify
peritoneal metastases.
CT arterial portography is a very sensitive technique for detec-
tion of liver metastasis. This procedure requires fluoroscopic/

Figure 11.28  Anastomotic Leak. Axial MDCT demonstrates high density ascites
representing extravasted oral contrast in this patient status postterminal ileum
resection and ileocolic anastomosis. Pneumoperitoneum is also seen.
angiographic guided catheter placement in the superior mes-
enteric artery using the Seldinger technique through the femo-
ral artery. Intraarterial injection of contrast material results in
intense portal vein enhancement of the normal liver. Both meta-
static disease and benign perfusion abnormalities manifest as fill-
ing defects on CT portography, and therefore the sensitivity of
this test is less than perfect. Likewise, intraarterial hepatic artery
injection (hepatic arteriography) can aid in identifying liver
metastasis as they will enhance brightly. Some studies have sug-
gested that combined CT arterial portography and CT hepatic
arteriography significantly improved the detect ability of hepatic
metastases.(96) However, these unified CT-angiography sys-
tems are not widely available and require an invasive procedure.
Furthermore, a recent study (97) showed that the use of portal
venous phase enhanced MDCT as the only preoperative imag-
ing technique in the assessment of colorectal cancer metastases
allowed accurate preoperative staging (sensitivity, 85.1%; positive
predictive value, 96.1%).
Colorectal Cancer Recurrence
Local recurrent tumor usually appears as a soft-tissue mass in or
near the surgical site. Due to the often largely extrinsic component
of local recurrence, CT is better than colonoscopy at demonstrat-
ing the early, mass like tumor recurrence.(98, 99) This appearance
can mimic postoperative fibrosis, although fibrosis usually appears
more linear without a discrete mass. Following abdominoperineal
resection, it is common to see soft tissue density within the pre-
sacral space. When this material remains plaque-like, fibrosis is
likely. Often, distinction between postoperative fibrosis and recur-
rent tumor is not possible unless serial scans are obtained. CT
findings clearly indicative of recurrent malignant disease include
enlargement of a soft-tissue mass over time, enlarging lymphade-
nopathy, and invasion of contiguous structures.
CT performed with intravenous contrast material is the imaging
modality of choice for detection of recurrent tumor within the liver.
CT has been shown to be more helpful in diagnosis of recurrent
 limitations of colorectal imaging studies
Figure 11.29  Postoperative Abscess. Axial MDCT demonstrates a large air
fluid collection (abscess) in the operative field, in this patient status posttotal
colectomy and ileorectal anastomosis. The anastomotic suture line can also be
seen. The large amount of gas in the abscess suggests communication with the
gastrointestinal tract.
hepatic metastases than laboratory studies (liver function tests, mea-
surement of carcinoembryonic antigen level).(80, 100) The impor-
tance of abdominal CT is reflected in the surveillance guidelines
proposed by the American Society of Clinical Oncology.(101) The
guidelines recommend annual CT of the abdomen for 3 years after
primary therapy for patients who are at high risk of recurrence.
Postoperative Complications
MDCT is often used to diagnose postoperative complications
such as abscess, anastomotic leak, fistula, small bowel obstruc-
tion, ileus, and pulmonary embolus (small bowel obstruction
and ileus will be covered later). Before postoperative day five, it
is difficult to differentiate normal postoperative intraperitoneal
free air and fluid from fluid or air from an anastomotic leak or
abscess.(102) Findings suggestive of an anastomotic leak include
an inappropriate volume of free air or fluid in the abdomen. The
presence of extraluminal oral contrast (Figure 11.28) confirms an
anastomotic leak.(102)
CT is the most accurate imaging test for diagnosing abscess
formation in the postsurgical patient.(103) The combination of
water soluble oral contrast and an intravenous contrast agent is
essential in differentiating between a fluid-filled bowel loop and
an abscess. The CT appearance of an abscess is variable depend-
ing on its age and location. Early abscess appears as a mass
with an attenuation value near that of soft tissue. As the abscess
matures, it undergoes necrosis with a central region of near-water
attenuation surrounded by a high attenuation rim that usually
enhances.(104) Approximately one third of abscesses contain
variable amounts of gas (Figure 11.29).(104–108) Postoperative
packing materials used for hemostasis, such as oxidized cellulose
and gelatin bioabsorbable sponge, can mimic a gas-containing
abscess. Findings that may help differentiate are: linear arrange-
ment of tightly packed gas bubbles, an unchanged appearance on
subsequent examinations, and lack of either a gas-fluid level or an
(a)
(b)
Figure 11.30  A and 11.30B Acute Appendicitis. Axial MDCT demonstrates
an obstructing calcified appendicolith with an abnormally dilated, enhancing
appendix surrounded by inflammatory fat stranding.
enhancing wall.(109, 110) A low-density mass containing a high
density object suggests a foreign body abscess caused by a retained
surgical sponge (gossypiboma).(111) Although CT findings are
highly suggestive of abscess, they are not specific. Other masses
that can have a central low attenuation include a cyst, pseudo-
cyst, hematoma, urinoma, lymphocele, biloma, loculated ascites,
thrombosed aneurysm, and necrotic neoplasm. Because a specific
diagnosis of abscess based on CT findings alone is not possible,
correlation with clinical history is important. Percutaneous nee-
dle aspiration may be necessary to make a definitive diagnosis
(See interventional radiology).
Fistula formation between the bowel and other organs such as
the bladder, vagina, or skin can form as complications of surgi-
cal or radiation therapy. Fistula can be identified with IV or oral
contrast and are demonstrated as extension of contrast from
one organ to the other. Oral and IV contrast should not be used
simultaneously for a suspected bowel/bladder fistula because
contrast in the bladder could be from renal excretion or a bowel/
bladder fistula.
Pulmonary embolism can occur in cancer and postoperative
patients. Since the introduction of spiral MDCT, CT angiography

 improved outcomes in colon and rectal surgery
Figure 11.31  Appendix Mucocele. Axial MDCT demonstrates distension of the
appendix with mucus.
Figure 11.32  Lipoma. Axial MDCT demonstrates a 2–3 cm, round, sharply
defined tumor with homogenous fat density (-80 to -120 H) adherent to the
sigmoid colon.
(CTA) has become the method of choice for imaging the pulmo-
nary vasculature, and has replaced invasive pulmonary angiog-
raphy as the reference standard for diagnosis.(112–117) Another
advantage of CTA over pulmonary angiography is the ability to
identify alternative or additional diagnosis such as: atelectasis,
pneumonia, pulmonary edema, pleural, and pericardial effusions,
and many others. CT venography (CTV) combined with CTA
can be used as a comprehensive examination of the deep venous
system to detect both PE and deep vein thrombosis (DVT). CTV
is performed by scanning of the pelvis from the iliac crest to the
popliteal fossa approximately 120 s after completion of the CTA.
CTV could potentially salvage the occasional suboptimal PE study
by diagnosing a DVT and guide interventions such as vena cava
filter placement. Numerous studies have cited 97% agreement
between CTV and US.(118–122) The addition of CTV increases
the gonadal radiation exposure, and should be used selectively
on the basis of risk-benefit considerations (e.g., avoided in young
patients and reproductive female patients).(116)

Appendix
Acute Appendicitis
MDCT has a high sensitivity (91–100%) and specificity (91–
99%) in diagnosing acute appendicitis (123–126). The diagnosis
of acute appendicitis is based on finding: an abnormally dilated
(>6 mm), enhancing appendix; appendix surrounded by inflam-
matory periappendiceal fat stranding; focal thickening of the
base of the cecum; periappendiceal abscess; or obstructing calci-
fied appendicolith (Figures 11.30A and 11.30B). The most com-
mon reason for a false-negative diagnosis is related to a paucity of
intraabdominal fat often seen in pediatric patients and patients
with a lean body habitus.(127–130) Optimal cecal opacifica-
tion and distention are important because without cecal opaci-
fication a distended appendix can be mistaken for a small-bowel
loop.(131, 132) Therefore, intravenous, oral, and rectal contrast
should be used. Appendicitis may cause reactive dilatation of the
small bowel and mimic a small-bowel obstruction, resulting in
a missed diagnosis of the underlying problem. In addition, the
dilated small bowel impedes the flow of oral contrast, so that
opacification of the cecal region is suboptimal, creating difficulty
in diagnosis. Therefore, a small-bowel obstruction in patients
who have no history of surgery or cause for obstruction is suspi-
cious for appendicitis, especially in younger patients.(130)
Mucocele and Tumors of the Appendix
Mucocele refers to distension of all or a portion of the appendix
with mucus secondary to obstruction by appendicolith, adhesions,
or tumor.(133) Most commonly, this lesion is a retention mucocele
and is asymptomatic (Figure 11.31). Some cases are caused by muci-
nous cystadenomas or cystadenocarcinomas of the appendix.(133,
134) Continued secretion of mucus produces a large (up to 10 cm),
well-defined, cystic mass in the right lower quadrant, which may
have a thin rim of wall enhancement or calcification.(135) Rupture
of the mucocele may result in psuedomyxoma peritonei causing
gelatinous implants and mucinous ascites throughout the peritoneal
cavity. Although an enhancing nodular component is concerning
for malignancy (136), neoplastic and retention mucoceles cannot
be reliably distinguished by imaging studies. Adenocarcinoma of
the appendix is rare and is usually discovered in the clinical setting
of suspected appendicitis in an older adult. Imaging demonstrates a
soft tissue mass within or replacing the appendix.(133) Lymphoma
of the appendix appears similar to appendicitis, but is typically larger
with a diameter of 3 cm or greater.(137)
Carcinoid is the most common tumor of the appendix
accounting for 85% of all tumors.(133) Carcinoid of the appen-
dix usually appears as a focal enhancing mass in the distal
appendix.(133, 138) Carcinoid metastases to mesentery and
the liver enhance brightly on arterial phase imaging because of
their vascularity.(138–146) Three-dimensional CT angiography
is useful to fully appreciate the mesenteric mass and its relation-
ship to the vessels, which is important for surgical planning.
(140–147) In addition to the liver, metastases can be seen on CT
in the lung and bones.
Other Tumors of the Colon
CT remains the imaging study of choice for detection of benign
and malignant tumors of the colon other than adenoma and
 limitations of colorectal imaging studies

Figure 11.34  Small Bowel Obstruction. Axial MDCT demonstrates multiple

Figure 11.33  GIST. Axial MDCT demonstrates a large heterogenous exophytic dilated loops of small bowel with air fluid levels. Intraluminal fluid distends the
mass with cystic degeneration and necrosis that communicates with the lumen of bowel and acts as a natural contrast agent.
adjacent colon and small bowel.

adenocarcinoma. Metastases to the colon can be seen on con-

trast enhanced MDCT, if they are large enough; but CT cannot
differentiate primary tumor from metastasis.(148) One of the
most common benign colonic tumors is a lipoma. Lipomas can
be easily diagnosed by demonstrating a 2–3 cm, round or ovoid,
sharply defined tumor with homogenous fat density (-80 to -120 H)
(Figure 11.32).
Colonic lymphoma usually appears as either a marked thicken-
ing of the bowel wall that often exceeds 4 cm, or a homogeneous
soft-tissue mass without calcification. Lymphoma characteristi-
cally causes much larger soft-tissue masses than adenocarcinoma.
Owing to the softness of the tumor, the lumen is commonly
dilated or normal, rather than constricted, and bowel obstruction
is uncommon. The absence of desmoplastic reaction and diffuse
lymphadenopathy help to differentiate lymphoma from adeno-
carcinoma.(149–150)
Gatrointestinal Stroma Tumors (GIST) can be benign or
malignant and cannot be diffentiated on cross sectional imaging
without distant metastases to the liver or peritoneum.(151) GISTs
Figure 11.35  SBO from Adhesions. Axial MDCT of same patient in Figure 11.II-
can appear as an exophytic or intraluminal mass, and size var- L-1 shows abrupt transition from dilated to nondilated bowel suggests adhesions
ies from millimeters to 30 cm. Cystic degeneration, hemorrhage, as the cause. A suture line from the patient’s colonic resection and ileocolonic
and necrosis are common in large lesions with calcification rarely anastomosis is seen.
noted (Figure 11.33). The tumor cavity may communicate with
the colon lumen and contain air or oral contrast. Sarcomas that
arise in the bowel, anorectum, or omentum are indistinguishable right abdomen. The axis of torsion is in the ascending colon above
from malignant GIST.(151) Tissue types include leiomyosarcoma, the ileocecal valve. Signs of bowel ischemia include benign wall
fibrosarcoma, and liposarcoma. thickening, “thumbprinting”, inflammation of pericolic fat, and
pneumatosis (air in the bowel wall).(152)
Sigmoid and Cecal Volvulus
Small Bowel Obstruction
Diagnosis of large bowel volvulus is usually made by plain radio-
graphs or fluoroscopy, but CT is used to detect evidence of isch- Accuracy of Diagnosis and Causes of SBO
emia. Sigmoid volvulus is seen on CT as distended colon with the CT has gained favor as the initial radiologic examination of
mesenteric twist appearing as a “whirl.” Cecal volvulus has a similar patients with SBO because it can often determine the cause,
appearance with the apex of the distended colon pointed toward severity, and transition point of obstruction.(153–158) The sen-
the right lower quadrant and the “whirl” of cecal mesentery in the sitivity of CT for high-grade SBO is 90–96%, with a specificity of


 improved outcomes in colon and rectal surgery
Figure 11.36  Ileocecal Intussusception. Axial MDCT CT demonstrates
characteristic findings of the distal segment (intussuscipiens) dilated with a
thickened wall. Its lumen contains an eccentric, soft-tissue mass (intussusceptum)
with an adjacent crescent of fat density that represents the invaginated mesentery.
Figure 11.37  Pneumatosis Intestinalis. Small bowel ischemia is suggested by the
decreased segmental bowel-wall enhancement and pneumatosis intestinalis.
91–96%.(153, 157, 159–165) The 3, 6, and 9 rule can be used to
detect bowel dilatation on CT scans. Oral contrast is not always
necessary as the intraluminal fluid distends the bowel and acts as
a natural contrast agent (Figure 11.34). Oral contrast should be
avoided in patients with a high grade or complete SBO. Adhesions
cause 50% to 75% of SBOs, but are often not directly visualized
by CT. Beaklike narrowing or abrupt transition from dilated to
nondilated bowel suggests adhesions as the cause (Figure 11.35).
Obstruction from tumor, abscess, intussusception (Figure 11.36),
inflammation, and hernia are readily diagnosed with CT.
Paralytic/Adynamic Ileus
Paralytic or adynamic ileus appears as dilation of small bowel
without a transition zone. The colon may be distended or

Table 11.5  CTC laxative preparations.
Laxative Agent Limitations
Sodium Phosphate Because of rare reported instances of acute
phosphate nephropathy, avoid use in
elderly with hypertension, patients
taking angiotensin-converting enzyme
inhibitors, and patients with renal or
cardiac insufficiency (184).
Magnesium Citrate Avoid in severely compromised patients who
cannot tolerate mild fluid or electrolyte
shifts.
Polyethylene Glycol (PEG) Most favorable safety profile but poorest
adherence because of the consistency,
taste, and large volume (4 L) that must be
ingested.
collapsed and this should not be mistaken for evidence of a tran-
sition zone. CT is reported to be less accurate in patients with
low-grade or partial SBO and it may be difficult to distinguish
between a SBO and paralytic or adynamic ileus. In such cases the
“small bowel feces” sign, which is gas bubbles mixed with particu-
late matter in the dilated bowel, is a reliable indicator of a SBO.
(161–166) If oral contrast reaches the colon, a complete SBO is
not present.
CT Enteroclysis
CT enteroclysis is useful in the evaluation of equivocal cases,
and is performed by placing a tube in the fourth portion of the
duodenum with infusion of 1 to 1.5 L of dilute contrast into the
small bowel. The addition of coronal reformations is a valuable
adjunct to the transverse scans because it improves identification
and exclusion of bowel obstruction.(167)
Closed Loop Obstruction, Strangulation, and
Intestinal Ischemia
CT can diagnose closed loop obstruction of the small bowel
and bowel ischemia. The “beak” or “whirl” sign may be seen at
the obstruction and volvulus.(168) Dilated bowel loops with
stretched and prominent mesenteric vessels converging on a site
of obstruction suggest a closed loop obstruction. Decreased seg-
mental bowel-wall enhancement and pneumatosis (Figure 11.37)
are associated with small-bowel ischemia.(169) The diagnosis of
small-bowel ischemia in the presence of obstruction has reported
sensitivities varying from 75% to 100%, and specificities of 61%–
93%.(170–174)
computed tomographic
colonography (ctc)
Colorectal Cancer Screening and the
Advanced Adenoma
Computed tomographic colonography (CTC) or Virtual Colon­
oscopy is an excellent technique for the detection of colorectal
polyps and cancer. Because colorectal cancer has an identifiable
precursor lesion, the advanced adenoma (polyp), there is a gen-
uine opportunity for prevention rather than detection alone.
 limitations of colorectal imaging studies
(216, 217) CTC’s sensitivity for polyp detection is similar to
(175) or better than (176) double-contrast barium enema. CTC
has accuracy similar to that of optical colonoscopy (OC) both
in high-risk groups (177–180) and in a low-prevalence screen-
ing population (181). Also, CTC has the potential to become an
accepted technique for evaluation of the nonvisualized part of
the colon after incomplete OC.(182)
CT Colonography (CTC) Technique
Adequate CTC software is critical for accurate interpretation,
but even the best software system will fail if colonic preparation
is inadequate. Colonic preparation involves a clear liquid diet the
day before the exam and a laxative for catharsis.(183) The laxative
for a standard CTC bowel preparation is sodium phosphate, which
is used in nearly 90% of cases (Table 11.5).(183) Dilute barium is
used to tag residual feces, and water soluble diatrizoate serves the
dual purpose of uniform fluid tagging and secondary catharsis.
(185) Gaseous distention can be achieved with room air or CO2,
and the insufflations can be automated or manually controlled by
the patient or the medical staff (technologist or physician). Both
supine and prone axial scans are obtained with 3D software recon-
structions. At least 8 to 16 detector CT is needed with 1.25 mm
collimation (Figures 11.38 and 11.39).
Figure 11.38  Normal CTC Supine Axial 2D Images.
Benefits, Complications, and Limitations of
CT Colonography (CTC)
CTC does not involve the sedation or recovery time associated with
OC. With the short scan time of MDCT scanners, patients must
tolerate maximum inflation for only a few seconds, as opposed to
OC and barium enema. A survey of patients undergoing colorec-
tal cancer screening found that patients prefer CTC over OC and
barium enema.(186) Unlike colonoscopy and barium enema, CTC
allows visualization of organs outside the colon. Although nonen-
hanced CTC (at one-fourth the standard radiation dose) is not
adequate for screening, all solid abdominal and pelvic pathology,
important disease such as abdominal aortic aneurysm, renal cell
carcinoma, ovarian cancer, and other neoplasms can be detected.
The most beneficial situation would be the discovery of an asymp-
tomatic early process that could be cured with early treatment. The
safety profile of CTC has been extensively reviewed. The largest
U.S. study, the combined Working Group on Virtual Colonoscopy
(187), found that CTC was a very safe, noninvasive procedure
(Table 11.6) By combining the Working Group results with two
other large multicenter studies (188–189), the total number of
CTC examinations exceeds 50,000. None of the cases of perfora-
tion from these three groups resulted in patient death. Many cases
of CTC–related perforation have involved high-risk symptomatic
patients for whom OC was either incomplete or contraindicated.
No cases of symptomatic perforation resulted from patient-con-
trolled insufflations or automated CO2 delivery. Staff-controlled
manual insufflations lack the inherent safeguards of the other
two methods and have accounted for virtually all known cases
Table 11.6  Working group on virtual colonoscopy experience
(187) — (21,923 CTC performed between 1997 and 2005).
Screening CTC (11,707 patients) Diagnostic CTC (10,216 patients)
No cases of perforation 2 cases of perforation (1 asymptomatic,
1 symptomatic)
Note: Overall complication rate of 0.02%
Symptomatic perforation rate of 0.005% (one in 21,923 patients).
The 1 patient in 21,923 with a symptomatic perforation was a patient with known
annular carcinoma of the sigmoid colon who was already symptomatic prior to
CTC, and massive pneumoperitoneum was found after a few puffs of air were
delivered.(187)
Figure 11.39  Normal CTC 3D Image of the
Colon.

 improved outcomes in colon and rectal surgery
Table 11.7.  Results from Kim et al.(195)
Primary CTC Primary OC
Variable (n = 3,120) (n = 3,163)
Use of OC 246 3,163
# of Advanced Adenomas
>10 mm 103 103
6–9 mm 5 11
<5 mm 1 3
Invasive Carcinoma 14 4 for patients with one or two small CTC-detected polyps has also
Note: Only 3 subcentimeter polyps with high-grade dysplasia (0.05%), and there
were no subcentimeter cancers.
Total of 2,006 polypectomies to remove diminutive polyps (<5 mm), which
yielded only 4 advanced lesions (0.2%).
of symptomatic perforation. The risk of perforation with auto-
mated or patient-controlled distention methods approaches zero
among asymptomatic adults.(190) The automated CO2 delivery is
not only safe but also results in improved colonic distention and
reduced spasm.(191)
Although the capability of CTC to depict polyps is both opera-
tor and technique dependent, this modality has a relatively high
specificity.(176, 178–181) Some of the inconsistent results in pre-
vious studies have been attributed to reader inexperience, inap-
propriate protocol, and lack of image software technology. CTC
trials involving cohorts with protocols restricted to a primary 2D
approach fared poorly (192–194), whereas those that relied on
2D and 3D polyp detection performed well (178–181, 195).
Primary CT Colonography Screening with Selective Optical
Colonoscopy
CTC cannot replace optical colonoscopy (OC), as it is an essential
diagnostic tool for the nonsurgical removal polyps. As a screening
test applied to asymptomatic adults; however, OC is a relatively
invasive procedure, with reported perforation rates of 0.1–0.2%.
(196–200) Given that a small minority of screening patients actu-
ally harbors a clinically relevant lesion (181, 201–206), the high
rate of negative screening studies may come into question now
that a less invasive alternative, CTC, is becoming widely available
and greatly improved from the past. Therefore, primary CTC with
selective OC deserves consideration as a preferred screening strat-
egy. In this approach patients are screened with CTC and patients
with polyps >10 mm are offered same-day OC with polypectomy.
Patients with polyps 6 to 9 mm are given the option of CTC sur-
veillance or OC with polypectomy. To avoid any confusion, or
anxiety, potential diminutive lesions (≤5 mm) are not reported.
In a large screening study of asymptomatic adults by Kim et al.
(195) (Table 11.7) found that CTC and OC screening methods
resulted in similar detection rates for advanced neoplasia within
the same general population. The results of this study also sug-
gest that a 10 mm threshold for polypectomy at asymptomatic
screening would probably capture the vast majority of clinically
relevant lesions. The study noted scarcity of small advanced
neoplastic lesions and marked decrease in the use of OC and
total rates of polypectomies in the CTC group (Table 11.7);
which suggests that this screening approach is a safe, clinically

effective, and cost-effective filter for therapeutic OC.(195) Markov
modeling of large cohorts has also shown that the strategy of not
reporting diminutive polyps (<5 mm) during CTC screening is a
cost-effective approach that can substantially reduce the rate of
polypectomy and complications without any sacrifice with respect
to cancer prevention.(204) However, the clinical management of
polyps 6 to 9 mm that are detected during CTC is controversial.
One approach is to offer OC for polypectomy to all patients with
polyps >6 mm.(207) An option of short-term CTC surveillance
been suggested.(208) Potential benefits include the decreased use
of resources, procedural risks, and cost. Potential drawbacks are
the possibility of following a polyp that harbors a focus of cancer.
Ultimately, more investigation will be needed to determine which
strategy is more beneficial for polyps <10 mm that are found
during CTC. Furthermore, by combining CTC and OC screen-
ing efforts, the overall screening compliance could substantially
increase.(192)
CT Colonography Follow-Up after Surgery
for Colorectal Cancer
More than half of colorectal cancer recurrences are distant metas-
tases to the liver and lungs (209, 210) and most local recurrences
lack an intraluminal component (210). CTC is usually performed
without IV contrast for screening, but CTC performed with
IV contrast enhancement could accomplish the dual function
of annual CT surveillance of the abdomen and liver, as well as
examination of remaining colonic lumen. CTC could also have
a role in postsurgical patients in whom optical colonoscopy has
failed or in patients with a colostomy. The limitations of CTC
in the postoperative patient include extrusion of surgical staples,
inflammatory polyps, and benign ulcers. Extruded staples can
be clearly distinguished from true polyps on 2D images by their
high attenuation.(211) Because inflammatory polyps and benign
ulcers are not distinguishable from adenomatous polyps on CTC,
follow-up OC and biopsy will be needed.(211) Nevertheless, it
would be efficient if CTC could eliminate through screening
those patients whose colon is normal, while also performing the
dual function of evaluating the entire abdomen for metastatic
disease. Also, the ability of IV contrast enhanced CTC to provide
images of the bowel wall, extracolonic tissues, lymph nodes, and
liver in one setting may provide a more accurate preoperative
staging of colorectal cancers.(212, 213) A recent study found that
CTC colorectal cancer T staging overall accuracy was 73–83%,
and N staging was associated with an overall accuracy of 80%.
(214) Thus, contrast-enhanced CTC is a fairly accurate technique
for preoperative staging of colorectal tumors.(212, 213)
flouroscopy
Barium Enema
Single and Double Contrast Barium Enema (DCBE)
Single Contrast Barium Enema is performed by filling the rectum
and colon with barium through an enema catheter after inflat-
ing a retention rectal balloon. Double Contrast Barium Enema
(DCBE) or Air Contrast Barium Enema (ACBE) is performed
similarly, except the colon is partially filled with undiluted
 limitations of colorectal imaging studies
Figure 11.40  Annular Carcinoma. DCBE demonstrates an annular “apple core”
stricture characterized by circumferential narrowing of the bowel with mucosal
destruction and shelf-like, overhanging borders.
barium. Once the barium reaches the middle transverse colon, the
enema bag is lowered to the floor and the rectum is drained by
gravity. Using a pneumatic bulb, room air is insufflated into the
colon. The radiologist manipulates the amount of air insufflated;
and analyzes the barium-coated mucosal surface to detect abnor-
malities. Fluoroscopic guidance allows the radiologist to opti-
mize technical components. Afterwards, overhead radiographs
are obtained in projections that the radiologist cannot obtain at
fluoroscopy. Both single and DCBE can identify malignant stric-
tures, but the double contrast of air and barium provides better
visualization of the mucosa and colon polyps.(215) The radio-
graphic appearance of the lesion depends on the profile in which
the lesion is imaged and the location of the lesion relative to the
barium pool. It is not possible to distinguish between the sporadic
adenomatous polyps and polyposis syndromes using contrast
studies.(216) The appearance of polyps and early cancers can
be sessile, polypoid pedunculated, or carpet lesions. Colorectal
carcinomas may manifest as polypoid, semiannular, or annular
strictures. Annular strictures are characterized by circumferential
narrowing of the bowel, with overhanging borders referred to as
“apple core” lesions (Figure 11.40). Benign strictures from isch-
emic, infectious, and inflammatory processes, in contrast, tend to
have smooth, tapering borders. The positive predictive value for
malignant strictures on DCBE is 96% (sensitivity, 63–66%) and
the positive predictive value for benign strictures is 84–88% (sen-
sitivity, 88–86%, respectively).(217) On occasion, however, the
area of narrowing in diverticulitis may have more abrupt borders
and may mimic the appearance of tumor. If the barium enema
examination reveals equivocal findings, colonoscopy should be
performed after treatment for diverticulitis to rule out an under-
lying carcinoma. When annular carcinomas are nonobstructive,
it usually is possible to perform DCBE so that the colon may
be evaluated for other synchronous neoplasms. Performance
of DCBE should not be performed in patients with large bowel
obstruction, acute colitis, or when there is concern for bowel per-
foration, as barium can cause peritonitis. In these situations, a
water-soluble contrast agent should be used.(216)
Limitations of Double Contrast Barium
Enema (DCBE)
DCBE is a valuable tool in colorectal cancer screening, but the
examination is not without limitations. When lesions are missed,
both perceptive/interpretive and technical errors are responsible.
(218, 219) Perceptive/interpretive errors occur when lesions are
overlooked because of superimposed bowel loops or are hidden
by deep haustral folds. Also, polyps that are small and flat or that
directly abut a haustral fold may be subtle. Another area that may
pose perceptive diagnostic difficulties is the ileocecal valve. While
some carcinomas arising at the ileocecal valve may be obvious
polypoid lesions, others may manifest as relatively subtle splay-
ing or distortion of the valve.(220) Incompetence of the ileocecal
valve can degrade the quality of barium enemas by preventing
full colonic distention and allowing the small bowel to obscure
segments of the colon.
Internal hemorrhoids appear either as thickened, undulating
folds that extend 3 cm or less from the anorectal verge or as a
cluster of small submucosal nodules that has been likened to the
appearance of a bunch of grapes.(221) In many cases, internal
hemorrhoids can be diagnosed confidently on the basis of the
radiographic findings. On occasion, however, large or thrombosed
hemorrhoids can mimic the appearance of tumor, whereas rectal
carcinomas that infiltrate the submucosa can mimic the appear-
ance of hemorrhoids.(221, 223) Digital rectal examination and/
or proctoscopy therefore should be performed whenever the
radiographic findings are equivocal.
Technical errors occur due to poor bowel preparation and
adherent stool can be difficult or impossible to differentiate from
true polypoid lesions. Regimens to prepare the colon are similar
to CTC and OC. Scout images are taken before the study and if
stool is seen in the colon a rescheduled barium enema examina-
tion may be performed after more rigorous bowel preparation.
DCBE are a fairly safe procedure, but the referring physician
should state if a recent endoscopic intervention has been per-
formed. There should be a 1-week interval between barium enema
examination and performance of large-forceps biopsy through a
rigid sigmoidoscope, snare polypectomy, or hot biopsy; because
these endoscopic interventions may tear the colonic mucosa and
result in a small risk of perforation. Performance of a small-
forceps biopsy through a flexible sigmoidoscope or colonoscope
does not preclude performance of barium enema examination on
the same day.(224, 225)
DCBE has been exhaustively reviewed, usually retrospectively.
DCBE has a sensitivity of 70% for polyps >7 mm (226–229) and
a sensitivity of 81–95% in detecting polyps >1 cm in diameter
(226–228). The detection rate for colorectal cancer or malignant
stricture ranges from 70% to >96% (230–232). The American
Cancer Society guideline for colorectal cancer screening includes
DCBE examinations at 5- or 10-year intervals for patients with
average risk and older than 50 years of age.(233) In conclusion,
DCBE can be used to detect most polyps (>10 mm) that are at

 improved outcomes in colon and rectal surgery

Figure 11.41  Ulcerative Colitis Late in the Disease. DCBE demonstrates blunting
of the haustral markings with a narrow tubular appearance of the sigmoid colon,
referred to as a “lead pipe colon”.

Table 11.8  Small Bowel Studies. Figure 11.42  Crohn’s Disease “String Sign”. Small bowel follow through
demonstrates fibrosis and progressive thickening of the bowel wall that narrows
Examination Technique Benefits and Limitations the terminal ileum, producing the “string sign”.

Small Bowel Follow Patient drinks barium Demonstrates the

Through (SBFT) while a series of mucosal surface, but
in the submucosa. As the ulcerations enlarge, inflammatory psue-
supine abdominal is insensitive; and
films are obtained limited by overlap dopolyps (islands of residual mucosa) and inflammatory polyps
until the terminal of bowel loops, poor (islands of inflamed mucosa) appear as irregular projections into
ileum and cecum are distension, and the bowel lumen. Late in the disease (Figure 11.41), there is blunt-
filled. intermittent filling. ing of the haustral markings with a narrow tubular appearance to
Small Bowel This study provides more the colon, referred to as a “lead pipe colon”.(216) The terminal
Enteroclysis uniform distension
ileum is usually normal, but rare backwash ileitis may produce an
of the bowel, even
distribution of ulcerated and patulous terminal ileum. Barium contrast studies
barium, superior are not able to distinguish UC associated polyps from adenoma-
anatomic detail, tous polyps or dysplasia; and UC associated cancers tend to be
and shorter overall flat or infiltrating and do not always appear as typical neoplasms.
examination time.
Therefore, contrast enemas are not recommended for routine
surveillance.(216)

Crohn’s Disease and Crohn’s Colitis

risk for malignant degeneration and provides an invaluable pub-
lic service by helping to lower the mortality rate due to colorectal
cancer.(234)
Ulcerative Colitis
Barium enema can be used to confirm the diagnosis of UC, to dif-
ferentiate it from Crohn’s disease/colitis, and to assess the extent
and severity of disease. The radiographic appearance of UC
depends on the state of the disease process.(216) Early in the dis-
ease, the mucosa is stippled with barium adhering to the conflu-
ent, superficial ulcers. Collar button ulcers are deeper ulcerations
of thickened edematous mucosa with crypt abscesses extending
The appearance of Crohn’s disease in the small bowel and the
colon is similar (Table 11.8). Shallow, 1 to 2 mm depressions usu-
ally surrounded by a well-defined halo, called aphthous ulcer-
ations, are the earliest mucosal lesions seen in Crohn’s disease.
(235) Other hallmarks are: (1) thickened and distorted folds; (2)
fibrosis with thickened walls, contractures, and stenosis (Table
11.3). Fibrosis and progressive thickening of the bowel wall
narrow the lumen producing the “string sign” in the terminal
ileum (Figure 11.42). Pseudodiverticula of the colon are formed
by symmetric fibrosis on one side of the lumen, causing saccu-
lar outpouchings on the other side. Deep ulcerations are larger
and often linear, forming fissures between nodules of elevated


 limitations of colorectal imaging studies

Figure 11.43  Divertivulitis. Barium enema demonstrates a deformed colon wall

with diverticular sacs.

edematous mucosa (“cobblestone pattern”). Contrast enemas are

better than colonoscopy at identifying and characterizing fistulas,
strictures, and the distribution of d
­ isease.(236)

Diverticulosis and Diverticulitis

Diverticula are often seen on barium enema examinations, as
barium or gas-filled sacs outside the colon lumen. Barium enema
examination is considered safe for diverticulitis, except when
signs of free intraperitoneal perforation or sepsis are present.
Diverticulitis appears as deformation of the colon wall in asso-
ciation with diverticular sacs (Figure 11.43), and occasionally
extravasation of barium outside the colon lumen. Abscess can
cause extrinsic mass effect on the adjacent colon and barium
can leak into the abscess cavities. A colovesical fistula is the most
common diverticular associated fistula, but contrast enemas are
able to make the diagnosis only 20% of the time.(237)
Colonic Lymphoma, Submucosal, and Extracolonic Lesions
Lymphoma can appear as small or large nodules, which may
ulcerate and perforate. Diffuse infiltration of the bowel wall
results in bulbous folds and thickened bowel wall. In contrast
to primary colorectal cancer, narrowing of the lumen is uncom-
mon, and dilation occurs when transmural disease destroys
innervations.
Endometriosis commonly implants on the sigmoid colon and
rectum.(238) Defects are frequently multiple and of variable
size. Barium studies demonstrate sharply defined defects that
compress, but do not usually encircle the lumen. Benign pelvic
masses such as ovarian cysts, cystadenomas, teratomas, and uter-
ine fibroids produce smooth extrinsic mass impressions on the
colonic wall, which is displaced but not invaded. Malignant pel-
vic tumors and metastases involved with the colon often cannot
be differentiated from primary tumors by imaging methods, and
Figure 11.44  Cecal Volvulus. Water soluble contrast enema demonstrates a
beak like termination at the point of obstruction in the ascending colon with a
markedly dilated cecum seen high in the abdomen.
Crohn’s disease may look similar. Lipomas appear as a smooth,
well-defined, round filling defect, usually 1 to 3 cm in diameter.
The tumors are soft and change shape with compression.(239)
(CT can confirm. See CT scan: other tumors of the colon).
Water-Soluble Contrast Enema
Volvulus and Intussusception
Sigmoid volvulus appears as obstruction that tapers to a beak at
the point of the twist, usually approximately 15 cm above the anal
verge. Mucosal folds spiral into the beak at the point of obstruc-
tion. Cecal volvulus appears as a beak like or twisted termination
at the point of obstruction in the ascending colon with a dilated
cecum high in the abdomen (Figure 11.44).
Ileocoloc and colocolic intussusception on contrast studies
demonstrate barium trapped between the intussusceptum and
the receiving bowel, forming a coiled-spring appearance.
Postoperative Complications and Anastomotic Assessment
Water-soluble contrast enemas are frequently used postop-
eratively to examine a colocolic, colorectal, coloanal, or ileal—
anal anstomosis.(240) The studies are performed by retrograde


 improved outcomes in colon and rectal surgery

Figure 11.45  Anastomotic Leak. Water soluble contrast enema shows extravasation
of contrast into the presacral space.
Figure 11.47  Normal Defecogram. Lateral radiograph is obtained with the
patient in a neutral position after a thick barium paste is placed into rectum.

Figure 11.46  Anastomotic stricture. Small bowel follow through and water Figure 11.48  Anorectal Angle. The anorectal angle is created by the intersection of the
soluble contrast enema demonstrate an ileal pouch–anal anastomotic stricture. long axis of the anal canal and a line drawn along the posterior wall of the rectum.


 limitations of colorectal imaging studies

administration of a water-soluble contrast under the weight of
gravity or by direct hand injection via a catheter inserted into the
anal canal. Radiographic findings of an anastomotic leak include
the extravasation of contrast freely into the peritoneal cavity or
into a contained cavity (Figure 11.45). Water-soluble contrast
enema is more sensitive than CT with rectal contrast.(240) Total
proctocolectomy and ileal pouch—anal anastomosis (Figure
11.46) complications include anastomotic stricture.(241–244)
Some studies have cited an anastomotic diameter of 8 mm or less
as the threshold value for diagnosing strictures that may need
dilatation procedures before ileostomy closure.(245)
Physiologic Examinations
Chronic constipation and incontinence are common complaints
with many possible etiologies. Multiple examinations are avail-
able to assess the physiology of the lower GI tract, including
defecography, anorectal manometry, balloon proctography, and
colon transit studies.
Defecography
Defecography (evacuation proctography) is a dynamic evalua-
tion of the anatomy and mechanics of defecation. A thick bar-
ium paste is deposited within the rectum. Static lateral images
are obtained with the patient in a neutral, anal contraction, and
straining position. Fluoroscopic video is then obtained during
the act of defecation. The static images allow measurement of the
anorectal angle, the angle created by the anal canal, and posterior
wall of the rectum (246) (Figure 11.47 and 11.48). As the patient
defecates, the anorectal angle should straighten and approach
180 degrees. Abnormally high or low anorectal angles suggest a
mechanical cause for the patient’s constipation. The length that
the anorectal junction descends during defecation can be mea-
sured as well. An abnormal length of descent (>5 cm) of the ano-
rectal junction can be a source of pudendal nerve damage and,
if chronic, incontinence.(247) The most common abnormal-
ity detected by defecogram is a rectocele. A rectocele is an out-
pouching of the rectum, usually along the anterior wall. Retained
barium in the rectocele can document incomplete rectal evacua-
tion. In severe cases of rectoceles, internal rectal prolapse can be
observed by defecogram. A negative defecogram can exclude such
conditions as enteroceles, sigmoidoceles, rectal prolapse, rectal
intussusception, puborectalis muscle dysfunction, and postero-
lateral pouches.
throughout the colon. A functional outlet obstruction, such as
rectal prolapsed or anismus, is suggested if there is delayed transit
time with clustering of the radiopaque markers in the rectosig-
moid colon.(246)
Anorectal Manometry and Balloon Proctography
Anorectal manometry is performed to assess rectal sensation and
motor function. The rectum is distended by a balloon. The nor-
mal response to rectal distention is contraction of the external
anal sphincter and relaxation of the internal anal sphincter. Loss
of this reflex can be detected by anorectal manometry and can
be seen in Hirschsprung’s disease or severe idiopathic constipa-
tion.(249) Balloon proctography is a similar examination where
the rectal balloon is filled with a contrast material, allowing visu-
alization of the rectum. Visual assessment of the rectum with
calculation of the anorectal angle can be performed in addition
to measurement of the anorectal pressure.(248) Some studies
suggest that balloon proctography is less sensitive than defec-
ography in detecting certain anatomic abnormalities, including
rectoceles.
ultrasonography (us)
Transabdominal Ultrasound and Intraoperative
Ultrasound (IUS)
Ultrasonography (US) utilizes sound waves to provide real time
imaging of the body. A transducer is placed on the patient that
not only generates sound waves (of a single frequency) but also
detects the reflected echoes. US can successfully image solid
­visceral organs and fluid filled structures. US is superb at differ-
entiating between cystic and solid structures, and is frequently

Colorectal Transit
Colorectal transit times can be documented by having the patient
ingest a barium meal and obtaining serial abdominal radio-
graphs. All the barium should be cleared in a normal patient in
4 days. Retained barium after 4 days confirms delayed colorec-
tal transit time.(248) An alternative method utilizes radiopaque
rings (Sitzmarkers®, Konsyl Pharmaceuticals, Ft Worth, TX) to
assess colonic transit time. Twenty four markers are ingested. The
patient is instructed not to use enemas, laxatives, or supposito-
ries for 5 days. Radiographs are obtained daily or on days 1, 3,
and 5.(249) Eighty percent of the markers should pass in 5 days
and all of the markers normally pass by the seventh day.(246, Figure 11.49  Appendicitis. Axial view of the appendix reveals a thickened and
248) The diagnosis of colonic hypomotility/inertia is suggested if hypoechoic wall. An appendicolith is represented by the hyperechoic material
there is delayed transit time and the markers are scattered evenly seen within the lumen (arrow).


 improved outcomes in colon and rectal surgery

Figure 11.50  Colon Cancer Liver Metastasis. US of the liver demonstrates an

isoechoic mass with a hypoechoic peripheral halo. This “target” appearance can
Figure 11.52  Normal Endoluminal Ultrasound.
be seen in a variety of disease processes but is a common finding in metastatic
colon cancer and hepatocellular carcinoma.

Figure 11.51  Normal Layers of Colon on Intrarectal ultrasound (Graphic

representation of 5 layers).

called to do so. The US beam will be completely reflected by

bone and sufficiently scattered by air to thwart imaging distal to
these substances. When the transmitted sound wave reflects off
a moving target, the returning echo will have a slightly different
frequency (the Doppler Effect). Doppler US capitalizes on this
principle and allows the determination of direction and veloc-
Figure 11.53  Ultrasound of uT3 rectal mass.
ity of a mobile target.(250) The most frequent application for
Doppler US is the detection and quantification of blood flow.
Specifically, Doppler US is extremely helpful in evaluating the
upper and lower extremities for deep venous thrombosis. of intraluminal gas.(251) Nonetheless, US can detect abnormal
US has many advantages. It is an inexpensive, widely available loops of bowel. Wall thickening, hyperemia, fecoliths, bowel dis-
modality that provides real time, multiplanar images with no tention, wall edema, and noncompressibility all can be detected by
radiation exposure to the patient. The US equipment is mobile, ultrasound and suggest intestinal pathology. US can be helpful in
allowing critically ill patients to be imaged within the ICU. The diagnosing a wide variety of disease processes including appendi-
structures that can be studied by US include arteries, veins, liver, citis (Figure 11.49), intussusception, inflammatory bowel disease,
spleen, gallbladder, bile ducts, pancreas, kidneys, bladder, uterus, colitis (from numerous causes), and neoplasm (Figure 11.50).
and ovaries. Transabdominal US is typically limited in its evalu- Due to the superior sensitivity and specificity of other imaging
ation of the gastrointestinal tract. Intraluminal bowel gas will modalities, US evaluation of the bowel is typically reserved for
obscure the surrounding anatomy. Therefore, patients should be situations where limitation of radiation exposure is desired (i.e.,
NPO for 4 to 8 hours before being imaged to reduce the volume pediatric and pregnant patients).

 limitations of colorectal imaging studies

Intraoperative ultrasound (IUS) can provide important infor- (a)

mation to the surgeon and is commonly used to evaluate the liver
for metastatic disease and guide the subsequent metastasectomy.
IUS is particularly useful in delineating the relationship between
hepatic tumors and adjacent vasculature.(252) Studies have
shown that IUS provides vital information to the surgeon during
the procedure that will affect surgical decision making in up to
38% hepatic metastasectomy.(251)

Endoluminal Ultrasound
Endoluminal ultrasound’s (EUS) impact on the workup for col-
orectal cancer continues to expand. Transrectal US appears to be
the most accurate imaging modality in determining the extent
of local invasion of rectal cancer.(253) EUS can delineate the
components of the intestinal wall. Images typically consist of five
rings of different echogenicity (3 hyperechoic and 2 hypoechoic)
that allow the localization of the mucosa, muscularis mucosa,
submusoca, muscularis propria, and serosa (254)) (Figure 11.51).
Colorectal tumors will appear as a hypoechoic mass that distorts
the normal bowel architecture (Figure 11.52 and 11.53). EUS can
accurately identify the specific layers of the bowel wall invasion,
thereby elucidating the tumor stage.(255) Recent studies have
shown that transrectal US has difficulty differentiating between
tumor and peritumoral inflammation, thereby producing a ten- (b)
dency to over stage a recently diagnosed cancer. EUS is often used
in conjunction with traditional endoscopy to allow direct visual-
ization of the mucosa, assess the depth of wall involvement, facili-
tate biopsy, and evaluate for pericolonic lymphadenopathy. While
EUS has the ability to detect local lymph node involvement, cross
sectional imaging (CT, MRI, or PET) is still needed to evaluate for
regional and distant metastatic disease.(255)
Nononcologic applications of EUS include the evaluation of
the colon, rectum, and anus for strictures, fistulas, and abscesses.
Transanal US is often used in the evaluation of incontinence as it
can detect defects within the internal anal sphincter, external anal
sphincter, puborectalis sling, and pelvic musculature.(254)

magnetic resonance imaging (mri)

In magnetic resonance imaging, strong magnetic fields and tar-
geted radiofrequency pulses are harnessed to map the location
of protons within the body. Depending on the specific imaging
parameters utilized, protons within fat (T1 MRI sequences), or
water (T2 MRI sequences) can be selectively displayed. Ionizing
radiation and iodinated contrast agents are not used. MRI images
are degraded by motion and the combination of bowel peristalsis
and diaphragmatic movement has traditionally limited the appli-
cation of MRI in the evaluation of gastrointestinal pathology.
(254) Ferromagnetic metals cannot be taken into the magnetic
field and therefore most surgical implanted devices have been
transitioned to MRI compatible materials. Care must still be
taken with certain implanted devices as the strong magnetic field
may cause malfunction. Confirmation of MRI compatibility with
the manufacturer is required for implanted devices such as car-
diac pacemakers, cochlear implants, spinal cord stimulators, and
basal ganglion stimulation devices. Nephrogenic systemic fibrosis
(NSF) is a disorder seen exclusively in patients with chronic renal
insufficiency that presents with diffuse systemic sclerosis with
Figure 11.54  A and 11.54B Terminal Ileitis in Crohn’s Disease. Axial (A) and
coronal (B) T1-fat saturated MRI images demonstrate mucosal enhancement
within the terminal ileum (arrow) with no enhancement in the adjacent normal
ileum (arrow head). The mucosal enhancement indicates active terminal ileitis.
particularly severe cutaneous fibrosis. In 1997, NSF was linked
to gadolinium exposure in patients with renal insufficiency. The
FDA has recently placed a black box warning on gadolinium
­containing MRI contrast agents.(256)
Technological advancement with quicker image acquisition has
reduced motion blurring and has allowed the diagnostic assessment
of the sigmoid colon and rectum (anatomically fixed structures).
(257) While MRI can be useful in the diagnosis of inflammation of
the GI tract (for example, appendicitis, Crohn’s disease, and ulcer-
ative colitis) (Figure 11.54), the largest advances have been made
in evaluation of colorectal cancer.(254) The effectiveness of MRI
is similar to CT for the initial staging of colorectal tumors.(258)
MRI is very accurate evaluating the pelvis for local rectal tumor

 improved outcomes in colon and rectal surgery

(a)

Figure 11.55  Perirectal Mass. Fluid sensitive (STIR) T2 MRI of the pelvis shows
a hyperintense mass adjacent to the rectum, worrisome for rectal carcinoma.
(b)
However, after resection, this mass was found to be a high grade liposarcoma.

extension (Figure 11.55), and has an advantage over CT in the

evaluation of tumoral invasion of the levator ani, mesorectal fascia,
internal and external sphincter muscles.(258–259) Endorectal MRI
is a promising new technique that can help evaluate the depth of
local tumor invasion. Endorectal ultrasound has been shown to be
equally sensitive and specific as our currently available endorectal
MRI and can be performed in a fraction of the time.(258, 260)
MRI is also a valuable tool in detecting distant metastatic
disease. Metastatic foci within the brain, skeleton, and liver are
readily detected with MRI. Local tumor recurrence can be dif-
ferentiated from mature fibrosis if the surgical resection was at
least 1 year prior. Unfortunately, immature fibrosis (<1 year old)
cannot be successfully distinguished from recurrent tumor with
MRI.(258, 259) (c)

nuclear medicine imaging

Positron Emission Tomography
Positron Emission Tomography (PET) has been approved by
Medicare for the diagnosis, staging, and restaging of colorectal
cancer since 2001.(261) Unlike other imaging modalities that
rely on architectural distortion, PET scans detect neoplasm
based on physiologic differences between normal tissue and
cancer cells. Malignant cells have a higher baseline metabolic
state, increased mitotic activity, and consume more glucose.
PET scans utilize the glucose analog F-18 fluorodeoxyglucose
(F-18 FDG). F-18 FDG is transported into the cell through
transmembrane glucose transporters but, unlike glucose, it
does not undergo further metabolism.(261, 262) This causes an
accumulation of F-18 FDG within the tumor cell. Fluorine-18
emits positrons that subsequently undergo annihilation when
contacted by electrons. This annihilation produces gamma
photons that are summated by specialized detectors and allow Figure 11.56  A–11.56C Comparison between CT and PET. Figure 11.56A
image generation. demonstrates multiple discrete areas of hypermetabolism within the liver on
PET scan, representing metastatic colon adenocarcinoma. Figure 11.56B shows a
The photon count and inferred amount of glucose uptake is noncontrast CT scan of the same patient. The multiple metastatic foci are nearly
reported in standard uptake values (SUVs). The SUV takes into impossible to detect without contrast. Figure 11.56C. Iodinated contrast helps to
consideration the dose of F-18 FDG injected and body surface delineate between normal hepatic tissue and hypodense metastatic disease.


 limitations of colorectal imaging studies
Figure 11.57  PET-CT. PET-CT images show a focal area of hypermetabolic activity in the presacral space, adjacent to the patient’s low anterior resection site for rectal
cancer, representing an area of recurrence. Note that this lesion may have been overlooked on the noncontrast CT.
area.(261) In general, a SUV value above 2.5 is suspicious for
malignancy but may also be secondary to an inflammatory or
infectious process.(262) Care must be taken when relying on
SUVs as they are only semi-quantitative and many variables affect
the reported numeric value. One particularly strong variable is
the serum glucose. A high serum glucose level will reduce tumor
uptake of F-18 FDG and lower SUV values. Patients typically fast
overnight and avoid carbohydrates before the procedure.(262)
Blood glucose levels are checked before the examination with a
level below 200 mg/dl desired.
PET imaging of the colon is very sensitive (>90%) but lacks
specificity (40–60%) due to physiologic bowel glucose uptake and
hypermetabolic benign lesions, including colitis and benign pol-
yps.(262) The main advantage of PET is its superiority over CT
in the detection of metastatic colorectal cancer. PET will detect
increased glucose metabolism in regional lymph nodes or dis-
tant metastatic sites (Figure 11.56) that do demonstrate enough
architectural distortion to be detected as abnormal by CT exami-
nation. PET has also been shown to be superior to CT in the eval-
uation of colorectal cancer recurrence (Figure 11.57) (263). PET
can help monitor response to chemotherapy and radiation treat-
ment but does not have the ability to detect microscopic residual
disease (262).
One of the main limitations of PET is low spatial resolution.
This problem has largely been overcome by a new technique that
allows the concurrent acquisition of PET and CT images dur-
ing a single examination. PET/CT augments the localization
of malignancy in contiguous or overlapping structures.(262)
Differentiation of tumor from infection is problematic when the
standard uptake value is only minimally elevated as regional lym-
phocytes will metabolize an abundance of F-18 FDG. Likewise,
colonic adenomas/polyps can demonstrate hypermetabolism
and be misinterpreted as a tumor. Tumors that have a low cell
density, small size, or low metabolic activity (including carcinoid
and mucinous adenocarcinoma) have a higher likelihood of a
false-negative result.(261, 262)
Gastrointestinal Scintigraphy
Nuclear medicine scintigraphy is a useful tool for the colorectal
surgeon. A biologically significant substance (RBC, leukocyte)
is labeled with a radioactive isotope that will subsequently emit
gamma radiation. These gamma photons are detected by scin-
tillation cameras and diagnostic images are generated. Nuclear
medicine scintigraphy is especially helpful in answering a specific
question. The evaluation for intraabdominal abscess, Meckel’s
diverticulum, carcinoid tumor, biliary abnormality, pernicious
anemia, and colonic transit time can be performed with radio-
isotope labeled leukocytes, technetium, octreotide, iminodia-
cetic acid, vitamin B12, and diethylene triamine pentaacetic acid
(DTPA), respectively.(264)
With the expanding use of fused PET-CT imaging, traditional
nuclear medicine scintigraphy has a limited role in the manage-
ment of colorectal neoplasia. In tumors that are known to have
high false negative PET rates (i.e., mucinous adenocarcinoma),
radioisotope labeled monoclonal antibodies may help in evaluat-
ing for occult metastatic disease or recurrence.(264, 265) While
multiple monoclonal antibodies have been approved by the FDA,
none are currently in widespread clinical use.(266)
Tc-99m red blood cell scintigraphy is a frequently utilized
examination for the evaluation of lower gastrointestinal bleed-
ing. The patient’s RBCs are labeled with the radioisotope tech-
netium-99m (employing either an in-vivo or in-vitro method)
in an attempt to identify red blood cells within the lumen of the
GI tract, thereby localizing the source of bleeding. Three criteria
are needed to confirm a gastrointestinal bleed. The radiotracer
uptake pattern should conform to bowel anatomy, increase in
intensity over time, and propagate in an antegrade or retrograde
fashion (Figure 11.58). Multiple intraabominal abnormalities,
including hepatic hemangiomas, accessory splenic tissue, or
colonic angiodysplasia, can simulate a GI bleed but these abnor-
malities will not change in location over time. A false negative
Tc-99m RBC scintigram can be secondary to a slow intesti-
nal bleeding rate or an intermittent bleed.(266) The reported

 improved outcomes in colon and rectal surgery
(a)
(b)
Figure 11.58  A and 11.58B. Lower Gastrointestinal Bleeding. Figure 11.58A
shows a single image of a Tc-99m red blood cell scintigram with a GI bleed
originating in the transverse colon, near the hepatic flexure. Figure 11.58B is taken
5 minutes later and shows the radiotracer uptake pattern conforming to bowel
and moving in an antegrade fashion towards the splenic flexure.
sensitivity and specificity of Tc-99m RBC imaging has been
reported as high as 93% and 95%, respectively.(264, 266) Tc-99m
RBC scintigraphy can detect GI bleeding rates as low as 0.2 cc/
minute (compared to 1.0 cc/minute for traditional angiography),

Figure 11.59  Percutaneous Abscess Drainage. Axial CT image demonstrates
needle placement into the large fluid/air filled abscess.
and is a sensitive tool that can help isolate the vascular territory
of a bleed and direct percutaneous or surgical intervention.(266,
267) In an unstable patient, a Tc-99m sulfur colloid can be used
to detect GI bleeding. Sulfur colloid scintigraphy requires less
time for patient preparation and image acquisition but has a
lower sensitivity for detecting gastrointestinal bleeding.
interventional radiology
Gastrointestinal (GI) Bleeding
The angiographic diagnosis of GI bleeding is based upon visual-
ization of extravasation of contrast into the bowel lumen, and a
high rate of bleeding (1 cc/min) is required to visualize extravasa-
tion.(268) Angiograms are positive in only about 50% of patients,
and a positive Tc-99m RBC scintigraphy scan within the first 5–9
minutes, makes angiography more likely to identify extravasa-
tion.(269) The two techniques used for lower GI arterial bleeding
are vasopressin infusion and embolization.
Vasopressin (pitressin) infused into the proximal SMA or
IMA causes both smooth muscle constriction and water reten-
tion. Vasopressin can control lower GI bleeding in up to 90% of
cases, and half of the patients will never bleed again. Vasopressin
requires monitoring in an ICU. Rare complications include car-
diac or digital ischemia from vasoconstriction, or hyponatremia
from water retention.(268–270)
Embolization controls GI bleeding by decreasing the arterial
pressure and flow to the point that hemostasis can occur, with-
out creating symptomatic ischemia. Large particles, Gelfoam, or
microcoils can be used. Embolization is successful in over 90%
of cases, with few instances of bowel ischemia. Rebleeding is
reported to occur in 20% of patients. Patients should be moni-
tored for bowel ischemia. Delayed ischemic colonic strictures
have been reported.(268–270)
Percutaneous Abscess Drainage (PAD)
Percutaneous abscess drainage (PAD) has played a major role in
decreasing the morbidity and mortality associated with surgical
 limitations of colorectal imaging studies
Figure 11.60  US Guided Biopsy of Colon Cancer Liver Metastasis. US image
demonstrates needle placement into hepatic tumor of uncertain etiology. This
was proven to be metastatic colon adenocarcinoma by pathology.
exploration. CT is the most appropriate modality in image guided
PAD (Figure 11.59).(271) PAD of an intraabdominal abscess is
effective with a single treatment in 70% of patients and increased
to 82% if a second drainage is performed.(272) The overall
findings from a large series of 2311 PADs report a success rate
of 80–85%.(273) Complication rates of PAD are between none
and 10%. Vascular laceration may occur and, if the vessel is small,
the bleeding will usually stop spontaneously.(274) Percutaneous
abscess drainage may be complicated by bowel perforation from
the needle or catheter transversing the bowel. If the patient devel-
ops signs of peritonitis after catheter penetration of bowel, then
surgical intervention may be required.(275)
Image-guided Percutaneous Biopsy
The majority of image-guided biopsies can be performed on an
outpatient basis. All interventional procedures can result in bleed-
ing, but this complication can be reduced by correction of any
coagulopathy before the procedure.(276) US offers the advantage
of real-time needle visualization, low cost, portable, and no ion-
izing radiation (Figure 11.60). US guidance can be problematic
in obese patients because the echogenic needle can be hard to
visualize in echogenic fat. Lesions located deep to bone or bowel
cannot be biopsied with US owing to lack of visualization of the
lesion. CT can be used to guide biopsy needles to virtually any
area of the body. CT provides excellent visualization of lesions
and allows accurate identification of organs between the skin and
the lesion.(277) Disadvantages of CT include increased cost, ion-
izing radiation, and longer procedure times. Complications of
abdominal, liver, or lung biopsy include bleeding, introducing
infection, pneumothorax, and hemoptysis. Postprocedure pneu-
mothorax may occasionally require chest tube placement and
observation in the hospital.(276, 277)
Radiofrequency ablation (RFA) and Chemoembolization
of Hepatic Metastasis
Radiofrequency ablations (RFA) of liver metastasis are per-
formed similar to image-guided needle biopsy, with the RF
probe taking the place of the needle. The RF probe is placed in
the hepatic tumor and vibrates at a high frequency, conduct-
ing heat into and ablating the tumor.(278). Studies show that
the overall 5-year survival rate for colorectal liver metastasis
treated by RF ablation is similar to surgical series (25–40%).
(279) There are no absolute contraindications, and relative con-
traindications include low platelets and coagulopathy. RFA of
hepatic tumors is associated with very low complication rates,
generally below 2%. Complications include pain, pleural effu-
sion, bleeding, and abscess formation.(278)
The treatment of certain tumors (metastatic hepatic lesions)
with intravascular delivery of chemotherapeutic agents can be
­palliative and prolong life, but is not considered curative.(280)
A wide variety of chemotherapeutic regimens are used. These
chemotherapeutic medications are usually mixed with an embo-
lic agent that slows flow and allows the drugs to remain in the
organ. Metastatic disease to the liver can also be embolized by
Yttrium-loaded microspheres that emit beta-radiation. Fulminant
hepatic failure or liver abscess formation occurs in <1% of
patients. Gallbladder infarction due to chemoembolization is rare.
(280–282)
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
12 Transanal endoscopy
Terry C Hicks
challenging case
A 60-year-old woman with a strongly positive family history
of colorectal cancer undergoes a colonoscopy. She has a 1.5 cm
pedunculated polyp snared from the transverse colon. Five days
after the colonoscopy the patient experienced two bloody bowel
movements. She presents to the emergency room with a heart
rate of 120 and a blood pressure of 100/70.
case management
You have two large bore intravenous lines started and begin rapid
infusion of 2 L of lactated Ringers. Blood is drawn for a CBC,
basic metabolic profile, coagulation studies, and type and cross
for 4 units of packed RBC. A nasogastric tube is placed and ­billous
heme negative fluid is aspirated. A proctoscopy reveals blood and
clots in rectum, but no source of bleeding.
A tagged RBC scan is obtained which is immediately positive
in the cecum. An angiogram of the ileocolic artery reveals active
bleeding in the cecum. Using a micro catheter, the interventional
radiologist is able to embolize a segmental vessel and the bleeding
ceases. The patient is transferred to the ICU for observation.
INTRODUCTION
Endoscopy is commonly used to evaluate the gastrointestinal (GI)
tract. Endoscopy of the lower GI tract may include colonoscopy, flex-
ible sigmoidoscopy, rigid proctoscopy, and anoscopy. While each of
these procedures may have associated risks, discussion of colonos-
copy will address the other procedures. This chapter will address the
technical and nontechnical issues associated with this procedure.
Colonoscopy is a procedure commonly used to diagnose and treat
colonic conditions. It is a natural extension of the colon and rectal
physical exam, and it has significant advantages over other examina-
tions of the lower GI tract. This procedure allows direct inspection of
the mucosal surface with the potential to identify and/or treat polyps,
neoplasia, vascular lesions, and inflammatory bowel disease. The suc-
cess of a colonoscopy is dependent on operator experience, patient
selection, as well as the timing and extent of the bowel preparation.
Although colonoscopy is an invasive procedure, complications
are fortunately infrequent. However, major complications associ-
ated with colonoscopy can result in significant morbidity or even
death. Serious complications can arise with either a diagnostic or
therapeutic colonoscopy and include: perforation, hemorrhage,
postpolypectomy coagulation syndrome, problems related to
mechanical bowel preparation, infections, and anesthetic mala-
dies (intravenous medications).(1)
Nontechnical Complications
Colonic complications may occur that are essentially unrelated to
the actual technical performance of the procedure. These com-
plications include patient selection, method of preparation of
the colon, and administration of medication for sedation before

and during the procedure, as well as the clinical decisions that are
made concerning those patients who are on anticoagulation.
Minimizing preventable colonoscopic complications begins
with the patient selection process. The endoscopist needs to
identify those patients who have enhanced risks for endoscopist
injury. This can usually be accomplished by obtaining an appro-
priate medical history and physical examination, along with any
necessary laboratory studies.
Before performing an endoscopic examination of the colon,
the physician must consider the patient’s general condition. The
risk of potential injury must be balanced against the anticipated
therapeutic gain, and this includes being cognizant of the patient’s
ability to tolerate injury. For example, a patient with signs or
symptoms suggestive of a colorectal carcinoma who requires a
colon evaluation, but who has recently had a myocardial infarc-
tion, may be better evaluated with CT colography or barium
enema. Consultation with a patient’s obstetrician is appropriate
to insure that the test is merited and falls within acceptable safety
guidelines for patients in their last two trimesters of pregnancy.
Other relative contraindications to a colonoscopy include large
abdominal aortic aneurysms or substantial splenomegaly.
Colorectal Preparation
Every effort should be utilized to cleanse the colon of feces and
­particulate matter before the examination as an adequate bowel
preparation is one of the most important factors in avoiding injury
and maximizing the quality of the exam. The ultimate success of the
colonoscopy depends on operator experience as well as the timing
and extent of bowel preparation. Inadequate colon preparation is
reported in approx. 25% of cases and leads to lower cecal intubation
rates and decreased polyp detection.(2–4) Other potential problems
associated with a suboptimal bowel preparation include: increased
rate of complications, longer procedural times, or the need to for
repeat examination.(4, 5)
Among the many factors that lead to inadequate bowel prepa-
rations, poor compliance due to incomplete consumption of the
preparation is the most frequent etiology.(6) Reports of poor com-
pliance are usually attributed to the patient’s intolerance of the
high volume of ingested cleansing solutions.(7) Some preparations
are associated with specific adverse effects in some subpopulations,
including those who have renal insufficiency, preexisting electrolyte
abnormalities, or congestive heart failure. The clinician must be
cognizant of the advantages and disadvantages for different bowel
preparations in order to obtain not only the best clinical exam but
also to protect the patient from complications.
The variety of colonoscopy preparations in clinical use involve
combinations of diet restriction and laxatives. As an adjunct, most
bowel preparations include a period of time during which the
patient is restricted to a clear liquid or low residue diet, to reduce the
amount of stool in the colon. However, dietary restriction by itself
 transanal endoscopy
is insufficient to adequately cleanse the colon. Current cleansing
preparations include lavage solutions (usually polyethylene glycol—
electrolyte lavage solution) and hypertonic electrolyte solutions.
Oral Lavage
Oral lavage methods have been developed to reduce the time required
for mechanical cleansing (usually only 2–4 hours are required). Oral
lavage consists of the ingestion of a large volume of osmotically bal-
anced, nonabsorbable solutions that act as a purgative, clearing the
colon of stool through mechanical forces. Polyethylene glycol (PEG)
containing preparations have become the most preferred method of
colonic preparation.(8) A meta-analysis of eight trials reported that
PEG preparations were associated with either an adequate or excel-
lent preparation in 70% of patients.(9) Unfortunately, up to 20%
of patients are unable to complete the PEG preparation because of
the poor palatability of the solution or its required large volumes.
Recently, there have been new strategies to increase the efficacy in
patient tolerability of PEG containing solutions. Recent studies
have evaluated whether or not there is increased tolerability when
using flavor versus nonflavor preparations.(10) There are also recent
reports of investigations into the use of lower volume PEG solutions
(i.e., 2 L rather than the standard 4 L), with or without the utiliza-
tion of adjunct purgatives.(11) Other variations include the addition
of adjunct purgatives (senna, magnesium citrate, or bisacodyl) in an
effort to increase the efficacy of PEG solutions.(12, 13)
To assist patients with the volume of fluid that must be ingested
some endoscopists have tried adding metoclopramide, in the hopes
that it would reduce nausea and increasing bowel motility. A study
by Brady et al. (14) (a small placebo trial) utilizing metclopramide
as an adjunct reported no significant benefits in the terms of bowel
preparation or decrease in abdominal discomfort.
Contraindication to oral lavage solutions include significant gas-
tric retention, suspected or established mechanical bowel obstru­
ction, severe colitis, or the presence of ileus.
Hypertonic Electrolyte Solutions
Salt-based agents for bowel preparation are known as saline laxa-
tives and include those containing magnesium cations or phosphate
anions. Salt-based agents work by exerting a hyperosmotic effect in
the intestines. The poorly absorbed magnesium or phosphate ions
within the small intestine result in retention of water that directly
stimulates stretched receptors and increases peristalsis.
Sodium phosphate (NaP) is one of the more commonly used
saline laxatives and is available in liquid or tablet form. This
hyperosmotic product draws fluid into the intestinal tract result-
ing in a purgative action. Proponents of the utilization of NaP
refer to studies that show that in healthy individuals the prep is
safe, better tolerated, and equally or more effective than PEG.
(15, 16) It is imperative to note that the downside of using oral
sodium phosphate solutions is the potential for significant fluid
shifts which can precipitate intravascular volume depletion.
A few cases of nephrocalcinosis with subsequent renal insuffi-
ciency have also been reported.(17) The effect seems to be age and
dose related. Additional risk factors for this unusual occurrence
include underlying renal disease, dehydration, hypercalcemia,
or hypertension with the use of angiotensin-converting enzyme
(ACE) inhibitors or angiotensin receptor blockers (ARBs).
These issues makes it imperative that (NaP) not be used in
patients with congestive heart failure, decompensated cirrho-
sis, renal failure, or those presenting with baseline electrolyte
abnormalities.(18) There is also the current concern for the
development of hyperphosphatemia. Patients who have renal
insufficiencies (familial filtration rate of <50% of normal) can
develop life threatening hyperphosphatemia. Most patients with
normal renal function find the sodium phosphate NaP prepara-
tion safe. Rejchrt and his colleagues reported on the utilization
of NaP preparations and its effects on the colonic lining. They
found the preparation induced mucosal lesions, erosions, and
aphthous lesions in up to 3% of patients.(19) They concluded
that this preparation should not be utilized for patients under-
going diagnostic evaluation for potential inflammatory bowel
­disease because it may lead to misinterpretation secondary to the
mucosa lesions induced by the preparation.(20)
As discussed previously, multiple studies have indicated the
necessity for good bowel cleansing before endoscopic evaluation, as
it adds not only to the quality of the examination, but also reduces
potential complications. At present, the choice of bowel preparation
is dependent on the clinical context, and the presence or absence
of associated risk factors. The endoscopist should be cognitive of
these issues before prescribing a colonoscopy preparation.
Intravenous Sedation
Conscious sedation reduces patient symptoms during endos-
copy, but accounts for significant risks including vasovagal reac-
tions and cardiopulmonary events. Conscious sedation can in
fact cause respiratory depression, hypotension, tachycardia, or
brachycardia.(33, 34) Patients who develop severe hypotension
or hypoxia associated with sedation are also at risk for myocardial
infarction. To reduce these risks and prevent excessive sedation, it
is important that the physician and/or nurse providing the medi-
cation carefully titrate it throughout the procedure.(35) In the
United States, it is standard to monitor blood pressure, pulse, and
oxygen saturation on a timely basis throughout the procedure. It
is also common to administer supplemental oxygen via nasal can-
nula. It is interesting to note that a prospective study of private
patients (men and women), less than one-third were willing to
undergo colonoscopy without sedation.(36)
At present, the most commonly utilized agents for colonoscopic
sedation are meperidine, fentanyl, and midazolam. Meperidine
and fentanyl are used for analgesia. Fentanyl has a shorter time
of onset and recovery, while meperdine appears to potentiate the
sedative effect of benzodiazepines. Midazolam provides an anter-
ograde amnesia and possesses a short half life, which is a distinct
advantage for the safety of the patient. Midazolam also poten-
tiates the narcotic effect and permits the reduction of narcotic
doses and their associated complications. The utilization of these
agents affects the psycho­motor function of the patient for hours,
and thus postprocedure monitoring is necessary before their dis-
charge from endoscopy unit. Some centers are now evaluating the
use of propofol (Diprivan). Propofol lacks analgesic effect but is
a rapid onset and effective sedative. It also has a shorter recovery
time. Propofol’s most serious potential side effect is sudden respi-
ratory depression, which may require intubation in order to con-
trol the airway. Therefore, utilization of this drug usually requires

 improved outcomes in colon and rectal surgery
administration by an anesthesiologist, a nurse anesthetist, or a
dedicated physician. Most endoscopy centers, with an adequate
number of procedure rooms and recovery space have not found
this drug cost-effective.
Hemodynamic depression is managed with increased intrave-
nous fluids, while respiratory depression is treated with supple-
mental oxygen and sedation reversal. Naloxone (Narcan); 0.4 mg
intravenously (or 0.2 mg intravenously and 0.2 mg intramuscu-
larily) will reverse the narcotic effect. Flumazenil (Romazicon);
0.2 to 1.0 milligrams intravenously, will reverse sedation from
Midazolam. Excessive colonic distention may produce a vasova-
gal reaction which responds to increased intravenous fluids and
decompression of colon gas. Significant bradycardia, secondary
to the sedation may require administration of atropine (0.5 mg
IV every 3–5 minutes to a dose of 3 mg).
Infectious Disease Complications
Colonoscopy can produce infectious complication by transmis-
sion of disease from patient to patient, from patient to examiner, or
from bacteremia related to the procedure. Current national recom-
mendations for mechanical cleansing of endoscopic equipment,
if followed properly, should prevent the transmission of such dis-
eases as HIV and hepatitis. Transmission of disease from patient to
examiner can also be prevented by appropriate eye, facial, and hand
protection and endoscopic suites should be equipped with goggles,
disposable aprons and gloves, or facial splash guards.
The incidence of bacteremia associated with colonoscopy has
been reported from 1 to 20%. Despite the potential risks of bacter-
emia, there are presently only five reported cases of endocarditis
associated with colonoscopy, despite the millions of colonoscop-
ies performed annually.(37, 38) The American Heart Association
(AHA) had previously recommended antibiotic treatment for
patients that were described as high-risk (patients with pros-
thetic heart valves, congenital cardiac malformations, surgically
constructed systemic pulmonary shunts, and previous history
of endocarditis). More recently, the AHA SBE prophylaxis panel
after extensive study, now recommends that the risk of antibiotic
Figure 12.1  Management of postpolypectomy hemorrhage.

complications greatly outweighs the potential for bacteremia
leading to endocarditis. They conclude that no antibiotics should
be administered for SBE prophylaxis during colonoscopy.(39)
TECHNICAL COMPLICATIONS
Hemorrhage
Hemorrhage after colonoscopy is most commonly associated
with polypectomy, but can occur with diagnostic procedures.
Hemorrhage is most frequently associated with intraluminal bleed-
ing, but can also arise from extraluminal sources, such as a mesen-
tery laceration, secondary to mechanical forces produced during
instrumentation. Splenic injury or rupture results in intraperi-
toneal hemorrhage (see miscellaneous complications section for
more details). Hemorrhage following colonoscopic polypectomy
has a prevalence that ranges between 1–2.5%, and is the most
common complication of polypectomy.(21) The hemorrhage
may be an immediate or delayed event and has been reported up
to 14 days postpolypectomy.(22) Those hemorrhages occurring
during the endoscopic procedure represent 1.5% of polypecto-
mies, and those in the delayed setting, after the completion of the
procedure represent 2% of polypectomies.(23)
Immediate hemorrhage upon transection of the pedicle of a
pedunculated polyp occurs because of inadequate coagulation
of the feeding vessels. Pedunculated polyps, >1 cm in diameter
with fixed stalks have the highest risk for immediate hemorrhage,
as they have substantial vessels.(24) The utilization of the cold
biopsy technique can result in capillary bleeding, which is usually
of no clinical significance. The corollary to this observation is that
significant bleeding can occur with cold or hot biopsy techniques
if the patient is being treated with anticoagulants or antiplatelet
medications. Though most postpolypectomy hemorrhage is self-
contained, the endoscopist must respect the clinical potential of
the bleeding to produce enough hypotension as to cause stroke,
myocardial infarction, or frank shock.
With persistent and significant ongoing bleeding, the endo-
scopist my have difficulty in locating the residual stalk. This
 transanal endoscopy
makes it imperative that the source be quickly controlled at the
onset of bleeding before the field being obscured by blood and
clot. Initially, the endoscopist can utilize the polypectomy snare
to regrasp the stalk and hold it taut for approximately 15 minutes
without the utilization of any electrocautery. This maneuver if
unsuccessful can be performed again and this usually suffices to
control the bleeding. Other options are: the placement of clips or
detachable snares. If these are not available, the residual stalk can
be injected with 1–10,000 solution of epinephrine plus saline, or
the base of the residual stalk can be recoagulated without enough
energy to transect the stalk. Many endoscopists now suggest that
if one identifies a potentially significant polyp that might produce
postpolypectomy bleeding (i.e., large in size or patient’s condition
mandates they continue anticoagulation), that the utilization of
clips or a detachable snare in advance of the resection may be
beneficial. It should be noted that if one elects to use electrocau-
tery after initial snaring, that they should be careful to prevent full
thickness injury at the site.
Delayed hemorrhage occurs when the retained scar from a
polyp site separates prematurely from the coagulation bed, lead-
ing to hematochezia. This type of bleeding usually occurs within
2–15 days of the after the procedure, typically within the first
7–10 days. Postpolypectomy bleeding can be significant enough
to require in-hospital fluid resuscitation and potential therapeu-
tic intervention. These patients usually have arterial bleeding, and
pass bright red bloody bowel movements spaced at close intervals
(i.e., 30–60 minutes).(25) The active bleeder (after appropriate
resuscitation) may benefit from a prompt colonoscopy without
bowel prep to identify the site of bleeding. If the bleeding site is
located it can be treated with judicious multipolar cautery, injec-
tion of epinephrine solution, detachable snare, or placement of
hemoclips. Often times, it is clinically difficult to determine if the
hemorrhage has ceased because the hematochezia may continue
for several hours afterwards. If the hemorrhage appears persistent,
despite local efforts or if the patient needs urgent intervention,
the location of the active bleeding may be identified with a tagged
RBC scan.(26) If the scan is positive, arteriography can confirm
the bleeding location and offers potential treatment modalities
for either selective arterial vasopressin infusion, or emboliza-
tion. The choice depends upon the patient’s clinical history and
­presentation as well as the skill and experience of the radiogra-
pher. Figure 12.1 describes the authors’ and editors’ management
algorithm for postpolypectomy bleeding.
Prophylactic techniques during polypectomy may decrease the
incidence of postpolypectomy bleeding.(27) During the tech-
nique of taking a large polyp, some endoscopists use a saline inter-
mucosal lift or an epinephrine solution injection into the stalk of
the polyp in efforts to control hemostasis. Detachable snares and
clips have also been used with a similar goal in mind. Although
successful, even in skilled hands, clips may slip or transmit cur-
rent if cautery makes contact with the metal. Detachable snares
may slip from their initial position, or if pulled too tight can cut
through the base of the polyp, leading to the problem that one is
trying to prevent. The absence of national guidelines concerning
the prophylactic approaches to postpolypectomy bleeding, makes
each endoscopist responsible for evaluating the clinical situation
and being cognitive of his level of expertise.
Table 12.1  Anticoagulant recommendations.
After Diagnostic After Therapeutic
Drug Before Procedure Procedure Procedure
Aspirin Continued or Continued or Restarted 5–7 days
stopped 7 days started day of after
prior procedure
Clopidogel Held for > 7 days Restarted Restarted 7 days
prior day after after
procedure
Warfarin Held for > 3 days Restarted Restarted 1–5 days
prior and check day after after
PT procedure
Note: PT Prothrombin time.
Another factor in postpolypectomy hemorrhage relates to the
management of patients on antiplatelet agents or anticoagulants.(28,
29) The American Society for Gastrointestinal Endoscopy has rec-
ommended that aspirin need not to be stopped before polypectomy
as there is insufficient evidence supporting an increased risk with
its utilization.(30) However, many endoscopists will hold a patient’s
aspirin for 7 days if their indication for taking aspirin is weak. If the
patient can tolerate it, the author and editors withhold clopidogrel
(Plavi®, Sanofi-Aventic, Bridgewater, NJ) for a minimum of 7 days
before the colonoscopy and hold warfarin for a minimum of 3 days
before the procedure and check a prothrombin time (PT) before the
colonoscopy.(31) Therapeutic procedures are usually safe with an
INR of <2.(32) If the patient’s INR is above this level, the procedure
may be delayed until the INR is lower or if the anticipated need
for a therapeutic procedure is low (e.g., a screening indication) a
diagnostic procedure may be performed with the understanding
that if significant lesions are identified, therapeutic maneuvers (i.e.,
biopsy or polypectomy) will be deferred.
Patients who cannot tolerate reversal of anticoagulation (a
determination usually made by the patient’s cardiologist or neu-
rologist) can often be managed with a bridging with enoxaparin
sodium (Lovenox®, Sanofi-Aventic, Bridgewater, NJ) or consid-
ered for alternate procedures such as CT colography.
Recommendations for restarting anticoagulation or antiplatelet
agents postpolypectomy are difficult clinical decisions that must
be based on the patient’s risk-benefit ratio, (i.e., the risk of stroke,
or coagulation of cardiac stents versus the risk of postpolypectomy
hemorrhage). Unfortunately, there is little prospective data to sup-
port recommendations. The author and editors restart these medi-
cations at their normal daily dose the day following a diagnostic
procedure. Recommendations after a polypectomy depend on the
size and number of polyps removed and the level of anticoagula-
tion at the start of the procedure. Warfarin is ­usually started at the
normal daily dose, 1–5 days after the procedure, while clopidogrel
is restarted 1 week after the procedure.(32) Anticoagulant recom-
mendations are summarized in Table 12.1.
Perforation
The most serious complication of colonoscopy is overt perfo-
ration.(40) Perforation can result from mechanical forces dur-
ing colonoscopic insertion or from barotrauma during colonic
insufflation, or during the process of polyp removal. Perforation

 improved outcomes in colon and rectal surgery

Table 12.2  Colonoscopy perforation rates. significant loop, allowing the shaft of the scope to make a lacera-
Author, Year
tion in the bowel wall, away from the tip of the scope, which may
(Reference) Colonoscopies, n Perforations, n (%) Setting go on unrecognized. Significant clinical experience, along with
judgment and good technique, serve as the best preventative tools
Lo and Beaton, 26,708 12 (0.045) University, against a perforation.(50, 51)
1994 (44) teaching
Farley et al., 57,028 43 (0.075) Mayo clinic,
1997 (43) teaching
Miscellaneous Complications
Anderson et al., 10,486 10 (0.19) Mayo clinic,
Though the major complications associated with colonoscopy
2000 (44) teaching are hemorrhage and perforation, there exists a large body litera-
Araghizadeh 34,620 31 (0.09) Ochsner ture that has reported rarely encountered complications. These
et al., 2001 (45) Clinic, include incarceration of the colonoscope within an inguinal
teaching hernia, (52) cecal volvulus with subsequent perforation, (53)
Korman, et al., 116,000 37 (0.03) ASC, private ischemic colitis, (54) aortic thrombosis in a patient with Bechcet’s
2003 (46) practice syndrome, (55) and splenic injury (56).
Cobb et al., 43,609 14 (0.032) Teaching There have been approximately 59 clinical reports which
2004 (47)
detail 67 cases of splenic injury, following diagnostic or thera-
Lqbal et al., 78,702 66 (0.084) Mayo clinic,
2005 (48) teaching
peutic colonoscopy.(56, 57) The authors note the most likely
Levin et al., 16,318 15 (0.09) Kaiser
etiology of splenic injury is related to the performance of the
2006 (49) Permanente procedure rather than any therapeutic maneuver. It is theorized
that the mechanism of injury is thought to be excessive traction
on the splenocolic ligament or adhesions. This theory has been
occurs in 0.6% to 0.8% of diagnostic procedures and 0.5% to confirmed by laparotomy in several of the reported cases. It is
3% (See Table 12.2).(41, 42) Perforation is diagnosed during the interesting to note that in most of the injuries, the endoscopists
procedure by observation of extraluminal fat or other intraab- felt the procedure had been performed without difficulty. The
dominal contents (e.g., small bowel, liver) via the colonoscope. presentation for these injuries span between 6–24 hours, and
These patients usually report immediate pain and demonstrate vary from vague abdominal pain of the left upper quadrant,
signs of peritoneal irritation. Patients that develop symptomatol- with mild orthostatic hypotension, and a decreased hematocrit
ogy postprocedure vary from, asymptomatic free intraabdomi- to severe hypotension and shock. It is suggested that an abdomi-
nal air, a tense abdomen, or florid peritonitis and sepsis. Patients nal CT scan is the most helpful diagnostic test as it may show a
presenting with localized symptoms can be observed and treated splenic laceration, with free intraperitoneal blood or a splenic
with intravenous fluids, antibiotics, and bowel rest.(43) Patients hematoma. Most of the cases, required surgery, and the patient’s
who present with or develop signs of generalized peritoneal irri- overall condition dictated whether an emergency intervention
tation during observation, should receive a laparotomy. Repair was necessary. Observation and conservative management was
or resection of the perforation is performed with or without a rarely successful. Awareness of the potential for splenic injury
diverting ostomy. An algorithm for the management of colono- during colonoscopy is important as it may help avoid any delay
scopic perforations is presented in Figure 12.2. in diagnosis. Unfortunately, these cases are so rare that no iden-
It is important to remember that a perforation can come from tifiable risk factors have been documented that potentially could
an unsuccessful encounter with the colon wall with the tip, help prevent this complication.
the deflection bend, and/or the shaft of the colonoscope. The Patients with reducible hernias, merit additional attention by
inexperienced examiner can drive the tip of the scope through the endoscopist who must consider the benefits of a diagnostic or
a large diverticulum; or may, while advancing the scope form a therapeutic procedure versus the potential for injury or the delay

Figure 12.2  Management of colonoscopic perforation.


 transanal endoscopy
until the hernia is repaired. For patients with reducible inguinal
hernias, the procedure can be performed with general pressure
on the hernia sac during the colonoscopy or with the utilization
of a truss. Should the colonoscope become incarcerated in an
inguinal hernia, a “pulley” technique has been described where a
relatively large easily graspable colonoscope loop is created within
the hernia sac and then is withdrawn over the pulley “hand” one
limb at a time.(52) Development of a cecal volvulus, may occur
with a hypermobile cecum.(53)
Postpolypectomy Syndrome
The postpolypectomy syndrome is believed to result from a
transmural burn to the colonic wall and usually presents with
a syndrome similar to that of diverticulitis.(58) This represents
the second most common polypectomy complication with rates
ranging from 0.5% to 1%.(59) Usually this complication occurs
in the thin right-sided bowel after removal of a sessile polyp or
performance of a hot biopsy. It is felt that the factors leading to
this syndrome include the utilization of high cumulative quality
and longer duration of electrocautery. It is also possible for the
electric current to enter the mucosa opposite the polyp if the tip
of the polyp is allowed to touch the opposing wall during the
application of the cautery. Moving the polyp back-and-forth dur-
ing cautery may dissipate the current. This syndrome is usually
seen in sessile polyps that are >2 cm in diameter.(60)
The patients may present within hours of the procedure but
some may not show some significant symptomology until 5–6
days postprocedure. Patients usually present with pain which
may or may not include fever, an elevated white count, and local-
ized tenderness. Initial studies include plain x-rays or a CT scan,
which confirm by definition an absence of free air. Patients are
started on broad spectrum antibiotics and bowel rest, then most
importantly patients are examined over appropriate intervals to
make sure there is no progression from the localized tenderness
to frank peritonitis.(61) Fortunately, most of the patients that are
properly managed progress to recovery without surgical inter-
vention, and they can be discharged when their pain has resolved,
and their white blood cell count has normalized. Prevention of
postpolypectomy syndrome aided by adherence to the previously
described guidelines for a safe polypectomy.
Proctoscopic Perforations
Proctoscopic perforations are rare, serious complications of
intestinal endoscopy.(62) Nelson et al. reported only three per-
forations in 16,325 proscopic exams.(63) The injury most com-
monly occurs when the bowel wall has been weakened by disease
such as colitis, a rectal tumor, or constricting lesion. The line of
force during insertion guides the scope to the anterior rectal wall
where the usual site of injury is located between the peritoneal
reflection and the rectosigmoid junction.(64) The perforation
is usually recognized as the scope enters the peritoneal cavity or
the endoscopist encounters the perirectal fat or local bleeding.
(52) Significant rectal trauma with a rectal perforation requires
operative treatment. Most authors believe that delayed treatment
increases the mortality from 8% to 20%.(65) The major mor-
bidity and mortality are associated with the fact that the proxi-
mal colon typically is not mechanically cleansed. The treatment
involves resection of associated pathology, repair of the perfora-
tion site, rectal washout, pelvic drainage, and a diverting colos-
tomy (see chapter 35).(66)
Summary
Training, experience, and conservative technique help to mini-
mize complications associated with endoscopic procedures of the
colorectum. Prompt recognition and appropriate management of
complications help to minimize the patient’s morbidity.
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
13 Laparoscopic colorectal surgery
James W Fleshman and Jonathan S Chun
CHALLENGING CASE
A 28-year-old male is undergoing an ileocolic resection for Crohn’s
disease. During insertion of a right lower quadrant (RLQ) trocar, sig-
nificant bleeding is observed from the right lower retroperitoneum.
MANAGEMENT
It appears that the right iliac vein has been injured by the trocar. A
Babcock clamp is used to temporarily occlude the bleeding using
direct pressure. The anesthesia personnel are informed of the pos-
sibility of significant blood loss. While pressure is continued by an
assistant, the surgeon rapidly opens the abdomen using a vertical
midline incision. With a retractor in place, the Babcock is replaced by
the surgeon’s hand. With continued tamponade, proximal and distal
control of the vessel is obtained. The venotomy can now be repaired
using vascular techniques. It is usually not possible to repair a major
vascular injury with laparoscopic techniques. If proximal and distal
control can be obtained an experienced laparoscopic surgeon may
attempt the repair, but the threshold for opening should be low.
INTRODUCTION
The rising demand for laparoscopic techniques for colorectal surgery
arises from a number of purported benefits, including a reduction
in postoperative ileus, decreased pain, earlier recovery, fewer adhe-
sions, and smaller incisional hernias. This enthusiasm, however,
has been tempered by, among other things, the long learning curve,
increased operative times, and concerns about the oncologic out-
comes of laparoscopic resection for curable colon cancer. Concern
over cancer implants in trocar sites led to a temporary national
moratorium on laparoscopic resection for colon cancer from 1994
to 2004, and multiple national surgical societies called for these pro-
cedures to be performed only under the ­auspices of controlled trials.
A number of prospective, randomized trials, including the Colon
carcinoma Laparoscopic or Open (COLOR), Conventional versus
Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC),
and Clinical Outcomes in Surgical Therapy (COST) studies, have
helped address some of these concerns and delineate some of these
advantages and disadvantages.(1–7) This chapter will address some
of these concerns and address how best to optimize outcomes for
laparoscopic surgery in various colorectal disease processes.
ADVANTAGES
Postoperative pain and suppression of pulmonary function are
well-known sequelae of abdominal surgery. While physician bias
and patient expectations make a truly objective assessment of
pain difficult, multiple prospective, randomized trials have found
a reduction in narcotic requirements in patients undergoing
laparoscopic colectomy.(5, 6, 8) In the COST trial, patients who
underwent successful laparoscopic resections had decreased use
of both oral and intravenous analgesics.(1)
In an attempt to document improved pulmonary function
in patients undergoing laparoscopic surgery for colon cancer at

the Cleveland Clinic, preoperative and postoperative spirometry
was performed every 12 hours postoperatively in 55 patients
­randomized to the laparoscopic surgery group and 54 patients
in the open surgery group.(5) These measurements consisted
of an 80% recovery of baseline forced vital capacity and forced
expiratory volume in-second from each patient. The median
recovery for the laparoscopic group was 3 days vs. 6 days in the
conventional group. Schwenk et al. had similar results in a simi-
larly designed trial.(8) These results suggest a reduction in post-
operative pain and quicker recovery of pulmonary function in
patients undergoing laparoscopic colectomy.
Reduction in postoperative ileus is another proposed major
advantage of laparoscopic surgery. Time to recovery of bowel func-
tion, either flatus or tolerance of food, and time to bowel move-
ment are surrogate markers for the length of the postoperative ileus
most patients experience after abdominal operations. Virtually all
publications, whether retrospective or prospective, have shown a
statistically significant reduction in the time to recovery of bowel
function. The advantage appears to be 1–2 days in these studies. The
mechanism by which ileus is reduced is unknown, but may relate to
decreased bowel manipulation, decreased intestinal exposure to air,
exposure to the protective effects of carbon dioxide pneumoperito-
neum, or reduced narcotic demands from a smaller incision.
The biases of the treating physician and the higher expecta-
tions of patients undergoing laparoscopic surgery make it diffi-
cult to accurately and reliably determine the true time to ileus
resolution. Investigators have, therefore, sought to more formally
evaluate the return of bowel function. Canine and porcine mod-
els have looked at intestinal myoelectric activity as well as radio-
nucleotide techniques in animals that underwent laparoscopic
resection.(9–11) These studies confirmed a quicker return of
bowel function following laparoscopic vs. open resection.
The combination of reduced ileus, decreased pain, and quicker
recovery of pulmonary function would logically add up to a reduced
length of stay for patients following laparoscopic resection. This benefit
appears to be a 1–2 day advantage among patients undergoing laparo-
scopic resection. The introduction of clinical pathways has been par-
ticularly effective and more reliable in patients undergoing minimally
invasive approaches.(12, 13) Early ambulation, early feeding protocols,
and early switch to nonnarcotic oral analgesics have reduced length of
stay for laparoscopic and open procedures. “Fast-tracking” has shown
that a 2 day stay after laparoscopic or open colectomy is possible.(14)
This may be useful, as patients get used to transferring in-hospital care
to home care and become invested in the short hospital stay.
Though it is widely accepted that laparoscopic surgery results in
fewer adhesions than open surgery, this is difficult to quantify in the
context of a clinical trial. A recent observational study by Dowson
et al. however, looked at 46 patients (13 laparoscopic and 33 open)
who underwent laparoscopy after a previous colectomy. They
found a statistically significant difference in adhesions between the
two groups, with the laparoscopic group having a lower score.(15)
 laparoscopic colorectal surgery
While this study was limited due to its small sample size, it does
confirm long-held beliefs about decreased adhesions after laparo-
scopic vs. open surgery, which should help to make later reopera-
tions safer. In the past, 3-stage operations for inflammatory bowel
disease were felt to be a disadvantage to both the surgeon and the
patient. However, laparoscopic total abdominal colectomy and
ileostomy to remove the inflamed ulcerative colitis colon, wean
steroids, and improve nutrition can be performed without risking
increased adhesions at the time of ileal pouch construction and
completion proctectomy. The time between these two procedures
can also be reduced using laparoscopic approaches.
Fertility, especially in females, is an issue after pelvic surgery,
particularly restorative proctocolectomy. Multiple studies have
suggested that fertility is adversely affected in women undergo-
ing restorative proctocolectomy.(16–18) This is likely related to
adhesions in the pelvis causing scarring of the Fallopian tubes.
Laparoscopy, with its decreased adhesion formation, may offer
benefits in preserving fertility in reproductive-age females.
Obesity and a large amount of visceral fat can make laparoscopic
colorectal procedures particularly challenging. The associated
comorbid illnesses often associated with obesity, however, would
seem to make this group of patients the ideal group to benefit from
laparoscopy. Delaney et al., in a case-matched comparative study
of patients with a body mass index >30, found no difference in
median operating time, complications, readmission, or reopera-
tion rates.(19) The median length of stay, however, was significantly
shorter (3 vs. 5.5 days) after laparoscopic colectomy. Twenty-eight
patients did require conversion, but the lengths of stay, complica-
tion, readmission, and reoperative rates were no different than for
patients undergoing open colectomy.
Senagore et al. studied a series of 260 patients and compared
outcomes between patients with a BMI above 30 and those with
a BMI below 30 undergoing segmental colectomy.(20) The obese
group had a significantly higher rate of conversions (23.7% vs.
10.9%), longer operative times (109 minutes vs. 94 minutes),
higher morbidity rate (22% vs. 13%), and a higher anastomotic
leak rate (5.1% vs. 1.2%). While this increase in complications
paralleled those in obese patients undergoing open colectomy,
Senagore et al. concluded that laparoscopic colectomy is feasible
and safe, with the main benefit of a shorter hospital stay.
While operative times are longer in obese patients, the use
of a hand-assist device may offer the surgeon a useful tool to
cut down these times, particularly in this challenging group of
patients. Marcello et al. found that the use of a hand-assist device
allowed for the more efficient completion of technically chal-
lenging and complex procedures while preserving the benefits
of a laparoscopic approach.(21) The average BMI of patients in
their study was only 28.1 in the hand-assist group vs. 26.3 in the
straight laparoscopic group. While their results cannot be used
to definitively state that a hand-assisted approach is superior in
obese patients, they do suggest that it could be a useful tool to
overcome the challenge of completing laparoscopic procedures
on these patients.
DISADVANTAGES
A number of challenges have prevented laparoscopic colorectal
surgery from becoming more widely accepted and utilized by sur-
geons. Most general surgeons perform fewer than 50 segmental
colon resections per year. Laparoscopic colectomy, unlike laparo-
scopic cholecystectomy, requires working in multiple quadrants
of the abdomen, making depth perception and proprioception
more difficult. Several studies have evaluated the learning curve
for laparoscopic colectomy and suggested that this curve ranges
from 20–50 cases, but may be as high as 150 before the surgeon
is able to handle all eventualities during a laparoscopic colec-
tomy. The standardization of technique required for entry into
the COST trial resulted in no detriment in oncologic outcomes
even though the study was undertaken during early laparoscopic
experience and the conversion rate was 20% (25% first half to
19% second half).(22–24)
The CLASICC trial, which was a prospective, randomized trial
comparing laparoscopic and open resection of both colon and
rectal cancer in the United Kingdom, also required that surgeons
perform at least 20 laparoscopic resections in order to enter the
study.(2) Even with this level of experience, the rate of conversion
decreased from 38% to 16% over the course of the study—July
1996 to July 2002. This suggested that 20 cases were likely not
enough to reach the plateau of the learning curve. The COLOR
trial also highlighted the value of surgeon volume in improving
patient outcomes.(3) In this trial out of Europe, the median oper-
ative time for high-volume (>10 cases/year) vs. low-volume (<5
cases/year) hospitals was 188 minutes vs. 241 minutes. Conversion
rates were 9% with high-volume groups vs. 24% for low-volume
groups. High-volume groups resected more lymph nodes, had
fewer complications, and shorter hospital stays, but there was no
difference in oncologic outcomes.
Operative times are generally longer with a laparoscopic
approach. This difference is approximately 40–60 minutes
longer for the laparoscopic technique depending on the portion
of colon removed (left > right). While operating times decrease
with surgeon experience, they do not reliably decrease to the level
of an open approach. The use of a hand-assist device may be a
viable solution to decrease the operative times while still main-
taining the benefits of a laparoscopic approach. A multicenter,
prospective, randomized trial by Marcello and colleagues, com-
paring short-term outcomes of left/sigmoid colectomies and
total colectomies with a hand-assisted approach vs. a straight
laparoscopic approach showed a statistically significant decrease
in operating times with a hand-assisted approach (reduced by
33 minutes for sigmoid colectomy, reduced by 57 minutes for
total colectomy).(21) They also found no differences in the time
to return of bowel function, tolerance of diet, length of stay,
postoperative pain scores, or narcotic usage between the two
groups. The MITT Study group did not include right colectomy
since this procedure is routinely performed via a straight lapar-
oscopic or laparoscopic-assisted approach in the same time as
an open operation.(21)
TREATABLE CONDITIONS
Colon Cancer
The treatment of colorectal cancer has been among the most con-
troversial topics in the discussion surrounding the application of
laparoscopic techniques to colorectal surgery. This controversy
centered on early reports of cancer implants at trocar and inci-
sion sites and the fear of an inadequate oncologic resection. While

 improved outcomes in colon and rectal surgery
later studies suggested that the incidence of wound implants was,
in fact, no greater than in open surgery when performed by expe-
rienced surgeons, the controversy was one of the main factors that
resulted in a call for a moratorium on laparoscopic resection for
colon cancer outside of the auspices of a randomized, controlled
trial.(25, 26) This resulted in a variety of randomized, controlled
clinical trials which served to put to rest many of these concerns
and help delineate the true advantages and disadvantages of a
laparoscopic approach.(1–5, 8, 27)
The first large single-center randomized controlled trial was
published by Lacy et al. in 2002, with a median follow-up of 39
months.(4) They, in fact, reported a higher cancer-related survival
for the laparoscopic group. While there was no difference between
the laparoscopic and open groups in Stage II cancers, they reported
a significantly improved survival in the laparoscopic group for Stage
III cancers. The results of the COST trial, which consisted of nearly
900 patients randomized to open or laparoscopic colon resection,
showed no difference in overall or disease-free survival between the
two groups.(1, 28) It also did not report the same advantage for
Stage III patients that Lacy et al. did. As Fleshman et al. point out,
the survival advantage that Lacy and colleagues reported may be the
result of an underpowered subset analysis. The theory that the sur-
vival advantage was due to some physiologic benefit of laparoscopy
is not borne out by the results of the COST trial.(28) Reassuringly,
the COST trial reported only two wound recurrences in the laparo-
scopic group, and one in the open group. The CLASICC trial out
of the United Kingdom also showed similarly reassuring results,
though the rate of conversions was higher.(2) The meta-analysis of
these trials by Bonjer et al. confirms the equivalence of open and
laparoscopic treatment of colon cancer.(29)
The results of these large, multicenter, randomized trials illus-
trate a number of important points in maximizing the outcomes
for laparoscopic colon resection. The importance of surgeon expe-
rience and judgment cannot be overstated. The consequences of
using laparoscopic resection for potentially curable malignan-
cies as “learning cases” are potentially devastating to the patient.
Strict adherence to oncologic principles, just as in open surgery, is
paramount, and the dangers of sacrificing these principles in the
name of a minimally invasive approach are obvious. The impor-
tance of rigorously testing new techniques under the auspices of
a randomized, controlled trial is also highlighted by these results.
The controversy and emotion that arose over the initial reports
of wound implants following laparoscopic colectomy have been
laid to rest by the results of these multiple trials. It is safe to say
that laparoscopic colon resection for cancer, when guided by the
proper principles, is as safe as open resection, with a number of
tangible benefits to the patient.
Endoscopically unresectable “benign” polyps, at first glance,
would appear to be an ideal case for a laparoscopic resection by a
surgeon who is still on their “learning curve.” However, multiple
authors have reported that upwards of 18–22% of these “benign”
lesions are found to have adenocarcinoma on final pathology.
(30–32) Large, flat lesions with high-grade dysplasia are more
likely to have cancer present and these criteria should guide the
surgeon in their decision making. Thus, a surgeon with little
experience with laparoscopic resection should approach these
cases with great caution. It is vital that these cases be approached

as formal cancer operations, with strict adherence to the usual
oncologic principles.
INFLAMMATORY BOWEL DISEASE
While Crohn’s disease presents its own unique set of challenges for
a minimally invasive approach, it can also provide a unique oppor-
tunity. In severe Crohn’s disease, severe inflammatory changes in
the mesentery, the presence of abscesses or fistulae, and the dif-
ficulty in assessing bowel involvement are all challenges that need
to be overcome by the surgeon. Isolated terminal ileal disease, how-
ever, would seem to be an ideal setting for a minimally invasive
approach, especially for the relatively inexperienced laparoscopist.
The high incidence of reoperation in Crohn’s patients makes lapar-
oscopy for the initial surgery an appealing option. While rand-
omized, controlled trials are scarce, multiple recent studies support
laparoscopy as a viable option in many cases.(33–39)
The advantages associated with a laparoscopic approach in
Crohn’s disease are the same as those seen in the previously
described cancer trials. Resolution of ileus, resumption of diet,
postoperative pain, and length of stay were all improved with a
laparoscopic approach. In a prospective, randomized trial from
Milsom et al. of patients undergoing open or laparoscopic ileocolic
resection for refractory Crohn’s disease, the pulmonary function,
morbidity, and length of stay were all improved in the short-term
with a laparoscopic approach.(40) These studies support the use
of laparoscopy in Crohn’s disease, even, in the right setting, for the
inexperienced laparoscopist. As always, the surgeon’s judgment is
paramount, and there should be a low threshold to switch to an
alternate approach in the right situation. There is no difference in
recurrence of Crohn’s disease between patients treated by a lapar-
oscopic or open surgical approach.(37)
Ulcerative Colitis
The slow acceptance of laparoscopic total proctocolectomy revolves
around a couple of factors. First, the early reports of laparoscopic
total colectomy were unfavorable. The Cleveland Clinic Florida
group published several reports of their results with laparoscopic
proctocolectomy for ulcerative colitis in the early 1990s.(41, 42)
They reported longer operative times and higher blood loss than
in the open group without the desired benefits. At that time, the
authors discouraged the laparoscopic approach to total colectomy.
These initial reports highlight the importance of the aforemen-
tioned learning curve. As surgeons have gained experience with
segmental resection, and as technology has advanced, the role of
laparoscopic total colectomy for inflammatory bowel disease is
being reevaluated and is gaining wider acceptance.
More recent reports support the use of laparoscopy for total colec-
tomy and proctocolectomy with and without ileoanal pouch con-
struction, with the same advantages for laparoscopy for segmental
resections. While some groups have performed laparoscopic total
colectomy on an urgent basis for patients with refractory colitis, it
is not routinely recommended for those patients with toxic colitis.
(43) A recent study from Chung et al. (44) compared their results of
a laparoscopic or open approach to total abdominal colectomy for
severe colitis and its impact on subsequent restorative proctectomy.
They found that patients undergoing a laparoscopic approach had
a faster resumption of diet, less narcotic usage, shorter hospital
 laparoscopic colorectal surgery
stays, and a shorter time to subsequent restorative proctectomy and
ileostomy takedown. The rate of complications between the lapar-
oscopic and open groups was similar. Stewart et al. showed that
accelerating doses of immune suppressants and steroids resulted
in higher rates of complications. Thus, utilization of laparoscopoic
abdominal colectomy as the initial operation to treat severe ulcera-
tive colitis, with few adhesions and quicker arrival to the final goal
of reconstructive surgery, is a good alternative to continued medi-
cal therapy in some cases.(45)
Laparoscopic total colectomy and proctocolectomy are techni-
cally challenging operations with 3 to 5 hour operative times. The
use of hand-assisted techniques may be a way to cut down on this
time while still realizing the benefits of laparoscopy. Rivadeneira
et al. in a comparative study from the Lahey Clinic, compared the
hand-assisted approach to conventional laparoscopy in patients
undergoing laparoscopic proctocolectomy (10 HAL, 13 standard
laparoscopy).(46) The operative times decreased in the HAL group
(mean 247 minutes), while remaining constant in the laparoscopic
group (mean 300 minutes, p < 0.05) over the course of the study.
There was no disadvantage in terms of bowel function, length of
stay, or outcome in this study.
STOMA CREATION
The creation of a stoma can be an ideal scenario in order for a sur-
geon to gain experience in laparoscopic colorectal surgery. It is an
excellent way to achieve the benefits of minimally invasive surgery
while not dealing with the same ramifications as ­discussed with sur-
gery for resectable colon cancer. There are studies that have shown
that laparoscopic stoma creation is a viable alternative to an open
approach, with benefit shown in several studies in both morbidity
and mortality.(47, 48) The key, just as in open surgery, is to ensure
that the limbs of the stomas are oriented properly and that the fas-
cial opening is adequate in order to preserve the blood supply. Also,
adequate mobilization of the bowel in order to eliminate tension
on the stoma is critical. In particularly obese patients, the surgeon
should give consideration to a divided loop-end stoma. By leaving
the stapled closed distal limb within the abdomen and delivering
only the proximal functioning end through the fascia, less tissue
needs to be brought through the abdominal wall opening. However,
when creating an end stoma, it is critical to ensure that the proximal
limb is opened. Measures such as marking proximal and distal limbs
of bowel with sutures or clips, insuflating air into the distal bowel
via the anus, or performing flexible endoscopy of the stoma are rou-
tine procedures in many center to minimize this occurence.
Potential complications of laparoscopic stoma formation
include those related to laparoscopy itself—including insuffla-
tion needle or trocar injury, air embolism, arrhythmias, CO2
intolerance, and subcutaneous emphysema—and those related
to laparoscopic colorectal surgery in particular. These particular
complications mostly relate to unfamiliarity with the anatomy
as seen through the laparoscope and include ureter, iliac, and
mesenteric vessel injury, as well as improper orientation of the
limbs of the stoma. As with all laparoscopic surgery, it is critical
not to retract or grasp out of the field of view in order to avoid
any collateral injury that is not immediately recognized.
If tension is noted on the loop of bowel selected for the stoma
site, further mobilization may be of benefit to release the bowel or
colon from the retroperitoneal fixation. This should also reduce
the incidence of retraction and stricturing at the stoma site. A
particular skill needed in the performance of laparoscopic stoma
construction is the knowledge of bowel/colon anatomy and rela-
tionships of the intestine to adjacent structures as well as vascular
anatomy to provide adequate blood supply even to a stoma pulled
through a thick abdominal wall. Thus, even though considered a
basic laparoscopic case, a certain level of colorectal surgical skill
is needed.
DIVERTICULITIS
Laparoscopy for diverticulitis, while not fraught with the onco-
logic ramifications of colorectal cancer, presents its own set of
challenges, both in the elective and the acute setting. The fibrosis
associated with recurrent disease in the elective setting, and the
inflammatory changes in the acute setting present their own set
of technical issues, and the inexperienced laparoscopist in partic-
ular should proceed with caution and retain a low threshold for
conversion to an open approach or a hand-assisted approach.
As laparoscopy gains more popularity in the management of
acute intraabdominal processes like appendicitis or perforated
peptic ulcers, the question arises as to whether it may be of benefit
in management of diverticulitis in the acute setting. The mainstay
of treatment for generalized peritonitis secondary to diverticuli-
tis remains open sigmoid resection with end-colostomy.(49) The
subsequent colostomy reversal, however, can be difficult because
of the significant adhesions that result. In an effort to ease some
of those difficulties, different groups have experimented with
various strategies, including a laparoscopic Hartmann’s proce-
dure, and laparoscopic peritoneal lavage with no resection and
subsequent elective, one-stage resection.(50, 51)
Bretagnol et al. looked at 24 patients who underwent laparo-
scopic management of perforated sigmoid diverticulitis, of whom
19 were found to have purulent or fecal (Hinchey III or IV) peri-
tonitis. They noted a morbidity of 8%. Laparoscopic sigmoid
resection was ultimately performed on these patients electively,
with a conversion rate of 16%.(50) Myers et al. in a prospective
study of 100 patients, attempted laparoscopic peritoneal lavage
on all consenting patients with generalized peritonitis from per-
forated diverticulitis.(51) Their primary endpoints were opera-
tive success and resolution of symptoms. They were successful
in 92 patients, with morbidity and mortality rates of 4 and 3%.
Two patients developed postoperative pelvic abscesses requiring
drainage while two patients represented with diverticulitis at a
mean follow-up of 36 months. While they did not look at later
reoperation, their results do suggest that laparoscopic peritoneal
lavage in expert hands may be a viable option in the acute setting
and allow avoidance of a colostomy.
The timing of surgery after an acute attack of diverticulitis also
remains a question. Zingg et al. in a retrospective study of 178
patients undergoing laparoscopic-assisted sigmoid resection for
diverticulitis found that patients undergoing surgery during the
same hospitalization had a significantly higher conversion rate,
37.7% vs. 12.9%.(52) In addition, the converted patients had an
increased surgical morbidity, though this was not statistically sig-
nificant (23.8% vs. 19.1%). Hospitalization was significantly longer
at 13.5 vs. 10.5 days. Their results suggest that patients who respond

 improved outcomes in colon and rectal surgery
to initial antibiotic therapy and wish to undergo laparoscopic-
assisted sigmoid resection would be better served by delaying
colectomy for 6 or more weeks. Similarly, Reissfelder et al. looked
prospectively in 2006 at 210 patients who underwent laparoscopic
sigmoid resection for acute diverticulitis.(53) They were divided
into two groups, one with an elective resection 5–8 days after initial
antibiotic treatment, and the other 4–6 weeks after their initial hos-
pitalization. There was a statistically significant increase in conver-
sions and anastomotic leaks in the early group, again supporting
the idea of delayed resection after the initial episode.
As noted earlier in this chapter, a hand-assisted approach is
a potentially attractive way to preserve the benefits of laparos-
copy while cutting down on operative times and conversion
rates. These benefits may be applied to surgery for diverticulitis,
­particularly in complicated cases (i.e., abscess or fistula). Lee et al.
in 2006 compared operative times and outcomes between patients
undergoing hand-assisted laparoscopic sigmoid resections and
those undergoing a totally laparoscopic approach.(54) Patients
with complicated diverticulitis were found to have significantly
shorter operative times and lower conversion rates when com-
pared to those undergoing a totally laparoscopic approach.
Ureteral stents should also be considered in patients undergoing
laparoscopic surgery for diverticulitis. The indications, however,
are the same as in open surgery—reoperation, severe inflamma-
tion, or the presence of an abscess. Lighted stents are generally not
necessary, as the stents can be felt by the surgeon, even in a totally
laparoscopic approach. The surgeon should resist the temptation
to utilize stents too liberally, as they carry their own set of risks,
including bleeding, ureteral obstruction, and perforation.
The existing data suggests that a laparoscopic approach to treat-
ment of sigmoid diverticulitis may offer a number of benefits over
an open approach. Case selection and surgeon experience, as with
other disease processes, is paramount. Strong consideration should
be given to a hand-assisted approach in complicated cases. As a
general principle in the treatment of diverticulitis, the use of lapar-
oscopic techniques should not compromise the surgical procedure
by reducing the amount of colon removed or failing to resect to the
level of soft, normal rectum on the distal resection margin.
RECTAL PROLAPSE
Abdominal fixation procedures for rectal prolapse may offer an ideal
opportunity for a laparoscopic approach. The lack of a specimen or
an anastomosis solves two of the most potentially vexing problems
in laparoscopic colorectal surgery. Laparoscopically-assisted resec-
tion rectopexy, however, also may offer many of the same benefits
over the open procedure. Whether a resection is involved or not,
abdominal fixation procedures may offer an excellent opportunity
to learn how to mobilize the rectum laparoscopically, which can
then be applied to more extensive procedures, including procto-
colectomy or rectal cancer surgery.
Ashari et al. in 2005, looked at ten years’ worth of prospec-
tively collected data of patients undergoing laparoscopically-
assisted resection rectopexy for full-thickness rectal prolapse.(55)
A total of 117 patients were included in the study. Operative times
decreased from a median of 180 minutes in their early experi-
ence, down to 110 minutes in the latter part of their experience.
At a median follow-up of 62 months, only 2.5% of patients had

full-thickness prolapse recurrence. Mucosal prolapse recurred
in 18% of patients, while 4% of patients required dilation of an
anastomotic stricture. This mucosal prolapse recurrence may be a
result of less adhesion formation in the pelvis after a laparoscopic
dissection.
Solomon et al. in 2002, published the findings of a randomized
clinical trial of laparoscopic vs. open abdominal rectopexy for rec-
tal prolapse, with a total of 40 patients with full-thickness rectal
prolapse randomized to the laparoscopic and open group.(56)
Patients were placed on a clinical pathway, which was designed
to result in discharge before postoperative day 5. Not surpris-
ingly, mean surgical time was greater in the laparoscopic group
(153 vs. 102 minutes, p < 0.01). Nineteen of twenty patients in the
laparoscopic group were discharged by day five, while only nine
of nineteen in the open group were able to achieve that goal. Total
narcotic usage was less in the laparoscopic group as well.
While these results are encouraging, the follow-up on these
patients is short. In addition, the 18% mucosal prolapse reported
by Ashari et al. is concerning. Long-term follow-up is essential
in these patients before laparoscopy for rectal prolapse can be
considered the gold standard. Other considerations such as ante-
rior deep pelvis mobilization, preservation of the anterior lateral
stalks, and combination of sigmoid resection and rectopexy will
need to be evaluated to derive the true place of laparoscopic treat-
ment of rectal prolapse.
COLONOSCOPIC PERFORATION
Iatrogenic perforation of the colon during colonoscopy is a for-
tunately rare complication. Treatment has generally consisted of
laparotomy and repair vs. resection. Because the colon has usu-
ally undergone mechanical bowel preparation, simple oversewing
of the defect is generally safe and effective. Just as laparoscopy is
being applied more often to the repair of perforated peptic ulcers,
it would seem logical that it may offer benefits in the treatment
of colonoscopic perforation. Bleier et al. in 2008, looked at a
series of 18 patients in a four-year period who underwent sur-
gical treatment of iatrogenic perforation.(57) Eleven patients in
the laparoscopic group and seven patients in the open group had
similar operative times. The patients in the laparoscopic group,
however, had statistically significant shorter lengths of stay, fewer
complications, and shorter incision lengths. Laparoscopic repair
of colonoscopic perforation may become the next step after con-
servative therapy fails and avoid major morbidity and prolonged
recovery if accomplished in a timely fashion.
TECHNICAL CONSIDERATIONS OF GOOD
LAPAROSCOPIC PRACTICE IN COLORECTAL SURGERY
A significant part of minimizing morbidity and mortality and maxi-
mizing outcomes in laparoscopic colorectal surgery centers around
a number of technical considerations, including trocar placement,
use of instruments, and techniques for vascular control.
TROCAR PLACEMENT
The most commonly used trocars are 5 or 10 mm, depending on
whether a stapler will be used, and the size of the camera. When
selecting the sites, it is important to place them far enough apart
to avoid “swordfighting.” They must be placed in a position that
 laparoscopic colorectal surgery
allows the surgeon to reach the extremes of the opposite quad-
rants with the instruments. It is important that the trocars and
the monitors be placed, and the surgeon and assistant positioned
such that the surgeon is working in-line with the camera, the
intraabdominal pathology, and the monitors. This maximizes
the ability of the surgeon to work efficiently while minimizing the
potential awkwardness of working against the camera.
The trocars should be placed in such a manner that they are
inserted above the level of the bowel. This avoids the potential
danger of sticking the bowel or other structures with the instru-
ments each time they are inserted through the trocars. The skin
incisions should be large enough to allow the trocars to be placed
without undue skin trauma, but should be small enough to avoid
unnecessary movement of the trocars, air leaks through the skin
site, or falling out of the trocars.
When inserting the trocars, the surgeon should take care to
insert them at right angles to the tangent of the curve of the
abdominal wall to avoid tearing the peritoneum and reduce the
risk of an oblique insertion. The abdominal wall should always
be illuminated to avoid injury to blood vessels, which can cause
nuisance bleeding throughout the operation. The trocars should
always be inserted under direct vision and the surgeon should
always look at the trocar after placement to ensure that any bleed-
ing from the abdominal wall is dealt with early. In addition, the
surgeon should make sure the retainer rings are visible on the
peritoneum, so that the trocar is fully fixed in place, and will not
move unnecessarily.
Nonbladed trocars hold a number of advantages over bladed
trocars. They may help to avoid bowel injury, and also limits the
size of the peritoneal opening. The healing pattern of nonbladed
trocars through the peritoneum is also better than that of bladed
trocars.
The options for insertion of the initial trocar are an open tech-
nique and a closed technique using a Veress needle. While both
methods have their proponents, it is the opinion of the authors
that an open technique should always be utilized in a patient who
has undergone previous abdominal surgery. The risk of injury to
bowel or blood vessels is significantly higher with a blind insertion
in a patient with adhesions. Options for open insertion include
the use of a Hasson trocar, or in the case of a hand-assisted lapar-
oscopic operation, direct guidance through the hand-port.
In nearly all cases, the bladder should be decompressed with
a Foley catheter. This is particularly important in cases where
a suprapubic trocar will be placed, so as to avoid any injury to
the bladder upon insertion. An oral gastric tube will also insure
­gastric decompression.
INSTRUMENTS
One of the mantras for open surgery has included avoidance of
direct handling of the bowel with instruments, especially forceps.
The lack of hands inside the abdomen should not change this
dictum, if at all possible. The surgeon should try to avoid unnec-
essary grasping of the bowel. If needed, the instruments should
instead be used to push and retract. Rather than grasp the bowel
directly, the surgeon should try to grasp the surrounding fat
instead. The use of the most atraumatic graspers possible, such
as the “wavy” grasper, is essential. When retracting, the surgeon
should make every effort to retract in a 3-dimensional manner so
as to maximize the effectiveness of the retraction.
Wound protectors and specimen bags are two ways in which
to avoid contamination of the wound by the specimen. This can
have particular implications when dealing with a cancerous speci-
men, or a contaminated specimen, such as the acutely inflamed or
perforated appendix. The skirt of the handport used in a hand-
assist case is a very effective wound protector. If the handport is
not available, some form of ring drape should be used.
Placing a sponge into the abdomen, either through a 10 mm port,
or through the handport, can be a very effective technique. It can be
used to pack the bowel out of the way, protect the bowel, or reduce
free-flowing blood which can impair visualization. It can be a very
effective way to protect the bowel during retraction so that the sur-
geon is pushing on the sponge instead of directly on the bowel.
VASCULAR CONTROL
Methods for vascular control include monopolar cautery, ultra-
sonic coagulation, clips, staplers, and bipolar devices. While each
method has its advantages and disadvantages, it is important to
keep several issues in mind. The monopolar device should never
be used on larger vessels (i.e., ileocolic artery, inferior mesenteric
artery, inferior mesenteric vein). While the ultrasonic shears are
effective for vessels <7 mm in size, they have not been proven
to be effective on vessels larger than that. Bipolar devices have
been proven to be effective on vessels as large as 7 mm and can
be an effective and efficient way to manage vascular pedicles.
While staplers are also effective for large vascular pedicles, two
caveats should be kept in mind. The stapler requires the use of
at least a 10 mm trocar, and the surgeon must beware of bleed-
ing through the staples as well. No matter what the method of
control, the surgeon should always make sure to have an alter-
nate means of control available in the operating room. Perhaps
the two most common and simplest methods are the Endoloop
or surgical clips.
CONCLUSION
Laparoscopic colorectal surgery offers many potential benefits
over traditional open surgery, including quicker return of bowel
function, decreased pulmonary morbidity, shorter hospital stays,
and improved cosmesis. Its widening use across the spectrum
of colorectal diseases, while exciting, is also cause for caution
amongst all colorectal surgeons. The key to optimizing out-
comes in laparoscopic colorectal surgery lies in following several
key principles, including careful patient selection, strict adher-
ence to oncologic principles, meticulous attention to technical
details, and a willingness to alter one’s approach when needed.
The ­surgeon should not look upon conversion as a failure, but
rather as a switch to an alternative approach. The judicious use
of a hand-assisted approach may offer a way for the surgeon to
preserve the benefits of laparoscopy while providing a means to
complete complex and time-consuming cases in a safer and more
efficient manner.
Ultimately, randomized, controlled trials with long-term
­follow-up will be needed to truly determine the role of laparoscopy
in managing colorectal diseases. If the aforementioned ­benefits are
maintained in the long run with durable results, then laparoscopy,

 improved outcomes in colon and rectal surgery
performed in expert hands, may ultimately become the standard-
of-care for treating many of these disease processes.
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
14 Medical legal issues
Charles F Gay Jr and Terry C Hicks
Challenging Case
A 60-year-old woman with a strongly positive family history of color-
ectal cancer undergoes a colonoscopy. She has a 1.5 cm pedunculated
polyp snared from the transverse colon. Five days after the proce-
dure, she presents to the emergency room with a lower GI bleed. She
is hemodynamically stable and you admit her for observation. She
remains stable and is discharged 2 days later with no further bleeding
episodes. The hospital risk manager calls you to discuss this case.
Comments
When you meet with the risk manager, you inform her that you
had seen the patient in your office before the procedure. During
this office visit, you had discussed with the patient, her risk fac-
tors, indications for the procedure, details of the procedure,
and potential risks. This conversation was documented in your
office note and the patient signed a consent for the procedure.
The ­procedure was performed in the usual fashion. You feel that
you have a good relationship with the patient and the records are
well documented. Although any untoward outcome could lead to
­litigation, the risk manager agrees that you have taken the appro-
priate actions to minimize your risk.
INTRODUCTION
As surgery enters the next millennium, it finds itself at the cross-
roads of a serious medical liability crisis. This chapter will briefly
review important aspects of the United States medical liability
situation and then addresses some risk-prevention techniques for
colorectal surgeons. This includes a general overview of the legal
process pertaining to medical malpractice issues and tips to help
prevent and defend such cases. It is intended to provide practical
information that can be used by medical care providers.
Magnitude of the Problem
A lack of affordable liability insurance is leading some doctors to
retire prematurely; relocate their practices to nonlitigious areas,
practice without insurance, or drop risky procedures. Some of the
specific examples are as follows:
•• Over the past decade, hundreds of emergency rooms have
been forced to close their doors at least temporarily even
though the number of emergency visits have climbed over
20%.(1)
•• In many areas of the country, pregnant women are finding it
more difficult every year to get the care they need. A survey
by the American College of Obstetricians and Gynecologists
found that one in seven OBGYNs in the United States have
stopped practicing obstetrics because of the medical liability
crisis, and more than 12% of OBGYNs have decreased their
numbers of deliveries for similar reasons.

•• The American Hospital Association says that more than
half of the hospitals are having difficulty recruiting doctors
because of the medical liability crisis.(2)
•• More than half of hospitals surveyed in “crisis” states said
their local community lost doctors because of the medical
liability crisis.
•• 71% of surveyed neurosurgeons said they no longer perform
aneurism surgery, 23% no longer treat brain tumors, and
75% no longer operate on children.
•• At one point, in Palm Beach County, Florida, only four neuro-
surgeons were available to handle emergency calls in the area’s
13 hospitals, leaving most emergency rooms with no coverage.
The evidence is clear that there exist a medical malpractice crisis
in the United States, and at present multiple grass route efforts
are being undertaken to address this on a local as well as on a
national level. The American Medical Association has continued
to add states to its liability crisis list, and more and more physi-
cians are finding that insurance premiums are becoming beyond
their reach. The most important fallout of this situation is that
access to care is being endangered especially in rural areas and
among low-income, inner-city populations.
By 2003, medical liability cost reached $26 billion—a 2000%
increase over 1975. Medical liability costs are rising far more rapidly
than the overall medical costs. From 1975 to 2000, medical costs
rose 449%, while medical liability costs rose by 1,642%. A study by
Blue Cross Blue Shield of “crisis” states found huge jury verdicts
where the primary driver for higher liability premiums.(3) Based
on comprehensive jury verdict research, there is little doubt that
soaring jury verdicts are serious-ongoing problems. At present, half
of the jury awards in medical liability cases exceed $1 million, and
the average award is $4.7 million.(4) The number of mega awards
has skyrocketed especially in states with no limits on noneconomic
damages. For the past several years, juries have awarded lottery-size
verdicts of $80, $90, or even $100 million.(5)
Many physicians feel the medical liability crisis is very straight-
forward. They note that medical liability costs are soaring faster
than the rate of overall healthcare costs and the rate of inflation,
leading directly to increasing insurance premiums for doctors.
In short, their position is that the litigation system generates too
many lottery-size verdicts, and encourages too many meritless
cases. As a result, insurance companies are fleeing the market,
making it more difficult for doctors to obtain liability coverage
at any price. The US Department of Health and Human Services
concluded: “The excess of a litigation system raises the cost of
healthcare for everyone, threatens Americans access to care, and
impedes efforts to improve the quality of care”.(6)
Other major impacts of the malpractice crisis are the practice
of defensive medicine and a negative impact on the young physi-
cians in training. In a recent AMA survey, 48% of the students
 medical legal issues
in their 3rd and 4th year of medical school indicated the liability
situation was a factor in their specialty choice.
It is of interest to note that overall 75% of medical liability
claims in 2004 were closed without payment to the plaintiff; and
of the 7% of the claims that went to a jury verdict, the defend-
ant won 83% of the time. Unfortunately, physicians that win at
trial still have large fees to pay for their defenses. The average cost
being $93,559 per case where the defendant prevailed at trial. In
all cases where the claim was dropped or dismissed, the cost of the
defendants averaged $18,774.(7)
Until medical liability issues are resolved, physicians will be
forced to continue to deal with the present medical legal climate,
and it is our hope that the following information will provide
some guidelines to lower their exposure to medical legal risks by
utilizing proactive risk management steps.
In today’s litigious society, physicians who practice good medi-
cine, exercise effective communications skills, establish rapport
with the patient, and accurately document care have the best
chance of averting malpractice claims. Even when physicians
do all of these, however, a bad outcome may still result in the
patient’s filing a claim for malpractice.(8) Research appears to
support the position that a patient who perceives the physician
as having good interpersonal skills and communication is less
likely to sue.(9) There are ways to conduct a medical practice that
deter patients from making claims and, even after one is made,
can enhance the chances of winning the case.
Physician-Patient Relationship
Medicine has changed dramatically in the last few decades
because of extraordinary technologic advances that have resulted
in specialization, such as colorectal surgery. This fragmentation
often decreases the opportunity to communicate effectively with
patients, who have also become much more demanding consum-
ers, increasingly aware of their “rights” through media and law-
yer advertising. Health insurers contribute to the problem, not
only by creating incentives that discourage referrals to a specialist
but also by placing restrictions on the specialist, once referral is
made, that can impede opportunities to establish rapport with
the patient. Under such circumstances, it is important to make
the most of each opportunity to listen to the patient, remember
and use the patient’s name, explain procedures in lay terms (avoid
medical terminology), and take the time necessary to answer any
and all questions. Remember that listening to a patient’s ques-
tions and complaints will be much less time consuming than
defending a malpractice claim.
Still one of the best books for improving communication and
relationships is Dale Carnegie’s How to Win Friends and Influence
People.(10) For a more practical guide with a medical orientation
one should read Malpractice Prevention and Liability Control for
Hospitals, by Orlikoff and Vanagunas.(11)
The frequency of medical malpractice claims has been on
the rise since the early 1970s.(12) As long as the contingency
fee system exists and there is not a loser pay provision, the rise
in suits against physicians will likely continue. Accordingly, it is
incumbent on the well-educated and well-trained specialist to be
aware of areas of treatment in colorectal disease that present an
increased risk of malpractice claims.
High-Risk Areas in Colorectal Treatment
The following circumstances associated with increased risk for
malpractice claims in colorectal disease have been identified.(13)
Delay in diagnosis of colon and rectal cancer and appendicitis
Iatrogenic colon injury (e.g., colon perforation)
Iatrogenic medical complications during diagnosis or treatment
Sphincter injury with fecal incontinence resulting from ano-
rectal surgery
Lack of informed consent
The colorectal physician who is aware of these potential high-risk
conditions can use risk-prevention strategies to avoid litigation.
Informed Consent
Physicians should be mindful that consent and informed consent
are quite different concepts. Consent implies permission. Informed
consent is assent given based on information provided or knowledge
of the procedure and its inherent risks, benefits, and alternatives.
Courts have long recognized that “Every human being of adult
years and sound mind has a right to determine what shall be done
with his own body.”(14) The law of informed consent may vary
to some degree from state to state, but regardless of the law of the
state, each patient should be allowed an exchange of information
with the physician before a procedure is done. Informed consent
is not satisfied by merely having the patient sign a form. It is satis-
fied when consent was obtained after full disclosure of the risks,
benefits, and alternatives, of the procedure.
Many states use the “reasonable practitioner standard” to judge
whether informed consent was obtained. This standard focuses
on what a reasonable physician would disclose. The physician’s
duty is not to disclose all risks but primarily those that are sig-
nificant or material. A risk is material depending on its likelihood
of occurrence or the degree of harm it presents. The focus is on
whether a reasonable person in the patient’s position probably
would attach significance to the specific risk. This is the “reason-
able patient standard” that some state courts apply.
Moreover, to prevail on a claim for lack of informed consent, in
most states the patient must still prove causation (i.e., that he or
she would not have consented to the procedure if informed of the
risk. As a practical matter, it is difficult for a patient to persuade a
judge or jury that even though the surgery was needed to relieve
pain or disease, he or she would not have consented if told of the
risk of, for example, perforation of the colon. This is particularly
true when a patient is told of much more severe risks such as death
or paraplegia and agrees to the surgery. In that regard, the ques-
tion to be answered by the judge or jury on an issue of informed
consent is whether a reasonable patient in the plaintiff ’s positions
would have consented to the treatment or procedure even if the
material information and risks were disclosed.
The following points should always be discussed with the patient:
•• The general nature of the proposed treatment or procedure
•• The likely prospects for success of the treatment (but no
guarantee)
•• The risks of failing to undergo the treatment
•• The alternative methods of treatment, if any, and their inher-
ent risks

 improved outcomes in colon and rectal surgery
Suffice it to say that good rapport with the patient coupled with
accurate and complete charting are the best tools to deter suits
based on informed consent and to provide a heavy shield in
defending them.
Documentation
The importance of good communication and rapport with
patients (i.e., treating patients as you would like to be treated) can-
not be overemphasized in deterring lawsuits; however, ­complete
and accurate documentation of patient care is invaluable to a
defense of claims. In addition, good documentation may well nip
in the bud a potential claim when the plaintiff attorney consider-
ing filing suit reviews the record and care is fully documented.
Plaintiff attorneys are more likely to bring suit when the case is
poorly documented, because they can more easily argue that what
happened in the care of the patient was sinister and improper.
Where documentation is clear and accurate, the plaintiff attorney
may be deterred from filing suit because what ­happened is easily
proved from the record. Thus judgment becomes the issue when
documentation is accurate, and judgment used by physicians in
most cases is easier to successfully defend than a vague, evasive,
and poorly documented chart.
The following are some time-honored rules for charging that
help defend against malpractice claims.
Charting
A. Thorough and accurate charting is your primary shield to
liability.
B. If an event in which you are involved gives rise to litiga-
tion, chances are your testimony will not be taken for 1 or 2
years after the event. Accordingly, your chart will provide the
­content and guidelines for your testimony.
C. Most important: If it is not charted, it was not done, nor
was it observed, administered, or reported. In Smith v. State
through Dept of HHR, (15) the court stated:
The experts concluded that decedent’s condition required
continued monitoring and that charting should have been
done on a regular basis. The experts also agreed that the
lack of documentation indicated that no one was properly
observing the decedent, based on the standard maximum
“not charted, not done.”
  …The evidence indicates that the decedent was not ade-
quately monitored in this case. The nurses did not specifically
recall the patient, and thus the best evidence of their actions
would have been the documentation of the chart (emphasis
added).
D. General guidelines
  1. If you are the treating or primary physician, make a daily
entry on the chart.
  2. Chart at the earliest possible time.
  3. If the situation prevents you from charting until later, state
why and that the recorded times are best estimates and not
fully accurate.
  4. Always record the time (designate AM or PM) and the date
of every entry.
  5. Chart all consultations.

  6. Never black out or white out any entry on a chart. Should
you make a mistake in charting, place a single line through
the erroneous entry and label the entry “error in charting.”
However, if a hospital policy exists that governs errors in chart-
ing, follow it. An addendum is acceptable if placed ­properly
in sequence with the date and time it is made. An addendum
squeezed between progress notes is inappropriate.
  7. Write legibly.
  8. Spell correctly.
  9. Chart professionally; do not impugn or insult the patient.
10. Never alter the medical records.
11. Do not insult, impugn, or criticize colleagues, co-workers, or
support staff.
12. Always designate the dose, site, route, and time of medication
13. Sign your entries on the chart.
14. Do not chart an incident report in your notes.
15. Chart objectively, not subjectively; do not use ambiguous
terms (examples below)
Subjective Objective
Patient doing well. Patient denies any complaints.
Awake, alert, and oriented.
Vital signs stable: BP, 100/70: P, 72; R, 18
Breath sounds within normal Respirations regular and unlabored.
limits (WNL)
Breath sounds clear and equal bilaterally on
auscultation. No rales or rhonchi noted.
Circulation check WNL. Pedal pulses noted bilaterally. Nail beds
blanch quickly and toes warm to touch.
Patient denies any pain or tingling.
16. Document use of all restraints and safeguards, and patient
positioning (extremely important in surgery).
17. Document all patient noncompliance.
18. Document all patient education and discharge instructions,
and patient responses.
19. Always document patient status on transfer or discharge.
20. Record the patient’s name on each page of the medical chart.
21. Use accepted medical abbreviations.
22. Do not chart in advance.
E. Guidelines for charting in the ambulatory setting
  1. Always chart the return visit date and the date that was pro-
vided to the patient.
  2. Always chart all cancelled and missed appointments.
  3. Document all telephone conservations and their content.
  4. Chart all prescriptions and refills, as well as patient teaching
regarding prescriptions.
  5. Chart all follow-up and discharge instructions. If possible,
have the patient or his or her representative cosign these
instructions.
Anatomy of a Malpractice Suit
Initial Phase
Once a patient initiates a claim for medical malpractice, the physi-
cian should immediately place a call to the risk manager or to the
 medical legal issues
malpractice insurance carrier. An attorney will usually be selected,
and the physician should insist that the appointed counsel be expe-
rienced and have a well-established reputation in the ­handling of
malpractice cases.
Physicians should work closely with the defense attorney to
review and analyze the allegations of the suit, with particular
focus on the strengths and weakness of the case. This team effort
can often substantially enhance the strength of the defense by
educating the attorney on the medical aspects of the case.
Pretrial Discovery
During this stage, each side will discover the facts and opinions
in the case. Written questions, or interrogatories, can usually be
propounded to obtain written responses. Depositions usually
­follow the written discovery and are important to the overall out-
come of the case. Before testifying by deposition or otherwise, it is
advisable that the physician be thoroughly familiar with the facts,
including previous and subsequent medical care of the patient
and the allegations against the physician. This requires careful
review of medical records, other depositions, and all medical data
related to the case. A conference should be held with the attorney
before the physician’s deposition. They physician should allow
ample time to confer with the defense attorney before testifying.
Remember that the judicial system is adversarial, and the pur-
pose of the deposition is not to convince the plaintiff attorney
to understand that the case is frivolous. They physician is there
to answer the questions and defend the care administered, not to
educate the plaintiff attorney.
The deposition is simply the physician’s testimony, given under
oath, before a court reporter, in an informal setting. Attorneys for
both defendant and plaintiff are present. Any party to the lawsuit
may be present, but often the physician is the only party present.
The testimony is taken down in question-and-answer form.
Under the laws of discovery, the plaintiff attorney has the right
to ask the defendant physician proper questions. The physician
is present simply to discharge a legal obligation to answer proper
questions.
The physician’s deposition is most important. A good effort
is essential for an effective presentation. Close cooperation with
the defense attorney in preparation is fundamental. Above all, a
physician must be his or her own person.
Thorough preparation will assist physicians in giving a deposi-
tion with which they will be perfectly comfortable when they see
the printed transcript, that is, one that will be easily defended,
should any part of it later be challenged.
The following suggestions for giving testimony in depositions
can be helpful to the physician:
  1. Tell the truth; you must testify accurately.
  2. Do not guess or speculate. If you do not know the answer to
a question, say so.
  3. If you are not certain of what the attorney is asking, ask that
the questions be clarified or repeated. Do not attempt to
rephrase the question for the interrogator (e.g., “If you mean
such and such,”).
  4. Keep your answers short and concise. Do not volunteer
information. Answer only the question posed.
  5. Be courteous. Avoid jokes and sarcasm.
  6. Think about each question that is posed. Listen to each word.
Formulate an answer, then give the answer. Do not permit
yourself to become hurried.
  7. Do not argue with opposing counsel. If an argument is
­necessary, your attorney will do it for you.
  8. If you realize that you have given an incorrect answer to a
previous question, stop at that moment and say so; then
­correct your answer.
  9. Be aware of questions that involve distances and time. If you
make an estimate, make sure everyone knows it is an estimate.
10. Do not lose your temper, no matter how hard pressed. This
may be a deliberate ploy; do not fall for it.
11. Do not anticipate questions. Be sure to let the attorney
­completely finish the question before you begin to respond.
12. Do not exaggerate or brag.
Testing Your Memory of the Case
You have the right to refer to the chart or hospital records when-
ever you wish. Your memory is usually a composite of events you
recall as jogged by your records. Watch for generalities, ploys, and
tricky questions by the plaintiff attorney during the deposition.
Generalities. Often the plaintiff ’s attorney will begin with gen-
eral questions, such as, “Doctor, how do you treat a patient when
you suspect he has X disease?” In all likelihood, the lawsuit to
which you are a party involves X disease or involves the plaintiff ’s
attorney trying to make it X disease. You really cannot answer
this question, and you should say just that. X disease probably
occurs in various forms, and you have been given no particular
information—no patient complaints, no patient history, no find-
ings on physical examination, no results of laboratory studies, no
clinical impression—all factors you must know to diagnose and
treat intelligently. The question is simply too general.
A similar question might be “Doctor, what are the standards for
making a diagnosis of X disease?” Again, you should advise that
this question is too broad and defies rational response because no
details have been given. You, as a physician, do not immediately
diagnose X disease or any other diagnose X disease or any other
disease. You evaluate all the data in light of your formal train-
ing and clinical experience in considering or making a diagno-
sis. Patient signs and symptoms are innumerable. You must have
­specifics. For example, in one doubtful clinical presentation, you
may have to order a particular set of laboratory studies; in another,
the evidence of a certain disease process may be more definitive
and clear-cut from the history and clinical examination.
A proper question is, “Doctor, what are the characteristics of X dis-
ease?” Particularly if your case involves X disease, you should know
its characteristics, but you should also point out that they are general
characteristics and most certainly will vary in specific instances.
The point is, you must avoid generalities. You must demand
specifics. Try to make the questioner stick to the specific case.
Ploys
Question: “Doctor, you have no memory of events independent
of your records, do you?”
Appropriate response: “I have an excellent recall of the events when
I refer to the records.”

 improved outcomes in colon and rectal surgery
Ploy: “Doctor, if an event is not noted in your records or in the
hospital records, is it fair to say that event did not occur?”
Appropriate response: “That is incorrect. It is impossible for a
­physician to note everything that occurs. My records are for my
own use, to jog my memory. Thus I note pertinent highlights,
which when later reviewed give me the complete picture at the time
in question.”
Remember that physicians treat patients, not charts. You may
properly testify to the following:
1. What you actually recall
2. What you recall with the assistance of your records
3. What is recorded
4. What your routine or standard procedure is, even when such
is not recalled and not recorded
Tricky questions. Many plaintiff attorneys will use questions
cleverly phrased to evoke a response that can later be used against
the physician.
Possibilities. Questions phrased in terms of possibility invite
speculation and are improper. The criterion is reasonable medical
probability.
Question: “Doctor, isn’t such and such possible?” or “Couldn’t
such and such have happened?”
Appropriate response: “Most improbable.”
Doing things differently. Almost all malpractice cases involve
the “retrospectroscope” or Monday morning quarterbacking to
suggest the physician knew things beforehand that were only
learned later or that the physician has 100% control over the
­healing process.
Question: “Doctor, is there anything you would do differently
now if you had Mrs. White’s case to treat again?”
Appropriate response: “My recommendations to Mrs. White
were based on her complaints, her history, and findings at the
time and on my clinical impression at that time. The course
I ­recommended was appropriate on the basis of those factors.
Question: “Doctor, you did not intend for Mrs. White to have
this complication, did you?”
Appropriate response: “Of course, no harm to Mrs. White was
intended. At the time of my recommendations, there were good
prospects for a good result. The procedure (or regimen) does have
known complications, and that is why the risks were explained to
her beforehand.”
Many other factors are involved in preparing for and ­suc­cessfully
testifying by deposition or at trial.(16) Suffice it to say that effec-
tive and sincere testimony is critical to a successful defense in
malpractice cases. Ineffective testimony can render a defensi-
ble case indefensible. Many tricks and ploys may be used by the
plaintiff attorney, and the physician who is prepared with a basic
understanding of how to answer such questions can substantially
enhance the defense.
Trial
After pretrial discovery, the physician should have a clear under-
standing of the evidence and witnesses, the experts in particular,
to be use against him or her at trial. Working with the defense
attorney to rebut this evidence and to assist with selection or

expert witnesses to testify for the defense is strongly advised and
helps the physician to prepare the defense.
At the trial, the physician is carefully observed at all times
by the judge and jury, and the physician’s trial testimony,
mannerisms, and behavior are critical to a favorable verdict.
A well-trained and educated physician who portrays a sincere,
conscientious, and caring attitude about the patient’s well-
being greatly increases the chances of a favorable jury verdict,
even where severe complications have occurred and there may
be questions of the appropriateness of the course of treatment
chosen.
Conclusion
The defense of medical malpractice claims is similar to the
defense of criminal cases. The physician stands accused and rep-
utation is usually an issue of great importance. The emotional
costs to the physician are sometimes staggering. The physician
should recognize that until some meaningful tort reform is
enacted, these cases will likely continue to increase and should
be dealt with as a regrettable aspect of practice.(17) Under these
circumstances, it is best to accept the reality of the medicolegal
arena and use the best means available to aggressively defend and
win the malpractice case.(18)
References
  1. The American College of Emergency Room Physician; cited
in Federal Medical Liability Reform. Alliance of Specialty
Medicine; 2005.
  2. The American Hospital Association. Professional Liability
Insurance: A Growing Crisis; 2003.
  3. Blue Cross Blue Shield Assoc. The Medical Malpractice
Insurance Crisis: The Impact of healthcare and access; 2003.
  4. Manhattan Institute. Malpractice maladies: Doctors continue
to flee states without – of – control medical – injury- verdicts;
2005.
  5. U.S. Dept. of Health and Human Services. Addressing the
new healthcare crisis: Reforming the medical litigation
­system to improve the quality of healthcare; 2003.
  6. U.S. Dept. of Health and Human Services. Addressing the
new healthcare crisis; Reforming the medical litigation
­system, improve the quality of healthcare; 2003.
  7. The American Medical Association. Medical liability reform;
2006.
  8. Entman SS, Glass CA, Hickson GB et al. The relationship
between malpractice claims history and subsequent obstetric
care. JAMA 1994; 272: 1588–91.
  9. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that
prompted families to file medical malpractice claims follow-
ing perinatal injuries. JAMA 1992; 267: 1359–63.
10. Carnegie D. How to Win Friends and Influence People. New
York: Simon & Schuster; 1936.
11. Orlikoff J. Vanagunas A. Malpractice Prevention and
Liability Control for Hospitals. Chicago: American Hospital
Association; 1988.
12. Danzon PM. The frequency and severity of medical mal-
practice claims: New evidence. Law Contemp Probl 1986; 49:
57–84.
 medical legal issues

13. Kern K. Medical malpractice involving colon and rectal dis-
ease: a 20-year review of United States civil court litigation.
Dis Colon Rectum 1993; 36: 531–9.
14. Schloendorff v. Society of New York Hospital, 211 NY 125,
105 NE 92,93; 1914.
15. Smith v. State, through Dept of HHR, 517 SO2d 1072. La
App 3d Cir; 1987.
16. Taraska JM. The physician as witness. In Legal Guide for
Physicians. New York: Matthew Bender, 1994: 1–56.
17. Taraska JM. Tort reform. In Legal Guide for Physicians. New
York: Matthew Bender, 1994: 1–64.
18. Gay CE. Medicolegal issues. In Hicks TC, Beck DE, Opelka
FG, Timmcke AE. eds, Complications of Colon and Rectal
Surgery. Baltimore: Williams & Wilkins, 1996: 468–77.


15 Miscellanous conditions
M Benjamin Hopkins and Alan E Timmcke

Challenging Case
A 26-year-old man has a 2 month history of perianal itching. He
has variable bowel movements and no family history of colorectal
cancer. Physical exam demonstrates thickened perianal skin with
ridges in a circum anal pattern. The sphincter tone is normal and
no masses or tenderness is appreciated.

Case Management
A diagnosis of pruritis ani is made and the patient was placed on
additional dietary fiber and instructed on anal hygiene (keeping
his perianal area clean and dry). In addition to the management
of conditions already discussed, a number of others merit discus-
sion, including pruritis ani, condyloma acuminatum, Human
Immunodeficiency Virus, and other sexually transmitted diseases.

Pruritus Ani
An itching and burning sensation about the anus is referred to
as pruritus ani. Frequently mistaken by patients for symptoms
of hemorrhoids, the symptoms can be very discouraging and
frequently wax and wane. Despite its ubiquity, pruritus ani is an
under-diagnosed condition. The majority of patients choose to
self medicate and do not seek medical care.(1) It affects males
more frequently than females by 4:1.(2) Most patients complain
of itching and burning made worse during hot, humid weather
or after exercise. The itching sensation can advance to the point
of distress, driving some to suicide. On physical exam, the affected
area can vary from mild erythema and excoriations to marked skin
thickening, cracking, and lichenification (Figure 15.1). Excessive
scratching or vigorous cleansing of the afflicted area can exacer-
bate the condition.
The etiology of pruritus ani, like other dermatitides, can range
from poor hygiene, poorly absorbent or ventilated clothing, exces-
sive or improper cleansing, and dietary intolerances. Fecal soilage
can be a strong irritant to the perianal area leading to skin irritation.
Causes of soilage can include incomplete wiping due to skin tags or
Figure 15.1  Priritis ani.
other anatomic imperfections, loose or tenacious stool consistency,
and poor anal sensation or sphincter tone. A small study of 39 males
(23 of whom had pruritus ani) demonstrated a greater rise in rectal Contact dermatitis should be ruled out as a possible etiology.
pressure associated with decreased anal pressure, and longer dura- Clues to this diagnosis include recent use of new creams, toiletry
tion of internal anal sphincter relaxation.(3) Clothing choice has items, or new laundry detergent. After the initial irritation from
also been associated with ­idiopathic pruritus ani with tight fitting, these agents, itching and pain can be exacerbated by continued
nonaerating fabrics exacerbating the problem. Additionally, hirsute scratching and abrasion. Occasionally, home remedies can worsen
patients are more prone to episodes of pruritus ani. Foods such as the condition as well.
caffeinated beverages, chocolate, tomatoes, and citrus fruits have Often, simple reassurance can be the best treatment for idi-
been shown to cause pruritus ani.(4–6) Coffee in particular has opathic pruritus ani. Knowing that there is no underlying disease,
been associated with pruritus ani, with increased amounts of cof- such as cancer, can provide just as much benefit as lifestyle changes.
fee intake being associated with worsening symptoms. One pos- Lifestyle changes should include improved cleanliness, changes in
sible etiology for this is a decreased internal anal sphincter tone, clothing, as well as dietary changes. Patients should cleanse them-
similar to that seen in relaxation of the lower esophageal sphincter selves several times a day avoiding excessive scrubbing of the
with gastroesophageal reflux disease. affected area. If available, showering after bowel movements can


 miscellanous conditions
be very effective. Patients should be instructed to dry the area with
a hair dryer or with a blotting technique to avoid trauma to the
anal area. Dampened toilet paper may assist in gentle cleansing,
but Baby wipes or Tucks should be avoided as they may excessively
traumatize the perianal area after defecation. Choice of clothing
can exacerbate the condition, with loose fitting, soft cotton clothing
providing some relief. Dietary changes involve excluding ­possible
causative foods for 2 weeks to see if the condition improves. If the
symptoms resolve or improve, suspected foods may be reintro-
duced to ascertain which cause recurrence or worsening of the
itching or burning sensation.
Occasionally, hydrocortisone cream may be used to overcome
severe problems. The cream decreases inflammation and irrita-
tion, thus promoting healing. However, prolonged use of a steroid
cream may lead to atrophy of the skin with further breakdown and
worsening conditions. Due to this concern, hydrocortisone cream
should not be used for more than 2 weeks. Other skin protective
creams may be used in the initial stages and then transitioned to
dry powders for long-term relief.
More extreme measures at treating pruritus ani have been
attempted. These include injections with alcohol, oil soluble anes-
thetics, and methylene blue into the perianal skin.(7, 8) While
providing some temporary relief, abscess formation, skin break-
down, and skin sloughing can occur. While these outcomes can
be treated with local drainage and antibiotics, the morbidity and
poor success rate prevents them from being effective treatments.
Surgical undercutting of the perianal skin has also been described.
(9) While the skin can be made insensate, recurrence of the der-
matitis occurs. Additional problems with abscess formation and
sepsis have been described. As with injections, the risks of surgical
undercutting outweigh the benefits.
Other causes of pruritus ani need to be excluded during the
workup. Hemorrhoids, anal fissures, psoriasis, rectal and anal can-
cer, as well as colon cancer have all presented with an itching or
burning sensation of the anus.(10) While the relation of cancer
to pruritus ani is unknown, patients presenting with itching in
their presenting complaints had longer duration of itching than
those with benign causes.(10) Additional medical problems such
as diabetes, antibiotic use, fungal and parasite infections, and anal
intercourse need to be investigated as well.
Condyloma Acuminatum
Human papillomavirus (HPV) is the causative pathogen in con-
dyloma acuminatum. The condition affects nearly 20 million
sexually active adults, with 5.5 million new cases occurring each
year.(11) The virus is spread via close contact with an infected
individual and autoinoculation to other body surfaces is possi-
ble. Anogenital warts from HPV is considered the most common
anorectal infection among homosexual men. Anorectal warts
are more common than penile warts owing to the moist, warm
environment thought to be favorable to their growth. In addi-
tion to perianal lesions, intraanal lesions are common among
homosexual men.(12) Therefore, in order to successful treat
these patients, internal as well as external therapies need to be
utilized to ­prevent reinfection. Additionally, the patient and all
sexual partners should be treated to prevent repeat inoculation.
Treatment options for patients include excision and destruction.
Excision of the condyloma generates a tissue diagnosis as well
as typing of the causative papillomavirus.(13) Due to the risk
of malignant transformation, histopathologic examination is
recommended for all patients undergoing treatment. The tech-
nique used involves elevating the lesion with local lidocaine/
epinephrine injection, and excising the lesion; taking great care
that the underlying musculature is left intact. One must also be
careful to leave as much of the normal skin and mucosa as pos-
sible. Complications of intraanal excision can include strictures
of the anal canal. Sitz baths are helpful during convalescence to
assist in wound healing. Unfortunately, surgical excision has a
high recurrence rate ranging from 9% to 46% depending on the
study.(14, 15)
Destructive techniques used in the treatment of condyloma
include electrocautery, cryotherapy, laser therapy, immunotherapy,
and various topical agents. Fulguration of the condyloma using
electrocautery and curettage of the destroyed tissue is an effec-
tive tool in treating condyloma. Care must be taken to prevent
deep burns which can damage the surrounding skin and lead to
deep wounds and severe scarring. This method can be of par-
ticular use within the anal canal if appropriate precautions are
taken. Cryotherapy is similar to electrocautery in that the wart
and underlying tissues are destroyed, leading to sloughing of the
condyloma. Cryotherapy has been reported to lead to a foul smell-
ing and damp slough thought to result in a higher recurrence
rate. Again, great care must be taken to ensure that surrounding
healthy tissue is not damaged. Laser therapy is another destructive
technique to eliminate condyloma. Similar to other destructive
techniques, complications include loss of tissue, fibrosis, and anal
stenosis.(16) Additionally, aerosolized viral particles generated
during laser therapy can inoculate the medical provider and result
in respiratory papillomas.(17)
Several topical agents are available for treating anal condyloma.
They can be applied in the office setting by medical personnel
as well at home by the patient. Trichloroacetic acid, podophyl-
lin, and imiquimod are currently available. Trichloroacetic acid
is a caustic agent used to chemically burn the anal wart. The
acid must be applied to the anal wart after cleansing the peri-
anal area. Liberal application of trichloroacetic acid will lead
to burning and necrosis of normal skin and should be avoided.
The acid should be applied to the wart only. After application,
the wart should have a frosty white appearance. Treatment
of anal canal lesions should include blotting the lesion with a
swab before removing the anoscope. This prevents burning of
the adjacent mucosa. The caustic effects of trichloroacetic acid
include skin necrosis, ­fistula in ano, and anal stenosis. Patients
should return to the office every 7–10 days for reapplication.
Swerdlow and Salvati reported a recurrence rate of 25% using
this technique.(18)
Podophyllin is a topical agent which can be applied in the
office setting or by the patient at home. Podophyllin is applied to
the warts themselves, taking care to not apply to uninvolved skin.
Podophyllin is a destructive agent which leads to necrosis of the
treated areas. Complications of podophyllin treatment can run the
gamut of local skin irritation to systemic toxicity. Complications
including fistula in ano, anal stenosis, and skin necrosis have been
reported.(19) If large doses are applied to the skin, hepatic, renal,

 improved outcomes in colon and rectal surgery
gastrointestinal, and neurologic complications have occurred.
Pregnancy is an absolute contraindication for the use of topical
podophyllin. Treatment with podophyllin has a clearance rate of
about 50%, but the recurrence can be as high as 90%. This high
recurrence rate necessitates repeat treatments.
Imiquimod is a newer agent in the arsenal against anal condy-
loma. It can be applied in the office setting as well as at home and
has been shown to have similar efficacy to podophyllin and other
fulguration techniques.(11) As opposed to destructive applica-
tion creams, imiquimod stimulates the innate and cell mediated
immune response to clear papillomavirus infected cells. The
cream is applied to the wart and left in place for 8 hours, and then
the washed off. Imiquimod is applied 3 times a week for up to
16 weeks of therapy. As imiquimod is not cytodestructive, con-
cerns of skin necrosis and fistula formation seen with other abla-
tive therapies are not realized. Langley and colleagues reviewed the
cost-effectiveness of imiquimod therapy and found a combination
initial imiquimod treatment followed by second-line therapy for
recurrence gave the highest success rate and the lowest total cost of
therapy.(20) Second-line therapy included fulguration techniques
used in the office.
It should be noted that all topical agents have lower success
rates when used to treat highly keratinized warts. Due to this
­limitation, intraoperative techniques may better treat these
chronic lesions. If other lesions recur, subsequent treatment with
topical agents can be considered.
Immunotherapy as described by Abcarian et al. has been shown
to effect regression of the condyloma lesions.(21) The therapy
consisted of an autologous vaccine created from the patient’s wart
tissue. Intramuscular injections were given once the vaccine was
created. Difficulty and expense in creating this immunotherapy
have curtailed its widespread use.
Due to the increased risk of papillomavirus lesions leading to
anal squamous intraepithelial lesions and an increased risk of
cancer, many are advocating screening techniques similar to rou-
tine papanicolaou screening in women. Screening should include
identifying risk factors such as human immunodeficiency virus
(HIV) status, history of anal warts, and history of anal pain and
bleeding. Pap testing using a liquid medium allows for the collec-
tion of epithelial cells for analysis.(22) The increased incidence
of squamous cell carcinoma transformation in the HIV posi-
tive population should lead the clinician to screen these patients
yearly.
Human Immunodeficiency Virus
Due the depressed immune system, HIV positive individuals are
at increased risk of wound complications following surgery. Of
those affected, more severe HIV disease leads to higher morbidity
and mortality from minor surgical procedures including hemor-
rhoidectomy, lateral internal anal sphincterotomy, and transrectal
biopsies. Due to the high complication rates, surgical treatment of
benign anorectal diseases should be approached carefully. Before
surgical intervention, viral load, and immunosuppression should
be carefully evaluated.(23)
Treatment of anal ulcers involves identification of the causative
agent and appropriate medical management. Etiologies of anal

ulcer in the HIV patient include herpes virus, syphilis, cytomega-
lovirus, and cryptococcus.(24, 25) Surgical management is reserved
for chronic, nonhealing ulcers and includes local debridement,
unroofing of ulcerative cavities, and steroid injection into the cav-
ity. Complications of surgery include prolonged drainage, poor
wound healing, incontinence, and superinfections.
Treatment for fistula in ano and perianal abscesses in an HIV-
infected patient remains the same as HIV negative patients.
However, abscesses and fistula appear more frequently in the more
advanced stages of HIV infections. Surgical therapy is ­warranted
for source control of the affected area, but the complication rate is
high. Patients should be advised of the increased risk of nonheal-
ing wounds, recurrence, and sepsis. Surgical management should
include conservative strategies used in the treatment of anorec-
tal disorders seen in Crohn’s disease. Draining setons and drain-
age catheters (Malecot and Pezzar drains) should be the initial
treatment in those with severe immunodeficiency. Fibrin glue as
well as collagen plugs could also prove useful in the treatment of
­perianal fistula.
Kaposi’s sarcoma can lead to abdominal pain, lower and upper
gastrointestinal bleeding, malabsorption, obstruction, and perfo-
ration.(26, 27) The clinician must understand that gastrointestinal
disease can occur in the absence of skin manifestations. Surgical
treatment for gastrointestinal disease is reserved for bleeding,
obstruction, and perforation. Chemotherapy is used to treat the
manifestations of Kaposi’s sarcoma. Complications of medical
management include paralytic ileus and necrosis or ­perforation
of the bowel.
As stated previously, the depressed immune system in HIV posi-
tive patients yields higher complication rates with surgery. Therefore,
any abdominal colorectal procedure will carry higher rates of wound
infections, dehiscence, anastomotic leak, bowel obstruction, and fis-
tula formation. If colorectal resections are required, creation of a
diversion with stoma formation has been shown to decrease the rate
and severity of subsequent complications.(28–30)
Colitis secondary to cytomegalovirus (CMV) infection has an
increased rate among the HIV population. Autopsies of those
infected with HIV have demonstrated CMV coinfections to be
present in almost 90% of those studied.(31, 32) All areas of the
­gastrointestinal tract can be involved; however, colonic involve-
ment predominates. Lower gastrointestinal bleeding and ulcer per-
foration are common causes for surgical intervention. Ileocolitis
and proctocolitis can be indications for partial or total colectomy.
It should be noted that any indicated colorectal surgery should be
approached cautiously and that the most conservative manage-
ment possible should be pursued. Previously mentioned surgical
complications among the immune compromised patients should
guide the surgeon’s interventions in treating these patients with
the most conservative care.(24, 28)
Common Anorectal Sexually
Transmitted Diseases
Herpes simplex virus (HSV) is transmitted via direct skin con-
tact and results in small, painful vesicles about the perianal skin.
Lesions typically last for 2 weeks and remain contagious even in
the asymptomatic stage. Vesicles can become secondarily infected
 miscellanous conditions
and are noted to have erythematous edges. Proctitis can occur
and is diagnosed with endoscopic evaluation demonstrating an
inflamed and friable mucosa. Swabs taken from the ulcerations
are sent for viral culture and polymerase chain reaction (PCR).
Treatment involves medical management and local debride-
ment for superimposed infections. Of note, Elsberg syndrome
can develop on this patient population. The ­syndrome describes
a sacral radiculitis which includes symptoms of ­constipation,
urinary retention, lower extremity weakness, and parasthesias.
Magnetic resonance imaging and polymerase chain reaction
testing of the cerebrospinal fluid (CSF) can aid in the diagno-
sis. Management includes local analgesic creams for sympto-
matic relief and good hygiene to prevent secondary infections of
the affected area. Antiviral medications are available which can
decrease the severity and length of viral recurrences, but does
not cure the ­disease. Patients must be counseled that viral shed-
ding can occur at any stage in the disease progression, even when
the patient is asymptomatic.
Chlamydia trachomatis infections can lead to proctitis, with
symptoms of rectal urgency, bleeding, and pain. If the infection
progresses proximally, bloody diarrhea can occur. Endoscopic eval-
uation demonstrates diffuse inflammation and ulcerations. PCR
and cultures reveal the diagnosis. Treatment includes antibiotics
such as doxycycline and azithromycin.
Neisseria gonorrhea is a gram-negative diplococcus which infects
the mucous membranes via direct contact. This infection can lead
to proctitis, urethritis, cervicitis, pharyngitis, and conjunctivitis. In
men, transmission occurs via anal receptive intercourse. Women
may become infected by similar means or from autoinoculation
secondary to a vaginal infection. After an incubation period rang-
ing 3 days to 2 weeks, proctitis or cryptitis may occur. Symptoms
can include pruritus ani, bloody discharge, and pain. Disseminated
gonorrhea occurs if the disease is not treated; pericarditis, meningi-
tis, and arthritis are manifestations of disseminated disease. A thick,
purulent discharge can be expresses from the anal crypts and is highly
suspicious for gonoccal proctitis. This discharge should be collected
on Thayer-Martin plates for identification via culture. Management
includes systemic antibiotics with ceftriaxone, cefixime, flouroqui-
nolones, or azithromycin. Current treatment of gonorrhea also
includes treatment of a presumed Chlamydia infection.
Another common sexually transmitted disease is syphilis,
caused by the spirochete, Treponema pallidum. Anorectal disease
presents much like other sites of inoculation: a chancre repre-
sents the first stage of the disease. These ulcerative lesions may
be associated with pain and inguinal adenopathy. Rectal symp-
toms may include discharge or bleeding. If untreated, the first
stage of syphilis resolves within 2–4 weeks with subsequent pro-
gression to secondary syphilis. A macular rash on the torso and
extremities denotes secondary syphilis. Condyloma lata may be
present during this time as well as mucosal ulcerations. Without
treatment, this condition will spontaneously resolve within a few
weeks. Tertiary syphilis with its neurologic and vascular seque-
lae will eventually develop if left untreated. Serologic testing with
Venereal Disease Research Laboratory (VRDL) and rapid plasma
regain (RPR) will provide the diagnosis. The treatment of choice
remains penicillin G and doxycycline.
References
  1. Nelson RL, Abcarian H, Davids FG, Persky V. Prevalence of
benign anorectal disease in randomly selected a population.
Dis Colon Rectum 1994; 88: 341.
  2. Wexner SD, Dailey TH. Pruritis ani: diagnosis and manage-
ment. Curr Concepts Skin Disorders 1986; 7: 5–7.
  3. Farouk R, Duthie GS, Pryde A, Bartolo DC. Abnormal tran-
sient internal sphincter relaxation in idiopathic pruritus ani:
physiologic evidence from ambulatory monitoring. Br J Surg
1994; 81: 603.
  4. Kranke B, Trummer M, Brabek E et al. Etiologic and causative
factors in perianal dermatitis: results of a prospective study in
126 patients. Wien Klin Wochenschr 2006; 118: 90.
  5. Friend WG. The cause and treatment of idiopathic pruritus
ani. Dis Colon Rectum 1977; 20: 40–2.
  6. Daniels GL, Longo WE, Vernava AM. Pruritus ani: causes
and concerns. Dis Colon Rectum 1994; 37: 670–4.
  7. Stone HB. Pruritus ani. Treatment by alcohol injection. Surg
Gynecol Obstet 1926; 42: 565–6.
  8. Turell R. Tattooing with mercury sulfide for intractable anal
pruritis. Surgery 1948; 23: 63.
  9. Lockhart-Mummery JP. Diseases of the Rectum and Colon.
London: Baillere; 1934.
10. Daniel GL, Longo WE, Vernava AM 3rd. Pruritus ani. Causes
and concerns. Dis Colon Rectum 1994; 37: 670.
11. Sauder DN, Skinner RB, Fox TL, Owens ML. Topical imiqui-
mod 5% cream as an effective treatment for external genital
and perianal warts in different patient populations. Sex Transm
Dis 2003; 30: 124–8.
12. Sohn N, Robilotti JG. The gay bowel syndrome, a review of
colonic and rectal conditions in 200 male homosexuals. AM
J Gastroenterol 1977; 67: 478–84.
13. Wexner SD. Sexually transmitted diseases of the colon, rectum
and anus. Dis Colon Rectum 1990; 12: 1048–62.
14. Thomas JPS, Grace RH. The treatment of perianal and anal
condyloma acuminata: a new operative technique. Proc
R Soc Med 1978; 71: 180–5.
15. Gollock JM, Slatford K, Hunter JM. Scissor excision of
­anogenital warts. Br J Venereal Dis 1982; 58: 400–1.
16. Krebs HB, Wheelock JB. The CO2 laser for recurrent and
therapy resistant condylomata acuminatum. J Reprod Med
1985; 30: 489–92.
17. Volen D. Intact viruses in CO2 Laser plumes spur safety
­concern. Clin Laser Monthly 1987; 5: 101–3.
18. Swerdlow DB, Salvati EP. Condyloma acuminatum. Dis
Colon Rectum 1971; 14: 226–9.
19. Boot JM, Stolz E. Intralesional interferon -2b treatment of
Condylomata acuminata previously resistant to podophyllin
resin application. Genitoruin Med 1983; 65: 50–3.
20. Langley PC, Tyring SK, Smith MH. The cost effectiveness of
patient-applied versus provider-administered intervention
strategies for the treatment of external genital warts. Am
J Managed Care 1999; 5: 69–77.
21. Abcarian H, Sharon N. Long term effectiveness of immuno-
therapy of anal condyloma acuminatum. Dis Colon Rectum
1982; 10: 648–51.
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 improved outcomes in colon and rectal surgery
22. Mathews WC. Screening for anal dysplasia associated with
human papillomavirus. Top HIV Med 2003; 11: 45–9.
23. Wexner SD. AIDS: what the colorectal surgeon needs to
know. Perspect Colon Rectal Surg 1989; 2: 19–54.
24. Cohen SM, Schmitt SL, Lucas FV, Wexner SD. The diagnosis
of anal ulcers in AIDS patients. Int J Colorect Dis 1994; 9:
168–73.
25. Viamonte M, Dailey TH, Gottesman L. Ulcerative disease
of the anorectum in the HIV positive patient. Dis Colon
Rectum 1993; 36: 801–5.
26. Danzig JB, Brandt LJ, Reinus JF, Klein RS. Gastrointestinal
malignancy in patients with AIDS. J Gastroenterol 1991; 86:
715–8.
27. Laine L, Amerian J, Rarick M, Harb M. The response of symp-
tomatic gastrointestinal Kaposi’s sarcoma to chemotherapy:
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28. Burack JH, Mandel MS, Bizer LS. Emergency abdominal
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29. Zelnick R, Poulard JB, Auguste LJ, Vretakis G, Margolis IB.
Surgery in the AIDS patient. AIDS Patients 1991; 1: 10–4.
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31. Welch K, Finkbeiner W, Alpers CE et al. Autopsy findings in
AIDS. JAMA 1984; 252: 1152–9.
32. Chachova A, Dietrich D, Krasinski K. 9 (1,3-dihydroxy-
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16 Quality and outcome measures
Janak A Parikh, Sushma Jain, Marcia L McGory, and Clifford Y Ko
Challenging Case
A 64-year-old male is scheduled for a left colectomy for a carcinoma.
His past medical history is significant for a 3 vessel cardiac bypass.
Case Management
The patient’s primary care physician has placed the patient
on beta-blockers. Prophylactic antibiotics (second generation
cephalosporin) are ordered to be given within 1 hour of surgery.
Pneumatic compression stockings are ordered for placement in the
holding area. Unfractionated heparin (5,000 units subcutaneously)
is ordered for 2 hours before start of the operation. The patient’s
body hair is removed with a clipper. Efforts are made to keep the
patient normothermic during and after surgery. Prophylactic
antibiotics are not continued after surgery. Final pathology docu-
ments a T3N1M0 adenocarcinoma. The patient is referred to a
medical oncologist for consideration of adjuvant chemotherapy.
For the first time in its history, the United States is at an impasse
in healthcare. Rising healthcare costs, an aging population, and
a growing number of uninsured Americans are causing concern
among payers and lawmakers. These concerns have led to a large-
scale effort to assess and improve the quality of healthcare delivered
to Americans. A major impetus for quality improvement was the
realization that continuing to increase healthcare expenditure was
not feasible. In 2007, the United States spent approximately 16% of
its gross domestic product, or $2.3 trillion on healthcare, with pro-
jections forecasting a rise to 20% of GDP by 2016.(1) While these
numbers far exceed what other countries spend on healthcare, they
do not ensure that Americans receive better healthcare than other
countries. In fact, with over 46 million people who are uninsured,
and an infant mortality that is ranked 37th in the world, Americans
are arguably not getting the most value out of their healthcare dol-
lar.(2) The focus on quality in healthcare is a reality that current
and future physicians will have to acknowledge, as transparency
via public reporting of physician performance is likely in the near
future. Currently, most efforts remain at the hospital level. In this
chapter, we explore the concept of quality, the various methodolo-
gies of quality improvement (including the use of performance
measures), and examine some of the quality improvement efforts
that are currently ongoing.
Defining Quality of Care
Though interest in healthcare quality is seemingly new, some
have long understood the need to measure and improve the
quality of healthcare in the United States. In the arena of quality
improvement research, the challenges have been how to define
quality, how to measure it, and how best to improve it. As defined
by the Institute of Medicine (IOM), quality of care is defined as
“the degree to which health services for individuals and popula-
tions increase the likelihood of desired health outcomes and are
­consistent with current professional knowledge.”(3) A more basic
but equally accurate definition is the delivery of appropriate care
at the right time to the right patient, and done right.
In the past, the concept of healthcare quality was not at the
political and social forefront as it is today. Many probably assumed
that healthcare in the United States is of the highest quality and far
superior to healthcare elsewhere in the world given our techno-
logical advances and expenditures. However, in 1999, this notion
visibly began to be challenged in the public eye.
The 1999 IOM report “To Err is Human: Building a Safer Health
System” was the first report that challenged the perception of a safe
high quality healthcare system in the United States.(4) The IOM
report pointed out the human errors in the healthcare industry and
helped identify potential faulty systems, processes, and ­conditions
within our current healthcare system that led healthcare providers
to make mistakes. It is estimated that as many as 98,000 people die in
hospitals every year as a result of preventable medical errors.(4, 5)
Introduction
These types of medical errors not only affect patient’s physical
and psychological discomfort, but also increase hospital costs and
decrease a patient’s societal productivity. Most importantly, the IOM
report forced creation of national goals and recommended a four-
tiered approach to achieve patient safety—first, to create leadership;
second, to have a nationwide public mandatory reporting system to
identify and learn from medical errors; third, to raise performance
standards and expectations for improvements in safety; and fourth,
to implement safety systems in healthcare organizations.(4)
Based largely on the results of the 1999 IOM report, the IOM next
developed a report entitled “Crossing the Quality Chasm: A New
Health System for the 21st Century”, which defined six ­specific aims
for improvement: (1) Safety (e.g., avoiding errors in drug administra-
tion by simplifying the protocols for drug delivery), (2) Effectiveness
(e.g., appropriate chemotherapy for stage II or III colorectal cancer),
(3) Patient-Centeredness (e.g., patients having access to their own
medical record information and to healthcare providers by email,
phone etc.), (4) Timeliness (e.g., reducing waiting time for provider
appointments or in the emergency room), (5) Efficiency (e.g., stream-
lining forms to reduce paperwork so that providers can spend more
time on patient care), and (6) Equity (e.g., patients should receive
appropriate care regardless of race, age, gender, ethnicity, income,
geographic location).(6) The goal of outlining these six specific aims
was to help our current healthcare system to cross the chasm that lies
between what is currently being delivered by the healthcare system
and the quality of care that should be delivered.(3)
History of Quality Assessment and Quality
Improvement in Surgery
The goal of improving quality and outcomes is actually not new
to the discipline of surgery. Ernest Amory Codman, M.D. (1869–
1940), a surgeon, was the founder of the “End Result Idea”, and

 improved outcomes in colon and rectal surgery
father of the medical quality movement.(7, 8) In 1895, he gradu-
ated from Harvard Medical School and interned at Massachusetts
General Hospital (MGH). He later joined the surgical staff at
MGH and became a member of the Harvard faculty. In 1914, he
proposed evaluating surgeon competency at MGH. He believed
that “every hospital should follow every patient it treats long
enough to determine whether the treatment has been successful,
and then to inquire ‘if not, why not’ with a view to preventing
similar failures in the future.” In fact, he is quoted as saying: “…
I am called eccentric for saying in public that hospitals, if they
wish to be sure of improvement,
1. Must find out what their results are.
2. Must analyze their results, to find their strong and weak points.
3. Must compare their results with those of other hospitals.
4. Must care for what cases they can care for well, and avoid
attempting to care for those cases which they are not quali-
fied to care for well….
5. Must assign cases to the members of the staff (for treatment)
for better reasons than seniority, the calendar or temporary
convenience
6. Must welcome publicity not only for their successes, but for
their errors, so that the Public may give them help when it is
needed.
7. Must promote members of the Staff on a basis which gives
due consideration to what they can and do accomplish for
their patients.”(7)
In this regard, Dr. Codman made one of the most important
contributions in the history of outcomes research in health-
care. However, his thinking was well before its time. The MGH
refused his plan and asked him to resign. Dr. Codman eventu-
ally established his own hospital (which he called the “End
Result Hospital”) to pursue his performance measurement and
improvement objectives. To support his “end results theory,” Dr.
Codman publicly reported these data in a book entitled A Study in
Hospital Efficiency. Of the 337 patients discharged between 1911
and 1916, Dr. Codman recorded and published 123 errors. He
systematically documented errors in diagnosis and treatment for
every patient, and followed each patient for years after ­discharge
to evaluate the end results of care. Not surprisingly, he was the
first to institute the mortality and morbidity conference. Due to
his immense interest in the quality of care delivered to patients,
Dr. Codman helped lead the founding of the American College of
Surgeons’ (ACS) Hospital Standardization program which later
became the Joint Commission on Accreditation of Healthcare
Organizations.(7, 8) Unfortunately, Dr. Codman’s ideas were
probably too revolutionary for that time period and, as a result,
were not well received. In point of fact, we are still working today
towards implementing many of Dr. Codman’s original concepts
with respect to documentation of complications and evaluating
the end results of surgical care in our patients.
The Donabedian Model of Quality of Care
Today, the most commonly used paradigm for quality improve-
ment is the Donabedian model. In 1988, Donabedian developed
a framework for assessing quality of care that involved three

domains: structure, process, and outcomes.(9) The structural
components of care refer to the physical characteristics of the
institution. In a hospital, these would include the characteristics
of the hospital and provider. Examples of structural components
would be the hospital’s volume for a particular procedure, board
certification of its physicians, or the presence of a computerized
order entry system. Process components include interactions
that occur between the provider and patient, and are com-
monly considered the most direct predictors of quality of care
because they identify a priori steps to make improvements
and are not affected by patient characteristics (i.e., higher
mortality rates for surgeons/hospitals with sicker patients).
Examples of specific process measures include such things as
timely administration of preoperative antibiotic prophylaxsis,
use of sequential compression devices and/or heparin to prevent
deep venous thrombosis, and the use of postoperative chemo-
therapy in patients with stages III colon cancer. Finally, outcome
components of care are probably most familiar to surgeons, and
include morbidity, complications, and mortality. Two important
issues to consider when using outcome to judge quality are that in
order to be optimally used, outcomes require risk-adjustment to
compare different providers or facilities. Additionally, while out-
come measures may be used to identify poor care, in and of itself,
outcomes might not readily identify how to actually improve
care. If a surgeon’s risk-adjusted anastomotic leak rate is high, the
cause may not be immediately or readily known, or identifiable.
Nevertheless, outcome measurement is an important component
of quality improvement because it has great face validity, as well
as being the “standard” by which structural and process-based
measures are validated. In point of fact, there have been numer-
ous projects that have made comparisons between hospitals
and physicians outcomes.
Improvement based on Structural Measures
Established as a nonprofit organization in 2000 by a small
group of large corporations that purchase healthcare for their
employees, the Leapfrog Group’s growing consortium of major
companies and other large private and public healthcare purchas-
ers provide health benefits to more than 37 million Americans.
(10) The mission of the Leapfrog group is to use the purchas-
ing power of its members to influence the quality and afford-
ability of healthcare. In mid-2001, the Leapfrog Group began
­collecting hospital data to evaluate healthcare quality in six
regions in the United States. Currently, the Leapfrog data cover
over half the U.S. population and 58% of all hospital beds with
over 1,300 participating hospitals nationwide.(11) Their efforts
to improve the value of healthcare have been important.
The Leapfrog Group encourages its member companies to
adhere to the following four purchasing principles in buying
healthcare for their enrollees:
•• Educating and informing enrollees about the safety, quality
and affordability of health care and the importance of compar-
ing the care providers give with initial emphasis on the safety
and quality practices.
•• Recognizing and rewarding healthcare providers for major
advances in the safety, quality, and affordability of their care.
 quality and outcome measures
•• Holding health plans accountable for implementing the
Leapfrog purchasing principles.
•• Building the support of benefits, consultants and brokers to use
and advocate for the Leapfrog purchasing principles with all of
their clients.(11)
In their quest, the group established measures by which to rate
hospitals. Each quality measure had to meet four criteria:
•• There is overwhelming scientific evidence that these quality
and safety leaps will significantly reduce preventable medical
mistakes.
•• Their implementation by the health industry is feasible in the
near term.
•• Consumers can readily appreciate their value.
•• Health plans, purchasers, or consumers can easily ascertain
their presence or absence in selecting among healthcare pro-
viders.(11)
Using these criteria, the Leapfrog Group identified four struc-
tural measures to improve care. These included the existence of a
computer physician order entry system, evidence-based ­hospital
referral (EHR), intensive care unit (ICU) staffing by physicians
experienced in critical care medicine, and the Leapfrog Safe
Practices Score.(11)
Of these measures, the one that has probably gained the most
attention in surgery is the evidence-based hospital referral. This
measure is founded on literature that demonstrates a volume-out-
come relationship for certain complex procedures—more specifi-
cally, that higher volume hospitals purportedly have better outcomes.
The procedures currently with established volume-­outcome rela-
tionships and the current EHR procedures include coronary artery
bypass grafting (CABG) (≥450/year), percutaneous coronary inter-
vention (AAA) (≥400/year), aortic valve replacement (≥120/year),
abdominal aortic aneurysm repair (AAA) (≥50/year), esophagec-
tomy (≥13/year), pancreatic resection (≥11/year), and bariatric
surgery (>100/year).(12) Other procedures that have evidence to
suggest a volume-outcome relationship include carotid endarter-
ectomy, lower-extremity bypass, mitral valve replacement, gastrec-
tomy, cystectomy, pneumonectomy, lobectomy, and nephrectomy.
(13) Relative to this textbook, the volume-outcome relationship in
colorectal cancer surgery is varied. While a recent systematic review
found a significant surgeon volume-outcome relationship in color-
ectal cancer surgery, the magnitude of effect on mortality was small
(1–2%).(14–17) This is consistent with the analysis by Birkmeyer
et al. upon which the Leapfrog criteria are based.(13)
Although there are multiple studies to support the volume-
outcome relationship established by The Leapfrog Group, there
are several potential issues that warrant further discussion. First,
the analyses in most studies do not account for the possibility that
surgeons with similar volumes may have very different outcomes
because of systematic differences in processes of care. Thus, a
high degree of clustering of outcomes may lessen the impact of
volume on outcomes.(18) A second concern is the somewhat
arbitrary nature of the cutoffs. For example, several recent ­studies
exploring the volume-outcome relationship for CABG and AAA
have demonstrated similar outcomes at lower volumes than
the Leapfrog cutoffs. Finally, selective referral may potentially
increase disparities, as the disenfranchised likely will not be able
to participate in the referral process. Still, volume is being used
as a proxy for quality of care, and in this regard, volume-based
referral is probably a reasonable way to improve quality at this
point in time.
Improvement Based on Process Measures
Compared to both structural and outcome measures, the use of
process measures has the advantage of identifying a ­priori steps that
lead to improvements in quality. Furthermore, process measures
are not affected by patient characteristics and thus do not require
risk-adjustment. For these reasons, process measures play an
important role in the Centers of Medicare and Medicaid Services
(CMS) effort to improve quality of care. In October of 2005, CMS
introduced the Surgical Care Improvement Project (SCIP).(19) The
goal of SCIP was to reduce surgical complications by 25% by the
year 2010.(19) Many national organizations came together to form
an expert panel to develop the SCIP measures. At present, there are
approximately 20 measures. These measures target four domains of
care, namely, prevention of postoperative infection, prevention of
postoperative venous thromboembolism, prevention of cardiac events,
and prevention of ventilator-associated pneumonia. There are specific
process measures in each domain. For example, prevention of post-
operative infection involves such things as administration of appro-
priate prophylactic antibiotics 1 hour before incision, use of clippers
to remove hair, maintainence of normoglycemia postoperatively for
cardiac surgery patients, and postoperative normothermia for color-
ectal surgery patients. A full list of measures is provided in Table 16.1.
Hospital participation in SCIP is voluntary at the time of this writ-
ing, and at present there is financial incentive for hospitals to enroll in
the program since there is “pay for participation.” However, the SCIP
measures may become pay-for-performance measures in the future.
Currently, CMS has several surgical pay-for-participation measures
scheduled to be implemented in October 2008 (Table 16.2).(20–22)
In December 2007, CMS unveiled its most recent effort to
improve healthcare quality by launching the Physician Quality
Reporting Initiative (PQRI). Mandated by the 2006 Tax Relief
and Health Care Act, PQRI is a provider-level quality improve-
ment project whose initial aim is to have providers submit data
on several CMS quality measures.(23) PQRI is another pay-for-
participation program in which physicians who participate will
earn an incentive payment of 1.5% of their total allowed charges
for the Medicare Physician Fee Schedule covered services. The
incentive payments are based on reporting from January 1, 2008
through December 31, 2008 and are scheduled to be disbursed
in mid-2009 from Medicare Part B funds. In total, there are 134
reportable measures that span all areas of care. Healthcare pro-
fessionals that are eligible to participate in the PQRI program
include physicians, dentists, optometrists, nurse practioners, and
physical therapists to name a few. For surgeons, there are approx-
imately 14 measures, with an additional 7 measures which are
­generally applicable to all physicians (Table 16.3).(24)
Outcomes
Similar to the ideas of Dr. Codman, knowing one’s outcomes may
help drive quality improvement. One of the best examples of this

 improved outcomes in colon and rectal surgery

Table 16.1  Surgical Care Improvement Project (SCIP) measures.

SCIP Measures

Target Areas Measures

1.   Surgical Site Infection 1.  Prophylactic antibiotic received within 1 hour prior to surgical incision.
2.  Prophylactic antibiotic selection for surgical patients.
3.  Prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients).
4.  Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose.
5.  Postoperative wound infection diagnosed during index hospitalization. (OUTCOME)
6.   Surgery patients with appropriate hair removal
7.  Colorectal surgery patients with immediate postoperative normothermia.
2.  Adverse Cardiac 1.  S urgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period.
Events 2.  Intra- or postoperative acute myocardial infarction (AMI) diagnosed during index hospitalization and within 30 days
of surgery. (OUTCOME)
3.  Deep Vein 1.  S urgery patients with recommended venous thromboembolism prophylaxis ordered.
Thrombosis 2.  Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours
after surgery.
3.  Intra- or postoperative pulmonary embolism (PE) diagnosed during index hospitalization and within 30 days of surgery.
(OUTCOME)
4.  Intra- or postoperative deep vein thrombosis (DVT) diagnosed during index hospitalization and within 30 days of surgery.
(OUTCOME)
4.  Postoperative 1.  Number of days ventilated surgery patients had documentation of the Head of the Bed (HOB) being elevated from recovery end
ventilator related date (day zero) through postoperative day seven.
pneumonia 2.  Patients diagnosed with postoperative ventilator-associated pneumonia (VAP) during index hospitalization. (OUTCOME)
3.  Number of days ventilated surgery patients had documentation of stress ulcer disease (SUD) prophylaxsis from recovery end date
(day zero) through postoperative day seven.
4.  Surgery patients whose medical record contained an order for a ventilator weaning program (protocol or clinical pathway).
Miscellaneous 1.   Mortality within 30 days of surgery.
2.   Readmission within 30 days of surgery.
3.  Proportion of permanent hospital end stage renal disese (ESRD) vascular access procedures that are autogenous AV fistula.

Table 16.2  Centers for Medicare and Medicaid Services (CMS)
surgical pay-for-participation measures.
CABG 1.   Aspirin prescribed at discharge
2.  CABG using internal mammary artery
3.  Prophylactic antibiotic within 1 hour prior to
surgical incision
4.  Prophylactic antibiotic selection for isolated
CABG patients
5.  Prophylactic antibiotics discontinued within
487 hours after surgery end time
6.   Inpatient mortality rate
7.   Postoperative hemorrhage or
hematoma
8.  Postoperative physiologic and metabolic
derangement
Hip & Knee 1.  Prophylactic antibiotic received within
Replacement 1 hour prior to surgical incision
2.  Prophylactic antibiotic selection for hip and
knee replacement patients
3.  Prophylactic antibiotics discontinued within
24 hours after surgery end time
4.   Postoperative hemorrhage or hematoma
5.  Postoperative physiologic and metabolic
derangement
6.   Readmissions 30 days postdischarge
7.  Hip/Knee Surgery Patients with Recommended
Venous Thromboembolism Prophylaxis
Ordered
8.  Hip/Knee surgery patients Who Received
Appropriate Venous Thromboembolism
Prophylaxis Within 24 Hours Prior to Surgery
to 24 Hours After Surgery
notion is the National Surgical Quality Improvement Program
(NSQIP) and its association with the marked improved surgical
care in the Veteran Affairs (VA) hospitals. During the mid-to-late
1980s, the VA hospitals came under a great deal of public scrutiny
over the quality of surgical care in their 133 VA hospitals. In 1991,
Congressional leaders were concerned that the operative mortal-
ity at VA hospitals was higher than that at private hospitals for the
same procedure. In an effort to address this quality issue, congress
passed a law which mandated the VA to report its risk-adjusted
surgical outcome annually and to compare them to national aver-
ages. In response to this mandate, the VA established the National
VA Surgical Risk Study (NVASRS) in 44 VA medical centers.(25)
In this study, a dedicated nurse at each site collected preoperative,
intraoperative, and 30-day postoperative data on over 95 outcome
variables for more that 117,000 major operations. Using this data,
researchers developed a risk-adjustment model and were able to
determine risk-adjusted 30-day morbidity and mortality rates in
nine surgical specialties. Given the feasibility of the study, helped
by the nationwide electronic medical record which has been in
place in VA hospitals since 1985, the VA established the NSQIP in
1994. Each year, data from 110,000 major surgical cases are added
to the database. Most importantly, the program has been highly
successful, reducing 30-day mortality rates by 31% and 30-day
morbidity rates by 45%.(26) This success was further solidified
when, in 2002, the IOM named NSQIP “the best in the nation”
for measuring and reporting surgical quality outcomes.(25)
Given the success of NSQIP and the increasing focus on
healthcare quality, private hospitals questioned whether or not


 quality and outcome measures

Table 16.3  Surgery-related Physician Quality Reporting Initiative (PQRI) measures.

Surgery Specific Measures

Perioperative Care: Timing of Antibiotic Prophylaxis—Ordering Physician

Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an
order for prophylactic antibiotic to be given within 1 hour (if fluoroquinolone or vancomycin, 2 hours), prior to the surgical incision (or start of procedure when
no incision is required)
Perioperative Care: Selection of Prophylactic Antibiotic—First OR Second Generation Cephalosporin
Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin
prophylactic antibiotic, who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures)
Description: Percentage of noncardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who
received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Description: Percentage of patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low
Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given
within 24 hours prior to incision time or within 24 hours after surgery end time
Perioperative Care: Timing of Prophylactic Antibiotics—Administering Physician
Description: Percentage of surgical patients aged 18 and older who have an order for a parenteral antibiotic to be given within 1 hour (if fluoroquinolone or
vancomycin, 2 hours) prior to the surgical incision (or start of procedure when no incision is required) for whom administration of prophylactic antibiotic has
been initiated within 1 hour (if fluoroquinolone or vancomycin, 2 hours) prior to the surgical incision (or start of procedure when no incision is required)
Use of Internal Mammary Artery (IMA) in Coronary Artery Bypass Graft (CABG) Surgery
Description: Percentage of patients aged 18 years and older undergoing isolated coronary artery bypass graft (CABG) surgery using an internal mammary artery (IMA)
Preoperative Beta-blocker in Patients with Isolated Coronary Artery Bypass Graft (CABG) Surgery
Description: Percentage of patients aged 18 years and older undergoing isolated coronary artery bypass (CABG) surgery who received a beta-blocker preoperatively
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures)
Description: Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic antibiotics AND who
received a prophylactic antibiotic, who have an order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time
Prevention of Ventilator-Associated Pneumonia—Head Elevation
Description: Percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who had an order on the first ventilator day for head of bed
elevation (30–45 degrees)
Prevention of Catheter-Related Bloodstream Infections (CRBSI)—Central Venous Catheter Insertion Protocol
Description: Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal
sterile barrier technique (cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous
antisepsis) followed
Vascular Access for Patients Undergoing Hemodialysis
Description: Percentage of patients aged 18 years and older with a diagnosis of end stage renal disease (ESRD) and receiving hemodialysis who have a functioning AV
fistula OR patients who are referred for an AV fistula at least once during the 12-month reporting period
HIT- Adoption/Use of Health Information Technology (Electronic Health Records)
Description: Documents whether provider has adopted and is using health information technology. To qualify, the provider must have adopted a qualified electronic
medical record (EMR). For the purpose of this measure, a qualified EMR can either be a Certification Commission for Healthcare Information Technology
(CCHIT) certified EMR or, if not CCHIT certified, the system must be capable of all of the following:

• Getnerating a medication list

• Generating a problem list
• Entering laboratory tests as discrete searchable data elements
HIT- Adoption/Use of e-Prescribing
Description: Documents whether provider has adopted a qualified e-Prescribing system and the extent of use in the ambulatory setting. To qualify this system must
be capable of ALL of the following:

• Generating a complete active medication list incorporating electronic data received from applicable pharmacy drug plan(s) if available
• Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all safety checks (defined below)
• Providing information related to the availability of lower cost, therapeutically appropriate alternatives (if any)
• Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s
drug plan
Pain Assessment Prior to Initiation of Patient Treatment
Description: Percentage of patients aged 18 years and older with documentation of a pain assessment (if pain is present, including location, intensity and description)
through discussion with the patient or through use of a standardized tool on each initial evaluation prior to initiation of therapy
Surgery-Related Measures
Chemotherapy for Stage III Colon Cancer Patients
Description: Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are prescribed or who have received adjuvant chemotherapy
during the 12-month reporting period

(continued)


 improved outcomes in colon and rectal surgery

Table 16.3  (continued).

Surgery Specific Measures

Radiation Therapy Recommended for Invasive Breast Cancer Patients who have Undergone Breast Conserving Surgery
Description: Percentage of invasive female breast cancer patients aged 18 through 70 years old who have undergone breast conserving surgery and who have received
recommendation for radiation therapy within 12 months of the first office visit
Universal Documentation and Verification of Current Medications in the Medical Record
Description: Percentage of patients aged 18 years and older with written provider documentation that current medications with dosages (includes prescription, over-
the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements) were verified with the patient or authorized representative
Patient Co-Development of Treatment Plan/Plan of Care
Description: Percentage of patients aged 18 years and older identified as having actively participated in the development of the treatment plan/plan of care. Appropriate
documentation includes signature of the practitioner and either co-signature of the patient or documented verbal agreement obtained from the patient or, when
necessary, an authorized representative
Screening for Cognitive Impairment
Description: Percentage of patients aged 65 years and older who have documentation of results of a screening for cognitive impairment using a standardized tool
Screening for Future Fall Risk
Description: Percentage of patients aged 65 years and older who were screened for future fall risk (patients are considered at risk for future falls if they have had 2 or
more falls in the past year or any fall with injury in the past year) at least once within 12 months

a NSQIP-style program could be implemented in non-VA hos-
pitals and if it would have the same benefits. To explore these
questions, a pilot study was launched in 1999 at three non-VA
hospitals: Emory University, the University of Michigan, and the
University of Kentucky.(25) Despite the study being limited to
general and vascular surgery cases, the study determined that the
data collection and transmission methods, as well as the risk-
­adjustment models were applicable in the private sector. The
success of this pilot study attracted the attention of the American
College of Surgeons (ACS) which, in 2001, began to take an
active role in developing a NSQIP system for private hospitals by
obtaining funding from the Agency for Healthcare Research and
Quality (AHRQ) to expand the pilot program to 14 additional
hospitals, including several community-based hospitals.(25)
Using the AHRQ grant, the ACS developed the infrastructure to
make it feasible to roll the NSQIP to private sector hospitals. This
included the development of a web-based data collection system,
training nurses to abstract and enter data, and to gather a team
of analysts to risk-adjust the outcomes and prepare reports of
the member hospitals. Once the infrastructure was in place, the
ACS opened the ACS NSQIP to all private ­hospitals in October
of 2004. The current program has over 200 participating hos-
pitals and has expanded its scope to address over 10 surgical
­specialties, with additional ones being developed.(25)
One area of outcomes-based quality improvement that has
gained a lot of recent attention is the so-called hospital acquired
conditions, or “never events.” These are a list of 27 events first
released publicly by the National Quality Forum (NQF) in
November of 2006 (Table 16.4).(27) In 2007, The Leapfrog Group
recognized hospitals that met certain criteria in the situation of
when a “never event” occurred. These criteria included apologiz-
ing to the patient and/or family, reporting the event to JCAHO,
performing a root cause analysis to prevent future events, and
to waive all costs directly related to the adverse event.(10, 27)
Recently, CMS has made a push not to reimburse the hospital for
costs attributable to a “never event.” This is one of the best exam-
ples to date of a payer levying a financial disincentive against a
hospital for poor quality.
Quality of Care in Colorectal Disease
There are a number of quality assessment/quality improvement
projects in colorectal surgery and colorectal disease. In addition
to the already described “performance measures” (e.g., SCIP), a
number of investigative projects have been performed that have
studied and identified some potential additional quality meas-
ures, as well as importantly studied how we might collect such
data. A few of these projects are discussed below to offer a feel for
the type and variety of projects that have been performed.
One important project initiated with the support of the
American Society of Colon and Rectal Surgery (ASCRS) is The
Vermont Colorectal Cancer Project.(28) This project demon-
strated that a statewide quality improvement project that required
surgeons to input case data was feasible, with a compliance rate of
78%. Using these principles, the project was expanded to the New
England area with the New England Colorectal Society project
registry, a prospective, multiinstitutional regional database of
patients undergoing surgery for colorectal cancer at 13 partici-
pating hospitals.(29) The study importantly found that surgeons
were willing to participate in a collaborative, multi-institutional
database, and this set the groundwork for successful data collec-
tion to evaluate and improve colorectal cancer care.
A number of additional studies have addressed colorectal can-
cer quality of care. For example, the American Society of Clinical
Oncology (ASCO) in part established the National Initiative on
Cancer Care Quality (NICCQ) to develop quality of care meas-
ures for breast and colorectal cancer.(17, 30, 31) The NICCQ
project team developed 25 process-based quality measures that
spanned four domains of care: (1) diagnostic evaluation (10
measures); (2) surgery (4 measures); (3) adjuvant therapy (10
measures); and (4) surveillance (1 measure). Using a different
set of processes and methodologies, the ACS developed a similar
set of quality measures for breast and colorectal cancer. Both the
NICCQ and the ACS submitted these measures to the NQF for
their endorsement. Facilitated by the NQF, the ACS and NICCQ
agreed to synchronize their measures (Table 16.5).(32)
After development of the NICCQ measures, compliance was
determined using multiple sources (e.g., hospital cancer registries,


 quality and outcome measures

Table 16.4  National Quality Forum (NQF) hospital acquired conditions (never events).

 1 Unintended retention of a foreign object in a patient after surgery or other procedure

 2 Patient death or serious disability associated with patient elopement (disappearance)
 3 Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate,
wrong preparation or wrong route of administration)
 4 Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products
 5 Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility
 6 Patient death or serious disability associated with a fall while being cared for in a healthcare facility
 7 Artificial insemination with the wrong donor sperm or donor egg
 8 Surgery performed on the wrong body part
 9 Surgery performed on the wrong patient
10 Wrong surgical procedure performed on a patient
11 Intraoperative or immediately postoperative death in an ASA Class I patient
12 Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
13 Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as
intended
14 Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility
15 Infant discharged to the wrong person
16 Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility
17 Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare facility
18 Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility
19 Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates
20 Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility
21 Patient death or serious disability due to spinal manipulative therapy
22 Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
23 Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility
24 Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility
25 Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
26 Abduction of a patient of any age
27 Sexual assault on a patient within or on the grounds of the healthcare facility
28 Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the
healthcare facility

Table 16.5  American Society of Clinical Oncology (ASCO),
National Comprehensive Cancer Network (NCCN), Colorectal
Quality Measures, and Commission on Cancer (CoC) Joint
Quality Measures for Colorectal Cancer.
Area
Colon 1.  Receipt of adjuvant chemotherapy within 4
months of diagnosis for patients <80 years
of age with AJCC Stage III (lymph node
positive) colon cancer
2.  ≥12 lymph nodes should be removed and
pathologically examined for resected colon
cancer
3.  Receipt of radiation therapy within 6
months of diagnosis for AJCC stage III
colon cancer patients
Rectum 4.  Receipt of postoperative adjuvant
chemotherapy within 9 months for AJCC
stage II or III rectal cancer
this is much higher than the 55% compliance rate found for most
types of care.(33) Potential reasons for higher compliance may
be the urgency of a cancer diagnosis (beyond chronic conditions
such as diabetes) and the multidisciplinary approach to cancer
treatment. However, selection bias may increase compliance rates
since the NICCQ study only examines 4-year survivors and it is
possible that those who died received lower quality care.
In 2001, the National Cancer Institute (NCI), in collaboration
with the VA, launched a project entitled “Cancer Care Outcomes
Research and Surveillance Consortium” (CanCORS) to measure
the quality of care patients received in colorectal cancer and lung
cancer care. This prospective observational cohort study on nearly
10,000 patients (4,921 with colorectal cancer and 5,105 with lung
cancer) addressed how patient, provider, and system character-
istics affected the care patients received and their outcomes.(34)
The goal was to better understand the reasons behind disparities
in cancer care. The two central goals of the project were to:

1) Determine how the characteristics and beliefs of cancer patients

patient surveys) in a sample of stage II-III colon cancer survivors
in 5 metropolitan areas approximately 4 years after diagnosis.
Overall compliance was 78% for all 25 measures; by domain,
compliance was 87% diagnostic evaluation; 93% surgery; 64%
adjuvant therapy; and 50% surveillance.(17, 32) Interestingly,
and providers and the characteristics of health-care organiza-
tions influence treatments and outcomes, spanning the contin-
uum of cancer care from diagnosis to recovery or death.
2) Evaluate the effects of specific therapies on patients’ survival,
quality of life, and satisfaction with care.(34)


 improved outcomes in colon and rectal surgery
Data collection was completed in April 2007, with 15 years of
followup data on the initial cohort. The study used surveys of
patients, providers, and caregivers to meet the study objectives.
Currently, data are being analyzed to understand the regional
variation in cancer care.
A number of studies have attempted to develop quality ­indicators,
which serve to distinguish acceptable from unacceptable care. In 2006,
McGory et al. published a comprehensive set of quality ­indicators
for patients undergoing colorectal cancer surgery. McGory et al.
used the RAND/UCLA Appropriateness Method to determine the
validity of the candidate indicators using colorectal cancer experts.
(35–39) This method uses an expert panel and a systematic review
of the literature to identify candidate quality ­indicators. McGory
et al. focused on process and structural measures. The 142 indicators
(92 rated as valid) fall under 6 quality domains: surgeon privileging
(e.g., credentialing for laparoscopic colectomy), preoperative evalu-
ation (e.g., staging), patient-provider discussions (e.g., informed
consent), medications (e.g., antibiotic prophylaxis), intraoperative
care (e.g., prevention of ureteral injury), and postoperative manage-
ment (e.g., control of blood glucose).
Similar to McGory et al. Gagliardi et al. used a 3-step modified
Delphi approach to identify the 45 key indicators, of which 37
(82%) were considered valid by the panel.(40) This method also
used an expert panel and a systematic review of the literature to
identify candidate quality indicators. This study reports the top
15 prioritized quality indicators as their final recommendation
for improving the quality of colorectal cancer surgery as rated
by the expert panel, including 4 outcome measures (e.g., 30-day
mortality) and 4 province level measures (e.g., 5-year survival).
Putting it together
Overall, the development and use of quality and outcome meas-
ures still remains a work in progress with the current levels of
underuse, overuse, disparities, and inefficiencies. The goal to
improve the quality of care is not the issue. What remains the issue
is how to improve the quality of care. We have attempted to show
how strategies for improvement have been based on structural,
process, and outcome components—all with their individual
advantages, but also with their recognizable limitations. To date,
there doesn’t appear to be one best way to improve care, which
probably means that a combination of measures and metrics will
be needed. In the field of colon and rectal surgery, the basic qual-
ity measures applicable to most every colorectal surgeon are the
SCIP measures at the hospital level, and the PQRI measures at the
individual (surgeon) level, but more are probably forthcoming.
There are some potential “disease related” measures for colorectal
cancer, but they generally address chemo and radiation therapies.
The only potential surgery-related measure, which is clearly not
solely a surgical issue, is the 12-node measure (i.e., evaluation of a
minimum of 12 lymph nodes in a colon cancer resection). There
has been demonstrable pushback to this measure, and at present, is
not endorsed by the NQF as an “accountability” measure.
Probably the single most important measure for evaluating
and improving care, regardless of strategy, is obtaining accurate
data that is actionable. Specifically, the collection, analysis, and
­feedback of data have yielded quality improvement in a variety of
environments and fields, including colorectal surgery.

The future of quality of care evaluation and improvement is
difficult to predict. The use of quality and outcome measures as
described in this chapter may only be in its infancy. As data systems
become increasingly powerful and sophisticated, and as evidence
in the literature continues to build, we suspect that increasingly
more quality and outcome measures will be developed and used.
The developed measures will likely become increasingly actiona-
ble and clinically meaningful, which will help to advance the field
of quality improvement.
For us to improve our outcomes in colorectal surgery at the
present time, knowing our own quality is paramount. In this
regard, participation in quality improvement programs that col-
lect, feedback, and benchmark data is probably warranted. In
addition, participation in studies that advance the levels of evi-
dence is needed. Finally, recognizing that quality improvement is
an iterative process is essential. All of this highlights the impor-
tance of surgeon involvement to guide quality improvement in
surgery in the right direction.
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­volume and surgical mortality in the United States. N Engl
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 quality and outcome measures
15. Ho V, Heslin MJ, Yun H, Howard L. Trends in hospital and
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28, 2008; Abstract.
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hqi/faqs-year1-3.jsp#Hospital%20Quality. Accessed May 30,
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29, 2008; Abstract.
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Veterans Affairs’ NSQIP: the first national, validated, out-
come-based, risk-adjusted, and peer-controlled program for
the measurement and enhancement of the quality of surgical
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20and%20Clinical%20Affairs/NCCN/ASCO%20
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33. McGlynn EA, Asch SM, Adams J et al. The quality of health
care delivered to adults in the United States. N Engl J Med
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Clinical practice guideline development: methodology pers­
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cancer in vulnerable elders. J Am Geriatr Soc 2007; 55(Suppl
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39. McGory ML, Shekelle PG, Rubenstein LZ, Fink A, Ko CY.
Developing quality indicators for elderly patients under-
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
17 Hemorrhoidal surgery
Dan R Metcalf and Anthony J Senagore

Challenging Case
A 38-year-old man presents to your office after receiving an urgent
hemorrhoidectomy 1 year previously. He had continued pain and
bleeding with bowel movements. He feels his anus is “too tight”
and continues to be symptomatic despite attempts at dilatation,
daily fiber, and stool softeners. Examination reveals three healed
incisions and anal stenosis. The anus will only admit the tip of
your finger with discomfort.

Case Management
The patient has anal stenosis due to removal of an excessive
amount of anoderm with his surgery. The management of refrac-
tory posthemorrhoidectomy stenosis usually requires some type
of flap repair. The choice of flap repair selected will depend on the
degree of stenosis and the surgeon’s experience. The editors have
found one or multiple house advancement flaps to be the most
common option chosen in our practice.

Introduction
Few diseases are more chronicled in human history than sympto-
matic hemorrhoidal disease.(1, 2) Citations of hemorrhoidal dis-
ease have been noted in historic texts dating back to Babylonian,
Egyptian, Greek, and Hebrew cultures.(1, 2) A multitude of treat-
ment regimens have been offered including anal dilation, vari-
ous topical liniments, and the often feared red hot poker.(3, 4)
Although few people have died of hemorrhoidal disease, some
patients wish they had particularly after therapy and this fact led
to the beatification of St. Fiachre, the patron saint of gardeners
and hemorrhoidal sufferers.(5) This chapter will guide the practi-
tioner to a more humane approach to hemorrhoidal disease with
the emphasis on cost-effectiveness and obtaining superior short
and long-term outcomes.
Anatomy/Etiology
Hemorrhoidal cushions are located within the submucosa of the
upper anal canal and are a normal component of the anorectal
anatomy. These cushions are composed of blood vessels, smooth
muscle (Treitz’s muscle), connective tissue, and elastic tissue.(6)
(Figure 17.1) Anatomically, the hemorrhoidal cushions appear
with marked predictability in the right anterior, right posterior, and
left lateral positions, although there may be intervening secondary
hemorrhoidal complexes which obscure this classic anatomy.(6)
The blood supply to the anal cushions is derived from the superior
rectal artery, a branch of the inferior mesenteric; the middle rectal
arteries arising from the internal iliac arteries; and the inferior rec-
tal arteries arising from the pudendal arteries. The venous drainage
transitions from the portal venous system above the level of the
dentate line to the systemic venous system below this level.(6)
Anal cushions contribute to the maintenance of anal continence
and allow the anal canal to dilate during defecation without tearing.
Figure 17.1  Sagital section of anal cushion showing internal and external
hemorroids.
(6) Consequently, in some patients hemorrhoidectomy may result
in various degrees of incontinence or leakage. Hemorrhoidal ­disease
occurs as the result of abnormalities within the connective tissue
of these cushions producing bleeding with or without prolapse of
the hemorrhoidal tissue.(7) This can occur as the result of exces-
sive straining, chronic constipation, or low dietary fiber.(8) A clear
understanding of the pathophysiology is important when consider-
ing therapeutic interventions. At the earlier stages of disease, when
the major manifestation is transudation of blood through thin
walled damaged vascular channels, ablation of the vessels should
be adequate. In contrast, when there is significant disruption of the
mucosal suspensory ligament in the late stages of the disease, a tech-
nique resulting in fixation of the mucosa to the underlying muscu-
lar wall is necessary for effective therapy.(9) Internal anal sphincter
dysfunction may play a role, as a number of investigators have dem-
onstrated increased internal anal sphincter tone in patients with
hemorrhoidal disease.(10–12) In reality, a combination of all of the
above factors are important for the ultimate development of large
prolapsing hemorrhoids.
Hemorrhoids are divided into two groups, external and internal.
External hemorrhoids are located distal to the dentate line and are
covered by modified squamous epithelium (anoderm). In contrast,
internal hemorrhoids are covered by columnar or transitional epi-
thelium and are located proximal to the dentate line. Internal hem-
orrhoids are further divided into grades based on size and clinical


 hemorrhoidal surgery
symptoms. Grade I internal hemorrhoids bulge into the lumen and
produce bleeding; Grade II internal hemorrhoids protrude with
bowel movements and reduce spontaneously; Grade III internal
hemorrhoids protrude spontaneously or with bowel movements
and require manual reduction: Grade IV internal hemorrhoids are
permanently prolapsed and irreducible.(13) Mixed hemorrhoids are
those with components of both internal and external hemorrhoids.
Although there tends to be a correlation between symptoms and the
grade of hemorrhoidal disease, therapeutic decisions should not be
based solely on these criteria. As will be outlined later, it is impor-
tant to consider the relative role of internal hemorrhoidal tissue in
addition to external hemorrhoidal skin tagging when choosing a
modality for complete resolution of the patient’s symptoms.(7)
Clinical Evaluation
Among the most common symptoms associated with hemor-
rhoidal disease are bleeding, protrusion, and pain. However,
Mazier reported on a series of 500 patients with anorectal com-
plaints they associated with their hemorrhoids and ultimately,
only 35% of patients were found to have any significant hemor-
rhoidal disease at all.(14) Hemorrhoidal bleeding is characteristi-
cally painless and bright red and seen on the toilet paper or in
the commode after a bowel movement. However, more vigorous
bleeding can occur as the hemorrhoids enlarge, particularly in
advanced stages when a portion of the complex is fixed externally,
allowing the blood to drip or spurt into the commode. Generally,
prompt reduction of the protruding mass will alleviate this symp-
tom. Acute thromboses of internal or external hemorrhoids are
usually associated with a palpable mass and severe pain. These
patients typically present with extreme discomfort and on clinical
examination the diagnosis is frequently obvious.
Examination of the patient with hematochezia should be tai-
lored by the age of the patient and include sufficient investigations
to rule out a proximal source of bleeding such as inflammatory
bowel disease or neoplasia. Hemorrhoidal bleeding as a cause of
anemia is an uncommon occurrence with an incidence of 0.5 per
100,000 per year.(15) Consequently, hemorrhoids should not be
dismissed as the cause of iron deficiency anemia.
The authors examine patients in the left lateral position with
the knees drawn up toward the chest as high as possible. This
approach allows relative patient comfort and the ability to clearly
inspect the perianal skin, perform anoscopy, and proctosig-
moidoscopy. A careful digital examination of the anal canal and
distal rectum should be performed with the addition of prostate
examination in male patients. Examination with an anoscope is
essential to adequately inspect the hemorrhoidal tissue and anal
canal. Inspection of the three common locations for hemorrhoids
should be performed with documentation of the size, friability,
and ease of prolapse. Documentation of anal pathology should
be described by anatomic position (anterior, posterior, etc.,) to
avoid confusion regarding the position in which the patient was
examined. Upon completion of this portion of the exam, a deci-
sion should be made regarding the need for more proximal evalu-
ation of the colon and rectum. However, rigid proctoscopy should
be the minimum in all patients. After appropriately ­grading the
hemorrhoidal disease, discussion can ensue with the patient
regarding the various treatment options.
Nonexcisional Options
The majority of patients with hematochezia attributable to hem-
orrhoids can be managed conservatively without surgical inter-
vention. Dietary and lifestyle modification, reduction of straining
with defacation, sclerotherapy, infrared coagulation, and rubber
band ligation are described in chapter 18. These options are
­considered before considering excisional options.
Excisional Hemorrhoidectomy
Approximately 5–10% of patients will require surgical manage-
ment of their hemorrhoids.(16) Excisional hemorrhoidectomy
should be considered in those patients with extensive sympto-
matic disease who have failed or are not candidates for medical
and nonexcisional options. In addition to this, the customary
indications for hemorrhoidectomy include frequent or per-
sistent prolapse requiring manual reduction resulting in dis-
comfort and anal seepage, and hemorrhoids associated with
conditions such as fissure, fistula, ulceration, or extensive anal
skin tags. The final indication for excisional hemorrhoidectomy,
although debatable, is the development of acutely thrombosed
and ­gangrenous internal hemorrhoids. It is apparent however
that similar full excisional hemorrhoidectomy can be per-
formed using standard closed hemorrhoidectomy techniques
without undue complications. Specifically, the risk of steno-
sis appears unwarranted if careful technique is used and the
maximum amount of anoderm is preserved with skin bridges
between excision sites. In the case of limited external hemor-
rhoidal thromboses, surgical excision may also be warranted
for more rapid pain relief and avoidance of a residual skin tag.
(17–20) Limited external thromboses can be easily managed in
the office setting with local anesthesia and complete excision
with or without skin closure.(Figure 17.2)
Options for excisional hemorrhoidectomy include the follow-
ing techniques: Milligan-Morgan hemorrhoidectomy; Ferguson
Closed hemorrhoidectomy; Whitehead hemorrhoidectomy; sta-
pled hemorrhoidectomy; and variations of the Milligan-Morgan
and Ferguson techniques using alternative energy devices. The use
of lasers for excisional hemorrhoidectomy offers no advantage
and in fact causes delayed healing, increased pain, and increased
cost.(21) The procedures are usually performed in the operating
room after minimal preoperative bowel preparation. The choice
of anesthetic is typically left to the anesthesiologist and patient,
however local anesthesia supplemented by the administration of
intravenous narcotics and propofol is very effective and short act-
ing. The use of spinal anesthesia, although effective, may increase
the risk of postoperative urinary retention do to a higher intraop-
erative administration of intravenous fluids.
The Milligan-Morgan hemorrhoidectomy (Figure 17.3), which
is widely practiced in Europe, was originally described in 1937
and its efficacy has subsequently been documented in many
series.(22–24) This technique involves resection of the internal
and external hemorrhoid complex, ligation of the arterial pedicle,
and preservation of the intervening anoderm.(22) The distal ano-
derm and external skin are left open to heal by secondary inten-
tion to minimize the risk of infection. This technique has been
proven to be a safe and effective means for managing advanced
hemorrhoidal disease.(22) However, the open wounds typically

 improved outcomes in colon and rectal surgery
take 4–8 weeks to heal and can be a cause of considerable discom-
fort and prolonged morbidity after this procedure.
The closed Ferguson hemorrhoidectomy (Figure 17.4) was
proposed as an alternative to the Milligan-Morgan technique
and enjoys a similar large body of evidence regarding its safety
and efficacy.(17–20) This technique utilizes an hourglass-shaped
excision of the entire internal and external hemorrhoidal com-
plex (centered at the midportion of the anoderm), preservation
of the internal and external anal sphincters, and primary closure
of the entire wound. Occasionally, it is necessary to undermine
flaps of anoderm and perianal skin to allow excision of inter-
mediate hemorrhoidal tissue, while preserving the bridges of
anoderm between pedicles. This technical adjustment will avoid
postoperative strictures.
The Whitehead hemorrhoidectomy (Figure 17.5), described in
1882, involves a circular incision at the level of the dentate line
with subsequent circumferential excision of the hemorrhoidal
tissue and relocation of the dentate line which is often a com-
ponent of prolapsing hemorrhoids.(25) Although this technique
had a long period of widespread use in the United Kingdom, it
was subsequently largely abandoned because of the high rates of
mucosal ectropion and anal stricture.(26–29) However, using a
modification of the original technique it has enjoyed renewed
support by some surgeons in the United States with minimal
stricture rates and no occurrences of mucosal ectropion.(30–31)
Despite these promising reports, the Whitehead procedure is
technically demanding because of the need to accurately identify
the dentate line and relocate it to its proper location.
Stapled hemorrhoidopexy is a relatively novel technique
with growing acceptance as an alternative to excisional hemor-
rhoidectomy for the treatment of grade III and grade IV hemor-
rhoids. The technique, as described in 1998 by Antonio Longo (32),
involves circumferential excision of the mucosa and submucosa
above the hemorrhoids using a circular stapler resulting in reloca-
tion and fixation of the internal hemorrhoids. Briefly, a circular

Figure 17.2  Excision of thrombosed external
hemorrhoid.
anoscope is inserted into the anal canal to reduce the prolapsing
tissue and allow placement of a circumferential purse-string suture
4 cm proximal to the dentate line into the mucosa and submucosa.
A 33 mm hemorrhoidal circular stapler (EthiconEndo-Surgery;
PPH03) with the anvil fully extended is then advanced proximal to
the purse-string which is then gently tightened around the shaft of
the stapler. The free ends of the suture are then threaded through
the lateral channels of the stapler housing to provide traction on
the purse-string as the stapler is closed and advanced into the anal
canal. Once in position the stapler is closed and fired. The staple
line should be inspected for hemostasis and bleeding controlled
with an absorbable suture.(Figure 17.6) Numerous randomized
controlled trials comparing stapled hemorrhoidopexy to conven-
tional hemorrhoidectomy have substantiated the benefits of sta-
pled hemorrhoidectomy, namely reduced operating room time,
less pain and analgesic use, and earlier return to work with similar
symptom control.(33–36) In a prospective, randomized, controlled
multicenter trial comparing stapled hemorrhoidopexy and closed
hemorrhoidectomy Senagore et al. reported less pain, less pain at
first bowel movement, less analgesic use and similar symptom con-
trol using stapled hemorrhoidopexy in which 88% of patients were
treated as outpatients.(36) As demonstrated in a recent systematic
review of 25 randomized, controlled trials comparing stapled hem-
orrhoidopexy to conventional hemorrhoidectomy, stapled hem-
orrhoidopexy is a safe and effective procedure for the treatment
symptomatic hemorrhoids with superior short-term outcomes.
(37) This review indicates that the incidence of recurrent hem-
orrhoids is significantly higher at one or more years after stapled
hemorrhoidopexy (5.7% vs. 1%), however, the overall recurrence
or persistence of hemorrhoidal symptoms was similar between the
groups (SH vs. conventional: 25.3% vs. 18.7%, p = 0.07).(37) In a
retrospective review of 291 patients submitted to stapled hemor-
rhoidopexy with grade III and grade IV hemorrhoids, the overall
recurrence rate after a minimum follow-up of 5 years was 18.2%.
(38) They showed a tendency for higher recurrence in grade IV
 hemorrhoidal surgery

(A) (B) (C)

(D) (E) (F)

Figure 17.3  Open (Milligan-Morgan) hemorrhoidectomy. (A) External hemorrhoids grasped with forceps and retracted outward. (B) Internal hemorrhoids grasped
with forceps and retracted outward with external hemorrhoids. (C) External skin and hemorrhoid excised with scissors. (D) Suture placed through proximal internal
hemorrhoid and vascular bundle. (E) Ligature tied. (F) Tissue distal to ligature is excised. Insert depicts completed three bundle hemorrhoidectomy.

(A) (B) (C) (D)

Figure 17.4  Modified Ferguson excisional hemorrhoidectomy. (A) Double ellipitical incision made in mucosa and anoderm around hemorrhoidal bundle with a
scalpel. (B) The hemorrhoid dissection is carefully continued cephalad by dissecting the sphincter away from the hemorrhoid. (C) After dissection of the hemorrhoid
to its pedicle, it is either clamped, secured, or excised. The pedicle is suture ligated. (D) The wound is closed with a running stitch. Excessive traction on the suture is
avoided to prevent forming dog ears or displacing the anoderm caudally.


 improved outcomes in colon and rectal surgery
(A) (B) (C)
Figure 17.5  Whitehead hemorrhoidectomy. (A) Suture placed through proximal internal hemorrhoid for orientation. Excision started at dentate line and continued to
proximal bundle. (B) Internal hemorrhoidal tissue excised above ligated bundle. (C) Vascular tissue excised from underside of elevated anoderm. (D) End of anoderm
reaproximated with sutures to original location of dentate line. (E) Completed procedure.
hemorrhoids with a significantly higher reoperation rate.(38) In
some instances this was thought to be related to inappropriate
patient selection. In a large series reported by Jongen et al. stapled
hemorrhoidopexy with good patient selection was associated with
a low rate (3.4%) of reoperation for persistent or recurrent hemor-
rhoidal prolapse.(39)
The data clearly indicate that stapled hemorrhoidopexy is a
safe and effective option to treat symptomatic hemorrhoids with
superior short-term outcomes. Although a higher rate of late
recurrence is reported with this technique in the current literature,
an appropriately designed randomized trial with adequate power
and longer follow-up is needed to ultimately define the durability
of stapled hemorrhoidopexy. Patient selection for ­stapled hemor-
rhoidopexy may also play an important role in short and long term
outcome analysis.
Improper technique with PPH has led to significant complica-
tions. Placement of the purse-string suture too high (cranial) or
too deep has led to a full thickness excision and occasional anas-
tomotic leaks with subsequent sepsis and some deaths. Placement
of the purse-string suture too low may lead to impaired conti-
nence (inclusion of sphincter muscle in staples) or pain. Chronic
pain following PPH may respond to anti-inflammatory agents or
time. Some success in refractory patients has been obtained with
removal of residual staples (usually done under anesthesia) or
injection of long duration steroids.
In the quest to provide patients with the benefit of less post-
operative pain, alternative devices such as the Harmonic Scalpel®
and LigaSure™ have recently been used to perform excisional
hemorrhoidectomy. There have been four randomized, controlled
trials published in an attempt to assess the efficacy of Harmonic
Scalpel® hemorrhoidectomy.(40–43) Although all studies indicate
that the harmonic scalpel is an effective alternative with a simi-
lar complication profile to more conventional methods, there is
inconsistency regarding the short term benefits such as postop-
erative pain across these studies. Multiple randomized, controlled
trials evaluating LigaSure™ hemorrhoidectomy to conventional
techniques have been performed; (44–50) Most of these stud-
ies demonstrate a reduction in postoperative pain and operating
time when using the LigaSure™. A multicenter, prospective, ran-
domized study by Altomare et al. showed significantly less pain

(D) (E)
12 hours after defacation, lower analgesic requirements, and faster
return to work and normal activity with no difference in early or
late complications.(48) Both instruments have been shown to be a
safe and effective alternative to conventional hemorrhoidectomy.
However, the added cost, conflicting short term outcomes, and
lack of long term follow-up prelude recommendations for their
routine use. At the present time, conventional methods of exci-
sional hemorrhoidectomy remain the “gold standard”.
Postoperative Complications
Regardless of the excisional technique used for treatment of
advanced hemorrhoidal disease, the key to effective patient
management is avoidance of postoperative complications.
Pain
The anoderm has a rich supply of sensory nerves and pain
arises from involvement of the anoderm below the dentate line.
Posthemorrhoidectomy pain is associated with reflex spasm of the
urethral and anal sphincter muscles. Spasm of these muscles leads
to difficulty voiding and urinary retention and difficulty with evac-
uation and constipation. Both of which are covered later. From the
patient’s perspective, pain is the most feared element of the pro-
cedure. A variety of analgesic regimens have been recommended,
usually consisting of a combination of oral and parenteral nar-
cotics.(51–55) Local anesthetic agents such as 0.5% bupivacaine
solution may provide analgesia for up to 6–8 hours after surgery.
The use of ketorolac has demonstrated considerable efficacy in
managing posthemorrhoidectomy pain.(51) Alternative adminis-
tration routes for narcotics either by patch or subcutaneous pump
have been successful in controlling pain, however due to the risk
of narcotic respiratory depression, administration by these routes
can be risky in the outpatient setting.(53–55) The most appropri-
ate regimen following outpatient hemorrhoidectomy appears to
be intraoperative use of ketorolac, sufficient doses of oral narcotic
analgesics for home administration, and supplementation of the
narcotics by an oral nonsteroidal medication.
Urinary Retention
Urinary retention is a frequent postoperative complication follow-
ing hemorrhoidectomy with an incidence from 1–52%.(16, 56–58)
 hemorrhoidal surgery

(a) (b) (c)

(d) (e) (f)

Figure 17.6  Stapled anoplasty (procedure for prolapse and hemorrhoids [PPH]). (A) Retracting anoscope and dilator inserted. (B) Monofilament pursestring suture
(eight bites) placed using operating anoscope approximately 3–4 cm above anal verge. (C) Stapler inserted through pursestring. Pursestring suture tied and ends of
suture manipulated through stapler. (D) Retracting on suture pulls anorectal mucosa into stapler. (E) Stapler closed and fired. (F) Completed procedure.

A variety of strategies have been used to treat this problem includ-
ing parasympathomimetics, alpha-adrenergic blocking agents, and
sitz baths.(59, 60) However, prevention seems to be the best strategy
by limiting perioperative fluid administration to 250 ml, avoiding
the use of spinal anesthesia and anal packing, and prescribing an
aggressive oral analgesic regimen.(56) Elderly men with obstructive
uropathy are at increased risk for urinary retention. If catheteriza-
tion becomes necessary, intermittent catherization under sterile
conditions is the option of choice. Urologic consultation may be
sought for patients with persistent symptoms of bladder outflow
obstruction.
Hemorrhage
Early postoperative bleeding (<24 hours) occurs in approxi-
mately 1% of cases and represents a technical error requir-
ing return to the operating room for repair of the offending
wound.(61) Occasionally bleeding may continue undetected,
with blood ­accumulating in the capacious rectum. The first


 improved outcomes in colon and rectal surgery
sign of this complication may be pallor, tachycardia, and hypo-
tension. This patient requires fluid resuscitation and a return
to the operating room for suture ligation or diathermy control
of the bleeding site.
Bleeding from the staple line when using a PPH can be con-
trolled by oversewing the bleeding point of the staple line. This is
less common with the second generation 33 mm hemorrhoidal
circular stapler (Ethicon endosurgery; PPH03) which has a shorter
stapler height.
Delayed hemorrhage occurs in 0.5–4% of cases of excisional
hemorrhoidectomy and often occurs at 5–10 days postoperatively.
(62–64) The etiology has been held to be early separation of the
ligated pedicle before adequate thrombosis in the feeding artery can
occur.(65) Hemorrhage in this situation is frequently significant and
requires some method for control of ongoing hemorrhage. Options
include return to the operating room for suture ligation, or tampon-
ade at the beside by Foley catheter or anal packing.(66–68) The out-
come after control of secondary hemorrhage is generally good with
virtually no risk of recurrent bleeding. It may be helpful to irrigate
out the distal colon and rectum at the time of intraoperative control
of hemorrhage to avoid confusion in the postoperative period.
Constipation and Fecal Impaction
Fecal impaction is a distressing complication of excisional hemo­
rrhoidectomies. Postoperative pain, the patient’s fear of pain
associated with defecation, and the constipating effects of nar-
cotics are contributing factors. Hence, providing adequate anal-
gesia and patient reassurance are important. Patients should be
instructed on the importance of adequate hydration. Many sur-
geons also recommend bulking agents and/or laxatives (e.g., pol-
yethylene glycol solution), and topical anesthetics before a bowel
movement to facilitate evacuation.(69) When fecal impaction
is identified, early, simple irrigating enemas may help clear the
anorectum of impacted feces. If the impactions are soft, an oral
cleansing regime (17 gm of polyethelyene glycol solution in 4 oz
of water every 15–20 minutes until the impaction is cleared) may
be utilized.(70) In more severe cases, manual disimpaction under
conscious sedation or general anesthesia may be necessary.
Infection
Infection of the urinary tract may result from either stasis of urine
or instrumentation of the urinary tract. A 3% incidence has been
reported from one institution following hemorrhoidal surgery.
(16) A urine culture should be obtained before administration of
appropriate antibiotics.
The anoderm harbors an abundance of potentially pathologic
bacterial microorganisms. Despite this, infective complications
after hemorrhoidectomy are infrequent. Bacteremia and sepsis
have been documented after hemorrhoidectomy, but abscess
formation is rare unless a hematoma becomes infected. Isolated
liver abscesses have been reported, and this very rare complica-
tion should be considered in patients with postoperative fever. It
is usually currently identified by abdominal CT scan.
Another potential infectious complication is postoperative pel-
vic sepsis. This can occur after any anorectal procedure includ-
ing rubber band ligation and excisional hemorrhoidectomy.
Classic findings include anorectal pain, fever, and difficulty

with urination. A high index of suspicion is required as delay in
diagnosis can have fatal consequences. As described in chapter
18, patients with suspected pelvic sepsis require resuscitation,
diagnostic evaluations (pelvic CT scans and/or anoscopic evalu-
ation), and treatment (broad spectrum antibiotics and debride-
ment of necrotic tissue).
Anal Stenosis
Anal stenosis results from excessive stripping of anal mucosa,
which may leave inadequate bridges of anoderm for healing to
occur without stenosis.(71) Secondary hemorrhoids should be
managed with either submucosal hemorrhoidectomy or conserv-
ative methods such as sclerotherapy or rubber band ligation at a
subsequent visit. In mild cases, stenosis may simply be a web that
disappears with graduated anal dilatation in the office. In more
severe cases, surgical intervention may be required to relive ste-
nosis. Surgical correction may be accomplished by one of several
reconstructive operations including skin and subcutaneous tissue
flaps. These flap techniques are discussed in chapter 20.
Mucosal Ectropion (Whitehead Deformity)
Mucosal ectropion with the classic “Whitehead deformity”
is commonly seen after an incorrectly performed procedure
described by Whitehead.(22) As described previously, the oper-
ation entails making a circumferential incision at the level of the
dentate line, elevating a flap of anal mucosa, and performing a
submucosal hemorrhoidal excision. Redundant mucosa is then
excised, and the anal canal is reconstructed with sutures. If the
reconstruction does not relocate the dentate line in the correct
location in the anal canal, anal mucosal will be located in the
distal anal canal or perineum. Persistent mucous discharge and
perianal irritation may result. Correction requires resection of
the mislocated anal mucosa and reconstruction, which usually
requires flaps.
Fecal Incontinence
Incontinence of feces results chiefly from damage to the internal
anal sphincter during hemorrhoidectomy.(72) The internal anal
sphincter is a thin, whitish, smooth muscle composed of circular
fibers located just beneath the anal mucosa. It is almost always
absent at the anal verge because its inferior limit is a few milli-
meters proximal to it. During surgery, the hemorrhoidal column
should be lifted off the internal anal sphincter, which must be
identified before excision of hemorrhoidal tissue. It is important
to document the state of continence in patients before surgery.
Soiling and fecal leakage are the chief impairments of continence
resulting from internal anal sphincter damage. Treatment for soil-
ing and leakage includes bulking agents and slowing agents (e.g.,
loperamide) and consideration of biofeedback therapy. Attempts
to surgically repair damaged internal sphincter muscle have been
disappointing.
Anal Fistula
Fistula in ano is an uncommon complication of hemorrhoidec-
tomy and is thought to occur more commonly after a closed pro-
cedure.(73) The fistula is usually a simple submucosal tract that
may be treated by simple unroofing.
 hemorrhoidal surgery
Anal Tags
Anal skin tags after hemorrhoidal excision are not uncommon.
Usually these tags are edematous areas of anoderm that generally
resolve spontaneously some weeks after surgery. Reassurance will
help allay patient’s concerns. It the tags remain bothersome or are
associated with symptomatic pruritis, they can be excised in the
office using local anesthesia.
Special Situations
Postpartum Hemorrhoids
Postpartum hemorrhoids that are refractory to conservative
measures may require surgical management. Hemorrhoidectomy
in this setting is safe, has a low prevalence of complications, and
in many cases will minimize recovery time. Proper patient posi-
tion (usually left lateral Sims) and good anesthetic techniques are
important. As in other urgent hemorrhoidectomies, preservation
of as much anoderm as possible is also critical.
Anorectal Varices
Unlike hemorrhoids, varices result from portal venous hyperten-
sion. Differentiation from hemorrhoids is essential because exci-
sion of varices may result in venous bleeding that may be difficult
to control. A history of anal bleeding in a cirrhotic patient should
arouse suspicion. Varices may be present in the rectum, anal canal,
or anal verge.(74) Duplex Doppler ultrasonography of the anorec-
tum may confirm the diagnosis. Active bleeding from varices will
usually require oversewing with a continuous suture technique.
Conclusion
The management of symptomatic hemorrhoidal disease should
be directed at the symptom complex of the patient. The major-
ity of these patients can be effectively treated by reducing strain
at defacation, correcting constipation, the use of any of a variety
of anal ointments. For those patients with persistent symptoms,
either injection or banding of the internal hemorrhoids offers
predictably successful results. Only a minority of patients should
require excisional hemorrhoidectomy by any of the described
techniques. Stapled hemorrhoidopexy, Harmonic Scalpel®, and
LigaSure™ all offer safe and effective alternatives to the tradi-
tional open or closed excisional hemorrhoidectomy, however
more long-term data is needed to provide recommendations for
their routine use.
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
18 Nonoperative therapy for hemorrhoid disease
Kerry Hammond and Charles B Whitlow
Challenging Case
A 50-year-old male, otherwise healthy, presents to your office and
after evaluation is diagnosed with grade 3 internal hemorrhoids.
Rubber band ligation is performed and is well-tolerated. Forty-
eight hours later he develops urinary retention and worsening
anal pain.
Case Management
The patient’s symptoms are suggestive of pelvic or postband-
ing sepsis. The patient should be examined urgently, admitted,
started on broad-spectrum intravenous antibiotics, and intrave-
nous fluids. A foley catheter should be placed and blood work
(CBC, metabolic profile, etc) obtained. A CT scan of the abdo-
men and pelvis should be considered. If the initial exam (includ-
ing anoscopy) is not adequate or demonstrated necrotic perianal
tissue, the patient should receive an exam under anesthesia and
debridement of any necrotic tissue.
Introduction
“Hemorrhoids” are among the most frequent presenting com-
plaints of patients evaluated in the outpatient setting by colon and
rectal surgeons. In a 1990 review of data from the National Center
for Health Statistics, Johanson and Sonnenberg determined a 4.4%
prevalence of symptomatic hemorrhoids in the U.S. population.(1)
In a subsequent study of data collected by the National Hospital
Discharge Survey, the same authors found that the annual number
of surgical hemorrhoidectomies performed in the United States
had decreased from a peak of 117 per 100,000 patients in 1974 to
a nadir of 37 per 100,000 in 1987.(2) This decrease in operative
procedures is likely the result of improvements in nonoperative
therapies for symptomatic internal hemorrhoids.
Anatomy and Pathophysiology
Hemorrhoids are cushions of vascular and connective tissue located
in the subepithelial space lining the anal canal. Arteriovenous sinu-
soids between the terminal branches of the superior rectal arteries
and the superior, middle and inferior rectal veins are encompassed
by these cushions. These sinusoids lack a muscular wall, predispos-
ing them to bleeding.(3–5) Hemorrhoidal prolapse develops as
the supportive connective tissue matrix is compromised by age
and trauma.(6, 7)
A simple grading system has been widely adopted for the clini-
cal assessment of symptomatic internal hemorrhoids. This 4-part
grading system can be used by clinicians to describe the extent of
a patient’s pathology and to differentiate which treatment options
are appropriate (Table 18.1). (4–12)
Clinical Evaluation
It is not uncommon for patients to attribute any anorectal dis-
comfort to hemorrhoids. Therefore, a careful history and physical

Table 18.1  Grading system for internal haemorrhoids.
Grade Physical Characteristics
I Prominent hemorrhoidal vessels without prolapse
II Prolapse with valsalva; reduce spontaneously
III Prolapse with valsalva; manual reduction needed
IV Prolapsed hemorrhoids that cannot be reduced
examination is necessary to differentiate hemorrhoidal disease
from other pathological processes.
Bleeding is the most common symptom associated with
internal hemorrhoidal disease. Patients who have bled second-
ary to hemorrhoids typically describe painless bleeding which is
bright red in color. This usually occurs with defecation, and may
be ­limited to the appearance of blood on toilet tissue.(8) More
severe bleeding may result in dripping of blood or even pulsatile
bleeding into the commode.
Hemorrhoidal prolapse can cause a sensation of incomplete
emptying or mucous discharge. Patients with a significant degree
of prolapse often complain of pruritis and difficulty maintaining
anal hygiene.
Physical examination should include a thorough visual and
digital inspection of the perianal soft tissue and anorectum to rule
out conditions such as fissure, abscess, and neoplasm. Anoscopy
can be performed in the office setting and is useful to determine
the extent of hemorrhoidal enlargement. Colonoscopy should be
considered for evaluation of bleeding if indicated by age, family
history of colorectal cancer, or other risk factors for colorectal
cancer.(7, 8, 10)
Treatment
Conservative Management
The goal of medical management is to provide symptomatic relief
by reducing straining during defecation and thereby eliminating
the repetitive trauma that contributes to hemorrhoidal conges-
tion and prolapse.
Dietary modification is the cornerstone of conservative manage-
ment for symptomatic hemorrhoids. A diet high in fiber (20–30 g/
day) promotes the formation of soft, formed stool that requires
less straining to eliminate. In a 2006 meta-analysis, Alonso-Coello
et al. evaluated the impact of supplemental fiber on symptoms
related to hemorrhoids.(13) This analysis included 7 studies in
which 378 total patients had been randomized to fiber or nonfiber
controls. Pooled analysis for overall improvement in symptoms
demonstrated a 47% risk reduction of persistence of symptoms
for patients randomized to fiber supplementation. Four stud-
ies that addressed bleeding as an individual outcome showed a
combined 50% relative risk reduction in the fiber treatment arm.
(14–17) No significant difference between treatment and placebo
 nonoperative therapy for hemorrhoid disease
arms was found in three studies that addressed hemorrhoidal
prolapse.(14, 15, 17)
Supplemental fiber can be delivered in several forms. Resistant
starches, found in legumes and grains, are polysaccharides that are
resistant to a-amylase digestion. Fermentation by colonic bacte-
ria with consequent increases in colonic gas production can pro-
duce abdominal bloating and flatulence. Soluble fiber dissolves in
water and produces a viscous solution in the gastrointestinal tract.
Sources of purified soluble fiber include psyllium (Metamucil®,
Konsyl®), inulin (FiberChoice®), pectins, and Methylcellulose
(Citrucel®) a semisynthetic soluble fiber that is not fermented by
colonic bacteria. Insoluble fiber passes largely unaltered through
the gastrointestinal tract with minimal fermentation in the colon.
Natural sources of insoluble fiber include foods such as dark leafy
vegetables and whole wheat products. Calcium polycarbophil
(Fibercon®) is a synthetic bulking agent with properties similar
to those of insoluble fiber.(18, 19)
While allergic reactions to the active or inactive ingredients
in dietary fiber supplements are rare, patients may experience
variable levels of adverse effects such as abdominal bloating and
flatulence after incorporating these products into their daily diet
regimen. A period of gradual dosage increase or trial-and-error
with different formulations may be necessary to identify the ideal
supplement in order to maximize compliance.
There is a paucity of data on the utility of stool softeners and
laxatives in the treatment of symptomatic hemorrhoids. These
agents may be a useful adjunct for patients with severe chronic
constipation who do not experience optimal relief with bulking
agents alone.
Warm sitz baths and topical agents are frequently prescribed
components of a conservative treatment regimen. Dodi et al.
demonstrated a significant reduction in anal canal pressure after
patients with anorectal disorders soaked in water at 40ºC.(20)
Numerous topical agents are available for treatment of the acute
symptoms of hemorrhoids. Most of these agents provide a local
anesthetic effect which suppresses the burning and itching sensa-
tions associated with hemorrhoidal prolapse. While there is no
compelling data to support the use of these compounds, the risk
of side effects is relatively low and patients typically report some
symptomatic relief with their use. Patients should be advised to
limit the duration of use of topical steroids, as prolonged usage
has the potential to cause chronic perianal dermatitis.(21)
Sclerotherapy
Injection sclerotherapy, first described in 1869 by John Morgan
of Dublin, is the oldest form of nonsurgical hemorrhoid treat-
ment still in use today. This technique was originally described
using iron persulphate to inject external hemorrhoids.(12) The
aim of sclerotherapy is to obliterate the vascular component of
the hemorrhoid and induce scarring to prevent further prolapse.
Sclerosants in current clinical use include 5% phenol in oil, 5%
quinine, and urea and 1–3% sodium tetradecyl sulfate. The scle-
rosant solution is injected by 25 gauge needle into the apex of each
hemorrhoidal bundle above the dentate line.(6–12) Sclerotherapy
is contraindicated in patients with inflammatory bowel disease,
portal hypertension, immunocompromised states, active anorec-
tal infection, and prolapsed thrombosed hemorrhoids.(7)
Sclerotherapy is most effective for treatment of grade 1 or 2
internal hemorrhoids. Variable success rates have been reported
for this mode of therapy. In a 1988 survey, Mann et al. reported
that 88% of patients felt that their symptoms had improved at
4 weeks posttreatment.(22) In contrast, Senapati and Nicholls
demonstrated no significant difference in bleeding symptoms
in a randomized, controlled trial (n = 43). (23) Complications
associated with injection sclerotherapy are rare, and typically
result from deep placement of the injection. Urinary retention,
prostatitis, prostatic abscess, and mucosal sloughing have been
reported.(7–9)
Rubber Band Ligation
In medieval times, hemorrhoid ligation was performed by
encircling the entire prolapsed hemorrhoid with thread.(8)
This concept was modernized by Blaisdell in 1958 (24) and
was further refined by Barron in 1963 (25) with his descrip-
tion of hemorrhoid ligation using small rubber bands. Using
specialized instruments, rubber band ligation is performed by
grasping excess tissue at the hemorrhoid apex and deploying a
rubber band to constrict the hemorrhoidal blood supply. The
encircled tissue sloughs after 5–7 days, creating a scar that fixes
the remaining tissue to the rectal wall and consequently reduces
the degree of prolapse.
Rubber band ligation can be performed using a Barron or
McGivney hemorrhoid ligator coupled with a modified Allis
clamp, or with a McGown type suction ligator. (Figure 18.1) The
authors prefer the suction ligator, which is designed for single-
operator use. Rubber bands must be placed at least 2 cm above
the dentate line to avoid severe pain. If the patient expresses
discomfort during the tissue grasping/suction phase of the pro-
cedure, the procedure should be abandoned. Severe pain imme-
diately following rubber ligation may necessitate band removal,
which can be performed using a hooked probe.(7) Alternatively,
injection of bupivacaine into the hemorrhoid above and below
the level of the rubber band provides several hours of relief and
subsequent pain is adequately treated with narcotics. While up
to three hemorrhoids can be banded in a single session (26, 27),
the authors typically limit treatment to one or two columns to
minimize patient discomfort related to excessive banded tissue
within the anal canal.
In a review of 39 published studies (8,060 patients), Wechter
found pain to be the most common complication (5.8%) follow-
ing hemorrhoid banding. Other potential complications include
hemorrhage (1.7%), incontinence (0.9%), thrombosis (0.6%)
and infection (0.04%).(28) Patients may on occasion experience
vasovagal symptoms immediately after band placement, includ-
ing diaphoresis, bradycardia, nausea, and hypotension.(12) This
usually spontaneously resolves after allowing the patient to lie
down for 10 to 15 minutes.
Postbanding hemorrhage typically occurs 4 to 7 days after the
procedure. It is related to the band falling off after necrosis of tis-
sue is complete and is most commonly self-limited. More severe
bleeding may require operative ligation.
Although rare, several cases of postbanding sepsis have been
reported.(28–30) In a 2006 review, McCloud et al. examined
10 case reports of sepsis following rubber-band ligation of

 improved outcomes in colon and rectal surgery

(A)

(B)

(C)

(c)

Figure 18.1  Banding an internal hemorrhoid. The internal hemorrhoid is teased into the barrel of the ligating gun with (A) a suction (McGown) ligator or (B) a
McGivney ligator. (C) The apex of the banded hemorrhoid is well above the dentate line to minimize pain.

hemorrhoids (17 total cases, 6 fatal). The majority of these 17
patients developed local or retroperitoneal abscesses within the
first week following banding. Common presenting symptoms
included perineal induration and pain, urinary difficulties, and
fever.(31) Patients with these or similar symptoms following
rubber band ligation of hemorrhoids should undergo a thor-
ough clinical evaluation including appropriate imaging studies
(CT Scan) and physical examination, with initiation of broad-
spectrum antibiotics, and surgical drainage or debridement if
indicated.
Reported success rates for hemorrhoid banding vary according to
length of follow-up and grade of hemorrhoids treated. In 2004, Iyer
et al. reported a series of 701 patients who underwent rubber band
hemorrhoid ligation, with an overall success rate of 70.5%. The median
follow-up time was 1,205 days. Although there was not a statistically
significant difference in success between the 4 grades of hemorrhoids
treated, patients with grade 1 and 2 hemorrhoids demonstrated the
most improvement (72.4% and 73.1% respectively).(32) A 1998 sur-
vey of 92 patients by Savioz et al. found 77% and 68% of patients to be
free of symptoms at 5 and 10 years postbanding.(33)


 nonoperative therapy for hemorrhoid disease

Figure 18.2  The infrared photocoagulator creates

a small thermal injury. Thus several applications
are required for each hemorrhoidal column.

Treatments 1st degree 2nd degree 3rd degree 4th degree Acute prolapse with

Dietary X X X X X
Banding X X X

Sclerotherapy X X X

Infrared coagulation X X X

Excisional X X X Emergent
hemorrhoidectomy
Stapled X X X (?)
hemorrhoidopexy
Multiple X
thrombectomies and
multiple bandings

Figure 18-3  Management of Hemorrhoids by Classification.

Infrared Photocoagulation Complications associated with IRC are infrequent. As with

Infrared photocoagulation (IRC) utilizes infrared radiation to
induce protein necrosis at the base of the hemorrhoidal pedicle.
The depth of tissue penetration can be controlled by altering the
optical wavelength of the coagulator and the contact time.(9)
Using a slotted anoscope to visualize the hemorrhoid, the pro-
cedure is performed by placing the tip of the photocoagulator at
the base of the hemorrhoid and delivering a 1–1.5 second pulse
of energy (Figure 18.2). Three or four applications to each hem-
orrhoid are recommended for optimal results. This creates a 3–4
mm2 area of coagulation which ulcerates and forms a scar within
2 weeks.(12) Most authors advocate treatment of 1–3 hemor-
rhoids per session. Additional treatments can be performed as
indicated at 3–4 week intervals.(7, 12)
rubber band ligation, pain can occur if the light is applied distal
to the dentate line but is typically of shorter duration and lesser
severity. Excessive applications can result in bleeding. Rarely,
ulceration can progress to fissure formation.(12)
Comparison of Techniques
Numerous randomized trials have been published comparing the
available nonsurgical techniques for treatment of symptomatic
hemorrhoids. In a 1995 meta-analysis, MacRae et al. evaluated the
results of 18 of these studies. They found that patients treated with
rubber band ligation were less likely to require further therapy than
those treated with sclerotherapy (p = 0.031) or IRC (p = 0.0014).
However, the incidence of postprocedure pain was significantly


 improved outcomes in colon and rectal surgery
higher in patients who underwent rubber band ligation than the
sclerotherapy (p = 0.03) and IRC (p < 0.0001) cohorts.(34)
Summary
Most patients with symptomatic hemorrhoids can be successfully
treated with conservative management and nonsurgical techniques
performed in the office setting. The authors and editors generally
favor a conservative approach, beginning with a trial of supplemental
fiber with sitz baths and topical preparations for symptomatic relief.
If no improvement in symptoms results after 4–6 weeks, we pro-
ceed with rubber band ligation or IRC, repeating these techniques
if necessary at 4–6 week intervals. Symptomatic prolapse may be
an indication for rubber band ligation at the initial evaluation since
conservative treatment alone is unlikely to result in complete resolu-
tion. Surgical hemorrhoidectomy (discussed in chapter 17) may be
necessary in cases of failure of nonsurgical management, large grade
3 or 4 hemorrhoids or acutely thrombosed hemorrhoids. In all cases,
a careful history and physical examination is necessary to rule out
other causes of anorectal pathology. Management options for vari-
ous classes of hemorrhoids are summarized in Figure 18.3.
References
  1. Johanson JF, Sonnenberg A. The prevalence of hemor-
rhoids and chronic constipation. An epidemiologic study.
Gastroenterology 1990; 98: 380–6.
  2. Johanson JF, Sonnenberg A. Temporal changes in the occur-
rence of hemorrhoids in the United States and England. Dis
Colon Rectum 1991; 34: 585–93.
  3. Thompson WHF. The nature of hemorrhoids. Br J Surg 1975;
62: 542–52.
  4. Nivatvongs S. Hemorrhoids. In Gordon PH, Nivatvongs S,
eds. Principles and Practice of Surgery for the Colon, Rectum,
and Anus. 3rd ed. New York: Informa Healthcare USA, Inc,
2007: 143–66.
  5. Margolin DA, Hammond KL. Hemorrhoids, Anal Fissure,
Perianal Abscess, and Fistula in Ano. In Rakel RE, Bope ET,
eds. Conn’s Current Therapy 2007. Philadelphia: Saunders/
Elsevier. 2007: 614–8.
  6. Madoff RD, Fleshman JW. American Gastroenterological
association technical review on the diagnosis and treatment
of hemorrhoids. Gastroenterology 2004; 126: 1463–73.
  7. Beck DE. Hemorrhoidal Disease. In Beck DE, Wexner SD, eds.
Fundamentals of Anorectal Surgery (2nd ed). W. B. Saunders
Company Ltd. 1998: 237–53.
  8. Dennison AR, Whiston RJ, Rooney S, Morris DL. The manage-
ment of hemorrhoids. Am J Gastroenterol 1989; 84(5): 475–81.
  9. Hardy A, Chan CLH, Cohen CRG. The surgical management
of haemorrhoids: a review. Dig Surg 2005; 22: 26–33.
10. Cataldo P, NealEllis C, Gregorcyk S et al. Practice parameters
for the management of hemorrhoids (revised). Dis Colon
Rectum 2005; 48: 189–94.
11. Salvati EP. Nonoperative management of hemorrhoids:
­evolution of the office management of hemorrhoids. Dis
Colon Rectum 1999; 42(8): 989–93.
12. Larach S, Cataldo TE, Beck DE. Nonoperative treatment of
hemorrhoidal disease. In: Hicks TC, Beck DE, Opelka FG,
Timmcke AE. Complications of Colon and Rectal Surgery.
Baltimore: Williams & Wilkins 1997: 173–80.

13. Alonso-Coello P, Mills E, Heels-Ansdell D et al. Fiber for the
treatment of hemorrhoids complications: a systematic review
and meta-analysis. Am J Gastroenterol 2006; 101: 181–8.
14. Moesgaard F, Nielsen ML, Hansen JB, Knudsen JT. High-
fiber diet reduces bleeding and pain in patients with haem-
orrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum
1982; 25: 454–6.
15. Webster DJ, Gough DC, Craven JL. The use of bulk evacuant
in patients with haemorrhoids. Br J Surg 1978; 65: 291–2.
16. Hunt PS, Korman MG. Fybogel in haemorrhoid treatment.
Med J Aust 1981; 2: 256–8.
17. Broader JH, Gunn IF, Alexander-Williams J. Evaluation of a
bulk-forming evacuant in the management of haemorrhoids.
Br J Surg 1974; 61: 142–4.
18. Tan KY, Seow-Choen F. Fiber and colorectal diseases: separating
fact from fiction. World J Gastroenterol 2007; 13(31): 4161–7.
19. Bennett WG, Cerda JJ. Benefits of dietary fiber: Myth or
medicine?. Postgraduate Medicine 1996; 99(2): 153–6, 166–
8, 171–2 passim.
20. Dodi G, Bogoni F, Infantino A et al. Hot or cold in anal pain?
A study of the changes in internal sphincter pressure profiles.
Dis Colon Rectum 1986; 29: 248–51.
21. Johanson JF. Nonsurgical treatment of hemorrhoids. J Gastro­
intest Surg 2002; 6(3): 290–4.
22. Mann CV, Motson R, Clifton M. The immediate response to
injection therapy for first-degree hemorrhoids. J R Soc Med
1988; 81: 146–8.
23. Senapati A, Nicholls RJ. A randomised trial to compare the
results of injection sclerotherapy with a bulk laxative alone in
the treatment of bleeding haemorrhoids. Int J Colorectal Dis
1988; 3: 124–6.
24. Blaisdell PC. Prevention of massive hemorrhage secondary to
hemorrhoidectomy. Surg Gynecol Obstet 1958; 106: 485–8.
25. Barron J. Office ligation treatment of hemorrhoids. Dis
Colon Rectum 1963; 6: 109–13.
26. Lee HH, Spencer RJ, Beart RW Jr. Multiple hemorrhoidal band-
ings in a single session. Dis Colon Rectum 1994; 37: 37–41.
27. Lau WY, Chow HP, Poon GP, Wong SH. Rubber band liga-
tion of three primary hemorrhoids in a single session: a safe
and effective procedure. Dis Colon Rectum 1982; 25: 336–9.
28. Wechter D, Luna G. An unusual complication of rubber band
ligation of hemorrhoids. Dis Colon Rectum 1987; 30: 137–40.
29. O’Hara VS. Fatal clostridial infection following hemor-
rhoidal banding. Dis Colon Rectum 1985; 28: 291–3.
30. Russel TR, Donohue JH. Hemorrhoidal banding: a warning.
Dis Colon Rectum 1985; 28: 291–3.
31. McCloud JM, Jameson JS, Scott AND. Life-threatening sepsis
following treatment for haemorrhoids: a systematic review.
Colerectal Disease 2006; 8: 748–55.
32. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber
band ligation for symptomatic primary and recurrent inter-
nal hemorrhoids. Dis Colon Rectum 2004; 47: 1364–70.
33. Savioz D, Roche B, Glauser T et al. Rubber band ligation of
hemorrhoids: relapse as a function of time. Int J Colorect Dis
1998; 13: 154–6.
34. MacRae HM, McLeod RS. Comparison of hemorrhoidal
treatment modalities: a meta-analysis. Dis Colon Rectum
1995; 38: 687–94.
19 Surgery and nonoperative therapy of perirectal abscesses and anal fistulas
Brian R Kann and Charles B Whitlow

Challenging Case abscesses and fistula-in ano. Abscesses are classified accord-
A 40-year-old male with poorly controlled HIV infection develops ing to their location in relation to the potential anorectal
severe anorectal pain with associated fever. On physical examina- spaces (perianal, ischiorectal, intersphincteric, and supraleva-
tion, an obvious perirectal abscess is present 2 cm from the anal tor) (Figure 19.1). Pus can spread circumferentially through
verge, just to the right of the posterior midline. Appropriate inci- the intersphincteric, supralevator, and ischiorectal spaces.
sion and drainage is performed and the patient is treated with a Circumferential spread though contralateral ischiorectal spaces
short course of oral antibiotics, with resolution of the acute event. can occur via the deep postanal space, resulting in formation
Several months later, he presents with purulent discharge from of a horseshoe abscess. Anal fistulas are classified according to
the drainage site as well as a second area in the posterior midline, their relationship to the anal sphincter complex (intersphinc-
4 cm from the anal verge. Exam under anesthesia demonstrates teric, transsphincteric, suprasphincteric, and extrasphincteric),
a single primary fistula opening anal canal, in the posterior mid- as described by Parks (Figure 19.2).(2)
line 3 cm proximal to the dentate line, which communicate with The diagnosis of most anorectal abscesses is typically straight-
both secondary openings. Draining setons are placed, and biop- forward. Patients usually complain of pain and swelling at the
sies from the fistula tracts show no evidence of Crohn’s disease site, and fever is not uncommon. Examination will demonstrate
or malignancy. Six weeks later, he presents in septic shock due to
worsening perineal infection requiring a diverting colostomy.
(A)
Case Management
The patient is initially managed with additional drainage and a
diverting colostomy. After recovering, he is initiated on highly
active anti-retroviral therapy (HAART) with an excellent response
in his CD4 count and his viral load become undetectable. After an
MRI of the pelvis demonstrates no further infection in the pelvis,
an anal fistula plug is placed to attempt to close the fistula; within
a week, the plug has dislodged. An attempt at closing the fistula
with an endorectal advancement flap several weeks later also fails.
Further biopsies again show no evidence of Crohn’s disease or
malignancy, and a second attempt at endorectal advancement
flap closure performed 12 weeks later also fails. The patient has
decided not to pursue further surgery for the fistula and remains
diverted via a colostomy with draining setons in place.

INTRODUCTION (B)
Anorectal abscesses and fistulae-in-ano can be incredibly frustrating,
both for the patient and the managing physician. Meaningful outcomes
data with large, prospective randomized trials regarding the manage-
ment of these entities is extremely limited. This chapter addresses the
surgical as well as nonoperative management of these common prob-
lems, focusing on means of improving clinical outcomes.

Etiology and Diagnosis

The vast majority of anorectal abscess are cryptoglandular, resulting
from obstruction of the anal ducts and glands, resulting in stasis,
infection, and abscess formation.(1) Less common causes include
inflammatory bowel disease, tuberculous infection, trauma, malig-
nancy, and radiation. Most anal fistulas are the long-term mani-
festations of anorectal abscesses; persistent epithelium in the tract
between the infected duct and external opening created by surgical
or spontaneous drainage leads to fistula formation.
An intricate understanding of anorectal anatomy is essen-
tial to the diagnosis and subsequent management of anorectal Figure 19.1  Anorectal spaces. (A) Coronal section. (B) Sagital section.


 improved outcomes in colon and rectal surgery
(A) (B)
Figure 19.2  Classification of fistula-in-ano. (A) Inttersphincteric. (B) Trans-sphincteric. (C) Suprasphincteric. (D) Extrasphincteric.
Figure 19.3  Goodsall’s rule.
erythema, swelling, and possibly fluctuance at the site of the
abscess. Severe rectal pain associated with defecation and a
paucity of physical findings should raise one’s suspicion for an
intersphincteric abscess. Confirmation generally requires exam
under anesthesia with palpation of a fluctuance within the wall
of the anal canal or needle aspiration of purulent material from
the intersphincteric space. Severe gluteal pain in the absence of
significant findings on exam may be suggestive of a supralevator
abscess. Supralevator abscesses may develop as an upward exten-
sion of an ischiorectal or intersphincteric abscess, or they may
develop as a downward extension of a pelvic abscess. Exam under
anesthesia and/or computed tomography (CT) imaging is gener-
ally required for diagnosis.
The initial diagnosis of fistula-in-ano is also fairly straight-
forward, though classifying the type of fistula and defining the
anatomy can be much more difficult. The patient will usually
give an antecedent history of an abscess that has either drained
spontaneously or required surgical drainage. Examination may
demonstrate an external (secondary) opening seen as an eleva-
tion of granulation tissue with a discharge of pus, sometimes

(C) (D)
elicited on rectal examination. Identification of the internal
(primary) opening by anoscopy is usually difficult, and exam
under anesthesia is often required. Goodsall’s rule Figure 19.3 is
useful, though its reliability has been questioned, especially when
dealing with anterior fistulas; Cirocco and Reilly demonstrated
that in patients with anterior secondary fistula openings, 71%
tracked to an anterior midline primary opening, and in women
with anterior secondary fistula openings, only 31% tracked radi-
ally inward to the nearest crypt.(3)
Because of the difficulties in defining fistula anatomy, preopera-
tive imaging has, in many cases, become common practice. Available
imaging modalities include CT scan, fistulography, endoanal ultra-
sonography, and magnetic resonance imaging (MRI). CT scanning
is really useful only in defining abscesses related to fistulas.(4) CT
attenuation of the anal sphincter and pelvic floor is similar to that
of the fistula itself; therefore, the fistula itself is difficult to see
unless it is filled with air or contrast.(5) Fistulography as an ini-
tial diagnostic measure has several limitations.(6) Smaller exten-
sions from the primary tract may not fill with contrast if they are
plugged with debris. Also, there is no visualization of the sphinc-
ter complex or levator ani in relation to the location of the fistula.
Besides creating the potential for spread of sepsis, accuracy rates
are poor, ranging from 16–48%, with a false positive rate of 12%.
(6, 7) The place of fistulography may be in evaluating recurrent
fistulas, patients with Crohn’s disease, and patients who have had
multiple prior anorectal procedures with altered anatomy (7),
though with more readily available endoanal ultrasound and anal
MRI, its use will likely continue to decline.
The use of anorectal endosonography in the diagnosis of ano-
rectal fistulas has gained considerable attention in recent years.
It helps to identify the anatomy of the fistula in relation to the
sphincter and may also be used to aid in delineation of complex
fistulae and occult suppuration.(8, 9) The technique is relatively
simple, inexpensive, readily performed in an office ­setting, and
well tolerated by the patient. Lengyel et al. reported that endorec-
tal ultrasound correctly predicted surgical findings in 124 of 151
(82%) patients with anal fistulas.(10)
Some concerns have arisen regarding the sensitivity of endoanal
ultrasound. Seow-Choen prospectively demonstrated poor sen-
sitivity in detecting primary extrasphincteric and suprasphinc-
teric tracts and secondary supralevator or infralevator tracts.(11)
The use of hydrogen peroxide injected into the fistula tract can
improve the sensitivity of endorectal ultrasound for evaluation
of anorectal fistulas. Cheong demonstrated a 24% increase in
locating fistula tracts and a 28% increase in the demonstration
 surgery and nonoperative therapy of perirectal abscesses and anal fistulas
of primary fistula openings with the addition of hydrogen perox-
ide.(12) Other studies have confirmed the increased sensitivity of
hydrogen peroxide-enhanced endorectal ultrasound, with some
studies reporting concordance rates as high as 95%.(13–16)
The use of three-dimensional endoluminal ultrasound (3D-EUS)
has greatly increased the sensitivity of identifying and defining fis-
tula anatomy.(17) A study by Giordano et al. comparing 3D-EUS
to conventional (two-dimensional) EUS found that 3D-EUS was
significantly more accurate in assessing the fistula tract and site of
primary opening.(18) As with conventional EUS, the sensitivity of
3D-EUS is increased even further with the injection of hydrogen
peroxide into the fistula tract.(19) In a comparison with endoanal
MRI, hydrogen peroxide-enhanced 3D-EUS was found to be supe-
rior for detection of secondary fistula tracts, fluid collections, and
determining the location of primary ­fistula openings.(20, 21) The
authors suggested hydrogen peroxide enhanced 3D-EUS as a less
expensive, yet equally sensitive, alternative to endoanal MRI.
Anorectal MRI has emerged as a valuable tool in assessing
­complex anorectal fistulas. The best spatial resolution is achieved
by using a dedicated endoanal coil, combined with a surface
coil to increase the field of view.(5) The precise location of the
­primary opening can be identified and information regarding the
­relation of the fistula to the sphincter, sphincter integrity, second-
ary tracts, and supralevator extension can be obtained. However,
the disadvantages include expense and expert interpretation
which may not be readily available in all centers.
In a study of 104 patients comparing clinical examination, endo-
anal ultrasonography, and MRI, accurate classification of fistula
anatomy by MRI was 97%, compared with 81% by ultrasound,
and 61% by clinical examination.(22) Barker reported concordance
rates for MRI diagnosis of 86% for primary fistula tracts, 91% for
secondary extensions, 97% for the presence of horseshoe abscess,
and 80% for the position of the primary opening.(23) In this study,
failure of healing in 9% of patients was due to pathology missed at
the time of surgery that was seen on preoperative MRI. Beckingham
demonstrated a sensitivity and specificity of MRI for detecting ano-
rectal fistulas of 100% and 97%, respectively.(24) In this study, MRI
missed only one fistula with a complex transsphincteric tract.
Phased array (PA) MRI can provide even more precise infor-
mation regarding fistula anatomy when compared with body coil
MRI. Beets-Tan et al. (25) reported a study in which PA-MRI was
performed in 56 patients who then underwent fistula surgery. The
surgeons were initially blinded to the MRI findings until they felt
that they had determined the course of the fistula intraoperatively,
at which point the PA-MRI findings were revealed. In 12 (21%)
patients, PA-MRI imaging added additional information regarding
fistula tract anatomy not found by the surgeon on initial explo-
ration. The highest benefit was in patients with Crohn’s disease
(40%) and recurrent fistula-in-ano (24%).
An emerging technique in the imaging of anal fistulas is high-
resolution MR fistulography, in which images are obtained before
and after the intravenous injection of gadolinium, following
which images are subtracted that show only enhancing tissues,
i.e., the wall of the fistula tract.(5) Schaefer et al. (26) performed
a study of 36 patients who underwent preoperative MR fistulog-
raphy, then underwent fistula surgery with the surgeon blinded
to the MRI results. When operative findings were compared with
MRI findings, 89% agreement was seen. In all four patients in
which there was discordance between operative findings and MR
findings, multiple complex fistulas and abscesses in a setting of
Crohn’s disease were present.
In terms of improving the outcomes of patients who will require
surgery for anal fistulas, it is well established that clear identifica-
tion of the anatomy is essential. Regardless of the modality used, it
seems prudent, with the technology available today, that preopera-
tive imaging of anything more than a simple intersphincteric or
low transsphincteric fistula be performed to minimize the poten-
tially significant morbidity associated with anal fistula surgery.
Surgical Management
Incision and Drainage
The mainstay of treatment of anorectal abscesses is incision and
drainage. There is no role for treatment with antibiotics alone with-
out drainage. Most perianal and superficial ischiorectal abscesses
can be drained in the office or emergency room setting after infil-
tration of local anesthetic. A cruciate incision should be made over
the area of fluctuance, taking care to stay as close to the anal verge
as practical in the event that a fistula develops later. The skin edges
should be excised to allow for adequate drainage without the need
for continued packing. Alternatively, catheter drainage may be
employed, as described by Beck (27), making a small incision over
the area of fluctuance and placing a small (10–16 French) mush-
room-tipped catheter in the abscess cavity. The catheter is typically
removed when the drainage has decreased and the abscess cavity
has closed down around the drain (usually 5–10 days later). Care
should be taken not to cut the catheter too short to prevent it from
retracting completely into the abscess cavity.
Larger ischiorectal abscesses may require sedation, regional
anesthesia, or general anesthesia for sufficient drainage. Adequate
patient comfort is essential, as attempts to drain an abscess in an
inadequately anesthetized patient lead to unnecessary patient dis-
tress, and will almost assuredly result in incomplete exploration
and drainage of the abscess.
Intersphincteric abscesses should be drained via division of
the internal sphincter along the length of the abscess, followed by
marsupialization of the wound. Drainage of a supralevator abscess
depends on the etiology of the abscess. If it arises from an inter-
sphincteric abscess, drainage should be performed transrectally by
division of the internal sphincter, as external drainage would result
in the development of a suprasphincteric fistula. If the origin is
an ischiorectal abscess, drainage should be performed externally,
through the perianal skin. If the abscess originates from an infec-
tious process in the pelvis, drainage may be performed through
the rectum, ischiorectal fossa, or abdominal wall by percutaneous
drainage, ensuring that the primary infectious process is addressed.
Management of horseshoe abscesses and fistulas can be especially
problematic. Adequate treatment of horseshoe abscesses typically
requires drainage of the deep postanal space via a midline incision
between the coccyx and anus, spreading the fibers of the superficial
external sphincter. An open internal sphincterotomy is performed
in the posterior midline and counter-incisions are made over each
ischiorectal fossa to allow for drainage of the anterolateral exten-
sions of the abscess, as initially described by Hanley.(28) Rosen et al.

 improved outcomes in colon and rectal surgery
(29) reported that patients with horseshoe abscess/fistula required
a median of 4 (range 1–9) operations; at a mean follow-up of 49.3
months, 60.7% of patients had either healed perineal disease or were
asymptomatic with controlled disease. Those who underwent pos-
terior midline sphincterotomy as part of their surgical ­management
were more likely to be asymptomatic postoperatively (p = 0.047).
There is little role for antibiotics after adequate surgical drain-
age of an anorectal abscess. Those for whom treatment with
antibiotics should be considered postdrainage include patients
with valvular heart disease or prosthetic valves, extensive soft
tissue cellulitis or induration, prosthetic devices, joint replace-
ments, diabetes, and those who are immunocompromised or
immunosuppressed.(30)
Fistulotomy
The surgical management of anal fistulas rests on three main prin-
ciples: eliminating the fistula, preventing recurrence, and preserving
sphincter function. Identification of the primary opening and divi-
sion of as little sphincter muscle as possible are essential to achieving
these outcomes. Methods used intraoperatively to identify the pri-
mary opening include passage of a probe, injection of a dilute solu-
tion (hydrogen peroxide, methylene blue, or milk) via the secondary
opening, tracing granulation tissue present in the fistula tract, and
identifying puckering of the anal crypt when traction is placed on
the tract.(30) Preoperative determination of fistula anatomy may
also be determined using imaging modalities, as described earlier.
Most simple intersphincteric fistulas and low transsphincteric
fistulas can be managed by simple “lay-open” fistulotomy with
curetting of the tract and marsupialization of the wound edges.
Higher transsphincteric, extrasphincteric, and suprasphincteric
fistulas are generally not appropriate for simple fistulotomy, as the
end result would be division of a large portion of anal sphincter,
resulting in altered fecal continence.
Primary fistulotomy at the time of initial abscess drainage is con-
troversial. Some argue that in the acute phase it is easier to trace
the supporative process and identify the fistula tract. This eliminates
the source of infection and may decrease the rate of recurrence; in
turn, this may potentially eliminate the need for further surgery and
its accompanying morbidity. Fucini reported no recurrences in 51
of 58 primary fistulotomies where an internal opening could be
identified and no “major” incontinence, though impaired control
of flatus was seen in 17%.(31) Tang et al. showed in a prospective
randomized trial of drainage alone versus drainage and fistulotomy
for acute perianal abscesses that there was no statistical significance
in terms of recurrence.(32) The concept of primary fistulectomy
at the time of abscess drainage also is controversial. Schouten and
van Vroonhoven prospectively demonstrated that fistulectomy was
associated with clinically significant disturbances in anal function in
39.4% of patients treated with primary fistulectomy, compared with
21.4% of patients treated with secondary fistulectomy.(33)
Seton Placement
In the management of higher transsphincteric fistulas, preserving
the sphincter becomes even more essential. In these instances, place-
ment of a seton may be of benefit. A seton may be used in a cutting
fashion by dividing the skin and lower portion of the anal sphincter
and gradually tightening the seton over regular intervals. A seton

may also be used to allow for prolonged drainage, without gradual
tightening. Indications for the use of a seton include identification
and promotion of fibrosis around a complex fistula that encircles
most of the sphincter, marking the site of a transsphincteric fis-
tula in cases of severe anorectal sepsis where the normal anatomic
landmarks have been distorted, in anterior high transsphincteric
fistulas in women, in high transsphincteric fistulas in HIV-positive
patients with poor wound healing, to promote long-term drainage
in patients with Crohn’s disease, and when there is suspicion that a
primary fistulotomy will result in incontinence.(34)
Treatment of suprasphincteric fistulas can become extremely
complex, as laying-open of the entire fistula tract would inevitably
lead to incontinence. The use of a cutting seton in combination
with division of the internal sphincter and the superficial ­portion
of the external sphincter to the level of the secondary opening
has been reported with successful healing in 63% of patients.
(35) Kennedy and Zegarra (36) described a modification of this
approach using internal sphincterotomy along with opening of
the tracts outside the external sphincter without division of any
portion of the external sphincter, which is encircled by a seton to
promote fibrosis and drainage; they reported complete healing in
66% of posterior fistulas and 88% of anterior fistulas.
Extrasphincteric Fistulas
Surgical management of an extrasphincteric fistula depends on its
etiology. If it arises as a consequence of an anal fistula, the lower
portion of the internal sphincter is divided and the rectal opening
is closed with a nonabsorbable suture, with or without temporary
diversion. If the fistula is the result of trauma, drainage must be
performed along with closure of the rectal opening and proximal
diversion. If the fistula is the result of downward tracking of a ­pelvic
abscess, treatment of the primary process is essential. It is prudent
to have a low threshold for temporary proximal diversion, as pro-
gressive perineal sepsis can lead to ­devastating consequences.
Advancement Flap
In patients for whom primary fistulotomy is not appropriate,
the use of an anorectal or endorectal advancement flap is a use-
ful alternative. These patients include women with anterior fis-
tulas, patients with inflammatory bowel disease, patients with
high transsphincteric and suprasphincteric fistulas, and those
with multiple previous fistula operations.(37, 38) A full-thickness
flap incorporating a portion of the internal sphincter should be
advanced at least a centimeter beyond the primary fistula opening
and sutured into place with absorbable sutures without tension
(Figure 19.4).
Schouten et al. (39) reported successful fistula closure in 33
of 44 (75%) patients with anal fistulas treated with endorectal
advancement flaps. In patients with no or only one attempt at
repair, the healing rate was 87%, compared with 50% in those
with two or more prior attempts. In a series of 107 patients with
anal fistulas arising from a number of etiologies who underwent
endorectal advancement flap, Kodner et al. reported successful
healing in 93% of patients, though nine patients initially failed
and required a second procedure.(40) In a series of 29 patients
with cryptoglandular and obstetric-related fistulas, Dixon et al.
(41) reported 69% (20 of 29) fistula resolution with endorectal
 surgery and nonoperative therapy of perirectal abscesses and anal fistulas
(A) (B)
Figure 19.4  Anorectal advancement flap. (A) Transphincteric fistula in ano. (B) Enlargement of external opening. (C) Flap of mucosa and muscle created. (D) Flap
advanced and closed after excision of distal edge containing fistula.
advancement flaps at 3 months follow-up. Additionally, of the
nine patients who failed, fistula resolution was seen in 4 (44%)
after a second procedure, for a total success rate of 83%. Healing
rates of 63.3% to 81% have also been reported for the use of
endorectal advancement flaps for the management of complex
anal fistulas.(42, 43)
Endoanal advancement flaps have also been utilized with vary-
ing degrees of success in the management of anal fistulas. Chew
and Adams (44) reported successful fistula closure using an anal
sphincter advancement flap, as opposed to an endorectal advance-
ment flap, in six patients with a mean, follow-up of 8.1 months.
Amin et al. (45) reported overall 83% healing in patients under-
going V-Y advancement flaps for fistula closure, although two
patients required repeat surgery. Continence was preserved in all
patients. Zimmerman et al. (46) reported only 46% healing with
anocutaneous advancement flaps, with success inversely correlated
with the number of previous attempts at fistula repair.
Fibrin Glue
The injection of fibrin glue into the tract(s) of a fistula-in-ano is
a simple method used to impart closure. Advantages include easy
application, preservation of sphincter integrity, minimal patient
discomfort, and the opportunity to repeat applications when the
initial treatment fails. Earlier trials utilized injection of autologous
fibrin adhesive prepared from the patient’s own blood. Cintron
et al. reported successful healing in 22 of 26 patients treated
with autologous fibrin at a mean follow-up of 3.5 months.(47)
The same group reported less success (17 of 25 patients) with a
commercially produced sealant.(48) Less favorable results were
seen at a mean follow-up of 1 year, with 54% healing in patients
treated with autologous fibrin sealant and 64% healing in patients
treated with commercially produced fibrin sealant.(49) Most fail-
ures occurred within the first 3 months, though failures were seen
as late as 11 months postoperatively.
Additional studies initially failed to show consistent results.
A small randomized, controlled trial comparing fibrin glue to con-
ventional treatment (fistulotomy or seton placement with or with-
out later advancement flap) failed to show an advantage to fibrin
glue for simple fistulas, though more complex fistulas healed with
fibrin glue (69% vs. 13%, p = 0.003).(50) Sentovich (51) reported
complete healing in 17 of 20 (85%) patients treated with fibrin glue
at a mean follow-up of 10 months, though he later reported a less
favorable healing rate of 69% in a larger series of 48 patients at
(C) (D)
a median follow-up of 22 months, including retreatment of ini-
tial failures. Even less favorable healing rates of 14–33% have been
reported in other series.(52–54)
More recently, improved outcomes in larger series have been
published. In prospective study of 36 patients, Maralcan et al.
reported a complete healing rate of 83.3% at a mean follow-up
of 54 weeks.(55) Adams et al. reported healing in 66% of patients
treated with fibrin glue with a mean follow-up of 3 months, with
94% of these patients asymptomatic at 6 month follow-up.(56)
Fibrin glue has also been evaluated as an adjunct to advance-
ment flap closure of anal fistulas. Ellis and Clark (57) performed a
prospective, randomized, controlled study comparing flap repair
alone (n = 30) to flap repair with fistula tract obliteration using
fibrin glue (n = 28). At a median follow-up of 22 months, the
recurrence rate for fistulas treated with advancement flaps alone
was 20%, compared with 46.4% for fistulas treated with advance-
ment flaps with fibrin glue (p < 0.05). The authors postulated
that obliteration of the fistula tract with fibrin glue may prevent
effective drainage from beneath the advancement flap, leading
to a higher failure rate. Van Koperen et al. (58) also showed that
outcomes were worse when obliteration of the fistula tract with
fibrin glue was combined with endorectal advancement flap.
As a more economical alternative to fibrin glue, Jain et al. (59)
proposed using cyanoacrylate glue as a means toward achieving fis-
tula closure. They reported complete fistula closure at 6 month fol-
low-up in 17 of 20 patients after primary injection, and complete
healing in two of the three initial failures after a second injection,
for a composite 95% healing rate. Proposed advantages of cyano-
acrylate as opposed to fibrin include a cost reduction of approxi-
mately two-thirds, commercial preparation in premade collapsible
tubes that do not require premixing, and a longer shelf-life. Barilleri
et al. (60) reported similar results with complete healing at 18 month
follow-up in 15 of 21 patients. Four additional patients healed with
repeat applications, for a composite healing rate of 90.2%.
Modifications of the fibrin adhesive technique have been
attempted, also with little improvement. The addition of cefoxitin
to the fibrin adhesive failed to improve healing rates in a study
performed by Singer et al. nor did closure of the primary opening.
(61) In fact, healing rates with both modifications were lower than
their earlier published result with fibrin adhesive alone.(47, 48)
Gustafsson and Graf (62) looked at the addition of a gentamycin-
enriched collagen adhesive beneath rectal advancement flaps and
found no difference in healing rates. In a prospective study with

 improved outcomes in colon and rectal surgery
more favorable outcomes, Zmora et al. were able to achieve a 53%
healing rate in a prospective study of 60 patients with complex
cryptoglandular fistulas treated with fibrin glue with intraadhe-
sive ceftazidime.(63)
The wide variety of successful healing in studies looking at the
use of fibrin glue in the treatment of fistula-in-ano is multifactorial.
Differences in the trials include patient selection, use of autologous
versus commercially prepared fibrin adhesive, etiology of the fistula
(cryptoglandular vs. Crohn’s disease vs. other causes), complexity
of the fistula, and length of follow-up. While the application of the
tissue adhesive seems fairly straightforward, there are also assuredly
subtle differences in the application techniques of different sur-
geons. The heterogeneity of the published trials makes direct com-
parisons very difficult. While success rates vary over a wide range,
the advantages of attempting to treat high transsphincteric fistulas
with fibrin glue in terms of simplicity of technique, negligible com-
plication rate, and ease of reapplication for failed treatments make
it an attractive option, at least initially. Most ­surgeons seem willing
to accept a higher than expected failure rate in exchange for a low
complication rate, understanding that treatment failures will need
to be addressed in some other manner.
Anal Fistula Plug
The topic that has perhaps generated the most discussion in recent
years is the use of the Surgisis® Anal Fistula Plug™ (AFP) (Cook
Surgical, Inc., Bloomington, IN). The AFP is a cone shaped bio-
prosthetic fashioned from Surgisis®, a bioabsorbable xenograft
made of lyophilized porcine intestinal submucosal. Surgisis® has
been used extensively in abdominal and inguinal hernia repairs.
(64–66) It is relatively resistant to infection, produces no foreign
body or giant cell reaction, and becomes repopulated with host
cell tissue within 3–6 months, providing mechanical integrity
while acting as a scaffold to guide tissue incorporation. The AFP
is inserted into the fistula tract and secured at the level of the pri-
mary opening. The principal effect is to close the primary fistula
opening, though incorporation of the AFP into the tract itself can
theoretically contribute to fistula closure. The advantages of this
technique include negligible risk of incontinence postoperatively,
relative simplicity in placement of the AFP, less postoperative
patient discomfort, and the ability to repeat the procedure in cases
of failure without major consequences.
Johnson et al. (67) initially reported a small, nonrandomized,
prospective cohort study comparing the efficacy of fibrin glue
versus AFP in the treatment of high transsphincteric fistulas. At a
mean follow-up of 14 weeks, in the fibrin glue cohort, healing was
seen in 40% (4 of 10), whereas in the AFP cohort, 13 of 15 (87%)
had healed (p < 0.05). The main advantage of the plug technique
compared with fibrin glue was felt to be the ability to securely close
the primary opening, which is felt to be a critical step in the suc-
cessful treatment of anal fistulas. The drawback of fibrin glue is its
liquid nature, and its tendency to run out of the fistula tract, even
when both primary and secondary openings are sutured closed.
Champagne et al. (68) went on to report an overall healing
rate of 83% for cryptoglandular fistulas treated with an AFP in
a series of 46 patients followed for a mean of 12 months (range
6–24 months). The same authors reported a similar 80% success
rate for treatment of Crohn’s-related fistulas with an AFP in 20

patients at a median follow-up of 10 months.(69) Ellis (70) also
reported success in a small group patients with transsphincteric
(n = 13) and rectovaginal fistulas (n = 5) with 88% complete fis-
tula closure at a median follow-up of 6 months.
Other studies report inconsistent results. Van Koperen et al.
reported a series of 17 patients treated with an AFP with only 41%
success.(71) Patients with cryptoglandular disease and no history
of previous fistula surgery fared better than those with a history of
previous surgical intervention. In the small subsets of patients with
Crohn’s disease (n = 1) and HIV infection (n = 2), 100% healing
was seen, as opposed to 29% complete healing (4 of 14) in patients
with cryptoglandular disease. Schwandner et al. (72) reported an
overall success rate of 61%. The subset of patients with Crohn’s
fistulas related to Crohn’s disease showed higher closure rates than
those with fistulas of cryptoglandular origin (85.7% vs. 45.5%).
More recent studies have varied widely in their results, reporting
healing rates ranging from 24% to 71.4%.(73–76)
One of the largest prospective studies was reported by Ky et al.
(77) The authors studied 45 patients with simple (n = 24) and
complex (n = 20) anorectal fistulas treated with AFP’s. An early
healing rate of 84% at 3 to 8 weeks postoperatively progressively
declined to 54.6% at a mean follow-up of 6.5 months. Healing
rates were significantly higher in patients with simple rather
than complex fistulas (70.8% vs. 35%, p < 0.02) and in patients
without Crohn’s disease compared to those with Crohn’s disease
(66.7% vs. 26.6%, p < 0.02).
Despite a number of publications attesting to the safety and
efficacy of the AFP, uniformity of opinion was lacking because
of contradictory reports in the literature as well as a lack of Level
I evidence showing any clear benefit. Because of this, a consensus
conference involving 15 surgeons with extensive experience with
the AFP was held in May 2007 to make formal recommendations
regarding inclusion/exclusion criteria, pre-, intra-, and postop-
erative management, and definition of outcome failure.(78)
Some technical notes regarding placement of the plug bear men-
tioning. It is essential that all sources of perineal sepsis are resolved
prior to placement. The use of pre- or postoperative antibiotics and
preoperative bowel cleansing has not been studied in a prospec-
tive, randomized fashion. In most of the studies described herein, a
preoperative dose of intravenous antibiotic was administered, and
varying regimens of postoperative antibiotics were utilized. The
consensus panel did not make specific recommendations regard-
ing preoperative bowel preparation; a single dose of preoperative
systemic antibiotics was recommended without postoperative
­continuation.(78) Thorough cleansing of the fistula tract with
hydrogen peroxide is generally recommended. Mechanical cleans-
ing via curetting, debridement, or brushing is not recommended
due to disruption and enlargement of the tract. The technique of
fixation of the plug to the primary opening recommended by the
manufacturer involves a figure of eight absorbable suture through
the mucosa, submucosa, and internal anal sphincter that inverts the
proximal end of the anal fistula plug beneath the mucosa, anchor-
ing it to the tract while closing the primary opening over the plug
(Figure 19.5). Earlier studies as well as the manufacturer’s recom-
mendations suggested fixation of the distal end of the plug to the
secondary fistula opening as an essential step in plug placement.
Most surgeons have abandoned this step, now simply trimming the
 surgery and nonoperative therapy of perirectal abscesses and anal fistulas
(A)
(B)
Figure 19.5  AFP product insert.
distal end of the plug flush with the skin without fixation, as it has
been suggested that external fixation creates tension on the primary
fixation site with patient movement, predisposing to plug extru-
sion. The consensus panel also recommended not fixing the distal
end of the plug to the secondary opening. The majority of AFP
failures are due to plug extrusion, untreated or persistent source(s)
of perineal sepsis, or postoperative infectious complications.
Ligation of Intersphincteric Fistula Tract
An interesting new concept in the surgical management of fistula-
in-ano has recently been described—ligation of the intersphincteric
fistula tract (LIFT).(79) In this method, intersphincteric dissec-
tion is performed and the fistula tract is identified and ligated in
this plane, leaving the sphincter muscles themselves undisturbed.
The authors reported complete fistula healing in 17 of 18 patients
(94.4%), with a mean healing time of 4 weeks and no disturbances
in anal function. While this study was small and observational in
(C)
(D)
nature, the simplicity of the technique and its negligible impact on
sphincter function certainly warrant further investigation.
Additional Issues
Recurrence
Recurrence after incision and drainage of an anorectal abscess
and anal fistula, should be considered as two entities. True recur-
rence after abscess drainage is typically due to inadequate drain-
age or inadequate postoperative care. What is more commonly
seen is actually “persistent” disease as the abscess cavity matures
into a fistula. Vasilevsky and Gordon reported recurrent or per-
sistent disease in 48% of patients (11% recurrent abscess, 37%
fistula-in-ano) after undergoing incision and drainage of ano-
rectal abscesses.(80) Results similar to these have been reported
by several authors, which argue against primary fistulotomy at
the time of initial abscess drainage, as unnecessary fistulotomy

 improved outcomes in colon and rectal surgery
with potential altered fecal continence can be avoided in approxi-
mately 50% of patients.
Common reasons for recurrent anorectal infection include missed
infection at the time of initial drainage in adjacent anatomic planes,
presence of an undiagnosed fistula at the time of initial abscess drain-
age, and failure to completely drain the abscess initially.(81) In a series
of 500 patients undergoing anorectal abscess drainage, Onaca et al.
reported that 7.6% required reoperation within 10 days of the initial
procedure.(82) Factors leading to reoperation included incomplete
drainage (23%), missed loculations (15%), missed abscesses (4%),
and postoperative bleeding (3%). Horseshoe abscesses were associ-
ated with a 50% rate of operative failure.(82)
Similarly, recurrent fistula-in-ano is often seen after surgi-
cal management due to a failure to identify a primary opening
or recognize secondary extensions of a fistula. Secondary tracts
accounted for early recurrences in 20% of patients studied by
Sangwan. (83) Sygut et al. reported a 14.3% recurrence rate after
surgical management of fistula-in-ano, though recurrence was
much more common after surgery for recurrent fistulas (51.7%)
than primary fistulas (5.4%).(84) In this same study, recurrence
was also more common in multi-tract fistulas (32.4%) than
single-tract fistulas (12%).
Recurrence rates after fistulotomy range from 0–18% (Table 19.1).
Premature closure of the fistulotomy wound is a clear risk factor for
recurrence; this can be prevented by creating an external wound
larger than the anal wound, ensuring that the internal wound will heal
first. Meticulous postoperative care is essential to avoid bridging and
pocketing of the wound.(99, 100) Epithelialization of the tract may
also occur, leading to persistent fistula-in-ano.(101) Garcia-Aguilar
et al. performed a retrospective study that reviewed the records of
624 patients undergoing surgery for fistula-in-ano in an effort to
determine factors associated with recurrence and incontinence.(98)
Recurrence was seen in 8% of patients; univariate and multivariate
regression analysis showed that factors associated with recurrence
included complex fistula type, horseshoe extension, lack of identi-
fication, or lateral location of the primary fistula opening, previous
fistula surgery, and the experience of the surgeon. Recurrence rates
after staged fistula repairs using setons range from 0% to 9% (34, 98,
102–109), though the largest study with a 0% recurrence rate had
only 21 patients.(106)
Interestingly, the success rate of fistula surgery has been shown to
decrease with time. In a study by van der Hagen et al. (110), recur-
rence rates following fistulotomy at 12, 48, and 72 months were 7%,
26%, and 39%, respectively, with 33% of recurrences occurring in
the first 24 months after surgery. A similar trend was seen following
the use of endorectal advancement flaps, with recurrence rates of
22%, 63%, and 63% seen at 12, 48, and 72 months respectively; 69%
of recurrences were seen within the first 24 months. Van Koperen et
al. (111) demonstrated recurrence rates at 3-year follow-up of 7%
for fistulotomy, and 21% for rectal advancement flaps.
Mizrahi et al. (112) described features associated with fistula
recurrence in a series of 106 consecutive endorectal advancement
flaps performed on 94 patients. Recurrence was seen in 40.4% of
patients at a mean follow-up of 40.3 months. Recurrence was
not associated with prior attempt at repair, type of fistula, ori-
gin of fistula, preoperative steroid use, postoperative bowel con-
finement, postoperative antibiotic use, or creation of a diverting

stoma. Recurrence was significantly more common in patients
with Crohn’s disease (p < 0.04). Sonada et al. reported a simi-
lar recurrence rate of 36.4% of patients undergoing endorec-
tal advancement flap for repair of anorectal and rectovaginal
fistulas in a series of 105 patients.(42) Factors that negatively
impacted the healing rate were Crohn’s disease (p = 0.027) and a
diagnosis of rectovaginal as opposed to anorectal fistula (0.002).
Patients on oral corticosteroid therapy showed a trend towards
recurrence, though this did not reach statistical significance; no
patients taking more than 20 mg/day of prednisone achieved
long-term healing.
Cigarette smoking has been shown to negatively impact ­fistula
closure after endorectal advancement flap. In a series of 105 patients
undergoing endorectal advancement flap for anal ­fistulas not
related to Crohn’s disease, Zimmerman et al. reported successful
fistula closure in 69%.(113) In patients who did not smoke ciga-
rettes, healing was seen in 79%, compared with 60% in smokers
(p < 0.037). Furthermore, a significant correlation was seen between
the healing rate and the number of cigarettes smoked per day
(p = 0.003). Using intraoperative laser Doppler flowmetry, it has also
been shown that median bloodflow before endorectal advancement
flap in nonsmokers was 35 volts, ­compared with 18 volts in smokers
(p = 0.018).(114) Thus, it seems likely that impaired wound heal-
ing due to diminished perfusion may be a contributing factor in
the failure of endorectal advancement flaps in smokers. Efforts to
encourage smoking cessation preoperatively should be undertaken
to minimize postoperative morbidity.
Incontinence
Fecal incontinence after abscess drainage should be relatively
infrequent and is typically the result of iatrogenic damage to the
sphincter mechanism. Compromised continence may also be
seen postoperatively if the external sphincter is damaged dur-
ing ­incision and drainage in patient with borderline preopera-
tive ­continence. Inadvertent injury to the puborectalis during
drainage of supralevator abscesses has also been reported.(115)
Prolonged packing may prevent granulation tissue formation
and promote generation of excessive scar tissue.(116) Primary
fistulectomy at the time of incision and drainage has also been
reported to cause disturbed fecal continence.(33)
On the other hand, incontinence rates following surgical
management of fistula-in-ano vary widely. The incidence of
incontinence is related to the complexity of the fistula and the
level of the primary fistula opening, with complex fistulas and
those with posterior and high openings and fistula extensions at
a higher risk.(97) Posterior fistulotomy has a higher incidence
of recurrence due to a more circuitous route of the tract, result-
ing in division of more sphincter muscle. Drainage of extensions
may damage small nerves and create scar tissue around the ano-
rectum.(97) The incidence of incontinence is also related to the
patient’s preoperative sphincter function and their would-heal-
ing ability. The incidence of impaired continence also increases
with age and is more common in females.(98) Fecal seepage
without true sphincter compromise can occur if the edges of a
fistulotomy wound do not heal completely, preventing complete
closure of the anus and allowing for leakage of fecal contents,
and flatus.
 surgery and nonoperative therapy of perirectal abscesses and anal fistulas

Table 19.1  Results of fistula surgery.

Author Year No. Patients Recurrence % Incontinence %

Bennett (85) 1962 108 2.0 36.0

Hill (86) 1967 626 1.0 4.0
Lilius (87) 1968 150 5.5 13.5
Mazier (88) 1971 1000 3.9 0.001
Ani & Solanke (89) 1976 82 17.0 1.0
Marks & Ritchie (90) 1977 793 – 3, 17, 25*
Ewerth et al. (91) 1978 143 2.8 3.5
Adams & Kovalcik (92) 1981 133 3.8 0.8
Kuijpers (93) 1982 51 4.0 10.0
Sainio & Husa (94) 1985 199 11.0 34.0
Vasilevsky & Gordon (95) 1985 160 6.3 0.7, 2.0, 3.3**
Fucini (96) 1991 99 3.0 0, 0.2, 0.5***
Van Tets (97) 1994 19 – 33.0
Sangwan (83) 1994 461 6.5 2.8
Garcia-Aguilar et al. (98) 1996 293 7.0 42.0

* 3% solid stool, 17% liquid stool, 25% flatus.

** 0.7% solid stool, 2.0% liquid stool, 3.3% flatus.
*** 0 solid stool, 0.2% liquid stool, 0.5% flatus.

In a large review of 844 patients undergoing surgery for anal
fistulas, Rosa et al. (117) demonstrated a 6.9% incidence of altered
postoperative sphincter function. Incontinence to flatus was seen
in 4.0%, liquid stool in 2.6%, and solid fecal material in 0.3%.
The majority of patients in this series underwent fistulotomy or a
combined fistulotomy-fistulectomy method. Sygut et al. reported
postoperative gas and/or stool incontinence in 10.7% of patients
undergoing surgical management of anal fistulas, mainly in the
form of fistulotomy and cutting setons.(84) In this study, rates
of incontinence were higher following surgery for recurrent vs.
primary fistulas (39.7% vs. 3.7%) and after surgery for multitract
as opposed to singletract fistulas (29.4% vs. 8.3%). In a review of
624 patients undergoing anal fistula surgery, Garcia-Aguilar et al.
(98) showed that 45% of patients complained of some degree of
altered continence. Factors associated with postoperative inconti-
nence included female sex, high fistula type, type of surgery, and
previous fistula surgery. Incontinence after staged fistulotomy
using a seton ranges from 0% to 64%.(34, 97, 98, 102–109) Again,
all of the studies showing no recurrences were small, with the
largest being only 20 patients.(105)
In a study looking at long-term functional outcome, Van
Koperen et al. (111) reported that after fistulotomy for low cryp-
toglandular fistulas, fecal soiling was seen in 41% of patients and
fecal incontinence was seen in 2.8% of patients at 3 year follow-up.
Following rectal advancement flaps, soiling was seen in 43% and
incontinence was seen in 2.9% at 3 year follow-up. None of poten-
tial risk factors examined (sex, age, prior fistula surgery, smok-
ing) were significant in both univariate and multivariate analysis.
Schouten et al. (39) showed that 35% of patients had deteriorated
continence postoperatively after endorectal advancement flap. The
number of previous attempts at fistula repair did not adversely
affect continence.
Zimmerman et al. (46) reported deteriorated continence after
anocutaneous advancement flap in 30% of patients. Aguilar et al.
reported disturbances in continence to flatus in 7% and liquid
stool in 6% in a series of 189 patients undergoing fistulectomy
with endorectal advancement flap.(118) Kodner et al. reported
unchanged or improved continence in 98% of patients undergo-
ing endorectal advancement flap for anorectal fistulas.(40) Other
series have reported no alteration in postoperative continence
after rectal advancement flaps.(45, 119)
Toyonaga et al. performed an interesting study looking at pre-
and postfistulotomy manometry studies.(120) They found that
fistulotomy significantly decreased maximum resting pressure
(85.9 to 60.2 mmHg, p < 0.0001) and length of the high pressure
zone (3.92 to 3.82 cm, p = 0.035), but did not affect voluntary
contraction pressure (164.7 to 160.3 mmHg, p = 0.2792). Anal
sphincter dysfunction, in the form of soiling, incontinence to fla-
tus, or incontinence to liquid stool, occurred in 20.3% of patients.
Multivariate analysis showed that while fistulotomy did not affect
voluntary contraction pressure, those with lower preoperative
voluntary contraction pressures were more likely to suffer from
altered continence postoperatively, as were those who had under-
gone multiple drainage procedures. Age, sex, previous fistula sur-
gery, duration of symptoms, and location and level of the primary
opening did not significantly influence continence postoperatively.
The authors concluded that preoperative anal manometry may
be helpful in choosing the proper surgical procedure for patients
with fistula-in-ano.
Manometry studies following endorectal advancement flaps
performed by Uribe et al. (121) also showed significant reduc-
tion in maximum resting pressure 3 months after surgery (83.6
vs. 45.6 mmHg, p < 0.001), as well as significant reduction in
maximum squeeze pressure (208.8 vs. 169.5 mmHg, p < 0.001).
Disturbed anal continence was seen 21.4% of patients. None of
the variables looked at (age, sex, previous fistula surgery, Crohn’s
disease) were predictive of postoperative incontinence. In con-
trast, manometry studies following endorectal advancement


 improved outcomes in colon and rectal surgery
flaps were performed by Kreis et al. (122), showing no difference
in preoperative and postoperative maximum squeeze pressure
(100.0 vs. 118.0 mmHg), maximum resting pressure (56.6 vs.
52.8 mmHg), rectal compliance (4.4 vs. 3.5 ml/mmHg), or any
other anorectal manometry parameter.
Other studies evaluating preoperative manometric parameters
differ somewhat. Chan and Lin (123) examined 45 patients with
intersphincteric fistulas and showed low preoperative resting pres-
sure to be the only independent factor predicting postoperative
incontinence. In a prospective study by Perez et al. (124) looking
at combined fistulotomy with primary sphincter reconstruction,
there were significant preoperative differences seen on manom-
etry between continent and incontinent patients that disappeared
after operation. There were neither clinical nor manometric dif-
ferences between pre- and postoperative values in fully continent
patients, although three patients (12.5%) reported minor altera-
tions of continence.
Crohn’s Disease
The overall incidence of anorectal fistulas associated with Crohn’s dis-
ease limited to the ileocecum is 20–25%; this rises to approximately
60% when Crohn’s disease affects the rectum.(125) Disease isolated
to the anorectum is seen in only 5% of patients.(126) Fistulizing
anorectal Crohn’s disease can be among the most frustrating con-
ditions surgeons are called upon to manage. Surgical treatment is
fraught with the problems of poor wound healing, delayed wound
healing, and sphincter injury. It is widely held that incontinence in
patients with anorectal Crohn’s disease is usually the result of aggres-
sive surgeons and not aggressive disease.(127) Thus, a conservative
approach is practiced in most instances, taking extreme care to pro-
tect the sphincter. When in doubt, one cannot be faulted for simply
draining the suppurative process by placing a draining seton.
Any acute infectious process must be drained appropriately and
medical management of the disease should be optimized before
even considering surgical treatment. For low-lying posterior fistu-
las, fistulotomy may be considered, especially if there is not rectal
disease. Anterior fistulotomies in females should be avoided because
of the risk of postoperative incontinence. Endorectal advancement
flaps are also a viable option, especially when there is no rectal
­disease. Joo et al. (128) described 31 endorectal advancement flaps
performed in 26 patients, resulting in fistula eradication in 71% of
cases. Success was more likely in the absence of concomitant small
bowel Crohn’s disease than in patients with concomitant small
bowel Crohn’s disease (87% vs. 25%, p < 0.05). Other series have
shown that the presence of Crohn’s disease predisposes endorectal
advancement flaps to failure.(42, 112)
Data regarding the efficacy of the Surgisis© AFP is mixed. As
mentioned earlier, O’Connor et al. reported the AFP to be effective
in 80% of patients and 83% of fistula tracts in a series of 20 patients
with 36 fistula tracts. Patients with single fistulas were more likely
to have success and success was not correlated with antitumor
necrosis factor therapy.(69) Schwander et al. actually showed better
healing rates with AFP’s in patients with anal fistulas and Crohn’s
disease than in patients without Crohn’s (85.7% vs. 45.5%). On the
other hand, Ky et al. (77) reported complete fistula healing with an
AFP in 26.6% of patients with Crohn’s disease compared to 66.7%
of patients without Crohn’s (p < 0.02).

For patients with fulminant perineal sepsis due to fistulizing
perineal Crohn’s, a low threshold for a diverting stoma must be
entertained, especially since a large number of these patients will
go on to require proctectomy.
Nonsurgical Management
For the most part, there is no role for nonoperative management
of anorectal abscesses. Occasionally, an early inflammatory pro-
cess, marked by pain and erythema or induration without fluc-
tuance, may be prevented from progressing to an abscess with
early initiation of antibiotic therapy. However, once an abscess
has formed, antibiotics alone are insufficient. Failure to appropri-
ately drain an anorectal abscess in a timely manner subjects the
patient to the risk of progressive perineal sepsis, including opera-
tive risks associated with surgery in the septic patient, technical
complications associated with anorectal surgery in the face of
severe inflammation (unclear anatomy, bleeding, risk of inadver-
tent sphincter injury), and necrotizing perineal soft tissue infec-
tion (Fournier’s gangrene) with associated mortality rates as high
as 67% (129–132), as described below.
Nonoperative management of anal fistulas falls into two main
categories – those related to cryptoglandular disease and those
related to Crohn’s disease. There is very little in the literature
regarding nonoperative management of chronic cryptoglandular
fistulas. Obviously, acute suppurative processes must be drained,
typically with a seton. Draining setons may be left in place indef-
initely, with little consequence other than patient discomfort. As
discussed later, in exceedingly rare cases, invasive carcinoma may
develop in the setting of a chronic fistula.
Conservative (nonoperative) therapy for anal fistulas in the set-
ting of Crohn’s disease is the standard approach typically followed.
(331) Initial drainage of the acute suppurative process without
division of the fistula tract is typically performed by placing drain-
ing setons. Long-term indwelling draining setons may be used as
an effective management modality for complex perianal Crohn’s
fistulas, without a negative impact on continence.(134)
A number of medical therapies are utilized for the treatment
of anal fistulas related to Crohn’s disease. Ciprofloxacin has been
reported to improve symptoms in two small, uncontrolled trials.
(135, 136) Metronidazole had also been studied in a number of
uncontrolled trials with varying rates of symptom relief and fistula
healing.(137–140) Metronidazole must be used for maintenance
to be effective, as high recurrence rates are seen on discontinua-
tion.(133) The combination of ciprofloxacin and metronidazole
has also been shown to be effective in a small retrospective study
at reducing symptoms and healing fistulas; most patients in this
series also regressed with cessation of treatment.(141)
A number of immunomodulators are also employed in the
medical management of perianal Crohn’s fistulas. Azathioprine
and 6-mercaptopurine have been shown to induce complete
fistula closure in 31–39% of patients, with even higher rates of
symptom reduction without complete closure.(142–144) Again,
recurrence occurred frequently with discontinuation of treat-
ment. Methotrexate and cyclosporine A have each been shown
to be efficacious in inducing remission on patients with Crohn’s
disease (145, 146), though data regarding their effect specifically
on anal fistulas resulting from Crohn’s disease has been lacking.
 surgery and nonoperative therapy of perirectal abscesses and anal fistulas
Infliximab, a chimeric monoclonal antibody against tumor
necrosis factor-alpha (TNF-α), has revolutionized the medical
management of Crohn’s disease. In mucosal biopsies of patients
with Crohn’s disease, enhanced secretion of TNF-α with failure
to release enhanced quantities of soluble TNF-α receptors is
seen. Infliximab reduces disease activity by blocking the effects
of TNF-α and has been shown to be an effective maintenance
therapy in patients with Crohn’s disease with fistulas (147) and
without fistulas.(148) Despite a lack of convincing Level 1 data
proving the efficacy of infliximab specifically in the setting of
perianal Crohn’s fistulas, its use in this setting is becoming more
widespread.
Long-term data regarding the efficacy of infliximab in effect-
ing perianal fistula closure is lacking. The combination of seton
drainage and infliximab infusion has been shown to be effective
as well, with healing rates ranging from 47–100%.(149–151) The
timing of seton removal in these patients is not clear. If removed
too early, the patient is at risk of developing recurrent perianal
abscesses, and if they are not removed, complete fistula healing
will not occur. Poritz et al. (152) reported 44% complete anal
­fistula healing when the seton(s) were removed between the
­second and third infliximab infusions.
As the use of infliximab escalates, patients who have failed treat-
ment are undergoing subsequent surgical intervention for anorec-
tal fistulas, raising concerns over whether preoperative infliximab
treatment has an adverse effect on anal fistula surgery. Gaertner
et al. (153) showed that patients with Crohn’s disease and anal
fistulas who were treated initially with infliximab and underwent
subsequent surgical treatment showed similar healing rates com-
pared with patients who did not undergo previous infliximab
treatment (60% vs. 59%). Kraemer et al. (154) reported that 9 of
11 patients with Crohn’s disease and anal fistulas who underwent
preoperative infliximab treatment followed by advancement flaps
demonstrated complete healing. Thus, it seems feasible to proceed
with anal fistula surgery after failed infliximab treatment, expect-
ing to acceptable rates of wound healing.
HIV-positive patients
Patients with anorectal abscesses who are HIV-positive require
timely incision and drainage, as presentation is often delayed. In
this population, the use of adjunct antibiotics is strongly recom-
mended. Because these patients are at increased risk if of poor
wound healing (155), care should be taken to minimize the size
of surgical wounds while ensuring adequate drainage. In one
study (155), serious septic complications or uncommon pre-
sentations of anorectal sepsis were seen in 13% of HIV-positive
patients who initially presented with anorectal suppuration. In
another study (156), perianal sepsis in HIV-positive patients
was frequently associated with in situ neoplasia. Interestingly,
immunosuppressive disease has not been found to contribute
to the need for early reoperation following initial abscess drain-
age.(82)
In a review by Munoz-Villasmil et al. (157) of 83 immunocom-
promised patients with perianal sepsis, 28% were HIV-positive. In
this population, 91% of surgical wounds were healed in 8 weeks.
Incontinence was seen in 6% of patients postoperatively, and
recurrence was seen in 7%.
Carcinoma Associated with Fistula-In-Ano
In rare instances, patients with long-standing anal fistulas may
go on to develop invasive carcinoma. Although this occurs more
commonly in the setting of Crohn’s disease, carcinomas arising
from anal fistulas have been reported in patients without Crohn’s
disease.(158, 159) While Crohn’s disease is associated overall with
an approximately 6-fold increase in colorectal cancer compared
to the general population (160), the incidence of anal cancer aris-
ing from an anal fistula in the setting a Crohn’s disease is signifi-
cantly lower.
In a series of over 1000 patients with anorectal manifestations of
Crohn’s disease, Ky et al. (125) reported seven patients (0.7%) who
developed invasive carcinoma related to anorectal fistulas. Four
patients developed squamous cell carcinoma and three developed
adenocarcinoma. The average duration of Crohn’s disease before
cancer diagnosis was 14 years and average age at diagnosis was
47 years. Presenting symptoms included pain (n = 5), persistent
­fistula (n = 2), persistent anal ulcer (n = 1), and rectovaginal
fistula (n = 1). In four patients, the diagnosis of carcinoma was
overlooked at initial examination, resulting in significant delay
in diagnosis. All four patients with squamous cell carcinoma
were treated with chemoradiation. Two of these were success-
fully treated with no evidence of residual disease. One died of
carcinoma 6 months after treatment. The fourth patient required
abdominoperineal resection due to persistent disease and died 1.5
years later. One of the patients treated successfully with chemo-
radiation developed a second primary squamous cell carcinoma
11 years later, which was successfully treated with wide local exci-
sion. All three patients with adenocarcinoma were treated with
abdominoperineal resection. One received preoperative chemo-
radiation; this patient died 3.5 years later. Of the remaining
2 patients, one died in the early postoperative period, and the
second died of unrelated causes 5 years later.
A number of other case reports in the literature describe patients
with carcinoma arising from chronic fistulas and unhealed wounds
in a setting of Crohn’s disease.(161, 162) The take home message is
that one must maintain a high degree of suspicion for carcinoma
in patients with persistent or complex anal fistulas, especially in
the setting of long-standing Crohn’s disease. In this setting, com-
plex fistulas with associated anorectal strictures and/or severe
anorectal pain mandate a thorough examination. In cases where
anorectal examination is limited or unequivocal, exam under
anesthesia with biopsy or curettage of the fistula tract is essential.
Because lesions are typically diagnosed at a later stage of disease,
prognosis is poor. Timely diagnosis and institution of appropriate
therapy is essential to improve survival rates.
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20 Surgery and nonoperative therapy of anal fissure
Jaime L Bohl and Alan J Herline

Challenging Case POSTERIOR

A 35-year-old woman presents with a recurrent posterior anal
­fissure. She had a left lateral anal sphincterotomy 4 years ago for
an unresponsive anal fissure. Her fissure healed until 6 months
ago. She has had two previously vaginal deliveries. Exam reveals
a posterior anal fissure with exposed sphincter muscle and a sen-
tinel skin tag. Anal manometry revealed mildly decreased rest-
ing pressure and a hypertonic squeeze pressure. The patient’s
symptoms have not responded to stool softners and topical
medication.
Case Management
A repeat sphincterotomy is relatively contraindicated due to the
decreased sphincter function. An acceptable surgical option is an
advancement flap.
Introduction
An anal fissure is a longitudinal tear or ulcer in the anal canal
from the dentate line to the anal verge. Fissures affect both genders
equally, across age groups with young and middle aged adults con-
stituting the majority of patients.(1) Although the true incidence
is not known, anal fissure is common. In a survey of Italian proc-
tology clinics, 10% of 15,000 consecutive referrals were diagnosed
with anal fissure.(2)
Fissures can be classified by etiology, location, and chronicity. It
is hypothesized that most fissures are caused by trauma to the anal
canal, usually from passage of hard stool. Anal fissures are com-
monly located in the posterior midline (75%), although a smaller
percentage can be found in the anterior midline (13%) and an
anterior and posterior location may be seen simultaneously (11%).
Anterior fissures are seen more commonly in women (19%).(1)
Fissures may be associated with other chronic medical conditions
such as Crohn’s disease, HIV/AIDS, tuberculosis, syphilis, or anal
carcinoma. Fissures in patient with these conditions typically
occur off the midline and may be multiple or irregular (Figure
20.1). These fissures are best treated according to the underlying
disease state. Early or acute fissures are a simple linear tear in the
anoderm. Fissures that have been present for >4 weeks show signs
of chronicity: the base of the fissure reveals internal sphincter fibers
with indurated edges, and a sentinel pile (cranial) or hypertrophied
apical papilla (distal). The chronicity of a fissure is important to
discern from patient history and clinical exam as this will affect
treatment recommendations.
Pathphysiology
The exact mechanisms leading to acute anal fissure and the
­factors that encourage fissure chronicity have been the subject
of debate. However, anatomic and physiologic studies suggest
an ischemic etiology to anal fissure chronicity. In 1986 Gibbons
and Read confirmed that patients with anal fissures had elevated
Acute and
Chronic anal fissure
Crohn’s disease Crohn’s disease
Ulcerative colitis Ulcerative colitis
Syphilis Syphilis
Tuberculosis Tuberculosis
Leukemia Leukemia
Cancer Cancer
HIV Acute HIV
and
Chronic
anal fissure
ANTERIOR
Figure 20.1  Fissure location related to etiology.
anal resting pressures and they hypothesized that elevated anal
resting pressures led to tissue ischemia and ulceration within
the anal canal.(3) This hypothesis was further supported by
anatomic studies performed by Klosterhalfen and colleagues
who showed that the posterior anal canal has a limited blood
supply compared to the rest of the anal canal.(4) The decreased
blood supply to the posterior anal canal was evident through the
lack of inferior rectal artery branches to the posterior anal com-
missure in 85% of postmortem specimens, and the decreased
capillary density in histologic specimens.(4) Schouten and
­colleagues put these findings together when they demonstrated
an inverse relationship between anal resting pressure and ano-
dermal blood flow.(5) Therefore, patients with anal fissure have
less blood flow to their posterior midline secondary to anal
hypertonia. The ischemia in the posterior midline allows per-
sistence of anal fissures and poor healing. Treatments for anal
fissure are therefore aimed at decreasing anal hypertonia and
increasing anodermal blood flow.
Anal fissures can be exquisitely painful despite the small size
of the lesion. Patients complain of sharp, persistent pain dur-
ing and after defecation, which may lead patients to avoid bowel
movements. Patients may also notice blood on the toilet tissue or
coating the stool with limited bleeding or perianal swelling.


 improved outcomes in colon and rectal surgery
Diagnosis
The clinician should inquire about known risk factors for fissure
including alteration in bowel habits (constipation or diarrhea),
childbirth, previous anorectal surgery, or associated medical con-
ditions. The clinician should also inquire to previous episodes
of the presenting symptom complex. The natural history of anal
fissure is one that waxes and wanes, sometimes with healing
between recurrences.
Anal fissure can be diagnosed by inspection of the anus. Patients
are usually too symptomatic to allow for digital examination or
anoscopy at the initial visit. If the clinician suspects another diag-
nosis because of an atypical location, the presence of multiple or
chronic fissures, or a fissure cannot be diagnosed by inspection, then
exam under anesthesia may be necessary. Suspicion of an alternative
diagnosis may warrant biopsy and culture of the anal lesions.
Treatment
Anal fissures have been treated with a variety of medical and surgi-
cal therapies. A growing body of randomized controlled trials has
helped to guide current treatment recommendations for anal fis-
sure. Currently available treatments include conservative therapy,
nitrates, calcium channel blockers, botulinum toxin, anal dilation,
open or closed lateral sphincterotomy, and anal advancement flap.
Conservative therapy comprises increased dietary fluid and fiber,
sitz baths, and stool softeners. Nitrates may include ointments of
nitroglycerin (NTG) or glyceryl trinitrate (GTN), nitroglycerin
transdermal patch, or other nitrate analogs such as isosorbide
dinitrate (IDN) or isosorbide mononitrate (IMN). Calcium chan-
nel blockers have been used in ointment or tablet form (diltiazem
or nifedipine). Finally, botulinum toxin (BT) has been used in
the treatment of anal fissure. It is sold in two commercially avail-
able preparations, Dysport (Speywood Biopharm Ltd, Wrexham,
UK) and Botox (Allergan, Irvine, CA, USA). Both preparations of
BT have been shown to have equal efficacy in the treatment of
chronic anal fissure (6) with 100 units of Dysport toxin having the
bioequivalence of 20 units of Botox. All of these medical and sur-
gical treatments have been used in randomized controlled trials to
assess the effect on fissure healing rates, anal resting pressure, pain,
and fissure recurrence. Other treatment effects which are impor-
tant to consider are complications such as incontinence to flatus or
stool, headache, hypotension, and allergic reactions. Importantly,
two recent meta-analyses of all medical and surgical treatments
used for anal fissure are available.(7–10) This has lead to improved
decision making regarding the treatment of anal fissure.
Conservative therapy is often used as a comparison to other
medical or surgical treatment. The effect of conservative therapy on
healing rate for anal fissure has been 50% for acute (11) and 34%
for chronic anal fissures.(7) Therefore, other medical and surgical
treatments should be tested with this therapy in mind. The effect
of conservative therapy on anal fissure healing rate, reduction in
symptoms, and safety profile has lead to the recommendation by
the American Society of Colon and Rectal Surgeons for conserva-
tive therapy to be the first line treatment of anal fissure.(12)
Acute Anal Fissure
Clinical experience dictates that over half of acute anal fissures will
heal within several weeks. Therefore, most clinicians recommend

conservative therapy for acute anal fissure. Conservative therapy
consists of fiber supplements and sitz baths with or without the use
of topical anesthetics. However, few randomized controlled trials
have evaluated acute anal fissure healing with conservative therapy
as compared to no therapy. One trial compared warm sitz baths
and 10 g of unprocessed bran to 2% lignocaine ointment or 2%
hydrocortisone ointment applied in the anal canal twice per day.
(13) After 3 weeks of treatment, patients treated with bran and sitz
baths had significantly more healed fissures (88%) than patients
treated with lignocaine ointment (60%). Unfortunately, patients
with healed fissures were not followed long-term and rates of fis-
sure recurrence were not measured. One randomized controlled
trial does suggest the ability of long-term conservative therapy to
prevent fissure recurrence.(14) Ninety patients with recently healed
posterior anal fissures were randomized and blinded to three dif-
ferent treatments groups for 1 year. Patients received either 5 g
unprocessed bran three times a day, 2.5 g unprocessed bran plus
2.5 g placebo, or 5 g placebo. Patients receiving 5 g of unprocessed
bran over 1 year had significantly fewer recurrences of anal fissure
(16%) as compared to patients who received the lower bran dose
(60%) or placebo (60%). In addition, within 6 months of discon-
tinuing treatment, the recurrence rate between the three groups
was similar. Finally, one study evaluated the role of sitz baths in
symptom relief and acute anal fissure healing while also providing
psyllium supplementation over 4 weeks.(15) Although there was
a trend toward improved pain scores after defecation and overall
intensity of pain, there were no significant differences in fissure
healing between groups (85%). The authors hypothesize that sitz
baths provide transient pain relief via a thermosphincteric reflex
which allows for decrease in sphincter tone and temporary pain
relief. However, sitz baths do not lead to long-term reduction in
anal tone that allows for fissure healing. Overall, these studies
show that fiber therapy is more effective in preventing acute anal
fissure recurrence, but only suggest that fiber therapy can improve
acute fissure healing.
In an effort to improve acute anal fissure healing rates and
maintain healing, some investigators have added anal dilation or
pharmacologic agents to conservative treatment. One study shows
no additional therapeutic benefit of twice daily anal dilation in
combination with stool softener and lignocaine jelly.(16) Another
small randomized study that included patients with both acute
and chronic fissures compared topical nitroglycerin to topical
xylocaine.(17) In patients who had acute fissures, those receiving
topical nitroglycerin had fissure healing rates of 92% compared
to 0% of the control arm after 14 days of therapy. This treatment
effect persisted, with the same number of patients in the nitro-
glycerin group maintaining healing at 28 days compared to 50%
of patients who received xylocaine ointment. No long-term fol-
low-up data was provided and all treatment failures were referred
for lateral sphincterotomy. A larger randomized trial examined
the healing rate of acute anal fissure after treatment with 0.2%
nifedipine ointment twice daily compared to conservative therapy.
(18) Patients who received nifedipine treatment had higher fissure
healing rates compared to conservative therapy (98 vs. 60%) after
4 weeks of treatment. One novel approach to achieve acute anal
fissure healing has been to compare the efficacy of gonyautoxin,
a paralyzing phytotoxin, to normal saline placebo which are both
 surgery and nonoperative therapy of anal fissure

Table 20.1  Randomized Controlled Trials of Nitrate Therapy versus Placebo for the Treatment of Chronic Anal Fissure.
Length
Number Treatment Groups Treatment Fissure Healing Follow-up Recurrence
Author/Year Patients (%) (weeks) Rates (%) Side Effects (%) (months) (%)

Lund 1997 (24)   80 P vs. 0.2 GTN  8 8 vs. 68 HA: 18 vs. 58  4 11.5%
BID (p < 0.0001) (p < 0.05) GTN
Kennedy 1999 (27)   43 P vs. 0.2 GTN  4 16 vs. 46 HA: 21 vs. 29 29 NR
TID (p = 0.001) Discontinued treatment: 13
Altomere 2000 (26) 132 P vs. 0.2 GTN  4 52 vs. 49 HA: 8 vs. 34 (p = 0.001)  3 19% GTN
BID (p = ns) Orthostatic hypotension: 6
Chaudhuri 2001 (25)   19 P vs. 0.2 GTN  6 22 vs. 70 Not reported  3 None
BID (p < 0.05)
Maan 2004 (28)   64 P / 5 xylocaine /  6 25 vs. 94 HA: 0 vs. 19 None NR
proctosedyl / 0.2 GTN (p < 0.0001)
BID

Carapeti 1999 (29)   70 P / 0.2 / 0.2+0.1qwk  8 32 vs. 67 all GTN HA: 27 vs. 72 all GTN  9 43 vs. 29
GTN (p = 0.008) (p < 0.001) (p = 0.7)
TID
Bailey 2002 (30) 304 P / 0.1 / 0.2 / 0.4 NTG  8 50- all groups Discontinued treatment: 3.3 None NR
BID or TID (p < 0.62)
Scholfield 2003 (31) 200 P / 0.1 / 0.2 / 0.4 GTN  8 38 vs. 47 all GTN HA: 13 vs. 31 all GTN None NR
BID (p = 0.3) (p < 0.01)

Wierre 2001 (31)   37 P vs. 1 IDN 10 35 vs. 85 HA:18 vs. 45 10 33 vs. 12

5x/day (p < 0.003)
Tankova 2002 (32)   19 P vs. 0.2 IMN  3 22 vs. 80 HA: 0 vs. 20  3 None
BID

Note: P = placebo; GTN = glyceryl trinitrate; BID = twice per day; HA = headache; TID = three times per day; NR = not recorded; NS = not statistically significant;
NTG = nitroglycerin; IDN = isosorbide dinitrate; IMN = isosorbide 5-mononitrate.

injected into the internal anal sphincter.(19) This study included
17 patients with acute anal fissure and was eventually unblinded
secondary to a large treatment effect of the toxin. Patients with
acute anal fissures had a healing rate of 100% at 15 days as com-
pared to 0% of the 3 patients who received placebo. All patients
who were injected with the toxin showed a significant decrease
in anal resting pressure from baseline. Complications included
minor bleeding but did not result in any cases of incontinence to
stool or flatus. After 14 months of follow-up this treatment effect
has been maintained. In all, these studies show that the addition of
a pharmacologic agent can increase the healing rates of acute anal
fissure; however, larger trials are needed to replicate these results.
Chronic Anal Fissure
Medical Therapy
Anal fissure chronicity is attributed to sphincter hypertonia and
decreased anodermal blood flow in the posterior anal canal. Pharma­
cologic manipulation of the hypertonic internal anal sphincter has
been sought, given the permanent changes that can occur with surgi-
cal intervention. Medical treatments that result in temporary relaxa-
tion of the internal anal sphincter or chemical sphincterotomy have
been used in the treatment of chronic anal fissure.
Nitrates
Nitrates have been shown to have a relaxing effect on the human
internal anal sphincter (IAS). Ex vivo studies on the human
IAS show that nitric oxide (NO) mediates sphincter relaxation
through enteric inhibitory neurons which are found within the
muscle fibers.(20) Nitrates which are NO donors are readily avail-
able pharmacologic agents. Loder et al. demonstrated that GTN
ointment causes a decrease in anal resting pressure in normal and
anal fissure patients which was comparable to sphincterotomy.
(21) Schouten and colleagues then showed that anal resting pres-
sure decreased and anodermal blood flow increased after chronic
anal fissure patients were treated with isosorbide dinitrate.(22)
They concluded that the reduction in anal sphincter pressure and
increased blood would contribute to early pain relief, while fis-
sure healing would require more time. More recent studies have
shown conflicting data on the ability of nitrates to significantly
decrease anal resting pressure in chronic anal fissure patients.
Thornton et al. clarified these conflicting results with a regression
analysis which showed that patients who were mostly likely to
heal their fissure in response to nitrate therapy were those with
higher pretreatment anal resting pressures and a greater percent
reduction in posttreatment anal resting pressures.(23) Based on
these physiologic studies, nitrates have become an obvious choice
for the pharmacologic treatment of chronic anal fissure.
Nitrates versus Placebo
There are ten randomized controlled trials in the English litera-
ture which compare nitrate therapy to placebo or conservative
therapy in adults with chronic anal fissure. (Table 20.1) There
have been a variety nitrate preparations, ointment strengths,


 improved outcomes in colon and rectal surgery
schedules, treatment length, and instructions for nitrate adminis-
tration that have been utilized in these studies.
Five randomized controlled trials have measured the effect of
0.2% GTN ointment in comparison to placebo.(24–28) In these
studies a total of 338 patients were instructed to apply an active
versus inert ointment to their anal canal either twice or three time
daily for a period of 4 to 8 weeks. Outcome measures included
fissure healing, pain, mean anal resting pressure (MARP), fissure
recurrence, and ointment side effects. Four of these studies were
able to measure an increase in anal fissure healing rates with nitro-
glycerin ointment compared to placebo.(24, 25, 27, 28) However,
there was a wide range of GTN treatment effect (8–52% pla-
cebo vs. 46–94% GTN). The fifth and largest study included 132
patients and did not measure a difference in healing rates between
the placebo and GTN ointment (52% vs. 49%).(26) In four stud-
ies, pain was reported as a secondary outcome. In three studies
pain was significantly decreased after treatment compared to pain
at time of trial entry in both GTN and placebo groups.(24, 26, 27)
However, only one study measured a significant difference in pain
scores between GTN and placebo treatment groups.(28) All five
studies measured treatment effect on MARP. Two studies meas-
ured a decrease in MARP after treatment compared to time at trial
entry for both placebo and GTN groups.(25, 26) In the other three
studies, only the GTN treatment group had a significant decrease
in MARP.(24, 27, 28) One trial reported loss of decreased MARP
48 hours after discontinuing GTN therapy.(27) The most sig-
nificant side effect of nitrate therapy was headache. In four trials,
there was a higher rate of headaches in GTN patients (19–58%)
compared to placebo treated patients (0–21%).(24, 25, 27, 28)
There was also a difference in the severity of headache reported
between these two groups.(27) Ultimately, headaches lead to sub-
sequent decreases in dose or discontinuation of GTN for several
patients in each trial. In two studies there was an attempt to follow
patients long-term.(24, 26) The rate of fissure recurrence in the
GTN treated group was 11.5–19% after 3–4 months of follow-up.
Overall, these five trials suggest a slightly increased rate of anal fis-
sure healing with GTN ointment compared to placebo. However,
there is an increased incidence and severity of headache with
GTN treatment which may require a decreased dose for continued
patient compliance. Despite healing, there may be a high rate of
fissure recurrence within several months of follow-up.
Three additional trials have tested the effect of increasing doses
of GTN ointment on anal fissure healing rate, MARP, pain scores,
headache, and anal fissure recurrence.(29–31) Two trials com-
pared placebo with 0.1%, 0.2% and 0.4% GTN ointment (B,S).
The third trial compared placebo with 0.2% GTN ointment and
an increasing dose of GTN ointment which started at 0.2% and
was increased by 0.1% every week to a dose of 0.6% GTN.(28) All
treatment was administered for 8 weeks and applied either BID or
TID. In these trials there was only one that measured a difference
in fissure healing rate of the GTN treatment group compared to
placebo.(29) There were no differences found in fissure healing
rate with changes in GTN dose. One trial reported a 21% reduc-
tion in pain when treated with 0.4% GTN compared to placebo.
(30) There was no difference in pain scores between placebo and
GTN or between GTN doses in the other studies.(29, 31) Across
these three trials, MARP was not uniformly decreased in the nitrate

treated group compared to baseline. All three studies reported a
high incidence of headache in the GTN group (31–72%) com-
pared to placebo (13–27%). Headaches were more frequent and
severe with increasing dose of GTN ointment. Follow-up was
­performed in one study. One third of anal fissures that initially
healed recurred within 9 months.(29) These trials demonstrate
that increasing doses of GTN do not increase the rate of fissure
healing or improve fissure related pain, but do result in more
severe and frequent headaches. Again, recurrence when reported,
occurs in up to one-third of patients.
Two additional studies have used alternative nitrate prepara-
tions for the treatment of chronic anal fissure for comparison
with placebo. Wierre et al. used 1% isosorbide dinitrate oint-
ment five times per day for 10 weeks.(32) There was a significant
­difference in fissure healing rate between placebo and active oint-
ments (35 vs. 85%). However there was no significant change in
MARP throughout the trial period. There was also a significant
incidence of headache in the treatment group (45%) compared to
placebo (18%) with 10% of patients in the active treatment dis-
continuing therapy. Thirty-three percent of patients in the active
treatment arm had fissure recurrence and requested alternative
therapy. Tankova et al. used 0.2% isosorbide mononitrate on
chronic anal fissures compared to placebo administered BID over
a 3 week treatment course.(33) Eighty percent in the active treat-
ment arm healed their fissures compared to 20% in the placebo
group. Twenty percent in the active group had headaches which
were treated with mild analgesics. No recurrences were seen in
3 months of follow-up. The authors of both these studies agree
that different nitrate preparations can be used to treat chronic
anal fissure but that more studies are required to determine the
optimal preparation, dose, and schedule of nitrate therapy.
Two studies have compared 0.2% GTN ointment to a transder-
mal nitroglycerin patch for either 6 or 8 weeks of treatment.(34, 35)
In both studies the transdermal patch was a 10 mg dose that was
applied for either 12 or 24 hours. These studies found that both
preparations resulted in equivalent fissure healing rates at 6 weeks
(65–73%), 8 weeks (63–67%) and 12 weeks (79–81%). One trial
reported a decrease in pain from baseline by 50% in both the oint-
ment and patch patients.(35) The rate of headache was substantially
lower in one study (16–19%) (34) compared to another (63–72%)
(35) but both studies reported the headache to be responsive to
mild analgesics and equal in occurrence between the two treat-
ment groups. Six percent of patients in one study reported transient
incontinence to flatus which had resolved by the time of trial resolu-
tion.(35) Recurrence at 3 months for one trial occurred in 9–15%
(34) patients and 25% in the other.(35) In all, 0.2% GTN ointment
seems equivalent to transdermal patch in the rate of anal fissure
healing, pain relief, side effects, and recurrence.
Overall, chronic anal fissure healing rates after treatment with
nitrates (49%) may be slightly improved compared to placebo
(37%).(7) Nitrate therapy may decrease pain associated with anal
fissure but with a concomitant increase in headaches (27%) that
can lead to noncompliance. Given the side effect profile and high
recurrence rates after nitrate therapy (33%), the patient may request
alternative therapeutic interventions. Nitrate therapy remains a
treatment alternative for patients wanting to avoid surgery and
does not exclude the patient from other therapies in the future.
 surgery and nonoperative therapy of anal fissure

Table 20.2  Randomized Controlled Trials of Nitrates versus Surgical Sphincterotomy for the Treatment of Chronic Anal Fissure.
Length of
Author/ Number Treatment Groups Treatment Fissure Overall IC Flatus Follow-up Recurrence
Year Patients (% ointment) (weeks) Healing (%) Side-effects (%) HA % (%) (months) (%)

Oettle 24 NTG/ LIS 4 83 vs. 100 NR NR NR  1 NR

1997 (40) TID (p = NS)
Richard 82 0.25/0.5 GTN/LIS 6 30 vs. 90 84 vs. 29 21 None  6 38 vs. 3
2000 (36) TID (p = 0.00) (p < 0.0001)
Evans 60 0.2 GTN/LIS 8 61 vs. 97 NR 33 7.4  5 45 vs. 4
2001 (37) TID (p < 0.001)
Libertiny 70 0.2 GTN/LIS 8 54 vs. 100 NR 20 2.8 24 16 vs. 2.8
2002 (38) TID (p = 0.02)
Parellada 54 0.2 IDN/LIS 6 67 vs. 96 30 vs. 44 NR 4 4 @ 5 wk 24 13 vs. 0
2004 (39) TID (p < 0.001) (p = NR) 15 @ 24 wk
Mishra 40 0.2 GTN/LIS 6 90 vs. 85 40 vs. 70 15 15  4 NR
2005 (41) BID (p = 0.347) (p = NR)

Note: NTG = nitroglycerin; LIS = lateral internal sphincterotomy; TID = three times per day; NS = not statistically significant; NR = not recorded; GTN = glyceryl
trinitrate; IDN = isosorbide dinitrate.

Nitrates versus Sphincterotomy
Nitrate therapy has been compared to internal sphincterotomy for
the treatment of chronic anal fissure. Six studies have compared
these two treatments in a randomized controlled fashion.(36–41)
(Table 20.2) Four studies found internal sphincterotomy to be
superior to nitrate therapy for fissure healing after 6–8 weeks.
(36–39) The two studies which showed no difference in ­fissure
healing between treatment groups, were smaller and measured a
larger nitrate treatment effect than is traditionally seen (83–90%).
Richard and colleagues found nitrate therapy to help fissure related
pain despite poor fissure healing (36). Parellada and colleagues
found a posttreatment decrease in MARP from baseline in both
treatment groups (30%) without a significant difference between
groups.(39) Four studies found a significant rate of headaches
in nitrate treated patients.(36–38, 41) These headaches caused
significant problems with patient compliance and 20–30% of
patients discontinued ointment application. In comparison, there
were relatively few and minor side effects in patients undergoing
sphincterotomy. While one study measured a high rate of postop-
erative incontinence to flatus (44%), this decreased to 15% after
2 years follow-up.(39) Initially, Richards et al. did not find any
difference in immediate postoperative continence scores between
patients treated with nitrates or sphincterotomy.(36) After 5 years,
the investigators contacted 62% of the study patients. With the
use of a sensitive incontinence scale, there were still no differ-
ences in continence scores between the two groups. However, 2/3
of patients reported some degree of incontinence. Finally, fissure
recurrence occurred rarely in patients undergoing sphincterot-
omy (0–4%) compared to high rates of recurrence among patients
treated with nitrates (13–45%). In all, nitrates are significantly less
effective than sphincterotomy for fissure healing, acute relief of
pain, fissure recurrence, and number of treatment side-effects
when administered for treatment of chronic anal fissure.
Calcium Channel Antagonists
Given the frequency of adverse side effects with nitrate therapy,
other medical treatments have been sought for patients with
chronic anal fissure. Calcium channel antagonists have been used
as alternative agents for temporary chemical sphincterotomy.
Calcium is necessary for tonic contraction and spontaneous activ-
ity in the IAS smooth muscle.(42) When IAS muscle is subjected
to a calcium channel antagonist, nifedipine, tone and spontaneous
contraction of the muscle is inhibited. Therefore, a calcium chan-
nel antagonist may reduce the IAS hypertonia that is observed
in chronic anal fissure. Indeed, nifedipine has been shown to
decrease anal resting pressure in normal controls and patients
with anal fissure or hemorrhoids.(43) Nifedipine decreased anal
resting pressure by approximately 30% in all groups. Decreased
anal pressure is thought to cause increased anodermal blood flow
and allow for fissure healing. Carapeti and colleagues showed that
diltiazem ointment significantly reduced anal resting pressure
and allowed for 67% of patients with chronic anal fissure to heal
over 8 weeks. However, they were unable to measure a significant
difference in anodermal blood flow using laser Doppler before
and after diltiazem administration.(44) Due to the ability of cal-
cium channel antagonists to reduce anal resting pressure, they
have been used as alternatives to nitrates for chemical sphincter-
otomy in patients with chronic anal fissure.
Calcium Channel Antagonists versus Placebo
One study has compared the efficacy of a calcium channel antago-
nist, nifedipine to a treatment consisting of lidocaine, and hydro-
cortisone ointment for the treatment of chronic anal fissure.(45)
(Table 20.3). One hundred and ten patients were given either 0.3%
nifedipine ointment or 1.5% lidocaine plus 1.0% hydrocortisone
ointment for twice daily application over 6 weeks. Patients who
were given nifedipine ointment had a significant reduction in anal
resting pressure (11%) from baseline after 3 weeks of treatment. In
addition, 95% of these patients had a healed fissure after 6 weeks.
Positive treatment effects were not seen in the placebo treatment
arm with manometric studies measuring a 4.4% increase in anal
resting pressure, and only 16% of patients experienced fissure
healing. The patients did not report any side effects. Six percent of
patients treated with nifedipine had fissure recurrence, 66% were


 improved outcomes in colon and rectal surgery

Table 20.3  Randomized Controlled Trials of Calcium Channel Blockers for the Treatment of Chronic Anal Fissure.
Length of Fissure Overall
Author/ Number Treatment Groups Treatment Healing Side Follow-up Recurrence
Year of Patients (% ointment) (weeks) (%) Effects (%) (months) (%)

Perrotti 110 1.5 lidocaine + 1.0 6 16 vs. 95 None 18 55 vs. 6

2002 (45) hydrocortisone vs. 0.3 N BID (p < 0.001) (p = NR)
Kocher 60 0.2 GTN vs. 2 D BID 6–8 86 vs. 77 72 vs. 42 3 2 vs. 0
2002 (47) (p = 0.21) (p = 0.01) (p = NR)
Bielecki 43 0.5 GTN vs. 2 D BID 8 86 vs. 86 33 vs. 0 None NR
2003 (46) (p = 0.95) (p = NR)
Ezri 52 0.2 GTN vs. 0.2 N QID 24 58 vs. 89 40 vs. 5 12 31 vs. 42
2003 (49) (p < 0.04) (p < 0.01) (p = NR)
Mustafa 20 0.2 GTN vs. 20 mg PO N BID 8 70 vs. 60 30 vs. 10 3 0 vs. 10
2005 (50) (p = NS) (p = NR) (p = NR)
Shrivastava 90 P vs. 0.2 GTN vs. 2 D BID 6 33 / 73 / 80 0 / 67 / 0 12 13 / 32 / 50
2007 (48) (p = <0.02) (p = NR) (p < 0.015)
Ho 132 LIS vs. TS vs. 20 mg PO N BID 6 96/ 95/ 16 No 4 0/ 2.4/ 57
2005 (51) (p < 0.001) difference in (p = 0.003)
continence
Katsinelos 64 LIS vs. 0.5 N TID 8 100 vs. 97 19 vs. 50 20 0 vs. 7
2006 (52) (p = 0.49) (p = NR) (p = NR)
Jonas 2001 50 60 mg PO D vs. 2 D BID 8 38 vs. 65 33 vs. 0 6 11 vs. 7
(53) (p = 0.09) (p = 0.001) (p = NR)

Note: N = nifedipine; BID = two times per day; NR = not recorded; GTN = glyceryl trinitrate; D = diltiazem; QID = four times per day; NS = not statistically significant;
LIS = lateral internal sphincterotomy; TS = tailored sphincterotomy; TID = three times per day.

retreated and, once again, their fissure healed. This is in compari-
son to 55% recurrence in the placebo arm. Of the 47 patients who
did not achieve fissure healing or who suffered a recurrence after
placebo treatment, 45 elected to have nifedipine treatment at the
study conclusion with a 95% healing rate. While this study is prom-
ising for the use of nifedipine as an alternative to nitrate therapy for
chronic anal fissure, the extent of treatment effect is questionable
given the low fissure healing rate in the placebo arm.
Calcium Channel antagonists versus Nitrates
Five studies have compared calcium channel antagonists to nitrate
therapy in patients with chronic anal fissure. (Table 20.3) Three
of these studies have used 2% diltiazem ointment in comparison
to 0.2% or 0.5% GTN administered over 6–8 weeks.(46–48) All
three studies report no difference in anal fissure healing between
the GTN or diltiazem treated groups. In all three studies, there
were more overall side effects and headaches in the nitrate treated
patients compared to the diltiazem treated patients. In the larg-
est of the three studies, recurrence occurred sooner and more
­frequently among patient receiving GTN compared to diltiazem.
(48) Overall, diltiazem ointment has equal efficacy to GTN oint-
ment for anal fissure healing with fewer side effects, and possibly
a lower rate and longer interval to recurrence.
Two studies used nifedipine preparations for comparison with
GTN for the treatment of chronic anal fissure.(49, 50) In one study,
a 0.2% nifedipine ointment (49) was used while oral nifedipine
was used in the other.(50) Ezri et al. found the nifedipine oint-
ment to be superior to the GTN ointment in healing anal fissure.
They also found a higher rate of overall side effects in the GTN
treated group. However, both treatment arms were found to have
a high recurrence rate over 12 months (31–42%). In contrast, the
oral nifedipine was equivalent to GTN ointment in fissure healing,
recurrence, and side effects. These two studies demonstrate that
multiple preparations of calcium channel antagonists may be used
for the treatment of chronic anal ­fissure with equal healing efficacy
and fewer side effects than GTN ointment.
Calcium Antagonists versus Sphincterotomy
Two studies have compared calcium channel blockade (oral and
ointment preparations) to lateral internal sphincterotomy in the
treatment of chronic anal fissure.(49, 50) (Table 20.3) While both
studies measure a high rate of fissure healing in patients undergo-
ing sphincterotomy (95–100%), there is a wide range in the fissure
healing rate for patients receiving nifedipine treatment (16–97%).
In one study, oral nifedipine was used.(51) The authors report
a significant problem with patient compliance in this treatment
arm secondary to side effects, slow fissure healing, and minimal
symptomatic improvement. Overall 41% of patients in the oral
nifedipine group experienced these problems, and 70% withdrew
from the study. While these patients were analyzed on an inten-
tion to treat basis, the effect of oral nifedipine on fissure healing
may have been substantially decreased. In contrast, Katsinelos and
colleagues measured a high rate of fissure healing after treatment
with nifedipine ointment (97%) that was not significantly differ-
ent from fissure healing after sphincterotomy (100%, p = 0.49).
(52) The increased treatment effect of nifedipine ointment may be
secondary to a higher dose that was used in this study compared to
others (0.5% vs. 0.2%). In addition, topical calcium channel antag-
onists have been proven more effective than oral preparations in
fissure healing and side effect profile.(53) Overall, these studies
suggest that oral calcium channel antagonists do not increase fis-
sure healing rates but do increase side effects. However, increases
in ointment concentrations may increase treatment ­efficacy with-
out a change in adverse side effects.


 surgery and nonoperative therapy of anal fissure

Table 20.4  Randomized Controlled Trials of Botulinum Toxin for the Treatment of Chronic Anal Fissure.
Author/ Number of Follow-up
Year Patients Treatment Groups Fissure Healing (%) Side Effects (%) (months) Recurrence (%)

Maria 30 0.4 ml saline vs. 20 U B 13 vs. 73 (p = 0.003) IC flatus: 3.3 overall 4 None
1998 (57)
Colak 62 Lidocaine BID 4 wks vs. 50 U B 21 vs. 71 (p = 0.006) None 2 NR
2002 (61)
Siproudis 44 0.4 ml saline vs. 100 U Dysport 32 vs. 32 (p = NS) Perianal 3 9.1 vs. 13.6
2003 (62) thrombosis: 9.1 vs. 18.2 (p = NS)
Abscess: 13.6 vs. 4.5
Brisinda 50 0.2%GTN BID 6 wks vs. 20 U Ba 60 vs. 96 (p = 0.005) GTN: 20% HA 15 None
1999 (64) BT: None
DeNardi 30 0.2% GTN BID 8 wks vs. 20 U B 3 months: 67 vs. 47 (p = 0.51) GTN: 20% HA 36 33 vs. 33
2006 (66) BT:None (p = NS)
Fruehauf 50 0.2% GTN BID 2 wks vs. 30 U B 2 weeks: 52 vs. 24 (p < 0.05) 26% overall 3 NR
2006 (67) GTN: 48% HA
Brisinda 100 0.2% GTN TID 8 wks vs. 30 70 vs. 92 (p = 0.009) GTN: 34% HA 21 20 vs. 0
2007 (65) U Ba BT: 6% IC flatus (p = NR)
Mentes 101 LIS vs. 0.3U/kg BT (20U or 98 vs. 74 (p < 0.001) IC: 8 vs. 0 12 5 vs. 11
2003 (71) 30U) B (p = NR)
Iswariah 38 LIS vs. 20 U B 6 weeks: 86 vs. 41 (p = 0.004) IC: no difference 6 10 vs. 53
2005 (70) (p < 0.05)
Arroyo 80 LIS vs. 25 U B 12 months: 93 vs. 45 (p < 0.001) IC: 7.5 vs. 5 (p = NS) 36 7.5 vs. 55
2005 (69) (p < 0.001)

Note: B = Botox; IC = incontinence; BID = two times per day; NR = not reported; NS = not statistically significant; GTN = Glyceryl trinitrate; HA = Headache;
TID = three times per day; LIS = Lateral Internal sphincterotomy
a. Crossover after 2 months treatment.

In summary, topical calcium channel antagonists may be used
in the treatment of chronic anal fissure. They have similar efficacy
to nitrates with a lower occurrence of side effects. Topical prepa-
rations of nifedipine or diltiazem are preferred over oral prepara-
tions due to a higher fissure healing rate and fewer side effects
compared with oral administration. Sphincterotomy remains the
gold standard for healing of chronic anal fissure, but given the
chance for incontinence after surgery, topical calcium channel
antagonists are preferred for first line therapy.
Botulinum toxin
Botulinum toxin (BT) is an exotoxin produced by the bacterium
Clostridium botulinum. BT has been used medically in the treatment
of multiple diseases in which there is muscular hypertonicity. Chronic
anal fissure is characterized by internal anal sphincter (IAS) hyperto-
nia and has been treated with BT since 1993. The exact mechanism
of BT on internal anal sphincter relaxation is still unclear. In striated
muscle, BT binds to presynaptic nerve terminals and prevents the
release of acetylcholine, resulting in paralysis. However, in smooth
muscle, BT reduces the release of excitatory neurotransmitters from
sympathetic nerves and probably causes IAS relaxation through
sympathetic blockade.(54) Manometric studies demonstrate a sus-
tained decrease in mean anal resting pressure (MARP) when BT is
injected into the internal anal sphincter. This sustained reduction in
MARP is in contrast to the short-lived relaxation seen in response to
GTN therapy. This longer period of IAS relaxation after BT injection
may lead to higher rates of chronic anal fissure healing secondary to
improved blood flow to the posterior commissure.
Multiple studies have been performed to determine the opti-
mal dose and method of delivery for BT to the IAS. Most studies
have been performed to determine the BT dose with the highest
fissure healing rate and the least amount of complications.(55–59)
All these studies show that fissure healing rates are improved with
increasing BT doses. Botox doses as high as 40–50 units of have
been used in a single injection. Increasing doses do not lead to
higher complication rates but do lead to more significant decreases
in MARP from baseline.(57) This increased efficacy is secondary
to a dose dependent diffusion of the toxin through the IAS muscle.
Higher BT doses have a direct effect throughout the muscle whereas
smaller BT doses demonstrate a gradient of paralysis through the
muscle length.(58) Other factors which may lead to variations in
clinical response are differences in drug dilution volumes, number
of injection sites, presence or absence of antibodies, variations in
active drug, and susceptibility of target cells. Maria et al. examined
the role of BT injection site on fissure healing.(60) Their hypothesis
was that posterior injection of BT leads to impaired diffusion of
the toxin secondary to increased fibrosis around posterior fissures.
Indeed, they found that 20 units of Botox on either side of the ante-
rior midline resulted in lower mean anal resting pressures as well as
higher fissure healing rates compared to 20 units of Botox admin-
istered on either side of the posterior midline. Results from these
studies show BT is safely administered in high doses (30–40 units
Botox) as initial therapy and may be more effective if administered
in the anterior rather than posterior midline.
Botulinum Toxin versus Placebo
Three randomized studies have evaluated BT efficacy in com-
parison to a “placebo” treatment.(61–63) (Table 20.4). In two
studies, normal saline injections of a volume equal to that of
the toxin used, were injected into the IAS.(62, 63) In the third

 improved outcomes in colon and rectal surgery
study, lidocaine ointment was applied twice daily and with bowel
movements for a 4 week period.(61) In two studies, there was a
significant difference in fissure healing between placebo and BT
treated patients (13–21% vs. 71–73%).(61, 63) In the third, there
was no measured difference in fissure healing between the two
groups (32%).(62) Maria et al. also reported a 25% posttreat-
ment decrease in MARP from baseline in the toxin group but not
in the placebo group.(63) Reported side effects in these studies
were minimal with incontinence to flatus in one patient, peri-
anal thrombosis in six and perianal abscess in four of 136 total
patients. The recurrence rate was not consistent among these
studies with reports of no recurrence compared to a high of 13%
in the BT treatment group after 4 months. The different findings
in these three studies which compare BT to placebo for chronic
anal fissure may be explained by methodological differences and
baseline differences in the study groups at randomization. In one
trial there were more men and higher maximal voluntary anal
squeeze pressures in the placebo group as compared to the BT
treated group.(63) This may have lead to a difference in treat-
ment effect. Also, one trial was not able to be blinded second-
ary to the use of ointment in the placebo group and injection in
the toxin group.(61) It is unclear whether clinicians who were
grading fissure healing were blinded to randomized treatment
groups. Finally, the third study was stopped early before reach-
ing the intended sample size because of newly published stud-
ies demonstrating BT efficacy in fissure healing. Despite these
methodological differences and group differences after rand-
omization, these studies suggest that BT is superior to placebo in
the healing of chronic anal fissure. examination. Based on these studies, patients who are at high risk
Botulinum Toxin versus Nitrates
Four randomized trials have compared the efficacy of BT to GTN
ointment.(64–67) (Table 20.4) In each trial there were differences
in the length of treatment (2–8 weeks) and application frequency
(2–3 times per day) of GTN ointment. There were also differences
in the dose of BT used with two studies using 20 units of Botox
and the other two studies using 30 units. Two studies found a sig-
nificant improvement in anal fissure healing for patients treated
with BT compared to 0.2% GTN ointment (92–96% vs. 60–70%).
(64, 65) A third study measured an advantage of GTN treatment
administered over 2 weeks compared to BT (52% vs. 24%).(67)
These findings are surprising given the previous studies which
show 4–8 weeks are needed to achieve fissure healing with GTN
treatment. In the fourth study, there was no difference in treat-
ment efficacy between BT and GTN ointment administered over
8 weeks.(66) However, this is the smallest of the four studies and
may not have been adequately powered to measure a difference
in treatment efficacy. Patients treated with GTN ointment were
more likely to suffer adverse side effects (20–34% headache) in
comparison to BT treated patients (0–6% temporary inconti-
nence to flatus). Fissure recurrence was more frequent in GTN
treated patients in one study (65) but not in another.(66) In a dif-
ferent study, long-term fissure recurrence after BT treatment was
42% after 42 months.(68) Overall, these studies show a benefit of
BT compared to GTN in terms of short term fissure healing and
adverse medication effects. Frequent fissure recurrence after GTN
and BT treatment has been observed.

In two studies of GTN versus BT treatment crossover was per-
formed at 2 months.(64, 65) Patients who did not heal with their
initial treatment and accepted the alternative treatment were able to
achieve fissure healing with the alternative treatment In both studies,
patients who failed BT and then received GTN (8 patients), expe-
rienced fissure healing within 2 months. Twenty one patients who
failed GTN and then received BT achieved ­fissure healing within 2
months. These studies suggest that patients who fail initial therapy
with GTN or BT, can be successfully treated with an alternative med-
ical therapy before surgical treatment is considered.
Botulinum Toxin versus Sphincterotomy
There are three randomized studies which compare outcomes
for patients receiving either BT or internal sphincterotomy (IS).
(69–71) (Table 20.4) In these studies, IS was superior to BT for
fissure healing (86–98% vs. 41–75%). While sphincterotomy is
usually avoided secondary to fears of incontinence, there was no
significant difference in continence scores in any of these four
studies. Incontinence after fissure treatment with either BT or
sphincterotomy was associated with lower mean anal resting
pressures after treatment and age >50 years.(69) Fissure recur-
rence was also more common in BT treated patients compared to
IS treated patients.(69, 70) Recurrences were seen 6–12 months
after fissure healing.(69) Recurrence was associated with certain
clinical and manometric risk factors. These include symptom
duration greater than 12 months, presence of a sentinel pile,
­persistently elevated mean anal resting pressure and amount of
time slow wave and ultra slow waves are present on manometric
of anal fissure recurrence should undergo IS as a first line ther-
apy. In patients who are at high risk of incontinence after IS, the
first line therapy should be BT since healing can be achieved with
lower complications even if repeat injection is required.
Overall, BT injections can be used for the treatment of chronic
anal fissure with improved fissure healing rates compared to
­placebo and GTN. Fissure healing may take longer after BT treat-
ment when compared to fissure healing after IS, but is associated
with few complications. Patients at high risk of incontinence (age>
50 yrs, previous anorectal surgery, multiparous females, diagnosis
of inflammatory bowel disease) should be treated with BT before
IS. Anal fissure recurrences after BT treatment are common, but
can be treated with repeat BT injection without adverse effects.
Surgical Therapy
While surgical treatment of chronic anal fissure has been employed
since the 19th century, improved pathophysiologic understanding in
the middle of the 20th century, led to the reintroduction of surgical
treatments. In 1964, Watts, Bennett and Goligher described stretch-
ing of the anal sphincter with finger dilation, and Eisenhammer
recommended sectioning the internal anal sphincter to reduce
sphincter resting pressure.(72, 73) Since their initial description,
anal dilation and sphincterotomy have been used in numerous
randomized controlled trials to determine the ideal ­surgical treat-
ment for chronic anal fissure. Overall there is a clear benefit of
sphincterotomy compared to anal stretch for fissure healing and
postoperative incontinence. This has been confirmed in clinical tri-
als as well as manometric evaluations. After sphincterotomy, mean
 surgery and nonoperative therapy of anal fissure
anal resting pressure is permanently reduced in patients with anal
fissure who have been shown to have significantly elevated preop-
erative resting pressures compared to controls.(74) Yet, the initial
surgical techniques of Watt and Eisenhammer have been revised
with multiple studies comparing the efficacy of modified surgical
interventions on fissure healing, recurrence, anal resting pressure,
and treatment complications such as incontinence.
Anal Dilatation
Anal dilation has been used in three different forms for the treat-
ment of chronic anal fissure. Gentle, graduated anal dilation
has been accomplished with standardized anal dilators (20–27
mm) which are increased in size over several weeks of treatment.
Anal dilation has also been achieved with a one time pneumatic
­balloon dilation of the sphincter to 1.4 atmospheres. Finally, anal
dilation has been performed using anal stretch with 4–6 finger
dilation of the sphincter. All these techniques have been criticized
for the poorly controlled sphincter stretch that results in damage
to both the internal and external sphincter. The result of uncon-
trolled sphincter stretch can lead to high rates of incontinence
for both flatus and stool that may be permanent. In reality, each
of these forms of anal dilation lead to variable degrees of control
over the amount of sphincter stretch and thereby affect fissure
healing, recurrence, and incontinence rates differently.
The forceful anal stretch procedure has the least amount of
standardization on sphincter dilation. It has been compared to
the gold standard, internal anal sphincterotomy, in five rand-
omized controlled trials.(75–79) Three of these studies found that
internal sphincterotomy was superior to anal stretch secondary to
higher fissure healing rates (90–97% vs. 70–71%) with signifi-
cantly lower rates of incontinence (3.3–20% vs. 20–39%).(75–77)
The other two studies found an advantage in fissure healing rates
after anal stretch at 4 month follow-up with comparable rates of
fissure recurrence and incontinence.(77, 79) However, these two
studies have been criticized for high drop out rates, short follow-
up, and question of inadequate sphincterotomy. Overall, internal
sphincterotomy is superior to forceful anal stretch for the surgical
treatment of chronic anal fissure.
Given previous criticisms, techniques for controlled anal stretch
have been developed. When graduated anal dilators are used over
several weeks, the effect on fissure healing is inconsequential and
not better than placebo.(80) The addition of heat to anal dilators
along with nitroglycerin ointment may lead to improved fissure
healing rates (94% at 12 months). (81) However, this was a small
study which has not been replicated. Controlled anal stretch
with increased dilation effect has been attempted with pneu-
matic balloon dilation. In a prospective clinical trial, Renzi and
colleagues measured the effect of anal balloon dilatation to 1.4
atmospheres over six minutes. In 33 patients, 94% healed within
5 weeks of treatment, 3% recurred over 12 months and 6% of
patients had transient incontinence. These treatment effects were
achieved with a measureable decrease in anal resting pressure
with no visible sphincter defect on endorectal ultrasound.(82)
This study was followed by a randomized controlled trial of 36
patients who received either pneumatic sphincter dilatation or
nitroglycerin ointment.(83) At 30 days, 95% of patient undergo-
ing pneumatic sphincter dilation had healed fissures compared
to 40% of patients who received nitroglycerin ointment. While
local wound problems such hemorrhoid thrombosis occurred in
the short-term, there were no patients who complained of prob-
lems with continence after pneumatic dilation. In all, graduated
anal dilation is not more effective than placebo for the treatment
of chronic anal fissure, while pneumatic balloon dilation of the
sphincter may result in improved fissure recurrence and incon-
tinence rates than those seen with forceful anal dilation. Further
studies of pneumatic balloon dilation are needed to see if it is in
fact comparable to internal sphincterotomy.
Sphincterotomy
Internal sphincterotomy has also been subjected to revisions in
technique. Initially, Eisenhammer described division of the exter-
nal sphincter and then modified his technique to that of the inter-
nal sphincter at the posterior midline.(73) Overtime, it became
apparent that fissurectomy with posterior midline sphinctero-
tomy resulted in a “keyhole deformity” or deep furrow in the
excision site which interfered with closure of the anal canal while
at rest.(84) This deformity lead to increased rates of incontinence
compared to lateral sphincterotomy with longer healing times.
(78) Posterior sphincterotomy has subsequently been abandoned
in favor of lateral internal sphincterotomy.
Lateral internal sphincterotomy has also been performed in an
open and closed fashion. The open technique involves a 1–2 cm
skin incision over the intersphincteric groove and lateral to the
anal canal.(85) The internal anal sphincter is then separated from
the external sphincter and mucosa up to the dentate line so that
it can be divided under direct vision. Closed internal sphincter-
otomy was first described by Notaras in 1969.(86) With this tech-
nique, an 11 blade scalpel is inserted through the anoderm into
the intersphincteric plane. While using a finger for guidance, the
surgeon rotates the blade 90 degrees and an internal sphincterot-
omy is ­performed upto the dentate line. Given the blind technique
of closed internal sphincterotomy, surgeons have questioned the
adequacy of sphincter division using this technique. In fact, closed
sphincterotomy has been compared to open sphincterotomy in
4 randomized controlled trials with 299 patients.(87–90) All four
studies found equivalent rates of fissure healing (90–100%), and
recurrence (0–10%). Incontinence occurred infrequently (4.1–
7.5%) and improved with time. Therefore, both open and closed
techniques have been shown through randomized controlled
­trials to have equal outcomes.
Surgical treatment of chronic anal fissure can lead to variable
rates of incontinence to gas and liquids that can be temporary or
permanent. In an effort to reduce rates of incontinence after sphinc-
terotomy, investigators have sought to determine the optimal length
of sphincterotomy which allows for fissure healing but minimizes
postoperative incontinence. Two randomized studies have exam-
ined the role of sphincterotomy length on fissure healing, recur-
rence, and incontinence. In these studies, limited sphincterotomy
to the fissure apex was compared to a full sphincterotomy to the
dentate line.(91–92) Fissure healing rates were similar (88–100%)
in both studies. In one study there was no fissure recurrence after
24 weeks of follow-up (91), and, in the other, there was a 13.2%
treatment failure rate in the limited sphincterotomy group.(92)
There were also short-term differences in incontinence between

 improved outcomes in colon and rectal surgery
limited versus full internal sphincterotomy. In one study, early
incontinence in patients undergoing full sphincterotomy (10.9%)
was increased compared to patients who underwent limited sphinc-
terotomy (2.2%, p = 0.039). (91) However, this difference did not
persist with long-term follow-up with only 2 patients who under-
went full sphincterotomy reporting persistent incontinence. In the
other study, there was no significant difference in posttreatment
and baseline incontinence scores between the two types of sphinc-
terotomy.(92) Overall, internal sphincterotomy up to the dentate
line has been shown to produce faster healing and pain relief but is
associated with increased rates of early incontinence compared to
sphincterotomy to the fissure apex.
Given the significant variation in incontinence rates after sphinc-
terotomy, several investigators have sought to further characterize
incontinence in patients with chronic anal fissure with respect to
type, frequency, and permanence. In a study of preoperative and
postoperative incontinence in 126 patients with chronic anal ­fissure,
Anmari and colleagues found that 28% of patients had minor
preoperative disturbances in continence that persisted postopera-
tively.(93) Casillas and colleagues found that patients endorsed a
higher rate of incontinence in response to a questionnaire than was
recorded in their medical record or was reported in a telephone
survey.(94) In other studies, risk factors for incontinence were
identified.(95–96) These include preexisting sphincter injuries, IAS
division >50%, injury to external anal sphincter during the proce-
dure, functional impairment with age, shorter sphincter in females,
and posterior keyhole deformity. While external anal sphincter
injury during anal stretch and a posterior keyhole deformity after
posterior sphincterotomy clearly result in higher rates and more
severe forms of incontinence, the presence of other risk factors in
patients who are undergoing lateral internal sphincterotomy result
in lower rates of minor incontinence which are frequently tempo-
rary. In fact, some incontinence scales are so sensitive to changes
in continence, that one study identified no impairment in quality
of life despite decreases in continence scores.(97) Overall, inconti-
nence after sphincterotomy remains a real complication that must
be considered in patients at higher risk (female, older age, previous
anorectal surgery) with subsequent modification of the surgical
procedure if necessary.
Refractory fissures
Several recent studies have been performed to identify character-
istics associated with fissure persistence despite treatment. In one
study the etiologic and manometric differences between anterior
and posterior anal fissures which failed to heal with nitrate therapy
were examined. When comparing patients with both anterior and
posterior fissure who failed medical therapy, Jenkins and ­colleagues
found that anterior fissures were more common in younger women
(33 years vs. 44) and were more likely to be associated with obstetric
trauma and an occult external anal sphincter defect.(98) Patients
with anterior fissure were also more likely to have normal or low
anal resting pressures compared to controls. This was ­significantly
different from the elevated resting pressures measured in patients
with posterior fissure. In addition, the maximum squeeze pressure
was significantly lower than normal controls and patients with
posterior fissure. Corby and colleagues also found that postpartum
females have lower anal resting pressure and squeeze pressures than

they did antepartum.(99) Thus, postpartum females who develop
anal fissure (9% incidence) have reduced anal canal resting pres-
sure and treatments to decrease internal sphincter tone can lead to
incontinence.
Other investigators have sought to identify medical therapy
that can act as rescue treatments for patients with persistent anal
fissure before a surgical treatment is undertaken. In one study
2% diltiazem ointment was used for treatment of chronic anal
fissure refractory to GTN.(100) Fissure healing occurred in
49% of patients with no recurrence over 8 weeks of follow-up.
Healing was not dependent on whether a full course of GTN was
­completed with fissure persistence or GTN treatment was discon-
tinued secondary to adverse side-effects. In two other studies BT
was used to treat nitrate resistant fissures (GTN and ISDN). (101,
102) Forty-three to 50% of patients with nitrate resistant fissures
achieved healing with BT treatment. Patients with nitrate resistant
fissures have also been randomized to another course of nitrates
or nitrates plus BT.(103, 104) More patients healed their fissures
with a combination of BT and nitrates (47–67%) compared to
BT alone (20–27%). More studies are needed to determine the
optimal treatment for refractory or persistent fissures.
Alternative surgical therapies are available for chronic anal fis-
sure associated with low anal resting pressure or for those that
persistent after surgical sphincterotomy. These include island
advancement flaps. Nyam and colleagues described advancement
flaps in a series of patients with low anal resting pressure and
maximum squeeze pressure.(105) Some patients had external
sphincter defects and others had previous fissure surgery. Patients
underwent fissurectomy with flap coverage by perianal skin. All 20
patients healed with one contracture at the donor site and mini-
mal donor site discomfort. Leong et al. compared anal advance-
ment flap to lateral internal sphincterotomy for the treatment
of chronic anal fissure.(106) More patients healed with sphinc-
terotomy (100%) compared to anal advancement flap (85%).
A number of flaps, such a V-Y anoplasty, have been described for
chronic anal fissure with good success (Figure 20.2). A key to reduc-
ing complications with flap closure is careful hemostasis, which
reduces the risk of hematoma formation, flap loss, and infection.
Design of the flap with good length-to-width ratio is important
to ensure adequate vascularity and minimal tension. (107) Anal
advancement flaps remain an important surgical alternative for
patients with low pressure fissures and persistent fissure despite
previous anorectal surgery.
Complications of Surgery for Anal Stenosis
Acquircd anal stenosis can be a late sequela of a variety of
anorectal surgical procedures. It has been reported to occur after
5 to 10% of radical hemorrhoidectomies and after fissurectomy,
radiation injury, and Moh’s chemosurgery.(108, 109) The cause
of these strictures is excessive removal of the anodermal lining
of the anal canal: and thus is generally preventable. In cases of
severe, symptomatic anal stenosis, a variety of flaps can be used
to resurface the anal canal and expand its circumference. The
key to success with any of these flaps is that they be carefully
designed to maintain vascularity and that subflap hematoma
formation is averted to minimize the risk for infection and flap
necrosis.
 surgery and nonoperative therapy of anal fissure
(A) (B)
(A) (B)
Patients should undergo complete mechanical and antibiotic
bowel preparation before surgery. After surgery, bowel activ-
ity may be restricted with a clear liquid diet for a day or two.
After this period, patients are allowed a regular diet and given
fiber supplements and laxatives to avert constipation One final,
important point is the limitation of patient activity for several
weeks so that flap motion is minimal, to allow neovascularity
to occur
Anal S-plasty (Figure. 20.3) was first proposed by Ferguson
(110) as a method to correct Whitehead deformities in 13
patients. Later Corman et al. (111) modified the procedure for
use in the management of anal stenosis. The key to the success of
this approach is development of ’ large, full-thickness skin flaps
with a base-to-length ratio >1.0. Ferguson recommended a base
of 7 to 10 cm and maintenance of a thin layer of fat globules on
the deep aspect of the flap so that adequate vascularity can be
ensured. He further cautioned against overzealous hemostasis on
the flap itself so as not to impair blood flow. The flaps are then
rotated toward the anal canal so that the anodermal defect can
be resurfaced. The flaps are sutured in place, and the remaining
semilunar defect is sutured to allow its primary healing. It is wise
Figure 20.2  V-Y anoplasly. (A) Incisions create
a V-shaped or triangular flap which is advanced
to close defect. (B) Closure of skin behind “V”
pushes the flap into the anal canal, and the flap is
sutured in place.
(C)
Figure 20.3  Ana1 S-plasty. (A) Ectroion is excised
and S-shaped incisions are created. (B) and (C)
flaps are rotated lo close the defects and sutured
in place.
to use a closed suction drain beneath the flap to avert seroma or
hematoma formation.
For less severe anal strictures that require less skin coverage, the
Y-V anoplasty, is an excellent alternative because it is simple to per-
form and is less traumatic for the patient. This technique was ini-
tially described by Penn (112) in 1948. Again, successfu1 healing of
the flap requires a length-to-base ration <3.0. Gingola and Arvanitis
(113) presented a series of 14 patients. Thirteen healed within 14
days with no episodes of infection or hematoma formation. Five
patients sloughed a small portion of the flap tip but required no
additional treatment. Experiences reported by other authors sup-
port the low rate (10 to 25%) of tip necrosis and the high rate (85
to 92%) of stenosis relief associated with this technique (114, 115).
It must be remembered, however that Y-V advancement flaps limit
how much anal resurfacing can be accomplished.
Other uses for the Y-V advancement flap have been advo-
cated. Rosen (116) used it to treat anal stcnosis and ectropion
(Figure 20.4).The blood supply for this flap is based on perfo-
rating vessels in the subcutaneous fat. The Y-V advancemcnt
flap is well suited for covering the lower anal canal but has lim-
ited application for stenosis above the dentate line.

 improved outcomes in colon and rectal surgery

(A) (B) (C)

Figure 20.4  Y-V anoplasty. (A) Y shaped incision is made. (B) V-shaped flap is mobilized and advanced to the top of the defect. (C) Flap is and sutured in place.

(A) (B) (C)

Figure 20.5  House advancement flap. (A) House-shaped flap is created. (B) The flap is advanced into the anal canal and (C) sutured in place.

(A) (B) (C)

Figure 20.6  Diamond flap. (A) Diamond-shaped flap is created. (B) The flap is advanced into the anal canal to fill the defect. (lnsert demonstrates perforating
subcutaneous blood supply). (C) Flap is sutured in place.

Other techniques of flap formation have been suggested. Conclusion

Christensen et al. (117). proposed the use of “house” advance-
ment pedicle flaps. The editors prefer the house flap because it is
easy to construct, can cover as much as 25% of the anal circumfer-
ence, and permits primary closure of the donor site (Figure 20.5).
If additional coverage is needed, two, three, or four flaps may be
used. Caplin and Kodner (118) recommended the use of the dia-
mond flap for many of the same reasons (Figure 20.6).
Chronic anal fissure is a common and painful anorectal dis-
order. Many treatments are available for benign idiopathic fis-
sures. The goal of treatment is to reduce the high anal resting
pressure or internal sphincter hypertonia in fissure patients.
First line therapy consists of either topical nitrates or calcium
channel antagonists. If topical therapies fail, a repeat treatment
course can be prescribed. As second line therapy, botulinum


 surgery and nonoperative therapy of anal fissure
toxin injection or internal sphincterotomy can be performed.  
Ideally, patients who are at risk of incontinence after inter-
nal anal sphincter division should attempt medical therapy
(age>50, multiparous female, previous anorectal surgery). If
sphincterotomy is contemplated for high risk patients, preop-  
erative anal manometry and ultrasound should be considered.
Alternatively, fissurectomy with anal advancement flap can be
performed. There is scarce data on the ideal treatment for resist-  
ant anal fissure. Patients at high risk of fissure persistence may
be considered for internal sphincterotomy as first line therapy
(symptom duration >12 months, presence of a sentinel pile,  
persistently elevated mean anal resting pressure).
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
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21 Surgery for pilonidal disease and hidradenitis suppurativa
Paula I Denoya and Eric G Weiss

Challenging Case
A 35-year-old healthy male undergoes pilonidal cystectomy by
wide local excision down to sacral fascia. Six months postop-
eratively his wound has failed to heal as manifest by a persistent
4 × 4 cm by 2 cm deep granulation bed.

Case Management
The patient has a nonhealing pilonidal wound. Options include
surgical reexcision with intensive postop wound management or
some type of excision and flap closure as described in this chapter.

INTRODUCTION
Pilonidal disease and hidradenitis suppurativa are both condi-
tions affecting the perianal area, and therefore are often referred
to the colorectal surgeon for management. The management of
these diseases can be quite challenging. Both conditions may be
complicated by recurrent disease and may result in significant
scarring or large open wounds in the perianal or coccygeal area.

Pilonidal Disease
Pilonidal disease is a chronic suppurative condition which occurs
most commonly in the sacrococcygeal area. It typically presents
as a painless cyst or sinus opening in the gluteal cleft, as an acute
or recurrent abscess, or as chronic draining sinuses. It most com-
monly affects Caucasian males between the ages of 15 and 30
and is essentially not seen after the age of 45. The true incidence
is unknown, but pilonidal disease is responsible for the loss of
­significant healthcare resources and workhours.
Historical Perspective
Pilonidal disease is believed to have been first described by Mayo
(1) in 1833. The term “pilonidal,” originating from the Latin
words for “hair” and “nest,” was not coined until 1880 by Hodges.
(2) The disease became more widely known during World War
II, when the number of soldiers developing it put a burden on
the military. At this point, it acquired the name of “jeep disease;”
a term coined by Buie (3) based on the idea that the disease was
caused by trauma to the skin of the lower back from riding in jeeps
for extended periods of time under hot and sweaty conditions.
Early in the documented history of this disease, the etiology
was believed to be congenital. The pilonidal cysts and sinuses
were thought to be embryologic remnants resulting from failed
involution of the neural tube structures. This theory was sup-
ported by studies of fetuses, which identified remnants of midline
structures. It was believed that these structures would normally
involute before birth, but sometimes failed to do so and led to the
development of pilonidal sinuses.(4)
In 1946, Patey (5) introduced a theory of an acquired etiology
for pilonidal disease, suggesting that hair piercing into the sacro-
coccygeal skin caused the sinuses and infected cysts. This acquired
Figure 21.1  Pilonidal cyst opened after excision showing hair inside cyst cavity.
theory was later supported by other studies (6–8) and is now widely
accepted as the etiology of pilonidal disease. Loose hairs from the
head or back fall and accumulate in the gluteal cleft. The hairs are
then drilled into the skin deep in the cleft by friction from the but-
tocks rubbing together while walking. As the person ambulates, the
hairs get pulled into the sinus, creating a cyst containing hair and
debris. This can periodically get infected and drain spontaneously
through lateral sinus tracts, or present acutely as an abscess. Studies
of surgical specimens have found cysts containing hair and debris,
but hair follicles have never been found in the cyst wall itself, sup-
porting the theory that the hair is of external origin.(9) (Figure
21.1) Bascom studied the midline pits and believed that these are
likely enlarged hair follicles which are involved in the etiology of
the disease.(10) He theorized that ingrown hairs originating in
these midline gluteal hair follicles were pushed into the subcutane-
ous fat and resulted in pilonidal abscess. Pilonidal disease has also
rarely been described in other areas of the body, such as the hands
of barbers (11), sheep shearers (12), and others who handle loose
hairs.(13) This further supports the acquired nature of the disease.
Diagnosis
The diagnosis is made by physical examination in a patient who
generally fits the demographics of being hirsute and in the 2nd or
3rd decade of life. Characteristic findings on exam are small mid-
line pits at the superior aspect of the gluteal cleft, approximately
3–5 cm from the anus. (Figure 21.2) There may be only one or mul-
tiple pits present, and there may be tufts of hair or debris in them.
Some patients may also have lateral fistula openings which can


 improved outcomes in colon and rectal surgery
Figure 21.2  Chronic pilonidal disease showing midline pit.
periodically drain purulent discharge. In the acute presentation, the
patient may present with an abscess which is usually found just off
the midline, along with the typical finding of midline pits. (Figure
21.3) The differential diagnosis includes perianal abscess or fistula,
hidradenitis suppurativa, and other presacral or spinal lesions such
as chordoma or ependymoma. However, pilonidal disease can usu-
ally be identified by its characteristic location in the gluteal cleft
away from the anus, and by the presence of midline pits. In severe
cases where there is doubt, imaging with CT scan or MRI (14) may
be useful, though usually not necessary.
There have been rare reports of malignancy developing in
chronic pilonidal sinuses. Most commonly these are squamous
cell carcinomas. These tumors are fairly aggressive, with a high
recurrence rate and poor prognosis.(15, 16)
Management of Acute Disease
The treatment for an acute pilonidal abscess is similar to that of
an abscess in any other location. Incision and drainage, leaving
the wound to heal by secondary intention, is the accepted treat-
ment modality. The patient can be positioned either in lateral
decubitus or prone position, though prone is generally preferred.
Incision and drainage may be performed under local, regional,
or general anesthesia, and may be done in an ambulatory ­setting
such as the office or emergency room. The area should be prepped
in standard fashion and local anesthetic infiltrated over the area
of fluctuance. A vertical incision or an ellipse of skin should be
made over the fluctuant area, 1–2 cm off the midline. Purulent
fluid, along with hair or other debris, may be found in the cyst
cavity. This should be removed and the cavity packed. An alter-
nate technique for patients with a large abscess cavity is to use
catheter drainage, as described in Chapter 19. The patient may
be discharged on antibiotics to treat the overlying cellulitis if
present and instructed in wound care. In a series of 73 patients

Figure 21.3  Acute pilonidal abscess. Note midline opening with abscess slightly
to the right of midline.
undergoing incision and drainage for first presentation of pilo-
nidal abscess, 58% healed the wounds within 10 weeks, and 21%
recurred during the 18 month follow-up period.(17) This recur-
rence rate of approximately 20% is consistent with that found
throughout the literature.
Management of Chronic Disease
Chronic pilonidal disease may present in several forms: a nonheal-
ing wound after initial drainage, chronically draining sinuses, or
recurrent pain and infection. The goals of definitive treatment of
the disease are to remove the diseased tissue in a manner that will
prevent recurrence, to change the local environment of the gluteal
cleft, to decrease the chance of recurrence and allow healing, and
to allow the patient to resume their normal activities and return
to work quickly. There is no one ideal approach to managing this
disease.
Nonsurgical Treatment
There is very little role for purely nonsurgical management of pilo-
nidal disease. In select patients who are found to have asympto-
matic midline pits with no evidence of infection, it is possible to just
observe the patients. Prophylactically, the patient may be instructed
to ensure good hygiene, to keep the area of the gluteal cleft dry,
and to periodically shave the area to keep hairs from accumulating.
Patients who present with acute abscess will require drainage, but
sometimes may be able to be managed nonoperatively afterwards.
 surgery for pilonidal disease and hidradenitis suppurativa
Table 21.1  Procedures for pilonidal disease: wide excision with healing by secondary intention or primary closure.
Hospital Time Follow-up
Study Closure Number of Patients (days) Healing Time (days) Infection (%) Recurrence (%) (months)

Sondenaa et al. Open 60 Outpatient 86 13 5 50

(24) (1996)
Closed 60 Outpatient 23 30 10 50
Al-Salamah et al. Open 192 4 (-) 3.12 3 35
(27) (2007)
Closed 188 3.6 (-) 4.2 3.7 36
Fazeli et al. (45) Open 72 1.76 41 13.9 4.2 22
(2006)
Mentes et al. (25) Closed 493 5.5 (-) 1.2 5.6 18
(2006)
Tejirian et al. (26) Open 26 (-) 147 (-) 35 (-)
(2007
Marsupialization 42 (-) 42 (-) 2 (-)

Note: (-) not described.

Approximately 20% of patients who undergo abscess drainage
will suffer from recurrent disease. There is little information avail-
able regarding the nonoperative treatment of these recurrences.
Armstrong et al. (18) reported faster healing in 101 patients who
were managed with gluteal cleft shaving and good perineal hygiene
following incision and drainage, when compared with 229 patients
who underwent surgical management after drainage. Following
these initial findings, the authors implemented a policy of nonop-
erative management for their patient population. They reported
only 150 hospital admissions for complications of pilonidal ­disease
during the study period of 17 years, of whom only 23 patients
required surgical management. They did not specifically report how
many total patients were under their care during the study period. It
is likely that the patients who responded well to nonoperative treat-
ment had milder disease than the ones that required further surgery.
This conservative approach can be considered in select patients with
mild disease, or in patients with significant medical contraindica-
tions to surgery. Many surgeons advocate some form of depilation
following surgery to aid in healing. Whether this is shaving, waxing,
chemical depilation, or laser treatments can be left up to individual
patient or surgeon preference.(19)
Other methods that have been described with varying success
are fibrin glue or phenol injections into the sinuses. Greenberg
et al. reported a series of 30 patients treated with fibrin glue
injection with no recurrence or infection after a follow-up of 23
months.(20) Another study of six patients who had injection of
fibrin glue into the sinus after curettage of pits reported no recur-
rences at 1 year.(21) However, this technique has not been tested
in larger case series or randomized trials.
Phenol sclerotherapy has been used for treatment of pilonidal
disease with varying success. Early studies showed potential benefit
in uncomplicated cases. Dogru et al. reported a series of 41 patients
(22) who had crystallized phenol applied to the wounds after
­limited excision of midline pits. Most patients required 2–3 appli-
cations, and 95% healed completely. There were two recurrences of
disease. However, another study of 45 patients who had 1–2 mL of
80% phenol solution into the sinus reported 60% healing, and five
patients developed abscess requiring operative drainage.(23)
Surgical Options for Chronic Pilonidal Disease
Operations for chronic pilonidal disease involve excision of the
diseased tissue. This may result in a large defect which is difficult
to close in an area which is subject to significant tension and mois-
ture. This challenge has fueled the development of many different
surgical techniques in an attempt to find the ideal operation. So
far, no technique has proven to be ideal. This section of the chapter
will review the most common operations and give an algorithm
for the surgical approach to the management of chronic disease.
The operations described may be performed in prone or lateral
decubitus position, under regional or general anesthesia. The jack-
knife prone position, with the operating table flexed at the waist
approximately 30 degrees and the buttocks taped apart, provides
the ideal exposure for most operations and is recommended unless
contraindicated by individual patient factors. Standard periopera-
tive antibiotics are given before incision. There is no need to con-
tinue antibiotics postoperatively unless there is overlying cellulitis
from acute infection. Many of these operations may be done on an
outpatient basis. The more complex flaps require the patients to
remain in the hospital on bedrest for approximately 2 days. These
patients may also receive postoperative antibiotics for a few days
until the drains are removed. Sutures are usually removed between
7 and 10 days after surgery.
Wide Local Excision
The most commonly performed operation for pilonidal disease
is wide local excision. An elliptical incision including all sinus
tracks is made and carried down to the sacrococcygeal fascia, so
that the entire cyst is removed. There is debate as to the best way
to manage the large wound that results. The benefits of leaving the
wound open to heal by secondary intention include less chance of
infection or wound breakdown, but this is counterbalanced by the
increased time required to completely heal the wound, the need
for frequent dressing changes, the added discomfort of having an
open wound, and the increased time lost from work. There are few
randomized trials which examined this problem. (Table 21.1) A
series of 120 patients (24) who were randomized to either excision
left open to heal by secondary intention or excision with primary


 improved outcomes in colon and rectal surgery
(A)
(D)
Figure 21.4  Marsupialization. (A) The diseased tissue is excised with electocautery. (B) The cavity is debrided. (C) The edges of the wound are then sutured down to
the base of the wound using absorbable suture. (D) Resulting in a small open wound.
wound closure reported less infectious complications(13% vs.
30%) and recurrences(5% vs. 10%) with the open technique, but
more overall wound complications. Slightly more patients in the
open group were not satisfied with the outcome of treatment(8%
vs. 5%). However, a larger series of 493 patients (25) treated with
midline excision and primary closure via an oblique elliptical inci-
sion which crossed the midline showed recurrence rate of 5.6% at
18 months, with very low incidence of wound infection(1.2%),
hematoma(0.4%), or wound dehiscence (1%) postoperatively.
The benefit of faster healing time and smaller final scar slightly
outweighs the possible increase in infection or wound dehiscence.
Recurrence is related more to inadequate excision of diseased
­tissue rather than to closure technique.
Excision or Unroofing with Marsupialization
Another option to leave a smaller wound is marsupialization. The
excision of tissue is carried out as described above. Then the skin

(B)
(C)
edges are tacked down to the base of the wound using absorb-
able suture. This leaves a smaller and more shallow wound which
is easier to pack.(Figures 21.4a–d) By not completely closing the
wound, there is a theoretical decrease in wound complications, and
the duration of healing is less than for a fully open wound. Simply
unroofing the wound versus excision also results in a smaller
wound. A study of 26 patients who underwent wide local excision
and 42 who had unroofing and marsupialization reported sig-
nificantly longer healing times (21 vs. 6 weeks) and wound com-
plications requiring reoperation (35% vs. 2%) in the wide local
excision group.(26) Simple unroofing without ­marsupialization
has become the preferred initial operation for pilonidal disease
and the editors’ institution.
A more recent series of 380 patients (27) who underwent exci-
sion with either primary closure or wound left open reported
similar length of stay, wound infection rate, and recurrence rate
among the two groups. However, the length of time off from work
 surgery for pilonidal disease and hidradenitis suppurativa
(A)
Figure 21.5  Bascom operation. (A) A vertical incision is made overlying the cyst, 1 cm away from the gluteal cleft. The cyst cavity any communicating fistula tracts are
debrided. The midline pits are excised, with the wounds communicating to the cavity. (B) The midline wounds are closed primarily with absorbable suture and the
vertical wound is packed lightly and left to heal by secondary intention.
and healing time were significantly shorter in the group that had
the wound closed primarily.
Limited Excision
In an attempt to minimize the morbidity of this disease, some
surgeons have advocated a more limited excision of the sinuses
rather than removing all the surrounding tissue. This technique
is recommended for patients with limited disease, defined as four
or less pits and no concurrent abscess or active infection. The
technique as described by Oncel et al. (28) requires excising each
individual pit along with a funnel-shaped cone of tissue around
the track. Methylene blue may be injected into the pits to aid
in identifying the tracks, though some authors believe that this
leads to excision of more tissue than is necessary. Additionally,
if two pits are found to be connected, the fistula overlying them
should be unroofed. The goal is to remove all pits along with
their underlying tracks and granulation tissue. The wounds are
then left open to heal by secondary intention. The same group
reported their medium-term follow-up of 62 patients treated
with this technique.(29) They found that the patients were able to
return to work in 2 days and healed completely in 43 days. They
reported one recurrence after 1 year of follow-up. Mohamed
et al. (30) reported a prospective randomized trial of 83 patients
assigned to wide excision with ­primary closure, wide excision
with wound left open, or limited excision of fistula tracks. They
found that the limited excision group had shorter operative
time, shorter length of stay and less postoperative pain, while the
wide excision with open wound group had the longest time to
complete healing. There was no difference in recurrence among
the three groups and therefore recommended a limited excision
approach when possible.
(B)
Bascom Operation
Bascom described a different operation (10) based on his theory
that treatment of pilonidal disease should center around remov-
ing the midline follicles or pits rather than excising large amounts
of tissue. The goal of this operation is to excise the midline pits,
drain the underlying abscess, and elevate the gluteal cleft. A verti-
cal incision is made overlying the chronic abscess approximately
1 cm away from the gluteal cleft. The abscess cavity is then deb-
rided, and any communicating fistula tracts are identified and
undermined so that they connect to the open wound. The midline
pits are excised via small incisions encompassing each one indi-
vidually. These wounds are closed with nonabsorbable suture. The
lateral wound is left open to heal by secondary intention and hair
in the area is shaved until the wound is completely healed. (Figure
21.5) Bascom reported his experience with 149 patients (7) with
3.5 year follow-up after follicle-excision surgery and found that
16% had recurring problems, but that these were all minor and
did not cause added morbidity. All his patients were able to return
to work within 1 day of surgery and took approximately 3 weeks
to heal the lateral wound. In a series of 218 patients (31) who
underwent Bascom’s operation, 84% were performed under local
anesthesia and all patients were discharged home the same day.
6% had infectious complications and 10% recurred, with com-
plete healing in all but 1 patient, who required further surgery.
Surgery for Complicated Pilonidal Disease and
Nonhealing Wounds
While most patients who undergo surgery for pilonidal disease
heal without complication, a few return with chronic nonhealing
wounds. Many of these patients are those who underwent wide exci-
sion and were left with an open wound to close secondarily or those

 improved outcomes in colon and rectal surgery

Table 21.2  Advanced procedures for pilonidal disease.

Technique Study Year Number of Patients Hospital time (days) Healing time (days) Infection (%) Recurrence (%) Follow-up (months)

Karydakis flap Kitchen et al. (1996)

34
141 (–) (–) (–)   4 18
Karydakis flap Akinci et al.46 (2000) 112 2.6 13.2 1.8    0.9 28
Karydakis flap Keshava et al.35 (2007)   70 (–) 80 (–)    4.2 36
Rhomboid flap Bozkurt et al.47 (1998)   24 4.1 17.5 0   0 27
Rhomboid flap Milito et al.48 (1998)   67 5.3 14 0   0 74.4
Rhomboid flap Arumugam et al.42 (2003)   53 4 14 13   7 24
Rhomboid flap Topgul et al.43 (2003) 200 3.1 12.8 1.5    2.5 60
Rhomboid flap Katsoulis et al.49 (2006)   25 4 (–) (–)   4 20
Bascom operation Senapati et al.31 (2000) 218 Outpatient 28 6 10 12
V-Y flap Dylek et al.50 (1998)   23 10 21 4   0 18
Z-plasty Fazeli et al.45 (2006   72   2.86 15.4 9.7    4.2 22

(-) not described.

(A) (B) (C) (D) (E)

Figure 21.6  Karydakis flap. (A) Schematic of the operative field depicting a pilonidal cyst slightly to the left of midline with two midline pits. (B) An elliptical incision is
made encompassing the cyst and pits. The excision is carried down to the sacrococcygeal fascia. (C) The medial edge of the wound is raised as a flap crossing the midline.
(D) The tape retracting the buttocks is released so that the wound edges are able to be approximated without tension. (E) Final result showing a vertical incision closed
primarily away from the midline, resulting in a flattened gluteal cleft.

whose incisions broke down. Those patients who have recurrence
after initial surgery or have unacceptable scars also are included in
this group. Several methods have been described to excise tissue in
the gluteal cleft and close the resulting defect with a flap technique.
(Table 21.2) These methods may be used as the initial treatment
approach, and also for complicated recurrent disease.
In 1973, Karydakis (32) described an asymmetric advancement
flap technique which results in excision of the disease, a primarily
closed wound, and a flatter gluteal cleft. An elliptical incision is
made vertically and centered off midline to the most affected side.
The incision should encompass all midline pits and skin sinuses.
The incision is carried down to the sacrococcygeal fascia, remov-
ing the affected tissue. A skin flap is raised under the medial edge
of the wound and across the midline.When the buttocks are
released and approximated, the edges of the wound should come
together easily. The incision is closed primarily off the midline,
and a flatter gluteal cleft is created. (Figure 21.6) This is believed
to aid in healing and lessen recurrence. External drainage is
useful to prevent fluid collections under the flap, though one study
found no effect on wound infections or recurrence.(33) In his
series of 6,545 patients treated with this technique (6), Karydakis
reported less than 1% recurrence rate. While this excellent result
has not been replicated, many smaller series have reported accept-
able results. Kitchen reported a series of 141 patients treated by
this technique.(34) He found a recurrence rate of 4%. 23% of
his patients had recurred after previous operations for pilonidal
disease, and all of them were cured after this procedure. More
recent series have reported recurrence rates ranging from 0 to
4%, with 5% to 8% wound complications.(35–38) Similar results
have been obtained in obese patients.(39)
A modification of this technique was described by Bascom in
2002, known as the “cleft lift” or “Bascom II” procedure.(40) An
important key to this operation is preoperative skin marking of
the patient. With the patient standing up, the buttocks are pushed
together so the line of contact between the two may be marked with
a pen. When the buttocks are taped apart with the patient lying
prone, the area between the pen markings delineates the limits of
the flap dissection. An asymmetric ellipse is drawn off midline to
include the midline pits. This ellipse is then excised, with the inci-
sion reaching to the sacrococcygeal fascia. The flap, consisting of


 surgery for pilonidal disease and hidradenitis suppurativa
(A) (B)
Figure 21.7  Rhomboid Flap. (A) A rhomboid incision encompassing the pilonidal
cyst and midline pits is marked on the skin, along with a lateral extension. The
rhomboid is composed of 2 120º angles and 2 60º angles. Line BC is drawn at a 90º
angle to Line CD. Line AB is drawn vertically down. All lines should be of equal
length. The cavity is excised down to fascia and debrided. The flap is raised and
mobilized to cover the defect. (B) The flap is rotated into the defect so that Point
2 meets Point E, Point 1 meets Point D, and Point A meets Point C. This results in
a primarily closed wound and flattened gluteal cleft.
skin and subcutaneous fat, is then mobilized towards the affected
side, breaking up the scar tissue in the subcutaneous fat. The flap
should be mobilized until the plane of dissection reaches the pen
mark on the contralateral buttock. When the tapes are released, the
edges of the flap should come together. A drain is placed under
the flap and the incision is closed, resulting in a scar off the mid-
line and a flattened gluteal cleft. In the original article describing
the technique, 27 patients who underwent the procedure after
undergoing multiple failed operations were described.(40) They all
healed completely, most having the sutures removed at 1 week, and
none recurred after a mean follow-up period of 20 months. A series
of 24 patients treated with the same technique but without drain
placement reported no hematomas, seromas, or infections, and
patients returned to work in 3 weeks. They had no recurrences with
a follow-up of 10 months.(41) This procedure is a useful option
for patients who have failed previous attempts at cure or who have
chronic unhealed wounds.
Other rotational flap techniques have been described for this
disease, along with myocutaneous flaps and skin grafting. The
rhomboid flap is another commonly used operation. Limberg or
Dufourmentel flaps are some of the more common variations of
this type of flap. For this flap, a rhomboid incision is made which
includes the diseased tissue, with the vertical axis being along the
gluteal cleft. This is carried down to the sacrococcygeal fascia.
A triangle of skin and subcutaneous fat is incised lateral to this and
then rotated into the defect.(Figure 21.7) A drain may be placed per
surgeon preference. Patients stay in the hospital on average 4 days
and sutures are removed in approximately 10 days. In a series of
53 patients with 24 month follow-up, 13% developed wound infec-
tions, 7% recurred, and all had an average healing time of 2 weeks.
(42) Another study reported on the results of 200 patients who
underwent Limberg rhomboid flap reconstruction. These patients
had an overall recurrence rate of 2.5%, with complications includ-
ing minimal flap necrosis in 3%, seroma formation in 1.5%, and
wound infection in 1.5%. The average length of stay was 3.1 days
and time to return to work was 12.8 days.(43) Other fasciocutane-
ous flaps which have been described include V-Y flaps, Z-plasty,
W-flaps, and a variety of other rotational flaps. The goal of all of
them is to allow the surgeon to excise the diseased tissue as widely
as necessary and close the defect primarily without tension while
flattening the gluteal cleft. All these flaps have similar complication
and recurrence rates, and the choice of which to utilize in each case
depends on the size of the defect to be closed and the individual
surgeon’s experience with each.
The Nonhealing Sacral Wound
Fortunately, most patients have limited disease that responds to
conventional treatment. However, a few patients present with
large open sacral defects, either due to complications of wide
excision left to close secondarily, or as a result of failed primary
closures.
Several myocutaneous rotational flaps have been described for
closing large wounds, which fortunately are not encountered very
frequently. Flaps based on the gluteus maximus are frequently
used to cover sacral wounds with good results. These techniques
are beyond the scope of this book and are most often performed
in conjunction with plastic surgeons.
Another adjunct to sacral wound healing may be the vacuum
wound closure system. Vacuum wound closure systems may be
useful in patients who have defects which are not able to be closed
primarily for a variety of reasons, and have been used extensively
in defects due to pressure ulcers, traumatic wounds, and post-
surgical perineal defects. A series of five patients with extensive
complex infected pilonidal sinuses underwent excision with
placement of a vacuum sponge.(44) Patients used the device for
6 weeks, after which wet-to-dry dressing changes were initiated.
Complete epithelialization was observed in 12 weeks. One patient
did not tolerate the device, and another required a return to the
operating room for further debridement, after which the wound
healed with use of the vacuum device.
Pilonidal disease presents many treatment challenges, and
therefore, multiple treatment approaches exist. Depending on the
specifics of each case and individual surgeon experience, different
approaches may be considered. An algorithm based on extent and
chronicity of the disease is presented here. (Figure 21.8)
Perianal Hidradenitis Suppurativa
Hidradenitis suppurativa is a chronic inflammatory disease of the
apocrine sweat glands. The disease was first described by Velpeau
(51) in 1832, and its association to sweat glands in the skin was
described by Vernuil (52) in 1864. These glands are found prima-
rily in the groin and axilla, which are the most common sites of
involvement of disease. However, they can also be found in the
perineum, perianal area, scrotum, and labia. Hidradenitis suppu-
rativa affects patients beginning in adolescence and peaks around
age 40. The incidence of hidradenitis suppurativa is estimated to be
1:300. Perianal disease appears to be more common in men.(53)
Pathophysiology
Apocrine sweat glands are coiled tubular secretory structures
which empty into the hair follicle. They are similar to eccrine sweat
glands except that these empty directly to the skin. The etiology of
hidradenitis suppurativa is unclear, but appears to be multifac-
torial. Obstruction of the apocrine gland duct is likely to be the
inciting event, leading to secondary infection and rupture of the

 improved outcomes in colon and rectal surgery
Algorithm for management of chronic pilonidal disease
Chronic Pilonidal Disease
Limited Disease
Midline excision ± closure
+ contraindications to surgery or marsupialization
- Hygiene Sinus excision
- Depilation Bascom operation
Figure 21.8  Algorithm for management of pilonidal disease.
gland with extension into the surrounding dermis and subcutane-
ous fat. The infection then spreads to neighboring glands and is
manifested by cellulitis and abscess. Initially, the infection resolves
with simple incision and drainage, but long-term disease recur-
rence may lead to scarring and fistula formation. Microbiologic
studies of the infected tissues have shown that skin flora is the
usual pathogen for axillary disease, though enteric aerobes and
anaerobes have also been isolated from perianal lesions. Many of
the older studies were indeterminate as they evaluated superfi-
cial swab cultures. However, cultures of deeper tissue have shown
Staphylococcus aureus and coagulase-negative staphylococcus in
most of the samples.(54)
Diagnosis
Patients with perianal hidradenitis present with recurrent peri-
anal abscesses which may extend to involve the perineum, labia or
scrotum, buttocks, or the inguinal region. The lesions may start
out as a simple abscess, but tend to evolve with time into thick
scarred skin with open wounds and chronically draining sinuses.
Perianal fistulae may also be present. The differential diagnosis
includes perianal abscess, furuncles, carbuncles, lymphogranu-
loma venereum or other sexually transmitted diseases, pilonidal
disease, tuberculosis, actinomycosis, cat-scratch disease, granu-
loma inguinale, and Crohn’s disease. One way to differentiate
the etiology of perianal fistulae is that cryptoglandular fistu-
lae usually involve the dentate line and intersphincteric plane,
whereas fistulae associated with hidradenitis are found in the dis-
tal anal canal, where the apocrine glands are found. The dentate
line is normal in cases of hidradenitis. It is important to examine
other areas, such as the axilla and groin, as many patients with
hidradenitis suppurativa will have concurrent involvement of
these areas. Some factors which have been shown to be related to
this disease include altered immune response, smoking, obesity,
hormonal therapy, pregnancy, onset of puberty, familial factors,
and Crohn’s disease.(55–57) The Lahey Clinic reported their expe-
rience with 43 patients with perianal hidradenitis suppurativa.

Large
Complicated Disease
Wound
Karydakis flap
Rhomboid flap
Cleft Lift (Bascom II)
Myocutaneous flaps
V-Y flap
Vacuum sponge
Z-plasty
They found that 93% of the patients were male with a median
age of 29 years. Patients were initially diagnosed with pilonidal
­disease (28%), anal fistula (37%), and perirectal abscess (16%).
72% of their patients were smokers.(58) In a series of 61 patients
from The Cleveland Clinic, 24 (38%) were found to have concur-
rent Crohn’s disease. All had perianal hidradenitis, and 20 had
disease in other sites as well.(59) Often the diagnosis of perianal
hidradenitis is delayed due to the similarity of symptoms with
other perianal diseases and the possibility of other concurrent
disease processes. In situations where patients are being treated
for a certain condition and they are not improving, hidradenitis
should be considered as a possible complicating factor. ­Long-term
sequelae of perianal hidradenitis include disfiguring scars, local-
ized or systemic sepsis, and carcinoma, including squamous cell
or adenocarcinoma.(60–62)
Nonoperative Management
The treatment of perianal hidradenitis suppurativa is mainly
surgical. However, there is a role for nonoperative management,
particularly in the milder forms of the disease. Maintaining
good hygiene of the area is imperative to control infection.
Patients should keep the affected area clean and dry, reduce
moisture, avoid constricting or irritating clothing, and lose
weight. Topical antibiotics are often used in conjunction with
systemic antibiotics or alone to control secondary infection.
Topical clindamycin was shown in one double-blind randomized
trial of 30 patients to be of benefit in controlling infection.(63)
Systemic antibiotics are rarely indicated, except in cases with
significant cellulitis or ­bacteremia. In light of the similarities
between acne and hidradenitis suppurativa, isotretinoin has
been used to treat hidradenitis successfully. Brown et al. (64)
reported on a patient treated with 1 gm/kg of isotretinoin daily
for 20 weeks. The patient had no significant change in her
condition until 8 weeks into the treatment, at which point she
began to note improvement. Ultimately, she had an excellent
response with no relapse at the 18 week follow- up visit. Minor
 surgery for pilonidal disease and hidradenitis suppurativa
side effects such as xerosis, cheilitis, and elevated serum alka-
line phosphatase were reported, which resolved with comple-
tion of treatment.
Targeting the hormonal response of hidradenitis has also had
some success, including one retrospective study of 64 female
patients demonstrating that antiandrogen therapy was supe-
rior to systemic oral antibiotics in controlling disease.(65–67)
Other nonsurgical approaches have been attempted with varying
degrees of success, including granulocyte-macrophage colony-
stimulating factor (68), infliximab (69, 70), and oral zinc.(71)
Surgical Management
The centerpiece of treatment of hidradenitis is surgical excision.
Incision and drainage has a limited role to relieve pain and pres-
sure in cases of acute abscess. There is no long-term benefit to
the procedure, as it does not remove any of the affected tissue,
but may be necessary to relieve pain. Patients should receive sys-
temic antibiotics to treat the overlying cellulitis if present and may
require packing of the wound for several days. Unroofing of fis-
tula tracts is another procedure which may be useful in controlling
local infection, though this also does not excise the disease and
therefore has no benefit in preventing recurrence.
Excision of the diseased skin, including skin appendages and
subcutaneous fat, is required to adequately control the disease.
In mild cases, limited excision left to heal by secondary inten-
tion is appropriate. Primary closure is usually not possible and is
not advised, as the recurrence rate is increased. Rotational flaps
or skin grafting are more successful wound closure methods. In
a series of 106 patients, 70% underwent excision with primary
closure and the rest had closure with skin grafts or flaps. 69%
of the patients had a recurrence requiring surgery, the majority
of whom were in the primary closure group.(72) A series of 8
patients with perineal hidradenitis who underwent wide exci-
sion had their wounds either covered with meshed split-thick-
ness skin graft (5) or left open to heal by secondary intention.
(3) All patients healed well and had no surgical site recurrence,
though two recurred in other areas.(73) A larger series including
56 patients with gluteal or perianal disease was reported recently.
(74) Twenty-one (37.6%) and 17 (30.6%) patients had gluteal
and perineal disease, respectively. Squamous-cell carcinoma and
Crohn’s disease were observed in one patient each. Wide exci-
sion was performed in all patients. Thirty-two patients (57.1%)
were left to heal by secondary intention, and the remaining 24
patients underwent split-thickness skin grafting. Twenty-three
patients received a diverting colostomy. Mean time for complete
healing in the open wound group was 10 weeks and in the skin
graft group was 6 weeks. Five patients (9%) required a second
resection. Partial graft loss rate was 37.5% and only one patient
had a recurrence. The benefits of skin grafting or rotational flaps
include shorter healing times and less discomfort when com-
pared to an open wound; however, some of the large defects that
result from excision are difficult to adequately cover. When a
large wound must be left open, a wound vaccum sponge or silas-
tic foam may be of benefit.
In summary, the primary approach to perianal hidradenitis
suppurativa is surgical excision of all diseased tissue. The open
defect that results may be left open to heal secondarily and heals
uneventfully in most cases. In certain cases where the defect is
particularly large, a skin graft may be used. Fecal diversion is
rarely necessary in managing this disease, and should be reserved
for debilitated patients who will have difficulty keeping the open
wound clean, patients with fecal incontinence, or patients with
concurrent Crohn’s disease with perianal involvement.
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
22 Surgical treatment of fecal incontinence
Ann C Lowry and Dimitrios Christoforidis
Challenging Case
A 35-year-old woman presents to your office with complains of
fecal incontinence. She is G3 P3, all vaginal deliveries and one
child was 8 pounds. The patient reports fecal soiling for the last
year with progressive uncontrolled passage of flatus and occa-
sional identification of stool in her undergarments that she was
unaware of having passed. There is additional incontinence asso-
ciated with athletic activity. The incontinence severely affects the
patient’s life style.
Case Management
A complete history identifies no additional risk factors. Physical
examination reveals a thinned perineal body, decreased resting
tone, weak squeeze (especially anterior), and an anterior sphinc-
ter defect. A flexible sigmoidoscopy was normal, anorectal man-
ometry documents low resting tone and squeeze pressure. An anal
ultrasound confirms an anterior sphincter defect. The patient is
recommended to undergo an overlapping sphincter repair.
Epidemiology
Fecal incontinence (FI) is a common and underreported condi-
tion. It is embarrassing, stressful, and often leads to social isola-
tion. Nevertheless, only a third of symptomatic patients in the
USA discuss their fecal incontinence with their physician.(1) The
reported prevalence of FI varies depending on the population
studied and definition used. In nursing homes, it affects nearly
50% of residents.(2, 3) In a recent systematic review including
16 studies from across the world, the estimated prevalence of
fecal incontinence (excluding flatus incontinence) varied from
0.4% to 18%. A community based US telephone survey found a
prevalence of 2.2%.(4) A study from the UK analyzed over 10,000
questionnaires from community-dwellers using more strict cri-
teria; Major FI, defined as soiling of underwear, outer clothing
or bedding at least several times a month, was reported by 0.9 %
adults aged 40–64 years and by 2.3% of adults aged 65 years and
older.(5) In this and other epidemiology studies, men were found
to be equally affected by FI as women. However, clinical series on
FI are dominated by female patients as women seem to seek med-
ical attention more often. The true reason for that is unknown.
Beyond the psychological burden and the medical morbid-
ity (such as urinary tract infections, skin breakdown, decubitus
ulcers) FI causes significant expense. Estimating total costs is
difficult because of imprecise prevalence data and frequency of
coexisting medical conditions. By analogy, urinary incontinence
was estimated to generate direct and indirect costs exceeding $14
billion in the year 2000 for US community dwellers.(6) In a US
study of 63 women with FI secondary to obstetric injury, the
average cost for evaluation and treatment of FI was 17,166 USD
per patient in 1999.(7) FI is obviously a significant public health
problem that deserves more attention.

Etiology
The physiology of the continence mechanism is complex. Sche­
matically, continence requires an anal sphincter and a rectal reservoir
that are anatomically intact, normally innervated, and coordinated,
a manageable fecal bolus and an adequate level of awareness and
desire to avoid incontinence. A great number of conditions, trau-
matic events, diseases, or medication may affect continence at one
or more of these levels at various degrees. FI is often multifactorial
and causality is not always easy to establish. Therefore, it may be
more appropriate to talk about risk factors rather than causes in the
etiological assessment of a patient with FI.
Anal sphincter
In women with FI, the most prevalent risk factor is childbirth.
The incidence of third or fourth degree tears identified clinically
at the time of vaginal delivery is 0.6 to 9%.(8) The clinical inci-
dence is an underestimate of the true sphincter injury rate, as
demonstrated by studies employing ultrasound imaging. A meta-
analysis of five large prospective studies assessing the integrity
of the anal sphincter after vaginal delivery with 2-dimensional
endosonography revealed a 27% incidence of anal sphincter
defect in primiparous women and an 8.5% incidence of new
sphincter defects in ­multiparous women.(9) Another study using
improved 3-dimensional endosonography on 55 primiparous
women reported evidence of trauma in 29% but only 11% had
evidence of external sphincter injury.(10) Among those women
with a documented third degree tear, FI will develop in one-third
to two-thirds.(8, 9) In the general population the true incidence
of persistent postpartum FI of solid stool is unknown but can be
approximately estimated at 3%. Other than obstetric trauma, the
anatomical integrity of the sphincter complex can be disrupted
by iatrogenic trauma during anorectal surgery and accidental
trauma or be the result of a congenital malformation such as
imperforate anus.
In addition to structural defects, alteration of sphincter inner-
vation also contributes to decreased sphincter function. It is well
recognized that traction injury to the pudendal nerve during
pregnancy and delivery contributes to obstetric-injury-related
FI.(11) Various conditions affecting the pelvic nerves, the spinal
cord or the brain may also result in sphincter atrophy and loss of
anal canal tone (Table 22.1).
Rectum
The reservoir function of the rectum may be impaired second-
ary to a) loss of capacity after rectal resection or space occupying
lesions, b) loss of compliance secondary to inflammatory bowel
disease, pelvic radiation, rectal ischemia, or collagen vascular
diseases and, c) loss of innervation following surgery, trauma, or
neurologic degenerative disease. Rectal mucosal prolapse or full
thickness rectal prolapse may cause FI by preventing complete
 surgical treatment of fecal incontinence

Table 22.1  Pathophysiology classification of risk factors for FI. Central Nervous System
Patients with dementia, some psychiatric disorders, or residual
Brain – central awareness
deficits from a stroke may lack awareness or interest in bowel
Dementia
CVA function and become incontinent. This type of FI is more preva-
Brain tumor, infection, trauma lent in elderly and institutionalized patients.
Psychiatric disorder
Psychotropic drugs Evaluation
Bowel – Fecal bolus Assessment of severity
Diarrheal states (malabsorption, IBD, infectious diarrhea, short gut syndrome, There is no objective test that reliably correlates with patient
radiation enteritis, laxative abuse etc.)
IBS
reported frequency and type of fecal incontinence. Since the physi-
Proctitis (radiation, IBD) cal morbidity associated with FI is minimal and the mortality
Gastrointestinal stimulant drugs and foods (caffeine, alcohol, aspartamine etc) practically null, morbidity and mortality data is not useful to
Anorectum – Neurologic impairment measure severity. However, the impact of FI on quality of life is
Spinal cord trauma, surgery, hernia, neoplasm immense. Consequently, any effort to rate FI should be based on
Diabetes mellitus the patient’s reported frequency and type of FI and its effect on
Multiple sclerosis quality of life.
spina bifida Baxter et al. (12) categorized the available measures of FI
(myelo)meningocele
pelvic fracture
into a) descriptive measures (e.g., Mayo Clinic FI Questionnaire,
Pelvic radiation Osterberg Assessment of FI, and constipation), b) severity scores
prostatectomy including grading systems (e.g., Parks’ scale, Williams scale) and
proctectomy summary scores (e.g., FI Severity Index (FISI), Cleveland Clinic
obstetric injury Florida FI score (CCF-FI), Vaizey score) and c) impact measures
rectal prolapse
chronic straining
which can be disease specific (e.g., Fecal Incontinence Quality of
pelvic floor descent Life (FIQL), FI-Manchester Health Questionnaire) or global (e.g.,
aging SF-36). A diary is a useful way to document the frequency and type
idiopathic of FI episodes; the data can be used to calculate a score or simply
Rectum – anatomic impairment reported as number of FI episodes per week or days with FI per
Sphincter-saving operations (low anterior resection, coloanal anastomosis, week. In clinical practice, FI is often described as minor (mostly
restorative proctectomy procedures) underwear staining and/or gas incontinence without uninten-
Rectal neoplasm tional loss of true bowel movements) or major (accidental loss of
Extrinsic compression
Collagen vascular disease
partial or whole bowel movements), urge or passive incontinence.
Rectal ischemia Obviously, these descriptions are insufficient to compare patients
Pelvic radiation in studies or to assess treatment outcome precisely.
Rectal agenesis Popular measures in research are severity summary scores.
Anal sphincter – anatomic impairment They are usually based on frequency and type of FI episode.
obstetric injury Some systems incorporate the use of a pad or the presence of
anorectal surgery (fistula surgery, internal sphincterotomy, anal stretch, lifestyle alteration. However, few scoring systems are based upon
hemorrhoid surgery) patient’s perspective in the assignment of values. Most of these
anal impalement
anal intercourse
scores attribute the same importance to episodes of gas incon-
imperforate anus tinence as episodes of solid stool incontinence. An exception is
Pseudoincontinence
the FISI which was designed based on patients’ numerical rat-
anorectal condition: prolapsing hemorrhoids, rectal prolapse, fistula in ano
ings of severity of various frequencies of gas, mucus, liquid stool,
troublesome hygiene: obesity, physical disability and solid stool incontinence.(13) Nevertheless, frequency-based
scores, even with a meticulous use of a FI diary to register events,
will overlook the fact that patients often make dramatic lifestyle
sphincter closure; if left untreated, these conditions may lead to changes to avoid FI episodes. Therefore, a validated impact meas-
sphincter and pudendal nerve damage. ure such as the FIQL (14) should be used in addition to severity
summary scores.

Fecal bolus History and Physical

Formed stool is easier to control than liquid stool. An accelerated
intestinal transit with increased stool volume can cause urgency
and soiling even in patients with normal anorectal function and
will precipitate true FI in a patient with a weakened continence
mechanism. Constipation on the other hand, can lead to impac-
tion and overflow incontinence in patients with deficient rectal
sensation combined with weakened sphincter muscles.
The goals of a thorough history in a patient with FI are multiple.
First, the interview should define character (seepage, passive/urge),
severity, and impact on quality of FI. The character often ­suggests the
underlying physiopathology. Generally, internal sphincter defects,
prolapse or loss of sensation cause seepage and passive incontinence
whereas external sphincter defects cause primarily urge incontinence.
A deficient rectal reservoir through loss of capacity or ­compliance


 improved outcomes in colon and rectal surgery

will result in urge incontinence as well with stool clustering and more accurate assessment of sphincter defects with endoanal
increased frequency. Secondly, the history should identify concomi- ultrasound (EAUS). Since the decision between medical or sur-
tant symptoms, such as urinary incontinence and pelvic organ pro- gical management (sphincter repair) of FI is largely based on
lapse since FI is frequently only part of a more general pelvic floor the extent of sphincter injury, imaging of the sphincter makes
dysfunction. Thirdly, questions should elicit underlying risk factors, sense. Both EAUS and MRI (with endorectal coil) appear to be
particularly those that are readily corrected (Table 22.1). Emphasis highly accurate in identifying sphincter defects (21), especially
must be given to a detailed obstetric history to identify surrogate of the distal part of the anal canal.(22) EAUS has the advantage
markers of a traumatic childbirth (instrumental delivery, prolonged of being inexpensive and readily available. Three-dimensional
second stage of labor, birth weight greater than 4 kg, episiotomy) EAUS (Figure 22.1a and 22.1b) and transperineal ultrasound
(8) and to evaluate the presence of FI symptoms in the postpartum may further increase accuracy.(23, 24) MRI depicts the external
period. A careful assessment of stool consistency and defecation
habits will help determine the potential benefits of a bowel regulat-
ing treatment. Finally, a detailed history of FI will guide selection of (a)
appropriate investigations.
Physical examination should identify possible causes, effects
and coexisting conditions of FI. Perineal scarring, diminished
perineal body, or palpable sphincter defects will suggest obstet-
ric trauma. A patulous anus is a sign of sphincter denervation.
Dermatitis and excoriation result from prolonged exposure to
feces and poor hygiene. Furthermore the clinician should actively ES
look for any anorectal conditions causing “pseudo-incontinence”
such as rectal prolapse or prolapsing hemorrhoids, skin tags,
mucosal ectropion, or fistula in-ano. Digital rectal examination IS
provides gross information on sphincter bulk, anal canal tone,
anal stenosis, and presence of masses. A vaginal exam is essential
to assess for coexisting conditions such as rectocele, enterocele,
uterine or vaginal apex prolapse and cystocele.

Additional studies
The aim of additional studies is to identify the cause of FI and
risk factors amenable to treatment. Endoscopic examination, at
least a flexible sigmoidoscopy if not a full colonoscopy, should be
performed to rule out conditions that may contribute to FI such
as polyps, malignant lesions, or inflammatory bowel disease. (b)
A variety of anorectal physiology tests (ARP) are available
to further clarify the etiology of FI. Sphincter anatomy can be
assessed by endoanal ultrasound or MRI; resting and squeeze
anal canal pressures can be measured by manometry; anorectal s
sensation and reflexes (minimal volume to elicit sensation, maxi-
mal tolerated volume, presence of rectoanal inhibitory reflex) can
be estimated by balloon inflation manometry or with techniques
that measure thermal change sensitivity or mucosal electrosen-
sitivity; integrity of sphincter innervation can be evaluated by
pudendal nerve terminal motor latency and electromyography;
defecation dynamics can be assessed by barium cinedefecogra-
phy, balloon expulsion tests, and more recently by dynamic MRI. ES
However, the need for ARP testing outside of research cent- IS
ers is still debated (15–17) for several reasons. There is relative
absence of standardization of test techniques and norm values
established from large cohorts of healthy individuals. Few stud-
ies have shown clear correlations between baseline ARP and
treatment outcome. Studies evaluating the clinical utility of ARP
have all too often included only small numbers of patients and
contained important design flaws. Having said that, in these Figures 22.1a and 22.1b  (a)EAUS image of a normal anal canal with complete internal
sphincter (IS) hypoechogenic ring and external sphincter (ES) hyperechogenic ring.
studies ARP testing appeared to improve the understanding of (b)EAUS image of anal canal with a wide internal (IS) and external sphincter (ES)
etiology and change treatment strategy of FI in approximately defect. Note the thickening and retraction of the internal sphincter and the anterior
15%.(18–20) Most changes in treatment strategy were due to scar (S) replacing the external sphincter.


 surgical treatment of fecal incontinence
sphincter clearly because of the contrast between fat and ­striated
muscle and accurately visualizes external sphincter atrophy.
External sphincter atrophy can also be accurately diagnosed with
3D-EAS (25); its significance is not fully understood but it may
adversely affect outcome after sphincterplasty.(26) The value of
sphincter imaging has also been demonstrated in men with FI.
The presence of a sphincter defect –an internal sphincter defect
secondary to anal surgery in the vast majority of men – was a
clear predictor of failure of conservative ­management.(27)
In conclusion, the assessment of a patient with FI must include
a directed, detailed history and examination. After excluding cases
of “pseudo-incontinence” or minor seepage additional work-up
must include endoscopy and sphincter imaging, especially if treat-
ment with sphincteroplasty is considered. Defecography is helpful
to confirm suspected rectal procidentia. The utility of further ARP
studies will depend on local availability and expertise.
Treatment
Medical therapy
Initial treatment of FI should be conservative even if there is little evi-
dence to guide clinicians in the selection of drug therapies.(28) The
main targets of medical treatment of FI are intestinal transit and stool
consistency. A thorough work-up is mandatory in patients with FI
related to chronic diarrhea to identify and treat the underlying cause
of diarrhea. Dietary changes and prescription of either fiber supple-
mentation or fiber restriction must be individualized to each patient
as the change in bowel transit can be very variable.(29) In a placebo
controlled trial, psyllium and gum arabic, two natural soluble fibers,
were shown to reduce by 50% the proportion of incontinent stools in
39 patients with FI of loose or liquid stools.(30) Antidiarrheal medi-
cation (loperamide, diphenoxylate plus atropine, bile-acid binders,
codeine) is the next step in medical management of FI. Loperamide
has been shown to be more effective than diphenoxylate plus atropine,
and have fewer side effects than both diphenoxylate plus atropine and
codeine.(31) In addition to its effect on intestinal motility, loperamide
may improve sphincter tone and rectal sensation.(32) In an open label
trial in 18 patients with idiopathic FI, amitriptyline, a tricyclic antide-
pressant agent, was shown to improve FI scores in 89% of patients after
4 weeks of treatment; the proposed mechanism is a decrease in ­rectal
motor complexes and stool frequency.(33) Further studies are needed
to evaluate the true efficacy of this drug.
A different approach of medical treatment is to enhance anal
sphincter function by application of topical agents, such as
phenylephrine gel, an α1-adrenergic agonist. Three small dou-
ble blind placebo trials from the St. Mark’s hospital in the UK
showed significant improvement in sphincter tone (34) and FI
symptoms in half of ileal pouch patients (35) and in one third of
FI patients with anatomically intact sphincters.(36) Conversely,
Park et al. (37) in a double blind trial on 35 patients with FI after
low anterior resection found no improvement in FI or quality of
life scores with 30% topical phenylephrine compared to placebo.
Limited efficacy combined with frequent allergic reactions, limits
wider acceptance of this treatment.
Constipation and impaction can lead to overflow incontinence.
Such patients will benefit from routine tap-water enemas or laxa-
tives to empty the rectum regularly. Patients with postdefecation
seepage may also benefit from routine enemas as well as appli-
cation of cotton wicks at the anus and barrier creams to avoid
excoriation and pruritus.
Anal plugs for the management of FI is a different approach that
appears intuitive to many patients. A recent Cochrane review of pub-
lished randomized trials suggested that anal plugs seem to be difficult
to tolerate but if they are tolerated, they can be a useful tool in FI pre-
vention either as substitute or adjuvant treatment option.(38) Anal
plug models exist in a variety of forms, sizes, material, and function.
Devices with intrarectal sensors alerting the patient of an imminent
bowel movement with a beep have also been described.(39, 40)
Biofeedback
The goal of biofeedback is to improve external sphincter contrac-
tion (strength and duration) in response to rectal distention by
providing the patient with feedback information on perform-
ance and progress. In general, three different protocols are used:
(1) coordination training, which teaches patients to contract
their external sphincter muscle in response to rectal distention
counteracting the reflex internal sphincter relaxation; (2) sen-
sory training, which teaches patients to recognize progressively
smaller volumes of rectal distention enabling them to contract
the sphincter in time; and (3) strength training, which teaches
patients to isolate and exercise their sphincter muscle without
using rectal distention. In most centers, either manometry equip-
ment or an EMG probe is used to provide “feedback” information
to patients. The three training methods are sometimes combined;
the length and number of sessions varies widely.
Biofeedback is widely used and often included as first line option
in treatment algorithms for FI. No obvious clinical or physiologic
predictors of success have been identified. Patient age, etiology of
FI, duration, and severity of symptoms do not appear to predict
outcome; biofeedback has been used successfully in a variety of
situations including presence of external sphincter defects (41) or
in patients with poor functional outcome after sphincteroplasty
for obstetric injury.(42)
A systematic review on biofeedback through 2000 (43) found 46
original studies, only 8 of which employed some form of control
arm. All but one study (44), which included patients with neurogenic
FI, reported improvement of symptoms in a range of 53–100% of
patients. Overall, 617 of 861 (72%) reported to be cured or improved.
The same author performed a Cochrane review (45), including only
randomized or quasi randomized trials and concluded that the cur-
rent literature provides no evidence that biofeedback or anal sphinc-
ter and pelvic floor exercises improve outcome compared to other
conservative management methods. Training to enhance rectal
discrimination of sensation seemed to be helpful in reducing FI in
one short follow-up ­randomized study.(46) In absence of high level
evidence, interpreting the ­literature on biofeedback is problematic.
Some patients seem to benefit and there has been no morbidity
reported. High motivation both from the patient’s and therapist’s
side are crucial p
­ rerequisites for a successful outcome.
Sphincteroplasty
Anal sphincteroplasty is an appropriate therapy for patients with
significant FI, unresponsive to medical therapy and a documented
anal sphincter defect.

 improved outcomes in colon and rectal surgery

Overlapping sphincteroplasty is usually performed under
general anesthesia, in the prone jack knife position after prior
mechanical bowel preparation and prophylactic antibiotics. A
curvilinear incision is made in the perineal skin closer to the vagi-
nal introitus than the anus to preserve tissue on the anal side. A
Lone Star® retractor is used for exposure and a needle tip electro-
cautery is preferred for more precise dissection with less char.
The external sphincter, en bloc with the internal sphincter and
anterior scar tissue is mobilized and dissected free from the skin
and ischiorectal fat laterally, from the posterior vaginal wall ante-
riorly and from the anoderm and rectal wall posteriorly. Careful
dissection, occasionally aided by inserting a finger in the vaginal
or rectal side, avoids buttonholing, especially on the rectal side.
Any injured venous sinuses on the posterior vaginal wall should
be suture ligated to avoid delayed hemorrhage. Care must be
taken with the posterolateral portions of the dissection to avoid
injury to branches of the pudendal nerve. Dissection in the mid-
line continues until soft, pliable tissue is reached on both the
vaginal and rectal sides and laterally until the two ends of the
external sphincter can be overlapped several centimeters without
tension. If the midline tissue is entirely scar tissue, it is divided to
perform an overlapping repair. If muscle is encountered in the
midline it is left intact and an imbricating repair rather than over-
lapping repair is performed. The overlapping repair is done with
absorbable 2–0 monofilament mattress sutures creating a snug
anal opening without excess tension on the mobilized tissue. The
wound is closed in a vertical or “T” fashion to decrease tension on
the skin. The center of the incision is left open and a short ¼ inch
Penrose or closed suction drain is placed through the opening
to facilitate drainage. The drain is removed before the patient’s
discharge. Vaginal packing may be placed to help with hemostasis
and if used is typically removed the next day. If planned, anterior
levatoroplasty is performed before the overlap. Proponents argue
that the levatoroplasty adds essential bulk to the perineal body and
lengthens the anal canal. Opponents believe that a levatoroplasty
increases the incidence of postoperative dyspaurenia. Diversion
of the fecal stream did not improve healing or functional results
of the repair in a randomized trial.(47)
As with any perineal wound, healing after overlapping sphinc-
teroplasty is slow with frequent separation of the skin edges.
Postoperative care includes the avoidance of impaction with the
use of bulk agents and tap water enemas and protection of the
surrounding skin with barrier ointments. Vaginal tampons and
intercourse are proscribed for 6 weeks.
One variation is the approximation of the ends of the sphincter
muscle rather than overlapping them. This technique is particu-
larly appropriate when a portion of the muscle is intact. In a ran-
domized study by Tjandra et al. (48) of 23 women with anterior
sphincter defects on EAUS, no functional difference was found
between patients repaired with the approximation technique and
those undergoing an overlapping repair.
Functional results after overlapping sphincteroplasty are good
or excellent approximately in two-thirds of patients in studies with
a follow-up under 4 years (Table 22.2a) and approximately in one
half of patients in studies with a longer follow-up (Table 22.2b).
Bravo-Gutierrez et al. reviewed functional outcome a median of
10 years after sphincteroplasty in 130 women and found that 58%
reported some incontinence of solid stool compared to 36% at
a 3 years follow-up.(49) Similarly, Barisic et al. found increased
failure rates with time as poor results were reported by 39% at 80
months compared to 9% at 3 months.(50) Malouf et al. reviewed
the results of sphincter repair in 46 patients a median (range)
of 77 (60–96) months.(51) Excluding 8 immediate failures 85%
of the others reported improvement at 15 months but only
50% at 77 months. Only 4 patients were completely continent
of stool but the median subjective rating of satisfaction with the
Table 22.2a  Functional results of sphincteroplasty – short and
midterm follow-up.
Months
Follow-up
Median Excellent
Author Year n (range) or Good Fair Poor
Nikiteas (106) 1996 42 38 (12–66) 60% 17% 23%
Oliveira (107) 1996 55 29* 71% 9% 20%
Young (108) 1998 57 18 86% — 14%
Gilliland (109) 1998 77 24 (2–96) 55% 14% 31%
Karoui (110) 2000 86 40a 81% — 19%
Buie (111) 2001 158 43a (6–120) 62% 26% 12%
Morren (112) 2001 55 40 (5–137) 56% 24% 20%
Pinta (113) 2003 39 22 (2–99) 31% 38% 31%
Evans (114) 2006 66 45* 77% — —
a. Mean.

Table 22.2b  Functional results of sphincteroplasty – long term follow-up.

Years Follow-up
Author Year n included/n initial Median (range) Excellent or Good Fair Poor

Londono-Schimmer (115) 1994 94/128 4.9 (1–8.2) 50% 25% 25%

Malouf (51) 2000 46/55 6.4 (5–8) 50% 9% 41%
Halverson (116) 2002 49/71 5.3 (2–11.8) 49% — 51%
Zorcolo (117) 2005 62/93 5.8a (2–9.3) 54% 16% 30%
Barisic (50) 2006 56/65 6.7a 48% 13% 39%
Bravo-Gutierrez (49) 2004 130/182 10 (7–16) 41% — 57%
Maleskar (52) 2007 64/72 at 7 62% 24% 15%
Grey (118) 2007 47/85 5–12 60% 36% 4%

a. Mean.


 surgical treatment of fecal incontinence
long term results was 8 out of 10. Other studies document more
optimistic results. Maleskar et al. reported on 64 of 72 patients
responding to a questionnaire after a median of 7 years.(52) The
median CCF-FI score dropped from 16 preoperatively to 5 at 12
months and to 7 at a median follow-up of 7 years. Ninety five
percent of patients were satisfied with the results and 62% were
fully continent or incontinent to gas only. Interestingly, Vaizey
et al. found no difference in incontinence scores, patient rating of
improvement or satisfaction between the findings at 20 months
and 60 months in a group of patients who underwent a repeat
sphincter repair following a failed repair.(53)
If the initial repair fails and a persistent defect is demon-
strated by ultrasound, repeat sphincteroplasty can still provide
satisfactory results (54, 55) even with long-term follow-up.(53)
Breakdown of the wrap is not the only cause of failure. Progressive
neuropathy and the aging process in general are thought to con-
tribute to some deterioration of symptoms over time.
Patients with poor results may be candidates for biofeedback,
artificial bowel sphincter, or sacral nerve stimulation.
The role of sphincteroplasty in patients with incontinence and
sphincter defects is evolving with the addition of new modali-
ties of therapy. Further research is necessary to determine which
patients are appropriate candidates and whether adjunct therapies
such as biofeedback or sacral nerve stimulation would improve
the functional results.
Artificial Bowel Sphincter
The artificial bowel sphincter (ABS) is a treatment modality for
urinary incontinence which was adapted for FI. In 1996, the man-
ufacturing company (American Medical Systems, Minnetonka,
MN, USA) adapted the original device for its use in FI as the
ActiconTM Neosphincter device. Although other models have
been recently developed (56, 57), this device is the most widely
employed and reported in the literature.
The ABS consists of three components: an inflatable cuff,
placed around the deficient sphincter, a pressure-regulating bal-
loon placed in the retropubic space, and a control pump placed in
the scrotum or labia. The three components and the connecting
tubing are filled with saline. In the neutral state, the fluid fills the
cuff occluding the anal canal. When the patient desires to defecate,
he empties the cuff by manually compressing the pump, which
pushes the fluid into the pressure regulating balloon. The cuff
refills spontaneously in approximately 45 seconds.
The ABS is an invasive procedure with significant morbidity.
Candidates include patients who have failed all medical treatment
and are not candidates for a sphincter repair. Sufficient perineal
tissue without excessive scarring or prior radiation and a normal
rectal reservoir are required to minimize risk for late erosion and
dysfunction.(58)
Mundy et al. (59) performed a systematic review of the litera-
ture published through 2002 on safety and effectiveness of ABS in
FI. They included 13 case series involving 1 to 112 patients with
a mean follow-up time of up to 60 months. No study included
a control group or reported intention to treat results prevent-
ing judgment of the true effectiveness of ABS. Approximately a
third to half of patients needed surgical revision of the ABS and
one quarter required explantation, most commonly because of
infection or erosion. Wound healing problems, material breakage
or migration, fecal impaction, chronic pain, and dissatisfaction
also occurred. In patients with successful implantation, all stud-
ies reported clinically significant improvements in FI severity and
quality of life.
O’Brien et al. (60) performed a randomized trial on 14 patients
with severe FI comparing ABS to optimal medical therapy. In
the ABS group one out of seven patients had explantation of
the device after failed wound healing and two had prolonged
hospitalization for repeated fecal impaction or wound healing
problems. At 6 months, the Cleveland Continence Score showed
a 75% improvement in the ABS group with significantly better
quality of life scores. No significant changes were observed in the
medical treatment group.
Long term follow-up studies on ABS report higher rates of
reintervention and explantation with a functional ABS (61–63)
remaining in approximately 50 to 60% of patients. Patients who
retained their ABS seemed to have sustained improvement of FI
and quality of life over time (63) but a significant number expe-
rience evacuation difficulties.(58, 61) Michot et al. (58) found a
reduction of the explantation rate from 50% to 20% when com-
paring their early and late experience. The authors related this
improvement to better patient selection and liberal use of divert-
ing colostomy. Parker et al. (63) found no difference in failure
rates over time. A convened “best practice group” of colorectal
surgeons, whose infection rate was 9% and long term functional
device rate 82% have recently introduced a protocol to minimize
infection.(64)
ABS provides good continence in those patients who retain
their device at the expense of significant surgical morbidity and
possible chronic evacuation difficulties. Recent guidelines for
intraoperative prevention of infection may help improve out-
comes by decreasing morbidity.
Dynamic graciloplasty
The concept behind dynamic graciloplasty (DGP) is to create a
sphincter with an autologous striated muscle wrap. The muscle
is then stimulated with a constant low-frequency electric current
by an implantable pulse generator with the goal of inducing the
fast-twitch, readily fatigued (Type II) muscle fibers to change to
slow-twitch, fatigue resistant (Type I) muscle fibers, similar to the
normal external sphincter. A pedicled gracilis flap is harvested on
one side, transposed, wrapped around the anus and anchored
with its distal tendon to the contralateral ischial tuberosity. The
electrode is implanted in the muscle or close to the obturator
nerve and the stimulator is implanted in the lower abdomen,
subcutaneously or beneath the rectus sheath. Increasing levels
of neurostimulation are used to condition the muscle during the
first 2 months. Thereafter, the patient can regulate defecation
with the aid of an external magnet by turning the stimulator off
to relax the muscle allowing emptying of the rectum and turning
the stimulator back on to maintain continence.
Similar to ABS, DGP is reserved as an alternative to colostomy
for patients suffering severe FI unresponsive to simpler treat-
ment. As opposed to the ABS, DPG involves transposition of
healthy tissue and can be applied even to patients with severe loss
of perineal tissue.

 improved outcomes in colon and rectal surgery
A systematic review of the literature through 1999 on DGP by
the Australian Safety and Efficacy Register of New Interventional
Procedures-Surgical found that DGP was effective at restoring
continence in 42 to 85% of patients but was associated with an
average risk of complications of 1.12 per patient and reopera-
tion of 0.14 to 1.07 per patient (65); none of the included studies
provided a high level of evidence. Overall DGP related mortal-
ity was 1% and the most common complications were infection
(28%), hardware dysfunction, or displacement (15%) and leg
pain (13%). The Dynamic Graciloplasty Therapy Study Group
undertook a large international multicenter prospective trial
including 115 eligible patients, 27 of whom had a preexisting
functioning stoma.(66–68) The success rate, defined as 50% or
more reduction in incontinent episodes, was 62% at 12 months
and 56% at 24 months for nonstoma patients and 37.5% and 43%
in patients with preexisting stoma at 12 and 24 months respec-
tively. Significant improvement in quality of life subscales was
noted. One patient died postoperatively and major complications
requiring hospitalization or surgical intervention occurred 89
times in 61 (50%) patients; 90% resolved completely. Rongen et al.
(69) from the Maastricht group reported the largest single center
experience with DGP on 200 consecutive patients with a median
follow-up of 5 years. The success rate (continent to solid and liq-
uid stool) was 72%, ranging from 52% in patients with congenital
FI to 82% in patients with traumatic FI. The success seemed to
persist over time as complications decreased and technical suc-
cess improved. Chronic evacuation problems persisted in 16% of
the patients. The indications for sphincter replacement surgery
either with ABS or DGP are decreasing in favor of SNS (70) given
the significant difference in morbidity. DGP is not available in the
USA as the producer of the stimulator (Medtronic Corporation,
Minneapolis, MN) decided not to pursue FDA approval.
Sacral Nerve Stimulation
Sacral Nerve Stimulation (SNS) is an innovative and rapidly
expanding treatment modality. It has been used for urinary
incontinence since 1981 and was approved by the FDA for that
indication in 1997. The observation that bowel symptoms simul-
taneously improved in many patients led to the first implantation
of a sacral nerve stimulator to treat FI in 1994.(71) In the USA,
a multicenter study completed enrollment of 120 patients in 2006
and the manufacturer (Medtronic Corporation, Minneapolis,
MN) is expected to pursue FDA approval in 2008.
The goal of placing a stimulating electrode into the sacral foramina
was to recruit residual function of the striated pelvic floor and exter-
nal sphincter muscles. Initial selection criteria for SNS stipulated
reduced or absent voluntary sphincter function, intact nerve-muscle
connection and an intact sphincter muscle.(72) It became apparent
that the effect of SNS was not limited to an increase of voluntary
squeeze pressure. Somewhat inconclusive and often contradictory,
studies suggest that SNS may decrease urge thresholds, reduce spon-
taneous rectal motility, reduce spontaneous sphincter relaxation,
and improve anal and perianal skin sensitivity.(72) Sheldon et al.
(73) showed in a crossover study in 10 women with FI that SNS also
affects the central nervous system; they documented a decrease in
corticoanal excitability. More recently, in a cohort of patients with FI
successfully treated with SNS, Gooneratne et al. (74) demonstrated

a normalization of elevated levels of rectal mucosal substance P, a
substance known to play a role in contractility and afferent signaling
in ­visceral sensation.
While the understanding of the physiology of SNS still remains
unclear, patient selection has become more pragmatic. The efficacy
of SNS can be tested on an individual patient temporarily with
minimal consequences and a high predictive value of permanent
therapeutic effect. The screening procedure consists of a percutane-
ous stimulation of the S2–S4 roots on both sides. The testing is done
under local or general anesthesia by insertion of a needle electrode
into the dorsal sacral foramina. The site ­providing the most effective
bellows-like motion of the pelvic floor along with plantar flexion of
the first and second toes (typically S3 root) is selected for tempo-
rary stimulation. Continuous stimulation is applied for a minimum
of 1 week. If the stimulation is well tolerated and successful (50%
or greater reduction in incontinent episodes per week or days with
incontinence per week), a permanent pulse generator is connected
to the electrode and implanted. Surgical replacement of the battery
is necessary after 7–10 years for Interstim I and 5–7 years for the
newer and smaller model Interstim II.
More than 75% of patients tested with temporary stimulation
will have a 50% or more improvement in symptoms, which is
required to justify permanent implantation (Table 22.3). The
therapeutic benefit seems to persist in studies with follow-up
over 2 years.(75–77) SNS has been shown not only to decrease
the frequency of FI but also to improve the ability to postpone
defecation (76), improve sexual activity (78) and quality of life.
(72, 79) A Swiss group performed a cost analysis on a cohort of
36 patients including expenses generated by failures and compli-
cations and found that SNS is more cost efficient than colostomy
or dynamic graciloplasty but obviously more expensive than
­conservative treatment alone.(80)
The indications for SNS have progressively expanded. Accepted
contraindications include conditions where implantation is impos-
sible or too risky (e.g., spina bifida, pilonidal sinus, ­pyoderma
gangrenosum), chronic diarrhea, irritable bowel syndrome, rec-
tal prolapse, mental or physical inability to adhere to treatment,
severe bleeding diathesis, pregnancy, and the presence of cardiac
pacemaker or implantable defibrillator.(81) Earlier contraindica-
tions such as previous rectal surgery, multiple sclerosis, Parkinson’s
disease, and spinal cord injury have been recently challenged.
(82) The most interesting controversial issue is the use of SNS in
patients with FI and sphincter defects as these patients are tra-
ditionally treated with sphincteroplasty. Initial studies did not
include patients with sphincter defects except very minor ones.
Dudding et al. (83) analyzed the 10 year experience with SNS at St.
Mark’s hospital in the UK in an effort to identify predictive factors
of success. Patients with evidence of sphincter trauma had a greater
risk of failure compared to patients with intact sphincters (7/29 vs.
0/16, p=0.04). Conversely, in a retrospective study, Melenhorst et
al. (84) compared a group of women with a functionally failed
but anatomically intact previous sphincter repair to a group of
women with an external sphincter defect of 17–30%. They found
no significant difference in baseline characteristics and a similar
outcome after a 2-year follow-up. In a controlled randomized
study Tjandra et al. compared SNS to optimal medical treatment.
Close to half of patients in the SNS arm had evidence of external
 surgical treatment of fecal incontinence

Table 22.3  Functional results of SNS in large studies.

Temporary Permanent f-up Baseline FI Fully
Study Stimulation Stimulation time Episodes Final FI Continent
Author Year Design (n) (n %) months (n) Episodes (n) (n %)

Matzel (76) 2004 prosp MC 37 34 (92) 24 8.3b 0.75 12 (37)

Jarrett (119) 2004 prosp MC 59 46 (78) 12 7.5b 1 19 (41)
Leroi (120) 2005 RCT MC 34 27 (79) 6–8a 7b 1   5 (26)
DB cross
Melenhorst (77) 2006 observ SC 134 100 (75) 26 31.3c 4.4 nr
Holzer (121) 2007 observ SC 36 29 (81) 35 7c 2 nr
Hetzer (79) 2007 observ SC 44 37 (84) 13 14b 5 nr
Tjandra (85) 2008 RCT MC 60 54 (90) 12° 9.5b 3.1 25 (47)

a. timepoint of evaluation.
b. median number of FI episodes per week.
c. median or mean number of FI episodes per 3 weeks; all differences statistically significant.
prosp MC: prospective multicenter.
observ SC: observational single center.
RCT: randomized controlled trial.
DB cross: double blind cross over.

sphincter defect (120° or less) and more than half had a previous
sphincter repair. Despite that, excellent results were achieved in the
SNS arm as 66% of patients had a 75–100% reduction of inconti-
nent episodes per week. On the contrary, patients in the medical
treatment arm experienced no change in FI severity or FI-related
quality of life scores. In absence of a randomized study that spe-
cifically addresses the question, there is currently no evidence to
support the idea that SNS should replace sphincteroplasty as avail-
able studies are subject to important patient selection bias.
Complications with SNS are rare and include wound problems
(dehiscence, seroma, infection, bleeding), electrode dislodgment
or fracture, pain at the site of the electrode or pulse generator,
excessive tingling in the vaginal region, loss of effect, or deteriora-
tion of bowel symptoms. Complications leading to explantation
of the stimulator occur in approximately 5%.(72, 85)
The role of SNS in the treatment of FI is expected to grow.
Further understanding of the physiology involved may improve
patient selection and stimulation modes. Peripheral nerve stimu-
lation may render the technique simpler and applicable to patients
with sacral abnormalities. Transcutaneous intermittent stimula-
tion of the posterior tibial nerve has been reported to improve
urinary continence and has been tried more recently in FI with
encouraging preliminary results.(86, 87) Direct stimulation of
the pudendal nerve is another field of investigation.
Injectable bulking agents
The goal of injectable bulking agents (IBA) is to restore a normal
contour of the anal canal and add bulk to provide a better seal. IBA
are usually injected under local anesthesia as an office or outpa-
tient procedure; the injections may be into the submucosa or in the
intersphincteric space and in all quadrants of the anal canal or at
the site of a sphincter defect. Injection under ultrasound guidance
in the intersphincteric space yielded better results than digitally
guided injections in a randomized study.(88) Small studies have
reported the use of Polytetrafluoroethylene (Teflon®), autologous
fat, glutaraldehyde cross-linked collagen (Contigen®), textured
silicon particles (Bioplastique®, renamed PTQ implantsTM), and
pyrolytic carbon coated zirconium oxide beads (Durasphere®),
but their true efficacy remains to be determined. The autologous
materials are short lived and adipose tissue injections carry the
risk of fat embolism. Cost as well as migration, ulceration, leak-
age, infection, pain and local, or distal inflammatory reactions
are concerns with the synthetic materials. The two most popular
agents are PTQ implantsTM and Durasphere®; both were shown
to be safe and to attenuate severity of FI in a majority of patients.
(88, 89) Quality of life improvements are less pronounced. Results
after long-term follow-up are mixed and reinjection is necessary
in some patients.(90, 91) An ongoing multicenter randomized
placebo controlled study on Durasphere ® injection will hopefully
help determine the place of IBA in the treatment of FI.(92, 93) The
FDA has not yet approved any IBA for the use in FI.
Antegrade colonic enema
In 1990, Malone described the creation of a continent stoma using
the appendix; this stoma was catheterized to perform ante grade
colonic enemas (ACE) in five patients with intractable FI.(94)
Modifications of the technique for patients in whom the appendix
cannot be used due to previous appendectomy or fibrosis include
construction of the stoma with a cecal flap or an “ileal neo-appen-
dix”. ACE is used frequently in pediatric surgery for children with
severe defecation disorders following anorectal malformations,
spina bifida, sacrococcygeal teratomas and other abnormalities.
Several small studies report its use in adults and even in patients
undergoing abdomino-perineal resection in combination with a
perineal colostomy.(95) Lefevre et al. (96) recently reported 25
adult patients with intractable FI treated with an ACE procedure.
After a median follow-up of 21 months, 22 patients were avail-
able: 4 had stopped performing enemas but 17 reported perfect
cleanliness. They performed enemas once every 2–3 days spend-
ing an average of 40 minutes. Stenosis of the mucocutaneous
junction occurred in 20%; the majority responded to dilatation.
It occurred more often in patients with native appendicostomy


 improved outcomes in colon and rectal surgery
than in those with an ileal neo-appendicostomy. Quality of life
measures showed significant improvement for physical health but
persistent low scores in ­psychological distress (96).(96) Others
have reported similar success and complication rates.(97–99)
As an option before an end colostomy, ACE may be appropriate
in some patients with intractable FI, particularly those in whom
incontinence is ­combined with constipation and who have failed
other therapies.
Postanal repair
Sir Allan Parks developed the postanal repair in the 1970s relying
on the theory that restoration of an obtuse anorectal angle would
improve continence by recreating a flap valve mechanism. The pro-
cedure was designed to treat neurogenic FI in patients with intact
sphincters. Through a V-shaped incision posterior to the anus, the
intersphincteric space is dissected proximal to the puborectalis; each
muscle layer is plicated in the midline. If an anterior levatorplasty
is added, the procedure is called total pelvic floor repair. Browning
and Parks (100) reported good to excellent results in over 80% but
others have failed to reproduce those findings.(101) Orrom et al.
(102) demonstrated that there were no significant changes in the
anorectal angle in patients after postanal repair questioning the
concept of the operation. Results tend to deteriorate over time (103)
which is an additional reason this treatment has fallen out of favor.
Colostomy
The colostomy is traditionally the end-stage treatment of intrac-
table FI. When it becomes an option, the patient has usually failed
several medical and surgical treatments and experienced years
of misery and socially debilitating symptoms. The patient must
accept a body image change and a whole new type of personal
care. Having said that, a colostomy offers undeniable advantages.
The patient can remain clean and be socially active. Perineal skin
irritation is cured. Special diets or transit regulatory medicine can
be stopped. On the other hand, there is a well-known morbidity
related to colostomy including immediate postoperative but also
longer term complications such as peristomal hernia, skin irrita-
tion, and appliance problems.
A systematic review compared DGP to colostomy in terms of
mortality, morbidity, efficacy, and cost-effectiveness.(65) While it
is intuitive that DGP resulted in better continence, mortality was
similar and morbidity favored colostomy. Colostomy was more
expensive than DGP in the long run provided that DGP does not
fail resulting in a late colostomy. There are no good quality stud-
ies comparing the quality of life of a patient with severe FI prior
and after colostomy. A cross-sectional study comparing patients
with rather moderate FI to patients with a well functioning colos-
tomy (the majority secondary to rectal cancer) found no signifi-
cant difference other than better average adjusted social function
scores for ostomates.(104) The two groups however were differ-
ent; patients with FI were younger and more often female, adding
further bias to this study. Data from rectal cancer surgery indi-
cate that an end colostomy after abdominoperineal resection does
not always equate to a lower quality of life than sphincter sparing
surgery.(105) The option of colostomy should be discussed early
enough and adequate counseling should be offered to the patient
to allow a mature decision to be taken.

Conclusion
Fecal incontinence is a common, underreported, devastating
­condition. The pathophysiology is complex and variable; the
­currently available instruments to measure the degree of dys-
function of the different components are often imprecise and not
standardized. The integration of quality of life scores and diary-
based results has substantially improved the reporting of severity
of FI in the literature. The initial step in management of patients
with FI is to diagnose and treat appropriately underlying condi-
tions of “pseudoincontinence” such as hemorrhoids, anal fistula,
mucosal prolapse, rectal prolapse and diarrheal conditions. The
first line treatment for true FI is medical and aims to regulate
bowel frequency and consistency. Biofeedback may provide some
relief to motivated patients. Those patients who fail medical treat-
ment and are physically fit enough for surgery should undergo
pelvic floor testing with sphincter imaging. Sphincteroplasty is
appropriate for patients with significant sphincter defects and
low anal canal pressures. For those who are not candidates for
sphincteroplasty, SNS seems to be the most promising solution.
ABS, DGP, and ACE are second line therapies that should be con-
sidered before end colostomy and may lead to good functional
outcomes especially in experienced centers.
The surgical treatment of FI has evolved significantly over the past
2 decades. Postanal repair and anal encirclement have been practi-
cally abandoned. While sphincteroplasty remains central, indications
for ABS and DGP are decreasing in favor of SNS. New treatment
modalities have been proposed, some were short lived (SECCA pro-
cedure), and others are still under investigation (IBA). Despite the
multitude of treatment options, the end colostomy may still be the
best compromise solution for many severely incontinent patients.
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
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23 Surgery for rectal prolapse
Steven R Hunt
introduction
Rectal prolapse (rectal procidentia) is defined as the full thickness
intussusception of the rectum through the anal canal. The annual
incidence of rectal prolapse is estimated to be 2.5 per 100,000 pop-
ulation.(1) The disorder tends to affect elderly women, psychiat-
ric patients, and patients with neurologic disorders. Presenting
symptoms are usually referable to the prolapse itself. Additional
presenting complaints include constipation, straining, inconti-
nence, and mucous soilage of the undergarments.
Surgery remains the only definitive therapy for rectal prolapse.
Over 100 operations have been described for the treatment of
procidentia. Generally, these procedures can be divided into peri-
toneal and abdominal approaches. The optimal procedure for
each patient should be determined by presenting symptoms and
patient comorbid disease.
Classification
In the strictest sense, rectal prolapse refers only to full thickness,
circumferential protrusion of the rectum beyond the anal canal.
While it is often clinically obvious, several other anorectal disor-
ders can imitate the condition. Circumferential prolapsed internal
hemorrhoids, when large, are frequently diagnosed as prolapse,
and prolapse is often diagnosed as hemorrhoids. Rectal polyps or
cancer can protrude through the anus and mimic ­prolapse. It is
important to differentiate between true procidentia and mucosal
prolapse, as the entities may have similar presenting symptoms.
Patients with mucosal prolapse frequently have a history of prior
anorectal procedures or trauma and the prolapse is often asym-
metric. Solitary rectal ulcers and colitis cystica profunda can
present with symptoms similar to rectal prolapse. These disorders
are associated with internal intussusception of the rectum, but
may coexist in patients with rectal prolapse. Both solitary rectal
ulcer and colitis cystica profunda are hypothesized to result from
repeated mucosal trauma and ischemia at the lead point of the
prolase. Significant rectal bleeding is relatively rare in patients
with procidentia, although it is a common presentation in soli-
tary rectal ulcer syndrome and ­colitis cystica profunda.
Internal rectal intussusception without prolapse may be a pred-
ecessor to rectal prolapse, although this association has not been
proven.(2) Rectal intussusception is frequently identified during
defecography performed to evaluate obstructed defecation or con-
stipation. It is also a common finding in asymptomatic patients.
(3) While it is clear that surgery is the mainstay of treatment for
complete rectal prolapse, the indications for surgical intervention
in cases of internal intussusception are less clear. Some authors
advocate surgical intervention in cases of symptomatic intussus-
ception, while others are more cautious in their approach.(4, 5)
In the author’s section, the initial approach to patients with rectal
intussusception is dietary modification and pelvic floor retrain-
ing through biofeedback. Surgery is generally reserved for patients
with complications of internal prolapse (solitary rectal ulcers and
colitis cystica profunda) who have failed conservative therapy.
Patient Evaluation and Investigations
As rectal prolapse is a benign disease, surgery need only be consid-
ered if the symptoms are debilitating. Frequency of the prolapse
and initiating factors (defecation, straining or standing) should
be documented. The presence of severe constipation or symp-
toms of obstructed defecation should be noted, as these patients
may require further evaluation. Fecal incontinence occurs in
60–80% of patients, and a frank discussion should ensue regard-
ing expected surgical outcomes with regard to continence. Most
large series show improvement in fecal incontinence in >40% of
procidentia patients after surgery, regardless of the approach.(6)
Continence may continue to improve over the first 6 to 12 months
postoperatively.
A detailed surgical history should be obtained, with special
attention to anorectal and pelvic operations, as this may influence
the ultimate surgical approach. In patients with recurrent rectal
prolapse, operative notes from the prior procedures should be
obtained and scrutinized. Female patients may have a history
of bladder or uterine prolapse, requiring consultation with a
urogynecologist and a combined approach. All patients with
prolapse should have a recent colonoscopy to rule out any
mucosal lesions.
Physical Exam
The diagnosis of procidentia is made by demonstration of the
prolapse in the surgeon’s office. Patients with advanced prolapse
may be able to produce the prolapse on the examination table
with minimal straining. If the patient cannot prolapse on the
examination table, they should be examined after straining on the
toilet. Once the prolapse has been achieved, the examiner should
first differentiate between full thickness prolapse and hemorrhoi-
dal or mucosal prolapse. Full thickness prolapse is characterized
by concentric mucosal rings, as opposed to the radially oriented
sulci seen with mucosal and hemorrhoidal prolapse.
The digital rectal exam should exclude other anorectal pathol-
ogy, and the sphincter tone and the squeeze pressure should be
evaluated. Female patients should be evaluated for the presence
of an enterocele or rectocele. Rigid proctoscopy should be per-
formed in the office to rule out any rectal tumors, and to evaluate
for solitary ulcer and colitis cystica profunda.
Generally, a physical exam and demonstration of the com-
plete prolapse in the office is sufficient evaluation before surgery.
Additional studies are sometimes required in certain cases.
Anal Physiology
Patients with chronic severe straining at stool should be evaluated
with anal physiology testing. Electromyography that demonstrates

 improved outcomes in colon and rectal surgery
a nonrelaxing puborectalis should prompt initiation of biofeed-
back therapy as an adjunct to surgery.
Postoperative continence can also be predicted on the basis of a
prolonged pudendal nerve terminal motor latency (PNTML) and
poor resting sphincter tone.(7, 8) We do not routinely obtain physi-
ologic studies in the evaluation of procidentia, as they are expensive
and a prolonged PNTML is not a contraindication for surgery.
Additional Studies
When the patient is unable to reproduce the rectal prolapse in
the office, defecography may be used to evaluate for internal pro-
lapse or other defecatory pathology. In patients with severe con-
stipation and prolapse, a colonic transit study may be obtained.
Concentration of the markers in the left and sigmoid colon on
(A) (B)
(D) (E)

day 5, in the setting of severe constipation, is an indication for a
resection rectopexy.
Operative Repairs
Although the modern operative procedures for rectal prolapse are
not particularly morbid, the patients are frequently elderly, and
morbidity is not trivial. Some series report mortalities as high as
7%. These patients often have significant comorbid conditions, and
the operative approach (perineal, open or laparoscopic) should take
these factors into account. The choice of procedure is frequently
­dictated by surgeon preference and experience; however, a one-­
size-fits-all approach may not be suitable for all patients.
In addition to the morbidity of the procedure, the evaluation of the
various surgical approaches to rectal prolapse must take efficacy and
(C)
Figure 23.1   Perineal rectosigmoidectomy. (A & B) Incision of rectal wall. (C)
Division of vessel adjacent to bowel wall. (D) Mesenteric vessels ligated. Stay
sutures previously placed in distal edge of outer cylinder are placed in cut edge of
inner cylinder. (E) Anastomosis of distal aspect of remaining colon to the short
rectal stump. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception.
In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker: New
York, 2003; 301–24. With permission.)
 surgery for rectal prolapse
(A) (B)
(D)
(E)
functional outcomes into account. Some techniques have excellent
results in terms of recurrence, but can predispose the patients to con-
stipation or evacuatory difficulties, trading one problem for another.
Perineal Repairs
The preponderance of the historical literature suggests that the
abdominal approach to rectal prolapse is superior to the perineal
approach in terms of recurrence rates. While most single institu-
tion studies report better outcomes for abdominal procedures,
this difference is not demonstrated in meta-analysis.(9, 10)
The major advantage of the perineal approach is the ability to con-
duct the operation under spinal or even local, anesthetic. The avoid-
ance of general anesthesia and an abdominal dissection makes this
the preferred approach for patients with significant comorbidities.
Perineal Proctosigmoidectomy (Altmeier Procedure)
The technique of perineal proctosigmoidectomy involves mobiliza-
tion and resection of the prolapsed rectosigmoid colon via a perineal
(C) (D)
Figure 23.2  Delorme’s procedure. (A) Subcutaneous infiltration of dilute epi­
nephrine solution. (B) Circumferential mucosal incision. (C) Dissection of
mucosa off muscular layer. (D) Plicating stitch approximating cut edge of mucosa,
muscular wall, and mucosa just proximal to dentate line. (E) Plicating stitch tied.
(F) Completed anastomosis. (From Beck DE, Whitlow CB. Rectal prolapse and
intussusception. In Beck DE. Handbook of colorectal surgery. 2nd edition. Marcel
Dekker: New York, 2003, 301–24. With permission.)
approach. Patients should have a complete mechanical bowel prepa-
ration. The prone-jackknife or left lateral position is preferred over
lithotomy, as it allows easy access to the operative field for the sur-
geon and assistant. While general anesthetic provides more comfort
for the patient, it is often necessary to use local or spinal anesthesia
in frail patients. The buttocks should be taped apart and a Lonestar
retractor is used to efface the anus and provide optimal exposure.
The procedure is begun by recreating the prolapse. Once the bowel
has been completely prolapsed, a circumferential incision is made
in the rectum approximately 1.5–2 cm proximal to the dentate line.
Using the electrocautery, this incision should be continued until the
full thickness of the rectal wall has been incised circumferentially.
The incised rectum is then everted and pulled downward. The
vaginal wall is frequently adherent to the prolapsed segment and
should be dissected away from the rectum to avoid the devastating
complication of a postoperative colovaginal fistula. The peritoneal
cavity is then entered by incising the peritoneum of the Pouch of
Douglas anteriorly. Entrance into the peritoneal ­cavity facilitates

 improved outcomes in colon and rectal surgery
(A) (B)
Figure 23.3  Anal encirclement (Thiersch). (A) Lateral incisions with prosthetic mesh tunneled around the anus. (B) Mesh completely encircling the anal opening.
(C) Completed anal encirclement procedure. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal surgery.
2nd edition. Marcel Dekker: New York, 2003, 301–24. With permission.)
delivery of the prolapsed rectum and division of the mesorectum.
The mesorectum is then divided and ligated with ligatures, or
alternatively, a vessel sealing device may be used. Division of the
mesorectum should be continued, advancing proximally on the
bowel until tension is encountered (Figure 23.1).
Once the redundant rectosigmoid has been mobilized, the ante-
rior peritoneum should be repaired, including seromuscular bites of
the anterior bowel wall, with a running absorbable suture to oblit-
erate the pouch. A levatorplasty should be considered if a defect is
present in the pelvic floor. If the levator muscles can be identified
without extensive dissection, plication should be performed ante-
riorly and posteriorly. The redundant bowel is then divided and a
hand-sewn anastomosis is fashioned using interrupted absorbable
sutures. Alternatively, the anastomosis may be created using a cir-
cular stapler with acceptable results.(11, 12)
Generally, patients have minimal narcotic requirements post­
operatively and ileus is exceedingly rare. Patients should be
ambu­lated and their diet is advanced on postoperative day 1.
Constipating regimens have no proven beneficial results. It is the
author’s practice to discharge patients after the first bowel move-
ment, but in some centers, the Altmeier procedure is performed
on an outpatient basis.(11)
In experienced hands, the Altmeier procedure has excellent
results, rivaling the abdominal procedures for recurrence rates.
Several recent large series report recurrence rates ranging from
6% to 16%.(7, 9, 11) Both incontinence and constipation are also
significantly improved after perineal proctectomy.(7, 9, 13) Some
authors describe significant improvement in recurrence rates if a
levatorplasty is performed.(14)
Fortunately, major morbidity and mortality for this procedure are
rare. The anastomotic leak rates are reportedly 1–2%, with signifi-
cant bleeding occurring in a similar percentage of patients.(7, 9, 14)

(C)
Delorme’s Procedure
Delorme’s procedure offers another alternative to the Altmeier
repair. The technique involves a submucosal resection of the
­prolapsed rectum, with plication of the muscularis propria. The
submucosal nature of the dissection in this procedure does not
allow for a concomitant levatorplasty.
As with the Altmeier procedure, mechanical bowel preparation
should be performed and the procedure conducted in the prone-
jackknife or left lateral position with effacement of the anus. Again,
local or spinal anesthesia may be used for infirm patients. The rectal
prolapse is delivered, and the submucosal plane is infiltrated with local
anesthetic containing epinephrine. A circumferential mucosal incision
is made 1 cm proximal to the dentate line. The submucosal plane
is identified and downward traction is applied to the mucosal tube.
Dissection is carried out within this plane to the apex of the prolapsed
segment of rectum. At this point, the exposed muscularis propria is
plicated with multiple bites in four quadrants using an absorbable
monofilament or braided suture. The redundant mucosa is then
excised and the plication sutures are tied. The mucosal edges are then
reapproximated using interrupted absorbable sutures (Figure 23.2).
The recurrence rate in most recent large series ranges from
13–27%.(15–17) The morbidity and mortality rates are similar
to those of the Altmeier repair. Improvement is reported in both
continence and constipation in most series where these func-
tional outcomes were evaluated.(16–18)
Given the uniformly inferior results of Delorme’s procedure
relative to the Altmeier repair, it is the author’s feeling that this
approach should not be used as a first-line perineal procedure.
Many advocate this procedure for the treatment of mucosal
prolapse; however, other, less involved techniques exist for this
disorder. Elastic rubber band ligation is frequently adequate for
modest mucosal prolapse. The circular stapler technique used in
 surgery for rectal prolapse

(A) (B)

(C) (D)

Figure 23.4  Mesh rectopexy (Ripstein). (A) Posterior fixation of sling on one side. (B) Sling brought anteriorly around mobilized rectum. (C) Sling fixed posteriorly on
the opposite side. (D) Sagittal view of the completed rectopexy. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck DE. Handbook of colorectal
surgery. 2nd edition. Marcel Dekker: New York, 2003, 301–24. With permission.)

the treatment of hemorrhoids is a second appealing option for
more advanced mucosal prolapse.
Anal Encirclement (Thiersch Repair)
Anal encirclement has almost reached the status of historical inter-
est, as it has been replaced by other procedures with more favora-
ble results. The procedure can be performed in a short period of
time with only local anesthetic. The original repair described by
Thiersch used a silver wire to encircle the anal sphincter complex.
The wire encirclement has fallen out of favor as the wire can break
or erode through the sphincters and anoderm. Marlex or Mersilene
mesh are the preferred alternative to wire, as they are softer and less
prone to breakage or erosion.
The operation can be performed in the prone-jackknife or
lithotomy position. After meticulous antiseptic preparation,
small posterior and anterior incisions are made 1 cm outside
the anal verge. A curved clamp is then tunneled through the
ischiorectal fossa from the anterior incision to the posterior


 improved outcomes in colon and rectal surgery
incision and one end of the mesh is then pulled through the
tunnel. This is duplicated on the opposite side and the other end
of the mesh is delivered. The redundant mesh is pulled through
and the prosthetic is tightened around an 18F Hegar dilator.
The mesh is then overlapped anteriorly and sewn to itself with
a nonabsorbable suture. The small incisions are then closed
with absorbable subcuticular sutures and the wounds are sealed
with Dermabond, to prevent subsequent soilage of the wounds
(Figure 23.3).
Anal encirclement procedures do not repair the prolapse, but
merely prevent external prolapse. Infectious complications are
common with the synthetic mesh, occurring in up to 33% of
patients.(19) Postoperatively, these patients frequently ­experience
­tenesmus and difficulty with evacuation.(20) This procedure
should be reserved for patients who have significant contraindi-
cations to more formal repairs. One relative indication for this
repair is the patient with ­significant hepatic ascites (not amenable
to ­transjugular intrahepatic portosystemic shunt) and debilitating
rectal prolapse.
Open Abdominal Repairs
A prerequisite to the open approach is the patient’s ability to toler-
ate a general anesthetic and laparotomy. A variety of abdominal
repairs are described in the literature, but only a few have withstood
the test of time. The common theme among these time-tested pro-
cedures is complete rectal mobilization and fixation of the rectum
to the sacrum. It is suggested that the fibrosis resulting from the
rectal mobilization is responsible for the long term fixation of the
rectum and avoidance of recurrence.(21)
All of the large series involving abdominal procedures show
improvement in fecal continence. The same cannot be said for
constipation, as rectopexy alone tends to worsen constipation. In
cases of severe constipation preoperatively, a sigmoidectomy may
be combined with rectal fixation.
The repairs discussed below all involve complete rectal mobili-
zation. In all cases, the rectal mobilization should be carried out
in the avascular plane outside the mesorectal fascia. The perito-
neum at the sacral promontory is incised and the plane posterior
to the superior rectal artery is identified. Great care should be
taken to prevent injury to the hypogastric plexus and the ureters
should be identified and avoided. When rectal fixation sutures
are placed, the position of the ureters should be reconfirmed
to prevent inclusion in the suture. These approaches are not
immune to the usual pitfalls of open laparotomy, with compli-
cations including small bowel obstruction, prolonged ileus, and
wound complications.
There is some controversy regarding the extent of rectal mobi-
lization. While some authors advocate division of the lateral rectal
ligaments to improve recurrence rates, there are some reports of
worsening constipation if the lateral ligaments are divided.(22) In
a small randomized prospective study comparing rectal mobiliza-
tion with and without division of the lateral ligaments, Mollen et
al. reported no difference between the two groups with regard to
constipation scores or to total colonic transit time. Anterior rec-
tal mobilization is recommended with all of these procedures, but
this is generally a minimal dissection as these patients tend to have
a deep Pouch of Douglas.

Mesh Sling Repair (Ripstein Procedure)
The Ripstein procedure involves the posterior mobilization of the
rectum down to the pelvic floor followed by fixation of the rec-
tum to the sacrum using a mesh sling. Before the advent of the
laparoscopic approach, this procedure was one of the most com-
monly employed abdominal techniques for rectal prolapse.
Patients should undergo a complete mechanical bowel prepa-
ration and the operation is performed in the lithotomy position.
A complete rectal mobilization is carried down to the pelvic floor.
A 3–4 cm wide piece of PTFE or polypropylene mesh is then fixed
to the sacrum approximately 1 cm to the right of the midline
using several nonabsorbable sutures. Traction is then applied to
the rectum in a cephalad direction and the mesh is fixed at mul-
tiple points to the anterior rectum by seromuscular bites of non-
absorbable suture. The mesh is then secured to the left side of the
sacrum approximately 1 cm off the midline, taking care to ensure
that the mesh does not constrict the rectum (Figure 23.4).
The results of the Ripstein repair are excellent in terms of
recurrence, with recurrence rates of 0–7% reported in large
recent series.(6, 23, 24) In spite of these enviable results, enthu-
siasm for this procedure has waned because of reports of mesh
erosion into the rectum, late colovaginal fistulas, stenosis, and
significant constipation following the procedure.(23) In light of
these complications and the success of other alternative therapies,
the Ripstein procedure’s role in the modern treatment of rectal
prolapse should be limited.
Posterior Mesh Fixation (Wells Operation)
The technique of the Wells operation is similar to that of the
Ripstein procedure, except the mesh fixation to the sacral promon-
tory is posterior. Theoretically, this posterior mesh orientation may
reduce the problems typically associated with the anterior sling.
The procedure was originally described using an Ivalon (polyvi-
nyl alcohol) sponge. In the US, experience with the Ivalon sponge
is limited, as it has not been approved for implantation. Instead,
many centers perform the procedure using polypropylene mesh.
Full mechanical bowel prep is performed and the patient is posi-
tioned in lithotomy position. The rectum is mobilized down to the
pelvic floor. Retracting the rectum anteriorly, a 5 × 8 cm piece of
mesh is then anchored to the sacrum in the midline using non-
absorbable suture. The rectum is then retracted cephalad and the
redundancy is eliminated. With the rectum under traction, the mesh
is sutured bilaterally to the lateral rectal mesentery. The mesh wrap
forms a trough around the dorsal half of the rectum and does not
cover the anterior rectal wall. The peritoneum is then closed over
the mesh to exclude it from the abdominal cavity (Figure 23.5).
With regard to recurrence, the Wells operation has exceptional
results with recurrence rates generally between 0–5% for most large
open series.(25–27) While there are fewer reported mesh compli-
cations, these series uniformly show a worsening of constipation
after the procedure.(25–28)
Suture Rectopexy
Before the laparoscopic era, suture rectopexy alone was not a
common procedure. This technique involves rectal mobilization
followed by suture fixation to the sacral promontory. Its appeal
lies in the fact that no foreign bodies are used, thus negating
 surgery for rectal prolapse
(A)
(C)
the complications of mesh infection and erosion. A prospective
randomized trial comparing open suture rectopexy to the Wells
operation found no difference in the two procedures in terms of
recurrence.(25) This procedure will be described in more detail
under laparoscopy, as it has evolved primarily as a laparoscopic
technique.
Resection Rectopexy (Frykman-Goldberg Procedure)
Constipation clearly worsens after rectopexy alone. Many authors
advocate sigmoid colectomy with rectopexy to alleviate postoper-
ative constipation. This technique, termed the Frykman-Goldberg
procedure, involves full rectal mobilization, sigmoid colectomy
(B)
Figure 23.5  Ivalalon (polyvinyl alcohol) sponge rectopexy (Wells). (A) Polyvinyl
sponge being fixed to the sacrum. (B) Sponge in place before fixation to the rectum.
(C) Incomplete encirclement of the rectum anteriorly with the sponge sutured in
place. (From Beck DE, Whitlow CB. Rectal prolapse and intussusception. In Beck
DE. Handbook of colorectal surgery. 2nd edition. Marcel Dekker:New York, 2003,
p301–324. With permission.)
with colorectal anastomosis, and suture fixation of the rectum to
the sacrum.
Patients require a complete mechanical bowel preparation and
are positioned in lithotomy. The rectum is completely mobilized
to the pelvic floor posteriorly. The lateral stalks are left intact. The
rectum is then retracted into the abdomen and the posterolateral
mesorectum is fixed to the presacral fascia using nonabsorbable
sutures. The sigmoid colon and upper rectum are then resected.
Mobilization of the splenic flexure is usually not required as the
redundant sigmoid colon allows for resection and subsequent
anastomosis without tension. The anastomosis is created with cir-
cular stapler. The original description of this procedure involved

 improved outcomes in colon and rectal surgery
fixation of the anterior rectum to the endopelvic fascia to eliminate
the cul-de-sac. Most modern proponents of this operation have
abandoned these anterior sutures as they have no proven benefit
and can be difficult to place safely.
The resection rectopexy has superior results with respect to
both recurrence and constipation. Most large series report recur-
rence rates in the low single digits.(9, 29–31) Morbidity rates range
from 0 to 35% and mortality from this procedure is low.(9, 29)
This remains the only commonly employed abdominal procedure
with significant improvement in postoperative constipation. One
relative contraindication to resection rectopexy is severe inconti-
nence with compromise of the anal sphincter, as sigmoidectomy
can worsen incontinence in this patient population.
The addition of a sigmoid resection confers a significantly
increased risk of anastomotic complications when compared to
rectopexy alone. Careful adherence to the usual tenets of a safe
colorectal anastomosis (a good proximal and distal blood supply,
a tension-free anastomosis, and air testing of the anastomosis)
should allow safe practice of this procedure.
Laparoscopy
Over the past decade, the laparoscopic approach to colorectal
diseases has become pervasive. The literature has been flooded
with series reporting the successful treatment of rectal prolapse
through minimally invasive techniques. Rectal prolapse lends
itself extraordinarily well to the laparoscopic approach, as the
procedure is isolated to one sector of the abdomen, and there is
frequently no specimen removal or anastomosis required, avoid-
ing a conventional incision altogether. Recent reports compar-
ing open to laparoscopic treatment of rectal prolapse find that
there are significant patient benefits to laparoscopy, including
decreased pain, quicker resumption of diet, earlier return of
bowel function, shorter length of stay, reduced hernia rates, and
a lower incidence of small bowel obstruction.(32–34) Mortality
rates for the laparoscopic approach are low. All of the open pro-
cedures discussed previously can be performed laparoscopically,
however the Ripstein procedure has proven tedious to complete
laparoscopically and is seldom performed.
In general, these laparoscopic procedures require a steep
Trendelenburg position to keep the small bowel and sigmoid
colon out of the pelvis. The mesorectum is frequently elongated
and thin in these patients. The mesorectal peritoneum is scored
at the sacral promontory and the plane behind the superior rec-
tal artery is identified with the aid of pneumoperitoneum. The
hypogastric nerves should be spared and the ureters identified.
The initial mesorectal mobilization should be posterior in the
avascular plane. As with the open approach, division of the lateral
ligaments is controversial. The author performs a circumferential
mobilization to the pelvic floor, including division of the lateral
ligaments. The editors prefer to leave the lateral ligaments intact.
The Wells repair has proven more amenable to the laparoscopic
approach than the Ripstein procedure. The laparoscopic technique
is similar to the open technique. Three or four laparoscopic ports
are required and the procedure is most easily accomplished with
a 30° camera, to allow for visualization deep in the pelvis. This
approach requires skill in laparoscopic sewing and knot tying. As
with the open Wells procedure, the recurrence rate is excellent,

with recurrence rates ranging from 0 to 4% in recent series.(35–37)
Functional outcomes were also analogous to the open procedure
in these series, with improvement in continence, but worsening of
constipation. Morbidity and mortality are low.
Laparoscopists, forever testing the premise that less is more, have
trended toward more suture repairs without mesh. The laparoscopic
suture rectopexy is more manageable, as it does not require challeng-
ing manipulations of mesh and involves less suturing. Again, three to
four ports are required and a 30° camera is recommended. After the
rectum is mobilized, it should be pulled in a cephalad direction and
the lateral stalks are sutured to the sacral promontory using nonab-
sorbable sutures. One suture on each side of the rectum is generally
sufficient. Patient’s diets may be advanced rapidly and they should be
ambulated early after surgery. It has been our practice to discharge
patients after their first bowel movement, however many centers per-
form this procedure with only a short postoperative stay.
The laparoscopic suture rectopexy has been proven effective in
several recently published series, with recurrence rates from 0%to
6%.(38–40) Continence is improved postoperatively, but the
benefit of this simple technique may be found in improvement
in postoperative constipation.(38, 40, 41) These series provide
hope that the suture rectopexy alone, without mesh, may rival the
mesh repair in efficacy, without the long term complication of
constipation. This may obviate the need for a concomitant resec-
tion, and thus decrease the difficulty and morbidity of the repair.
Some centers still favor laparoscopic resection rectopexy as the
primary procedure for rectal prolapse. As with the open tech-
nique, splenic flexure mobilization is usually not required. The
addition of sigmoidectomy increases the operative time relative
to suture rectopexy alone by nearly 100 minutes.(41, 42) Results,
as with the open technique, are excellent, with recurrence rates
from 0% to 2.5%.(4, 43) Both constipation and incontinence are
improved postoperatively.
No comparative studies between open and laparoscopic techniques
have proven a significant reduction in morbidity or mortality for
the laparoscopic approach, but trends seem to favor the laparo-
scopic approach.(34, 44) What is clear from the literature is that
the minimally invasive approach to rectal prolapse is not inferior.
The clear benefits of the laparoscopic approach in terms of cost,
length of stay, and decreased pain mandate consideration of this
approach when it is feasible.
Recurrent Prolapse
Recurrent rectal prolapse occurs with every procedure, and the sur-
gical approach to repair of the recurrence requires consideration
of the initial procedure. The mean time to recurrence is between
18 and 24 months. Patients who have recurred require physiologic
testing and defecography to evaluate for anismus. If anismus is
identified, these patients should be referred for biofeedback before
any surgical therapy.
There is no clear algorithm for management of recurrent pro-
lapse. Some authors advocate for a change in approach, performing
perineal procedures if the initial approach was abdominal, and vice
versa. Others promote the use of the same approach for repair of
the recurrence. No definitive published data exists on the proper
selection of the second procedure. The only absolute principle in
the treatment of recurrent prolapse is that if a resection is planned,
 surgery for rectal prolapse
any prior anastomoses must be resected in order to avoid an inter-
vening ischemic segment. Again, comorbid disease should play a
role in the selection of the procedure. Patients unfit for general
anesthetic should be offered a perineal approach if at all possible.
The few published series on the treatment of recurrent prolapse
offer little to no insight on the best approach. A series from the
University of Minnesota suggests that the abdominal approach is
superior to the perineal approach in terms of rerecurrence.(45) The
Cleveland Clinic Florida has published one of the larger series on
treatment of recurrent prolapse. Various surgical approaches were
used and it is not clear how the procedures are selected. Compared
to primary operations for rectal prolapse, there was no difference
in terms of recurrence, morbidity, and bowel function.(46)
A difficult situation arises in the patient who has had a prior
abdominal resection rectopexy, but is now unfit for general anes-
thetic. Before undertaking a perineal proctectomy in such a patient,
the surgeon must be sure he can mobilize and resect the prior anas-
tomosis. If not, the surgeon is left with three less than desirable
options. The patient may be counseled that an operation is not in
their best interest. A Delorme procedure may be performed, or the
patient may be offered anal encirclement.
Conclusion
While many procedures exist for rectal prolapse, only a few offer
acceptable results in terms of recurrence, postoperative bowel
function, and morbidity. Of the perineal techniques, the Altmeier
procedure appears to offer superior outcomes in terms of these
principles. All of the described open abdominal approaches have
satisfactory recurrence rates, but only the resection rectopexy shows
improvement in postoperative bowel function. Laparoscopy, with
all of its inherent advantages, may be the preferred approach. Of
these procedures, the laparoscopic suture rectopexy appears to
offer the best hope of achieving favored status, given the relative
simplicity of the procedure and its exceptional outcomes with
minimal morbidity.
The surgeon who treats this disease should possess the flexibility
and breadth of skills to tailor the procedure to the individual patient.
Surgeon preference and experience should play a role in the choice of
procedure, but should not justify a single procedure for a complex dis-
ease. An algorithm used in our section is to offer laparoscopic suture
rectopexy as the default technique. If a patient has severe constipa-
tion, a laparoscopic resection rectopexy is ­performed. The patient
with a hostile abdomen or the patient who is too infirm to undergo
an abdominal procedure is offered a perineal proctosigmoidectomy.
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24 Operative and nonoperative therapy for diverticular disease
R Scott Nelson and Alan G Thorson
Unlike other diseases in this text diverticular disease is a common
problem with multiple presentations.
Challenging Case #1
A 52-year-old male presents to the Emergency Department
with complaints of left lower quadrant (LLQ) abdominal pain
for the last 16 hours. The patient describes the pain as esca-
lating in nature, unrelieved with a bowel movement. History is
unremarkable except for hypertension, which is treated with a
beta-blocker. The patient denies any similar symptoms previ-
ously. Abdominal exam reveals a mildly distended abdomen,
with tenderness to the left lower quadrant, but no guarding or
rigidity. A basic metabolic profile is normal and complete blood
count reveals a leukocytosis at 14,000. CT scan of the abdomen
and pelvis with oral and rectal contrast demonstrates thicken-
ing of the sigmoid colon with mesenteric thickening but no
identifiable abscess or perforation.
CASE MANAGEMENT
In a 52-year-old male patient with the aforementioned findings, a
clinical and radiographic diagnosis of acute uncomplicated diver-
ticulitis is confirmed. Treatment should consist of broad spectrum
antibiotics, typically, Ciprofloxacin and Flagyl, IV fluids, and bowel
rest. Admission to the hospital is based on physical examination,
comorbidities, and CT findings. Treatment should be continued
until the patient’s pain has resolved or symptomatic improvement
is noted, and then oral intake may resume. Antibiotics are typically
continued for 7–10 days following resolution of pain.
CHALLENGING CASE #2
A 67-year-old female presents to the ED with a two day history
of escalating LLQ pain and evidence of diverticulosis on colonos-
copy 10 years ago. Physical exam reveals a tender LLQ without
peritoneal signs, and fullness to palpation. WBC count is elevated
at 17,000 and a CT scan shows a thickened inflamed sigmoid
colon with a 3 cm abscess on the medial aspect of the colon.
Case #2 Management
Any patient diagnosed with a diverticular abscess, elevated WBC
count, and pain, should be admitted to the hospital and started on
intravenous fluids and antibiotics. The risk of requiring an emer-
gent operation secondary to failure of conservative management is
0–30%. Patients with an abscess >2–3 cm should also be evaluated
for percutaneous drainage. Following these measures the patient
should be followed to assess clinical improvement. Resolution
based on physical exam and bowel activity can dictate further
conservative treatment. Elective surgery should be scheduled in
the near future based on the patient’s overall health and ability to
undergo an operation. Failure of conservative therapy deems that
an operation be completed during that hospitalization.
CHALLENGING CASE # 3
65-year-old male admitted for acute uncomplicated diverticu-
lar disease is started on antibiotic therapy. After 3 days of I.V.
antibiotic therapy and IV fluid the patient’s pain resolves. He is
switched over to oral antibiotics and started on a low residue diet.
The patient describes the same pain, increasing in the LLQ over
the next 24 hours. He is once again made NPO and I.V. antibiot-
ics are restarted. This time, attempts to switch the patient to oral
antibiotics are successful and he is discharged home. However 10
days later he returns with LLQ pain again and CT scan continues
to show uncomplicated diverticulitis. He is restarted on oral anti-
biotics and his pain resolves.
Case #3 Management
Chronic diverticulitis should be treated with an operation. There
are not many studies in the literature dedicated to just chronic
diverticular disease; however, it is a subject that probably does
not need such study. Patients with pain that is clearly attribut-
able to a surgical disease and that persists despite maximal medi-
cal therapy are candidates for an operation and should have the
problem dealt with.
CHALLENGING CASE #4
A 72-year-old female presents to her primary care physician for
the 4th time in 6 months with a urinary tract infection (UTI). The
patient has no known history of abdominal pain, and no previous
history of frequent UTI, and now has noticed pneumaturia. The
culture shows multiple organisms, including E. Coli. The last pre-
vious colonoscopy 2 years ago demonstrated diverticula, but was
otherwise normal. Abdominal exam reveals no abnormal find-
ings. What would be the best way to proceed in the diagnosis and
treatment of this individual?
Case #4 Management
This patient should undergo confirmatory testing and CT scan. If
the diagnosis is unsuccessful with barium enema, cystoscopy can
also be attempted. If the patient is a candidate for surgery and the
suspicion remains without confirmation, operative treatment is
indicated. Laparoscopic resection has been shown to be possible
in these types of cases as well.
CHALLENGING CASE #5
A 34-year-old female 2 weeks after a renal transplant for poly-
cystic kidney disease complains of anorexia and vague abdomi-
nal tenderness, more on the left side. Bowel movements which
had been normal have now stopped over the last three days.
A palpable kidney in the LLQ is not overly tender, and renal
function does not seem abnormal for the time since opera-
tion. No changes have been made in her immunosuppressive
medication.
249
 improved outcomes in colon and rectal surgery
Case #5 Management
Prophylactic colectomy for diverticulosis is not recommended
before transplant. However, the incidence of diverticulitis follow-
ing transplant is higher than the general population, though still
relatively rare in the transplant population overall. Additionally
patients receiving immunosuppressive therapy are at a higher
risk for complicated diverticulitis and, more importantly, delay
in diagnosis significantly increases their morbidity and mortal-
ity. Patients with polycystic kidney disease also show higher rates
of diverticulosis and diverticulitis as opposed to other popula-
tions. These patients require aggressive diagnostic evaluation
with CT scan and if diverticulitis is confirmed, aggressive surgical
management.
Incidence of diverticulosis and diverticulitis
It is estimated that nearly 30% of the U.S. population will have evi-
dence of diverticulosis by age 60. That number increases to 60%
by the time an individual reaches 80 years of age. (1) However,
of these patients, only 10–25% will develop symptomatic diver-
ticulitis and of those who become symptomatic only 10–20%
of individuals will require hospitalization. Of patients who are
hospitalized with symptomatic disease, 20–50% will require an
operation. (2) Overall, <1% of patients with diverticula will ulti-
mately require surgical management. In recent years there has
been a shift in the treatment of patients with diverticulitis as
more are treated as outpatients with oral antibiotics than with
hospitalization. (2) Left sided diverticula predominant among
the more western countries including the United States, Canada,
United Kingdom, Europe and Brazil. While left-sided disease is
still more common, right-sided disease is associated more with
eastern countries such as Japan, China, Korea, and Singapore.(3)
The male to female ratio appears to be about equal.
Classification
In order to determine how best to treat patients presenting with
diverticular disease, classification of the severity of the disease
is necessary. Diagnostic modalities have changed substantially
within the last 40 years and along with it our paradigms of treat-
ment. Park, in the late 60s and early 70s along with fellow con-
temporaries including Larson, and Haglund (4–6) attempted to
evaluate the natural history of diverticulitis in order to classify the
severity of disease. Many of the guidelines and recommendations
by various societies for the treatment of diverticulitis are based
on this original work. However, their diagnosis of the disease was
based on barium enema, physical examination, and pathology
reports. While all three methods are sufficient to make a diagno-
sis, the improved sensitivity and specificity of newer technology
has changed the way we diagnosis, classify and treat this disease
today. In recent years, criteria for the classification of diverticulitis
has changed from findings on barium enema, history and physi-
cal examination and colonoscopy to findings based on computed
tomography (CT) scanning. These scans now provide practical
and predictive information that assist in the classification and
severity of the disease process. A number of useful classification
systems have been developed to assist the physician in deciding
on a course of treatment.(1, 7, 8) These classification systems can
be based on CT scans findings (Table 24.1 and Figures 24.1, 24.2

Table 24.1  Ambrosetti classification of diverticulitis based on CT
findings.
Ambrosetti CT Classifications
Uncomplicated—colonic wall thickening, pericolic fat stranding, inflammatory
changes
Complicated—Extracolonic air, abscess, perforation
Table 24.2  Intra-operative classification.
Hinchey Classifications
Type I—Diverticulitis with no or local peritonitis
Type II—Diverticulitis with a small pericolic abscess
Type III—Diverticulitis with local purulent or fecal peritonitis
Type IV—Diverticulitis with diffuse purulent or fecal peritonitis
Table 24.3  Definitions of diverticular disease.
Diverticulitis Defined:
I. Diverticulosis
   1. Asymptomatic
II. Diverticulitis
   1. Noninflammatory
     A. Symptoms without inflammation
   2. Acute
     A. Complicated
     Perforation, Abscess, Phlegmon, Fistula, Bleeding
     B. Uncomplicated (Simple)
     Localized, thickening, fat stranding
   3. Chronic
     A. Recurring or persistent disease
     Symptoms with systemic signs (may be intermittent)
     B. Atypical
     Symptoms without systemic signs
   4. Complex
     A. Fistula, Stricture, Obstruction
   5. Malignant
     A. Severe, fibrosing
and 24.3), intraoperative findings (Table 24.2), or a more global
view of the disease (Table 24.3).
Ambrosetti has done extensive work on CT findings of diver-
ticular disease and developed a classification system based on the
appearance of the inflamed colon. (7) His work is simple and
divides patients into two groups; uncomplicated or complicated.
(Table 24.1) Other studies have looked at the size of the abscess
and amount of mesenteric air to determine if those are predictors
of failure of nonoperative therapy.(8)
Another useful method of evaluating diverticulitis was reported
in 1978 by Hinchey. This is based on findings at the time of sur-
gery and the decision for determining the correct surgical inter-
vention was based on this classification system.(9) This simple
formula divided the intraoperative findings into four categories
based on the amount and type of peritonitis. (Table 24.2)
However not all diverticular disease can be classified by CT
scan or at the time of an operation. In a recent description of the
 operative and nonoperative therapy for diverticular disease
disease, Thorson and Goldberg described the disease based on
the type of presentation, timing and duration of the disease, and
complexity.(10) (Table 24.3)
Acute Uncomplicated Diverticulitis
Nonoperative Treatment
Multiple reports have cited the successful treatment of uncom-
plicated diverticulitis in all patients, regardless of age.(11–16)
However, the treatment can be quite variable as cited in a recent
survey among members of the American Society of Colon and
Rectal Surgeons (ASCRS). (12) This survey found that the treat-
ment of patients with uncomplicated diverticulitis varied widely
between type and number of antibiotics used, feeding sched-
ule, and admission to the hospital. Further study into the nat-
ural history of the disease, with respect to both the short- and
long-term outcomes of patients with uncomplicated diverticu-
litis, is overwhelmingly in favor of conservative treatment with-
out operation. (13, 15–18) It is estimated that with conservative
treatment 70–100% of patients will improve. Patients are even
being treated as outpatients with oral antibiotics, sports drinks,
and frequent follow-up in an effort to limit cost related to
uncomplicated disease. (19)
Outcome Measures
Economic and morbidity models have been developed to evalu-
ate the cost and risk/benefit ratio of early versus late operation for
patients with uncomplicated diverticulitis. These studies deter-
mined that waiting, until after the 3rd or even 4th attack of docu-
mented diverticulitis, was both cost effective and less morbid on a
population based model, than performing an early elective oper-
ation. (9, 20) Traditional teaching about diverticulitis suggested
that patients suffering more than two episodes of uncomplicated
diverticulitis should undergo an elective operation. In fact, most
of the consensus data on elective resection after two documented
episodes comes from literature that was published before the use
of CT scanning and modern day antibiotic therapy. Because of
these and other studies, the American Society of Colon and Rectal
Surgeons (ASCRS) has revised its previous recommendations of
resection. The 2006 revised practice parameters now read, “The
decision to recommend surgery should be influenced by the age
and medical condition of the patient, the frequency and sever-
ity of the attacks, and whether there are persistent symptoms
after the acute episode.” (1) These new recommendations have
changed the traditional perspective taken on this disease process
and forces those involved in the care of patients with this disease
to reevaluate the literature and possibly modify their practice.
Thus today, surgeons must individualize the recommendation
for operation for each patient. One must take into account the
patient’s history, physical exam and diagnostic radiographic find-
ings, response to medical therapy and other comorbidities before
making recommendations for an operation.
Progression of Disease
One of the most feared complications of diverticular disease is
the need for an emergent operation with possible fecal diver-
sion. The increased morbidity and mortality to patients is not
insignificant when an emergent operation is required. However,
the need for emergent fecal diversion most commonly occurs
with a first episode of diverticulitis and is very rarely associated
with recurrent disease. It has been estimated that only 1 in every
2,000 pt/years of follow-up will require an emergent resection
after resolution of an episode of medically treated diverticulitis.
(17) A recent meta-analysis reviewing the outcomes of medi-
cally versus surgically treated uncomplicated diverticulitis dem-
onstrated that recurrent hospitalization was more frequent in
the medically treated group than in a surgically treated one.
Mortality rates for uncomplicated disease were generally low
though, regardless of the treatment chosen, especially in patients
less than 50 years of age. (21)
In addition to the fear of an emergent operation and possible
stoma, elective operation has long been recommended based on
risk of recurrence. In the 1950s it was reported that morbidity
and mortality were higher with recurrent attacks of acute inflam-
mation and early interval resection was a means of avoiding
those problems.(22–24) Recent studies have repeatedly shown
that recommendations for prophylactic operation to prevent the
need for an emergent operation are unfounded. In patients with
uncomplicated diverticulitis, Chautems followed 118 patients
after a first attack of uncomplicated diverticulitis for 9.5 years. Of
these patients, 71% had no recurrent episodes and of those that
did, none required emergent surgery.(25) In a population based
study of over 20,000 patients admitted with nonoperatively man-
aged diverticulitis only 5.5% required an emergent colectomy
or colostomy. Younger patients in this study were found to be at
higher risk than their older counterparts.(18) Other studies have
also demonstrated that the risk of patients requiring an emergent
operation from recurrent disease is much lower than previously
thought. (Table 24.4) The number of patients who would benefit
from prophylactic colectomy to prevent a future emergent opera-
tion consistently remains <5%.
A step-wise progression of diverticular disease from diverticulo-
sis to uncomplicated diverticulitis followed by complicated diver-
ticulitis and finally complex disease such as fistula or obstruction is
not the natural progression of this disease. Patients may present at
any stage of the disease ranging from asymptomatic to colovesicu-
lar fistula without a history of previous attack. Janes reported that
the idea that patients should undergo elective resection to avoid
a colostomy is incorrect; such a concept can scare patients into
“elective surgery.”(17) Prophylactic sigmoid resection based on the
premise of preventing the possibility of future colostomy does not
appear to be founded on evidence-based principles.
Age
Most studies define “young” patients as those <50 years of age.
Younger patients have been thought to have more virulent dis-
ease, with a higher risk for recurrence and emergent operation.
Recent publications have questioned whether or not this is the
case.(7, 15, 29–31) Nelson et al. observed that in 234 patients
>50 years of age, with a mean follow-up of 4 years after a CT
scan diagnosed episode of acute uncomplicated diverticulitis,
only 10 patients (4.2%) returned with a complicated episode; of
these, 5 (2.1%) required an emergent colectomy and colostomy.
(29) Anaya published a review of 25,058 patients hospitalized for
an initial episode of diverticulitis. Of the 20,136 patients treated
251
 improved outcomes in colon and rectal surgery

Table 24.4  Number of patients requiring urgent surgery who had a previous history of diverticular disease.

Pts Who Would Have Benefited

Emergent Operation Emergent Operation
From Prophylactic Colectomy

Pts with hx of Pts with a hx of

Ref Yr # pts Elective OR All Pts F/U in years
diverticulosis diverticulitis

Alexander (26) 1983 673 13   80 37 (5.4%) 10

Nylamo (27) 1990 113  3   48  2 (1.7%) 10
Lorimer (28) 1997 154 28 126 15 (5%)*  8
Somasekar (2) 2002 108  0 104 28 (2.7%)*  5

* Patients who had been hospitalized previously with diverticulitis.

Table 24.5  Natural history studies of uncomplicated diverticular disease as reviewed by Janes.(1)

1st Admit 1st Admit 2nd Admit 2nd Admit

Emergent Emergent
Ref Year # Pts F/U Diagnosis All Operations Recurrence
Operation Operation

Parks (4) 1969 455 1–16 Y BE, Path 138 Most 78 20

Larson (5) 1976 132 9Y BE, Path   33 NR 29  9
Haglund (6) 1979 392 6Y BE, Path   97 97 73  0
Ambrosetti (32) 1994 226 25 M CT, CE   66 NR 42  8

Ambrosetti (33) 1997 423 46 M CT, CE 112 33 27 NR

Makela (34) 1998 366 10 years CE, path, Scope 101 55 57 19

Biondo (30) 2002 327 24–90 months CE, CT, Path 103 78 52  4

nonoperatively, 19% developed a recurrence, with those >50 years
of age having a slightly higher recurrence rate (27% vs. 17%, p <
.001). They projected that a policy of routine, elective colectomy
in a younger population after an initial episode would require
13 elective operations to prevent one emergent colectomy. In this
large series, 73% of young patients resolved with medical man-
agement and never suffered a recurrence. Only 7% of all patients
<50 ever require an emergent operation. The risk of all patients
of any age requiring an emergency operation was 5.5%.(18)
These recurrence rates are significantly lower than previous
estimations which were >30% for younger patients. Very few
patients requiring an emergent operation had been previously
diagnosed with or suffered from diverticulitis. An estimated 75%
to 96% of patients presenting with peritonitis and requiring an
emergent operation have never been diagnosed with the disease
previously. This supports the notion that operating on patients
with a history of acute diverticulitis to prevent complications of
acute disease is ineffective at achieving that goal.(2, 26–28)
Although it seems intuitive that patients with more years
to live relative to their older counterparts are at a higher risk
of recurrence, there is little evidence available to suggest that
younger patients have a more virulent disease process that war-
rants aggressive surgical intervention. Despite the split over
recurrence, most groups recommend initial conservative treat-
ment. As mentioned before, risk/benefit models recommend
withholding resection until after three or four recurrent doc-
umented episodes. There has also been a suggestion that no
surgical treatment should be offered despite the number of
uncomplicated episodes.(8)
Nonoperative therapy for patients with uncomplicated diver-
ticulitis has been shown to be safe and effective in a majority of
this population. The ASCRS practice parameter on diverticular
disease also affirms that there is no clear consensus regarding
whether younger patients treated for diverticulitis are at increased
risk for complications or recurrent attacks.(1)
Risk of Recurrence
The risk of recurrence following an attack of uncomplicated
diverticulitis is low. The range of recurrent episodes of diverticu-
litis after one uncomplicated attack is 1.4–18%. (13, 15, 16) Janes
(17) reviewed 94 papers in an effort to review the evidence for rec-
ommendations put forth for elective resection after two attacks of
diverticulitis. They concluded that there is inadequate evidence to
suggest that complications are more likely to occur with each suc-
cessive hospital admission, or that the likelihood of a successful
response to medical treatment decreases (Table 24.5).


 operative and nonoperative therapy for diverticular disease

Acute Complicated Diverticulitis Risk of Recurrence—Indications for surgical treatment

Patients presenting with peritonitis should undergo an urgent
Outcome Measures
operation after appropriate resuscitation. Patients presenting
When determining how best to treat patients presenting with
with complicated disease without peritonitis should initially be
acute diverticulitis two questions need to be answered. First, what
treated conservatively with IV Fluids, NPO, antibiotics, and per-
category of diverticulitis is present based on history and physical
cutaneous drainage of any abscess. Evaluation in a recent study
examination and CT scan findings. Second, what is the feasibility
identified 511 patients diagnosed with complicated diverticulitis.
and indication for operation versus medical therapy? With the
Of these patients, 99 were diagnosed by CT scan with abscess and
advent and availability of CT scanning and its wide spread use for
16 of these underwent percutaneous drainage. Of those patients
typical symptoms of diverticulitis we are better able to classify the
with continued nonoperative treatment, even after percutaneous
disease. A patient presenting with an acute complicated episode
drainage, a recurrence rate of 42% was noted with an increased
of diverticulitis typically will have findings of abscess, phlegmon,
probability of emergent procedure. Based on these findings it was
or localized perforation on CT scan. In a recent review of patients
recommended that all patients with complicated findings on CT
presenting with complicated diverticulitis, 29.5% were found to
scan undergo an elective operation.(8)
have a paracolic abscess, 22.3% an acute phlegmon, 13.4% a fis-
Salem reviewed all hospitalized patients for the state of
tula, 22.6% an obstruction or stricture and 44% a contained or
Washington. After evaluating over 25,000 patients, percutaneous
free perforation.(35)
drainage and medical management were found to decrease the
Peritonitis, free intraabdominal air, or obstruction unrelieved
need for emergency operative interventions.(39)
by other methods is an indication for operation. Patients with
Other studies have shown that complicated disease is not a
signs of peritonitis or hemodynamic instability are not candi-
result of multiple uncomplicated episodes. Salem, et.al., demon-
dates for medical management and should be resuscitated and
strated that of 77 patients followed with complicated diverticuli-
taken to the operating room. However, many patients present-
tis, only eight had two or more previous episodes. A majority of
ing with an abscess, localized and contained perforation, or
patients (79.4%) with fistula, perforation, bleeding, and abscess
phlegmon are candidates for conservative therapy. These indi-
had no previous episodes of diverticulitis. They concluded that
viduals should be evaluated for possible percutaneous drainage
simple acute diverticulitis is not a good predictor for the develop-
with radiographic guidance. Once stabilized, patients with com-
ment of further complications from diverticular disease as only a
plicated diverticulitis should have a complete colon evaluation
minority of patients with complications had previous episodes of
and most should be scheduled for an elective operation. The
diverticulitis.(13)
American Society of Colon and Rectal Surgeons (ASCRS) have
Chapmen found that only 21% of patients presenting with
recommended that, “Elective colon resection should typically
free perforation and peritonitis had a previous history of disease.
be advised if an episode of complicated diverticulitis is treated
(40) Somasekar reviewed 108 patients admitted with complicated
nonoperatively.”(1) However, there is a growing body of evi-
diverticulitis. Of these, 104 required emergent surgery but only
dence to suggest that select patients with complicated disease
28 patients had a previous history of uncomplicated diverticuli-
may be safely managed if they respond to more conservative
tis. However, only 3 (2.7%) of these 28 patients had suffered two
measures.
previous episodes and would have qualified for an operation
Ambrosetti attempted a prospective trial of surgery versus
under the standard guidelines (2) Hart performed a case con-
observation after the 1st complicated attack of diverticulitis but
trolled study of patients presenting with perforated diverticulitis
abandoned the trial after 19 months as only 4 of the 52 (8%) had
and found that 78% had no previous history.(41)
a recurrence.(36)
Faramakis followed 120 patients from 30 centers over 5
years with complicated diverticulitis, defined as abscess, fis- Timing for Surgical Intervention
tula, obstruction, or free perforation. Of these patients, 32% Complicated diverticulitis is at this time an indication for opera-
developed a severe complication and 10 patients died. However, tion. Circumstances may arise that would make continued obser-
many of these patients were treated nonoperatively because they vation a wiser decision based on the age and comorbidities of the
were not felt to be surgical candidates and three times as many patient, but until further evidence is available operation contin-
patients died from cardiovascular or pulmonary complications, ues to be the standard of care.
compared to those who died from complications of diverticular Pain is a valuable indicator for the patient’s recovery, and pro-
disease.(37) vides a marker for evaluation. Attempts at initiating PO intake
One small study followed 28 patients after identification of and switching antibiotic therapy may be confidently made
complicated disease on CT scan. Ten patients were percutaneously based on the patient’s symptoms or lack of resolution of those
drained and the rest were treated conservatively. Two patients ulti- symptoms.
mately required operation during their initial hospitalization and Once the patient is pain free and has undergone an adequate
18 patients (24%) had recurrence. They concluded that most preoperative evaluation, surgery can be undertaken. Before any
patients could be managed without an operation or drainage. surgical procedure patients should undergo endoscopic evalua-
(38) However, until more evidence substantiates a clear path to tion of the colon in order to rule out other disease processes that
follow, operative resection remains the standard for most patients may need to be taken care of at the same time. Optimal timing for
presenting with complicated disease. performing an operation after medical treatment of a complicated

253
 improved outcomes in colon and rectal surgery
episode of diverticulitis has occurred and has never been studied.
However, it seems prudent to offer an elective operation within
6 to 8 weeks to allow the inflammatory process to settle and pro-
vide an opportunity for safest operation. Laparoscopic surgery
will also be easier without the inflammatory component of the
acute setting.
Chronic Diverticulitis
Indications for Medical versus Surgical Treatment
Chronic diverticulitis is typically defined as uncomplicated acute
diverticular disease that resolves with antibiotic therapy only to
flare again once antibiotics are discontinued. It is not a particu-
larly common entity within the spectrum of diverticular disease.
Patients initially respond well to antibiotic therapy but fail to
fully resolve their symptoms, or have frequent recurrences within
weeks of each other. Patients may experience multiple flares of
the disease that resolve spontaneously but continue to plague the
patient for weeks to months.
Indications for surgical treatment
Chronic diverticulitis is an indication for operation. However, the
correct diagnosis of recurrent or chronic diverticulitis must be
secure. Chronic abdominal pain unrelated to diverticular disease
has been described and an operation for pain without confirma-
tory findings is doomed to failure. Barium enema may be the
colon clearing test of choice in this situation as colonoscopy can
be associated with an increased risk of perforation in the face of
smoldering diverticular disease.
Best Timing for surgical intervention
Ideally, patients should be continued on their antibiotics up to
the time of operation. A bowel prep should be instituted in these
patients and their nutritional status be reassessed depending on
the amount of time they have had a chronic smoldering infection
and been unable to eat. A good starting place is to simply evaluate
the amount of weight lost over the recent past. Patients may be
candidates for either laparoscopic or open surgery, as both have
been shown to be safe and effective in the hands of well practiced
surgeons.
Complex Diverticulitis
Indications for surgical treatment
Complex diverticulitis is defined as patients with colonic fis-
tula, stricture or obstruction. Colovesicular fistulas are the most
common fistula, but colosalpingo, colocutaneous, colo-colo,
colovaginal, and coloenteric fistulas all have been reported as a
complication of diverticular disease. Bleeding divertula is not
typically associated with the inflammatory state of diverticulitis
and thus falls outside the scope of this chapter.
About 1–2% of patients with diverticulitis develop an internal
fistula.(6) Symptoms of fistula depend on the location. Dysuria,
fecaluria, and pneumaturia are the most common presenting
signs for colovesicular fistula. At times, symptoms go unnoticed
and a delay in diagnosis for a prolonged period of time is not
uncommon. Rarely, some patients who present with complex
diverticulitis have never formally been diagnosed with previous

episodes of diverticulitis. This may be because the patient never
sought medical attention despite having some symptoms, or the
symptoms were mistaken for gastroenteritis, or other such ail-
ment. Complications of diverticular disease appear to be related
more to the severity of the attack at a specific location than from
progression from simple to complex disease in an orderly fash-
ion. This inflammatory process may range from uncomplicated
to complex.
Contrast enema has been described as one of the ways to diag-
nose an abnormal connection between the colon and another
organ. However various reports put the success rate between
34–83%.(42, 43) Vaginography or cystoscopy are two other ways
to confirm the diagnosis. If suspicions are still present with rel-
evant symptoms, and CT scan confirms diverticulitis, operation
can be offered without confirmatory testing.
Whatever the source, patients with complex diverticulitis
should undergo an operation to correct the problem, unless the
patient is not a surgical candidate. These patients who are not
surgical candidates can be managed on suppressive antibiotics.
One important concept to remember is that fistulas do not rep-
resent an emergency. If the patient is appropriately draining, and
does not appear to be septic, there is no emergency to the opera-
tion. Complex fistulas have been managed with a single opera-
tion successfully in as many as 90% of cases, both with open and
laparoscopic techniques.(44–46)
Obstruction from diverticular disease is quite different. Patients
who present completely obstructed from diverticular disease will
require urgent decompression. Depending on the stability of the
patient, multiple options including resection and primary anasto-
mosis with or without proximal diversion, Hartmann procedure,
Turnbull colostomy, or stent placement are available for the sur-
geon. These patients may carry an extensive history of diverticular
disease. Ruling out other sources of obstruction, specifically colon
cancer, is important. If the patient has not been screened appro-
priately, one may choose to perform intraoperative colonoscopy
depending on the patient’s condition and state of the bowel. If this
is impossible during the operation, as is frequently the case, then
follow up colonoscopy should be undertaken after the operation.
Immunosuppressed Patients
Risk of developing diverticulitis
Difficulty arises in attempting to diagnosis diverticulitis in an
immunocompromised patient because many fail to manifest
the classical signs and symptoms of the disease. Patients who are
considered to be immunosuppressed include transplant recipi-
ents, those with an immunodeficiency syndrome, or those taking
immunosuppressive medications for arthritis, autoimmune dis-
eases, or inflammatory bowel disease. Patients who are especially
problematic are those that are receiving prednisone in dosages
>20 mg/day. They present with fewer symptoms, have a longer
time to operation, and higher mortality (85%) when compared
with patients receiving lower doses (13%).(47) Thus, any patient
taking higher doses of an immunosuppressive medication must be
considered immunosuppressed and evaluated accordingly. These
patients are much more likely to present with a free perforation than
their nonimmunocompromised patients.(48–50) Correlation
 operative and nonoperative therapy for diverticular disease
between a delay of diagnosis and mortality has also been demon-
strated in these patients.
Transplant patients make up an ever growing population that
requires immunosuppressive medication. The incidence of trans-
plant diverticulitis varies by the type of transplant performed;
however, all studies show a low incidence of the disease. One
report reviewed 2,000 patients over a period of 30 years following
renal transplants and reported a 0.5% risk of any colonic prob-
lems including diverticulitis.(51)
Many studies have reported an incidence of diverticulitis
among both lung and heart transplant patients that varies from
0.75% to 4%. However the hospital admission rate for diverticu-
litis in a “normal” population is 25–50 per 100,000 admissions
(0.025–0.053%), which is much less than in a transplant popula-
tion.(51–53) From 1985 to 1996, a review of six series including
986 of heart and lung transplant patients showed an incidence
of 0.75%. The authors concluded that pretransplant screening of
diverticulosis is not justified in the absence of symptoms.(54)
Other authors have evaluated their experience with compli-
cated diverticulitis in renal transplant patients. Of 1,211 patients,
13 patients had episodes of diverticular disease for a 1.1% inci-
dence. They concluded that the problem is rare but the clinical
presentation is atypical.(55)
One of the major benefits among the transplant population
was the introduction of cyclosporine because of the decreased
steroid requirement. It has been demonstrated that a nearly
50% decrease in the rate of complicated diverticulitis was
accomplished in patients who were treated with cyclosporine;
however, this did not reach statistical significance due to small
sample size.(55)
Prophylactic Sigmoid Resection
Most authors recommend that patients with symptomatic diver-
ticulitis with appropriate confirmation undergo sigmoid resec-
tion before transplant. Diverticulosis without symptoms though
does not require further investigation and is not an indication for
prophylactic resection. However, these patients are at a slightly
higher risk than the general population and should be monitored
closely.(55) Postoperative mortality is high in immunocompro-
mised patients who develop acute diverticulitis requiring opera-
tive intervention. An increased index of suspicion is necessary in
treating immunocompromised patients. An approach incorpo-
rating an aggressive evaluation with medical support and early
surgical exploration is generally warranted.
One specific population deserves mention and those are
patients with polycystic kidney disease. These patients appear to
have a higher incidence of complicated diverticulitis than other
transplant patients, and one study concluded that these individu-
als warrant more aggressive diagnostic evaluation for any symp-
toms. Pretransplant screening and prophylactic sigmoid resection
deserve further study.(55)
OPERATIVE MANAGEMENT
What manner of operation is best?
Three operations are typically recommended for patients requir-
ing a sigmoid resection. Open sigmoid resection, laparoscopic
sigmoid resection, or hand assisted laparoscopic resection (HAL).
Despite the recent eruption of literature and discussion about the
benefits of laparoscopic colectomies, only 5–10% of all colecto-
mies are currently performed using a laparoscopic technique.(56)
However, with increased training and utilization, it is anticipated
that this number will continue to increase substantially.
Open colectomy is the gold standard for comparison.
Laparoscopic colectomy has gained increased prominence fol-
lowing the successful application of this technique for other pro-
cedures. While it is still in its infancy, it is fast becoming the main
choice for a growing number of patients and surgeons. Many
large studies have been undertaken to assess the safety of laparo-
scopic colectomy as well as its economic feasibility.
Reported benefits of laparoscopic colectomy include shorter
hospital stay, less postoperative pain, earlier return of bowel func-
tion, and quicker return to daily activities. Other reported benefits
include less wound, respiratory, gastrointestinal, and cardiopul-
monary complications when compared to open surgery.(57–60)
The downsides of laparoscopic surgery include surgeon specific
initial higher complication rates and conversion rates associated
with a steep learning curve, longer operating room time, and
higher cost for operations.(58) However, a recent study looking
directly at total cost for open sigmoid resection versus laparo-
scopic sigmoid resection by Senagore (59), revealed that overall
total costs were significantly lower for laparoscopic patients, and
that operating room costs were not different between the two
types of surgery. They concluded that laparoscopic resection was
a cost effective means of managing sigmoid diverticular disease.
A key factor to keeping the costs equivalent between open and
laparoscopic resection was the minimization of conversion and
complication rates. A conversion rate of 6.6% was observed in
this study.
However, many factors go into a study like this including rou-
tine postoperative care, and surgeon and patient comfort levels
with earlier discharge. Despite this, slow but steady progress in
training of younger surgeons and greater familiarity with the new
techniques will more than likely make laparoscopic surgery the
standard of care in the future, much as laparoscopic cholecystec-
tomy has become.
Hand Assisted Laparoscopic (HAL) Colectomy has also been
compared against laparoscopic resection and been found to be
equivalent as far as outcome of patients.(56, 61) Benefits of HAL
have been shorter operating times when compared with straight
laparoscopic surgery as well as lower conversion rates. One recent
study identified an advantage to using HAL colectomy with com-
plicated diverticulitis and laparoscopic resection for uncompli-
cated diverticulitis.(56) The cost of utilizing a hand port was not
significantly different when offset by the faster operating room
time.(61)
Much depends on the ability of the surgeon to complete the case
without conversion. Conversion rates increase the total cost of the
operation as well as the potential morbidity rates for the patient.
In an article by Belizon (60) an analysis was made of patients
undergoing conversion to an open operation. Postoperative mor-
bidity was significantly higher for laparoscopic resection pro-
cedures that were converted to open after 30 minutes into the
255
 improved outcomes in colon and rectal surgery
operation. Wound complications and greater length of stay in the
hospital were the two most common findings. Obesity, adhesions,
bleeding, and inflammation beyond area of operation were the
most common predictors for conversion.
The best operation for an individual seems to be the opera-
tion the surgeon can perform. However, with advancing mini-
mally invasive techniques that can be implemented at a similar
cost structure, it behooves all surgeons to continue to educate and
modify their practices to provide the best care possible to their
patients.
Which Operation is Best?
Three different operations have been proposed for the treatment
of complicated diverticulitis with peritonitis. The first operative
approach described was the three stage procedure encompass-
ing drainage with stoma, followed by resection and anastomosis
with continued diversion, and finally by restoration of continu-
ity. The second approach involved resection and diversion or the
traditional Hartmann procedure (HP). However, this approach is
being challenged by the third approach of resection with primary
anastomosis. Primary resection with anastomosis (PRA) can be
performed with or without a covering stoma, and/or on-table
lavage. The three stage procedure will not be discussed here as it
is not considered standard of care and should be used only in very
infrequent situations.
In 1921, Hartman advocated his two stage resection which was
superior and quickly became the standard of care. However early
in the 1960s there were eight reports with a total of 50 patients
that underwent resection and primary anastomosis for general-
ized peritonitis with a low mortality of 10%.(63) Not much debate
is raised now with respect to patients presenting with recurrent
or chronic diverticulitis. They are typically managed in an elective
fashion with primary anastomosis. Patients are still traditionally
given a bowel preparation before surgery, at least in the United
States, and probably will for some time though there is a growing
swell within the literature questioning its necessity.
Patients who present with acute symptoms, typically Hinchey
stages III or IV, are taken to the operating room urgently. These
patients constitute approximately 3.2 per 100,000 patients.(63)
These patients present a dilemma, because typically they are
older, have a high number of comorbidities, and suffer a greater
number of complications. In a recent review by Salem reviewing
98 articles on the outcome of complicated diverticulitis based on
the type of operation performed, they identified 1,051 patients
who underwent a Hartmann procedure from 54 studies, and
569 patients having undergone a primary anastomosis from 50
studies. (Tables 24.6 and 24.7) Of the patients undergoing a pri-
mary anastomosis, 16% had covering stomas and 10% had on-
table lavage. The mortality rates of those in the Hartmann group
(19.6%) were much higher than those undergoing a primary
anastomosis (9.9%). The anastomotic leak rate in patients with
a primary anastomosis ranged from 6.3% to 19.3%. If a diverting
proximal stoma was performed at the time of a primary anas-
tomosis the anastomotic dehiscence rate fall to 6.3%. Wound
infections were also more frequently seen in the Hartman group
(24.2%) versus the primary anastomosis group (9.6%). Again,
patients with covering stomas had the lowest wound infection rate

Table 24.6  Outcomes of primary anastomosis in patients with
complicated diverticulitis—Salem et al.(61)
Primary Primary Primary Primary with
Anastomosis Anastomosis Anastomosis Anastomosis
Overall Alone with Stoma lavage
Mortality 9.9% 8.1% 9.2% 9.6%
# of Studies 48 29 17 3
# of Cases 548 297 109 52
Anastomotic Leak 13.9% 19.3% 6.3% 9.6%
# of Studies 29 14 8 3
# of Cases 353 145 64 52
Wound Infection 9.6% 16.4% 4% 12%
# of Studies 17 6 3 2
# of Cases 219 55 25 50
Table 24.7  Outcomes of Hartmann and Hartmann Reversal.
Salem et al. (61)
# of Wound Stoma
Mortality Leaks
Patients Infection Complications
Hartmann 1,051 198 (18.8%) 70 (24.2%) 12 (10.3%) NA
Hartman 787 6 (0.8%) 7 (4.9%) NA 20 (4.3%)
Reversal
at 4%. Patients undergoing a Hartmann procedure also required
a larger second operation than those who had PRA with or with-
out a covering stoma. Complications from a Hartmann reversal
were associated with a mortality of 0.8%, a wound infection rate
of 4.9% and an anastomotic leak rate of 4.3%. These patients also
experienced stoma complications (10.3%) that required medi-
cal attention. The conclusion was the primary anastomosis is no
worse than a Hartmann procedure and has several advantages
including higher restoration of continuity rate, less hospitaliza-
tion, and fewer infectious complications.(64)
Multiple studies have evaluated the morbidity and mortality of the
Hartmann procedure as well as the risks incumbent with takedown.
Most seasoned surgeons realize that at times restoration of continu-
ity can be more of a challenge to both patient and surgeon than the
original operation. This was demonstrated in a recent multicenter
prospective trial involving 415 patients with complicated diverticuli-
tis. Two hundred forty-eight patients underwent resection with pri-
mary anastomosis. The other 167 had a Hartmann procedure. The
mortality rate for those undergoing primary anastomosis was 4.0%
while those with resection and diverting colostomy was 23.4%. After
case adjustment, the data suggested that the Hartmann procedure
was associated with a 1.8 fold increase in likelihood of death. This was
not statistically significant. However a 2.1 fold increase in morbidity
was found between the two groups and this was significant. In part
this is due to the fact that surgeons typically reserved a Hartmann
procedure for those older patients with more comorbidities and thus
predisposed to a poorer outcome.(65)
Risks associated with Hartmann Reversal
Reversal of a Hartmann colostomy also carries with it a signifi-
cant risk that must be entertained when considering this opera-
tion for patients who will desire continuity in the future. Failure
 operative and nonoperative therapy for diverticular disease
Table 24.8  The cr-POSSUM scoring system.
Physiologic Parameters
Age <61 62–70
Cardiac No Failure Treatment for angina or HTN
Systolic BP 110–130 131–170
Pulse 50–80 80–100
Hgb 13–16 11.5–12.9
Urea 7.6–10 10.1–15
Operative Parameters
Type of Operation Minor Moderate
Peritoneal Contamination None Cloudy
Malignancy Status None, T1–2 T 3,4
Timing of OR Elective Urgent
to reverse the colostomy has been reported in 20–50% (61) of
patients and leak rates on reversal fall around 2–30% (61, 63)
Mortality has been reported anywhere from 0–10% and wound
infection rates range from 12–50%.
A strong interest in primary anastomosis has been revived in
the literature, with papers describing the successful outcomes of
patients undergoing this type of operation. However, few papers
are prospective, less are randomized, and such a trial is still needed
today to definitively answer the questions of safety and efficacy.
Multiple trials though have shown that the outcomes of primary
anastomosis are indeed as safe as a Hartman and in many cases
better. In a recent review, Constantinides et al. reviewed the out-
comes of patients undergoing Hartmann (66), primary resection
with anastomosis (PRA) (135 patients) and primary resection
with anastomosis and diversion (126 patients). Patients under-
going a Hartmann procedure had a morbidity and mortality
of 35% and 20% respectively. Primary anastomosis showed a
slightly higher morbidity and mortality at 55% and 30%, while
those with a primary anastomosis with diverting stoma demon-
strated a morbidity and mortality rate of 40% and 25% respec-
tively. Stomas were permanent in 27% of patients undergoing a
Hartmann procedure and 8% of those having a primary anasto-
mosis with diversion. They concluded that primary anastomosis
with defunctioning stoma may be an optimal strategy for selected
patients. Hartmann procedure should be reserved for patients
with an extremely high risk of perioperative complications and
only after consideration of long-term implications.(63)
Patients undergoing on-table lavage have been analyzed as well,
which showed similar outcomes to those who did not undergo
on-table lavage. Regenet, described 60 patients, all Hinchey III or
greater, in whom 27 underwent primary anastomosis with intra-
operative lavage and 33 who had a Hartmann procedure. In this
prospective observational study they found that the Hartmann
procedure took much less time to perform, but that the mortal-
ity and morbidity for both groups were equal. Three patients in
the intraoperative lavage group had an anastomotic leak (11%).
A Hartmann reversal occurred in 69% of the patients. The rever-
sal had its own associated morbidity of 24%, an anastomotic leak
>71
Edema, cardiomyopathy, coumadin Cardiomegaly, Raised JVD
>170 <90
100–120 <50
10–11.4 <10 or >18
>15
Major Complex Major
Pus Fecal
Mal + Nodes Mal + Mets
Emergent < 2 hours
rate of 7%, and no deaths. Postoperative stay after primary anas-
tomosis and intraoperative lavage was 18.4 days and Hartmann
Procedure was 38 days. They concluded that primary anasto-
mosis with intraoperative lavage and a Hartmann Procedure are
both adequate approaches for generalized peritonitis complicat-
ing diverticulitis.(17)
Covering stomas have been recommended by most studies
when primary anastomosis is performed because of the variable
anastomotic leak rate. Both diverting colostomies and ileostomies
have been described with equal success. Most of the poor out-
comes noted are not necessarily due to the operation performed,
but the comorbidities and peritonitis associated with the patient
and disease. These risks play more into the outcome of patients
than the type of operation performed.
Complications of Operation
Predictors of Morbidity and Mortality—Scoring Systems
Multiple scoring systems have been evaluated in attempts to pre-
dict outcome and risk in patients undergoing both elective and
emergent colon resection for diverticulitis. With an increasing
interest in outcomes by doctors, patients, and payers, predictive
scoring systems may be one of the many ways surgeons, hospitals,
and systems are evaluated.
Developed by Copeland in 1991, the Physiological and
Operative Severity Score for the enumeration of Mortality and
Morbidity (POSSUM) was developed as a tool to compare mor-
bidity and mortality in a wide range of general surgical proce-
dures. This was to facilitate surgical audit and the comparison
of hospital performance. It has been further adapted for patients
undergoing colon and rectal surgery and named cr-POSSUM
(Table 24.8). The idea was to adjust risk of a surgical procedure
based on the patient’s physiological condition and therefore
allow a more accurate comparison of a unit (or individual’s)
performance.
Oomen has been one of the physiological and operative sever-
ity score (POSSUM) score’s biggest proponents and has done
a number of studies attempting to validate the system. When
257
 improved outcomes in colon and rectal surgery
Table 24.9  The Mannheim peritonitis index.
Risk Factor
Age > 50
Female Sex
Organ Failurea
Malignancy
Preoperative duration of peritonitis >24 hours
Origin of sepsis not colonic
Diffuse generalized peritonitis
Exudate
Clear
Cloudy/Purulent
Fecal
a. Kidney failure = creatinine level > 177 umol/L or urea level
> 167 mmol/L or oliguria < 20 ml/hour; pulmonary
Insufficiency = PO2 < 50 mmHg or PCO2 > 50 mmHg
Intestinal obstruction/paralysis > 24 hours or complete
Mechanical ileus, shock hypodynamic or hyperdynamic
they compared the POSSUM, cr (Colorectal)-POSSUM and p
(General Surgery)-POSSUM they found that POSSUM over pre-
dicted mortality, while p-POSSUM and cr-POSSUM under pre-
dicted mortality for diverticular disease, but correctly predicted
mortality for cancer. In a confirmatory study here in the US how-
ever, Senagore found that all of the POSSUM scoring systems
over predicted mortality.(68, 69)
Another scoring system that has been developed and used
frequently in discussing outcomes and indications for the differ-
ent types of operations performed is the Mannheim Peritonitis
Index. Many studies have evaluated the efficacy of this scoring
system. Bielecki found that patients with colonic perforation and
an MPI > 25 had a 55% morbidity rate and 35% wound infection
rate.(70) Another study confirmed these findings after evaluating
172 patients with peritonitis; the MPI was able to predict 12 of
the 14 deaths. They also found that morbidity was related to the
MPI score.(71) (Table 24.9)
Complications of Procedure
Anastomotic Leak
Elective colectomy has been well documented to carry a very low
anastomotic leak rate, of about 1–3%.(64) However, in the face
of active inflammation or peritonitis, attempts at performing a
primary anastomosis carry a higher risk of anastomotic dehis-
cence. Primary anastomosis in the setting of Hinchey stage III or
IV carries a leak rate from 8–22%.(21, 64, 65, 72–74)
Mortality
Elective colectomy also carries with it a low mortality rate, typi-
cally >1%. A majority of deaths result from cardiovascular prob-
lems. However patients involved with complicated diverticulitis
face greater risks that can be evaluated with numerous scoring
systems. Mortality rates range from 0–36% in patients presenting
with peritonitis and depend greatly on their comorbidities and
time to operation.(74)

Failure to Reverse
Scores
Maggard looked at colostomy reversal at the population level for
the state of California. Of the 1,176 patients who had a Hartmann
5 procedure for diverticular disease, only 65% had a reversal at a
5 mean of 143 days. Younger men were more likely to have their
7 ostomy reversed, as opposed to older patients, and women.
4 Patients with more comorbid risk factors also had fewer rever-
4 sals. When evaluating all patients, 35% never had their ostomy
4 reversed during the 4 year study. Complication rates follow-
6 ing Hartmann reversal were quite high and included an overall
rate of 57.4%. Infection (9.1%), aspiration pneumonia (8.7%),
0 pulmonary edema (6%), and acute renal failure (4.9%) were all
6 problematic.(75)
12 Most of the literature quotes a 20–50% failure of reversal
rate on patients for a number of factors including; comorbidi-
ties, age, and failed attempts at reversal.(75–78) Boland et al.
found that 38% of patients suffered a major complication after
their reversal. Failure to restore continuity in their population
was 10.3%. Due to the morbidity of the Hartmann reversal as
well as the number of patients who either are not reversed or
fail an operative attempt at reversal they recommended always
trying a primary anastomosis first with diversion if possible.
(76) In another similar study Aydin et al. found that Hartmann
reversal was associated with a higher prevalence of surgical or
medical complications when compared with primary resection
and anastomosis. The overall postoperative morbidity and 30
day mortality rates for Hartmann reversal were 48.5% and 1.7%
respectively. Patients undergoing a primary resection with anas-
tomosis suffered a morbidity rate of 26% and mortality rate of
0.7% Having controlled for the number of comorbid conditions,
extent of diverticular disease, severity of peritoneal contamina-
tion and operative urgency, patients who underwent Hartmann
reversal were 2.1 times more likely to have an adverse surgical
event during their postoperative period.(77)
The difficulty with these comparative studies is that despite
attempting to find similar cohorts, patients who undergo a
Hartmann procedure are usually older, frailer, and sicker than
those that undergo a primary anastomosis. Surgeons generally
wish to correct the problem as fast as possible and get the patient
off of the operating room table. This creates the possibility of bias
in evaluating the literature, as patients undergoing Hartmann’s
versus primary anastomosis typically have a worse outcome.
However, when added with the risks of a second complex and
morbid operation of future stoma takedown, primary anastomosis
and diversion with a loop ilesotomy appears much friendlier. If the
patient is able to tolerate the extra 30 minutes required to perform
a primary anastomosis one should be performed with diversion.
Recurrence of diverticulitis after previous surgical resection
Recurrence of diverticulitis or its symptoms following resection
has been reported in 3–13% of elective cases.(79–81) Factors that
have been found to contribute to the recurrence of diverticulitis
after a resection include shorter resection length (79), and the
leaving behind of a cuff of distal sigmoid.(80) Most recently,
Thaler demonstrated that the level of the anastomosis is the
only significant determinant of recurrence after laparoscopic resec-
tion.(82) The practice parameters of the ASCRS set out several
 operative and nonoperative therapy for diverticular disease
Figure 24.1  CT scan of uncomplicated diverticular disease.
Figure 24.2  Coronal recoinstruction of CT scan demonstrating air in mesentery.
general recommendations regarding resection of diverticular dis-
ease. For elective resection, all thickened, diseased colon, but not
necessarily the entire proximal diverticula bearing colon, should
be removed. It may be acceptable to retain proximal diverticu-
lar colon as long as the remaining bowel is not hypertrophied.
Distally, all of the sigmoid colon should be removed to the level
of the rectum.(1)
Figure 24.3  CT Scan demonstrating drain in abscess cavity.
Timing of Closure
Timing of closure continues to be a contentious issue and
has not been fully settled. Traditional teaching is to wait 3 to
4 months to allow the inflammatory process to subside and
the patient to heal before performing another major opera-
tion. Mean time intervals in the literature range from 120 to
210 days. One study did compare closure at 4 and 8 months.
Complication rates associated with timing of reoperation were
2.5 and 5 times higher at 4 and 8 months respectively.(77)
Complications from the reversal included anastomotic leak,
and rectovaginal fistulas in women. These fistulas are attrib-
uted to improper dissection of the vagina and failure to care-
fully mobilize the rectum.
Conclusion
Diverticular disease appears to be increasing in incidence in an
ever widening spectrum of ages throughout the United States
and other developed countries. However, with more experi-
ence with the disease process, coupled with better medical thera-
pies and diagnostic measures, more patients are able to be managed
conservatively then ever before. Uncomplicated diverticular disease
may be treated medically without fear that recurrent episodes
will lead to more complicated findings. Complicated dis-
ease is being managed medically more aggressively than ever
before in an effort to prevent emergent operations. Primary
anastomosis with diversion as opposed to the traditional two
staged Hartmann procedure appears to be equally effective
without the downside of a second major operation. Certainly
the trends today for diverticular disease are to be less aggres-
sive with operative management, and treat each individual
case based on its own merits as opposed to the more stringent
guidelines of the past.
259
 improved outcomes in colon and rectal surgery
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261
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25 Abdominal surgery for colorectal cancer
Jason Hall and Rocco Ricciardi
Challenging Case
A 65-year-old woman with no significant past medical history
underwent a laparoscopic sigmoid colectomy for colon cancer.
The patient had a persistent postoperative ileus and on day seven,
a fever spike with increasing abdominal pain.
Case Management
A contrast enema revealed an anastomotic leak and she returned to
the operating room for laparotomy, abdominal washout, and end
colostomy. The anastomosis had a pinpoint defect posteriorly without
evidence of tension or ischemia. She responded well to antibiotics
and was discharged 16 days following her initial procedure.
INTRODUCTION
The need for improved quality in healthcare has reached the
consciousness of policy makers, providers, payers, and patients.
Following the publication of two Institute of Medicine reports:
To Err Is Human: Building a Safer Health System and Crossing the
Quality Chasm: A New Health System for the 21st Century, the qual-
ity of our nation’s health care has been critically examined while
outcomes questioned. The increased attention to healthcare has lead
to calls for better access, more equitable care, more rigorous moni-
toring and quality assessment, pay for reporting and potentially
pay for performance. In fact, to accelerate the diffusion and pace
of quality improvement efforts, the Institute of Medicine launched
the Redesigning Health Insurance Performance Measures, Payment,
and Performance Improvement Project. With an aim toward equi-
table and reliable high quality care, our nation has started down the
road of more measurement in order to gain better outcomes.
Quality has always been a major focus of attention for surgeons
but with the advent of pay for reporting and soon, pay for perfor-
mance, attempts to measure quality of care have become more hur-
ried. At this time, the focus have been on process measures such as
antibiotic prophylaxis and venous thrombosis prophylaxis but with
time, it is likely that we will see assessment of morbidity and mortal-
ity and potentially quality of life and patient satisfaction. With respect
to colon and rectal surgery, specific policies have been promoted to
improve care, including measurement and reporting of performance
data, payment incentives, and quality improvement initiatives.
Oncologic measures are under active development and will likely
standardize the way we manage colon and rectal cancer. It is for this
reason that our chapter on improving outcomes for abdominal sur-
gery in colorectal cancer is particularly important to readers of this
textbook and in particular surgeons who perform these procedures.
Procedures involving the colon and rectum are particularly prone to
high rates of morbidity and mortality and thus, techniques to reduce
the burden from disease of the colon and rectum are important.
Surgical resection remains the standard of care for curative
treatment of colorectal cancer. In order to improve outcomes,
numerous surgical techniques have been proposed to reduce
complications and improve outcomes in resections for colorectal
diseases. However, as with all surgical procedures, complications
related to preoperative, intraoperative, and postoperative factors
occur more often than we like to recognize. As the collective inter-
est in surgical outcomes has increased, surgeons have been charged
not only with improving their outcomes but also with document-
ing that improvements in surgical care are real and generalizable
to the population served. This chapter provides a systematic over-
view of the major recent developments in outcomes and quality
measurement in colorectal cancer. It also provides and evidence
based platform for the minimization and management of com-
mon surgical complications, thereby improving outcomes.
Oncologic Outcomes in Colorectal Cancer
A number of factors affect prognosis after colorectal resection
for cancer. Generally, oncologic outcomes for abdominal resec-
tion for colon cancers are inversely proportional to the patients’
stage of disease. Following attempted curative resection, survival
parallels the TNM stage (I- well above 90%; II- 65–90%; and
III- 45–75%).(1, 2) More specifically, local extent of disease, the
presence of metastatic disease, nodal involvement, adequacy of
regional node harvest, incomplete resection, preoperative CEA
level, tumor grade, and tumor biology have all been correlated
with oncologic outcomes.(3–7) Alternatively, tumor size and
gross tumor configuration have not been correlated with progno-
sis following surgery. Despite these patient and tumor factors, the
surgeon can greatly influence oncologic outcomes by perform-
ing a proper preoperative oncologic evaluation, adequate tumor
resection, and satisfactory nodal harvest.
Preoperative Evaluation
Following the diagnosis of colorectal cancer, the surgeon should
assess the patient’s surgical risk while determining local and
distant extent of disease. Despite the lack of consensus for pre-
operative testing of colorectal cancer, we adhere to a thorough
evaluation of the abdomen and chest to rule out distant disease
while determining the local extent of disease, especially when
planning a laparoscopic resection. Most importantly however,
before completing a colorectal resection, colorectal cancer patients
should have a complete assessment of the colon. Approximately
5% of patients will have a synchronous colorectal cancer and 25
to 76% patients will have a synchronous adenomatous polyp.
(8) Colonoscopy is advantageous for identifying the position of
the lesion while permitting tattooing for intraoperative localiza-
tion with laparoscopic resections. Also, some assessed lesions are
prohibitively large and thus the planned operation may require
alteration in order to address all of the colonic neoplasia.
Computed tomography, virtual colongraphy, and barium enema
are other methods that may be applied if a colonoscopy cannot
be performed for technical reasons. In addition, we have had

 improved outcomes in colon and rectal surgery
excellent results with intraoperative CO2 colonoscopy following
surgical extirpation thereby reducing the number of bowel preps.
Thus, an adequate assessment of the patient’s colonic disease
reduces the likelihood that the patient may require another pro-
cedure for a missed lesion.
Surgical Technique
In addition, to an adequate preoperative assessment, adequate
tumor resection is critical to ensuring a good prognosis. Appropriate
surgical margins critically influence outcome after colorectal
cancer resection. In addition to the proximal and distal bowel
margins, the radial or circumferential margin is particularly
important in the treatment of both colon and rectal cancers.(9)
The consensus of a 5 cm proximal and distal bowel margin is
generally adhered to for colon cancers, with data suggesting that
mural tumor migration rarely occurs beyond a 2 cm margin in
either the proximal or distal direction to cancer.(10) In the set-
ting of rectal cancer, a distal margin of as little as 1–2 cm has
become the rule in lower tumors, while it is important to note that
survival is adversely affected by a distal margin of <0.8 cm.(11)
Controversy regarding the point of ligation of the vascu-
lar pedicle has been a point of contention for years. Many sur-
geons argue that a high ligation of the vascular pedicle is critical
to ensuring good oncologic outcomes. However, a comparison
of high versus more distal ligation for left sided cancers by the
French Association for Surgical Research demonstrated no differ-
ence in survival.(12) Despite the fact that advocates of proximal
vascular ligation have little evidence to support improved out-
comes, the net effect of high ligation may be to improve lymph
node sampling. An adequate mesenteric resection to include an
appropriate nodal sample importantly predicts survival.(5) Given
the overwhelming data in this area, the College of American
Pathologists has recommended additional techniques to enhance
nodal recovery if <12 nodes are identified on initial examination.
(6) Similarly, several national organizations have proposed set-
ting benchmarks of 12 lymph nodes as a proxy of an adequate
oncologic resection for colorectal cancer.(13–17) This proposed
benchmark may someday serve as an important quality measure
to compare surgeons and providers treating colorectal cancer. At
this time however, advocates of lymph node benchmarks have
no evidence that such thresholds will result in real measurable
improvement in patient outcome.
Surgical advances in laparoscopic technique have resulted in
a rising tide of enthusiasm for laparoscopic cancer resections.
These advances have resulted in some improvement in short-
term outcomes, such as postoperative pain, length of ileus, and
hospital stay. Most importantly, multicenter trials of laparoscopic
resection versus open resections for colon cancer reveal no com-
promise in oncologic outcomes.(18) Despite early reports of port
site recurrences from laparoscopic oncologic resections, data
support the oncologic equivalency of laparoscopic colectomy in
the hands of experienced surgeons.(18, 19) Thus, oncologic out-
comes are comparable for the experienced laparoscopic surgeon
as compared to open surgery for colon cancer, with the proviso
that population based data are unavailable at this time. In addi-
tion oncologic results for laparoscopic proctectomy for rectal
cancer have been concerning.(20)

Surgical Outcomes in Colorectal Cancer
There are a number of complications that occur following col-
orectal resections for cancer. Although some are difficult to
avoid, we will stress methods to reduce the frequency of these
complications and improve outcomes.
Anastomotic Complications
Anastomotic complications are some of the most feared compli­
cations in colorectal surgery patients. Although rare, the dev­elop­ment
of anastomotic complications results in a prolonged postoperative
stay with a high cost to the patient, the healthcare system, and
society. Perioperative anastomotic complications can also lead
to long-term consequences including stricture, abdominal wall
hernia, permanent diversion, poor functional outcome, and need
for reoperative therapy. A number of variables have been linked to
the development of anastomotic complications, particularly the
technique employed, the conditions under which the anastomosis
is constructed, and other patient characteristics.
Anastomotic Leak
One of the most devastating outcomes of a new anastomosis
for colorectal cancer is anastomotic leak, occurring in 3–6%
of all colorectal cases. These leaks occur more commonly with
more distal resections and are reported to be as high as 15.3%
for low rectal reconstructions.(21) Although the development
of leak is frequently attributed to surgeon error, from technique
or judgment, patient characteristics also importantly influence
the development of leaks. For example, renal failure, chronic
obstructive pulmonary disease, steroid use, elevated white blood
count, and malnutrition have all been attributed to anastomotic
leak.(22, 23) In addition, operative factors such as low rectal
anastomoses, colocolonic anastomoses, intraoperative septic
conditions, difficulties encountered during the anastomosis, and
use of blood transfusion have been implicated.(22) Although
surgical construction of the anastomosis is an important variable,
there is no difference in the development of anastomotic leak
whether the reconstruction is stapled, hand-sewn in one-layer, or
even two-layers.(24, 25)
With respect to anastomotic technique, emphasis should be placed
on providing an adequate blood supply and ensuring a tension-free
anastomosis. Adequate blood supply can be confirmed with mul-
tiple methods: by dividing the marginal artery of Drummond or
other arcades and encountering pulsatile bleeding or by confirm-
ing bleeding at the cut edge of the colon. A tension free anasto-
mosis is also critical and can be facilitated by high-ligation of
the feeding vessel although this maneuver is not always critical.
Other techniques to reduce tension and increase mobility include
separation of the greater omentum from the transverse colon and
adequate mobilization of the approximating ends. In the setting of
low pelvic anastomoses, especially those anastomoses constructed
following the use of neadjuvant therapy, a protective proximal
intestinal stoma should be considered in order to reduce the life-
threatening consequences of anastomotic leak.(26)
In addition to tension free methods and adequate blood flow,
the local conditions under which an anastomosis is created can also
doom the construction. Attention should be focused on the patient’s
preoperative nutritional status. Golub et al. have demonstrated that
 abdominal surgery for colorectal cancer
an albumin concentration <3 g/L is associated with anastomotic
leakage.(22) In a multivariate analysis these authors also dem-
onstrated a relationship between preoperative corticosteroid use,
peritonitis, bowel obstruction, chronic obstructive pulmonary
disease as well as perioperative transfusion and the incidence of
anastomotic leakage.(22) Other authors have identified periop-
erative conditions which increase the risk of anastomotic leakage
and they include obesity, malnutrition, weight loss >5 kg, and use
of alcohol.(27) If the patient’s nutritional status is in question
or the local conditions are not favorable, it advisable not to con-
struct an anastomosis. Once the unfavorable circumstances have
been corrected the patient can undergo restoration of intestinal
continuity under more favorable circumstances.
Bowel preparations have traditionally been employed to clear the
bowel of feces before colorectal operations. This practice was thought
to decrease the likelihood of anastomotic leak by limiting the passage
of stool through the newly constructed anastomosis. More recent data
reveal an increase in anastomotic complications with the routine use
of bowel preparations.(28) Others have similarly demonstrated more
wound infections in addition to increased rates of anastomotic leak
in patients receiving mechanical bowel preparations.(29) Because of
the temporary starvation and electrolyte imbalance sometimes asso-
ciated with mechanical bowel preparations, it is not clear that this
practice represents anything more than surgical dogma. Despite the
growing body of data describing an advantage to no bowel prepa-
ration, surgeons in North America seem slow to move away from
this long-held practice, with many arguing the difficulty in colonic
manipulation during laparoscopic surgery in an unprepped bowel.
See Chapter 2 for a full discussion of this topic.
Once an anastomotic leak develops, it often becomes evident
within 5 to 8 days following the procedure. Yet in a more recent series
of 1,223 patients with intestinal anastomoses, 36% were identified
more than 30 days postoperatively.(30) The diagnosis is usually sus-
pected by clinical factors and often confirmed by radiologic exami-
nation. Patients with early clinical evidence of anastomotic leak can
present with fever, tachycardia, abdominal distention and tender-
ness, ileus, early diarrhea, or possibly septic shock. Depending on the
patient’s clinical condition, presence of any one of these factors is
indication for examination with a radiologic study. If there are obvi-
ous signs of peritonitis or hemodynamic collapse then urgent explor-
atory laparotomy is often preferable. Radiological investigation can
be performed with either abdominopelvic computed tomography
(CT) or with a soluble contrast enema. There have been conflicting
reports as to the superiority of each technique (31, 32); however, CT
scans have the additional benefit of demonstrating other intraab-
dominal pathology such as hematomas or abscesses.
If an anastomotic leak is demonstrated by clinical or radio-
logic means, antibiotics should be administered and the patient
resuscitated. Surgical exploration is then indicated to wash-out
the abdominal cavity and examine the anastomosis. If conditions
are favorable intraperitoneal anastomosis can be reconstructed
although most anastomotic leaks generally require the construc-
tion of a stoma. Alternatively, the management of left-sided and
low pelvic anastomoses is more complex. If the leak is secondary
to bowel necrosis or ischemia and there is not sufficient bowel for
reanastomosis, a colostomy should be created with a Hartmann’s
pouch. This procedure should be performed with consideration
of the fact that the majority of these patients will be left with per-
manent stoma.(33) If there is sufficient bowel for reanastomosis
and local conditions are favorable, revision of the anastomosis can
be considered with the protection of a proximal loop ileostomy.
If there is dense inflammation surrounding the anastomosis, a
loop ileostomy should be constructed and a large drain placed in
the perianastomotic area. A large number of anastomotic leaks
associated with localized peritonitis and abscess formation can
often be managed nonoperatively.(32) If there is a contained col-
lection, the patient should be treated with intravenous antibiotics
and drainage of the abscess should be considered by radiologic
means.(34)
Anastomotic Stricture
Anastomotic stricture is a common occurrence following colorec-
tal anastomosis, occurring in up to 30% of cases.(35) Strictures are
often asymptomatic but may also present with partial or complete
large bowel obstruction. The mechanism of stricture formation
is not completely understood, but may be related to anastomotic
leakage, pelvic sepsis, radiation injury, or local ischemia.(36, 37)
Numerous nonrandomized trials and meta-analyses have demon-
strated a higher rate of stenosis with end-to-end stapled anastomo-
sis. The presence of a proximal diverting colostomy also seems to
increase the risk of stricture, possibly due to the lack of dilation by
the fecal stream.(38–40) However, patients who undergo proximal
diverting ileostomy have generally more difficult anastomoses and
often the ileostomy is formed because of the potentially higher risk
for leakage. Thus, the higher risk of leakage in these patients may
be confounded by local factors or patient variables that have been
difficult to describe to date.
Strictures typically present within the first postoperative year
(41) and can be managed with a number of different modalities,
depending on the anastomotic site. Many are asymptomatic and
will resolve on their own as the bulk of the fecal stream slowly
dilates the stenosis over the course of a few months. Before any
therapeutic procedure is undertaken the operator should be con-
fident that a new stricture does not represent a cancer recurrence.
If there is uncertainty by visual inspection, the diagnosis can eas-
ily be ascertained through a formal biopsy of the anastomosis.
Most colonic strictures following surgery can be managed with
sequential digital manipulation, bougeinage, or hydrostatic bal-
loon dilation. Patients often require several treatments before
complete resolution and repeat dilations are more common fol-
lowing resections for cancer than for benign causes.(42) Newer
techniques involve the use of endoscopic stents as well as endo-
scopic transanal resection of strictures. Small published series
using these techniques report safe and satisfactory long-term
outcomes.(43) Surgical revision of the anastomosis is occasion-
ally necessary when the stricture is not accessible by endoscopic
means or recurs after numerous less invasive procedures.
Anastomotic Bleeding
Postoperative bleeding related to intestinal anastomosis is a rela-
tively rare but potentially serious event. The incidence in stapled
colorectal anastomoses is 1.8–5%.(44, 45) The method of con-
struction, whether stapled or hand-sewn, appears to be unrelated
to the development of this complication.(46) The diagnosis of

 improved outcomes in colon and rectal surgery
anastomotic bleeding is typically inductive as patients will pass
variable amounts of maroon colored blood with their first bowel
movement. More active bleeding commonly presents with large
amounts of blood per rectum. To prevent this complication, we
perform a simple examination of the staple line through the
enterotomy. All visible bleeding is controlled with sutures rather
than electrocautery as applying thermal energy to the staple line
may increase the likelihood of a full thickness burn injury.
The initial management of postoperative hemorrhage is typi-
cally nonoperative. Greater than 80% of patients will stop bleeding
without intervention but nearly 50% of patients will require a trans-
fusion.(47) Often simple techniques such as correcting the coagul-
opathy and halting unfractionated or low molecular weight heparin
are sufficient. Alternatively, treatment for hemodynamically stable
patients includes endoscopic electrocoagulation of the anastomotic
line (48), or injection of the staple line with epinephrine or clips.(49)
Although others have proposed that proximal colonic anastomoses
should not be treated endoscopically (48), the data contraindicat-
ing this belief is minimal. If endoscopic methods fail, some patients
are candidates for angiographic embolization or vasopressin treat-
ment. Obviously, angiographic options should be exercised with care
as embolization may interrupt the blood supply to the anastomosis
and thus result in bowel infarction as well as anastomotic leak.(50)
In addition, the use of vasopressin is also associated with myocardial
and intestinal ischemia and should be employed with caution.(51, 52)
Failure of the aforementioned hemostasis methods will often require
exploratory laparotomy and revision of the anastomosis.
Pelvic Hemorrhage
Massive pelvic bleeding is a difficult complication that can occur
rarely during proctectomy or retroperitoneal dissection. This
bleeding usually results from inadvertent violation of the avas-
cular presacral plane and resultant damage to the presacral veins.
Presacral venous hemorrhage is difficult to control and can be a
significant source of postoperative morbidity and mortality.(53)
Conventional methods of hemostasis rarely are effective and usu-
ally result in increased bleeding. If encountered, bleeding should
be controlled with direct pressure while the anesthesiology team
appropriately resuscitates the patient. Laparotomy sponges are
used to tamponade bleeding while microfibrillar collagen and
absorbable gelatin can be used. If simple tamponade does not
control the bleeding then sterile titanium thumbtacks can be
inserted into the bleeding point on the sacrum.(54) In addition,
endoscopic multifeed staplers used in laparoscopic mesh hernia
repairs are available.(55) Others have described fixing a 4-cm2
piece of rectus muscle to the bleeding vessel while applying a
high frequency electrical current to the muscle until it adheres to
the presacral fascia.(56) Alternatively, bonewax can be used with
some efficacy on the sacrum. In the most difficult circumstances,
the pelvis is packed with sponges and the patient returned to the
operating room in 1–2 days for laparotomy pad removal.(57)
Splenic Injury
Iatrogenic injury to the spleen is a potentially serious complication
of colectomy with significant long-term adverse consequences. It
is defined as any injury to the spleen caused by the operating team
during a surgical procedure. Splenic injury occurs during 1.2 to

8% of colorectal resections (21, 57, 58), although these figures
likely underestimate the incidence of the problem as conserva-
tively managed splenic injuries are rarely reported. Splenic injury
is associated with the proximity of the lesion to the splenic flexure
although traction on the peritoneal band attaching the greater
omentum and spleen appears to be the most common mecha-
nism by which the spleen is injured.(59–61) Other mechanisms
of injury include retractor and direct instrumental damage.(62)
Langevin reported no injuries to the spleen in 733 procedures in
which the splenic flexure was not mobilized but 3.1% of patients
requiring splenic flexure takedown sustained splenic injuries.(21)
Mortality rates are higher in patients who sustain splenic injury
after gastrointestinal surgery, particularly colorectal surgery.(63,
64) Splenic injury is associated with a higher incidence of early
infections, potentially from hematoma formation and subsequent
superinfection (58) or loss of splenic function. In a recent review
of California Cancer Registry and California Patient Discharge
Data, patients undergoing colorectal cancer resection with inad-
vertent splenectomy had an increased length of stay and a 40%
increase in the probability of death.(65)
There are few evidence-based recommendations for avoid-
ing intraoperative splenic injury but basic surgical principles are
obviously essential. To maximize exposure, the surgical incision
should be appropriately elongated in order to obtain adequate,
tension free, visualization of the appropriate structures in open
surgery. All hand-held and self-retaining retractors should be
placed with care and under direct visualization. Some authors
have recommended a modified lithotomy position with the sur-
geon standing between the patient’s legs during flexure mobi-
lization. This positioning permits clearer visualization of the
structures in the left upper quadrant.(21) Unnecessary traction
on the transverse and left colon should be avoided. Consideration
should be given to dividing the lienocolic ligaments before com-
mencing any left colonic resection.(62) If there is suspicion of
tumor invasion into the spleen an en-bloc resection should be
performed. There is some data to suggest the benefits of lap-
aroscopy in mobilization of the spleen. Malek reported on iat-
rogenic splenectomies in 1911 laparoscopic resections and in
5,477 open colon resections. The authors reported 13 iatrogenic
splenectomies, yet none following laparoscopic resection.(66)
Prompt recognition at the time of surgery is the first step to
the successful management of iatrogenic splenic injuries. Once
an injury to the spleen is recognized, there are two options, either
splenectomy or splenic preservation. Timely management allows
the surgeon to manage bleeding at the first operation, while
delayed recognition results in reduced chances of splenic salvage.
(67) Optimally, the surgeon should attempt to salvage the spleen
unless blood loss prohibits the more time intensive salvage meth-
ods. Techniques for splenic salvage are generally extrapolated
from the trauma literature. Small, minimally bleeding, capsular
tears generally improve with gentle tamponade whereas more
active bleeders may require more intervention to achieve hemo-
stasis. There is a long experience with various hemostatic agents
such as thrombin, absorbable regenerated cellulose, and microfi-
brillar collagen. These are often placed on top of the bleeder and
underneath a surgical pack for tamponade.(68) If these simple
measures fail, bleeding can be controlled by segmental ligation
 abdominal surgery for colorectal cancer
of the feeding hilar vessels or splenorrhaphy. With severe splenic
injury, complicated by continued hemorrhage and hemodynamic
instability, the surgeon should obviously consider splenectomy.
If splenectomy is performed, the patient should be administered
pneumococcal, meningococcal, and H. Influenza vaccine in order
to prevent overwhelming postsplenectomy sepsis.(69)
Ureteral Injuries
Due to the proximity of the ureters to the colon, injury is a com-
mon concern during colorectal operations. Although injuries to
the ureters are uncommon during simple resections, when they
occur, they can be devastating. The ureters are most commonly
injured in colorectal procedures during one of several maneu-
vers; while ligating the inferior mesenteric artery or dissecting at
the sacral promontory or laterally in the pelvis during division
of the lateral stalks of the rectum. Unfortunately only 20 to 30%
of intraoperative ureteral injuries are recognized at the time of
the transgression.(70) Despite the fact that few injuries are recog-
nized intraoperatively, ureteral injuries are best treated during the
initial operation as the local conditions are likely to be the most
favorable for a successful repair. Prompt diagnosis and institu-
tion of appropriate corrective surgical procedures often result in
a very satisfactory outcome in about 94% of cases.(71)
In order to prevent ureteral injuries, patients with difficult
anatomy i.e. extensive pelvic adhesions after proctectomy, a large
pelvic mass, or a phlegmon that makes identification of normal
anatomy difficult, consideration should be given to preoperative
stent placement. Ureteral stents permit quicker intraoperative
ureter indentification but do not completely eliminate the risk of
injury. In addition, ureteral stents permit quicker recognition of
ureteral injuries, permitting immediate repair. Since these repairs
can be technically challenging, they should be performed by a
surgeon who is well versed with these repair techniques. General
guidelines include debridement of necrotic tissues, ensuring
excellent blood supply, and performing a tension-free anastomo-
sis. More distal injuries of the pelvic portion of the ureter may be
handled by reinplantation.(72)
Autonomic Nerves Injury
Genitourinary function can be greatly altered by injury to the
pelvic parasympathetic and sympathetic nerves during colorectal
resections. Proper oncologic resection for rectal cancer has been
associated with a significant incidence (10–69%) of urinary and
sexual dysfunction.(73) Although urinary dysfunction is often
limited to the first few postoperative days, sexual dysfunction
may persist for months or indefinitely. Both forms of postopera-
tive dysfunction are related to the patients’ preoperative function.
Total mesorectal excision with autonomic nerve preservation has
been advocated as an effective approach to the minimization of
pelvic nerve injury. This technique mobilizes the mesorectum
circumferentially with sharp dissection along the correct pelvic
parietal planes while avoiding the pelvic nerves.(73) In addition,
damage to the sympathetic plexus is often encountered during
high ligation of the inferior mesenteric artery. The hypogastric
nerves should be identified as they course over the sacral prom-
ontory and preserved. Anterior dissection should be avoided
when unnecessary as dissecting in Denonvilliers’ fascia places the
nervi erigentes at risk. We preserve Denonvilliers fascia unless
the tumor is anterior or circumferential. When total mesorectal
excision and autonomic nerve preservation are combined sev-
eral authors have demonstrated a low frequency of bladder and
sexual dysfunction.(74, 75) Both of these techniques should be
considered standard when undertaking resection of the rectum.
Functional Outcomes
Gastrointestinal function following rectal cancer resection is
quite variable depending on the patient’s preoperative status, use
of chemoradiation, anastomotic technique and local factors, and
the development of anastomotic complications. Today, sphinc-
ter preservation procedures are being performed with increas-
ing frequency for the management of mid-rectal and low rectal
cancers. However, preservation of intestinal continuity frequently
leads to continence disturbances which range from inadvertent
passage of flatus to frank leakage of stool necessitating pad use.
(76–82) Patients with a straight low anastomosis may also suf-
fer from urgency, frequency, and clustering of bowel movements.
Poor function after sphincter salvage largely results from a com-
bination of four factors: damage to the sphincter complex; loss
of normal anorectal sensation; a reduced rectal capacity and
compliance, and a reduction in large intestine length resulting in
more liquid effluent reaching the anal canal.(83) Increased effort
has thus been exerted to minimize dysfunction following proc-
tectomy with a focus toward reconstruction using a neorectum.
In recent years, improved functional outcomes have been
reported following anastomotic reconstruction with a colonic
J-pouch or coloplasty. The most studied and accepted reconstruc-
tion option at this time is the colonic J-pouch, which is associated
with improved physiological and functional outcomes as com-
pared to the straight anastomosis.(83) Until recently, the advan-
tages of a J-pouch were thought to be short-lived, but a recent
multicentered study revealed sustained functional advantages after
2 years postoperatively compared to both the straight coloanal
anastomosis and the coloplasty.(84) Another common technique
is the use of a side to end Baker anastomosis, which in the short-
term has equivalent functional results to the colonic J-pouch or
coloplasty.(85) Unfortunately, recent data suggest difficulty with
complete evacuation of the Baker anastomosis as compared to
the colonic J-pouch.(85) It is for these reasons that we recom-
mend colonic J-pouch reconstruction for low anastomoses at 6
cm or closer to the anal verge.
Patient-Centered Outcomes
There has been a growing interest in medical and surgical out-
comes which are most important to patients rather than tradi-
tional measures of morbidity and mortality. This interest has
developed from the growing concern that medical care fails to
properly assess the needs of the patient. Patient-centered out-
comes, such as patient satisfaction or quality of life are particularly
meaningful for colorectal cancer patients. Despite the embry-
onic status of patient-centered outcomes in the surgical fields,
there has been a growing push toward accurate measurement.
Over the past 10 years, the Agency for Healthcare Research and
Quality has funded and administered the Consumer Assessment
of Healthcare Providers and Systems (CAHPS) program, a joint

 improved outcomes in colon and rectal surgery
public and private initiative to develop standardized surveys of
patients’ experiences with ambulatory and facility-level care.(86)
CAHPS surveys provide information about patients’ care expe-
riences rather than traditional clinical performance indicators,
such as cured of disease or morbidity and mortality.
The surgeons’ ability to measure and understand quality-of-
life and other patient centered outcome would be of great value
to the colorectal cancer patient undergoing surgery. In practical
terms, patient expectations would be clearer. Few tested and useful
patient centered metrics have been evaluated and even fewer are in
use today.(87) Despite the lack of real progress in this area, insur-
ers, patients, and others are very interested in determining what
patients think of the treatments we provide them. At this time, sur-
geons need to work closely with others to facilitate more compre-
hensive and nontraditional outcomes following surgical care.
Conclusion
In summary, this chapter on improving outcomes for abdomi-
nal surgery in colorectal cancer provides an overview of poten-
tial complications, methods to reduce complications, methods to
improve outcomes, surgical outcomes presently measured, and
the future of patient-centered outcomes in colorectal cancer sur-
gery. We have particularly emphasized the impact of the quality
movement and the role of outcomes on quality measurement and
assurance. The information presented in this chapter is critical as
quality metrics and measurement are likely to become more and
more important to the individual practitioner. Given that sur-
gery for colorectal cancer has become increasingly more technical
due to the refinement of open as well as laparoscopic techniques,
outcomes measurement will become more and more important
as we prove to our patients, payers, Congress, and ourselves that
our outcomes are optimal. Although payers and other govern-
ment groups have become the drivers of quality improvement, it
is our duty to measure our own outcomes, assess the quality of
care that we provide, and compare our own results with our col-
leagues. Internal efforts to improve quality are the most likely to
bring about real meaningful changes in outcomes for colorectal
cancer.
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82. Miller AS, Lewis WG, Williamson ME et al. Factors that
influence functional outcome after coloanal anastomosis for
carcinoma of the rectum. Br J Surg 1995; 82: 1327–30.
83. Brown SR, Seow-Choen F. Preservation of rectal function
after low anterior resection with formation of a neorectum.
Semin Surg Oncol 2000; 19: 376–85.
84. Fazio VW, Zutshi M, Remzi FH et al. A randomized multi-
center trial to compare long-term functional outcome, qual-
ity of life, and complications of surgical procedures for low
rectal cancers. Ann Surg 2007; 246: 481–90.
85. Machado M, Nygren J, Goldman S, Ljungqvist O. Similar
outcome after colonic pouch and side-to-end anastomosis in
low anterior resection for rectal cancer: a prospective ran-
domized trial. Ann Surg 2003; 238: 214–20.
86. Consumer Assessment of Healthcare Providers and Systems.
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87. Morris AM. Patient-centered outcomes after therapy for
colorectal cancer. Surg Oncol Clin N Am 2006; 15: 195–211.
26 Transanal approaches to rectal cancer
Sachin S Kukreja and Theodore J Saclarides
Challenging Case
A 67-year-old male underwent a screening colonoscopy and is
referred because a 3 cm adenocarcinoma was found approxi-
mately 12 cm from the anal verge. Preoperative workup with a
transrectal ultrasound and CT scan showed the lesion appeared
to be a uT1N0 cancer without metastatic disease. He has multi-
ple medical problems including a myocardial infarction 3 months
prior and is not felt to be a good candidate for radical surgery.
Case Management
The patient is offered Transanal Endoscopic Microsurgery (TEM);
a complete full-thickness excision is successfully performed. Post­
operatively, he has urinary retention. A bladder scan reveals 700 L
of urine within the bladder and catheterization is performed. The
retention resolves overnight and the patient is discharged the next
morning. Pathologic evaluation of the specimen revealed a pT1N0
rectal cancer.
INTRODUCTION
There are approximately 42,000 newly diagnosed rectal cancers
in the United States each year and approximately 9,500 people
die from their disease. Although adjuvant therapies continue to
improve outcomes, surgical management remains the cornerstone
of therapy as few patients can be cured without a surgical resection.
Surgical approaches are varied and are chosen based on the degree
of rectal wall invasion, tumor histology, the presence or absence
of lymph node metastases, involvement of the anal sphincter and
nearby pelvic structures, and disease comorbidities. Either a local
excision (with or without adjuvant therapy) or radical, transab-
dominal surgery (and possible chemoradiation) can be chosen. The
surgical management for rectal cancer has been evolving signifi-
cantly over the last few decades and across geographic boundaries.
Rectal Cancer and Surgical Options
Traditional and more commonly applied treatment with total
mesorectal excision (TME) through either a low anterior (LAR)
or abdominoperineal resection (APR) is the standard against
which other procedures are compared. Such interventions are not
without significant morbidity, including anastomotic leak, wound
infection or dehiscence, colostomy malfunction, or pelvic dissec-
tion complications (including defecatory, urinary and sexual dys-
function, and fecal incontinence). Although such techniques are
well-accepted treatment modalities, the search for less invasive
and less morbid techniques that provide sphincter preservation
and acceptable cure rates has led to the evolution of a wide vari-
ety of alternative surgical procedures. Although less-invasive pro-
cedures including transanal fulguration, endocavitary radiation,
and transsphincteric or transsacral approaches have been utilized,
the transanal approaches have proven to be the most popular and
safest overall with less morbidity and mortality.(1)
Determining whether a patient may be a candidate for sphinc-
ter preservation (either through trans-anal or trans-abdominal
means) usually begins during the patient’s initial assessment.
More often than not, the patient comes to the surgeon after ­having
already undergone lower endoscopy. Rectal bleeding may have
prompted an evaluation or the patient may have been asympto-
matic. Nonetheless, key questions related to the patient’s bowel
habits are critical in the assessment. Symptoms of tenesmus often
signal the presence of a large tumor which usually requires radi-
cal transabdominal surgery. Anal pain, with or without defeca-
tion may imply involvement of the anal sphincters or pelvic floor,
precluding a sphincter-preserving operation. Patients with fecal
incontinence should be identified in the preoperative workup
since proctectomy and sphincter preservation may worsen conti-
nence, condemning them to significant fecal soilage, even if such
a procedure is technically possible.
Both digital rectal exam (DRE) and rigid sigmoidoscopy are
required in the evaluation. Localizing the lesion to the lower, mid-
dle, or upper third of the rectum helps determine what options the
patient may have. Involvement of the anal sphincter, the tumor’s
spatial relationship to the anorectal ring, and fixation to the ­pelvic
side walls are important physical findings that help guide the deci-
sion making process. Additionally, the patient’s overall medical
status must be taken into consideration as some may not be able
to tolerate a large abdominal operation due to a myriad of comor-
bidities. Finally, before planning surgery, a complete colonoscopy is
essential to rule out synchronous lesions elsewhere in the colon.
Accessible well-differentiated cancers that are <4 cm in size, lack
lymphovascular invasion, occupy <40% of the bowel wall circumfer-
ence, and do not invade the muscularis propria have historically been
considered the most amenable to a transanal approach. Although
these criteria are not necessarily strict guidelines, tumors larger than
this are associated with a significantly higher incidence of lymph
node metastasis. Many authors will not offer a transanal approach
for lesions larger than 3 cm in diameter due to the risk of incomplete
excision. Upon DRE, those masses that are immobile and fixed are
likely to be transmural and hence, require a traditional TME surgery
following neoadjuvant therapy. It is well established that even in the
most experienced of hands, manual exam alone can differentiate T1/
T2 tumors from T3/T4 tumors only 80% of this time. Lymph node
metastases can be detected digitally in only 50% of instances.(2)
Rigid proctosigmoidoscopy allows the clinician to evaluate and
more accurately localize the tumors beyond what is within reach
of the DRE within the middle and upper rectum. Lesions that
may have been labeled as being 15 cm from the anal verge with
flexible endoscopy may be closer to the anus when evaluated with
a rigid scope. Various imaging modalities exist and should be uti-
lized to assess depth of invasion and the presence of lymph node
involvement; these include CT scan, MRI, and transrectal ultra-
sound (TRUS). With its ease of use, widespread availability, and high

 improved outcomes in colon and rectal surgery
overall accuracy, many clinicians rely on TRUS in their standard
preoperative work-up for rectal cancer and consider it to be the best
method of preoperative staging. Many series cite an accuracy rate of
90% for staging rectal wall penetration and an 80% accuracy rate
for assessing the status of the perirectal lymph nodes. Factors such
as peritumoral fibrosis, inflammation, increasing tumor height, and
operator experience have all been shown to decrease the sensitivity
of TRUS.(3) Some authors recommend the routine use of MRI with
endorectal coils to maximize sensitivity.(4) Although traditionally
indicated for only early (T1) lesions, trans-anal excision (TA) and
TEM can be offered to patients with more advanced disease in spe-
cific clinical circumstances especially when combined with radiation
and chemotherapy. Conventional TA is more commonly utilized in
the United States than TEM; however, neither approach is capable
of addressing nodal disease to its full extent. As a result, appropriate
patient selection is critical when using either procedure with cura-
tive intent. Compared to TA, TEM is more likely to achieve negative
margins and cause less specimen fragmentation.
Transanal Excision
A significant number of low rectal cancers (less than 5–10 cm from
the anal verge) can be approached by transanal excision, particu-
larly those that are early stage. The justification for less invasive
techniques is largely established by the low rate of nodal metasta-
ses in T1 disease. In the absence of significant nodal involvement
identified by CT, MRI, or TRUS, one can estimate the incidence of
positive lymph nodes to be 3%—if the lesion is favorable (well to
moderately differentiated, confined to the mucosa and submucosa,
have no vascular invasion, and small size). By contrast, poor histo-
logical grade confers a 12% risk of nodal involvement.(5) Clearly,
the issues are the ability to identify nodal involvement before surgi-
cal intervention and to remove the lesion with negative margins.
Local excision (TA) is considered acceptable for T1 adenocar-
cinomas that carry favorable prognostic features. Such character-
istics include small size (<4 cm), lack of fixation, histology that is
either moderately or well-differentiated and absence of vascular,
perineural, or lymphatic invasion. Reports describe cure rates as
high as 90% with a recurrence rate of <10% for patients with the
above characteristics. Unfortunately, there is significant variation
in the data, as a recent review of 41 retrospective studies shows a
5-year local recurrence rate of 12% with a range of 0–19%.(6)
As a general rule, local excision may be considered for less invasive
tumors with good histological characteristics. Local excision can be
considered for T1 and T2 (controversial) lesions depending on the
clinical circumstance, but is considered contraindicated for T3 (par-
ticularly without adjuvant modalities) if one seeks oncologic cure.
Comparable oncologic outcomes could be expected in T1 low risk
rectal cancers removed with local excision without adjuvant ther-
apy when compared with classic total mesorectal excision (TME).
However, the outcomes are significantly worse for T2 lesions when
adjuvant therapies were not applied. Recurrence rates in early T1 and
T2 disease are clearly affected by unfavorable histological character-
istics (e.g., Grade III, lymphovascular invasion). Because of this, local
excision alone is considered inadequate for T2, T3 tumors; some
authors, however, offer these patients neoadjuvant therapies.
Although there is clearly a role for TA excision in T1 disease
with favorable characteristics, many surgeons are looking at the

feasibility of treating more advanced cancers with less invasive
modalities than traditional TME. Studies that have evaluated
outcomes with T2 and T3 tumors are difficult to interpret due
to overall small population size and their retrospective nature;
however, several clinical reports demonstrated promise for treat-
ing more advanced disease, some showed improved outcomes
with adjuvant therapies before or after local excision.(7) A single
multicenter trial showed that local excision could control rectal
adenocarcinoma and reduce sphincter dysfunction with an over-
all 6-year survival of 85% and disease-free survival rate of 78% in
select T1 and T2 cancers (<4 cm, <40% circumference, negative
histological margins, and node-negative). It should be noted that
the oncologic outcomes for T1 lesions and T2 lesions treated with
adjuvant chemoradiation were roughly equivalent and ­differences
between histological grade was not evaluated.(8)
Locally advanced T3 rectal cancers represent an area of evolving
research. Although most centers offer such patients neoadjuvant
therapies followed by TME, some surgeons are attempting TA
excision on these tumors with satisfactory results. In a 2002 study
from the University of Florida, Dr. Schell performed TA excision
on patients whose tumors had been significantly downstaged
from T3 with neoadjuvant chemoradiation (15% of patients of
an initial 74). There was no local recurrence or nodal metastasis
after a mean follow-up of 55.2 ± 8.9 months (one patient devel-
oped distant metastasis). These patients had lesions 1–7 cm from
the anal verge. Although the overall study size was limited and
should not be considered the standard of care, it offers promise for
those patients with advanced disease who may not be candidates
for or refuse TME.(9) Similar results were demonstrated at the
University of South Florida in 2001. Twenty-six patients with T2
or T3 disease (5 uT2N0, 13T3N0, 7T3N1 and 1 un-staged patient)
underwent neoadjuvant therapy and subsequent local excision.
Following excision, no specimens had vascular, neural, or lym-
phatic invasion and six contained lymph nodes in the perirectal fat
without evidence of metastatic disease. Partial pathologic response
was demonstrated in nine and complete response in 17 patients.
Of the partial responders, all were offered but only two underwent
subsequent APR. With a mean follow-up of 24 months, none of
the complete responders had demonstrated recurrence.(10)
Transanal excision may remove perirectal lymph nodes directly
adjacent to the lesion while other nodes in the mesorectum may
still harbor metastatic disease. For this reason, some authors
favor adjuvant or neoadjuvant therapy (radiation with or with-
out chemotherapy) for more advanced lesions. The majority of
studies reporting recurrence rates are variable in their follow-up
and ultimate outcomes making interpretation difficult, but the
data does suggest a benefit for adjuvant therapies in this setting.
Risk factors for recurrence are related to the depth of the primary
tumor, surgical margins, histologic grade, and the status of the
perirectal nodes. Overall recurrence rates are decreased when local
excision is combined with radiation and chemotherapy, ranging
from 0–15% for T1 and T2 lesions, and 0–20% for T3 lesions.
(11–16) A review of the literature with regards to local excision
and recurrence rates with and without adjuvant therapies was
performed by Sengupta in 2001.(6) A summary of outcomes in
these patients is summarized and demonstrates the variability in
recurrence rates (Table 26.1).
 transanal approaches to rectal cancer

Table 26.1  Local Recurrence Rates by T-stage and Adjuvant Therapy (Sengupta, 2001, Ref. 6).
Local Recurrence Rates (%)

Study Follow-up Local Excision Alone Local Excision and Adjuvant Therapy

T1 T2 T3 T1 T2 T3
Mellgren et al. 2000 4.4 years 18a 47a
Russell et al. 2000 6.1 years 7 (1/14) 0 (0/13) 16 (4/25) 23 (3/13)
Chakravarti et al. 1999 51 month 11a 67a 0a 15a
Graham et al. 1999 56 month 0 (0/4) 0 (0/2) 0 (0/9) 0 (0/5)
Steele et al. 1999 48 month 5 (3/59) 13.7 (7/51)
Varma et al. 1999 6 years 4.7 (1/21) 45.5 (5/11) 25 (1/4) 0 (0/3) 0 (0/9) 0 (0/6)
Wagman et al. 1999 41 month 0 (0/8) 24 (6/25) 25 (2/8)
Le Voyer et al. 1999 46 month 6.7 (1/15) 12.5 (2/16) 25 (1/4)
Benoist et al. 1998 57 month 10 (2/19) 25 (2/8) 33 (1/3)
Kim and Madoff 1998 NS 9 (4/44) 24 (6/25) 50 (1/2)
Taylor et al. 1998 52 month 24 (6/25) 50 (4/8) 100 (1/1) 50 (1/2) 11 (1/9) 50 (1/2)
Bleday 1997 40.5 month 9 (2/22) 0 (0/21) 40 (2/5)
Valentini et al. 1996 54 month 11 (1/9) 17 (2/12)
Baron et al. 1995 55.3 month 19 (8/42) 20 (7/34) 27 (3/11)
Frazee et al. 1995 30 month 10 2/21 0 (0/9) 0 (0/2)
Willett et al. 1994 48 month 17a 20a
Ota et al. 1992 36 month 0 (0/16) 6.7 (1/15) 20 (3/15)
Huber and Koella 1992 NS 22 (2/9) 23 (3/13) 33 (2/6)
Cuthbertson and Simpson 1986 51 month 12.5 44 (4/9)
Killingback 1985 >18 month 17.8 (5/28) 33 (2/6)
Steams et al. 1984 ≥5 years 6.7 (1/15) 14 (2/14) 50 (1/2)
Hager et al. 1983 33–40.5 month 8.3 (3/36) 16.7 (3/18)

Note: NS = not stated.

a. Five-year actuarial local recurrence rates.

Techniques of Transanal Excision
Before surgery, rigid proctoscopy is done to determine the exact
location of the lesion and whether or not it is accessible with
conventional instrumentation. The rest of the colon is checked
for synchronous neoplasms with either colonoscopy or a contrast
enema. Overall fitness for general anesthesia is determined. In
preparation for the operation, a bowel cleansing is performed, this
will eliminate formed stool from the rectum and enhance visibil-
ity. The patient is positioned on the operating room table so that
access to the lesion is provided, this usually necessitates the prone
position for anterior lesions, the lithotomy position for posterior
lesions, and the decubitus position for laterally based lesions.
Various self-retaining retractors are available and are placed in the
anus and deployed. Once the lower edge of the lesion is visualized,
a clamp is placed on normal mucosa under the lesion and down-
ward traction is applied to the clamp. Stay sutures may facilitate
this process. This downward traction is an ongoing process dur-
ing excision so that the entire lesion is delivered into the operative
field. A rim of normal appearing mucosa is marked with cautery
points around the lesion and then a full thickness excision is per-
formed. It is important to obtain hemostasis as one proceeds since
a bloodless field is vital for maintaining ­visibility. Once the lesion
is excised, the wound is closed transversely so as to avoid nar-
rowing the rectal lumen. Transanal excision using conventional
instrumentation is limited to lesions located in the lower and pos-
sibly the mid rectum and for lesions which are not larger than 3 to
4 cm in diameter. More proximally located or larger lesions may
be beyond the capability of these retractors, however, this is highly
variable depending on the ­surgeon’s expertise, the body habitus of
the patient, and the laxity of the rectal wall.
Overall the complication rate from transanal excision is con-
sidered low and is usually limited to urinary retention, urinary
tract infection, bleeding, fecal impaction, and infections in the
perirectal and ischiorectal space. Most series cite a mortality of
virtually zero.
Transanal Endoscopic Microsurgery (TEM)
The introduction of Transanal Endoscopic Microsurgery (TEM)
by G. Buess over two decades ago opened the door to transanal
resection of lesions (both benign and malignant) beyond the
reach of conventional TA instruments with increasingly favorable
results through a method less invasive than radical open surgery.
Additionally, appropriately sized tumors with certain specified
histological characteristics could be removed with outcomes com-
parable to traditional surgery. With the potentially high recur-
rence rate of pT1 disease with TA excision and the morbidity of
traditional TME, many surgeons have been investigating TEM.
When compared with TA excision, the technique of TEM allows
for superior visualization, access to lesions further from the anal
verge within the mid and upper rectum, en-bloc resection rather
than fragmentation, and possible excision of the mesorectal fat
and the nodes contained within (Figure 26.1). Local recurrence
rates may be lower with TEM (compared with TA) excision due to
a reduced risk of implantation of viable tumor cells in the wound,
less tissue fragmentation of the tumor, and a higher likelihood of
obtaining negative margins.(1)
The safety and outcomes for TEM in T1 lesions with favorable
characteristics has been well-established. For this reason, TEM
alone is only indicated for T1 tumors if one seeks oncologic cure.
Multiple clinical trials have shown favorable oncologic outcomes


 improved outcomes in colon and rectal surgery
Figure 26.1  Schematic of TEM Specimen.
and low morbidity with virtually zero mortality. Winde was the
first to demonstrate in a randomized prospective trial that there
was no statistically significant difference in outcome between
TEM (n = 24) and open radical surgery (n = 26) for pT1 tumors
with a 5-year survival of 96% for both techniques. Overall, the
local recurrence rate was 4.1% for TEM (0% with radical surgery).
Patients who underwent TEM had decreased operative times, less
blood loss, a shorter hospital stay, lower analgesic needs, and less
morbidity.(17) Our personal experience from 1991–2003 (n = 53)
showed low recurrence rates and acceptable oncologic results in
patients with pT1 disease. In these patients, the average distance
from the anal verge was 7 cm (25% of which were further than
10 cm from the anal verge) and the average tumor size was 2.4 cm
with a local recurrence rate of 7.5%.(18)
Using TEM to cure rectal cancer has been largely limited to
“low-risk” T1 lesions while its role in T2 and T3 lesions is evolving.
TEM without adjuvant therapy is inadequate for T2 and greater
lesions and can be expected to have recurrence rates of 20–25%.
Tumors staged to pT2 have a high risk of lymph node metastasis
(16–40%).(5) Because many patients with rectal cancer are older,
may be either unfit to undergo radical resection, or refuse TME
due to its morbidities and the potential for an ostomy, many seek
to broaden the applications of TEM.
Multiple trials have taken place to evaluate the feasibility of
achieving adequate oncologic results with the overall improved
morbidity profile of TEM. In a study aimed to more clearly identify
T2 disease as potentially amenable to TEM, Lezoche randomized
70 patients equally to either TEM or LAR following neoadjuvant
therapy. These patients all had tumors <6 cm from the anal verge
and were <3 cm in overall size. After a minimum 5-year follow-up
(median 84 months), the local recurrence rate was 5.7% with TEM
and 2.8% with LAR. Distant metastasis was observed in 2.8% with
both population groups having equivalent survival of 94%.(19)
Similar results were noted when TEM and radical surgery groups
were compared when T1 (n = 52 and 17, respectively) and T2
(n = 22 and 83, respectively) lesions followed for 5 years after TEM
excision without adjuvant therapies. Their 5-year survival was equiv-
alent but the TEM group demonstrated a significantly increased local
recurrence rate for T2 lesions at 19.5% vs. 9.4%.(20)
Other studies followed the course of disease in those patients
that were either upstaged after what was thought to be T1 disease

before excision but did not receive further surgical therapy, or those
who were unfit or unwilling to undergo a more radical operation
for their advanced disease at time of initial presentation. Borschitz
retrospectively evaluated patients who had undergone TEM exci-
sion of “low-risk” T1 lesions, but were found to be pT2 (n = 44)
and did not undergo further surgery or treatment (n=14). It was
determined that local excision for T2 lesions was insufficient with-
out adjuvant therapies or radical reoperative resection. This was
true despite an R0 resection, “low-risk” lesions had a 29% local
recurrence rate within less than 2 years’ follow-up. If the patients
were “high-risk” or had positive or unclear histological margins, the
recurrence rate nearly doubled. “High-risk” lesions had poor tumor
grade, lymphatic invasion, or blood vessel involvement. With imme-
diate (within 4 weeks) reoperation, these patients had outcomes
similar to conventional surgery barring the presence of lymph
node metastasis. In those patients with “high-risk” characteristics,
lymph node metastases were more common and occurred despite
reoperation with significant local and systemic recurrence rates.
These patients should receive adjuvant chemoradiation following
their radical resections per standard protocols.(21) Although there
are more studies analyzing outcomes of TEM with both adjuvant
and neoadjuvant therapy, studies of adequate size and power are
still lacking and the indications for local curative surgery for lesions
more advanced than T1 remain gray.
In conclusion, there are few prospective studies evaluating the
benefits of adjuvant therapies and retrospective studies can be dif-
ficult to interpret. Overall, like transanal excision, recurrence rates
for lesions treated with TEM combined with adjuvant therapy are
lower when compared to TEM alone for T2 lesions. Preliminary
results and reviews of smaller trials comparing TEM excision of T2
lesions with postoperative chemoradiation seem to be on par with
the results of APR with adjuvant therapy from an oncologic per-
spective. As a result, the recommendation from some is to provide
adjuvant therapies for all lesions that are T2 or greater; whereas
TEM or TA alone are considered acceptable for T1 “low-risk”
lesions given the low likelihood of lymph node involvement.
Techniques of Transanal Endoscopic
Microsurgery
TEM resolves many of the limitations posed by conven-
tional transanal excision techniques, namely limited access to
lesions located beyond the distal rectum and poor visibility.
Consequently, the applicability of minimally invasive surgery
for rectal cancer is broadened. TEM employs an airtight, self-
contained system that constantly distends the rectum with
carbon dioxide insufflation, this along with the magnification
provided by the scope greatly improves visibility and allows for
a more precise excision and wound closure. As a result, one is
more likely to obtain tumor-free margins and avoid tumor frag-
mentation during the operation. The combined endosurgical
unit regulates four functions simultaneously. In addition to gas
insufflation, it allows for suction of smoke and blood, irrigation
of the scope lens, and monitoring of intrarectal pressure. The
stereoscopic binocular eyepiece provides four times magnifica-
tion of the field, alternatively, vision may be transmitted to a
video monitor. The long shafted instruments necessary for the
dissection are inserted through air tight working ports on the
 transanal approaches to rectal cancer
facepiece of the scope which is 20 cm in length. Depending on
the curvature of the sacrum, this scope may easily reach lesions
located in upper rectum or even at the rectosigmoid junction.
Patients are prepared for surgery in a fashion similar to con-
ventional transanal excision. A bowel cleansing is paramount.
The operation is performed under general anesthesia. Patients
are positioned on the operating room table so that the lesion
is located downward relative to the end of the scope. Again, for
posterior lesions, patients are placed in the lithotomy position,
while the prone position is chosen for anterior lesions. Once the
lesion is visualized, cautery points are placed 1 cm around the
lesion and a full thickness excision is performed. The specimen
is then fixed to a cork board or Telfa paper in order to orient the
pathologist to the deep and lateral margins. The wound is closed
transversely with a monofilament suture. Most patients can be
released the same day.
Complications of Transanal and TEM
The complication rates of TEM are significantly lower than
­traditional radical surgery. In a review of 12 studies performed by
Casadesus in 2006, the morbidity of 893 patients was evaluated.
(22) Complications were noted in 15.9% of the patients overall,
more than half of which were related to urinary retention or tran-
sient incontinence. These complications are typically seen early in
the postoperative period and very few patients required interven-
tion other than catheterization for resolution. The rate of bleed-
ing was also extremely low, seen in approximately 3% of cases of
TEM and rarely required either transfusion or operative interven-
tion. Postoperative fever, pelvic pain, and myocardial infarction
have been reported but are also extremely rare. Throughout the
literature, there is only one reported case of death directly follow-
ing TEM. This patient died from septic shock 4 weeks following
TEM excision of a rectal adenoma secondary to a retroperitoneal
phlegmon.(23) With TEM surgery, there is always the possibility
of rectal perforation, particularly with anteriorly located lesions.
Major complications of perforation, wound dehiscence, and
­fistula formation have all been reported. Perforation with intraab-
dominal contamination is a rare complication and is clearly both
operator and patient dependent and may require conversion to
an open operation for control. This can be especially problematic
in the older female who may have undergone prior hysterectomy.
Perforation in these patients may yield fistula formation. Wound
dehiscence has been described but is also a rare, but potential
complication. In a large review of 334 patients, a major complica-
tion rate of 5.5% was cited. This included both intraperitoneal
sepsis (n=3) and rectovaginal fistula (n=3).(24)
The vast majority of TEM outcomes are reviewed in terms of
oncologic results and complication rates. Remembering that one
of the reasons for the promotion of less invasive procedures is
sphincter preservation, some studies have analyzed continence
and sphincter function postoperatively. Manometric studies of the
anal sphincter have shown that the main risk for anal dysfunction
after TEM is preoperative anal dysfunction. Additionally, other
causes of postoperative anal dysfunction are advanced patient age,
direct tumor involvement of the sphincter, postoperative internal
sphincter defects, the extent and depth of tumor excision, loss of
anal mucosa, and duration of the procedures. Sphincter function
is affected by rectoanal perception and coordination, and electro-
sensitivity of the anal mucosa—all of which are affected by TEM.
Some patients also report an increase in bowel frequency which
is likely related to decreased rectal compliance following reduc-
tions in the overall rectal diameter from full-thickness or circum-
ferential excisions.(22) Despite these reports, complication rates
related to altered bowel habits remains exceedingly low (less than
2%) and the majority of these changes such as decreased resting
pressures are seen during physiologic testing, but are not often
clinically significant.(25, 26)
Transanal (TA) vs. Transanal Endoscopic
Microsurgery (TEM)
Few reviews directly comparing the results of TA vs. TEM excision
exist. Surgeons at the University of Vermont recently reviewed 171
patients treated between 1990 and 2005 by either traditional TA
excision (n = 89) or TEM (n = 82) for rectal cancers.(27) During
the course of their experience, they transitioned to the TEM
technique in 2001, after which only 20 TA excisions took place.
Although the results of seven surgeons were reviewed, only one
performed all the TEM. The two populations were similar with
respect to age, gender, lesion type, stage, and size with an overall
mean follow-up of 37 months (significant difference in follow-up
between the two groups due to their change to primarily TEM
during the time period studied). All patients with T1 lesions
with adverse features or T2 lesions received postoperative adju-
vant therapy. Patients with T3 lesions underwent local excision
only if they were considered too high risk for radical ­surgery or
if they refused traditional resection. The decision to give patients
with T3 lesions postoperative chemoradiation was made on an
­individualized basis.
Postoperative complications among the TA and the TEM
group were roughly equivalent (15% and 17%, respectively, p =
0.69) with the most common being urinary retention (6% and
7%, respectively). The TA group had six major complications
including two anovaginal fistulae, one leak requiring an opera-
tion, one bleed, one arrhythmia, and one patient who developed
renal failure. The TEM group had two anovaginal fistulae and two
leaks requiring operations. Overall, the difference between the
two groups was not found to be significant. However, the patients
who did undergo TEM enjoyed a significantly shorter hospital
stay (0.6 days vs. 1.5 days). With regards to oncologic outcomes,
90% of the patients who underwent TEM had negative margins.
TA patients had both a higher positive margin rate (15%) and
indeterminate margin rate (15%) (p=0.001). Specimens were
more likely to be removed intact rather than in a piece-meal
fashion with TEM vs. TA (95% vs. 65%, p < 0.001). Lastly, local
recurrence rates were dramatically improved with TEM (8% vs.
24%, p = 0.004) and such results were concordant with other ret-
rospective reviews. Two-thirds of the local recurrences with TEM
occurred after palliative resections defined as being T3 at the time
of diagnosis or patients were either too ill to tolerate or refused a
more radical operation. When considering only those TEM and
TA cases performed with curative intent, the recurrence rate fell
to 3% vs. 26% with transanal approaches (p = 0.06). No signifi-
cant difference in distal recurrence was demonstrated (1% with
TEM, 4% with TA). Although a criticism of the above data is the

 improved outcomes in colon and rectal surgery
Table 26.2  Outcomes with Transanal (TA) vs. Transanal Endoscopic
Microsurgery (TEM) for lesions up to T3 (Moore, 2008).
TA (n = 89)
TEM (n = 82) n (%) or Mean ± SD P Value
Any complication (yes) 12 (15) 15 (17) 0.69
Major complication 4 (33) 6 (40) poor differentiation and lymphovascular invasion, and of course,
Minor complication 8 (67) 9 (60) those whose excision is incomplete. Studies of patients that had
LOS (days) 0.63 ± 1 1.46 ± 3 0.007
Specimen fragmentation < 0.001
Whole 77 (94) 58 (65)
Fragmented 5 (6) 28 (31) characteristics had a significantly elevated risk of local recurrence
Unreported 0 (0) 3 (3) necessitating salvage surgery.(29)
Margins negative 74 (90) 63 (71) 0.001
Positive Recurrence 4 (5) 24 (29) 0.01
All cause mortality 2 (2) 26 (29) 0.01
disparity in follow-up between the two groups, most feel that the
vast majority of recurrences will usually occur within the first
2 years and the mean follow-up for both groups was well beyond
this time frame. With this, TEM appears to offer superior out-
comes to TA in patients with T1 or T2 lesions with appropriate
adjuvant therapies (Table 26.2).(27)
The Clear Advantages of Local Surgery
Although the oncologic advantages of TA or TEM excision of rec-
tal cancers remain controversial in many circles, few can argue the
benefits of pursuing a less invasive procedure. For patients whose
medical comorbidities may place them at a higher or even unac-
ceptable operative risk, TA or TEM approaches offer a solution
that may confer acceptable oncologic outcomes as well. The same
is true for those patients that have advanced disease but require
palliation of symptoms. Patients with unresectable distant dis-
ease, however, usually have large bulky primary tumors which
are not amenable to transanal excision. Both LAR and APR are
associated with significant morbidity and mortality which can
be avoided with either TA or TEM excision in the appropriately
selected patient. In patients who undergo traditional TA or TEM,
the overall complication rates remain low and overall morbid-
ity is minimal. A review of patients who had undergone TEM as
compared with TME showed that although long-term quality of
life was equal, patients who underwent TEM tended to have fewer
defecation disorders, and, although not statistically significant,
improved sexual function as well.(28)
When Local Surgery Fails
Following TA or TEM excision, aggressive surveillance is indicated
to detect recurrent disease. The reason for both local and distal
recurrence is not always clear, particularly in the face of what was
considered early disease and in the absence of involved excisional
margins. With regard to distant failure, occult disease may have
been present at the time of initial presentation but not identified
during the preoperative workup. In these instances, distant fail-
ure is not due to presumed inadequate local treatment, but rather
is a reflection of aggressive tumor biology. Local recurrence is
more frequently related to the mesorectal disease rather than at
the pelvic walls.(3) Additionally, fragmentation of the specimen

at the time of excision and the inability to remove full thickness
tissue during excision can predispose to local recurrence. In the
presence of recurrent rectal cancer, there is currently no role for
either TA or TEM from an oncologic perspective. Factors asso-
ciated with an increased risk of local recurrence include those
characteristics previously described as “high risk” which include
undergone TEM for T1 and T2 lesions without evidence of lymph
node metastasis found that patients who lesions carried the above
Recurrent disease requires a TME by way of either an LAR or
APR. Patients that undergo salvage TME have decreased survival
when compared with their counterparts that had the operation as
part of the initial management. In a study that evaluated patients
who had initially undergone TA excision (n=155) for lesions with
adverse histological characteristics and subsequently salvage APR
(n=21), the disease free survival was only 56% vs. 94% for those
who undergone immediate APR.(30)
Future Directions of Study
Traditional TA surgery is evolving into TEM in many circles as
surgeon familiarity and advanced laparoscopic skills become
increasingly prevalent. Although TA is widely practiced by many,
TEM confers the benefits of TA surgery with multiple clear clini-
cal advantages. The indications for TEM will continue to increase
in number as improved outcomes for more advanced disease are
demonstrated throughout the literature. Sentinel lymphangiog-
raphy may soon be applicable to colon and rectal cancer with
potential TEM utilization. Additionally, with neoadjuvant thera-
pies for advanced disease becoming increasingly effective in many
patients, subjecting such patients to radical surgeries after their
malignancies have often been reduced to a scar may prove to be
unnecessarily aggressive, further opening the door to TEM and
potential resection of the tissue that previously contained malig-
nancy. Research into necessary tissue margins for TEM following
such therapies is currently being undertaken. Although there will
always be a role for traditional TME in the form of both LAR and
APR procedures, the role of TA and TEM surgery continues to
expand within the management of rectal cancer.
References
  1. Whiteford MH. Transanal endoscopic microsurgery (TEM)
resection of rectal tumors. J Gastrointest Surg 2007; 11(2):
155–7.
  2. Nicholls RJ, Mason AY, Morson BC et al. The clinical staging
of rectal cancer. Br J Surg 1982; 69(7): 404–9.
  3. Bretagnol F, Rullier E, George B et al. Local therapy for rec-
tal cancer: still controversial? Dis Colon Rectum 2007; 50(4):
523–33.
  4. Maslekar S, Pillinger SH, Monson JR. Transanal endoscopic
microsurgery for carcinoma of the rectum. Surg Endosc
2007; 21(1): 97–102.
  5. Hermanek P, Gall FP. Early (microinvasive) colorectal carci-
noma. Pathology, diagnosis, surgical treatment. Int J Colorectal
Dis 1986; 1(2): 79–84.
 transanal approaches to rectal cancer
  6. Sengupta S, Tjandra JJ. Local excision of rectal cancer: what
is the evidence? Dis Colon Rectum 2001; 44(9): 1345–61.
  7. Ruo L, Guillem JG, Minsky BD et al. Preoperative radiation
with or without chemotherapy and full-thickness transanal
excision for T2 and T3 distal rectal cancers. Int J Colorectal
Dis 2002; 17(1): 54–8.
  8. Steele GD Jr, Herndon JE, Bleday R et al. Sphincter-sparing
treatment for distal rectal adenocarcinoma. Ann Surg Oncol
1999; 6(5): 433–41.
  9. Schell SR, Zlotecki RA, Mendenhall WM et al. Transanal excision
of locally advanced rectal cancers downstaged using neoadju-
vant chemoradiotherapy. J Am Coll Surg 2002; 194(5): 584–90.
10. Kim CJ Yeatman TJ, Coppola D et al. Local Excision of T2
and T3 rectal cancers after downstaging chemoradiation.
Ann Surg 2001; 234(3): 352–8.
11. Wong CS, Stern H, Cummings BJ. Local excision and post-
operative radiation therapy for rectal carcinoma. Int J Radiat
Oncol Biol Phys 1993; 25(4): 669–75.
12. Chakravarti A, Compton CC, Shellito PC et al. Long-term
follow-up of patients with rectal cancer managed by local
excision with and without adjuvant irradiation. Ann Surg
1999; 230(1): 49–54.
13. Paty PB, Nash GM, Baron P et al. Long-term results of local
excision for rectal cancer. Ann Surg 2002; 236(4): 522–9.
14. Bailey HR, Huval WV, Max E et al. Local excision of carci-
noma of the rectum for cure. Surgery 1992; 111(5): 555–61.
15. Willett CG, Compton CC, Shellito PC et al. Selection factors
for local excision or abdominoperineal resection of early stage
rectal cancer. Cancer 1994; 73(11): 2716–20.
16. Mendenhall WM, Morris CG, Rout WR et al. Local excision
and postoperative radiation therapy for rectal adenocarci-
noma. Int J Cancer 2001; 96(Suppl): 89–96.
17. Winde G, Nottberg H, Keller R et al. Surgical cure for early
rectal carcinomas (T1). Transanal endoscopic microsurgery
vs. anterior resection. Dis Colon Rectum 1996; 39(9): 969–76.
18. Floyd ND, Saclarides TJ. Transanal endoscopic microsurgi-
cal resection of pT1 rectal tumors. Dis Colon Rectum 2006;
49(2): 164–8.
19. Lezoche G, Baldarelli M, Guerrieri M et al. ������������������
A prospective ran-
domized study with a 5-year minimum follow-up evaluation
of transanal endoscopic microsurgery vs. laparoscopic total
mesorectal excision after neoadjuvant therapy. Surg Endosc
2008; 22(2): 352–8.
20. Lee W, Lee D, Choi S et al. Transanal endoscopic microsur-
gery and radical surgery for T1 and T2 rectal cancer. Surg
Endosc 2003; 17(8): 1283–7.
21. Borschitz T, Heintz A, Junginger T. Transanal endoscopic
microsurgical excision of pT2 rectal cancer: results and pos-
sible indications. Dis Colon Rectum 2007; 50(3): 292–301.
22. Casadesus D. Transanal endoscopic microsurgery: a review.
Endoscopy 2006; 38(4): 418–23.
23. Klaue HJ, Bauer E. Retroperitoneal phlegmon after transanal
endoscopic microsurgical excision of rectal adenoma. Chirurg
1997; 68(1): 84–6.
24. Mentges B, Buess G, Schafer D et al. Local therapy of rectal
tumors. Dis Col Rectum 1996; 39(8): 886–92.
25. Kennedy ML, Lubowski DZ, King DW. Transanal endoscopic
microsurgery: is anorectal function compromised? Dis Colon
Rectum 2002; 45(5): 601–4.
26. Cataldo PA, O’Brien S, Osler T. Transanal endoscopic
microsurgery—a prospective evaluation of functional
results. Dis Colon Rectum 2005; 48(7): 1366–71.
27. Moore JS, Cataldo PA, Osler T et al. Transanal endoscopic
microsurgery is more effective than traditional transanal
excision for resection of rectal masses. Dis Colon Rectum
2008; 51(7): 1026–30.
28. Doornebosch PG, Tollenaar RA, Gosselink MP et al. Quality
of life after transanal endoscopic microsurgery and total
mesorectal excision in early rectal cancer. Colorectal Dis
2007; 9(6): 553–8.
29. Lee WY, Lee WS, Yun SH et al. Decision for salvage treatment
after transanal endoscopic microsurgery. Surg Endosc 2007;
21(6): 975–9.
30. Baron PL, Enker WE, Zakowski MF et al. Immediate vs. sal-
vage resection after local treatment for early rectal cancer.
Dis Colon Rectum 1995; 38(2): 177–81.

27 Abdominoperineal resection
W Brian Perry, Fia Yi, Clarence Clark, and Danny Kim
Challenging Case
A 64-year-old woman is 7 days s/p an abdominopernneal resec-
tion for a T2N1 rectal adenocarcinoma. She had received preop-
erative. Her perineal wound has developed increased tenderness,
is swollen, and is draining pus.
Case Management
The patient’s wound is opened and the patient is started on three
times a day dressing changes. After 2 days the wound is clean and
a vacuum assisted closure (VAC) dressing is placed.
Introduction
Abdominoperineal resection (APR) completely removes the dis-
tal colon, rectum, and anal sphincter complex using both ante-
rior abdominal and perineal incisions, resulting in a permanent
colostomy. Developed more than 100 years ago, it remains an
important tool in the treatment of rectal cancer despite advances
in sphincter-sparing procedures. We will examine a brief history
of this procedure, current operative techniques and complica-
tions, expected results, (both oncologic and with regard to quality
of life), and what the future may hold for this procedure.
Several recent reports have noted the increase in the use of
sphincter-sparing options for patients diagnosed with rectal can-
cer. Abraham and colleagues found a 10% decrease (60.1–49.9%)
in the rate of APR from 1989 to 2001 as compared with low ante-
rior resection (LAR) using national administrative data.(1) When
controlled for several variables, including patient demographics
and hospital volume, patients were 28% more likely to have an
LAR later in the study period. Schoetz notes that LAR outnum-
bers APR three to one in the submitted case logs of recent color-
ectal fellows.(2) This ratio is similar to that found in the Swedish
rectal cancer registry, where approximately 25% of over 12,000
patients with rectal cancer underwent APR from 1995–2002.(3)
In no study or registry, however, has APR been eliminated.
History
Early in the twentieth century, most patients with rectal cancer
underwent perineal procedures to address typically advanced,
symptomatic disease. These included the transcoccygeal Kraske
approach and the transsphincteric approach developed by Bevan
in America, later attributed to A. York Mason. Patients were typi-
cally left with profound sphincter dysfunction or fistulae follow-
ing a protracted recovery. A two-staged operation, consisting of
an initial laparotomy and colostomy followed by perineal excision,
was used until the 1930’s with reasonable results.
The operation we now know as APR was first described by
Miles in 1908, but initial reports showed a high operative mortal-
ity, up to 42%. Improvements in perioperative care that came later
reduced this considerably. Refinements in technique continued
through the first half of the twentieth century. Gabriel described

the operation in one stage, with the abdominal portion done
supine and the perineal portion done in the left lateral position.
Lloyd-Davies’ synchronous approach to the abdomen and peri-
neum with the patient in the lithotomy position eliminated the
cumbersome and sometimes dangerous need to reposition the
patient while under anesthesia.(4) Recent advances have included
total mesorectal excision in patients undergoing APR and the
addition of methods to enhance perineal wound healing, espe-
cially in patients who have received neoadjuvant chemoradiation.
Minimally invasive techniques are also being applied to APR, with
good initial results.
Patient Preparation and Positioning
Preparation for abdominoperineal resection starts with marking
the ideal placement of the colostomy by the primary surgeon or
enterostomal nurse.(5) Patients are instructed to take a mechani-
cal bowel preparation the day before surgery consisting of sodium
phosphate solution or polyethylene glycol. Placement of an epidural
catheter may be considered to improve postoperative analgesia
and to reduce postoperative ileus.(6) Before induction of general
anesthesia, intermittent pneumatic compression devices are placed
on the lower extremities to reduce the risk of venous thromboem-
bolism.(7) Intravenous antibiotics with efficacy against enteric flora
are administered 60 minutes before incision to decrease rate of
­surgical site infection.(8) The abdomen and perineum are prepped
and appropriate monitoring is placed.
After induction of anesthesia, a urinary catheter is inserted; ure-
teral stents should be considered if the patient has had prior pelvic
surgery, tumor extension into the urinary tract, or prior pelvic radi-
ation. The patient is placed in the lithotomy position using Allen
stirrups with padding to prevent lower limb acute compartment
syndrome.(9) Positioning also includes symmetric hip extension,
knee flexion, and thigh abduction (Figure 27.1). Ultimately the legs
are balanced in the stirrups, such that the weight is resting on the
feet and the ankle and knee are in line with the opposite shoulder.
A rectal exam is performed under anesthesia followed by irrigation
with dilute betadine solution to remove any residual stool.
Operative Technique
The operative technique used today varies little from Ernest Miles’
description in 1908.(10) Unlike Miles’ method we prefer the two-
team approach with the patient in lithotomy position rather than
lateral semi-prone position. A nonabsorbable purse-string suture is
placed around the anus. The abdomen and perineum are prepared
with antiseptic solution and draped with openings for the abdomi-
nal and perineal dissections. The abdomen and pelvis are accessed
through a midline hypogastric incision that extends to the right
of or through the umbilicus. The abdomen is explored for meta-
static disease and synchronous colon lesions. After confirmation of
resectability, a self-retaining retractor is placed.
 abdominoperineal resection
The small bowel is packed into the upper abdomen with a moist
towel. The sigmoid and descending colons are then mobilized at
the white line of Toldt in the left lateral gutter. After confirming
adequate mobilization of the descending colon for an end colos-
tomy, the left ureter is identified and preserved. The peritoneum
incision is carried anterior followed by incision of the right lateral
peritoneum. The right ureter is identified and preserved and the
peritoneal incisions are connected anteriorly at the base of the
bladder. For convenience, the proximal sigmoid can be divided
with a linear stapling device and the cut end used as a handle
to aid with the dissection. A finger is passed below the inferior
mesenteric vessels with the plan to leave the sigmoid branches.
This helps minimize vascular compromise of the stoma. It is
unnecessary to ligate the inferior mesenteric artery at its origin as
this has not been shown to increase survival.(11)
The superior hemorrhoidal vessels are transected. The presacral
space is entered without breaching the endopelvic fascia and with
Figure 27.1  Leg positioning for abdominoperineal resection.
preservation of the mesorectum consistent with Heald’s descrip-
tion of total mesorectal excision.(12) After identifying this avas-
cular plane, the dissection is aided by using a lighted St. Mark’s
retractor to hold the mesorectum anteriorly. As the dissection
continues distally, Waldeyer’s fascia is divided with electrocautery
or sharply to avoid injuring the presacral venous plexus. Staying in
the avascular plane posteriorly and laterally minimizes bleeding.
The lateral ligaments are cauterized or suture-ligated close to the
pelvic side wall to maximize the radial margins. Denonvillier’s fas-
cia in males is dissected down to the pelvic floor anteriorly. Unless
the tumor is anterior, it is not necessary to expose the seminal vesi-
cles in males thus avoiding injury to the nervi erigentes. In females,
the presence of an anteriorly based tumor may require perform-
ance of a posterior vaginectomy. When the pelvic floor is reached
circumferentially around the rectum, the abdominal portion of the
dissection is completed. Once the pelvic dissection is completed,
the colostomy is created and the abdomen is closed.

 improved outcomes in colon and rectal surgery

When the abdominal operator has determined that the lesion

is resectable the perineal dissection begins simultaneously with
the abdominal portion of the case. The perineal dissection
begins with an elliptical incision from the perineal body in males
or the posterior vaginal introitus in females to a point midway
between the anus and coccyx. The incision should include the
entirety of the external sphincter muscle, but does not need
to extend laterally to the ischial tuberosities. Dissection is car-
ried down to the levator ani muscles with cautery to minimize
bleeding. The inferior hemorrhoidal arteries located posterior-
laterally are ligated. Using a finger on the tip of the coccyx as a
guide, the posterior dissection is directed anterior to the coccyx
and the anococcygeal raphe is divided. When all that remains
are the anterior attachments, the specimen is drawn through the
opening and used to provide traction to continue the remain-
ing dissection. The specimen is then removed and the pelvis is
irrigated. If sufficient levator muscle remains, the pelvic floor
is reapproximated to reduce the risk for perineal herniation.
Drains are placed and secured followed by closure of the skin
with interrupted permanent or absorbable monofilament suture
in a vertical mattress fashion.
Preservation of Sexual and Urinary Function
As described by Kyo et al. the neuroanatomy begins with the sym-
pathetic nerve fibers that travel through the lumbar splanchnic
nerves to the superior hypogastric plexus and then divide into
two hypogastric nerves. Parasympathetic fibers emerge from
the second, third, and fourth sacral spinal nerves as the pelvic
splanchnic nerves and join the hypogastric nerves to form the
inferior hypogastric (pelvic) plexus. The pelvic plexus is rectan-
gular and its midpoint is located at the tips of the seminal vesicles
on either side of the rectum (Figure 27.2). The most caudal por-
tion of the pelvic plexus travels at the posterolateral border of the
prostate, lateral to the prostatic capsular arteries and veins and
reaches the hilum of the penis.(13)
The rate of urinary dysfunction and impotence after rectal sur-
gery ranges from 33% to 70% and 20% to 46%, respectively, while
20–60% of potent patients are unable to ejaculate.(14) A surprisingly
large proportion of patients suffer various urinary tract problems
and sexual problems due to extended lymphadenectomy involving
the hypogastric nerve plexus. Therefore, preservation of the pelvic
autonomic nerves lowers the incidence of sexual and urinary mor-
bidity. With preservation of the superior hypogastric nerve plexus,
ejaculation is maintained in 90% of the patients.(15)
Utilizing precise dissection with preservation of autonomic nerves
Kim et al. noted an erection rate of 80%, penetration ability rate of
75% with only 5.5% of patients in their study reporting complete
inability for erection and intercourse. Study by Shirouzu et al. showed
oncologic equivalence between previously described extensive resec-
tion pre-1984 and plexus preserving low rectal surgery post-1985
with local recurrence rates 9.1 and 3.9%, respectively and 10-year,
disease-free survival rate of 77% and 81.5%, respectively. No signifi-
cant difference was noted among the groups.(16)
Methods of Closure
The perineal wound can be packed open, partially closed, or
­com­­pletely closed. The peritoneal defect above the pelvic space
Figure 27.2  Nerve supply to the rectum.
can also be sutured closed or left open. Adjunctive procedures
such as drainage of the pelvic space, with or without continuous
irrigation, and omental plugging may also be considered.
Rates of primary healing after perineal wounds are closed range
from 4% to 92%.(10, 17, 19) Open packing relegates all wounds
to secondary healing, is inconvenient, and often painful but may
result in a lower rate of chronic perineal sinus formation.(19)
Closure of the pelvic peritoneum has been advocated to prevent
perineal evisceration and postoperative small bowel obstruction.
However, it may prevent obliteration of the pelvic cavity, lead-
ing to formation of a persistent perineal sinus.(20) Loops of
small bowel may also become incarcerated in small defects in the
­peritoneal closure, resulting in postoperative bowel obstruction.
Two studies compared various methods of peritoneal and peri-
neal closure. Irvin and Goligher (19) prospectively randomized
106 patients undergoing proctectomy to one of three methods of
perineal closure: open packing of the perineal wound; primary
closure of the perineal wound without closure of the pelvic peri-
toneum with suction drainage of the pelvis; and primary closure
of the peritoneal and perineal wounds. The overall complication
rate was high: repeated surgery was necessary in 21% of patients
in the open packing group, most often because of hemorrhage,
and in 25% and 19% of the two closed groups, most commonly
for drainage of abscesses. Primary healing occurred in 45% of the
patients with primary closure of both the perineum and perito-
neum and in 43% of patients with open peritoneal and closed
perineal wounds.
In a prospective study part of a multicentre trial in Germany,
Meyer et al. published a standardized technique of perineal ­closure
that reduced wound complication rates from 17% to 5.4%. The
principle of their approach was to close the perineal wound tightly
in multiple layers (specifically the muscle and ischiorectal as well
as subcutaneous fat) which help to avoid the accumulation of fluid


 abdominoperineal resection
within the wound cavity. The residual amount of fluid is then
removed by closed suction drainage. Additionally, it is thought
that the addition of antibiotic carriers provides local infectious
prophylaxis leading to lower rates of perineal wound infection.
(21) This has also been demonstrated in two other ­prospective
randomized studies and can be considered an adjunct in decreas-
ing the overall morbidity of the perineal wound.(22, 23)
Myocutaneous flaps have been increasingly utilized in the initial
repair of the perineal defect, especially in patients who have
had preoperative radiation therapy. Chessin et al. at Memorial
Sloan Kettering reviewed their experience with rectus abdominis
myocutaneous (RAM) flap closures of the perineal defect.
Comparing the RAM flap group to a historical control, they found
that the incidence of perineal wound complications was 15.8% in
the RAM flap group compared to the 44.1% in the control.(24)
Butler et al. also looked at vertical rectus abdominis myocutaneous
flaps in previously irradiated patients undergoing APR. There was
a significantly lower incidence of perineal abscess (9% vs. 37%),
major perineal wound dehiscence (9% vs. 30%) and drainage
procedures required for perineal or pelvic fluid collections (3%
vs. 25%).(25)
In an effort to fill the pelvic space after rectal resection, Page
et al. advocates an omental plug. They describe mobilization of
the omentum on the left gastroepiploic arterial pedicle, with sub-
sequent placement in the pelvis. Advantages include increased
local blood flow and lymphatic drainage, and obliteration of the
pelvic space. The omental plug also has the advantage of keeping
the small bowel out of the pelvis, thereby decreasing the chance of
radiation enteritis in patients who require postoperative radiation
therapy. The authors report primary healing in 26 of 34 patients
(77%).(26) A recent publication by PJ Nilsson reviewed all avail-
able English language publications on the use of omentoplasty
in APR wound closure. Primary wound healing was the primary
outcome measure. Most authors reported positive results after
omentoplasty and one study showed significant improvement in
perineal healing rate at 6 months. Significant reduction in sinus
formation and wound dehiscence also was reported.(27) Despite
these promising results, there needs to be randomized trials with
well-described patient categories, end points and follow up to
firmly assess whether omentoplasty should be a standard part of
the wound closure.
Complications
Abscess
Abscess formation, intraperitoneal or of the perineal wound, is
the most common major complication after APR.(17) Incidence
of abscess formation ranges from 11% to 16% (17, 18, 28). In
some small series, the incidence of perineal wound infection is
100%.(19) This can be attributed to the large dead space remain-
ing after resection of the rectum and from fecal contamina-
tion. In a retrospective review of patients who had neoadjuvant
chemoradiation followed by APR, Butler observed that there
was a significant decrease of perineal abscess formation (3% vs.
37%) after the placement of a vertical rectus abdominis myocu-
taneous (VRAM) flap to the perineum. The well-vascularized
flap eliminates the dead space in the pelvis, reducing the risk of
fluid ­collection. The use of a VRAM flap should be considered in
patients who are at high risk for postoperative perineal wound
complications.(25) Alternatively, an omental pedicle flap sutured
to the perineal wound has been observed to decrease the rate of
abscess formation.(29)
Incision and drainage with local wound care is the treatment
of choice for local perineal wound abscesses. There is a small
increased risk of developing a perineal sinus after opening the
skin of a subcutaneous abscess.(30) Thus if the incision is heal-
ing well, the abscess may be amenable to percutaneous drainage.
In addition, percutaneous drainage is the preferred treatment of
presacral and pelvic abscesses.(31)
Intraoperative Hemorrhage
Hemorrhage during surgery can usually be attributed to an error
in technique, but when faced with a pelvis that had previously
received radiation therapy, hemorrhage may be unavoidable.
Bleeding may occur when dissection begins at the sigmoid. This
is usually easily identified and controlled. In the previously irradi-
ated pelvis, planes become distorted making it difficult to identify
vital structures. It is easy to stray laterally, which may result in iliac
vessel injury. These must be repaired immediately to avoid pro-
longed hemorrhage. In a pelvis that has not received radiation, or
if there is minimal fibrosis, meticulous dissection in the proper
plane down to the lateral stalks usually yields minimal bleeding.
The most troublesome bleeding in the pelvis comes from the
posterior dissection along the sacrum. Very rarely, there will be a
prominent medial sacral artery that may be injured. More com-
monly, the bleeding from the sacrum will come from the venous
plexus. If present, the basivertebral vein, which connects the inter-
nal vertebral venous system to the presacral system, can bleed
­profusely and be difficult to control. Ideally, by taking sharp dis-
section down the presacral plane, there should be little to no bleed-
ing.(32, 33) Unfortunately this space may be nonexistent in certain
patients or obliterated in an irradiated field. Bleeding from the sac-
rum can be controlled by packing, suture ligation, electrocautery,
finger compression, or thumbtack compression.
Thumbtack compression is a quick, safe, and effective method of
controlling sacral bleeding. There are several commercial applica-
tion devices available; however, using a clamp or forceps with ­finger
applications works equally as well (Figure 27.3). Thumbtacks also
prevent damage to the surround venous plexus that may occur
when using the other methods of attempting hemostasis, such as
direct suture ligation or excessive cauterization.(33, 34)
Postoperative Hemorrhage
Bleeding after the completion of the surgery is uncommon (<4%)
and is most commonly associated with perineal wounds that are
packed open.(35) When the perineal wound is packed open, it
is hemostatic until the first dressing change when the tampon-
ade is released. As the packing is removed, it may pull away
clot from surrounding tissues that can result in more bleeding.
Conservative treatment can be attempted with adequate resusci-
tation if needed, a reapplication of packing, and placement of the
patient on strict bed rest. If the patient remains stable, the pack-
ing may be removed in 48–72 hours.(36) Occasionally, reopera-
tion is necessary to control postoperative perineal hemorrhage.

 improved outcomes in colon and rectal surgery
Figure 27.3  Thumbtack occlusion of bleeding basivertebral vein.
Given that nearly all APR wounds are currently closed primarily,
this complication is rare.(37, 38)
Perineal Wound Complications
When comparing abdominoperineal resection with other abdom-
inal and pelvic procedures, the most striking difference is the peri-
neal dissection and ensuing perineal wound. Treatment of this
wound has long been the center of debate and controversy. Miles
in his original description in 1908, recommended open packing,
and his technique is still used by some surgeons. Over the following
75 years, many techniques to treat the perineal wound have been
developed, including partial closure, primary closure, and closure
with continuous irrigation or omental plugging. For purposes of
discussion, perineal wound complications of abdominoperineal
resection can be divided into four categories: hemorrhage, abscess,
perineal sinus, and perineal hernia.
Non Healing Wound and Perineal Sinus
Perineal sinus is defined as a perineal wound that remains unhealed
for a minimum of 6 months. Characteristics include a fixed fibrotic
pelvic cavity, a long, narrow track lined with a thick unyielding peel,
and a small external opening.(39)
Silen and Glotzer compared the pelvic space after APR with
the fixed pleural space after pneumonectomy. The pelvic space
is bound posteriorly and laterally by the rigid bony pelvis, ante-
riorly by the relatively unyielding genitourinary structures, infe-
riorly by the slightly mobile perineal floor (if surgically closed),
and superiorly by the peritoneal contents. Of all these borders,
certainly the peritoneal structures are the most mobile. They
contend that the pelvic space after APR is filled not with gran-
ulation tissue but with a combination of upward migration of
the perineal soft tissues and descent of the peritoneal contents
and argue that any forces (either iatrogenic, such as closure of
the peritoneum or prolonged packing of the pelvis, or second-
ary to complications, such as pelvic abscess or hematoma) that

produce a fixed fibrotic cavity are likely to result in a nonheal-
ing perineal wound.(30) Artioukh et al. reviewed their series of
APR non healing wounds and found several possible contrib-
uting factors, including distant metastases, excessive alcohol
consumption, cigarette smoking, transfusion requirement and
chemoradiation.
Other studies have also observed the increased risk in peri-
neal wound infection and nonhealing in those who have been
exposed to radiotherapy. The Swedish Rectal Cancer trial showed
an increase in wound infection from 10% to 20% and the Dutch
Colorectal Cancer Group had a 31% perineal complication rate
even in those exposed to short-course radiation.(40, 41)
Silen and Glotzer recommended that the peritoneal contents
be allowed to descend into the pelvis, the space be kept irrigated
and well drained to prevent fluid accumulation, and any packing
used in the perineal wound be removed early to prevent develop-
ment of fibrotic wound edges. Despite the excellent description
of perineal healing by Silen and Glotzer and the development
of multiple techniques for perineal closure, nonhealing perineal
wounds remain a common problem. Bacon and Nuguid noted a
40% incidence of persistent perineal sinus in 1042 patients after
rectal resection.(42) In almost 500 patients who underwent APR
at the Lahey and Mayo Clinics, 14–24% had unhealed perineal
wounds at 6 months.
Risk Factors
Inflammatory bowel disease versus carcinoma. Rectal resec-
tion is most commonly performed to treat low rectal cancer
or inflammatory bowel disease. Often the extent of soft tissue
resection is much greater in the treatment of rectal cancer with
complete removal of the levator musculature or posterior vagi-
nectomy advocated by some versus the intersphincteric proctec-
tomy (sparing the external anal sphincter and the levator ani)
often used in surgical treatment of inflammatory bowel disease.
An increase in perineal wound complications might be expected
after APR to treat cancer, but Irvin and Goligher found a 9% inci-
dence of unhealed perineal wounds in the treatment of cancer,
compared with a 33% incidence in proctectomies performed for
inflammatory bowel disease.(19) A more contemporary review
of the risk factors for perineal wound complications undertaken
by Christian et al. determined that higher rates of major wound
complications occurred in patients who had APR performed for
anal cancer (50%) as compared to rectal cancer (10%) or inflam-
matory bowel disease (8%). The reasons are unclear although the
extensive tissue dissection involved in a cancer operation with
larger soft tissue loss may be a possibility.(43) There is some evi-
dence to support this in studies that have shown that tumor size
can be a risk factor for poor wound healing.
Radiation Therapy. Radiation therapy is often used in the
treatment of rectal and anal neoplasia both preoperatively and
postoperatively. Christian et al. found that preoperative radiation
therapy for anal cancer patients appeared to be a risk factor for
poor wound healing. Artioukh et al. also found that patients who
had received preoperative radiotherapy were prone to wound
complications (39% vs. 6.7% who did not have radiotherapy).
Fecal Contamination. Fecal contamination during proctectomy
significantly decreases primary healing and may increase the risk
 abdominoperineal resection
of chronic perineal sinus formation. This complication is presum-
ably related to the development of pelvic infection with secondary
development of a fixed abscess cavity that makes obliteration of the
pelvic space more difficult.(30) Fecal contamination may also lead
to a higher incidence of perineal wound tumor recurrence.
Treatment
Nonhealing perineal wounds develop in 8% to 69% of patients
undergoing APR.(10, 18, 19, 28) Because of the scope of the prob-
lem, many techniques have been developed to ensure complete
healing. Early efforts included operative debridement with wide
drainage, including coccygectomy and even partial sacral resection.
(20) These measures were designed to eliminate the rigid fibrotic
space that always accompanies a nonhealing perineal wound. Often
these measures resulted in eventual healing but required exten-
sive wound care for many months. Despite this treatment, some
wounds failed to heal.
Alternative methods to improve healing and decrease wound
care have been developed. Oomen et al. published a set of guidelines
in treating persistent perineal sinuses or complex perineal wounds
with an overall 80% success rate in healing. Their ­algorithm
­consisted of VAC therapy for large defects before placing muscle
flaps in order to decrease the size of the defect. Depending on sinus
length, they either placed a transposition of rectus abdominal
muscle (for sinuses > 10 cm) or a gracilis muscle/gluteal thigh flap
(sinus < 8 cm). Initially success rate was 57%, but after second-
ary surgery in some of the patients, their success rate increased to
80%. Ultimately, the best outcomes were in patients who received
the gracilis or gluteal thigh flap.(44)
The VAC® closure system has also been used more to assist in
dealing with complex perineal wounds that result after extensive
operative debridement’s for persistent perineal sinuses. Pemberton
at the Mayo Clinic (45) published a review of their results with
various techniques in dealing with perineal sinuses. In patients
with difficult perineal sinuses requiring debridement and removal
of the coccyx and caudal part of the sacrum, the VAC® system
had complete resolution of the sinus in nearly all of their patients.
While their evidence is anecdotal, there are documented reports
with healing rates up to 95%.(46, 47)
Omentoplasty is another technique that has been evaluated in
both the primary repair of the perineal wound as well as in com-
plex perineal sinus disease. Yamamoto et al. reported six patients
with persistent perineal sinuses who underwent omentoplasty.
The perineal sinus tract was completely excised and communica-
tion with the pelvis attained. The left or right gastroepiploic vessels
were then ligated and the omentum brought down to the peri-
neum where it was lightly sutured to the skin. After a 28-month
follow-up period, 83% of the patients had completely healed
wounds without any complications.(48)
Perineal Hernia and Evisceration
Perineal hernias are fortunately very rare and often troublesome
to diagnose. Perineal hernia after abdominoperineal resection is
defined as bulging of peritoneal contents through an intact perineal
wound, and perineal evisceration describes extrusion of small
or large bowel through an open perineal wound. However, other
unusual contents have been described, including a leiomyoma,
an aggressive angiomyoma and a large bladder diverticulum.(49)
Evisceration typically occurs immediately after surgery and neces-
sitates repeat surgery with reduction of intestines and repeat pack-
ing. Perineal hernias are a rare complication and occur in about 1%
of patients after APR. This figure increases to 3% after pelvic exen-
teration. Initial symptoms include perineal bulging, often associ-
ated with fullness or pain on sitting.(50, 51) Occasionally, patients
complain of voiding problems if herniated bowel compressed the
bladder.(52) Rarely, skin breakdown occurs, resulting in exposed
bowel in the perineum. Perineal ­hernias, like parastomal and inci-
sional hernias, do not always require repair. Indications for surgery
are similar for all three postoperative hernias: patient discomfort
refractory to conservative therapy, bowel obstruction, incarcera-
tion, and impending skin loss. Cosmesis alone should rarely merit
surgical repair.
Risk factors that predispose patients to developing perineal her-
nias are not entirely clear. Coccygectomy, previous hysterectomy,
pelvic irradiation, excessive length of the small-bowel mesentery,
the larger size of the female pelvis, and possibly the failure to close
the peritoneal defect have been implicated as possible causes.(53,
54, 55) So et al. described 80% of their patients having perineal
wounds that were laid open or had multiple large drains inserted
through the wound which they postulate may have weaken the
wound and allow hernia formation.(56)
Diagnosis of perineal hernias can be difficult as traditional
fluoroscopic imaging techniques often do not identify them.
Other modalities have been used to include herniography, CT,
and dynamic MRI. A comparative study of dynamic MRI and
dynamic cystocolpoproctography showed that MRI was the only
modality that identified levator ani hernias.(49)
There is a paucity in large published series to describe which
technique of perineal defect closure is superior. Various case
reports and retrospective reviews provide much of the literature
in this respect. In a review of the literature, closure techniques
have ranged from the use of simple suture closure, prosthetic
mesh, human dura mater allograft (57), gracilis myocutaneous
flap (58), gluteus flap and retroflexion of the uterus or bladder.
(59) So et al. described their experience with closures and ulti-
mately found that recurrence rates were equal (20%) between
simple and mesh closures. Their repair consisted of simple
closure of the levator defect with nonabsorbable sutures. The
approach to the repair was also felt to be a point of consideration
in planning the operation. For the most part, a perineal approach
was adequate with the abdominal approach reserved for recur-
rent hernias, or those in whom laparotomy is necessary for other
reasons. The abdominal approach also provides good visualiza-
tion when suturing the mesh to the bony pelvis. A combined
AP approach is rarely necessary except under unusual circum-
stances. Skipworth et al. published their experience and tech-
nique of perineal hernia repair using Permacol® mesh. Using a
perineal approach, they isolated and ligated the sac in the stand-
ard fashion before proceeding to close the perineal defect with
4-O PDS (polydiaxonone) suture. The mesh was then fashioned
to the contours of the defect and sutured in place, tension free,
with interrupted 2-O Prolene sutures. A small suction drain was
then left superficial to the mesh and the thin, residual perineal
fascia closed with Vicryl sutures. They reported no recurrence

 improved outcomes in colon and rectal surgery
in the 18 months following the repair. There are also a grow-
ing number of case reports and prospective studies in the use of
laparoscopy for perineal hernia repairs. Dulucq et al. describe
their experience in a prospective study done over the course of
a year with three patients that had received laparoscopic mesh
repairs of their perineal hernia defects. A composite mesh was
fixed laterally to the border of the levator muscle, anteriorly
to the posterior face of the vagina with nonabsorbable sutures
and posteriorly with tacks to the sacral periosteum. One suction
drain was placed. The reported benefits include adequate visu-
alization of pelvic anatomy, the ability to look for recurrence,
and fast recovery. Long term results have yet to be published for
laparoscopic perineal hernia repairs, but this may be an attrac-
tive option for patients and surgeons as it often avoids making
large incisions in areas that have already been irradiated and can
therefore be difficult to heal.(60) Before embarking on a repair
of any postoperative perineal hernia it is imperative to exclude
the possibility of cancer recurrence.
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
28 Indications and outcomes for treatment of recurrent rectal cancer
and colorectal liver and lung metastasis
Harry L Reynolds Jr, Christopher T Siegel, and Jason Robke
Challenging Case
A 74 year old male underwent low anterior resection of the rectum
one year previously after preoperative chemotherapy and radia-
tion. Final pathology revealed a yPT2N0M0 lesion. He received
post operative chemotherapy as well. In follow up he was noted to
have an elevated carcinoembrionic antigen of seven. Digital exam
revealed a palpable mass at the finger tip. It was one half circum-
ferential, posteriorly based, involving the left pelvic sidewall and
was fixed. Located at five cm from the verge on rigid proctoscopic
exam, it was just at the top of the anorectal ring and involved the
previous anastomosis. Computed Tomographic (CT) scan of the
chest abdomen and pelvis revealed a posteriorly based mass adja-
cent to the sacrum without boney erosion. It suggested involve-
ment of the left pelvic sidewall. There was a two cm hypodense
lesion in segment three of the liver. The chest was clear. Positron
Emission Tomography revealed intense uptake in the pelvis and
in the hypodense area of the left lobe of the liver noted on CT.
Magnetic Resonance Imaging of the pelvis confirmed extension
into the pelvic sidewall but did not reveal boney involvement of
the sacrum. Colonoscopy cleared the proximal colon. Biopsies
confirmed a moderately well differentiated adenocarcinoma.
Case Management
The patient received a preoperative radiation boost to the pelvis
supplemented with capecitabine. He was re-explored and under-
went abdominal perineal resection. The left internal iliac artery
and vein were ligated and partially excised with a portion of the
left pelvic sidewall. He received an intraoperative radiation boost to
the left sidewall and sacrum where the tumor was adherent. It was
difficult to differentiate tumor from scarring over the sacrum, but
there was no gross boney involvement. Intraoperative ultrasound
of the liver revealed no other liver lesions and the left lateral seg-
ment metastasis was excised after the pelvic work was completed.
He was reconstructed with an end descending colostomy. He was
referred to oncology for further postoperative chemotherapy.
Introduction
Of the many challenges presented to the surgeon, patients
­presenting with recurrent rectal cancer can be among the most
daunting. Likewise patients with metastatic disease to the liver
or lung can be a technical challenge and can be difficult to sort
out as to who is an appropriate operative candidate. These
patients are best treated with a multidisciplinary approach with a
Colorectal or General Surgeon serving as the team leader.(1) In
this chapter we explore, in three separate sections, the indica-
tions and outcomes for surgical intervention in patients with:
1. Recurrent rectal cancer, 2. Liver metastasis, and 3. Lung metas-
tasis. Contributing authors include a Colon and Rectal Surgeon,
a Hepatobiliary Surgeon, and a Thoracic Surgeon.

Recurrent Rectal Cancer
Recurrent rectal cancers are among the most challenging for
the Colon and Rectal Surgeon to manage. A multidisciplinary
approach is truly essential in planning a comprehensive treat-
ment plan if success is to be achieved. The surgeon that takes on
these cases assumes the responsibility of organizing and lead-
ing a team of sub specialists consisting of Medical and Radiation
Oncologists, Urologists, Radiologists, Pathologists, Enterostomal
Therapists, and in selected cases, Plastic Surgeons, Vascular Surgeons,
Gynecologic surgeons, Hepatobiliary Surgeons, Thoracic Surgeons,
and Intensivists. The complexity of these patients makes it essen-
tial that they be treated at centers with the staff and resources
necessary to undertake their care.(1, 2)
Assessing Resectability
A thorough workup of the patient first consists of a careful history
and physical exam. Fitness for surgery should be assessed carefully as
one can expect a significant physiologic insult in those who come to
operation. Many will require extended en bloc resections of adjacent
organs with the potential for blood loss and volume shifts not usually
seen at initial proctectomy. Preoperative assessment by appropriate
sub specialists with emphasis on cardiac and pulmonary optimiza-
tion may be necessary in these frequently elderly patients. In some
patients surgical risk may be deemed prohibitive and nonoperative
management with combinations of chemotherapy and radiation
and/or stenting or palliative diversion may be necessary.
Assessing the extent of local and metastatic disease is best
achieved with careful physical and proctoscopic exam supple-
mented with appropriate radiologic imaging. The importance
of digital examination cannot be overemphasized. Determining
location with respect to the sphincter complex and adjacent
structures including vagina, uterus, prostate, seminal vesicles,
bladder, pelvic sidewall, and sacrum can be preliminarily assessed
with a careful digital rectal and vaginal exam. Bulk, mobility, and
fixation to surrounding structures should be carefully considered
with the digital. Pelvic recurrences are frequently extramucosal
and may not be appreciated endoscopically but may be felt on
digital. Rigid proctoscopic and digital exams are essential in
determining relationships to the sphincter complex as even with
pelvic recurrences, sphincter sparing options may be available in
selected patients. Involvement of the sphincter complex typically
necessitates abdominal perineal resection (APR).
A full colonoscopy is performed to rule out synchronous
lesions. Radiographic workup typically consists of PET CT to rule
out extrapelvic metastatic disease. PET CT may identify patients
with unsuspected metastatic disease, thus preventing overly
aggressive surgical intervention. Watson reported a change in
planned surgical intervention in 37% of patients based on PET
CT imaging in patients with recurrent colorectal cancer.(3)
 indications and outcomes for treatment of recurrent rectal cancer
High quality spiral CT scanning of the chest abdomen and
pelvis is frequently performed as well to define any question-
able metastatic lesions and to better define the extent of pelvic
disease. Pelvic MRI is felt by most authors to be the preferred
imaging modality for establishing the extent of adjacent organ
involvement for purposes of preoperative planning. MRI can
provide insight as to whether pelvic sidewall, seminal vesicles,
prostate, bladder, ureters, vascular structures, gynecologic struc-
tures, or sacrum are involved.(4–8) Although imaging can assist
in preop planning, no radiographic study can reliably differenti-
ate fibrosis and scarring from tumor, particularly in an irradiated
pelvis. Radiation induced inflammatory changes in the pelvis can
be PET positive as well, and can be confused for metastatic disease.
Although imaging can assist with planning, the ultimate determi-
nation of involvement and resectability is made at operation.
Reviewing previous operative notes and pathology reports can
provide insight into the adequacy of initial resection and can be
helpful in assessing likelihood of resectability at reoperation. Those
that have had an optimal cancer operation at the first exploration
with total mesorectal excision (TME) and high ligation of the infe-
rior mesenteric artery can be expected to have a much more diffi-
cult reexploration. With TME and high ligation initially, combined
with previous radiation therapy, recognizable planes are typically
absent. Those with more proximal tumors, non-TME initial resec-
tions, and/or ligation of the superior rectal vs. the inferior mesen-
teric artery (IMA) may well have some pelvic plane preservation,
making reexploration not so daunting a task. Those that have had
a proper TME with a coloanal anastomosis or abdominal perineal
resection can be expected to have more difficult lesions to deal with,
as recurrences can be expected to be adherent to adjacent struc-
tures, outside of the proper mesorectum. These tumors recur in
the sidewall, sacrum, anastomosis, perineal wound or in the gyne-
cologic or urologic organs. Those that recur laterally in the pelvic
sidewall or posteriorly on the sacrum are particularly challenging
in terms of obtaining an R0 resection. An R0 resection refers to a
complete resection with microscopically clear margins. R1 resec-
tion implies microscopic disease is left, and R2 implies gross dis-
ease is left behind. Those that recur at the anastomosis or anteriorly
in the adjacent vagina, uterus, prostate, seminal vesicle, or bladder
can frequently be completely excised with en bloc adjacent organ
resection.(9) Likewise, the occasional patient who presents with an
isolated nodal recurrence, high along the IMA after an initial low
ligation, may be resectable as well.
Pelvic sidewall recurrences can be very difficult to resect sec-
ondary to the extensive internal iliac arterial and venous branches
encountered. Anatomy is distorted by tumor and scar, and the des-
moplastic reaction associated with tumor and previous radiation
can make dissection hazardous as venous bleeding can be signifi-
cant. Likewise sacral recurrences below S1-2 typically can techni-
cally be resected, but morbidity and mortality can be significant.
(10) Local, limited anastomotic recurrences post low anterior resec-
tion and perineal recurrences post APR, without lateral or sacral
extension, are more likely to be amenable to R0 resection.(9)
Patients with extrapelvic metastatic disease are typically not offered
extended exenterative procedures. However, in selected otherwise fit
patients presenting with isolated resectable liver or lung metastasis,
it may be appropriate to proceed with extended resection. In those
with nonresectable metastatic extrapelvic disease, pelvic exenterative
procedures are felt to be contraindicated by most.
Role of Chemotherapy and Radiation
Our approach to a diagnosed pelvic recurrence initially involves
evaluation by medical and radiation oncology to determine if an
additional radiation boost can be delivered to the pelvis. This will
usually be administered with concomitant 5-FU based chemo-
therapy. Most patients will have received either preop or postop
chemoradiotherapy with there first resection. Most will receive an
additional preop boost of 30–40 Gy to the site, particularly if it is
a bulky recurrence, with plans for surgical exploration ~8 weeks
post radiation.(11–15) This is assuming the interval between radi-
ation and reirradiation is >6 months and the small intestine can
be excluded from the planned field.(11) This approach seems to
be well tolerated by most in our institution and has been validated
by others.(11–15) It is important to ensure exclusion of the small
intestine from the pelvis with reirradiation. Dresen reports that if
the small intestine is not excluded planned operation before irra-
diation may be undertaken for placement of a spacer for exclusion.
The spacer could be biologic such as the omentum or a nonbio-
logic such as a breast prosthesis or tissue expander. The patient is
typically diverted at the time of spacer placement.(11)
Intraoperative radiation therapy (IORT) can be offered via a
dedicated fixed intraop unit, a mobile unit or via after-loading
catheters place intraoperatively. This is a particularly valuable
treatment adjunct to patients with sidewall involvement, sacral
involvement, or major vascular involvement, where an extended
resection of involved areas cannot technically be accomplished or
will not be tolerated by the patient. This can be technically deliv-
ered to areas directly involved by tumor while shielding organs
particularly sensitive to radiation (i.e., ureters, small intestine, and
bladder).While no randomized trial has been performed to dem-
onstrate the value of IORT, such a trial is unlikely to be performed.
Positive circumferential margins in rectal cancer have been associ-
ated with excessively high local recurrence rates as demonstrated
by Quirke and others even after preop radiochemotherapy.(16,
17) It would seem illogical, and perhaps unethical, to randomize
patients to a nontreatment arm with a known or suspected posi-
tive margin when a modality such as IORT, with little morbid-
ity when applied appropriately, is available. There are multiple
studies, with historical controls, demonstrating decreases in local
recurrence and survival improvement, with little morbidity, when
IORT is applied appropriately.(5, 18–26) We feel that IORT is an
essential piece of the treatment algorithm. It is frequently very
difficult to differentiate a true positive margin from the fibrosis
and scarring associated with previous radiation therapy and pre-
vious pelvic surgery. Although frozen section analysis of surgical
margins can be helpful if positive, if we are clinically concerned
about margin status, IORT will be administered regardless of fro-
zen section results. Local recurrence rates in our institution have
been very favorable with this approach.(27) Likewise, others have
demonstrated favorable results with this approach.(5, 18–26)
With the addition of IORT to our armamentarium, it seems
overly aggressive to perform sacrectomy in all cases with sacral
adherence. Adherence to the presacral fascia is present in virtually
all patients who have undergone a TME and it is very difficult to

 improved outcomes in colon and rectal surgery
differentiate fibrosis from tumor. If there is suspicion clinically
of involvement, we will treat with IORT. Sacrectomy is preserved
for those who are fit for surgery with clear cortical destruction or
marrow involvement by CT/MRI below S1-2. Our initial experi-
ence with this approach is encouraging.(27) Postoperative che-
motherapy is usually recommended in our institution, but has
been variably administered in the literature.
Operative Approach
The patient is placed in modified lithotomy position. Initial explo-
ration is undertaken to carefully assess for extrapelvic metastatic
disease. Careful attention is paid to the liver and the abdomen is
assessed for carcinomatous implants. All adhesions are lysed and
the ureters are identified. Ureteric catheters are typically used.
The left colon is mobilized as is the splenic flexure and attention
is focused on the IMA root. If it has not been taken it is mobilized.
An assessment for resectablity is made and if the tumor is deemed
resectable, the IMA, if not previously ligated, is taken high. The neo-
rectum is mobilized posteriorly initially, laterally, then anteriorly.
The areas free from tumor involvement are most easily mobilized
and are approached first. As much easy dissection should be done,
as can be done, to identify landmarks initially. If anterior structures
are clinically involved they are taken en bloc with the neorectum.
It is much easier to take the bladder, seminal vesicles and prostate
en bloc with the neorectum than to try to separate them. If there is
firm adherence to the posterior aspect of the bladder, seminal ves-
icles or prostate, they should be taken en bloc. If the lesion is quite
low in the rectum and adherent to the prostate or vesicles alone, the
posterior portion of the prostate and/or the seminal vesicles may
be taken without the bladder, but this is much more challenging
technically than proceeding with en bloc cystoprostatectomy. In a
female en bloc posterior vaginectomy and hysterectomy should be
performed with any adherence. Pelvic sidewall involvement is tech-
nically difficult to resect secondary to the associated desmoplastic
reaction and loss of planes. The nervi erigentes and internal iliac
arterial and venous branches can be taken. However, back bleed-
ing from distal venous branches can be torrential and difficult to
control despite proximal ligation.
The dissection is completed to the pelvic floor circumferentially
and a decision is made as to whether sphincter preservation is pos-
sible. It is sometimes feasible to preserve the sphincters even if cys-
toprostatectomy is performed and a coloanal anastomosis may be
possible. A double stapled technique, transabdominal-transanal
hand sewn technique, low Hartmann, or APR may be necessary.
Any suspicious areas for microscopic involvement are treated with
IORT after specimen removal. IORT for posteriorly based or pelvic
sidewall based areas is relatively easily technically performed with
appropriate positioning of a shielding cone. However, it is techni-
cally challenging to dose anteriorly unless APR is performed and
the patient is moved to the prone position. This allows dose deliv-
ery via a cone placed through the perineal wound.
If there is gross tumor left behind, we typically will not per-
form an anastomosis. However, if there is a suspicion of potential
microscopic disease only, and this is treated with IORT, we will
consider reanastomosis, assuming adequate sphincters and an
appropriate margin. All coloanal anastomoses are covered with a
proximal diverting loop ileosotomy.

As noted above in the case of adherence only posteriorly, IORT
is usually performed after the specimen is withdrawn. If the
sacrum is clearly involved with tumor, sacrectomy is considered.
The dissection for sacrectomy begins posteriorly, typically with
internal iliac artery and vein ligation abdominally. The remain-
der of the dissection is completed, laterally then anteriorly. An
osteotomy may be started, typically with the help of an orthope-
dic consultant. The ostomy is created, the abdomen closed and
the stoma matured. A plastic surgeon may be involved prior to
ostomy creation if a rectus abdominus myocutaneous flap for
perineal defect reconstruction is considered. The remainder of
the sacrectomy is performed after turning the patient to the prone
position. Reconstruction is completed frequently with the aid of
the plastics consultant. Other flaps such as a gluteus myocutane-
ous flap may be considered.(10)
Expected Outcomes
Local recurrence after proctectomy occurs in 2.6 to 32% of
patients.(2, 28, 29) Chemotherapy and radiation offer palliation
only with median survivals reported between 10 and 17 months.
(2, 28, 30) It is estimated that ~50% of patients will present with
local recurrence only, without distant metastasis.(2, 31–33) The
concept of radical excision for potential cure of recurrent rectal
cancer is not new and was reported by Dunphy in 1947.(2, 34)
The literature has expanded in recent years with multiple larger
series reported with 5 year survivals ranging from 14 to 44%
(see table).(2, 5, 10, 11, 13, 35–44) In fact in a subset of patients
with R0 resections reported by Valentini a 67% 5 year survival
was noted.(15) Long-term outcome is directly related to ability
to clear local tumor in the pelvis and the absence of metastatic
disease. Surgical intervention alone typically does not suffice. It is
clear that a multidisciplinary approach is essential in these com-
plex patients. Case controlled data suggests IORT can decrease
local recurrence and play a role in a potentially curative treat-
ment algorithm even in the presence of a microscopically posi-
tive margin.(45–48) In the presence of gross persistent disease it
does not appear as effective, but may be useful in a multidisci-
plinary approach with pre and/or postop chemo-radiotherapy.
(27) Preop chemo-radiotherapy and postop chemotherapy are
typically employed as outlined previously.
Heriot et al. hypothesize that a significant number of patients
that could be candidates for resection likely are not operated
secondary to perceived excessive morbidity and mortality asso-
ciated with these difficult cases.(2) They argue, however, that in
carefully selected patients, resection is not only safe and reason-
able, but indeed offers the only chance of cure. They advocate an
extended radical en bloc resection of all involved or potentially
involved structures in the pelvis. The extent of resection involves
all involved areas of tumor/desmoplastic reaction. This radical en
bloc extended resection is to include involved common or exter-
nal iliac vessels with reconstruction, wide resection of the pelvic
sidewall, sacrectomy, and or partial resection of the bony pelvis if
clinically involved.(2) In their series IORT was utilized selectively
and chemo-radiotherapy was typically employed. In this excep-
tional series of 160 patients, only 7 were found to be unresectable.
Overall 5 year survival was 36.6% and cancer specific survival was
41.5% with a mean follow-up of 32 months. Unfavorable factors
 indications and outcomes for treatment of recurrent rectal cancer

Table 28.1  Site of involvement and likelihood of R0 Resection. Table 28.2  Outcomes in Recurrent Rectal Cancer.
Anastomotic or perineal wound R0 90% Author N 5 year Survival Morbidity Mortality
Anastomotic or perineal and anterior R0 72%
Dresen (11) 147 31.5 59 4.8
Lateral and/or posterior component R0 43%
Heriot (2) 160 36.6 27 0.1
Iliac vessels R0 17%
Maetani (35) 36 28 – –
N=119 patients with pelvic recurrence of colorectal cancer. Wiig (36) 47 18 38 4
Source: Moore et al. (9). Yamada (37) 64 23 50 2
Jiménez (38) 55 28 78 5
associated with impaired survival included a lymph node positive Kecmanovic (38) 28 17 43 10
primary tumor, margin involvement, use of IORT (likely second- Ike (40) 45 14 77 13
ary to use only in more difficult tumors), and lateral recurrence Lopez (41) 19 44 67 0
(sidewall involvement). Perioperative mortality was 0.6% (1/160) Kakuda (42) 22 12 68 5
secondary to hemorrhage, morbidity was 27%.(2) They note Moriya (43) 57 36 58 4
the need for extensive multidisciplinary involvement and plan- Vermaas (44) 35 16 70 3
ning, and comment that this surgery is not for the “occasional Mohiuddin (12) 34 22 – 0
participant”.(2) These data and others confirm that the overrid- Wanebo (10) 61 31 38 8
ing principle of this challenging surgery is to attempt to obtain Valentín (11) 59 39 – –
clear surgical margins.(2, 11, 49, 50) Others have pointed out Source: Adopted from de Wilt et al.(5)
that the pattern of pelvic invasion and the numbers of points of
fixation have adverse prognostic implications.(9, 51, 52) Heriot
et al’s data points to the difficulty in obtaining a clear margin as they represent a diverse mix of presentations and treatment
when the pelvic sidewall is involved which was noted by Moore algorithms. Some included combinations of patients with locally
et al. in the Memorial Sloan Kettering experience.(2, 9) They advanced primary tumors as well as recurrent tumors. Some used
noted that axial (anastomotic or perineal recurrences) or ante- extended exenterative resections with en bloc resection of adja-
rior based recurrences were more easily resected and had better cent bony and vascular structures and some did not. Some had
prognosis than lateral recurrences. This was felt secondary to the preoperative radiation boosts, some did not. Some utilized IORT
difficulty in obtaining a clear margin with lateral recurrences sec- and some did not. The five year survivals in the series outlined
ondary to the confines of the bony pelvis and the difficult vascu- ranged from 12 to 44%. The small numbers and mix of patients
lar problems encountered with the iliac branches along the pelvic makes comparisons of different approaches to the close surgical
sidewall. See (Table 28.1).(9) Other factors associated with low margin impossible. It is not clear from the data whether extended
likelihood of R0 resection include presentation with pelvic pain, en bloc resection of bony or vascular structures should be per-
radicular pain, or hydronephrosis.(5, 9) formed or IORT should be preferred in these cases. However,
The use of additional preop radiation therapy in those already although morbidity (27 to 78%) and mortality (0–13%) is signif-
radiated has been questioned for fear of introducing excessive icant regardless of approach, the overriding theme in these series
morbidity. Vermaas et al. note that the addition of a 50 Gy preop remains that a multimodality approach including surgery offers
dose was associated with a statistically significant improvement the only opportunity for cure, and that those patients having
in local control without increased morbidity in those eventu- the longest survival undergo R0 resection. There is a suggestion
ally undergoing resection compared to a historical group which that similar long term survivals and rates of local control can be
did not receive additional preop radiation.(53) Those that had obtained when IORT is utilized in patients with a microscopically
a complete response (10%) had an improvement in survival as involved or close margin.(5, 27)
well. No chemotherapy was used with the preop radiation.(53)
Dresen’s data also suggests that reirradiation is safe if the interval Treatment of Colorectal Liver Metastasis
to reirradiation is >6 months and the small bowel can be excluded Liver resection for the treatment of metastatic colon cancer was
from the field.(11) They recommend a 30–40 Gy preop boost in first described by Lortat- Jacob in 1952 (54–56) and in the US
combination with chemotherapy and introperative radiation if by Woodington in 1963.(57) Fifteen years later, Attiyeh (58)
necessary. described a series of 25 patients who had undergone liver resec-
They noted an increased ability to perform an R0 resection in tion for metastatic colon cancer with a 40% five year and a 28%
those reirradiated versus those who were not (64.9% vs. 29.2%, ten year survival. Although these early series were highly selected
p = 0.004) and an improvement in metastasis free survival at three patients, no other therapy to date provides a better therapeutic
years (58.7 vs. 17.8%, p < 0.001). As noted previously, others have benefit than complete resection of isolated metastatic colon can-
confirmed similar results.(13) It has been our practice to offer most cer to the liver.
patients a preop radiation boost combined with 5 FU based chemo- Historically, treatment with 5 fluorouracil and leucovorin for
therapy in those presenting with recurrent tumors as well, although metastatic colon cancer resulted in 5 year survival rates of less than
our numbers do not allow meaningful outcome comparisons.(27) 5%.(59, 60) The addition of Oxaliplatin and Irinotecan based regi-
Table 28.2 compares outcomes reported in several larger mens have improved the median survival for patients with stage IV
series. The interpretation of the data from these series is difficult disease to over two years (61), however 5 year survival rates have


 improved outcomes in colon and rectal surgery
remained below 10% (62). Interestingly in stage 3 disease, analy-
sis of patient survival reveals three groups with markedly different
survival rates. The difference in survival rates for the groups was
found to be dependent on extent of nodal involvement with sur-
vival ranging from 44% for stage IIIc patients, that is four or more
positive lymph nodes to 83% for stage IIIa, 1–3 positive lymph
nodes.(63, 64) The ability to identify a subpopulation within a
cancer stage which has a potential for improved survival also holds
true for patients with stage IV colon cancer patients.
Patients with isolated liver metastasis from their colon cancer
treated with multimodality therapy including surgery have a sig-
nificantly improved 5 year survival when compared to patients
with isolated liver metastasis treated with chemotherapy alone
(65–67) or patients with nonresectable stage IV disease.(68)
Approximately, 150,000 new cases of colon cancer were diagnosed
in 2007.(69, 70) It has been estimated that almost 20% will have
isolated liver metastasis at time of presentation and for patients
presenting with local disease, 25% will eventually develop isolated
liver metastasis and be eligible for resection.(69, 71) Because of
the marked improvement in survival for patients with metastatic
colon cancer to the liver treated with resection, identification of
patients who are candidates for surgical therapy and appropriate
management is of paramount importance.
Assessing Resectability
Evaluation to determine whether a patient with colon cancer meta-
static to the liver is a candidate for hepatic resection depends on
1) medical comorbidities of the patient, 2) anatomic extent of
disease in the liver and 3) the presence or extent of extrahepatic
disease. Before deciding whether a patient is a nonoperative can-
didate, thought should be given to downstaging with systemic or
hepatic artery infusional chemotherapy (72–74), combined resec-
tion and radiofrequency ablation (75, 76), staged resection (77)
and in the case of extended resections, portal vein embolization
(78, 79). While prior dogma limited candidates for resection based
on tumor margins, tumor number or extent of extrahepatic dis-
ease (80), the current National Comprehensive Cancer Network
(NCCN) guidelines describe outcome objectives to determine if a
patient may benefit from resection. The goals currently included in
the current NCCN guidelines focus on these ten points:
1) resection must be feasible based on adequate liver reserve
after resection and anatomic extent of disease 2) debulking is not
recommended, 3) there should be no unresectable extrahepatic
sites, 4) if tumors are downstaged, than all original sites must
be resectable, 5) resection should be the treatment of choice, 6)
ablations can be considered if all disease is treatable, 7) solitary
lesions have a better prognosis than multiple lesions, 8) arterial
embolizations should be performed only on a clinical trial, 9) the
primary tumor must have been resected for cure, and 10) reresec-
tions are possible in selected candidates (81).
Before surgical resection of liver metastasis, the patient
requires a full staging evaluation and risk stratification to deter-
mine operative risk. Staging evaluations include a CT scan of the
chest, abdomen, and pelvis obtained with oral and intravenous
contrast if possible. If poor renal function precludes IV contrast
administration for CT scanning then staging can be performed
with a noncontrasted CT scan of the chest and other imaging of

the abdomen. If the patient has mild, chronic kidney disease stage
1–3 (glomerular filtration rate > 30) than MRI scanning can be
helpful to fully evaluate the extent of disease in the liver.(82, 83)
Patients with advanced renal dysfunction, in which gadolinium
poses a significant risk, may require hepatic evaluation with
either transabdominal or laparoscopic ultrasound.
While prior studies have suggested precluding patients with
greater then three liver metastasis from consideration, outcomes
data would suggest that overall tumor burden, vascular involve-
ment and extrahepatic spread may be more important in the
decision algorithm.(84) The addition of (18F) fluoro-2-deoxy-
D-glucose (FDG) PET scanning to CT or MRI staging has assisted
in identifying patients with occult extrahepatic metastasis who
may not benefit from surgery.(85–87) In these studies, the addi-
tion of FDG-PET was useful in identifying 12% of patients who
were not surgical candidates, and altered surgical therapy in an
additional 23% who underwent operation. Interestingly, the abil-
ity to detect lesions less than one centimeter in the liver was only
25% in the data by Fong et al. and the recurrence within the first
year was 40% indicating even with PET scanning that a significant
number of liver lesions were missed on imaging. Other investiga-
tors have demonstrated that addition of FDG-PET has increased
both overall and disease free survival at 5 years with overall actu-
arial five year survival of 58% for patients which demonstrated
no extrahepatic PET positive lesions on preoperative imaging.
More recent reports have demonstrated the ability of recent
chemotherapy to affect the ability of FDG-PET to identify viable
tumor.(88–91) In a study by Akhurst et al. evaluating the sensi-
tivity of FDG-PET, patients undergoing surgery for resection of
metastatic colon cancer were evaluated by PET imaging. Thirteen
of 42 patients had received chemotherapy within three months
of surgery and 29 /42 had not. In the group which had received
chemotherapy 37% of lesions were PET negative as compared to
27% of the lesions in the no chemotherapy group. Interestingly,
no tumor >1.2 cm was missed in the group without chemother-
apy while some tumors as large as 3.2 cm were PET negative after
chemotherapy. In this study, 92% of all tumors smaller than 1 cm
were undetected by PET imaging. In a study by Carnaghi et al. PET
imaging sensitivity dropped to 62% after chemotherapy and was
as low as 18% for lesions under 1 cm in size. Taken together, these
data would support use of PET imaging prior to chemotherapy
to fully stage the extent of disease and nonreliance on conversion
of intrahepatic lesion to PET negative on decision making con-
cerning hepatic resection. Extrahepatic disease remains a relative
contraindication for liver resection although published studies
would support resection in limited cases if all extrahepatic disease
can be resected (92). Several studies have demonstrated decreased
survival rates for patients resected with positive portal or hepatic
artery lymph node metastasis (93, 94). Unfortunately, these stud-
ies do not comment on the use of adjuvant therapies after surgery
or whether patients had chemotherapy sensitive disease prior to
resection. In our practice we will offer resection to patients with
extrahepatic lymph node metastasis if the disease is localized to
the porta hepatis, is completely resectable at the time of surgery,
and had a favorable response to medical therapy. In addition to
staging studies, a medical workup would obviously include cardiac
evaluations for those displaying cardiac risk factors and pulmonary
 indications and outcomes for treatment of recurrent rectal cancer
function testing for those with significant lung disease or smoking
history. Cardiac stress echo testing can be performed for patients
with significant cardiac risk factors. Because there is considerable
variability between patients, decisions as to whether a patient is a
candidate for resection must take into account the patients overall
medical status and the type of procedure being planned.
Decision making regarding operative timing can be com-
plicated by presentation of the disease. For patients who pres-
ent with synchronous asymptomatic colon and liver disease,
no single treatment algorithm has been established in the field.
Acceptable treatment protocols range from complete resection of
the colon and liver disease at one operation (95–97) to neoad-
juvant chemotherapy followed by synchronous or staged colon
and liver resection (98–102). Outcomes from studies evaluating
simultaneous liver and colon resections have suggested higher
incidences of recurrence and lower overall 5 year survival rates
in patients undergoing combined resection. Other authors have
recommended a waiting period of 3 months between colon resec-
tion and liver resection in order to better select patients for sur-
gery (103, 104).
Regardless of the manner in which patients undergo resec-
tion, the efficacy of post operative chemotherapy has recently been
shown to provide a small survival advantage.(105, 106) Treatment
algorithms for resection of metachronous lesions have suggested
resection followed by either chemotherapy or hepatic artery infu-
sional (HAI) therapy.(81) Several studies have demonstrated a
improvement in disease free and overall survival with the use of
HAI (72, 74, 107–109), however, prior studies demonstrating lack
of efficacy, introduction of newer chemotherapeutic regimens
and high rates of mechanical problems with the pumps (110),
have limited there widespread use.
Patients who are candidates for liver resection and are on chemo-
therapy regimens including irinotecan, oxaliplatin, or bevacizumab
should be evaluated for hepatic dysfunction prior to surgery.(111)
Recent reports have associated the use of irintotecan-based che-
motherapy regimens with hepatic steatosis and oxaliplatin based
regimens with sinusoidal dilatation.(112, 113) These may occur
in 20–30% of patients on therapy. There has been concern that
Bevacizumab may potentially increase postoperative complications
and mortality due to its effect on vascular endothelial growth factor.
In a recent study evaluating 81 patients receiving chemotherapy with
Bevacizumab to 44 patients receiving chemotherapy alone, no signif-
icant increase in complications were seen after liver resection (114),
although increased morbidity and mortality has been reported with
patients having increased steatosis at time of resection (113, 115).
Preoperative preparation often is related to the extent of liver resec-
tion planned. For patients with bilobar disease treatment plans need
to be formulated to determine if the tumor can be treated all in one
operation or whether sequential procedures will be needed to treat the
full extent of the disease.(78, 99) In cases of bilobar disease preference
should be given to resection if possible. Occasionally, treatment will
involve a combination of resection with the possibility of radiofre-
quency ablation of remaining contralobar lesions. If the tumors are
located near or on the middle vein, and resection will involve removal
of more than 70% of the liver, then thought should be given to pre-
operative portal vein embolization to allow for hypertrophy of the
remaining segments prior to tumor removal. Studies have shown
decreased morbidity and mortality in patients undergoing preopera-
tive portal embolization before major surgical resection.(79, 116–119)
In order to determine the resectability of the patient, factors
such as extent of disease, number and location of lesions, synchro-
nous or metachronous presentation, and exposure to previous
therapy should all be taken into account. Special consideration
should be given for patients with rectal cancer with synchro-
nous liver metastasis. Current standard of care for primary rectal
cancers remains combined chemotherapy with rectal and pelvic
radiation. The most common regimen would use 5-fluorouracil
for radiation sensitization. The poor response rates of metastatic
lesions from this chemotherapeutic regimen have led some inves-
tigators to suggest initial treatment with oxaliplatin or irinotecan
containing regimens, yet local recurrence rates for rectal prima-
ries treated with this regimen followed by resection have not been
well defined. Currently there is no defined standard of care and
the treatment of these patients should be individualized.
Adjuvant Therapies
In addition to surgical resection and systemic chemotherapy, a signif-
icant number of alternative liver directed therapies exist. Treatments
including radiofrequency ablation, cryotherapy, microwave ablation,
chemoembolization, yttrium-90 and stereotatic high dose radiation
are alternate tools for site directed therapy.
Cryotherapy has been shown to be an effective treatment
for liver metastasis with or without resection.(120–124) When
initially introduced, complications including liver fracture, bleed-
ing, systemic cytokine induced lung injury, myoglobinuria and
pleural effusion reduced its overall popularity and widespread
use. Radiofrequency ablation was initially described in the treat-
ment of metastatic colon cancer in 1996.(125) While a much less
morbid procedure than resection or cryotherapy, limits to the size
of treatable tumors and higher incidence of recurrence as well as
lower overall survival when compared to resection have prevented
this from replacing surgery as the gold standard for therapy.(126,
127) Microwave ablation, chemoembolization and stereotatic body
radiotherapy remain investigational in the US at this time. Injection
of yttium-90 labeled beads into the hepatic artery of tumor con-
taining segments of liver has received approval by the Federal Drug
administration for the treatment of unresectable colon cancer
metastasis to the liver. Current trials are underway to determine the
role of this therapy in downstaging liver metastasis and as primary
therapy with chemotherapy in the adjuvant setting.
Operative Approach
Laparoscopy
Patients who have single or peripherally located metastatic lesions
may be candidates for laparoscopic liver resection. Anteriorly located
lesions in either the right or left lobes can often be approached in the
supine position. A full explanation of all the techniques and equip-
ment available for resection are beyond the scope of this chapter
but have been summarized recently in a review.(128–130) In our
practice, we find the LigaSure™ Vessel Sealing System (Valley Lab,
Boulder, CO) and the TissueLink Endo SH2.0™ Sealing Hook (SH)
(TissueLink Medical Inc., Dover, NH). to be the most useful for
laparoscopic resections. Port placement often varies significantly

 improved outcomes in colon and rectal surgery
depending on the location of the lesion to be removed. Addition
of the hand port has been described to assist with right lobe liver
resection and may be useful depending on the body habitus of the
patient, the location of the tumor and the characteristics of the
liver, i.e, underlying fibrosis, steatosis, etc. In general, a 5–15 mm
port is often placed in the plane of the liver dissection to facili-
tate stapling of the liver. The initial step of the procedure involves
localization of the tumor and demarcation of the liver division
plane. Laparoscopic ultrasound is needed to define the location
and extent of the tumor and to map the appropriate vascular
structures. The surface of the liver is marked in the division plane
often with electrocautery. The margin status for resection has been
a topic of considerable debate in the literature. Several studies have
suggested that no significant margin is necessary as long as the cap-
sule of the tumor has not been violated during the resection. Other
studies have suggested higher local recurrence rates when tumor
was present at the resection margin, regardless of the method of
resection.(131, 132) Resection can be performed with or without
hilar control. Vascular clamping before resection is not necessar-
ily needed. Parenchmal dissection can be performed with various
energy sources. Venous bleeding is controlled by adjusting the pres-
sure of the pnuemoperitoneum and the central venous pressure.
The portal vein and the hepatic vein are taken with a laparoscopic
GIA stapler using 2.5 mm staples.
The approach to posterior lesions can be more difficult.
Descriptions on resection techniques utilizing anterior and lat-
eral approaches to these lesions have been described (133, 134).
Resection principles are similar.
Open Resection
The majority of resections are performed using an open tech-
nique. Open approaches may be more appropriate if there are
multiple lesions, if the lesions involve or abut the major portal
structures or if obtaining a margin on or near a hepatic vein may
be difficult. For patients with bilobar disease or larger primary
tumors, laparoscopy at the time of, but prior to open resection
may help differentiate resectable from nonresectable patients.
Laparoscopic ultrasound is an invaluable aid in determining the
number and extent of hepatic metastases. Laparoscopy before
laparotomy in patients at high risk to have unresectable disease is
helpful to limit the patient morbidity and recovery time.
The approach to open resection differs from laparoscopic in
that vascular control is often mandatory in limiting operative
blood loss. Exposure is obtained with either a Mercedes incision
or via a Chevron approach. Use of the Bookwalter, Thompson or
upper hand retractor often aids in exposure. Again, full descrip-
tions of resection techniques are beyond the scope of this chap-
ter (reviewed in (135–137)) but in general formal resections do
not confer survival advantage. Studies which have evaluated long
term survival would suggest that liver conservation during the
resection of metasatic disease does not increase the overall recur-
rence rates and may confer a better long-term outcome.(138)
Expected Outcomes
Early series looking at survival of patients undergoing liver resec-
tion have demonstrated 5 year survival rates of 25–37%.(139,
140) Further screening patients with FDG - PET imaging has

resulted in increasing the sensitivity of identifying patients with
extrahepatic disease. Better patient selection has resulted in five
year survival rates of almost 60%.
Even with better imaging most patients will develop recurrent
disease of which half will have liver only recurrence. These patients
can safely undergo repeat resections with equivalent outcomes.(141–
143) Addition of adjuvant chemotherapy after resection has been
recommended as part of the NCCN treatment recommendations
based on improvement in survival for patients treated with 5-flour-
ouracil or oxaliplatin based regimens.(61, 105, 106) Treatment of
patients with synchronous colon and liver lesions with simultane-
ous liver and colon resection have demonstrated increased risk of
early recurrence and lower overall disease free survival. These data
were from studies conducted before treatment with current che-
motherapy based adjuvant therapies. Treatment of patients with
adjuvant therapy prior to liver resection has been advocated by
several different authors as a way to identify favorable, chemother-
apy sensitive tumors. Other authors have argued that resistance to
chemotherapy is a poor prognostic sign even in resectable disease.
(144) Multiple studies have demonstrated the ability to downstage
metastatic tumor burden in the liver by neoadjuvant therapy either
given systemically or by hepatic artery infusion. Rates of converting
unresectable colorectal liver metastasis to resectable disease vary
from 16% to 51%.(101, 145)
One inherent problem with current studies evaluating the effi-
cacy of various treatments for patients with stage IV disease is the
ability to control for the extent of disease in the treatment group.
Similar to the patients with stage III disease who can be divided
into three separate categories based on extent of nodal involve-
ment, stage IV patients represent a spectrum of disease burden
requiring a more complex substaging to accurately identify and
evaluate different treatment options. Unfortunately, this currently
does not exist. Several authors have reported risk factors which cor-
relate with patient outcome. In 1997, Fong et al. reported on scor-
ing system which included points awarded for size of the tumor,
disease free survival<12 months, number of tumors >1, node posi-
tive disease, and a CEA greater the 200. For patients with 0–1 point,
2–3 points, and 4–5 points, five years survival was 50%, 20% and
10% (146). Studies to evaluate the use of this and other scoring sys-
tems when applied to an independent population proved unsuc-
cessful and have led to the development of other nomograms for
predicting disease-specific survival.(147, 148) Although predicting
outcome is useful, a staging system is needed to be able to evaluate
treatment outcome in similarly controlled groups. One such sys-
tem has been recently proposed.(149)
Significant progress continues to be made in the treatment of
metastatic colon cancer to the liver. An aggressive multimodal
approach between surgical, medical and radiologic specialties is
required for optimizing outcome. While treatment algorithms con-
tinue to evolve, there is one tenet that remains constant: patients
need to be constantly reevaluated for the appropriate medical or
surgical care and that aggressive intervention can significantly
improve disease free and overall survival.
Colorectal Lung Metastasis
When colorectal cancer (CRC) is confined to the bowel, the work-
up and management are usually fairly straight forward. When
 indications and outcomes for treatment of recurrent rectal cancer
there is disease (suggested or proven) outside the bowel, the man-
agement becomes debatable. As early as the 1980s and 1990s, CRC
which had spread to the liver or lung was considered unresectable
at most hospitals, and therefore incurable. There are reports of
metastectomies going back to the 1940’s (150), but this approach
was not widely accepted. As new technologies developed, such as
chemoembolization, cryotherapy, radiofrequency ablation, and
safe techniques for metastectomies, aggressive medical centers
began resecting or ablating metastatic foci once the primary site
was controlled. These centers then began finding that in some sit-
uations metastectomy offered a chance at cure and long term can-
cer free survival. Those surgeons who pushed the envelope even
further began finding that repeat lung resections for second and
third recurrences can still offer chances at cure.(151–154) Cure
rates for metastectomies were not high, and most patients even-
tually developed further metastatic deposits and succumbed to
their disease, but a noticeable percentage maintained their disease
free state and lived normal life spans. From the patient’s perspec-
tive, this was a tremendous leap. Imagine the difference between
being told you have almost no chance of cure and will probably
die of cancer in the next few years, to being told that with some
extra surgery you may have a 25% chance of cure. Suddenly 25%
sounds like a wonderful number. In a day when cancer still is a
major cause of pain and suffering, we applaud those who work to
give us further means of saving patients, and will review some of
their work, as well as explain our approach to managing known
CRC with known or suspected lung metastases.
Assessing Resectability
The first step is finding and working up lung nodules. Suspected
lung mets can be found before or after the CRC is found. Most
commonly the bowel cancer is found first. Preoperative chest
x-rays may show an asymptomatic lung mass, or staging CT chest/
abdomen/pelvis +/- PET scan may show the suspected lung mass.
If the lung mass is seen on preoperative chest x-ray, then CT/PET
is recommended. Although biopsy and pathologic examination of
tumors is the gold standard for differentiating malignant nodules
from benign nodules, the radiographic characteristics can help.
Primary lung cancers tend to have irregular, spiculated borders, and
if >8 mm in diameter, most state-of–the-art PET scanners should
start to show PET activity. There are, of course exceptions to this.
Primary carcinoid tumors of the lung have smooth borders and
have low to no PET activity. Luckily these tend to be slow growing,
and if not biopsied right away, can be followed with serial scans
until growth is confirmed. Bronchoalveolar lung cancer (a variant
of adenocarcinoma) can present as a mass, but can also appear with
an infiltrative pattern which is often read as pneumonia, initially.
Failure to improve after a course of antibiotics, or lack of any recent
or current infectious symptoms in the patient should increase your
suspicion for cancer. Multiple smooth bordered nodules of varying
sizes, especially in a patient with a known CRC, tend to be metas-
tases. PET activity should start to show in colorectal metastases
greater than 10 mm. Large (>10 mm) lung nodules without PET
activity in the presence of a PET avid colorectal cancer are still con-
cerning, but could very well be non-malignant processes such as
rounded atelectasis, scar, or granulomatous disease. If old radio-
graphs, especially CTs, are available, then these should be viewed. If
the suspected nodules are not new, and have been present for more
than 2 years without increasing in number or size, then the likeli-
hood of metastatic disease or primary lung cancer is extremely low.
Any nodules that are new or increasing in size are suspect.
Once the lung nodules are found, the next step is deciding what
to do with them. Most CRC patients are middle aged to elderly
and a good proportion have smoking histories. We need to be just
as concerned about a second primary lung cancer as we are about
metastatic disease. Once again, the radiographic characteristics can
help. As stated before, multiple, smooth bordered, PET avid nod-
ules are probably metastatic CRC, but intrapulmonary metastases
from a lung cancer are still possible. A solitary PET avid lung mass
several centimeters in size, without any other suspicious metastatic
deposits either intra or extra-thoracic would be suspicious for a
primary lung cancer. While CRC can spread to the hilar, internal
mammary, and mediastinal lymph nodes, the presence of nodal
enlargement >10 mm would also make us suspect lung cancer
more than CRC. Differentiating lung cancer from CRC is impor-
tant because the survival of the cancers is different, and knowing
the patient’s prognosis may affect the aggressiveness of treatment
for the other cancer. For example, let us imagine that two nodules
are found in different lobes, with no other suspected sites of metas-
tases, in a patient with proven CRC. If both of these nodules are
resected and proven to be metastatic CRC, then aggressive manage-
ment of the primary cancer is warranted, since long term survival
may be 25–40%. On the other hand, if biopsies of the lung nod-
ules show primary lung cancer with an interlobar metastasis, then
the patient has stage IV lung cancer, and overall survival is usually
measured in months to a couple of years, and less aggressive CRC
management might be appropriate. If the PET scan shows sus-
pected disease in other extra-thoracic and extra-abdominal sites,
such as bone lesions, then these areas need to be biopsied before
embarking on lung resections. Usually CT guided biopsies of sus-
pected bone mets are safer and easier than lung resections.
Who to operate on, and in which order to operate (bowel or lung
first) can be tricky. Patient selection for lung surgery involves several
factors. These include 1) exclusion of other sites of metastatic dis-
ease 2) adequate lung function for resection based on pulmonary
function tests and clinical exam 3) ability to control intra abdomi-
nal disease. Excluding extra-thoracic and extra-colonic metastases
is critical. Spread of CRC to sites other than the liver and lung, such
as the bone, would preclude performing thoracic resections. If the
only sites of disease are the bowel, liver, and lung, and the abdomi-
nal surgeons feel that curative resections can be performed on these
two organs, then curative lung surgery is considered.(152, 153) In
order to resect portions of the lung, the patient must have enough
residual lung function not only to support life, but also allow for a
quality of life acceptable to the patient. Pulmonary function tests
are usually easy to obtain. We base our decision for resection on the
FEV1 (forced expired volume in 1 second), the diffusion of carbon
monoxide (DLCO), and the clinical exam. If after viewing the CT
chest and deciding on the extent of resection, the predicted postop-
erative (ppo) FEV1 is > 0.8 L, then surgery is considered. If the pre-
dicted postoperative DLCO is >40% of predicted, then surgery is
considered.(155) These formulas should by no means be followed
blindly. Just, if not more, important is the clinical evaluation of the
patient. As a general rule, if the patient can climb three flights of

 improved outcomes in colon and rectal surgery
stairs without having to stop due to shortness of breath, then they
should be able to tolerate a pneumonectomy or equivalent resec-
tion. I also ask if they can walk around the block without stopping.
Usually the PFT numbers will support the patient’s answers on the
clinical exam. Sometimes they don’t, and I tend to trust the clinical
exam over the numbers. For example, we had a patient whose FEV1
and diffusion capacity were >100% of predicted. Based on those
numbers a pneumonectomy should have been possible. When seen
in clinic he could barely walk from the waiting room to the exam
room due to dyspnea and desaturation. Conversely, one patient
had a PFT FEV1 of 0.7 L, but biked 5 miles a day with her husband
without oxygen. I based my decisions on the clinical evaluation,
did not operate on the first patient, and successfully performed a
lobectomy on the second patient. Some patients will be borderline
resectable based on PFTs and clinical exam. A split perfusion V/Q
scan can then be performed. With this test the nuclear medicine
doctors can estimate which parts of the lungs are performing what
percentage of the work. This allows for a more exact calculation
of ppoFEV1. For example, if a tumor is obstructing a lobar bron-
chus, then the V/Q scan should show that that lobe is contributing
almost nothing to the overall lung function, and resection can be
performed with no decrease in PFTs.
Operative Approach
As mentioned above, part of the decision is how much lung needs
to be taken out. Obviously, if we are aiming for cure, then all sites
of pulmonary metastases need to be addressed. Metastatic disease
is different than primary lung cancer. For lung cancer, anatomic
resection is the gold standard (156), with lobectomy being preferred
(unless pneumonectomy is required) over segmentectomy, and
segmentectomy preferred over wedge resection. Metastectomies are
the converse. Lung sparing is very important, especially since the
chance for future metastases is high. Also, larger anatomic resec-
tions of metastases offer no survival advantage, so wedge resec-
tions with negative margins are adequate. Anatomic resections
are considered when the size or position of the cancer precludes a
wedge resection. Tumors on the periphery of the lung <3 cm in size
can usually be excised by a wedge. Larger masses can sometimes
be resected by a wedge, especially if in the inferior lingula. Large
tumors, those positioned several centimeters deep to the visceral
pleura, mid basilar tumors, or those near the hilum will probably
require a segmentectomy, multiple segmentectomy (ex. basilar seg-
mentectomy, lingular sparing left upper lobectomy), or lobectomy.
Pneumonectomy will be described later. With this information a
thoracic surgeon can estimate the percentage of overall lung to be
resected, and calculate the ppoFEV1 and ppoDLCO.
Once it has been decided that the patient could undergo lung
surgery, the order of surgery is decided upon after discussion
between the colon, hepatic, and lung surgeons. If the thoracic
metastectomies can be performed with quick wedge resections
with low morbidity, then I would operate first if my finding will
change the other surgeons’ resections. If larger, more risky tho-
racic resections are needed (especially pneumonectomy), then
I would prefer the abdominal surgeons to proceed and make sure
that the primary tumor and intraabdominal metastases can be
controlled first. If the resection pathology is favorable and the
patient has recovered, then definitive lung resection is done. It is

nice for the patient if combined surgery can be performed. For
video-assisted thoracoscopic surgery (VATS) wedge resections
I feel comfortable removing the thoracic disease and then letting
the abdominal surgeons proceed at the same setting. The VATS
approach allows for less pain and earlier mobility, and usually
doesn’t hinder patient recovery from the laparotomy. If the lung
surgery requires a thoracotomy, lobectomy, or pneumonectomy,
I prefer not to operate at the same setting, as postoperative recov-
ery becomes much more difficult for the patient.
Video Assisted Thoracoscopic Surgery (VATS)
A relatively new factor that has changed our approach to metastecto-
mies is the VATS, or video assisted thoracoscopic surgery, technique.
Traditionally lung resection required a lateral or posterolateral tho-
racotomy. These incisions are painful, usually involve transecting
the latissimus muscle, require several days of hospital stay to recover
and several weeks or months as an outpatient to recover, and fre-
quently require epidural placement preoperatively for pain control.
As the size of the thoracotomy increases, the chance for chronic pain
increases as well. If the patient recurs on the ipsilateral side, then
repeat thoracotomies are needed. The amount of scar tissue in the
thorax increases after larger dissections, and any redo operation runs
the risk of having to deal with this. Sometimes the lung is so scarred
in that exposure and resection are not possible. Usually, however,
the surgery just takes longer as the scar tissue is dealt with, and may
require even further extension of the old incision to facilitate expo-
sure. Just like surgery in other areas of the body, the longer and more
difficult the dissection, the greater the risk of complications. With
VATS, wedge resections require only three incisions 10 mm or less in
length. Pain is managed more easily and discharge is usually antici-
pated in 1 to 2 days postop. Changing to lobectomy only needs one
of those incisions to be lengthened to a 3–4 cm utility incision. The
latissimus and serratus muscles are spared, and no rib notching is
needed. We no longer use epidurals, and instead leave a PCA (patient
controlled analgesia) for one day as well as placing a marcaine infuser
catheter in the intercostal space and subcutaneous tissue of the utility
incision. The marcaine pump we use will last for about three days.
On post op day 1 the PCA is discontinued and oral pain meds are
started. Discharge is anticipated on postop day 4–5 to home with-
out any chest tubes. Since the amount of intercostal muscle being
transected during VATS surgery is minimal, chest wall adhesions
with redo operations is usually minimal, especially after wedge resec-
tions. Even multiple surgeries on the same side can be managed with
only a short increase in operative time to take down adhesions, and
often the same incisions can be used.
Expected Outcomes
Now that we know how to work up a patient for lung surgery, decide
if they can tolerate lung surgery, and understand the latest approach
to lung resections, we need to review our chances for helping these
people survive metastatic CRC. We will review a select number of
studies. The Mayo Clinic, Rochester, reported in 1992 their experi-
ence with 139 consecutive lung resections for metastatic CRC.(154)
Resections were performed via wedge resection in 68, lobectomy in
53, and more extensive resections including pneumonectomy in 18.
During follow up, 19 patients recurred in the lung and needed repeat
resections. Median follow up was 7 years (range 1–20.4). Overall
 indications and outcomes for treatment of recurrent rectal cancer
5- and 20- year survival was 30.5% and 16.2%, respectively. Five   
year survival for solitary metastases was 36.9% compared to 19.3%
for patients with two lesions. For those who recurred and required
repeat resection, 5- year survival after the second resection was just  
over 30%. Twenty patients had extrapulmonary metastases as well as
lung lesions. Survival after resection for these patients was also 30%.
Interestingly, they noted that patients with prethoracotomy CEA  
levels >5 ng/ml had much poorer survival at 5 years compared to
lower CEA level patients (16% vs. 46.8%). This same poor prognos-
tic indicator has been realized by others.(151, 157) Based on their
experience, they supported resection of intra- and extrapulmonary  
metastases, even if they recur.
Irshad et al. reported on a 25 year experience, from 1975 to
1999, in which 49 patients underwent curative colorectal surgery  
followed by curative thoracic metastectomies. Overall survivals at
5, 10, and 15 years were 55%, 40%, and 25%. Patients with soli-
tary metastases did better, but multiple metastectomies still had a  
survival advantage.(158)
One area of debate is how aggressive of a resection should be
performed. More precisely, should a patient undergo pneumonec-  
tomy for stage IV colorectal cancer? Pneumonectomy alone carries
a higher mortality than lesser resections, with an operative mortality
around 7%. In centers accustomed to taking care of these patients,
and surgeons who specialize in this procedure, the mortality is lower.
Hendricks et al. looked at 10 cases of pneumonectomy for metastec-  
tomy and found 5 year survival of around 45%.(159) Koong et al.
reviewed 133 patients who underwent pneumonectomy or comple-
tion pneumonectomy for metastases. Of those patients who under-
went R0 resection, operative mortality was 3% and 5 year survival  
was 30%.(160) It is our practice to consider pneumonectomy for
metastatic CRC if the abdomen is cleared of disease, there is no sign
of extrathoracic metastases, and the surgical risk is acceptable.  
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
29 Chemotherapy for colon and rectal cancer
Liliana Bordeianou and Judith L Trudel
Challenging Case
A 56-year-old man presented with a 5 cm rectal cancer. It was
located posteriorally at 8 cm from the anal verge. The preop
ultrasound suggested a T3N1 tumor. The patient received pre-
operative chemoradiotherapy. He had a superb clinical response
with tumor shrinkage. Six weeks after completing the therapy,
the patient underwent a low anterior resection with a diverting
loop ileostomy. The final pathology was a T1N0 with five negative
lymph nodes identified. All margins were negative. Should the
patient receive postoperative chemotherapy?
Case Management
There is little data on which to base this clinical decision. Most
practioneers lean toward recommendations for postoptherapy
based on the pretreatment clinical stage if the patient receives
neoadjuvant therapy. In a good risk patient, most would recom-
mend 6 months of postoperative adjuvant chemotherapy.
Introduction
Colorectal cancer (CRC) is the third most common cancer diag-
nosed in men and women in the United States. Approximately
148,810 new cases of colon and rectal cancer were reported in
2007, with an estimated 49,960 deaths attributed to it.(1) This is
higher than the number of deaths attributed to pancreatic cancer,
liver and intrahepatic bile duct cancer or esophageal cancer.
While surgery remains the mainstay of treatment for this com-
mon disease, it is the recent noteworthy changes in the indications
for chemotherapy, the timing strategy as far as chemotherapy
administration and the actual therapeutic regimens used to treat
advanced colon and rectum cancers that may provide the next step
toward the improvement in the survival rates of these patients.
Chemotherapy Agents or Combinations Most
Commonly Used Against Colorectal Cancer
5-FU with Either Leucovorin or Levamisole
Since its original use in the 1950s, 5-FU remains one the oldest
chemotherapeutic agents used today to target colorectal cancer.
5-FU inhibits DNA synthesis via blockage of thymidylate syn-
thase. At first used alone, and then in combination with levami-
sole, 5-FU/levamisole combination was noted to significantly
decrease recurrence rates and improve overall survival, particu-
larly in Dukes’C patients.(2) This observation was subsequently
confirmed in a large study of 971 patients with stage III and IV
disease (intergroup 0035) which in 1990 showed that this drug
combination reduced the risk of cancer recurrence by 41% and
the overall death by 33 % in this group of patients.(3) Given
these results, this drug combination was regarded as gold stand-
ard therapy for CRC till 1996, when an even more effective regi-
men using 5-FU in combination with leucovorin (folinic acid)
was described.

Leucovorin is a 5-FU biomodulator. Leucovorin and 5-FU
form a stable ternary complex with thymydylate synthetase, per-
mitting prolonged inhibition of the enzyme by 5-FU. Its appli-
cability to stage II and stage II disease was confirmed by the
IMPACT (International Multicenter Pooled Analyses of Colon
Cancer Trials) study of 1,526 patients in 1995, which showed
that 5-FU/leucovorin increased the 3-year disease free survival
from 62% to 71% while overall survival increased from 78%
to 83%.(4) The NSAPB C-03 randomized trial of 1,081 stage
II and stage III patients comparing MOF (semustine, vincris-
tine and 5-FU) to 5-FU/leucovorin had documented a similar
advantage of 5-FU/leucovorin, with a 3 year disease-free sur-
vival increase from 64% to 73% and an overall survival increase
from 77% to 84%.(5)
The relative merits of levamisole and leucovorin as modulators
of 5-FU-based adjuvant chemotherapy, and the optimal duration of
treatment were documented in several studies between 1998 and 2000.
The NCCTG/NCIC (National Cancer Institute of Canada) study of
915 patients compared 6 months 5-FU/leucovorin; 6 months 5-FU/
leucovorin/levamisole; 1 year 5-FU/levamisole; and 1 year 5-FU/leu-
covorin/levamisole.(6) Triple therapy for 6 months was as effective
as 12 months; and 6-month triple therapy provided superior 5-year
overall survival and disease-free survival compared to 5-FU/levami-
sole.(6) The Intergroup trial 0089 of 3,759 patients compared 1 year
5-FU/levamisole; 5-FU/high-dose leucovorin for 32 weeks; 5-FU/
low-dose leucovorin for 6 cycles; and 5-FU/low-dose leucovorin/
levamisole for 6 cycles.(7) There were no differences between the
four treatment arms with regards to 5-year disease-free and overall
survival. The NSABP CO-4 study essentially confirmed these results.
(8) The QUASAR Collaborative Group study confirmed the survival
advantage provided by leucovorin modulation over levamisole.(9)
Based on the results of these studies, the new standard for treatment
was changed to 6 months of adjuvant chemotherapy with 5-FU/
leucovorin for stage III, node-positive disease.
Until recently, this course of therapy was the standard of care for
patients with advanced colorectal cancer. However, with increas-
ing understanding of the molecular basis of cancer and the devel-
opment of biologic-based therapy, chemotherapy for CRC has
evolved once more and a variety of new agents are now available
to treat this disease.
Oxaliplatin-Containing Regimens (FOLFOX, XELOX)
Oxaliplatin inhibits DNA replication through creation of bulky DNA
adducts. It was first introduced to treat patients with recurrent or meta-
static colorectal cancer that was otherwise unresectable. A study of 795
patients enrolled by Intergroup N9741 compared FOLFOX (oxalipla-
tin and infused fluorouracil plus leucovorin) to either IFL (irinotecan
and bolus fluorouracil plus leucovorin) or IROX (irinotecan and oxali-
platin) to show that patients treated with FOLFOX had an increased
median survival of 19.5 months (compared to 15 and 17.4 months in
 chemotherapy for colon and rectal cancer

the control arms) and an increased time to progression: 8.7 months as
compared to 6.9 and 6.5 months in the two control arms.(10) Given
the improved response rates with FOLFOX in metastatic disease, the
MOSAIC trial of 2,246 patients compared this regimen to the stand-
ard 5-FU leucovorin regimen in the adjuvant setting of resected colon
cancer. After a median follow-up of 56.2 months, the 3 year disease-
free survival in the FOLFOX group was 76.4% (compared to 69.8%
observed in 5-FU/leucovorin group).(11)
On the strength of these results, FOLFOX is now the most
popular first-line therapy for the adjuvant treatment of resected
CRC and for metastatic CRC. In patients interested in avoiding
IV infusions, the combination of capecitabine and oxaliplatin
(XELOX) may be used. Capecitabine is the prodrug to 5-FU, and
is administered orally.
Irinotecan-Containing Regimens (FOLFIRI, IFL, IROX)
Irinotecan inhibits DNA replication and transcription via topoi-
someraze blockade. Irinotecan has been shown to have activity
against CRC, though its effects are less pronounced than those
of oxaliplatin. IFL therapy (5-FU, leucovorin and irinotecan) has
been shown to be superior to 5FU/leucovorin therapy alone in
patients with metastatic colorectal cancer.(12) However, the N9741
Intergroup trial described above showed that patients treated with
FOLFOX had superior results to those treated with FOLFIRI (5-FU
and irinotecan), or IROX(irinotecan and oxaliplatin).(10) Based
on the results of this and other studies irinotecan containing com-
binations are now mostly used as second line therapy.(13)
Bevacizumab (AVASTIN®)
Bevacizumab (a monoclonal antibody that binds to the vascular
endothelial growth factor (VEGF) ligand) is one of the first biologic
therapy agents shown to be effective against CRC. Bevacizumab,
which blocks angiogenesis, was first found to improve efficacy of
FOLFOX alone in patients with metastatic disease: the median dura-
tion of survival for the group treated with FOLFOX and bevacizu-
mab was 12.9 months compared with 10.8 months for the group
treated with FOLFOX alone.(14, 15) Additional information on the
feasibility and efficacy of bevacizumab in combination with FOLFOX
or other oxaliplatin combinations was gleaned in the TREE-2 trial,
where the percentages of patients with progressive disease decreased
substantially in all arms when bevacizumab was added.(16)
Cetuximab (ERBITUX®)
Cetuximab (a monoclonal antibody blocking epidermal growth
factor (EGFR) is currently approved only as therapy as a single
agent or in combination with irinotecan for patients with previ-
ously treated advanced colorectal cancer. A number of recently
published trials suggested that patients treated with cetuximab
have a longer time to disease progression, and this effect is aug-
mented with addition of bevacizumab.(17)
Indications and Timing of Chemotherapy for
Colorectal Cancer
Adjuvant Chemotherapy for Stage III
and Stage IV Colon Cancer
While surgical resection is the only curative treatment for local-
ized colon cancer, the 5-year survival rates vary from 93% in
the patients with Stage I disease to 44% in patients with Stage
III disease (Table 29.1). For the patients who have undergone
potentially curative resection, disease recurrence is thought
to derive from clinically occult micrometastases. The goal of

Table 29.1  American Joint Committee on Cancer (AJCC) colon cancer staging versus survival (37).
Stage T Stage N Stage M Stage 5-year Survival

I T1 N0 M0 93%
(tumor invades submucosa) (no regional lymph nodes (no evidence of distant
T2 metastasis) metastasis)
(tumor invades muscularis propria)
IIA T3 N0 M0 85%
(tumor invades through muscularis propria into
subserosa or nonperitonealized pericolic tissues)

IIB T4 N0 M0 72%
(tumor directly invades into other organs and/or
perforates visceral peritoneum)

IIIA T1 N1 M0 83%
T2 (metastasis to 1–3 regional
lymph nodes)
IIIB T3 N1 M0 64%
T4
IIIC Any T N2 M0 44%
(metastasis to four or more
regional lymph nodes)
IV Any T Any N M1 8%
(distant metastasis)


 improved outcomes in colon and rectal surgery
postoperative (adjuvant) chemotherapy is to eradicate these
micrometastases.
Adjuvant chemotherapy for colon cancer has been studied for
at least 40 years. Interestingly, 5-FU monotherapy did not improve
5-year survival following curative resection.(18) However, the
discovery of modulators of 5-FU activity and of the effects of
combination regimens on survival reignited the interest in adju-
vant chemotherapy. The first large-scale trial to demonstrate a sur-
vival benefit for adjuvant chemotherapy in colon cancer, National
Surgical Adjuvant Breast and Bowel project (NSABP) C-01 included
1,166 patients with Dukes’ B or C colon cancer.(19) The patients
randomized to adjuvant MOF chemotherapy instead of surgery
alone had significant improvement in their 5-year overall survival.
These improvements became even more pronounced as advances
in chemotherapy described earlier and postoperative (adjuvant)
systemic therapy has become routine and standard for node posi-
tive or metastatic disease. Clinical data indicates that access to a
multidrug regimen consisting of two or more of the agents dis-
cussed earlier (in addition to 5-FU therapy) has almost doubled
median survival in the patients with advanced colorectal cancer
from 10–12 months to more than 20 months.
Adjuvant Chemotherapy for Stage II Colon Cancer
In contrast to the clear benefit of adjuvant chemotherapy for patients
with node-positive disease, its role in resected stage II colon cancer
remains controversial. While a number of clinical trials have included
stage II patients and have suggested a benefit from adjuvant therapy,
none of these have reached statistical significance. Several meta-
analyses have been performed to evaluate this question further. An
NSABP analysis of the data pooled from the adjuvant C-01, C-02,
C-03 and C-04 trials of 3,820 patients (1,556 with T3N0 disease)
suggested that the relative reduction in recurrence and mortality
from adjuvant therapy for patients with resected T3N0 colon cancer
was comparable to that seen in patients with node-positive disease.
(20) In contrast, a 2004 systematic review by the Ontario Cancer
Care Program did not find a statistically significant improvement in
survival in the T3N0 patients treated with at least one 5-FU chemo-
therapy regimen after surgery.(21) In hopes of settling this debate, a
panel of the American Society of Clinical Oncology reviewed all the
pertinent information in regards to this issue.(22) This panel con-
cluded that routine use of adjuvant chemotherapy for medically fit
patients with stage II colon cancer is not recommended.
Parenthetically, the panel also felt that selected patients with
stage II disease—such as patients with inadequately sampled
nodes, T4 lesions, perforation, or poorly differentiated histol-
ogy—could still be considered for adjuvant therapy.(22, 23) The
identification of patients with stage II colon cancer who might
benefit from adjuvant chemotherapy is an area of ongoing
research. The prognostic value of additional molecular markers,
such as microsatellite instability and loss of 18Q allele is being
investigated. (http://cancer.gov).
Neoadjuvant Chemoradiotherapy for T3
or Node-Positive Rectal Cancer
The management of rectal cancer is radically different from the
management of colon cancer. While recommendations for adju-
vant postoperative therapy for advanced colon cancer are based

on the pathological stage revealed by the surgical specimen, rectal
cancer staging determines initial management. This, after much
debate, is based on conclusive evidence that has clearly shown neo-
adjuvant preoperative therapy to improve local control, disease-
free survival, and overall survival compared to surgery alone or
to postoperative adjuvant therapy.
The Swedish Rectal Cancer Trial examined whether neoad-
juvant preoperative radiation therapy was of benefit to patients
with advanced rectal cancer. The study randomly assigned 1,168
patients to receive or not receive radiation therapy prior to sur-
gery. After 5 years, preoperative radiation therapy was associated
with significant improvements in both local control (89% vs.
73%) and overall survival (58% vs. 48%).(24)
The German Rectal Cancer Trial examined whether radiation
is more beneficial before or after surgery. The study randomly
assigned 823 patients with clinically staged T3/T4 or node-positive
rectal cancer to either neoadjuvant or adjuvant chemoradiotherapy.
With a 46 month median follow-up, preoperative chemoradiother-
apy was associated with a significantly lower local recurrence rate
(6% vs. 13%), though the 5-year disease-free and overall survival
rates were similar.(25) These two studies made preoperative radio-
therapy for advanced rectal cancer the standard of care.
At least two randomized trials have directly assessed the poten-
tial benefits of concurrent chemotherapy with neoadjuvant radi-
otherapy. A European trial randomly assigned 762 patients with
T3/4 rectal cancer within reach of the digital rectal exam to either
preoperative radiotherapy alone or preoperative chemoradio-
therapy. At a median 69 month follow-up, the combined modality
group had lower local recurrence rates (8.1% vs. 16.5 %), but the
rate of sphincter preservation surgery and 5-year overall survival
rates were similar.(26) Another study, EORTC 22921 showed a
similar benefit with chemoradiotherapy enhancing local control
in comparison to radiotherapy alone.(27)
Based on these studies, neoadjuvant chemoradiotherapy is
generally considered in all patients with T3 N0 and node positive
tumors of any T stage. Stage of the disease determines the need
for neoadjuvant therapy. Because of this, the importance of pre-
treatment staging of rectal tumors becomes paramount and can-
not be overemphasized. The standard of care now dictates that
all patients with rectal cancer should undergo a staging endorec-
tal ultrasound or pelvic MRI to determine initial management.
Tumors penetrating into perirectal fat and/or lymph nodes should
undergo neoadjuvant chemoradiotherapy. Tumors that do not
penetrate through muscularis propria (T1-2, N0) are candidates
for initial surgical resection. If the final pathological stage con-
firms the stage suspected on imaging, no further chemotherapy
(and/or radiation) is indicated. However, if the final pathology
reveals penetration into perirectal fat or into the lymph nodes,
postoperative chemoradiotherapy is indicated.
Adjuvant Chemotherapy Alone for T3
or Node-Positive Rectal Cancer
The benefit of 5-FU based postoperative chemotherapy in patients
undergoing chemoradiotherapy has not been studied in prospec-
tive randomized trials. However, in EORTC trial 22921, patients
who had received preoperative radiotherapy with or without
chemotherapy were then further randomized to postoperative
 chemotherapy for colon and rectal cancer

chemotherapy versus no further therapy.(27) In the entire group, stomatitis, vomiting and nasea. These side effects become much
there were trends favoring adjuvant chemotherapy in both 5-year more pronounced when mutidrug chemotherapy regimens are
progression free survival (58% vs. 52%), and overall survival used. For example, addition of oxaliplatin to 5-FU, which is the
(67% vs. 63%), but the trends were not statistically significant, most common first line chemotherapy regimen currently used in
Nevertheless, these results are frequently quoted as justification of the US to treat colorectal cancer (FOLFOX), leads to an increased
adjuvant chemotherapy for patients treated with or without preop- rate of diarrhea, nausea and vomiting, as well as alopecia. In
erative chemoradiotherapy. Further information of the benefits of addition, the rates of significant neutropenia become relatively
postoperative chemotherapy are expected from the multicentre high. One of the clinically relevant side effect of oxaliplatin-based
British CHRONICLE trial.(28) chemotherapy is a late-onset predominantly sensory neuropathy
with may require drug discontinuation despite ongoing tumor
Side Effects of Chemotherapy response. Ultimately, more than 50 percent of patients receiving
The benefits of modern chemotherapy with regards to its abil- FOLFOX discontinue treatment for reasons other than disease
ity to delay disease progression and improve survival in patients progression.(29)
with advanced colon and rectal cancer are unquestionable. Multidrug combinations adding irinotecan, or bevacizumab to
Nonetheless, these benefits should be balanced against individual the standard 5-FU can cause serious toxic events, mainly severe
patient tolerance to the side effects of chemotherapy (Table 29.2), hematological toxicity, diarrhea, thrombotic events, and neu-
as this may impact therapeutic effectiveness. The elderly and the rosensory disorders.(30) The 5-FU, leucovorin, irinotecan, plus
medically compromised patients represent a group at particular bevacuzimab regimen especially, while having the highest proba-
risk. Very few elderly patients or patients with renal/hepatic fail- bility of improving survival, might also lead to significant adverse
ure or other major comorbidities have been enrolled in clinical effects to as many as 84.9% of patients, including a 1.5% chance
trials; the choices of therapeutic regimens in these subgroups of gastrointestinal perforation.(30)
should be tailored to individual patients. While these side effects are temporary in patients undergo-
5-FU/leucovorin alone is fairly well tolerated, and the ing adjuvant treatment for nonmetastatic disease, their effect on
most commonly described side effects are those of diarrhea, quality of life becomes quite important when the treatments are
continuous and indefinite, as is the current practice in the patients
with metastatic disease. One potential way of reducing treatment-
Table 29.2  Side Effects and Mechanism of Action of Commonly related side effects in this cohort is via a “chemotherapy holiday”,
Used Chemotherapeutic Agents but the impact of a completely chemo-free interval on long term
Chemotherapy
survival is of significant concern. Two European phase II trials,
Agent Mechanism of Action Common Side-Effects OPTIMOX1 (which compared continuous FOLFOX versus main-
tenance chemotherapy with 5-FU/leucovorin) and OPTIMOX2
5-FU Inhibits DNA synthesis via Heartburn, nausea, vomiting, (which compared maintenance chemotherapy using a nonoxali-
blockage of thymidylate anorexia, stomatitis,
synthase esophagitis, diarrhea,
platin regimen versus a totally chemotherapy free interval) were
myelosuppression, cardiac designed to address some of these concerns.(31, 32) Their results
toxicity unfortunately suggested that a full break in therapy resulted in a
Oxaliplatin Inhibits DNA replication Peripheral neuropathy, decrease in overall survival and that some form of maintenance
through creation of anemia, treatment is preferable to chemotherapy-free intervals.
bulky DNA adducts thrombocytopenia,
neutropenia, nausea,
diarrhea, vomiting,
Future Directions
abdominal pain, fatigue One of the major drawbacks of the current chemotherapy regimens
Irinotecan Inhibits DNA replication Alopecia, diarrhea, for colorectal cancer is our inability to identify before treatment
and transcription via nausea, emesis, severe which patient will respond to a particular combination of
topoisomeraze blockade myelosupression, colitis, chemotherapy drugs. Knowledge of tumor gene expression and
gastrointestinal ulceration, other biomarkers will hopefully provide clues and inroads in this
gastrointestinal bleeding,
ileus
direction. Microarray profiling of gene expression in colorectal
Bevacizumab A monoclonal antibody Alopecia, thrombosis,
cancer patients has already been shown to stratify risk and predict
(Avastin®) that binds to the vascular bleeding, hyperkalemia, lymph node involvement.(33) Just like in patients with breast
endothelial growth factor hypertension, abdominal cancer, patients with CRC might soon be screened in a prospective
(VEGF) ligand and pain, anorexia, vomiting, fashion to determine those with stage III disease that are unlikely to
inhibits tumor blood diarrhea, neutropenia, recur or those who may be resistant to a particular drug regimen.
supply growth delayed wound healing
and wound dehiscence,
A promising area for colorectal cancer treatment is immuno-
bowel perforation therapy. The goal of cancer immmunotherapy is to stimulate the
Cetuximab A monoclonal antibody Fatigue, confusion, pruritis, body’s immune system in order to improve host defense mecha-
(Erbitux®) that blocks epidermal insomnia, abdominal nisms against growing tumors, through either cell mediated or
growth factor (EGFR) pain, nausea, vomiting, humoral immunity pathways. Over 25 different vaccines, virus-
and decreases tumor diarrhea,weakness, lung modified tumor cells, gene-modified tumor cells, tumor-antigen
growth disease, dyspepsia
derived peptides, tumor lysates, proteins or carbohydrates have


 improved outcomes in colon and rectal surgery
been studied in Phase I and II studies. Three large studies look-
ing at the immune stimulation with autologous irradiated tumor
vaccine plus BCG in colorectal cancer patients suggest that this
approach may have merits. For example, one study randomized 98
patients with colon or rectal cancer treated surgically to vaccination
with autologous irradiated tumor plus BCG versus placebo. While
the study did not find a significant difference in the outcomes
between the two arms, a subset analysis of the colon cancer patients
did show an improvement in disease-free survival.(34) Similarly,
Eastern Cooperative Oncology Group (ECOG) randomized stage
II and II colon cancer patients to surgery alone versus surgery and
vaccine and found that patients with a marked delayed cutaneous
hypersensitivity response had a trend toward better disease-free
and overall survival.(35) Finally a study of 244 patients with colon
cancer randomized to receive a postoperative vaccine showed that
the overall risk for recurrence was decreased by 44% in all vacci-
nated patients, with a 61% reduction in stage II patients.(36)
Conclusion
In the past 20 years, advances in the adjuvant treatment of colon
and rectal cancer have significantly increased the rates of disease-
free and overall survival, increased survival rates in metastatic
disease, and decreased the rates of recurrence. Ongoing research
focuses on developing more potent chemotherapeutic agents and
on identifying patients who may best benefit from those advances.
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
30 Radiation therapy: Acute and late toxicity
Roland Hawkins
Challenging Case
A 62-year-old man presents with blood per rectum. He has mild
rectal discomfort with bowel movements and a feeling of incom-
plete evacuation. Two years previously he received external beam
radiotherapy for prostate cancer. His rectal examination is normal
except for some blood on the gloved finger. A flexible sigmoidos-
copy demonstrates friable mucosa with neovascularity of the
distal 4 cm of rectum. The mucosa is friable with telangectasia.
Challenging Case Management
The history and endoscopic exam is suggestive of radiation proctitis.
Management includes fiber and topical therapy. The friable areas of
the rectum can be treated with topical application of a large swab
soaked with 10% formalin passed through an anoscope or proctos-
cope. Argon plasma coagulation is also effective treatment.
Introduction
Apart from a few exceptional circumstances, radiation treatment
is used as an adjunct to surgical resection in the potentially cura-
tive treatment of adenocarcinoma of the rectum. As such, it is
employed to reduce the tumor burden and eradicate deposits of
cancer in pelvic lymph nodes and soft tissue not removed, or not
expected to be removed, by the surgeon. In this setting, radiation
treatment is administered either before or following en bloc resec-
tion of the involved length of large bowel by low anterior (LAR) or
abdominal perineal resection (APR) that is intended to remove all
evident disease, i.e., to be an R0 resection. Preoperative treatment
is referred to as neoadjuvant or adjuvant, and postoperative treat-
ment as adjuvant. These are usually administered to patients with
locally advanced but resectable stage II or III disease (Table 30.1).
Less often adjuvant radiation treatment is administered following
local excision of less advanced disease. Local excision is elected in
patients with small distal rectal tumors to avoid APR or LAR.
Recurrence after apparently curative surgery for rectal cancer
may develop in structures adjacent to the margin of resection or
Table 30.1  Staging of rectal carcinoma.
TNM (AJCC
Dukes TNM Group and UICC) Description
A I T1N0M0 Tumor limited to submucosa,
T2N0M0 Tumor into, not through,
muscularis propria
B II T3N0M0 Tumor through muscularis
T4N0M0 propria
Tumor invades other organs or
through peritoneal serosa.
C III N1 or N2, any T N1 (1 to 3 nodes +), N2 (>3
nodes +)
D IV M1, any T or N Distant metastasis

regional nodes in the pelvis (local recurrence), or as metastasis
to the peritoneal surface or distant organs (distant recurrence).
Treatment with radiation and/or chemotherapy added to sur-
gery is judged as beneficial in so far as it increases overall patient
survival and reduces the incidence of local and distant recur-
rence. Overall survival is the most important outcome in judging
benefit. It is unambiguously evaluable and reflects the balance of
benefit and potentially lethal adverse effects of treatment. Local
recurrence is not often salvagable. Its prevention is important, if
not a requirement, for achieving cure of the disease. It may itself
be life threatening and may act as a source of distant metastasis.
Further, uncontrolled recurrence in the pelvis is particularly det-
rimental to the quality of life of patients who are not cured by
the treatment by causing pain, bleeding, infection, obstruction
and incontinence affecting bowel and urogenital organs. Distant
recurrence is important because it is the most unsalvageable life
threatening form of treatment failure.
Evolution of the method of radiation treatment over the past
30 years has produced what are now two more or less standard
regimens, referred to here as the short and long treatment courses.
The short course has been used only for preoperative treatment.
It typically consists of a dose of 25 Gy in fractions of 5 Gy each
over a period of 5 to 7 days with surgery following within a week.
The long course has been used for both pre and postoperative
treatment. It typically consists of 45 to 54 Gy in fractions of 1.8
to 2 Gy over a period of 5 to 6 weeks. When used preoperatively
the long course is usually followed by about 6 weeks rest before
surgery and may include concurrent chemotherapy.
There are several ways to compare the intensity of radiation
treatment courses that differ in fractionation of dose and are
given over different time intervals. One in current use consists of
calculating a biologically equivalent dose (BED) for each treat-
ment course using the relation: (1)
 
d g
BED = nd 1 + - (T - Tk)
a/b a
Wherein n is the number of fractions, d is the dose per frac-
tion, a/b is a ratio characteristic of cell type or tissue and ranging
from about 2 to 20 or more. For meta-analysis overview of the
effect of radiation in the treatment of rectal cancer a/b has been
assumed to be about 10.(2, 3) The value of the g/a ratio corrects
for the repopulation of cells during the length of the treatment
course and has been assumed to be 0.6 Gy per day. The value of
T is the time from first to last radiation fraction in days and Tk is
a lag time taken to be 7 days. With these parameters the BED of
the short course of 5 fractions of 5 Gy each is 37.5 Gy and that of
a long course consisting of 50.4 Gy in 28 fractions of 1.8 Gy each
is 40.9 Gy, implying they are roughly equivalent. The validity of
equation 1 in establishing equivalency with respect to the chance
 radiation therapy: acute and late toxicity

of eliminating pelvic cancer or causing any specific organ injury
is dependent on the appropriateness to the specific endpoint in
question and of the values chosen for a/b, g/a and Tk.
The physiologic death, disintegration, and disappearance of
nearly all cells lethally injured by radiation takes place only after
they and/or their descendents go through one or more, often
aberrant, mitotic cell divisions. An exception to this is some lym-
phocyte subsets that die within hours of irradiation. As a result
there is a time lag between irradiation and response of a cancer
that is variable and dependent on the mitotic activity of the can-
cer cells. This lag ranges from a few days up to a year or more
for the various carcinomas. A typical time to manifest the maxi-
mal response of a carcinoma to radiation is the order of a month
or two. The same phenomenon is in part responsible for delay
of up to a year or more in the development of some forms of
radiation injury. With short course preoperative radiation there
is little time for tumor response before surgery. There is evidence
that at surgery after short course irradiation the average tumor
size and average number of nodes with metastatic carcinoma has
decreased slightly but this is not sufficient to produce a change in
the distribution of tumor or nodal stage in a study population.(4)
With long course preoperative irradiation more time is allowed
for response of the disease and down staging to occur. This is
evident in some of the trials listed in tables 30.3 and 30.4 and was
demonstrated in a trial in which all patients were treated with 13
daily fractions of 3 Gy each and randomly assigned to surgery
within 2 weeks after the end of radiation or surgery 6 to 8 weeks
after radiation.(5)
With both the long and short course, radiation treatment is
directed at the pelvis with the superior border placed at about
the L5S1 interspace. The inferior border is placed at least 3 to 5
cm below the most distal extent of tumor or below the obdura-
tor foramen. For distal tumors it may include all or part of the
anal canal. In earlier studies treatment was restricted to anterior-
posterior directed beams.(6) More recently, laterally directed
beams that exclude bowel in the anterior part of the pelvis are a
standard part of treatment plans. Only the volume in which the
beams overlap is exposed to the full prescribed dose. This usually
includes, in addition to the rectum, small and large bowel in the
posterior pelvis, the posterior part of bladder and prostate, the
soft tissue in the ischiorectal fossa and presacral areas, the sac-
rum and the lymph nodes of the internal iliac and most distal
part of the common iliac chains. If there is extension of tumor to
invade urogenital organs the external iliac nodes are sometimes
included. After APR, the perineal incision, which tends to be a site
of recurrence, is included in the treatment volume.(7, 8)
Tables 30.2, 30.3 and 30.4 summarize several trials in which ran-
domization was between arms composed of various combinations
of pre and postoperative radiation and chemotherapy.(9–26) The
radiation treatment plans in each are similar to either the short or
long course described above and can be gleaned from the table by
noting the dose shown. When the dose is about 25 Gy it is a short
course and when 40 to 60 Gy it is similar to the long course. The
benefits and adverse effects of preoperative and postoperative radia-
tion treatment reported in these studies will be examined and com-
pared. Adjuvant treatment after local excision is also discussed.
Benefit of Adjuvant and Neoadjuvant
Radiation Treatment
Several randomized trials of postoperative adjuvant therapy in
the late 1970s and 1980s listed in Table 30.2 indicate that post­
operative radiation and chemotherapy can lead to statistically

Table 30.2  Postoperative adjuvant radiation studies.

Number Local (Pelvic) Overall Survival
Study Open/Closed of Pts. Therapy Arms Recurrence % at 5 years % at 5 years Comments

GITSG (9) 202 S 24 46 T3,T4 or N+

S–C 27 56 Semustine and 5Fu
S–44Gy 20 52
S–44Gy-C 11 59 (p = 0.07)
NCCTG (10) 204 S–50.4Gy 25 47 Semustine and 5Fu.
794751 S–50.4Gy+C 13 (p = 0.036) 57 (p = 0.02)
NSABP (11) 555 S 25 43 Semustine, 5Fu, vincristine
R-01 S–46Gy 16 (p = 0.06) 41
11/77 to 10/86 S–C 21.4 53 (p = 0.01)
Norway (12, 13) 144 S 30 50 Bolus 5Fu on 6 days during
S–46Gy+C 12 (p = 0.01) 64 (p = 0.05) radiation
NSABP (14) 694 S–C 14 58 Semustine, 5Fu, vincristine
R-02 S–50.4Gy+C 8 (p = 0.02) 58 in 10 week cycles or 5Fu
and leukovorin in 8 week
cycles.
Retrospective 99 LE (T1) 11 Concurrent chemotherapy
Study of Trans LE–xrt (T1) 0.0 for some patients
anal excision (15) LE–(T2) 67
MGH/Emory LE–xrt (T2) 15 (p = 0.004)
RTOG 8902 (16) 65 LE (T1, fav) 14.3 86 fav = favorable features, see
LE-xrt (T1,2,3) 17.6 72 text.

S indicates LAR or APR, LE is local excision, C is chemotherapy. A dose in Gy indicates irradiation. The dash line shows time sequence.


 improved outcomes in colon and rectal surgery

Table 30.3  Preoperative neoadjuvant radiation studies.

Number Therapy Local (Pelvic) Overall Survival

Study Open/Closed of Pts Arms Recurrence % at 5 years % at 5 years Comments

Stockholm I (1) 849 S 28 36 to L2 level no lateral

1980 to 1987 25Gy–S 14 (p < 0.001) 36 beam
Stockholm II (17) 557 S 25 39 Patients older than 80
3/87 to 5/93 25Gy–S 12 (p < 0.001) 46 (p = 0.03) excluded
(Pts having
curative surg)
Swedish Rectal (18) 1168 S 27 48 Patients older than 80
3/87 to 2/90 25Gy–S 11 (p < 0.001) 58 (p < 0.001) excluded
Dutch TME (19) 1861 S 10.4 64 Patients older than 80
1/96 to12/99 25Gy–S 5.6 (p < 0.001) 64 included
Manchester (20) 284 S 36 39 5Gy x 4, survival for
1981 to 1989 20Gy–S 13 (p < 0.001) 46 (p = 0.03) those having curative
resection:
MRC II (21) 289 S 48 19 20x2Gy; S four weeks
40Gy–S 32 (p = 0.04) 26 (p = 0.09) after xrt
Polish (22) 312 25Gy–S 9 67.2 Mostly TME
1999 to 2002 50.4Gy+C–S 14 (p = 0.17) 66.2 T3/T4. Patients older than
75 excluded
EORTC (23) 1011 45Gy–S 17.1 63.2 no post op C Stage I and age over 80
4/93 to 5/03 45Gy+C–S 9.6 vs. 67.2 with post excluded
45Gy-S–C 8.7 op C (p = 0.12)
45Gy+C–S–C 7.6
FFCD 9203 (24) 762 45Gy–S–C 16.5 67.2 Stage I and age over 75
1993 45Gy+C–S–C 8.1 (p = 0.004) 66.2 excluded

Symbols as in Table 30.2.

Table 30.4  Pre versus postoperative and chemotherapy studies.

Study Open/ Number of Local (Pelvic) Overall Survival

Closed Pts random Therapy Arms Recurrence % at 5 years at % 5 years Comments

Upsala (25) 471 25.5Gy–S 12 44 5.1x5Gy and 30x2Gy.

10/80 to 12/85 S–60Gy 21 (p = 0.02) 39 (p = 0.43)
German (26) 823 50.4Gy+C–S–C 6 74 TME, exclude stage I
2/95 to 9/02 S–50.4G+C–C 13 (p = 0.006) 76 (p = 0.80)    and age over 75

Symbols as in Table 30.2.

significant improvement in overall survival and the incidence
of local recurrence compared to surgery alone. Based on
Gastrointestinal Tumor Study Group and North Central Cancer
Treatment Group studies a U.S. National Institutes of Health
Consensus Development Conference in 1990 recommended
that postoperative radiation and chemotherapy be standard
treatment for stage II and III rectal cancer.(9, 10, 27) An advan-
tage of postoperative treatment is that selection for adjuvant
treatment can be based on pathologic staging whereas with pre-
operative treatment selection is based on necessarily imperfect
clinical staging.
The use of preoperative radiation has been extensively evalu-
ated in Europe. From inspection of the randomized trials in Table
30.3 it is evident that preoperative radiation treatment reliably
produces a clinically and statistically significant reduction in the
incidence of local recurrence by about 50 to 60%. This remains
true even in the Dutch Colorectal Cancer Group trial which was
designed to minimize the need for pelvic irradiation by mandat-
ing surgery to be total mesorectal excision (TME).(19) As indi-
cated in the entries in Table 30.2 and 30.3 for the surgery only
arms, TME is apparently more rigorously extirpative than the
surgery of historical practice. Its use reduced the local recurrence
at five years after surgery alone to 10.4% compared to the 25 to
28% found in comparable Stockholm I and II and Swedish rectal
trials, that did not require TME.(1, 17, 18)
About 35% of the patients in the Dutch study had disease
found in pelvic nodes making them stage III. Among this sub-
group, 20.6% of those who did not have radiation treatment and
10.6% of those who did suffered a local recurrence (p < 0.001).
About 28% had stage II disease. Among these the local recur-
rence rate without radiation was 7.2% and with radiation 5.3%
(p = 0.331). About 28% had stage I disease. Among these the
local recurrence rate was 1.7% without radiation and 0.4% with
(p = 0.091). Among 7% of patients with distant metastasis found


 radiation therapy: acute and late toxicity
at surgery (stage IV) there was local recurrence in 26.9% with-
out radiation and 15.9 with (p = 0.207). Thus, for all four stages
there was less local recurrence in patients who had radiation, but
the differential only reached statistical significance for the node
positive (stage III) subgroup and the entire randomized popula-
tion. Similarly it was found that the difference reached statistical
significance in the subgroup that had LAR but not in subgroups
that had APR or Hartman pouch surgery and in the subgroup for
which the distal tumor edge was between 5 and 10 cm from the
anal verge but not those more proximal or distal.
The Swedish Rectal study differs from the Dutch study in that
TME was not required.(18) The proportion of patients in each
stage was similar but the differential in rate of local recurrence
between arms of the trial was greater and statistically significant
for all stages. In the stage III subgroup of the Swedish study the
local recurrence was 40% without preoperative radiation and
20% with (p < 0.001). For stage II it was 23% without and 10%
with radiation (p = 0.002). For stage I it was 4% without and
2% with radiation (p = 0.02).
Comparison of these two studies suggests that benefit from
preoperative radiation in preventing local recurrence is maximal
if given to patients likely to have node positive (stage III) disease,
expected to have LAR as opposed to APR and with lowest tumor
extent in the mid to distal rectum. However, some reduction in
risk of local recurrence may be expected for all patients.
As shown in Table 30.3, overall survival rate was not affected
by the short course preoperative radiation treatment in the Dutch
TME trial and in the earlier Stockholm I trial. On the other
hand, in the Swedish Rectal trial the short course preoperative
radiation treatment produced a statistically significant gain in
overall survival. Two other short course preoperative radiation
trials, Stockholm II and Manchester showed statistically signifi-
cant improvement in overall survival among the subgroup that
actually underwent curative resection but not in all randomized
patients.(17, 20)
Failure to improve overall survival even though local recur-
rence rate is significantly reduced can occur in two important
ways. First, the dominant cause of death may be from develop-
ment of distant metastatic disease to such an extent that a small
incidence of local recurrence in the surgery only arm and its
reduction by radiation treatment has no statistically significant,
or even discernible, impact on survival. This may be the principle
explanation in the TME trial.
The other way the impact on survival of a local recurrence
advantage may be reduced, or lost, is if excess non rectal can-
cer deaths are produced in the radiation treatment arm. This is
likely the explanation for limitation of statistically significant
survival benefit to the subgroup that had curative surgery in the
Stockholm II trial.(17) At median follow-up of 8.8 years for this
trial 19% of the radiation arm patients and 12% of the surgery
only arm had died of non cancer causes (p = 0.1). There was car-
diovascular death in 13% in the radiation arm and 7% in the sur-
gery only arm (p = 0.07). This differential was established within
the first 6 months after surgery, during which 5% of irradiated
patients and 1% of the surgery only patients died from cardio-
vascular causes (p = 0.02). The excess cardiovascular deaths were
predominantly in patients older than 68 years. It is suggested this
is due to change in the coagulation properties of blood during the
several months of recovery from pelvic surgery and radiation that
leads to increased thrombotic events in the irradiated patients.
The only randomized study of preoperative radiation with a
surgery only control arm that used a radiation treatment regi-
men resembling the long course described above is the MRC II
trial.(21) Patients were eligible if they had a partially or totally
fixed rectal tumor on physical exam. The population likely con-
sisted mostly of T3 and T4 tumors, that is, there were likely more
locally advanced cancers than in the short course trials. As shown
in Table 30.2, there was a significant decrease in local recurrence
in the radiation arm and a tendency to increased survival, though
not statistically significant, similar to the findings in several short
course trials.
The Polish trial compares short-course preoperative radiation
with long-course preoperative radiation plus concurrent chemo-
therapy.(22) Most of the surgery was with TME. Patients were
clinically staged with physical exam, transrectal ultrasound and/
or MRI. Only those with evidence of T3 or T4 tumors that were
palpable on digital exam and had no anal sphincter involvement
were included. Patients found to have involved nodes at sur-
gery usually received postoperative chemotherapy. More in the
short course arm were node positive suggesting down staging by
the long course treatment. There was no difference in survival
between the two arms. There is a suggestive difference in local
recurrence favoring the short course but it did not reach statisti-
cal significance. There was no statistically significant difference in
the fraction that received a permanent stoma but with a tendency
to favor the long course arm for sphincter preservation.
The EORTC trial examined the effect of adding chemother-
apy to long course preoperative radiation with the finding that if
chemotherapy is given concurrently with preoperative radiation,
post operatively, or both, the rate of local recurrence is reduced
significantly relative to preoperative long course radiation with
no chemotherapy.(23) This suggests concurrent radiochemo-
therapy does not contribute much if postoperative chemotherapy
is given. On the other hand, the FFCD trial in which both arms
got postoperative chemotherapy reports a significant decrease in
local recurrence if concurrent chemotherapy is given with preop-
erative radiation.(24) There was no survival difference.
Two randomized trials listed in Table 30.4 have directly com-
pared pre and postoperative radiation treatment arms. In the
earlier Upsala trial the preoperative arm had the short course of
radiation.(25) Those randomized to the postoperative arm and
found to have stage II or III disease were treated with long course
to a higher dose of 60 Gy in 2 Gy fractions. In the recent German
trial the surgery was mandated to be with TME and clinical stag-
ing was intended to exclude stage I patients from the study.(26)
Those randomized to the preoperative arm and the subset of
those randomized to the postoperative arm who were proved to
have stage II or III disease at surgery received the similar regimens
of chemotherapy and radiochemotherapy though in different
sequence. The chemoradiotherapy consisted of 50.4 Gy in frac-
tions of 1.8 Gy each except that an additional 5.4 Gy to a reduced
volume was included in the postoperative treatment. Both these
trials showed a statistically significant difference in local recurrence
rate favoring the preoperative arm and no significant difference in

 improved outcomes in colon and rectal surgery
survival when grouped by intention to treat at randomization.
It is of note that 28% of the postoperative arm of the German
trial received no radiation treatment. Of these, in 18% the cause
was finding pathologic stage I disease and in 10% the cause was
postoperative death or complications or finding of stage IV dis-
ease at surgery. Patient selection and the treatment regimen of the
preoperative arm of the German trial is now standard treatment
in many institutions.
In all the above trials surgery consisted of LAR or APR. For
patients with evidence of a stage T1 or T2 rectal cancer distal to
the peritoneal reflection i.e., usually within 10 cm from the anal
verge, smaller than about 4 cm and occupying a limited fraction
of the circumference of the rectal wall, local excision via trans
anal, trans sphincteric (York-Mason) or posterior proctotomy
(Kraske) procedure may be able to achieve en bloc full thickness
excision of the tumor with negative margins. This limited surgery
may be elected in lieu of APR or LAR to preserve sphincter func-
tion or to avoid major surgery in those not fit or not willing to
undergo it. Comparison of local excision (LE) with APR or LAR
as to the ability to remove all the carcinoma has not been estab-
lished by any randomized trial. Nevertheless, it is expected that
limited local excision will not as reliably prevent local recurrence
as the more radical surgery, particularly TME. This is confirmed
by the local recurrence rates reported in the retrospective series
shown in Table 30.2, particularly for T2 disease. The decrease in
local recurrence with adjuvant radiation, with or without concur-
rent chemotherapy, suggests that the local excision with adjuvant
treatment is efficacious enough to be considered as an option
under some circumstances. Bias in the retrospective series would
be to select for radiation treatment those patients with unfavora-
ble features in their pathology such as positive or close margins,
lymphovascular invasion or high histologic grade. Thus, the ben-
efit from adjuvant treatment may be more than indicated by the
results shown.
The RTOG protocol 89–02 study enrolled patients with tumors
judged by their surgeon to be distal enough to not allow clearance
by LAR and who underwent local excision via trans-anal, trans-
sacral or trans-coccygial approach.(16) To be eligible the tumor
had to be mobile, <4 cm in size and occupy <40% of the rectal
circumference. Those patients with cancer found to be pathologic
stage T1, with histologic grade 1 or 2, excised with at least 3 mm
margins in all directions, absent any lymphatic or vascular inva-
sion and with normal CEA received no post operative treatment.
Patients lacking any one of these favorable features were treated
with radiation to the pelvis with boost to the tumor site to a total
dose of 50 to 56 Gy in 1.8 to 2 Gy fractions with concurrent 5Fu
chemotherapy. If the margin was microscopically positive or
closer than 3 mm the dose to the tumor bed was increased to
give a total dose of 59.4 to 65 Gy. The local recurrence rate for
T2 tumors, all of which received adjuvant treatment was 4 of 25
(16%) that for T3 tumors was 3 of 13 (23%). It is not clear what
the chance of salvage for local failure with APR is, but it may be
as much as 50%.(28) The results for local excision shown in Table
30.2 support the view that local excision with postoperative adju-
vant treatment with radiation and chemotherapy, although not
as likely to be curative as radical surgery, is an acceptable option
for tumors of a size and position which permit it, when there is

sufficient reason to avoid radical surgery. The treatment of early
rectal cancers has recently been reviewed.(29)
Acute Adverse Effects
The most common and limiting adverse effect that occurs during
and/or shortly after a course of pelvic irradiation (acute effect) is
diarrhea. A scale adopted by the RTOG and EORTC for reporting
acute effects of irradiation of the lower GI tract is representative
and in use in current trials.(30) Grade 1 is given for increased
frequency or change in bowel habits not requiring medication
or rectal discomfort not requiring analgesics. A score of grade 2
implies diarrhea requiring Immodium or Lomotil medication, or
mucous or bloody discharge not requiring sanitary pads or rec-
tal or abdominal pain requiring analgesic medication. A score of
grade 3 is given for diarrhea requiring parenteral support, mucous
or bloody discharge requiring sanitary pads or abdominal disten-
tion with distended bowel loops on radiograph. Grade 4 implies
acute or subacute bowel obstruction, or fistula or perforation, or
GI bleeding requiring transfusion or abdominal pain or tenesmus
requiring tube decompression or bowel diversion. Grade 3 and 4
are often combined and reported as severe adverse effects.
In the EORTC trial, 1011 patients were treated with preopera-
tive irradiation to a dose of 45 Gy in 25 fractions over 5 weeks.
(23) Half were randomly assigned to also have concurrent preop-
erative chemotherapy and half had none. Acute grade 2 toxic-
ity was reported in 38.4% of those who received the concurrent
preoperative chemotherapy and 29.7% of those who did not (p <
0.001). Grade 3 or 4 acute adverse effects are reported in 13.9% of
those whose treatment included preoperative chemotherapy and
7.4% of those who had only preoperative radiation (p < 0.001).
The rate of local recurrence as a first event was approximately 9%
at five years in those who received chemotherapy preoperatively,
postoperatively or both and 17% in those who had no chemo-
therapy at all (p < 0.002). There was no statistically significant
difference in overall survival. This suggests the additional acute
toxicity of preoperative concurrent radiation and chemotherapy
over that of preoperative radiation alone may not be necessary if
post operative chemotherapy is to be given. This is contradicted
by the FFCF trial.(24)
The incidence of severe diarrhea during postoperative radia-
tion treatment following LAR or APR depends on the specific
concurrent chemotherapy regimen. For 656 patients treated on
a phase III NCCTG trial it was found to be 13% for bolus infu-
sion of 5FU at a dose of 500 mg/m2 on each of three days of the
first and fifth week. It was 23% for infusion of 5FU at the rate of
225 mg/m2 per day given continuously for the entire length of the
course of radiation.(31) Improvement in survival at four years of
70% with the continuous regimen compared to 60% with bolus
infusion was felt to justify the definite, though modest, increase
in toxicity.
The type of surgery was also a significant determinant of the
risk of severe diarrhea. In those who had undergone LAR there
was a 31% rate of severe diarrhea compared to 13% in those who
had an APR (p < 0.001). This differential is not unexpected as
there is a significant rate of diarrhea after LAR in the absence of
radiation. In this regard, it is of note that the frequency of bowel
movements at the time of discharge after LAR via total mesorectal
 radiation therapy: acute and late toxicity

excision in 81 patients who were not treated with radiation aver-

aged about 8 per day.(32)
In the trial that randomized patients to pre versus post operative
long course chemoradiotheapy conducted by the German Rectal
Cancer Study Group the incidence of sever diarrhea among 399
patients randomized to preoperative treatment was 12%. Among
the 237 patients actually treated with postoperative radiation the
rate of severe diarrhea was 18% (p = 0.04).(26) The post opera-
tive arm included some 23% who had APR. Thus among those
who had an LAR, and are most comparable to patients in the pre
operative arm with respect to bowel and anal function, the rate
of severe diarrhea must have been >18% and the differential in
favor of pre operative treatment even greater. On the other hand
if the 110 patients in the post operative arm who, for one reason
or another, had no radiation treatment are included in the toxic-
ity score, there was no difference in rate of severe acute grade 3
or 4 toxicity.
Other grade 3 or 4 acute side effects reported in the German
study were hematologic and dermatologic. The percent grade 3
and 4 hematologic toxicity was 6% in the pre and 8% in the post
operative arms (p = 0.27). Dermatologic toxicity refers to radia-
tion dermatitis in the perineal skin or perineal crease suture line
(Figure 30.1). Grade 3 or 4 radiation dermatitis is reported for
11% of pre and 15% of the post operative patients who had radia-
tion (p = 0.09). The rate of grade 3 or 4 level acute toxicity of any
kind was 27% in the pre and 40% in the post operative patients
who had radiation (p = 0.001).
These results from two randomized studies support the con-
clusion that pre operative standard fractionated 5 to 6 week radi-
Figure 30.1  Radiation dermatitis.
ation treatment with chemotherapy produces less diarrhea and
other acute adverse effect than in comparable patients who have
the same treatment after surgery. The differential is definitely the genitourinary and other systems were less frequent than those
present. However it is a modest difference so that, in itself, it does manifest in the GI and neurologic systems.
not provide a compelling reason for preferring preoperative neo-
adjuvant treatment over postoperative treatment. Further more, Surgical Complications After
28% of patients in the post operative arm of the German study Preoperative Irradiation
were spared radiation treatment because of the finding of stage Patients treated preoperatively with short course radiotherapy in
I disease (18%) or distant metastasis (10%) at surgery, and thus the Stockholm I trial had surgical mortality of 8% compared with
had zero adverse radiation effects. 2% in the surgery only arm (p < 0.01).(1) Among patients over 75
The short preoperative radiation treatment course of 5 frac- years in age the mortality in the preop arm was 16% and again only
tions of 5 Gy each in one week rarely produces significant adverse 2% in the surgery only arm. The dominant cause of the increase in
effects in the 2 to 3 weeks during radiation treatment and before post operative death was cardiovascular. The radiation treatment in
surgical resection. In the Dutch TME trial, grade 1 acute gas- Stockholm I was specified to be with AP and PA directed beams only
trointestinal side effects were reported in 12%, grade 2 in 2.3% and encompassed, in addition to the pelvis, the para-aortic nodes
and grade 3 in 1 of 605 patients.(19) Acute neurologic effects of cephalad to the L2 vertebral level. With the inclusion of laterally
radiation were reported as grade 1 (requiring no intervention) in directed beams and restriction of the radiated volume to the pelvis as
7.5%, as grade 2 (requiring narcotic pain medicine or adjustment well as exclusion of the elderly patients in the subsequent Stockholm
of treatment) in 1% and grade 3 (intractable severe pain or caus- II, Swedish Rectal and Dutch TME trials the surgical mortality was
ing treatment interruption) in 2.8%. This has been attributed to not statistically different between preop radiation and surgery only
radiation induced lumbosacral plexopathy. It was first reported in arms.(17–19) For instance, in the Dutch TME trial the surgical mor-
patients treated with the short course in Upsala and in the Swedish tality was 3.5% in the preoperative radiation arm and 2.6% in the
Rectal trial.(33) It consists of pain in the lower extremities and surgery only arm (p = 0.38).(34) The in-hospital death rate was 4%
gluteal area and in a minority of the patients it was associated in the preop radiation arm and 3.3% in the surgery only arm (p =
with other lower extremity neurologic signs. In a few patients the 0.49) and very strongly correlated with age in both arms. There was
effect persisted or recurred for months to years. Acute neurologic no exclusion for age in this trial with the oldest patient being 92.
effects have not been reported with the lower fractional doses of In the Dutch TME trial there was no significant difference
the long course preoperative radiation treatment. Acute effects on between the two arms in operating time (median 180 minutes), or


 improved outcomes in colon and rectal surgery
length of hospital stay (15 or 14 days median).(34) Median blood
loss in the preop radiation arm was 1,100 ml. In the surgery only
arm it was 1,000 ml (p < 0.001). The percent of LAR patients with a
diverting stoma increased from 60 to 67% in the 60 days following
surgery. In the surgery only arm it increased from 54 to 63% (p =
0.17). A statistically significant difference in postoperative compli-
cations between the arms was found for cardiac events; 5% with
preop radiation and 3% surgery only (p < 0.05), psychologic disor-
ders; 4% with preop radiation and 1% surgery only (p < 0.01), and
for any complication; 48% in preop radiation arm and 41% sur-
gery only (p < 0.01). Complications in the APR patients occurred
in 29% of irradiated patients and 18% of surgery only patients
(p < 0.01). There was no significant difference in complication rate
among LAR patients, 11 and 12% in respectively the radiation and
surgery only arms. These results indicate that there is the potential
for short course preoperative radiation to complicate the ensuing
surgery and recovery particularly manifest in patients over the age
of 70 and even more so in those over the age of 80. This is mini-
mized but not eliminated by adherence to the now standard radia-
tion treatment planning specifications noted in the introduction.
The German trial required TME surgery but excluded patients
over the age of 75. The radiation treatment was the long course
(50.4 Gy in 28 fractions of 1.8 Gy each) with concurrent chemo-
therapy and was given either pre- or postoperatively.(26, 35) There
was 0.8% surgical mortality in the preop arm and 1% in the post
op arm indicating no increase attributable to the preop radioche-
motherapy. The incidence of any postoperative complication was
34.5% in the preop arm and 34% in the postop arm. Anastomotic
leak occurred in 13 and 12%, delayed wound healing in 5 and
6% of, respectively, pre and postop arms. All other complications
occurred in <3% of each arm with no significant difference.
The Polish trial randomized patients between preoperative short
course radiation and long course radiation with chemotherapy.(22,
36) Surgery was by TME for the more distal tumors and patients
over age 75 were excluded. The overall rate of complication events
was 31% in the short course arm and 22% in the long course arm
(p = 0.06) showing a near significant trend. The overall number
of patients suffering a complication was 27% in the short and
21% in the long arm (p = 0.27). Post operative death occurred in
0.7% of the long course and 1.3% of the short course arm (p =
1.0). Re-operation was needed in 8.2% of the short and 9.5% of the
long course patients (p = 0.85). No statistically significant differ-
ence, and no suggestive trend, was found to favor one or the other
arm with respect to other less severe complications.
In conclusion, it appears that if patients over age 75 are
excluded there is little or no significant increase in the risk of sur-
gical mortality and other complications with either the short or
long preoperative courses of radiation treatment. The risk of sur-
gical mortality and complications is likely increased by the short
course of preoperative radiation in the more elderly patients. It
has not been shown whether or not a similar increase in surgi-
cal risk is incurred in older patients with the long preoperative
radiochemotherapy course.
Chronic Late Adverse Effects of Radiation
Patients enrolled in the Dutch TME preoperative short course
radiation trial who were alive with no evident disease were sent a

questionnaire by mail to assess bowel, stoma and urinary function.
(37) A response was obtained from 597 (84% of those mailed).
Among these the median time since surgery was 5.09 years. The
mean number of bowel movements during the day among the 362
patients who had no stoma was 3.69 in the irradiated patients and
3.02 in the surgery only patients (p = 0.011). The mean number of
nocturnal movements was 0.48 in the irradiated patients and 0.35
in the surgery only (p = 0.207). Daytime fecal incontinence was
reported in 62% of those irradiated and 38% of the surgery only
patients (p < 0.001) and nocturnal incontinence in, respectively,
32 and 17% (p = 0.001). The incontinence also occurred more
often and was more troublesome in the irradiated compared to
surgery only patients. Pads were in use for incontinence and anal
mucous and blood loss in 56% of irradiated and 33% of surgery
only patients (p < 0.001). Among the 235 responding patients
with a stoma there was no significant difference between irradi-
ated and surgery only patients with respect to stoma function.
A review of the patients treated on the Dutch TME trial was
conducted to determine risk factors for development of fecal
incontinence.(38) Potential risk factors examined included age,
gender, childbirth, body mass index, cancer stage, tumor distance
from anal verge, anastomosis distance from anal verge, duration
of surgery, blood loss at surgery, presence of a pouch, temporary
stoma and anastomotic leak. No risk factors emerged as statis-
tically significant among the surgery only patients. Among the
preoperative radiation patients only blood loss at surgery and
distal tumor margin distance from the anal verge were statisti-
cally significant risk factors. Blood loss at surgery >1,400 ml had
relative risk (RR) of incontinence of 3.24 (p = 0.005) compared
to those with less blood loss. Relative to distance of distal tumor
margin <5 cm from the anal verge, distance between 5 and 10
cm had RR of 0.21 (p = 0.016), and >10 cm had RR of 0.13 (p =
0.003). The location of the distal tumor extent determines the
inferior extent of the radiation treatment port. Among those few
respondents who had the perineum, and consequently the entire
anal sphincter, included in the radiation field compared to those
who did not, the RR for fecal incontinence at 2 years after sur-
gery was 2.64 (p = 0.085) and at 5 years after surgery the RR was
7.45 (p = 0.059). It was also noted that the fraction of patients
reporting fecal incontinence increased after reaching a minimum
at 2 years postsurgery whereas that in surgery only patients it
increased only slightly. This time course is consistent with a late
effect of radiation on pelvic nerves and fibrosis.
Urinary function was not significantly different in irradiated
and surgery only patients. About 39% of patients in each group
reported incontinence of urine. Back and buttock pain, hip stiff-
ness and difficulty walking were not significantly different in the
two groups suggesting absence of chronic radiation induced lum-
bosacral plexopathy in this trial.
The rate of hospital admission was significantly increased in
the irradiated patients compared with surgery only patients in
the first 6 months after surgery. Admissions were for infection,
endocrine, cardiovascular and gastrointestinal diagnoses. Of
note, among gastrointestinal admissions, those for constipation
and abdominal pain were significantly increased in irradiated
patients but those for bowel obstruction were not. The rate of
hospital admission more than six months after surgery was not
 radiation therapy: acute and late toxicity
significantly different for patients in the two groups including for
myocardial infarction or stroke.
A comparative study by phone interview of patients two or
more years after they had undergone LAR for rectal cancer at
Mayo clinic reports significantly more bowel symptoms in the
41 who had also had postoperative long course pelvic irradiation
and chemotherapy than in the 59 who had only surgery.(39) The
fraction having more than 5 bowel movements a day was 37%
in the irradiated group and 14% in the surgery only group (p <
0.001). The fraction of patients who reported incontinence was
66% in the irradiated group and 7% in the surgery only group
(p < 0.001). In the irradiated group 41% wore a pad and in the
surgery only group 10% (p < 0.001). Urgency with inability to
defer defecation for 15 minutes was reported in 78% of the irra-
diated and 19% of the surgery only patients (p < 0.001).
A retrospective study of 192 patients who had LAR with colo-
anal anastomosis at the Mayo clinic and had preopertative (long
course) radiation, postoperative radiation or no radiation reports
anastomotic stricture was the most common late effect requir-
ing surgical intervention.(40) This occurred with nearly the
same frequency in all three groups; 16% no radiation, 14% preop
radiation and 15% post op radiation. It was usually managed
with dilation and was not a significant cause of permanent fecal
diversion. Permanent fecal diversion resulted from recurrence,
bowel obstruction, incontinence, fistula, stricture, abscess/leak
and patient preference. The five year survival without colostomy
was 92% in patients who had no radiation treatment and 72% in
those did (p < 0.001). There was no significant difference between
the rate in pre and post operatively irradiated patients.
A scale adopted by the RTOG and EROTC for reporting late
chronic effects of radiation on the bowel is as follows.(30) Grade
1 implies mild diarrhea, mild cramping, 5 movements per day,
slight rectal discharge or bleeding. Grade 2 implies moderate
diarrhea and colic, more than 5 movements per day, excessive
mucous or intermittent bleeding. Grade 3 implies obstruction or
bleeding requiring surgery. Grade 4 implies necrosis, perforation
or fistula. Fecal incontinence was not explicitly included in the
grading criteria.
The German trial reports grade 3 and 4 long-term gastrointes-
tinal effects, for example, diarrhea and small bowel obstruction, in
9% of the preop arm and 15% of the postop arm (p = 0.07); anas-
tomotic stricture in 4% of the preop and 12% of the post op arms
(p = 0.003).(26) Bladder dysfunction of grade 3 or 4 occurred in
2% of the preop and 4% of the postop arms (p = 0.21). Any grade
3 or 4 effect occurred in 14% of the preop and 24% of the postop
patients (p = 0.01). With the long course fractionation of pelvic
chemoradiotherapy for adjunctive treatment of rectal cancer, the
preoperative irradiation appears significantly less likely to produce
severe chronic long-term sequelae than postoperative irradiation.
The Polish trial comparing short course preoperative radiation
with long course preoperative radiochemotherapy at median fol-
low up of 48 months reports the overall incidence of late toxic-
ity as 28.3% in the short and 27% in the long course arms (p =
0.81).(22) The incidence of severe late toxicity, presumably grade
3 or 4, was 10.1% in the short and 7.1% in the long course arms
(p = 0.36). Severe gastrointestinal toxicity occurred in 5.1% of
the short and 1.4% of the long course patients, no p value given.
A quality of life questionnaire on anorectal function including
questions on bowel function, continence and urgency reports no
significant difference between the short and long course arms.
(40) For instance, 39% and 41% of, respectively, the short course
and long course patients reported use of pads. In answering the
question, “did your health status and/or treatment cause your
sexual life to decline” there also was no significant difference in
the two arms. This direct comparison of long and short course
preoperative treatment shows no statistically significant differ-
ence in late toxicity.
The evidence from the several trials summarized here indicates
that both preoperative and postoperative radiation treatment are
associated with increased chance of chronic adverse effect on bowel
function. The direct comparison of pre- and postoperative long
course radiochemotherapy in the German trial indicates there is
less likelihood of this with the preoperative treatment. The Polish
trial comparing long and short course preoperative irradiation
finds no clear difference and does not resolve the issue of which of
these has the least chance of producing chronic adverse effects.
Chronic Rectal Effects
In contrast to acute radiation injury, chronic injury is an indo-
lent process that can present three months after therapy comple-
tion or up to 30 years later.(41) In addition to the acute cellular
toxicity, radiation causes a progressive, obliterative arteritis, and
submucosal fibrosis. Transmural injury of the bowel wall can lead
to a progressive vasculitis, thrombosis and ultimately, to varying
degrees of ischemia and necrosis. This process may lead to nar-
rowing of the bowel lumen and eventual obstruction. The effects
of chronic radiation are primarily related to the total dose of radi-
ation received as well as the total volume of tissue irradiated.(42)
There is some evidence to suggest that chronic radiation proctitis
is more likely to occur in those initially experiencing severe acute
proctitis and this has been termed the consequential late effect.
(43) However, the absence of acute complications does not pro-
tect against the development of chronic radiation induced injury.
Several other factors have also been identified that may increase
the likelihood of developing chronic radiation injury. This
includes a history of prior abdominal or pelvic surgery, presum-
ably secondary to adhesion formation resulting in entrapment of
the bowel, and a history of vascular occlusive disease (including
hypertension and diabetes).(41, 44)
Of all the gastrointestinal organs, the rectum is most com-
monly affected by pelvic radiotherapy.(45) It has been estimated
that 75% of subjects receiving pelvic radiotherapy will experience
rectal symptoms during treatment and almost 20% will continue
with chronic proctitis.(46) In addition, 5% may develop perirec-
tal fistulas, strictures or incontinence. Symptoms include loose
stools, urgency, bleeding, pain, and tenesmus. Endoscopy reveals
friability and granularity, pallor, erythema or prominent submu-
cosal telangiectasias (Figure 30.2).(47) Histologic findings in the
chronic phase include severe vascular changes such as telangiecta-
sia of capillaries, platelet thrombi formation and narrowing of
arterioles always accompanied by lamina propria fibrosis and
crypt distortion.(48)
Though rectal bleeding is most often the presenting symptom
of chronic proctitis in the setting of prior radiation, it should

 improved outcomes in colon and rectal surgery
Figure 30.2  Radiation Proctitis.
not be assumed that this is the sole cause. As up to one-third of
patients were found to have a diagnosis unrelated to the previous
radiotherapy and 12% had a significant neoplasia, endoscopic
evaluation is mandatory. with new onset of hematochezia after
prior radiation therapy.(49)
Treatment
Numerous therapeutic agents have been evaluated and/or are
currently utilized against radiation-induced proctitis. In many
cases, patients presenting initially with symptoms suggestive of
radiation proctitis will first be offered treatment with antiin-
flammatory medications. This most commonly involves either
oral or enema delivered steroids or various 5-Aminosalicylic
acid (5-ASA) preparations. Though often utilized in both the
acute and chronic settings, evidence is lacking for the use of
steroid preparations in the treatment of radiation proctitis.
A prospective, randomized trial compared oral sulfasalzine plus
rectal steroids to rectal sucralfate and oral placebo. The sul-
fasalzine regimen did demonstrate a significant improvement
in both clinical symptoms and endoscopic findings, however, by
comparison clinically this was less effective than sucralfate.(50)
Sucralfate provides a protective barrier and promote epithelial
healing has allowed its use in the treatment of radiation procti-
tis. One randomized, controlled trial found that oral sucralfate
decreased diarrhea symptoms in both the acute and chronic
phases.(51) Short-Chain Fatty Acids (SCFA) act as a major fuel
source for colorectal mucosa. Two small randomized, placebo
controlled trials using SCFA enemas noted improvement in
symptoms and endoscopic findings.(41, 52)
Various endoscopic ablation therapies have been applied to
the treatment of chronic proctitis related bleeding due to local
telangiectasias. The two most commonly utilized approaches are
the laser and the argon plasma coagulator. There are no pro-
spective, randomized trials assessing either of these approaches,
only several retrospective case series. The largest series reporting
on the use of Nd:YAG laser found excellent response rates and
a significant decrease in rectal bleeding.(53) Rare complications
included mucous discharge, ulcers or stricture. Similar results

were obtained using an argon plasma coagulator in three treat-
ment sessions.(54) However, over 70% required maintenance
treatment over the long term.(55)
Four and ten percent formalin have been utilized for the treat-
ment of bleeding related to chronic proctitis. Two approaches are
commonly utilized, that of a rectal formalin irrigation and a dab
technique utilizing topical application of formalin with swabs
or soaked gauze. De Parades et al. reported a prospective case
series using the formalin gauze application and noted a beneficial
result in 70%.(56) However, significant rates of stricturing and
incontinence were reported. Numerous other retrospective series
have reported good success with formalin. Of those using a gauze
or pledget mediated application, at least a 75% success rate for
cessation or improvement in bleeding was reported.(57) Many
required multiple treatments though complications were mini-
mal. Due to the small volume used, 10% formalin is often used.
Of those reporting use of formalin rectal irrigations, 50 cc aliq-
uots of 4% formalin were utilized up to a total volume of 400–500
cc. Again a >75% success rate was noted with this approach, with
the most common reported complication being anal or pelvic
pain occurring in 25% of those treated.(58)
There is low level evidence supporting the use of hyperbaric
oxygen treatments for chronic radiation proctitis and a single
prospective series which reported significant improvement of
bleeding, diarrhea and urgency, but no change in rectal pain with
oral vitamins E and C.(59, 60) Metronidazole along with antiin-
flammatory agents (oral mesalazine and betamethasone enema)
produced a significantly lower incidence of rectal bleeding and
diarrhea in chronic radiation proctitis.(61)
Despite the numerous medical approaches available for the
treatment of radiation proctitis, surgical therapy remains an
option for refractory cases The indications for surgery are most
commonly rectum or rectosigmoid stenoses and rectovaginal fis-
tulae, while the most common presenting symptoms are rectal
bleeding, diarrhea, or tenesmus.(61) The majority of patients
undergo diversionary procedures (proctectomy with colostomy,
with or without a Hartmann rectal stump) with resection per-
formed less commonly. When continuity is restored, a coloanal
anastomosis (with or without colonic J-pouch) with proxi-
mal covering stoma is the procedure of choice in select cases.
Successful outcomes with diversion alone are reported in the
range of 72–73%.(62) In refractory rectal bleeding this option
has less morbidity. Overall, morbidity with surgical intervention
is extremely high, ranging from 30% to 65% with mortality rates
in the postoperative period reported at 6.7–25%.(62, 63)
Conclusion
Chemotherapy and radiation treatment to the pelvis as an adju-
vant to surgical resection, either individually or when both are
administered, reduces the chance of pelvic recurrence and can
increase the chance of a patient’s surviving the disease. This has
been demonstrated in several randomized trials for both the pre-
and postoperative treatment sequences, as noted in the tables and
in meta analyses.(2, 3, 64) However, the adjunctive treatment
has the potential for significant adverse effects. It is important
to select the form of adjuvant treatment likely to be most ben-
eficial. It is also important to select for adjuvant treatment those
 radiation therapy: acute and late toxicity
patients most likely to benefit and exclude those most likely to
suffer severe or life threatening adverse effects.
That preoperative treatment with radiation can complicate the
ensuing surgery and postoperative recovery is illustrated in the
occurrence of additional non cancer, mostly cardiovascular, deaths
among the irradiated patients in the immediate postoperative period
and the first six months post surgery in the Stockholm trials. Similar
adverse effect was not evident in the later Swedish and Dutch TME
trials that also used the short course radiation regimen nor was it
evident in the studies that used the long course preoperative treat-
ment regimens. These later trials were with better radiation therapy
technique and all but the Dutch TME trial excluded the most elderly
patients. Nevertheless, the potential for serious adverse effect on the
surgery is still a consideration. It is clear that this is minimized by
restricting the irradiated volume to those parts of the pelvis at risk
for harboring disease and that elderly patients are most at risk from
adding preoperative adjunctive treatment to the surgery.
Reduction in local recurrence by preoperative treatment is
present even when surgery is by TME. In the Dutch TME trial
the benefit was most significant in the node positive (stage III)
patients. It was present but rather small and did not reach statis-
tical significance in the other stage subgroups. This suggests that
patients, particularly those older than about 75, may be better
served by proceeding directly to surgery unless there is clinical
evidence or reason to suspect nodal disease. Postoperative radia-
tion and chemotherapy, if indicated by pathologic stage, is an
acceptable treatment option.
The German trial has provided evidence that preoperative
long course chemoradiation is in balance preferable to the similar
treatment postoperatively. The selection criteria and preoperative
treatment arm of the German trial are standard in many treatment
centers. However, given the inconclusive results of the Polish trial
comparing similar preoperative chemoradiotherapy with short
course preoperative radiation, another larger trial, with specifica-
tion of post surgery chemotherapy, comparing these two forms
of preoperative treatment may be helpful as both regimens have
features to recommend them. The short course has better com-
pliance, is more economical and has the theoretical advantage of
more timely removal of all evident disease than the long course.
The long course may facilitate complete surgical removal by more
down staging, provide earlier exposure of the patient to systemic
chemotherapy treatment and have less surgical and long-term
adverse effects than the large fractional doses of the short course.
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
31 Surgery for ulcerative colitis
Patricia L Roberts

Clinical Vignette Table 31.1  Truelove and Witts Criteria for Evaluating the Severity
of Ulcerative Colitis.
Challenging Case
A 35-year-old male is undergoing an ileoanal pouch procedure Fulminant
for ulcerative colitis. Following transection of the ileum flush Variable Mild disease Severe Disease Disease
with the cecum, the surgeon notes that it will be difficult for the Stools (Number/day) <4 >6 >10
pouch to reach the anus. Blood in stool Intermittent Frequent Continuous
Temperature (ºC) Normal >37.5 >37.5
Challenging Case Management Pulse (beats/min) Normal >90 >90
Difficulties with the ileoanal pouch reaching the anus occur for two Hemoglobin Normal <75% of Transfusion
main reasons: failure to mobilize the small bowel, or patient-related normal value required
factors such as obesity or a long narrow anal canal. Difficulty with Erythrocyte <30 >30 >30
reach is more common if a mucosectomy is performed rather than sedimentation
a double-stapled anastomosis. An S pouch may reach the anus eas- rate
ier than a J pouch. If the main reason for the pouch not reaching is Colonic features on Air, edematous Dilatation
x-ray wall, thumb­
patient obesity and a thickened mesentery, an initial total abdomi- printing
nal colectomy, ileostomy, and Hartmann closure of the rectum may Clinical Signs Abdominal Abdominal
be performed. Following weight reduction, an ileoanal pouch pro- tenderness distention
cedure can be performed. A series of technical maneuvers includ- and
ing mobilization of the small bowel up to the duodenum, scoring tenderness
the peritoneum over the superior mesenteric artery, and the crea- Source: After Truelove and Witts. BMJ 1955; 2: 1041–45.
tion of mesenteric windows can facilitate pouch reach. If, despite Reprinted with permission from Clinics in Colon and Rectal Surgery. Volume 17,
these maneuvers, the pouch does not reach, the pouch can be left Number 1, 2004, page 8.
in the pelvis, a loop ileostomy created, and, after a period of sev-
eral months, the pouch can then be joined to the anus. Additional moderate, and severe (5, 6) (Table 31.1). For patients with acute
details of these technical maneuvers are described in the text. colitis, stool studies should be done to rule out superinfection
with clostridium difficile, bacteria, or ova and other parasites.
INTRODUCTION A flexible sigmoidoscopy without bowel preparation with mini-
Ulcerative colitis is an inflammatory condition involving the colon mal insufflation of air is helpful to biopsy the rectum to exclude
and rectum. The incidence in the United States is 8.8 cases per cytomegalovirus (CMV). In one series of patients with steroid
100,000 person years.(1) Thus, in this country, there are approxi- resistant acute ulcerative colitis, the incidence of associated
mately 26,000 new cases of ulcerative colitis diagnosed annually and cytomegalovirus was 36%.(7) The majority of patients diagnosed
730,000 people with ulcerative colitis.(1, 2) Although many patients with CMV responded to administration of foscarnet or ganciclo-
are treated effectively with medical therapy, approximately 23–45% of vir. After exclusion of an infectious etiology, patients are treated
patients require colectomy. The risk of requiring colectomy is higher with intravenous steroids for 5–7 days. If there is no clinical
in patients with pancolitis than patients with left sided disease.(3, 4) response, cyclosporine or infliximab is considered. Patients who
This chapter concentrates on the indications for surgery, the opera- are reluctant to use cyclosporine or infliximab, or patients who
tive options, and the outcome of surgery for ulcerative colitis. do not respond, should undergo colectomy. While administra-
tion of steroids is associated with an increase in postoperative
Indications for Surgery complications, immunosuppressives do not appear to increase
Surgery for ulcerative colitis is divided into two categories: urgent the incidence of postoperative complications.(8)
or emergency surgery, and elective surgery. A small subset of patients may develop fulminant colitis. The
classification system of Truelove and Witts does not define ful-
Acute Colitis minant colitis, but Hanauer (9) has modified the classification
Urgent or emergent surgery is indicated for patients with acute system to define patients with fulminant colitis. In the classifica-
unresolving colitis or life-threatening complications associated tion system of Truelove and Witts, severe disease is defined as >6
with colitis, including fulminant or toxic colitis, hemorrhage, stools per day, a temperature >37.5 degree Celsius, a pulse of >90
colonic perforation, or obstruction. Severe acute colitis may occur beats per minute, hemoglobin <75% of normal, an erythrocyte
in 5 to 15% of patients with ulcerative colitis. The classification sedimentation rate of >30 mm/hr, the presence of air, edema-
system of Truelove and Witts is most commonly used and iden- tous wall, or thumbprinting on x-ray and abdominal tenderness.
tifies clinical parameters by which colitis is categorized as mild, Fulminant colitis is defined as >10 stools per day, continuous


 surgery for ulcerative colitis
bloody bowel movements, a temperature of >37.5 degree Celsius,
a pulse of >90 beats per minute, transfusion requirement, an
erythrocyte sedimentation rate of >30 mm/hr, dilatation of
the colon and abdominal distention and tenderness. The term
toxic megacolon has been used when the colonic distention of
the transverse colon exceeds 6 cm, but relying on this finding to
diagnose toxic colitis is not necessary, as some patients will have
“toxicity” in the absence of colonic distention. Prompt treatment
and diagnosis of toxic colitis is needed to avoid progression to
perforation. Approximately 20–30% of patients with toxic colitis
require emergency surgery.
Perforation in the setting of toxic or fulminant colitis substan-
tially increases the mortality rate. Patients whose condition wors-
ens or who fail to make substantial improvement after a period
of 48–96 hours should be considered for surgery to avoid this
complication.(10) Massive hemorrhage in patients with ulcera-
tive colitis is uncommon, accounting for <10% of emergency
colectomies performed for ulcerative colitis, and raises the pos-
sibility of Crohn’s disease.(11)
Emergency vs. Elective Procedures
The surgical options for patients who require emergency surgery
for acute colitis are aimed at restoring the patient back to a gen-
eral state of health and preserving reconstructive options for sub-
sequent surgery. The most common operation performed is total
abdominal colectomy with ileostomy, and either Hartmann closure
of the rectum or creation of a mucous fistula. Preoperative coun-
seling and marking by an enterostomal therapist is optimal. This
procedure removes the majority of the diseased bowel, avoids an
intestinal anastomosis in an ill patient, and preserves the option for
an ileoanal pouch procedure in the future. The colon is transected
at the level of the sacral promontory avoiding the need for a pel-
vic dissection. If the severity of disease as demonstrated by severe
ulcerations and friability of the bowel precludes safe closure of the
stump, a variety of other options may be employed. The stump may
be exteriorized as a mucous fistula. This requires a longer segment
of bowel and is associated with bleeding and mucus from an addi-
tional stoma. Alternatively, it has been suggested that extrafascial
placement compared with intraperitoneal closure of the Hartmann
stump may be associated with fewer infectious complications.(12)
Transanal drainage has also been suggested to decrease the inci-
dence of infectious complications associated with the Hartmann
stump.(13) Pelvic dissection and creation of a relatively short
Hartmann pouch should be avoided as this makes dissection and
subsequent ileoanal pouch creation more difficult. A laparoscopic
or open approach may be used for performance of total abdominal
colectomy and ileostomy in patients with acute colitis.(14)
Elective Procedures
The most common indication for elective surgery is intractabil-
ity to medical management defined as failure of medical ther-
apy. Intractability includes insufficient symptom control despite
intensive medical therapy. Due to loss of time from work, school
or activities in general, the patient may not have an acceptable
quality of life. The risks of medical therapy may be substantial
including potential complications from long-term steroid ther-
apy or complications of the side effects of medical therapy. In
children, growth retardation can result from poorly controlled
ulcerative colitis and is an indication for colectomy.
Patients with longstanding ulcerative colitis are at an increased
risk for the development of colorectal cancer. The exact risk is dif-
ficult to determine since many series have lacked longitudinal fol-
low-up or have included patients seen at tertiary referral facilities.
Surveillance colonoscopy with biopsy has been recommended in
patients with left-sided or pan colitis (defined as microscopic dis-
ease proximal to the splenic flexure) after 8 years of disease symp-
toms. At least 33 biopsies are necessary to obtain a sensitivity of
90%, and four quadrant biopsies are recommended every 10 cm
along the colon and in any abnormal appearing area. A recent
meta-analysis has estimated the risk of the development of color-
ectal cancer in patients with long-standing ulcerative colitis to be
2% at 10 years, 8% at 20 years, and 18% after 30 years of disease.
(15) There is no evidence to show that surveillance prolongs sur-
vival in such patients, although patients who develop cancers in a
surveillance program tend to have earlier stage cancers.(16, 17)
Proctocolectomy is indicated for patients with carcinoma,
nonadenoma-like dysplasia associated lesion or mass (DALM),
and patients with high grade dysplasia.(10) The presence of high
grade dysplasia should ideally be confirmed by two independent
expert pathologists. For those patients who underwent immedi-
ate colectomy, cancer was detected in 42% of patients with high-
grade dysplasia and 19% with low-grade dysplasia.(18) Although
patients with low-grade dysplasia should be offered colectomy,
the natural history of low-grade dysplasia is not as well defined.
The interobserver variation between pathologists confounds the
recommendations about low-grade dysplasia. Studies are con-
flicting, with one study of a surveillance program showing that in
patients with low-grade dysplasia the 5-year predictive value for
the development of cancer or high-grade dysplasia was 54%.(19)
Another study showed that only 18% of patients with low-grade
dysplasia progressed to high-grade dysplasia or a dysplasia associ-
ated lesion/mass.(20)
Strictures may also develop in 10–25% of patients with ulcera-
tive colitis, and while the majority are benign up to 25% are
malignant. Strictures which cause obstruction, develop in long-
standing disease, and are found proximal to the splenic flexure,
are most likely to be malignant and are another indication for
colectomy.(21)
PROCTOCOLECTOMY WITH BROOKE ILEOSTOMY
Proctocolectomy with ileostomy has previously been the “gold stand-
ard” operation for ulcerative colitis against which other operations
have been compared. This operation essentially cures the disease and
restores patients back to health and to a relatively normal life. It
is a one-stage procedure which removes the diseased mucosa and
has fewer potential complications than the ileoanal pouch proce-
dure. The main drawback is the presence of a permanent ileostomy,
something which most patients wish to avoid.
Indications
This operation is indicated in those patients who require surgery
for ulcerative colitis, but are not candidates for the ileoanal pouch
procedure. These patients include those who are elderly, have fecal
incontinence or an inadequate sphincter, patients with low rectal

 improved outcomes in colon and rectal surgery
cancers in association with ulcerative colitis who require proc-
tectomy and possibly pelvic radiation, and those patients who
opt for a permanent Brook ileostomy for personal preferences.
Furthermore, patients who develop pouch failure and require
pouch excision essentially have a completion proctectomy.
Operative technique
The preoperative period includes patient education about the
procedure and the effects of an ileostomy. Preoperative consulta-
tion with an enterostomal nurse is helpful. The stoma site selected
should be a flat area, away from bony prominences and creases.
Proctocolectomy is performed through either an open or
laparoscopic approach. Following mechanical bowel preparation
the day before surgery, the patient is administered preoperative
intravenous antibiotics and positioned in lithotomy position.
After performance of a standard colectomy, pelvic dissection is
performed. The retrorectal space is entered sharply and the pelvic
dissection is undertaken with careful attention to the ureters and
identification of the hypogastric nerves. The dissection is carried
out to the pelvic floor. A pack is placed posterior to the rectum
and the perineal dissection is performed. An intersphincteric dis-
section allows for a smaller wound, a relatively bloodless dissec-
tion, and presumably better healing. The perineal dissection is
carried out to the level of the pelvic dissection. After excision of
the colon and rectum, the wound is closed in layers and a Brooke
ileostomy constructed. A foley catheter is left for several days in
addition to a closed suction drain.
Outcome
Proctocolectomy with ileostomy is associated with fewer poten-
tial complications than ileoanal pouch procedure. In one series,
the long-term complication rate in patients undergoing procto-
colectomy with ileostomy compared to ileoanal pouch procedure
was 26% vs. 52%.(22) The most common long-term complica-
tions include stoma related complications. From a physiologic
standpoint, patients with an ileostomy are more prone to dehy-
dration, electrolyte abnormalities, and kidney stone formation.
Patients should be counseled to be aware of signs and symptoms
of dehydration. Although problems have decreased substantially
with modern pouching systems, preoperative stoma marking,
and the expertise of enterostomal nurses, patients may experience
peristomal skin irritation, parastomal hernia formation, stomal
retraction, fistula, and stomal stenosis. In the long-term, up to
one third of patients require operative revision.(23)
Slow or delayed perineal wound healing occurs in up to 25%
of patients after proctocolectomy with ileostomy. An intersphinc-
teric dissection may decrease the size of the perineal wound and
improve wound-related complications.(24) If infection or delayed
wound healing occurs, local wound care with examination under
anesthesia, debridement, and curettage is performed. The vacuum
assisted closure device has been helpful to treat persistent perineal
wounds.(25) In some cases, muscle transposition, such as gracilis
muscle transposition is necessary to heal persistent wounds.
As with any operation involving a pelvic dissection, sexual and uri-
nary dysfunction may occur from injury to the sympathetic and para-
sympathetic nerves. The incidence of sexual dysfunction is felt to be
less than that occurring in those patients who undergo proctectomy

for malignant disease. However, this may reflect the younger age of
patients undergoing proctocolectomy for ulcerative colitis. Impotence
occurs in 1–2% of patients and retrograde ejaculation may occur in
up to 5% of patients.(26) Dysparuenia and increase in vaginal dis-
charge occur in up to 30% of women from scarring and change in the
in-axis of the vagina.(27) Women must also be counseled about the
potential for infertility because of scarring pelvic adhesions.
Despite the fact that patients have undergone a major surgical
procedure, the quality of life remains high after proctocolectomy
with ileostomy. Overall 90–93% of patients are satisfied with their
quality of life.(28, 29) Despite the satisfaction, a number of difficul-
ties exist, including restriction of social and recreational activities in
up to 25%, and dietary restrictions in almost 30%.
Proctocolectomy With Continent Ileostomy
Another option for patients who require surgery for ulcerative
colitis is a continent ileostomy, introduced by Nils Kock in 1969.
(30) Despite initial enthusiasm, this operation is infrequently
performed today because of the appreciable number of complica-
tions associated with the procedure, in addition to the fact that it
has been largely supplanted by the ileal pouch anal anastomosis.
Indications for a continent ileostomy include those patients who
have undergone prior proctocolectomy with ileostomy and desire
a continent stoma, selected patients who have a failed ileoanal
pouch procedure, patients with ulcerative colitis and rectal cancer
who could not undergo an ileal pouch anal anastomosis (IPAA)
and patients with poor sphincter tone in whom the functional
results would be quite poor.
Advanced age and obesity are relative contraindications to per-
formance of the procedure. As with the ileoanal pouch procedure,
Crohn’s disease is a general contraindication to the procedure
because of the risk of recurrent disease which could necessitate
resection of the continent ileostomy.
Operative Technique
The operative technique involves initial performance of a proctocolec-
tomy. The continent ileostomy is then constructed using the terminal
40–60 cm of the ileum. A three limb pouch with an intussuscepted
nipple valve is used (Figure 31.1). The valve is created by intussuscept-
ing the efferent loop. After being tested for integrity and continence,
the exit conduit is brought through the abdominal wall. The site of
continent ileostomy is generally determined preoperatively with an
enterostomal therapist and is lower in the abdomen than a standard
ileostomy. Catheter drainage is maintained for approximately 4 weeks
to allow complete healing of the pouch.(31, 32) Guidelines for catheter
management have been outlined by Beck.(33)
A number of technical modifications have been made over the
years to prevent nipple valve complications. Mesh was initially
used to stabilize the valve, but the technique was abandoned
because of a high incidence (42.5%) of fistula formation.(31) A
recently described modification to avoid slippage of the nipple
valve is the “T-pouch” in which a portion of the ileum is folded
into the side of the pouch.(33, 34)
Outcome
In a large series of patients undergoing continent ileostomy with
a median follow-up of 11 years, 16.6% of patients required Kock
 surgery for ulcerative colitis

(A) (B) (C)

(D) (E)

Figure 31.1  Continent ileostomy (A) Three limbs of small bowel are measured and the bowel wall is sutured together. (B) After opening the bowel along the dotted
lines in (A), the edges are sewn together to form a two-layered closure. (C) A valve is created intussuscepting the efferent limb into the pouch and fixing it in place with
a linear noncutting stapler. (Inset: staples in place on valve.) (D) The valve is attached to the pouch side-wall with the linear noncutting stapler. A cross-section of the
finished pouch is shown. (E) After closure of the last suture line, the pouch is attached to the abdominal wall and a catheter is inserted to keep the pouch decompressed
during healing (Reprinted with permission).


 improved outcomes in colon and rectal surgery
pouch excision.(31) The number of complications associated
with the procedure was high with an average of 3.7 (range 1–28)
complications per patient.
Some of the most significant complications are associated with
nipple valve slippage which occurs because of the tendency of the
intussuscepted segment to slide and evert on the mesenteric aspect.
Manifestations of nipple valve slippage include difficult catheteriza-
tion, incontinence, and obstructive symptoms from obstruction of
the outflow tract. The incidence of nipple valve slippage is approxi-
mately 30%. A variety of technical modifications have been devised
to reduce the incidence of this complication. Use of prosthetic mate-
rials to wrap the valve reduces the incidence of nipple valve slippage
but is associated with abscess and fistula formation.(35) The T-pouch
modification (34) has been advocated to avoid this complication, but
there is currently no controlled data available.
Pouchitis is a well recognized complication of the Kock pouch
occurring in up to 25% of patients. It is manifested by increased
bowel frequency, often associated with blood and mucus and at
times, incontinence. The etiology of pouchitis is unknown, but
the majority of patients are treated effectively with antibiotics
and continuous pouch drainage.
Other complications associated with the procedure include
the development of fistula, parastomal hernia, and small bowel
obstruction.
Long-term results of patients with continent ilesotomies reveal
a cumulative success rate of 71% at 29 years in 96 patients followed
from 1972 to 2000.(36) The success rate with continent ileostomy
is appreciably less than with the ileoanal pouch procedure.
Total Abdominal Colectomy with
Ileorectal Anastomosis
Although the majority of patients with ulcerative colitis have rectal
involvement, a small number of patients with rectal sparing may
be treated with total abdominal colectomy and ileorectal anasto-
mosis. Such patients may subsequently require rectal excision for
diarrhea and poor functional results, ongoing proctitis, and malig-
nant transformation. Surveillance for the development of dysplasia
is recommended. Recent series have shown an average number of
bowel movements of 3–6/day after the procedure with a failure rate
of 11–57% (37, 38, 39). The incidence of developing cancer with
long-term follow-up ranges from 0–6% (40, 41, 42).
Restorative Proctocolectomy
with Ileoanal Pouch
Since its introduction in 1978, the ileoanal pouch procedure has
become the procedure of choice for patients who require surgery
for ulcerative colitis and familial adenomatous polyposis. Over
the years, the operation has undergone a series of technical modi-
fications and it can be performed with essentially no mortality
and good long-term outcomes. The procedure avoids the need
for a permanent stoma and removes the diseased bowel.
Indications
The most common indication for the ileoanal pouch procedure is
failure of medical therapy for ulcerative colitis or development of
complications from medical therapy which outweigh the benefit.
Additional indications include the development of dysplasia and

certain extraintestinal manifestations. Colon cancer is not a con-
traindication to the procedure, but performance of an ileoanal
pouch must not compromise the oncologic resection. IPAA is
usually not advisable in a low- or mid-rectal cancer because of the
need for chemoradiation therapy and the potential effects on the
pouch and the anal sphincter. Although the majority of patients
who undergo pouch surgery are young, age is not a contraindica-
tion to the performance of the procedure. We advise patients on a
case by case basis over the age of 65. Nocturnal leakage and incon-
tinence is more common in older patients who undergo pouch
surgery and preoperative assessment should include assessment
of anal sphincter function and extensive discussion about the
potential functional outcome.
Operative Technique
Preoperatively, the risks and benefits of the procedure are dis-
cussed with the patient, and consultation with an enterostomal
therapist is beneficial. An appropriate site for the intended stoma
is marked in the right lower quadrant. The procedure is perform-
ance after mechanical and antibiotic bowel preparation. Although
the procedure may be performed with an open or laparoscopic
approach, pouch surgery is increasingly being performed by a
laparoscopic approach. Retrospective case-matched comparative
studies have shown a longer operative time (median 330 min vs.
230 min), but a quicker return of bowel function (2 days vs. 4
days) and a shorter hospital stay (7 days vs. 8 days) with laparo-
scopic pouch procedures (43). A recent meta- analysis of 10 stud-
ies with 329 patients confirmed that despite a longer operative
time, patients had a lower blood loss, shorter hospital stay, and
smoother recovery compared to open surgery.(44) In a review
of 100 laparoscopic and 189 open ileoanal pouch procedures
for ulcerative colitis, patients reported excellent body image and
quality of life scores regardless of open or laparoscopic approach.
(45) In the past 5 years, the majority of the ileoanal pouch proce-
dures have been performed at our institution with a laparoscopic
hand-assisted approach.
The technical details of the procedure are outlined in videos
(CineMed-American College of Surgeons).
One of the critical maneuvers during the performance of ile-
oanal pouch surgery is the creation of a tension-free anastomosis
between the pouch and the anus. Undue tension on the anasto-
mosis leads to stricture formation, anastomotic leakage, potential
pelvic sepsis, and poor function. To perform a tension-free anas-
tomosis, the apex of the pouch should reach the inferior border
of the symphysis pubis. Assessment of potential pouch reach to
the anus is performed before pouch creation. In obese patients,
it may be necessary to perform an initial total abdominal colec-
tomy, ileostomy and Hartman closure of the rectum in anticipa-
tion of significant weight reduction and then pouch creation.(46)
An S-pouch may afford an additional 2 cm of length compared
to a J-pouch but it is more difficult to construct and has potential
efferent limb problems.(47) A tension-free anastomosis is more
difficult to achieve in male patients with a narrow pelvis, patients
with a long anal canal, obese patients, and patients who undergo
mucosectomy with handsewn anastomosis. To achieve adequate
length on the mesentery, a series of technical maneuvers is
performed, including mobilization of the posterior attachment
 surgery for ulcerative colitis
of the small bowel mesentery, exposing the inferior portion of
the head of the pancreas, and scoring the peritoneum of the small
bowel mesentery serially on the anterior and posterior surfaces.
(48) Each of these relaxing incisions confers an additional 1 cm
of distal reach. At least two relaxing incisions are made along the
course of the superior mesenteric artery. If additional length is
required, the mesentery of the small bowel is transilluminated to
delineate the loop formed by the ileocolic artery and the terminal
ileal branch of the superior mesenteric artery. Traction is placed
on the small bowel by grasping the intended apex of the pouch,
and vessels between the primary and secondary arcades that are
under tension are identified and ligated. This maneuver adds 2–5
cm of additional length. The terminal branches of the superior
mesenteric artery of the ileocolic artery can be divided for addi-
tional length. These vessels are clamped for 10–15 minutes before
ligation to confirm adequate vascularity of the ileum before divi-
sion. In selected cases, interposition vein grafts have been used
to obtain adequate mesenteric length.(49) If there is inadequate
length despite these maneuvers, the pouch may be left in the pel-
vis, and not anastomosed to the anal canal with plans to return at
a subsequent date for anastomosis. The weight of the pouch and
the dependent portion of it with the aid of gravity may facilitate
reach to the anus at a later date.
Outcome
The mortality after ileoanal pouch surgery is <1%. The major-
ity of the patients undergoing the procedure are young and oth-
erwise in good health, with the exception of ulcerative colitis or
familial adenomatous polyposis. Despite refinements in surgi-
cal technique, the operation is associated with an appreciable
number of complications.
A recent meta-analysis with a review of 5,215 patients who
underwent ileoanal pouch surgery between 1988 through 2000
revealed a preoperative diagnosis of ulcerative colitis in 87.5%,
indeterminate colitis in 2%, Crohn’s disease in 0.8%, familial ade-
nomatous polyposis in 8.9%, and other diagnoses in 0.7%.(50)
A diverting ileostomy was performed in 81.6%.
Functional results (bowel, urinary,
gynecologic and sexual function)
At a median follow-up of 37.2 mos after ileoanal pouch surgery
and ileostomy reversal, the mean defecation frequency was 5.2
during the day with a mean night-time frequency of 1.0.(50) Mild
fecal incontinence during the day occurred in 17%, while 3.7%
had severe fecal incontinence during the day and 7.3% had urge
incontinence. Bowel function deteriorates with advancing age.
(51) Prospective evaluation of long-term function reveals that
especially 12 years or more after surgery, major and minor incon-
tinence are worse. Twelve years following surgery, 27% of patients
vs. 9% (<12 years) had major daytime incontinence and 33% vs.
10% reported more major night time incontinence. Furthermore,
minor incontinence was seen in 48% of patients after 12 years vs.
16% of patients followed for under 12 years.(51)
The reported incidence of sexual dysfunction in a meta-analysis
of 21 studies including 5,112 patients was 3.6%.(50) The authors
point out the risk of underestimating complications due to a posi-
tive publication bias, and thus studies with negative results may be
less likely to be submitted and published. Indeed, a more recent
review has further quantified the impact of the ileoanal pouch
procedure on sexual and gynecologic function in women. A sys-
tematic review of 22 in 1,852 women who underwent restorative
proctocolectomy from 1980 to 2005 revealed a much more sig-
nificant impact on function.(52) The incidence of infertility was
12% before restorative proctocolectomy and 26% after (n = 945
women, 7 studies). Sexual dysfunction occurred in 8% preopera-
tively and 25% postoperatively (n = 419 women, 7 studies). More
Cesarean sections were performed after restorative proctocolec-
tomy, although no significant differences in pouch function and
no significant perineal trauma was seen after vaginal delivery, thus
suggesting that the mode of delivery should be based on obstet-
ric considerations. An increase in bowel actions was noted during
the third trimester but bowel activity returned to normal within 6
months of delivery. Peritoneal inclusion cysts which are associated
with pelvic sepsis and adhesions are an additional underreported
consequence of the ileoanal pouch procedure.(53, 54)
Complications
Despite refinements in surgical technique, restorative proctocolec-
tomy is associated with an appreciable number of complications
including pelvic sepsis, fistulas, strictures, fecal incontinence, pouch
failure, and sexual dysfunction. A recent meta-analysis on pooled
data of observational studies has been performed on 43 studies com-
prising 9,317 patients detailing the results and complications.(50)
Small Bowel Obstruction
Small bowel obstruction is a common complication after restora-
tive proctocolectomy ranging from 15–44% of patients, with
approximately half of patients requiring operation for treatment of
obstruction.(55) Small bowel obstruction occurs more commonly
after restorative proctocolectomy than after Brook ileostomy, pre-
sumably because of the cumulative increase in obstruction after
multiple procedures. Patients who develop early postoperative
small bowel obstruction are more likely to resolve with conserva-
tive measures than those patients diagnosed in later follow-up.(56)
In a series of 1,178 patients who underwent IPAA, the cumulative
risk of small bowel obstruction was 9% at 30 days, 18% at 1 year,
27% at 5 years and 31% at 10 years.(57) The most common site of
adhesions were pelvic adhesions (32%) and adhesions at the ileos-
tomy closure site (21%). Recent strategies to decrease the risk of
adhesions have focused on the use of a bioresorbable membrane
which has reduced the incidence, extent, and severity of adhesions
(58), as well as the use of laparoscopic surgery (which results in less
adhesions).
Postoperative Hemorrhage
Intraabdominal hemorrhage may occur from failure to secure the
vascular pedicles and from pelvic bleeding, in addition to bleed-
ing of the pouch suture or staple line. Pouch ischemia may also be
associated with bleeding. Pouch bleeding noted intraoperatively
is best treated by eversion of the pouch to expose the mucosa and
cauterization or suture ligation as needed. Postoperative bleeding
may require examination under anesthesia and/or pouch endos-
copy with suture or endoscopic clipping of the bleeding point.
Bleeding, especially 5–7 days after operation, may be associated

 improved outcomes in colon and rectal surgery

(A) (B)

Figure 31.2 Retrograde pouch study shows a presacral collection (A) confirmed on CT scan (B). Collections arising from the anastomosis are preferably drained into
the pouch to avoid a complex fistula.

with anastomotic dehiscence. In a series of 1,005 patients, pouch

bleeding occurred in 38 patients (3.8%) and was treated with local
irrigation with saline and adrenaline in 30 patients and transanal
suture ligation in 8.(59)

Pelvic sepsis
Pelvic sepsis is defined as pelvic abscess, anastomotic leakage or
dehiscence, or any pelvic or perineal infection. Some series distin-
guish between pelvic sepsis and anastomotic leak; pelvic sepsis gen-
erally results from a defect in the ileoanal anastomosis, anastomotic
leak, or defect of the other staple or suture lines. A meta-analysis
noted the incidence of pelvic sepsis to be 9.8%.(50) Manifestations
of pelvic sepsis include fever, leukocytosis, perineal pain, purulent
drain output, and prolonged ileus. As pelvic sepsis is a significant
cause of pouch failure and since those patients with sepsis are
more likely to have compromise of pouch function, any patient
suspected of having pelvic sepsis, should be evaluated and treated
expeditiously. CT scan confirms the diagnosis of pelvic sepsis, and
contrast in the pouch (either by instilling rectal contrast or contrast
through the efferent limb of the ileostomy) is useful in assessing
the integrity of the anastomosis. Alternatively, a pouchogram and
examination under anesthesia may be necessary. Intraabdominal
or pelvic abscess requires percutaneous or operative drainage in
Figure 31.3 Asymptomatic anastomotic sinus in patient before ileostomy closure
addition to broad spectrum antibiotics (Figure 31.2). For patients
often requires no further treatment. Delay in ileostomy closure and repeat pouch
with leakage from the anastomotic suture or staple line the abscess study generally shows healing.
can be drained into the pouch. This potentially avoids the develop-
ment of a complex fistula. Untreated pelvic sepsis results in fibrosis,
a stiff, non-compliant reservoir, and a higher incidence of ultimate incidence of anastomotic leakage from either the pouch-anal
pouch failure.(60) anastomosis or the pouch itself was 7.1%.(61) The incidence
of anastomotic leakage was more common in patients who did
Anastomotic leak or dehiscence not have a stoma at the time of pouch surgery. The presence of
Anastomotic leak after the ileoanal pouch procedure occurs a stoma may help to ameliorate the clinical manifestations of a
between 5–18% of patients. In a recent meta-analysis, the leak. A leak may occur at the pouch anal anastomosis or along any


 surgery for ulcerative colitis
Figure 31.4 A leak from the efferent limb of the pouch may be difficult to diagnose.
Such patients rarely heal with antibiotics and drainage alone and often require
exploration and repair.
of the staple or suture lines including the top of the J-pouch, the
ileoanal anastomosis, or the pouch itself. Manifestations of a leak
include the development of an abscess, fistula, or symptoms of
pelvic pain, diarrhea, and fever. Risk factors associated with leak
include tension on the anastomosis and ischemia resulting from
tension on the anastomosis. One study suggested a lower inci-
dence of pelvic sepsis associated with a double-stapled anastomo-
sis compared with a mucosectomy and hand sewn anastomosis.
(62) Management of anastomotic leak is individualized; patients
who have an asymptomatic sinus before ileostomy closure with-
out associated sepsis can be treated by delay in ileostomy closure
and in most cases, ultimate healing of the tract.(Figure 31.3)
Patients with peritonitis who have undergone restorative proc-
tocolectomy without diverting ileostomy require diversion and
drainage. Leaks from the tip of the J pouch are challenging both
to diagnose and treat and developed in 14 out of 1,309 patients;
all required surgical repair and none healed with conservative
treatment (63) (Figure 31.4). With expertise and individual-
ized management, pouch salvage can be was achieved in 88% of
patients who developed anastomotic leak.(64)
Stricture at the ileal pouch anal anastomosis
Strictures at the ileal pouch anal anastomosis occur in approxi-
mately 10% of patients, and are more common after mucosec-
tomy and handsewn anastomosis than after double-stapled
anastomosis.(65, 66) Tension on the anastomosis and ischemia
are associated with stricture formation. A lumen which admits
the DIP joint of the index finger is generally satisfactory for good
bowel function. Soft strictures are treated with gentle finger dila-
tion or with balloon dilators. Long fibrotic strictures are more
Figure 31.5 A pouch vaginal fistula is seen on retrograde study. Early fistulas
are due to infection and leak at the anastomosis while late fistulas often herald
unsuspected Crohn’s disease.
challenging to treat and pouch advancement and neoileoanal
anastomosis may be necessary to treat such patients.(67)
Pouch vaginal fistula
The incidence of pouch-vaginal fistulas ranges from 3–16%.(68)
Pouch-vaginal fistulas are a major potential cause of pouch fail-
ure. Fistulas which occur in the early postoperative period are most
commonly a manifestation of sepsis, and can occur from anasto-
motic leak and necessitation through the vaginal wall, or may result
from technical factors including entrapment of the perivaginal tis-
sue in the staple line (Figure 31.5). An important part of the ileoanal
pouch procedure is to ensure that the vagina is not incorporated
within the stapler. Late pouch-vaginal fistulas are more commonly
associated with unsuspected Crohn’s disease.(69)
Pouch-vaginal fistulas may manifest as pelvic pain, fever, a
“Bartholin’s abscess” which when drained has fecalent mate-
rial, or passage of gas. Fistulas which occur before ileostomy
takedown are treated by management of infection, delayed ile-
ostomy closure, and local repair. A number of procedures have
been described for treatment of pouch vaginal fistulas. Ultimate
success may be achieved in over 50% (70) but often requires mul-
tiple procedures. For patients with Crohn’s disease, the use of
infliximab and other biologics may be helpful.
Pouch anal fistulas
Early fistulas are generally a manifestation of sepsis and leakage
at the ileoanal anastomosis. Late fistulas may be crytoglandular
in origin and may also be a manifestation of Crohn’s disease. Our
preference is for liberal use of draining setons and avoidance of
fistulotomy.

 improved outcomes in colon and rectal surgery

Pouchitis
The most frequent long-term complication of the ileoanal pouch
procedure is the development of pouchitis, a nonspecific inflam-
mation of the ileal pouch mucosa. The precise etiology of pouchi-
tis has not been elucidated but it is believed to potentially result
from an overgrowth of anaerobic bacteria. It is disease specific and
more commonly seen in patients with ulcerative colitis; it is rarely
encountered in patients with familial adenomatous polyposis.
Patients with ulcerative colitis associated with extraintestinal man-
ifestations and patients with sclerosing cholangitis have a higher
incidence of pouchitis.(71, 72) Presenting signs and symptoms of
pouchitis include abdominal cramps, abdominal tenderness, fever,
and increase in stool frequency, often associated with blood or
mucus. The diagnosis may be made clinically, on the basis of endo-
scopic examination in addition to clinical findings, or on the basis
of histologic examination of the pouch mucosa; the lack of uni-
form criteria to make such a diagnosis accounts for the variation in
the incidence of pouchitis in many series. A pouchitis disease activ-
ity index has been devised which includes clinical, endoscopic, and
histologic features.(73) Pouchitis is generally treated with antibiotic
therapy and the most commonly used agents include metronida-
zole or ciprofloxacin. Some patients with pouchitis develop ongo-
ing symptoms, and for patients with refractory pouchitis or rapidly
relapsing symptoms, the use of probiotics appears to be helpful.
Probiotics may suppress the resident pathogenic bacteria, stimu-
late mucin glyocoprotein, prevent adhesion of pathogenic strains
to epithelial cells, and reduce host immune responses. Probiotics
may also be helpful in preventing recurrent pouchitis. A diagnosis
of Crohn’s disease should be considered in patients with chronic
pouchitis. In some cases, pouchitis is a cause of pouch failure.
Pouchitis has been termed by some as “the Achilles heel” of the
ileoanal pouch procedure. It is a cause of significant long-term
morbidity; elucidation of the cause of pouchitis would likely ben-
efit a large number of patients.
Dysplasia and Malignancy
Following construction, the ileoanal pouch undergoes a number
of histologic changes, and with time, the metaplastic changes result
in the ileal mucosa resembling colonic mucosa. These changes may
also occur because of inflammation in the pouch and raise concerns
of malignant transformation and the development of dysplasia.
Neoplastic changes appear to be extremely rare. The majority of ile-
oanal pouch patients who develop cancer had a prior cancer at the
time of pouch construction. The recent ASCRS guidelines do not
endorse routine surveillance of ileal pouches for dysplasia.(10)
Pouch Failure
Pouch failure defined as pouch excision or a nonfunctioning pouch
at 12 months after the ileoanal pouch procedure occurs in 5 to 15%.
While the majority of pouch failures occur within 2 years of pouch
construction, late pouch failures also occur. The common cause of
pouch failure include unsuspected Crohn’s disease, chronic pouchitis,
poor function with incontinence, persistent fistula, and other pouch
related complications such as stenosis with outlet obstruction.
Reoperative pouch surgery with an attempt to salvage the
pouch is challenging; pouch salvage is higher in patients with
ulcerative colitis than Crohn’s disease.(74)
Controversies
Reservoir Design
While the original report by Parks used an S-pouch configu-
ration, a number of other pouch configurations have been
described, including J-pouch, lateral isoperistaltic H-pouch,
and quadruple-loop W pouch. S pouches were initially asso-
ciated with an increased need for catheterization because of a
long distal ileal conduit. Shortening of the ileal conduit helps
to initially avoid this complication, however, with time, the
exit conduit of the S-pouch seems to elongate and obstructive
defecation can occur. An S pouch may confer additional length
compared to a J-pouch and may be the preferred configuration
if achieving adequate length to performed a tension-free anas-
tomosis in selected cases. The long outlet tract associated with
an H pouch has been associated with stasis, pouch distention,
and pouchitis.
There have been no significant differences in pouch func-
tion based on the configuration of the pouch. Due to the ease of
construction and the lack of compelling data favoring a specific
pouch design, J pouches are most frequently performed. Use of
an S or W pouch adds about 45 minutes to the time of the opera-
tive procedure.
A recent meta-analysis examined the short and long-term out-
come of J-, S- and W- reservoirs in patients undergoing restora-
tive proctocolectomy.(75) A total of 18 studies of 1,519 patients
(689 J, 306 W, and 524 S pouches) were reviewed. There was no
difference in the incidence of early complications among the
3 types of pouch design. The frequency of defecation favored an
S- or W- pouch design over a J pouch, although in practical terms
the difference of 1–1.5 stools in a 24 hour period is unlikely to
be of clinical significance to the patient. Night evacuation was
significantly lower for a W than a J pouch. S pouches were associ-
ated with a greater need for pouch intubation due to a long distal
conduit; W pouches also required intubation more often than
J pouches.
Mucosectomy vs. Double-Stapled Technique
The ileoanal anastomosis may be performed with a handsewn
technique after mucosal stripping (mucosectomy) or with a dou-
ble-stapled technique.
The initial technique reported by Parks was mucosal strip-
ping commencing at the dentate line and removing all diseased
mucosa, thus eliminating the risk of recurrent proctitis or neo-
plastic transformation. A potential advantage of the double-
stapled technique is greater technical ease, and potentially less
tension on the anastomosis. Preservation of the anal transitional
zone may minimize sphincter damage and improve functional
results. Three prospective randomized trials have not shown
an advantage for the double-stapled technique vs. the muco-
sectomy technique.(76, 77, 78) These trials have all been small
and are underpowered to demonstrate a difference. A meta-
analysis of 4,183 patients (2,699 hand-sewn vs. 1,488 stapled
IPAA) found similar early postoperative outcomes; however,
stapled IPAA patients had improved nocturnal continence and
had higher resting and squeeze pressures on anorectal physi-
ologic testing.(79)


 surgery for ulcerative colitis
Preservation of the anal transitional zone and performance
of a double-stapled technique leaves a residual 1–2 cm of dis-
eased rectal mucosa, which may be at risk for the development of
dysplasia and subsequent malignant transformation. It has been
suggested that patients who have had a double-stapled tech-
nique be followed in a surveillance program, with biopsies of the
retained columnar mucosa at least every 2 years beginning 8 to 10
years after the onset of symptoms of disease.(80) The recommen-
dations for biopsy are controversial and is an area where further
study is needed to define the natural history of the retained 1–2
cm of columnar mucosa. Other authors have not found the devel-
opment of dysplasia with long-term follow-up.(81)
Omission of ileostomy
Restorative proctocolectomy is most commonly performed in
two stages with an initial proctocolectomy, pouch construction,
and diverting ileostomy, followed by ileostomy takedown after
demonstration of satisfactory pouch healing. However, construc-
tion of a loop ileostomy may be associated with excessive stoma
output, dehydration, hernia, bowel obstruction, and subsequent
anastomotic complications associated with ileostomy takedown;
these have been cited as a reason to potentially avoid diverting
ileostomy in selected patients after ileoanal pouch construction.
Conversely, many feel that loop ileostomy construction will mini-
mize the potential consequences of pelvic sepsis (and potentially
reduce the chance of pouch failure).
This issue has been characterized by a great deal of passion and
no randomized controlled studies. A one stage procedure without
loop ileostomy is associated with a more difficult initial recovery
and most likely a slight increased rate of anastomotic disruption
and pelvic sepsis. An alternate view of this is that with fecal diver-
sion, some patients with minor leaks and sepsis may not be clini-
cally detected.
Loop ileostomy avoids some of the consequences of pelvic sep-
sis, which is a major cause of pouch failure. Despite aggressive
treatment the risk of pouch failure after pelvic sepsis is 20%, 31%
and 35% at 3, 5 and 10 years respectively.(61) A single stage IPAA
without loop ileostomy decreases the risk of ileostomy related
complications, and complications including small bowel obstruc-
tion associated with an additional operative procedure.
A recent review compared 17 studies with 1,486 patients (765
without ileostomy and 721 with ileostomy).(61) While there was
no significant difference in the functional outcome of the two
groups, those patients without an ileostomy had a higher inci-
dence of pouch related leak and stricture formation.
Selective omission of an ileostomy may be considered when an
anastomosis is intact and under no tension, the procedure is not
complicated by excessive bleeding or other technical difficulties
and the patient is not on high dose steroids before the procedure.
(10) The patient should be adequately counseled preoperatively
concerning the pros and cons of ileostomy omission.
Crohn’s Disease and Indeterminate Colitis
Crohn’s disease has been considered to be a contraindication to
the performance of an ileoanal pouch procedure because of the
risks of recurrent disease and the potential need for pouch exci-
sion with subsequent loss of substantial amounts of bowel.
However, there are some patients who undergo the procedure
for ulcerative colitis and an ultimate diagnosis of Crohn’s disease
is made. In general these patients are found to have a higher risk of
pouch failure from 28–52% (82, 83, 84, 85) compared to patients
with ulcerative colitis or familial adenomatous polyposis. In a cohort
of 32 patients out of 790 patients with an ultimate diagnosis of
Crohn’s disease, 93% had complications including perineal abscess/
fistula (63%), pouchitis (50%), and anal stricture (38%) (85). It is
not known whether administration of agents such as infliximab to
such patients will ultimately impact the incidence of pouch failure,
or whether it will delay the diagnosis or pouch failure. All efforts
should be made to confirm a diagnosis of ulcerative colitis and
exclude a diagnosis of Crohn’s disease preoperatively. In addition to
a thorough history and examination, a recent study suggested that
a family history of Crohn’s disease and serology positive for anti-
Saccharomyces cerevisiae immunoglobulin-A were more likely to be
diagnosed with Crohn’s s after IPAA (67%) than patients with either
risk factor (18%) or neither risk factor (4%) (86).
While techniques of restorative surgery for ulcerative colitis
have shown substantial advances over the past several decades,
further study focusing on improvements in complications and
functional outcomes will ultimately further improve a patient’s
quality of life.
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71. Lohmuller JL, Pemberton JH, Dozois R et al. Pouchitis and
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72. Penna C, Dozois R, Tremaine W et al. Pouchitis after ileal
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73. Sanborn WJ, Tremaine WJ, Batts KP et al. Pouchitis after ileal
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74. Fazio VW, Wu JS, Lavery IC. Repeat ileal pouch-anal anas-
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76. Seow-Choen F, Tsunoda A, Nicholls RJ. Prospective randomized
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77. Luukkonen P, Jarvinen H. Stapled vs. hand sutured ileoanal
anastomosis in restorative proctocolectomy: a prospective
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78. Reilly WT, Pemberton JH, Wolff BG et al. Randomized
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performed by excising the anal mucosa to ileal pouch-anal
anastomosis. Ann Surg 1997; 225: 666–76.
79. Lovegrove RE, Constantinides VA, Heriot AG et al. A com-
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4183 patients. Ann Surg 2006; 244: 18–26.
80. O’Riordain MG, Fazio VW, Lavery IC et al. Incidence and
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81. Herline AJ, Meisinger LL, Rusin LC et al. Is routine pouch
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
 improved outcomes in colon and rectal surgery
82. Hyman NH, Fazio VW, Tuckson WB, Lavery IC. Consequences
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Rectum 1991; 34: 653–7.
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84. Keighley MR. The final diagnosis in pouch patients for
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patients should be warned of the consequence. Acta Chir
Iugosl 2000; 47: 27–31.
85. Braveman JM, Schoetz DJ, Marcello PW et al. The fate of the
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32 Surgery for Crohn’s disease
Jorge Canedo, Tolga Erim, and Steven D Wexner
Introduction
Crohn’s Disease (CD) is a lifelong disorder of unknown etiology
characterized by chronic focal, transmural, and granulomatosos
inflammation that can affect any portion of the gastrointesti-
nal tract. The transmural inflammation often leads to fibrosis
and to obstructive clinical presentations. Crohn’s disease was
first described by B. Crohn, L.Ginzburg, and G.Oppenheimer
in 1932 as an inflammatory condition limited to the terminal
ileum.(1) Later, Lockhart-Mummery and Morson (2) described
granulomatous colitis, and the disease process was understood
to potentially affect the large bowel. It can occur from the mouth
through the anus.
The clinical symptoms are related to the site of the disease. As it
is more prevalent among the terminal ileum and right colon, the
most frequently symptoms are: diarrhea, weight loss, abdominal
pain, and perineal disease. But the clinical features indicate the
site of the disease.(3)
a) Oral: Aphthous ulceration on the background of a mucosal
edema is the most common oral manifestation of CD.
Additional lesions described include: granulomatous masses,
chelitis, and granulomatous sialadenitis. Lesions usually coex-
ist with an intestinal disease.
b) Esophagus: Although more rare, lesions here may cause
­dysphagia or pain.
c) Stomach and duodenum: Less than 5% of the patients pres-
ent with gastroduodenal Crohn’s disease; the distal antrum
and the duodenum are the most commonly affected areas.
Both sites can present as a peptic ulcer disease. In addition,
outlet gastric obstruction may occur after a healing stricture
in the antrum.
d) Small bowel: Some findings of extended involvement include
malabsorption, protein-losing enteropathy, diarrhea, anemia,
and steatorrhea. If segmental thickening or structuring devel-
ops, the patient may present with obstructive symptoms.
e) Ileocecal: Symptoms of obstruction are more frequently due
to inflammatory swelling or structuring. Transmural inflam-
mation and local sepsis often result in a palpable inflamma-
tory mass in the right lower quadrant.
f) Colon: involvement often includes the symptoms of diar-
rhea, associated with pain.
g) Perianal disease: Is common and may precede other manifesta-
tions; as a fistula, an abscess, or one or more fissures and tags.
Patients may also have systemic symptoms; fatigue, weight loss,
and fever are the primary systemic symptoms in Crohn’s disease.
Postprandial obstructed symptoms from narrowed intestinal
segments make the patient avoid eating. Weight loss may also be
related to malabsorption and, in children, may be the presenting
sign before any obvious intestinal manifestations of the disease.
Fever is common in patients with Crohn’s disease and may be
due to other chronic inflammation or due to a perforation with
associated fistula or abscess. Crohn’s disease is diagnosed most
frequently among people aged 15 to 30 years, with no differences
in prevalence between males and females. However, there is a
­second peak between the sixth and seventh decades of life (4) and
diagnosis may also be made during early childhood.
Since its discovery in the Mount Sinai Hospital in New York City
almost 76 years ago, the exact cause of Crohn’s disease remains
unknown. Among many theories are genetic, immunologic,
bacterial, and bacterial antigens. The current theory about the
pathophysiology is that the intestinal flora, in conjunction with
unidentified environmental factors trigger and drives an exaggera-
dated immunologic response in a genetically susceptible host.(5)
The result is a chronic inflammation that typically extends beyond
the mucosa and throughout to the serosa. Potential risk factors to
develop CD are smoking and having first degree relatives with the
disease.(6)
Evaluation
Symptoms of CD are heterogeneous, but most of the time include
diarrhea for more than 6 weeks, abdominal pain, and weight loss.
In most cases, the patient will have a clinic, radiologic, endoscopic,
and histological evaluation to have its diagnosis.
Crohn’s disease most often involves the distal small bowel and
proximal large bowel. Almost one half of all patients have dis-
ease that involves both the ileum and the colon. While another
one-third have disease confined to the small bowel, primarily
the terminal ileum. The clinical presentation might be divided
according to the main symptoms into:
1. Intestinal Symptoms
2. Extraintestinal symptoms
3. Biliary and Liver Manifestations
The patient with CD should undergo complete evaluation. In
most cases, the leading symptom that precipitates evaluation is
diarrhea. Eighty-five percent of patients with CD report more
than 5 bowel movements (BM) per day and weight loss as part
of the initial diagnosis.(7) The history and physical examina-
tion might uncover general complaints including weakness and
fatigue. In addition, as mentioned above, there are the specific
symptoms according to disease site.
On physical examination, paleness of the mucosa could indicate
anemia. Iron deficiency anemia occurs in up to 30% of the patients.
(8) Typically, the abdominal examination reveals abnormal bowel
sounds, detection of an abdominal mass, and pain to palpation.
Inspection of the perianal regional can provide evidence of fistula,
fissure, abscess, or skin tap. Rectal digital examination might detect
a stenosis or blood.

 improved outcomes in colon and rectal surgery
The initial complementary evaluation starts with blood tests
and stool examination.
Blood tests
Blood tests can either provide specific or nonspecific diagnosis,
as well the general health status of the patient. The introduction
of biological therapies in IBD has renewed interest in inflamma-
tory markers (especially C reactive protein (CRP)), given their
potential to select responders to these treatments. Controversy
exists as to whether or not CRP is a useful marker, and should
be preferred in CD as it correlates well with disease activity.(9)
But a more recent study showed that neither CRP nor other
biological markers were associated with the endoscopic lesions.
(10) Elevated leukocytes and thrombocyte time can also indicate
active inflammation.
Serologic response to various microbes and autoantigens
can develop into CD. In addition to the well-established atypi-
cal perinuclear antineutrophil cytoplasmic antibodies (atypical
P-ANCA) and anti-Saccharomyces cerevisiae mannan antibodies
(ASCA), a number of new antibodies have recently been dis-
covered and data on their clinical significance has been rapidly
increasing. The combination of atypical P-ANCA and ASCA,
may be of help in patients in whom distinction between CD
and Ulcerative Colitis is not obvious with the classic diagnostic
tools (patient history, radiologic examination, endoscopy and
biopsy).
Papp et.al (11) analyzed several studies, and found that these
combinations had sensitivities of 30% to 64%, specificity more
than 90%, and PPV from 77% to 96%. Newer markers derived
from various microbial inhabitants of the gut, such as Omp,
I2, and CBir1 offer new ways to stratify patients into serologic
subgroups. Also, glycan markers including antilaminaribioside
carbohydrate antibody (ALCA) (18–38%), antichitobioside car-
bohydrate antibody (ACCA) (21–36%), and antimannobioside
carbohydrate antibody (AMCA) (28%) may play an important
role in making a CD diagnosis or prognosis.(12) More impor-
tantly, 24–44% of the CD patients found ASCA negative in
one study were positive for one or more of the antiglycan anti-
bodies. The combination of several serological markers, such
as gASCA, pANCA, and ALCA, had the best accuracy. Their
increased amounts and levels of antibody responses against
gASCA, ALCA, ACCA, AMCA and Omp were associated with
more complicated disease behaviour (44.7% vs. 53.6% vs. 71.1%
vs. 82.0%) and a higher frequency of Crohn’s disease-related
abdominal surgery (38.5% vs. 48.8% vs. 60.7% vs. 75.4%).(12)
Although the prevalence of antibodies is also higher in healthy
relatives of IBD patients than in the control population, their
role as subclinical markers is yet to be established.
Stool marker
One example of a stool marker is neutrophil determination.
However, neutrophil determination in the stool is inefficient
because of its brief lifetime. This means that the sample should
be examined within a few hours of its collection. Other exam-
ples of stool markers include calprotectin and lactoferrin. They
are produced in significant amounts in white blood cells. The
mucosal barrier is altered in CD, allowing white cells to cross

the intestinal wall. Activated leukocytes infiltrate the mucosa
and can be detected in feces. Lactoferrin is an iron-binding
glycoprotein found concentrated in the secondary granules of
the neutrophils. Granule proteins can be released from living
cells, while cell death does not appear to increase this phenom-
enon. Calprotectin is a cytoplasmic antimicrobial component
in granulocytes, monocytes, and macrophages. But besides its
promises, D’Incà et al. (13) observed that calprotectin and lac-
toferrin determination appears to reflect endoscopic and his-
tological disease activity in ulcerative colitis but not in Crohn’s
disease.
Images
In clinical practice, imaging techniques are used at initial presenta-
tion to establish a diagnosis and to assess exact location, extent,
and severity of disease at the time. These methods are also used as
follow-up during and after treatment to direct treatment strategies
and determine optimal choice and dose of medication. Patients
with established CD typically undergo many investigations over a
lifetime.
Small bowel series
The small bowel has been defined for many years as the “black box”
of the gastrointestinal system, due to its lack of endoscopic acces-
sibility. Therefore, the conventional radiological methods (small
bowel enteroclysis (SBE) (Figure 32.1a, Figure 32.1b, Figure 32.1c)
and small bowel follow through (SBFT)) were the only imaging
methods that could provide information on the morphological
features of the small bowel valuable in the diagnosis and manage-
ment of CD. Both SBE and SBFT, when performed by experienced
examiners, appear to be characterized by similar sensitivity (85–
95%) and specificity (89–94%) in detecting the radiological lesions
typical of Crohn’s disease.(14) Preference for one technique or the
other largely depends on institutional standards. Both procedures
are able to evaluate small bowel peristalsis, including the presence
of strictures and/or dilations, the distensibility of the intestinal
loops, the presence of fistulae, the morphology of circular folds,
and morphology of the mucosal surface.
Enema
For primary evaluation, endoscopy has widely replaced the bar-
ium enema (BE) as diagnostic method. However, BE can provide
important additional information in the differential diagnosis of
chronic inflammatory colonic diseases or if intestinal intubation
is not achieved at colonoscopy. The advantage of a BE over endos-
copy is a clear and reproducible demonstration of the patterns of
distribution and character of the disease as well as the detection
of fistulae.(15) With the advance of CT and MRI images, and
wireless endoscopic capsule, barium examinations not only of the
stomach but also of the colon are decreasing in frequency.
The disadvantage of the enema is the same as the one for
SBE: limited information about transmural and extraintestinal
abnormalities.
Upper endoscopy
Lemberg et al. (16) concluded the need to include EGD in the
evaluation of children suspected of having IBD. The current study
 surgery for crohn's disease
(A)
(C)
found that in children with CD, 57.4% had endoscopic abnormal-
ities. These findings ranged from mild changes, such as erythema
or nodularity of the stomach, to more obvious features, such as
ulceration throughout the upper tract and cobblestoning of the
duodenum. In total, 80.3% of patients had histologic evidence
of inflammation in the upper gut; including granulomata, which
(B)
Figure 32.1  (A) Note the string like narrowing stricture at the terminal ileum
(arrows) with proximal bowel obstruction. (X-ray courtesy of Department of
radiology Cleveland Clinic Florida) (B-C) Multiple small bowel strictures with
associated proximal obstruction. (X-ray courtesy of Department of radiology
Cleveland Clinic Florida)
were evident in the upper gastrointestinal tract in approximately
one-quarter of patients with CD. EGD may help in the differen-
tial diagnosis in patients with indeterminate colitis after a biopsy
in the normal gastric mucosa (17) and may be used as therapeutic
intervention specifically in case of antrual or duodenual stricture.
EGD p ­ rovides good relief in symptomatic patients (17).

 improved outcomes in colon and rectal surgery

Colonoscopy
Approximately 50 percent of patients have ileocolitis which refers
to involvement of both the ileum and colon, highlighting the fact
that colonoscopy with intubation of the ileum plays a fundamen-
tal role in the diagnosis and evaluation of a patient with Crohn’s
Disease. Colonoscopic findings often include segments of normal
bowel interrupted by large areas of obvious disease.
In CD, the severity of an attack is usually evaluated accord-
ing to clinicobiological variables, like the Crohn’s Disease Activity
Index. Colonoscopy has an increased risk of complication in such
cases. But Nahon et al. (18) demonstrated that colonoscopy in
severe colonic CD is useful for the diagnosis of CD versus UC.
The benefits increase if the patient is suffering from a first attack
of inflammatory bowel disease, a situation which is particularly
common in cases of severe colitis, as has been reported in 2.3–
6% of CD.(19) In this study, colonoscopy with biopsies was able
to diagnose CD after initial presentation in 50% of patients by
showing either involvement of the ileum or intervening zones
of healthy mucosa within the colon. According to Minderhound
et al. (20), colonoscopy remains the gold standard for assessment
of severity of mucosa inflammation compared to several score
indexes, as well as serum and fecal markers.
Figure 32.2  New CT scan technology has improved and may substitute for
Transabdominal ultrasound (US) standard SBS in the near future. Note the thickened bowel wall at the stricture
(solid arrows) and dilated obstructed proximal bowel (arrows with dashed lines).
Parente et al. reviewed several studies that compared the accuracy
Image courtesy of Toshiba America Medical systems, Inc.
of bowel US with other imaging techniques (barium X-ray and/
or endoscopy) and surgery in localizing CD lesions within the
bowel.(21) But many of these studies have included small num- technique that can be usefully employed to study the pelvis and
bers of patients with CD diseases mainly confined to the small perianal inflammatory diseases in static and dynamic evaluations.
bowel. The overall sensitivity for diagnosis disease in the terminal Additional advantages of US are that it does not require costly or
ileum is approximately 90% with specificity of 93–97%. specific diagnostic instruments and can be performed with ade-
Bowel US has also been used to detect complications of CD. quate training and experience in most hospitals or offices.(24)
Although the presence of abscesses, fistulae, and strictures may be Doppler sonography is part of the entire sonographic evalua-
suspected from clinical history or specific complaints, it is usually tion of intestinal diseases which is helpful in estimating disease
necessary to undertake endoscopy, barium studies and computed activity, although it is not acceptable as the sole method to achieve
tomography (CT) to clearly diagnose these complications. Barium diagnosis.(25)
studies and CT scans are still considered the methods of choice in
detecting internal fistulae and abscesses in CD. Parente et al. in a CT scan
previous prospective study compared the sensitivity and specificity Conventional.  Computed Tomography (CT) has usually been uti-
of bowel US in detecting strictures in small bowel.(22) lized for the detection of extraintestinal complications of Crohn’s
Computed tomography is currently considered the nonsurgical disease (mainly intraabdominal abscesses) but is also suitable in the
‘gold standard’ for the diagnosis of CD-related abscesses. Both CT evaluation of bowel wall thickness/ strictures, prestenotic dilatations
and barium studies are known for their accuracy in detecting fistu- and fistulas. Nonenhanced CT scan is also used in the diagnosis of
las, although Maconi et al. (23) demonstrated that CT or SBE alone postoperative complications indicating (intraperitoneal abscesses,
might miss up to 30% of the fistulas, but US alone or in combina- anastomotic deiscence, extraabdominal abscesses and fistulas, inci-
tion with SBE can detect almost 90% of internal fistulas. US when sional hernias, ascites, volvulus, etc.). Conventional CT is limited in
compared to CT, showed an overall high accuracy comparable in its assessment of the small bowel because of the artifact caused by
the detection of intraabdominal abscesses. Although CT showed collapsed bowel loops.(26)
a slightly greater accuracy and positive predictive value than did
US. US also has a lower sensitivity in detecting deep abscesses. This Enteroclysis.  Because of the problems described above, CT-
finding can be explained by the well-known difficulties associated enteroclysis has been great results. The ability of multislice CT
with transcutaneous US examination of anatomic structures deep machines to image larger volumes shown (1500 to 2000 mL or
in the pelvis or between the intestinal loops, especially when over- more of contrast agent delivered by the positioning of a nasojeju-
lying bowel gas obscures the region of interest. The differentiation nal tube) at a faster speed with the ability to perform reconstruc-
between abscess and enlarged loop can be challenging. tion after the examination, has made CTE a more feasible exten-
Another feature in US is its utility in the evaluation of peria- sion of the conventional barium enteroclysis and CT methods of
nal disease. Transperineal US is a simple, noninvasive and cheap examining the small intestine (Figure 32.2). It can detect active


 surgery for crohn's disease
inflammatory changes (neutral enteral contrast with intravenous
contrast media) and complications such as fistulae, sinus tracts,
and strictures (positive enteral contrast).(27)
Volumetric.  More recently, a row multidetector-computed
tomography (MDCT) has been used to perform a virtual colonos-
copy. Virtual colonoscopy studies were performed with single-
row helical CT scanners using slices of 4 mm thickness.(28) With the
advent of MDCT technology, thinner collimation (up to 0.6 mm) is
possible. It is possible now to detect flat or ulcerated lesions of the
colon, the findings of which in the evaluation of IBD correlated
highly with conventional colonoscopic findings.(29)
The disadvantages in both CT enteroclysis and volumetric
evaluation included: radiation exposure, and the need for
intravenous
Endoscopic Ultrasound(EUS)
In the setting of IBD, EUS has been limited to detecting perianal dis-
ease. The accrual of EUS, MRI, and EUA are comparable. At 85%,
87%, and 91% respectively improved upon by employing any two
methods.(30) The use in fistula disease is well described; Schwartz et
al. (31) showed that EUS may identify patients with fistulae who can
discontinue infliximab without the recurrence of a fistula.
MRI
MRI allows the accurate assessment of both inflammatory changes
of the bowel wall and extramural complications of Crohn’s dis-
ease. The noninvasiveness of this technique and its lack of ion-
izing radiation has prompted many groups to perform systematic
studies of MRI for evaluation of Crohn’s disease. Technological
advances in MRI, including the use of respiration-suspended
sequences, improved coils, fat suppression, and intravenous gado-
linium, have extended the use of MRI in the evaluation of the gas-
trointestinal tract. MRI is capable of demonstrating pathology in
both luminal and perianal Crohn’s disease. One advantage of MRI
over other modalities is its ability to differentiate active inflamma-
tion from fibrosis in a thickened bowel segment.(32) It is also safe
in pregnancy and in renal failure. Inflammatory diseases featuring
intestinal wall abnormalities, exoenteric disease manifestations
and complications, disease activity, and, to a lesser extent, mucosal
abnormalities, can be appreciated on MRI. In addition, it has been
reported that the sensitivity and specificity of MRI in assessing
disease activity are 92 and 75%, respectively.(33)
Despite closure of draining external orifices after infliximab
therapy, fistula tracks persist in some patients with varying
degrees of residual inflammation, which may cause recurrent
fistulas and pelvic abscesses. MRI can detect whether complete
fistula fibrosis occurs with complete resolution of inflammation
in the internal fistula tracks.(34)
Diasadvantages of the MRI include the high cost of the exam
and the length of time to perform it.
Double Balloon Enteroscopy(DBE)
Endoscopic examination of the entire small bowel is technically
very difficult. Push endoscopy is often possible only to the proxi-
mal jejunum. In 2001, Yamamoto and Kito developed the double
balloon method as an insertion technique for the diagnosis and
treatment of small bowel disorders.(35) DBE requires bowel prepa-
ration, sedation, radiological exposure, and a 60–100 min exami-
nation time, but is able to take biopsies and perform therapeutic
endoscopy such as endoscopic enteroclysis, hemostasis, and bal-
loon dilatation. Oshitani et al. reported their initial experience in
40 patients. Deep small bowel involvement proximal to the terminal
ileum was revealed in 27 patients, and 24 (88.9%) of these patients
had no involvement of the terminal ileum itself.(36) Another study
showed an 80% success rate of stricture dilatation.(37) This tech-
nique therefore represents a promising method for diagnosis and
therapeutic intervention of small bowel strictures in CD and may
be able to avoid surgery in such patients. However, DBE requires an
experienced and skilled therapeutic endoscopist and can be quite
confusing, and therefore costly.
Wireless Endoscopic Capsule
Wireless capsule endoscopy (WCE), initially developed for small
bowel investigations in patients with occult bleeding, has been
studied in small bowel Crohn’s disease. WCE enables a painless and
radiation-free examination of much of the small bowel in an unse-
dated patient. Based on cost-effectiveness (US$ 20,000.00–US$
30,000.00), funding issues, and the inability to obtain tissue sam-
ples, it is unlikely that WCE will soon become the primary imaging
modality used to initiate a diagnosis of Crohn’s disease or to define
its extent at relapse.(38) WCE is well-tolerated by most patients,
requires no sedation, and carries few side effects. One of the com-
plications of WCE is capsule retention. In a series of 52 patients,
Park et al. (39) reported 5 retain WEC (9.6%). Two patients (3.8%)
had to undergo a surgery for WEC removal.
With the development of the “Given Patency Capsule (Given
Imaging Ltd, Yoqneam, Israel), capsule technology might be suit-
able for cases of suspected intestinal strictures by SBE. This self-
dissolving capsule is the same size as a capsule endoscope. The
difference is found at the cellophane-walled cylinder filled with
lactose, protected by a plug with a specially-sized hole that allows
influx of intestinal fluid, which in turn dissolves the lactose in a
predetermined amount of time. If the capsule is retained in the
gastrointestinal tract, it disintegrates into small, mostly soft, frag-
ments which can easily pass through strictures. Spada et al. pro-
pective studied 27 patients with known or suspected intestinal
stricture. Twenty and two had CD. Twenty-five patients (92.6%)
retrieved the “Given Patency Capsule” in the stools, including six
of them which were dissolved. In 2 cases (7.4%), the Given Patency
Capsule could not be retrieved in stools and expulsion was con-
firmed by fluoroscopy and by a Patency Scanner. One case (4.3%)
required hospitalization due to intestinal occlusion. But in this
case, the Given Patency capsule was retrieved. The authors con-
cluded that WEC done with the Given Patency Capsule was a safe
procedure even in the presence of stricture disease.(40)
PET scan
Positron emission tomography with fluorine 18–labeled fluoro-
2-deoxy-D-glucose (FDG-PET) is a functional imaging method
used to detect abnormalities in glucose metabolism in a variety
of disorders. Neurath et al (41) studied the efficacy of PET scan
in detecting active chronic inflammation on inflamed small and
large bowel segments in CD, and compared the results to those

 improved outcomes in colon and rectal surgery

Table 32.1  Image tests for Small Bowel CD. first, and biologics and immunomodulators are only initiated if
Modality Fistula Abscess Stricture Inflammation
the patient fails to achieve remission. Step-down therapy advo-
cates use of immunomodulators and, at times, biologic agents, in
SBE ++ - ++ ++ addition to or even before use of steroids and aminosalicylates, in
Colonoscopy + - ++ ++ order to achieve remission as soon as possible. These discussions
US + + + ++ have largely been inspired by the success of step-down therapy in
CT enteroclysis ++ ++ ++ ++ rheumatoid arthritis, success in severely ill patients and in some
MRI ++ ++ ++ ++ part by the strong marketing efforts of the pharmaceutical indus-
WEC - - + ++ try. Selection of appropriate therapy remains a decision which
DBE - - + ++ must be made on an individual basis.
PET + + - ++ The ideal drug for CD should induce and maintain remission
Scintigraphy + - + ++ quickly and with minimal side effects. There is no such drug right
now. Agents such as corticosteroids which are rather good at induc-
Legends: - not useful
tion of remission, are not effective in maintenance. Azathioprine
+ somewhat useful
and 6-mercaptopurine are the benchmark drugs for maintenance
++ very useful
of remission, are not as useful in induction because it takes several
months for them to be effective. The benefits of 5-ASA agents in
obtained by hydro-MRI and immunoscintigraphy with granulo- the management of acute CD and the maintenance of remission
cyte antibodies (GABs). The sensitivity was 85%, 87%, and 71%. are questionable.(46, 47, 48) Biologic agents such as Infliximab
The specificity was 89%, 93%, and 100%, respectively. and Adalimumab, which both induce and maintain remission, are
FDG-PET appears to be a reliable tool for detecting inflamed indicated only for patients considered to have moderate to severe
gut segments in CD with higher sensitivity and specificity than disease.
either MRI or scintigraphy.
5-Aminosalicylates (5-ASA)
Scintigraphy Although their benefit is at best questionable, aminosalicylates are
An increased number of T cells and macrophages within the gut often used for patients with mild-to-moderate colitis. The mecha-
lumen is a feature of CD. One of the main problems in the clini- nism of action of aminosalicylates in CD is not fully understood.
cal management of CD is the identification of patients undergoing In vitro investigation has shown many antiinflammatory and
early relapse in order to ensure that appropriate preventive treat- immunosuppressive properties such as inhibition of prostaglan-
ment is administered. Follow-up of patients in clinical remission din and leukotriene synthesis, free radical scavenging, impairment
is currently based on the calculations of clinical activity indexes, of white cell adhesion and function, and inhibition of cytokine
together with radiological and endoscopic studies. Scintigraphy synthesis.
with 99mTc-labelled interleukin-2 (99mTc-IL2) and with 99mTc- Sulfasalazine, initially approved by the FDA in 1950 for rheu-
HMPAO-labeled granulocytes (99mTc-WBC) has been evalu- matoid arthritis, has been used for decades in the treatment of
ated to detect the presence and extent of bowel inflammation in Ulcerative Colitis and CD. The drug is broken down by bacteria
patients with long-term inactive CD (>12 months). Annovazzi et in the colon into its two products, 5-aminosalicylic acid (5-ASA)
al compared the extent of uptake of 99mTc-IL2 and 99mTc-WBC and sulfapyridine. These components possess antiinflammatory
in patients with clinically inactive CD and, despite the absence (5-ASA) and antibiotic (sulfapyridine) properties. 5-ASA acts
of symptoms, 62% had either 99mTc-IL2 or 99mTc-WBC posi- directly on the colon and is not absorbed while sulfapyridine is
tive for inflammation.(42) Scintigraphy with labelled white blood mostly absorbed by the intestine and secreted into bile and, to a
cells (WBC) has been successfully used in CD patients to detect much lesser extent, into urine. Several clinical trials have shown
abscesses and to assess disease extent (particularly for the small that Sulfasalazine is more effective than placebo at inducing remis-
bowel) and activity. Almer et al compared the 99mTc-WBC to sion in mild to moderate disease, greatest benefit seen in those with
intraoperative and laparotomy findings and found a sensitivity of colonic or ileocolonic disease. However, Sulfasalazine has a slower
85% and specificity of 81% for bowel inflammation.(43) Although onset of action than prednisone and is considerably less effective. It
not used, scintigraphy can be an option as a noninvasive evaluation is not effective as a steroid-sparing agent, and, when used as adjunc-
for young children and fragile adults who might have more diffi- tive therapy, it is not more effective than prednisolone alone.
culty with invasive imaging modalities. Table 32.1 summarizes the As the sulfapyridine portion of Sulfasalazine accounts for
efficacy of the exams discussed above.(41, 44, 45) the majority of side effects, several aminosalicylate-containing
medications have been created over the years that do not contain
Medical therapy ­sulfapyridine and are thus sulfa free. The most commonly used
The etiology of Crohn’s disease (CD) is unknown, and therefore drug in this class is mesalamine. Several formulations of mesala-
no curative treatments are available. The last few years have wit- mine exist currently, with Asacol, Salofalk, Rowasa, and Pentasa
nessed a significant change in its treatment. Recent debate on being the most commonly used forms. They are formulated by
medical management of CD has focused on a step-up versus a either using different acrylic resins or by encapsulation in ethyl
step-down therapy. Step-up therapy has been the traditional cellulose micro granules, resulting in delivery of the drug to the
treatment option where steroids and aminosalicylates are started distal small bowel and colon. Other forms of mesalamine have


 surgery for crohn's disease
been created by the dimerization of 5-ASA to make the drug
active only once it reaches the colon. Examples of these are olsala-
zine (Dipentum), which has two 5-ASAs linked together, and bal-
salazide (Colazal), which is 5-ASA linked to an inert unabsorbed
molecule. The pharmacology, and thus the undesirable drug
absorption rates, differ between these drugs, although the clinical
importance of these characteristics is debatable.(49) In general,
mesalamine compounds are better tolerated than Sulfasalazine.
However, mesalamine has not been found to be an effective treat-
ment for induction or maintenance of remission in adequately
powered, randomized, placebo-controlled trials.(48)
Antibiotics
Metronidazole and Ciprofloxacin are the most commonly used
antibiotics in treatment of CD. The mechanism of action of anti-
biotics in Crohn’s are theorized to include decreased bacterial
concentration in the gut lumen, alteration of the microflora com-
position to favor beneficial bacteria, decrease in bacterial tissue
infection and micro abscesses, decrease in bacterial translocation
and systemic dissemination. In addition, some antibiotics act as
immunomodulators.(50, 51)
These agents have not been found to be efficacious in induc-
tion or maintenance of remission. The consensus view is that these
agents should be used for perianal fistulas and postoperative man-
agement after ileocolic resection or fistula/abscess operation for
CD.(52) However, this practice is not based on adequately powered,
controlled evidence. In fistulizing Crohn’s disease, antibacterials,
immunosuppressive drugs, infliximab, and surgery are often used
in combination.
Corticosteroids
The mechanism of action for this class of drugs in CD is through
antiinflammatory activity. Corticosteroid therapy is split into
systemic versus nonsystemic types. Conventional systemic cor-
ticosteroids such as prednisone and 6-methylprednisolone have
demonstrated efficacy in induction of clinical response and remis-
sion. It has also been well established that they are ineffective in
maintenance of remission. The National Cooperative Crohn’s
Disease Study achieved 60% remission, with 0.5–0.75 mg/kg/day
prednisone tapered over 17 weeks, compared with 30% on placebo
(NNT = 3).(53) The European Co-operative Crohn’s Disease Study
achieved 83% remission with 6-methylprednisolone, 1 mg/kg/day
over 18 weeks, compared with 38% on placebo (NNT = 2).(54)
Nevertheless, approximately 50% of recipients will either fail to
respond (steroid-resistant) or will be steroid dependent at 1 year.
(55) The use of conventional systemic corticosteroids in patients
with clinically quiescent CD does not appear to reduce the risk of
relapse over a 24-month period of follow-up.(56) No dose response
trial has been performed for prednisone. Treatment is usually started
at 40–60 mg daily dose of prednisone and, once response is attained,
it is tapered down 5 mg per week. The main disadvantage of sys-
temic corticosteroid therapy is its many side effects. Corticosteroids
are associated with increased risk for infections, osteoporosis, cata-
racts, hyperglycemia, and avascular necrosis of bones.
A newer steroid therapy that is widely used for CD is budesonide.
Budesonide is a corticosteroid with high affinity for glucocorti-
coid receptors but low systemic activity due to extensive first-pass
metabolism in the liver. It has been shown to be effective in induc-
ing remission in terminal ileal and right-sided colonic disease
with significantly less side effects than systemic corticosteroids.
A meta-analysis of five published trials found that budesonide
was superior to mesalamine and placebo in achieving remission.
It was found to be similar in effectiveness to prednisone except for
those with severe disease.(57) As for maintenance, an analysis of
four double-blind placebo-controlled trials of budesonide with
identical protocols revealed that budesonide 6 mg/day is effective
for prolonging time to relapse and for significantly reducing rates
of relapse at 3 and 6 months, but its effectiveness in maintaining
remission is lost when measured at 12 months.(58)
Immunomodulators
The mechanism of action of these drugs in CD is not thoroughly
understood. The most commonly used examples are azathio-
prine (AZA) and its metabolite, 6-mercaptopurine (6-MP). AZA
and 6-MP have been researched and used successfully since 1971
in patients with CD. AZA is a prodrug that is converted to 6-MP
and then metabolized to an active metabolite, 6-Thioguanine
Nucleotide (6-TGN). 6-TGN is incorporated into ribonucle-
otides, thereby exerting an antiproliferative effect on mitotically
active lymphocyte populations. AZA and 6-MP may also possess
direct antiinflammatory properties by inhibiting cytotoxic T-cell
and natural killer cell function and inducing apoptosis of T cells
through Rac1 target gene modulation.(59) Treatment can be initi-
ated with either drug at 50 mg/kg, and doses are adjusted while
monitoring for toxicity to 1.5–2.5 mg/kg for AZA and 1–2 mg/kg
for 6-MP. They are usually administered jointly with steroids for
induction of remission due to their relatively slow onset of action;
usually 3 months or more.(60) However, they have been found to
be effective in maintenance of remission in corticosteroid-induced
remission of mild to moderate CD, and in treatment of fistulizing
disease. They are also considered to be steroid-sparing agents, an
idea supported by a meta-analysis by Pearson et al.(61)
The use of AZA in CD has evolved in the past few years with the
support of new tests which can predict its toxicity and drug activity.
Therapeutic efficacy, bone marrow suppression, and liver toxicity
of AZA and 6-MP correlate with concentrations of its metabolite
6-TGN.(62) Thiopurine methyltransferase (TPMT) enzymatically
converts 6-MP to 6-methyl-mercaptopurine (6-MMP), diverting
metabolism away from 6-TGN. There is an inverse relationship
between expression of TPMT and level of 6-TGN. Therefore,
lower TPMT activity yielding higher levels of 6-TGN has been
associated both with an increased likelihood of clinical response
and bone marrow suppression.(59) TPMT deficiency is inherited
in an autosomal recessive manner with 1 in 300 subjects having
homozygous deficiency, and around 11% of the community hav-
ing intermediate enzyme activities.(63) Measurement of TPMT
genotype has been proposed to predict the likelihood of toxic-
ity to 6-MP or AZA since patients with low TPMT activity are at
increased risk of myelosuppression.(64) The strategy of determin-
ing TPMT activity in all patients before initiating treatment with
AZA could help to minimize the risk of myelotoxicity, as patients
with intermediate TPMT activity had fourfold more risk than
high TPMT activity patients.(65) It is currently recommended
to test all patients’ TPMT levels before treating with AZA/6-MP.

 improved outcomes in colon and rectal surgery
Although TPMT testing is helpful in avoiding early, profound
bone marrow suppression, it should not take the place of careful
monitoring of full blood counts throughout the duration of treat-
ment on AZA/6-MP. If the patient is a slow metabolizer, clinical
decision on treatment dose with consideration for lower dosing
and closer follow-up must be made, while those that are deficient
should not be treated due to bone marrow toxicity. Patients who
are found to be nonresponders are suggested to have metabolite
testing. The utility of measuring the 6-MP metabolites 6-TGN
and 6-MMP has been debated in the literature and even referred
to as the “metabolite controversy”. According to expert opinion, it
would seem reasonable to recommend checking 6-TGN/6-MMP
metabolites when patients are not achieving therapeutic efficacy
despite adequate weight-based dosing to ascertain noncompliance
or metabolism favoring 6-MMP.(59)
Methotrexate has also been shown to be effective in CD for
both treating active disease (66) and maintaining remission (67).
However, like AZA/6-MP, its slow onset of action limits its use in
induction therapy. Nausea is a common side effect of methotrexate,
but more serious concerns over opportunistic infections, hypersen-
sitivity pneumonitis, and hepatotoxicity add to the factors limiting
its use as a first line immunomodulator in treatment of CD.
Although some data have suggested a beneficial effect of high-
dose cyclosporine in active luminal CD (68), the benefit was not
durable (69). An open-label trial of 16 patients with fistulizing dis-
ease found that cyclosporine treatment resulted in 88% response
and 44% complete closure.(70) However, a comprehensive review
of the literature has shown that 39 patients with fistulizing ­disease
who were treated with cyclosporine had 82% relapse rate in absence
of oral cyclosporine.(71) Therefore, cyclosporine is not recom-
mended for use in luminal CD and its use in fistulizing disease
with subsequent maintenance therapy on AZA/6-MP is debatable.
(72) Cyclosporine has several serious side effects including renal
failure, seizures, and opportunistic infections.
Biologic Response Modifiers
In 1998, the FDA approved use of Infliximab for use in treatment of
moderate to severely active CD and patients with fistulizing Crohn’s
disease, who have had inadequate response to conventional ther-
apy. In fact, it is the first drug to gain FDA approval for treatment
of CD. Prior to the late 1990s, patients who had failed response to
first-line therapies or were steroid-dependent had few nonsurgical
options. The mechanism of action of biologic response modifiers
in CD is through the interaction of the interleukins and cytokines.
Neutrophils from patients with colitis (e.g., CD, ulcerative colitis,
and infectious colitis) all produce significantly more IL-1 and TNF
than neutrophils from healthy controls.(73)
Infliximab is a chimeric IgG-1 monoclonal antibody com-
prised of 75% human and 25% murine sequences, which has a
high specificity for and affinity to tumor necrosis factor (TNF)-α.
The pivotal trial for assessing the efficacy of Infliximab in CD in
1997 showed 33% rate of remission and 81% overall symptom
improvement in patients who had been resistant to conventional
treatment.(74) However, up to 40% of patients do not respond
to treatment initially. The standard dose of Infliximab at 5 mg/
kg of body weight given as infusion every 8 weeks can sustain
remission for up to 1 year in only 30% of initial responders. This

is likely due to a combination of loss of efficacy and intolerable
side effects. Infliximab also has modest steroid-sparing efficacy
where at week 54, about 3 times as many patients (29% vs 9%)
on Infliximab versus placebo had discontinued treatment with
corticosteroids while maintaining clinical remission.(75)
The efficacy of regularly scheduled treatment versus episodic
treatment with Infliximab for patients with CD was compared
in a posthoc analysis of the ACCENT I trial in 2004.(76) It was
shown that regularly scheduled treatment resulted in a higher
proportion of patients in remission at weeks 10, 14, 22, and 46
compared with the episodic treatment group. Patients were also
found to have improved mucosal healing, less likelihood of hav-
ing antibodies to Infliximab, fewer Crohn’s-related hospitaliza-
tions, and fewer surgeries if on regularly scheduled treatment.
Infliximab therapy causes antibody formation in up to 61%
of patients and they correlate with increased risk of transfusion
reactions as well as decline in efficacy.(77) Concomitant use
of AZA/6-MP has been shown to reduce rate of antibodies to
Infliximab (ATI), although currently there is no prospective trial
comparing remission and response rates in patients concomi-
tantly using AZA/6-MP and Infliximab.(78–80)
Infliximab is also effective in closure of perianal enterocutane-
ous and rectovaginal fistulas and maintaining fistula closure. Two
prospective, randomized, placebo-controlled trials have shown
closure rate of 55% at week 4 and maintenance of closure in 39%
of patients respectively.(81, 82)
In February 2007, Adalimumab gained FDA approval for the
treatment of moderate to severe CD. Adalimumab is a fully human
recombinant immunoglobulin G1 (IgG1) monoclonal antibody
that binds with high affinity and specificity to human soluble TNF.
Its efficacy is similar to Infliximab except that there is currently
not enough evidence to comment on its value in fistulizing dis-
ease.(83) However, certain features make it more attractive for
use in clinical practice. It is thought that Adalimumab may be
less immunogenic because it is a fully human antibody. Indeed,
some evidence does exist for inducing remission in those who
cannot tolerate Infliximab or have disease activity despite receiv-
ing Infliximab therapy.(84) Another advantage is that it is admin-
istered as a subcutaneous injection whereas Infliximab must be
given as an infusion.
Main side effects of Infliximab and Adalimumab include infec-
tions, infusion reactions, serum-sickness-like reactions and a pos-
sible increased risk of lymphoma. A tuberculin skin test should be
done before initiating therapy, as reactivation of latent tuberculosis
is a potential complication.
Prevention of Postoperative Recurrence
Approximately 75% of patients with CD require surgery within
the first 20 years after symptom onset.(85, 86) Several studies have
shown that, 1-year postresection, the endoscopic recurrence rate
is near 73% with clinical relapse rate of 50% in 5 years.(87, 88)
Increased risk of recurrence is associated with the following prog-
nostic variables at the time of surgery: female gender, perianal dis-
ease, smoking, use of 5-ASA, jejunal site, ileal and ileocolonic site,
and Nod2/Card15 gene variants. Severity of endoscopic recur-
rence at the neoterminal ileum within 1 year of surgery was found
to be the most powerful predictor of symptomatic recurrence.(89)
 surgery for crohn's disease
Most studies of postoperative recurrence of CD have found that
endoscopic findings predate clinical relapse.
Management options to prevent postoperative recurrence vary
and depend on the patient. The first line treatment, despite mar-
ginal efficacy, has been mesalamine. Most studies only demon-
strate a modest relative risk reduction in recurrence rates when
compared to placebo. A recent meta-analysis showed an abso-
lute risk reduction of 10% in postoperative patients at 2 years.
(90) The largest benefit was found in pts with ileitis and pro-
longed disease duration. The number needed to treat (NNT) to
prevent one relapse was found to be 10 patients.(91) Whether or
not this is a clinically relevant finding and the financial cost and
effort spent in taking these medications merit their use is highly
debatable. Azathioprine and 6-MP have both been used exten-
sively in the postoperative patient, but data is limited and shows
only modest efficacy for prevention of recurrence. The general
consensus is that larger blinded controlled trials are warranted.
A randomized, prospective, multicenter, placebo-controlled, dou-
ble-blind, double-dummy trial done in 2004 by Hanauer showed
relapse rates of 50% with 6-MP (50 mg), 58% with mesalamine
(3 g), and 77% with placebo.(92) There were several shortcomings
in this study, including the use of a suboptimal fixed dose of 6-MP,
a high drop-out rate, higher clinical vs endoscopic relapse rate, and
lack of a validated, reproducible clinical index used to judge clinical
relapse. A prospective, open-label, randomized study of 142 patients
who received AZA (2 mg/kg/day) or mesalamine (3 g/day) for
24 months found AZA effective in preventing relapse in those patients
who had undergone previous intestinal resection.(93) Shortcomings
of this study included open label bias. Currently, AZA/6-MP use is
recommended for postoperative prophylaxis in those patients who
are deemed to have high risk of recurrence or in those for whom
recurrence would have substantially harmful effects.
The use of antibiotics has been long debated in the prevention of
recurrence in the postoperative Crohn’s patient. There are no large
controlled trials that show clear effectiveness of the use of antibiotics
in postoperative Crohn’s patients beyond 1 year. One large trial on
metronidazole has shown a 4% clinical recurrence rate in the treat-
ment group versus 25% in placebo group at 1 year, 52% endoscopic
recurrence versus 75% in the placebo group at 3 months, and no
significant difference in clinical recurrence rate at 2 or 3 years.(94)
Another trial of Ornidazole showed an 8% clinical recurrence ­versus
38% with placebo at 1 year, but no significant difference at 2 or
3 years.(95) These agents may be considered for prevention of post-
operative recurrence but their utility beyond 1 year and potential for
considerable side effects in long- term use limit their clinical utility.
The last group that has shown possible effectiveness in post-
operative Crohn’s patients is the biologic response modifiers, but
these have yet to be adequately studied in this setting. A nonran-
domized, open-label, single-center experience involving 7 patients
who received Infliximab with methotrexate has demonstrated no
endoscopic or clinical recurrence at 2 years.(96) Adalimumab has
not been studied in this respect. Multicenter, randomized, con-
trolled studies are needed to further define the role of Anti-TNF
agents in postoperative recurrence of CD.
Treatments that have been shown to be ineffective in the pre-
vention of postoperative recurrence are systemic corticosteroids,
budesonide, probiotics, and interleukin-10.
Table 32.2  Indications for Surgery in Crohn’s Disease.
Failure of medical management Complications of Medical Management
Obstruction Inflammatory mass
Sepsis Free perforation/sepsis
Fistulae/abscess Hemorrhage/anemia
Dysplasia/carcinoma
Growth retardation
Nutritional Therapy
There is no proof that any food or substance is responsible for
causing the initial episode or recurrence of CD.(97) The biggest
challenge in patients with CD is restoration and maintenance of
weight, particularly in the presence of sepsis and/or obstruction.
Surgical Treatment
Indication
Table 32.2 summarizes the indications for surgical treatment of
a CD.(98)
Surgical management of CD has changed considerably dur-
ing the past as a result of numerous advances in medical therapy.
Regardless of these developments, patients with CD will undergo
a surgical procedure in up to 80% of the cases.(99) Patients often
come to the surgeons office with worsening symptoms, a compli-
cation, or as steroid-dependent.
•• Failure of medical therapy or complications of medical therapy
Surgery may be indicated if the medication cannot control
inflammation and its symptoms, or if the medication causes
significant intolerable or inducible side effects. Symptoms that
can be an indication for surgery includes diarrhea, anemia, pain,
weight loss, sepsis, and obstruction. Most patients are either ste-
roid-dependent or steroid-resistent (100) by the time of surgical
consultation. In addition, pancreatitis from GRMP, osteoporosis
from steroids, and leucopenia from infliximab are all potential
reasons for surgery to be recommended.
•• Acute and chronic disease complications
Although rates are decreasing, up to 20% of procedures are still
performed to treat acute complications.(101) Among the indica-
tions is toxic megacolon, obstruction, hemorrhage, perforation
with or without peritonitis, and abscess.
Perforation
According to the Viena classification, intestinal perforation is a
penetrating disease. The penetrating disease behavior is defined
by the occurrence of intraabdominal or perianal fistulas, inflam-
matory masses or abscesses, or perianal ulcers at any time in the
course of disease. Neither postoperative intraabdominal compli-
cations nor perianal skintags constitute evidence of penetrating
disease.(102) Penetration of the bowel wall often presents not as
an acute abdomen but as an indolent process related to fistuliza-
tion. Diffuse peritonitis due to perforation is a rare but recognized
complication of Crohn’s disease. Perianal disease manifestations
include perianal pain and drainage from large skin tags, anal

 improved outcomes in colon and rectal surgery
fissures, perirectal abscesses, and anorectal fistulae. Emergency
surgical therapy for a perforation behavior includes: free perfora-
tion, intraabdominal abscess or masses with sepsis, and intestinal
obstruction.
In Crohn’s disease, free perforation is a rare but severe com-
plication occurring in 1% to 3% of cases.(103) Free perforation
in the absence of a megacolon should alert for the suspicion of
CD. It can occur anywhere in the gastro-intestinal tract, from
the stomach through the colon; a distal stricture might exist and
make the perforation possible. Other etiologies for perforation
include the presence of malignancy, and of endoscopic proce-
dures. Frequently, the perforations are sealed. Gastro-duodenum
perforations are best treated by debridement and primary suture.
For jejuno-ileal perforations, resection and primary anastomosis
are best if feasible and conditions favorable. Factors associated
with postoperative complications include abscess, enterocutane-
ous fistulae, steroid-dependence, and albumin <2 g/L. If one or
more of the risk factors is present, a diversion is suggested.(104)
Colonic perforation in Crohn’s colitis, often seen in the setting
of toxic colitis, usually requires subtotal colectomy with rectal
preservation and end ileostomy. If the etiology is not toxic coli-
tis, a segmental resection and fecal diversion might be an option.
(105) A postcolonoscopic perforation must be managed regard-
ing the absence or presence of CD at the site of perforation and
elsewhere in the colon. If the perforation occurs in a diseased seg-
ment, the segment along with the perforation is reseated to allow
reconstruction with or without fecal diversion depending upon
the factors mentioned above.(104) If perforation occurs during
a follow-up for surveillance, resection or primary repair may be
feasible.
Abscess
Between 10–30% of patients with CD may present with intraab-
dominal abscesses. Abscesses can develop because of a local
sealed perforation, in association with a fistula, or postoperatively
because of intraabdominal contamination or anastomotic leakage.
Yamaguchi et al. found that almost 50% of the abscess were due
to an anastomosis (surgical anastomosis and peristomal) (106),
Preoperative percutaneous transcutaneous drainage and admin-
istration of antibiotics is preferable if possible. Otherwise, surgery
with resection of the disease site is necessary.
Perianal CD
Perianal Crohn’s Disease (PCD) occurs in 5–25% of CD patients
and can be associated with active disease in the proximal gas-
trointestinal tract or colon in about one-third to one-half of
patients. It is often associated with colonic and rectal inflamma-
tion. Perianal manifestations include cutaneous (tag and ulcer-
ations), anal canal lesions ­(fissures, ulcers, stenosis), and septic
(abscess, fistulas) (Figure 32.3).
The purpose of surgical treatment in PCD is to improve quality
of life and offer effective palliation, and therefore is reserved for
patients who develop perianal complications of the disease or are
unresponsive to aggressive medical therapy. The surgical treat-
ment of PCD can be divided into two main categories: urgent and
emergent treatment (to control perineal sepsis); and elective (to
treat sequelae such as perianal fistulas and anal strictures).(107)

Figure 32.3  Typical perianal Crohn’s Disease with associated fistulas and scars from
prior surgery (Picture taken by Badma Bashankaev, M.D., Cleveland Clinic Florida).
Prompt and definitive surgical incision and drainage is
required in all patients suspected of having acute abscesses.
These lesions will not spontaneously resolve and delays can lead
to uncontrolled sepsis with necrotizing infections, sphincter
impairment and anal stenosis. If a fistula is identified a noncut-
ting Seton (nonabsorbable suture) is inserted through the fistula
tract to ensure continuous drainage, leading to the resolution
of the perianal sepsis. Primary fistulotomy should be avoided.
Premature removal of the seton increases the incidence of recur-
rent perianal sepsis. If the abscess is superficial, the procedure
may be completed under anesthesia. It is important to mini-
mize trauma or additional injuries so that the incision must be
as close as possible to the anal verge. Excision of skin edge or
latex mushroom catheter placement can be utilized to obtain
adequate drainage.
Fistulotomy can be safely performed on simple (low) fistulas
which do not include any significant portion of the external anal
sphincter, in patients without active proctitis, well-controlled
proximal luminal disease and adequate continence.
Endorectal advancement flap is a surgical technique that
repairs perineal fistulas with the preservation of anal sphincter
function. The principal idea of this procedure is to surgically
close the internal opening of the fistula using a flap made of rec-
tal wall, allowing the healing of the fistula from inside out. The
reported success rate of endorectal advancement flap in patients
with Crohn’s perianal fistulas ranges from 25 to 100% in different
series, with an average success of approximately 50–60%.(108)
Elective surgery for PCD may include procedures for nonfistulous
complications such as dilation of anorectal strictures. Most com-
monly, however, patients with PCD will require surgery to repair
perianal and rectovaginal fistulas not responsive to medical ther-
apy, which may include fistulotomy, fibrin glue injection, transanal
endorectal flap advancement, and gracilis muscle interposition.
Fibrin Glue is a technically simple procedure for the treatment of
perianal fistulas and it is associated with low risk and early return
to normal activity. Fibrin glue is a blood by-product that uses the
activation of thrombin to form a fibrinclot, mechanically sealing the
 surgery for crohn's disease
fistula tract. Series using fibrin glue for perianal fistulas of mixed eti-
ologies have yielded success rates of approximately 30–70%.(109)
Gracilis transposition can be an option in patients after proc-
tocolectomy or others types of CD related fistulas in whom other
options may have failed before proctocolectomy.(110) Occasionally,
temporary diverting colostomy or ileostomy is required to control
symptoms, and in extremely severe cases resistant to both medi-
cal and surgical therapy, proctectomy or proctocolectomy may be
required.
The PCD score developed by Wexner et al. can be very helpful
in selecting therapeutic alternatives and in prognostication.(111)
The PCD Activity Index analyzes 6 features in PCD: abscess,
­fistula, fissure and/or ulcer, stenosis, and incontinence.
Obstruction
Gastrointestinal obstruction usually results from acute active
inflammation superimposed on a stenotic segment. Mass effect
from an adjacent phlegmon or abscess is not an uncommon sce-
nario. Malignancy must be excluded in CD strictures involving the
colon. Yamazaki et al. noted a 6.8% malignancy rate in 132 patients
with colonic Crohn’s disease complicated by stricture.(112)
Although traditionally by-pass without vagotomy was consid-
ered the best option for gastro-duodenal obstruction stricture-
plasty has become acceptable.(113)
Complete or near-complete intestinal obstruction unrespon-
sive to medical therapy requires surgical correction. Depending on
location, this treatment involves either resection or strictureplasty.
(114) If malignancy is present or suspected, a resection is obviously
indicated following standard oncologic principles.
Bleeding
Whereas mild gastrointestinal bleeding is a common manifes-
tation of inflammatory bowel disease, severe bleeding is a rare
phenomenon. CD has been reported to be an established source
of gastrointestinal hemorrhage, in 0.9% to 2.5% of patients with
this disease.(115) CD bleeding is often from a localized source.
This is caused by erosion of a blood vessel within multiple deep
ulcerations that extend into bowel wall. The small bowel is the
site of bleeding in 65% of cases, whereas the colon was involved
in 12%, and in 23% the site could not be identified.
It is important to exclude a gastroduodenal source before bowel
resection. Angiography is often performed to identify and possibly
treat the bleeding site by selective or superselective angiographic
infusion of vasopressin.(116) Embolization should be the initial
treatment of choice in CD in an attempt to avoid surgical resec-
tion. Cirocco et al. (115) reported that surgical resection offered
excellent palliation, with low mortality (3%) and a low rebleed-
ing rate (3.5%). Surgery is indicated in those patients who fail to
show improvement of bleeding after 4 to 6 units of blood, have
recurrent hemorrhage, or have other indications to resect diseased
bowel.(114) A bowel preparation is contraindicated, and the aim
is to remove the patient from life threatening hemorrhage.
Toxic Megacolon
Toxic megacolon is a potentially lethal complication which has
gradually decreased in incidence because of earlier recognition
and intensive management of severe colitis. A possible mechanism
is that mucosal inflammation sequentially leads to the release of
inflammatory mediators and bacterial products, increased nitric
oxide syntheses, generation of excessive nitric oxide, and colonic
dilation. Toxic megacolon affects all ages and both genders. Signs
and symptoms of acute colitis that are frequently resistant to
therapy are often present for at least 1 week before the onset of
acute dilatation. Severe bloody diarrhea is the most common pre-
senting symptom, while improvement of diarrhea usually occurs
because of the onset of megacolon. Other futures include malaise
and abdominal pain and distention.(117) Up to 47% of patients
require surgery due to failure in medical therapy. Factors affecting
mortality are age (>40), gender (female), and presence of colonic
perforation. The overall mortality rate is 16%.(118)
Although the frequencies of performed emergency surgery
have decreased, improved medical treatment has lead to higher
rates of elective operations. Siassi et al. published a 33 years expe-
rience, and prospectively found that the rates of elective sur-
gery rose from 69.5% (1970 to 1980) to 81.4% (1981–1991) and
80.9% (1992–2002) (101). This change might reflect the changes
in disease location. Combined large/small bowel resections such
as ileocecal resections increased from 27.5% (1970–1980) to
41.9% (1981–1991) and 67.1% (1992–2002) (101), as CD limited
to this region that is unresponsive to medical management is best
treated by ileocolectomy and anastomosis (119). Similar results
were found by Reissman et al. with a 59% rate of ileocolectomy
and anastomosis.(120)
Specific considerations in surgical techniques
for CD patient
The philosophy behind surgical intervention in Crohn’s disease
rests on the fact that Crohn’s disease is currently incurable and
potentially involves the entire intestine, and that surgery relieve
only the complications.
Strictureplasty
Over one-third of patients with CD will develop an intestinal
stricture and the great majority of these will require at least
one surgical procedure. The initial view was that strictureplasty
should only be undertaken for recurrent disease and in patients
who have had previous multiple resections. The potential benefits
of any surgery include symptom relief, improved nutritional sta-
tus, and reduced dependence on medication. The most obvious
advantage of strictureplasty over resection is that the development
of short bowel syndrome can be avoided. All jejunoileal strictures
and most duodenal strictures are able to strictureplasty.(121) The
procedure can also be undertaken in patients with symptomatic
anastomotic strictures. Table 32.3 shows current indications for
strictureplasty and contraindications.(122)
There are two main types of operation used. The Heineke–
Mikulicz procedure is used for strictures of up to 10 cm in length.
For strictures up to 25 cm long, the Finney procedure (a side to side
amastomosis) is done. Most of the others methods of strictureplasty
are generally derivations of one of the above methods, or a combi-
nation of both. In 2000, Tichansky et al. published a meta-analysis
that showed that Heineke-Mikulicz technique is most often used
for Crohn’s strictureplasty. However, the outcome revealed that the
Finney strictureplasty may reduce the reoperation rate.(123)

 improved outcomes in colon and rectal surgery

Table 32.3  Current indication for strictureplasty and (A)

contraindications.
Indication

Previous extensive (>100 cm) resections of small bowel

Short bowel syndrome
Duodenal strictures
Rapid recurrence of disease with obstruction
Strictures at previous anastomotic sites, particularly ileorectal or ileocolic
Fibrotic strictures within diffuse involvement of the small bowel
Small bowel stricture (active or nonactive disease)

Contra indications

Perforation of the small bowel, with or without peritonitis

Serum albumin <2.0 g dl
Fistula or phlegmonous inflammation at intended strictureplasty site
Likelihood of tension on closure of strictureplasty
Intended strictureplasty site next to segment requiring resection
Presence of malignancy (B)

Stricture biopsy
The morbidity rate ranges from 10.2–13%, with fistula forma-
tion as the most frequent complication.(123) Strictureplasty has
been found to be a safe and efficacious procedure for small bowel
Crohn’s disease.(124)

Resection
The most common surgery is ileocolic resection (Figure 32.4a,
32.4b, 32.4c), usually undertaken for medical therapy failure, fistula,
obstruction, mass, perforation, or malignancy. The development of
malignancy increased to 4 to 20 times of the average population.
As previously mentioned, strictureplasty site should be evaluated
for intraoperative biopsy and resection, the only procedure which
should be considered in the setting of carcinoma. Over the past two
decades, laparoscopic resection has demonstrated clear superiority
over laparotomy relative to postoperative recovery, cost, morbidity, (C)
cosmesis, and long-term bowel obstruction.(125–128)
Regardless of the technique of resection performed, the anas-
tomosis should be between two and of grossly normal bowel.
Histologic disease free margins and further resection add no ben-
efit and may predispose to the onset of short bowel syndrome.
Bemelman et al. (129) showed that medical therapy was able
to prevent surgery in one third of the cases of CD in the terminal
ileum. Patients who probably will fail medical therapy are those
with stenosis, extraintestinal manifestation, or known history of CD
for more than 5 years. Some patients might undergo resection if the
obstruction is contra-indicated to have strictureplasty. Many studies
compare the outcomes between medical therapy and conventional
laparoscopic procedure. A meta-analysis done in 2007 showed
14 studies with 881 patients. The operative time for laparoscopic
­surgery was longer, but morbidity was lower.(130)
The Surgical treatment for large bowel Crohn’s disease has
included total proctocolectomy, segmental colectomy or colec- Figure 32.4  (A)Terminal ileal strictures are the most common cause for surgery
tomy with ileorectal anastomosis (IRA), depending on severity and (Picture taken by Wang Hao, M.D., Cleveland Clinic Florida). (B) The best
surgical option for stricturing terminal ileal disease is often an ileocolic resection
disease distribution. Conventional proctocolectomy is reserved (Picture taken by Wang Hao, M.D., Cleveland Clinic Florida). (C) The length
for those patients with anorectal involvement, but in the 50% of the narrowing in the small bowel varies. (Picture taken by Wang Hao, M.D.,
of patients with large bowel Crohn’s disease with rectal sparing, Cleveland Clinic Florida)


 surgery for crohn's disease

(A) (B)

(C) (D)

Figure 32.5  (A) After an ileocolic resection, the recurrence is most commoly at the anastomotic site (arrow) (Picture taken by Jorge Canedo, M.D., Cleveland Clinic
Florida). (B) A 15 cm stricture; also note the creeping fat (Picture taken by Jorge Canedo, M.D., Cleveland Clinic Florida). (C) Small bowel resection and anastomosis.
(Picture taken by Jorge Canedo, M.D., Cleveland Clinic Florida). (D) Note the thick fibrotic stricture (Picture taken by Jorge Canedo, M.D., Cleveland Clinic Florida)

segmental resection or colectomy with an ileorectal anastomosis has
been used. A meta-analysis done in 2005 comparing segmental ver-
sus subtotal ⁄ total colectomy concluded that both procedures were
equally effective as treatment options for colonic Crohn’s disease,
however, patients in the SC group exhibited recurrence earlier than
those in the IRA group.(131) The choice of operation is dependent
on the extent of colonic disease. Better outcomes are expected for
IRA in patients with two or more colonic segments involved.
A meta-analysis done in 2007 compared the end-to-end anas-
tomisis to other configurations (132) and found that end-to-end
anastomosis after resection for Crohn’s disease may be associated
with increased anastomotic leak rates. Side-to-side anastomosis
may lead to fewer anastomotic leaks and overall postoperative com-
plications, a shorter hospital stay, and a perianastomotic recurrence
rate comparable to end-to-end anastomosis. Further randomized,
controlled trials should be performed for confirmation
Resection is contra-indicated in duodenum stricture, due the
high risk of the procedure. In order to avoid short small bowel
syndrome, the resection should include macroscopic intestinal
disease. It is known that activity of CD necessitating intestinal
resection diminishes over time, especially from more than 20 years
after the first resection.(133)
Bypass
Bypass surgery enjoyed popularity many decades ago, at the begin-
ning of CD surgery, when complication rates for resection were
high. However, it fell out of use due to high rates of recurrence,
great metabolic changes, higher risk of malignancy, and higher
rates of postoperative complications.(104)
Bypass surgery is currently undertaken for duodenal stricture,
although fecal diversion may have a long dysfunctional segment.
Diversion without resection may be indicated in very selective
situations, like severe perianal disease.(134)
Postoperative recurrence after surgery
Rates for recurrence after resection are up to 73% after 1 year,
although only 20% of patients have symptoms. After 3 years,
recurrence has been noted in 85% of patients, with symptoms
present in only 34%. The site of recurrence is usually the anasto-
mosis site.(135)


 improved outcomes in colon and rectal surgery
Reoperation for recurrence rates after strictureplasty is between  
24–26% after 5 years. Medical therapy may have a great value in
lowering rates of recurrence. Smoking significantly increases the
risk of recurrence after surgery for CD, especially in women, and
it is dose-dependent. Another feature that influences recurrence
after surgery is a short duration of disease before surgery.  
The site of the disease also affects recurrence rates, as small bowel
and ileocolic disease have higher rates of recurrence (Figure 32.5a,
32.5b, 32.5c, 32.5d). Perforation is associated with a higher rate  
of recurrence in patients who have had a colonic resection.(136)
Gender, family history of CD, blood transfusion, length of resection,
presence of granuloma in the specimen, and postoperative compli-  
cations do not correlate with recurrence.
Quality of life after surgery:  
Patients who undergo surgical treatment for CD experience improve-
ment in Health-related Quality of Life (HRQL) up to 1 year after
surgery. Most of the studies focus on assessment of quality of life for  
ileocolic resection, the most common procedure. Controversies exist
as to whether there is actually improvement or not in a long term fol-
low-up for these patients. Thaler et al. (137) concluded that HRQL  
actually reduces in patients with CD in a long-term follow-up, no
matter whether the surgery was open or laparoscopic compared to a
normal control population. And recurrence was the most important
factor adversely affecting quality of life.  
Casellas et al. (138) analyzed the impact of previous surgery
for complicated or refractory CD on HRQOL. The results indi-
cated that patients with active CD have a serious impairment in  
HRQOL and patients with a history of previous surgical bowel
resection are not different from patients who have never had
­surgery, as long as those patients remain in clinical remission.
 
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33 Ostomies
Vance Y Sohn and Scott R Steele
Challenging Case
A 55-year-old morbidly obese male undergoes a low ante-
rior resection with concomitant defunctioning loop ileostomy
for a T2 rectal cancer. Six weeks postoperatively, he presents to
the clinic with an obvious parastomal hernia that is easily reduc-
ible. He complains of worsening pain, difficulty with application of
his ostomy appliances, and symptoms of intermittent obstruction.
Case Management
In this patient, the optimal management includes reversal of the
ostomy after ensuring that the distal anastomosis has healed.
This is usually confirmed by a contrast study, often a gastrograf-
fin enema or CT scan with rectal contrast. An ostomy reversal
ameliorates and addresses all of the symptoms including the her-
nia, obstruction, and pain. After reversal, the skin of the ostomy
can be primarily closed, however extreme vigilance of the wound
is necessary secondary to an increased rate of local wound infec-
tion. Depending on the size of the fascial defect and correspond-
ing hernia, additional mesh may be needed for hernia repair.
Due to increased risk of infection of most prosthetics, biologic
materials should be considered as a first option. For patients who
are not candidates for ostomy reversal, various options are avail-
able and include both open and laparoscopic approaches. These
options include primary fascial repair, repair with biologic or
prosthetic mesh, and stoma relocation. The approach and the
method of repair is dependant on the surgeon’s preference and
experience. Certainly, observation for minimally symptomatic
parastomal hernias is the preferred option until stomal take-
down is possible.
Introduction
Intestinal stomas, either temporary or permanent, are the surgi-
cal exteriorization of either small or large bowel to the anterior
abdominal wall. An ostomy may be placed temporarily, often
when its primary purpose is to divert the fecal stream away from
an area of concern such as a high-risk anastomosis in a field of
prior radiation treatment, following a coloanal repair, or concern
for leak after a stapled end-to-end anastomosis. Once the distal
anastomosis has adequately healed, gastrointestinal continuity
can be reestablished when the ostomy is reversed. A permanent
stoma is created following an oncologic resection for rectal cancer
that includes removal of the anorectum and associated sphinc-
ter complex. In this instance, a descending colostomy would be
required to avoid perineal soiling with a coloanal anastomosis
in the absence of the sphincters. While there are various types
of ostomies described for a broad spectrum of disease processes
such as the neo-bladder construction with an ileal conduit, this
chapter will focus solely on outcomes for ostomies created with
the small or large bowel for colon and rectal diseases.
Psychological Impact of Living with a Stoma
Regardless of the type of ostomy, living with a stoma exacts
a ­tremendous psychological burden on patients and requires
adjustments to activities of daily living. In addition to the physical
adjustment of caring for an ostomy, the possibility of participating
in simple activities, such as dining out, often becomes disrupted
in the patient’s mind. Unfortunately, this is one of the major fears
of patients whether or not it is founded in reality. Yet, it is also
one that is often not discussed in detail before the operation, nor
able to be appropriately counseled and educated when stomas are
required in the emergent setting. In 1952, Sutherland et al., (1)
published the first report on the important psychological needs
of patients living with stomas. Since then, multiple studies have
reported the negative impact ostomies have on overall quality of
life.(2–6) It is not surprising that the presence of a stoma is asso-
ciated with decreased quality of life measurements in the imme-
diate and early postoperative setting.(7) Unfortunately, it often
appears that while overall quality of life, return to prior activity
levels, pain and fatigue all improve with time following surgery,
self-impression views such as body image and sexual function do
not seem to change with time.(8) Thus, despite evidence to the
contrary that a “return to normalcy” is achievable, many patients
can never get past the idea of having to live with a stoma. More
recently, Krouse and colleagues (9) evaluated the quality of life of
239 male patients from multiple Veterans Affairs (VA) hospitals
living with stomas. Their report, which was a case-control sur-
vey study, used various previously-validated quality of life indices
to compare patients with ostomies versus 272 patients who had
undergone similar operations, but not requiring stoma forma-
tion. Their study highlighted multiple important psychosocial
facts about patients living with ostomies. There was increased
self-reported postoperative depression and suicidal ideations
among respondents living with ostomies. Such feelings may have
been compounded by issues of coping and social acceptance, as
their fears related mostly to both others’ perceptions of patients
with stomas and their own personal fears of having stoma-related
accidents. As these fears became more frequent, they clinically
translated into decreased social interactions and eventual isola-
tion. The authors’ recommendation of encouraging social net-
working among ostomates to clarify issues and limit the trial and
error approach that many patients with ostomies undergo, is a
valid conclusion which should be supported by all physicians.
This is not to say that all patients do poorly or are mentally
burdened by living with a permanent stoma. In a large meta-
analysis of 1,443 rectal cancer patients from 11 studies, there was
no difference in general quality of life scores at 2 years following
surgery between those patients undergoing an abdominoperineal
resection from those undergoing a low anterior resection with in-
continuity reconstruction.(10) These contradictory findings may

 improved outcomes in colon and rectal surgery
Figure 33.1  Stomal placement. The site is selected to bring the stoma through the rectus abdominis muscle.
in part depend on the questionnaire given, the ­disease process
for which the stoma was created, and the preoperative functional
level of the patient. For example, factors such as patient age, (11)
decreased preoperative continence, (12) and severe active peria-
nal Crohn’s fistulizing disease (13) have all been shown to have
an improved quality of life following stoma formation. Thus,
while it would be inaccurate to state that placement of stoma
will end up with a lowered quality of life and significant psycho-
logical problems, it also is naïve to think that stoma creation will
not have a significant impact on a patient’s subsequent immedi-
ate and long-term recovery. It is well-established, that in addi-
tion to networking, a close relationship with a readily available
and experienced enterostomal therapist is an invaluable aspect
of the multidisciplinary approach. These expert therapists can
significantly alleviate initial fears and anxieties that often plague
patients living with a stoma. Furthermore, in our experience,
preoperative counseling about expectations, education regard-
ing the indication for the ostomy, and even “practicing” the
wearing of an appliance before surgery all aid in lessening the
psychological impact on the patient and promotes adaptation to
their ostomy.
Stoma Site Marking
In 2007, the American Society of Colon and Rectal Surgeons
(ASCRS), in collaboration with the Wound, Ostomy, and
Continence Nurses (WOCN) Society developed a position state-
ment on the value of preoperative stoma marking for patients
undergoing ostomy surgery.(14) Their ultimate goal was to
decrease stomal complications and improve quality of life for
patients. In addition to precise step-by-step instructions on
the proper siting of stomas, the statement recommended that all
patients scheduled for ostomy surgery undergo preoperative stoma
marking by an experienced, trained clinician. This evaluation

includes examining the patient in the lying, sitting, and stand-
ing positions, and accounting for patient factors such as previous
incisions, waist and belt lines, abdominal habitus, and hernias, to
determine the optimal stoma position that is crucial to decreasing
the incidence of stomal complications. One of the more impor-
tant aspects of this preoperative marking evaluation is the iden-
tification of the rectus abdominus muscle, as placement of the
stoma through the rectus muscle may prevent peristomal her-
niation or prolapse (Figure 33.1).(15) Furthermore, preoperative
siting allows for patient participation and education regarding
stoma care and the use of ostomy appliances. While this posi-
tion statement has yet to be clinically validated, previous reports
have demonstrated the importance of preoperative stomal siting.
In a retrospective analysis, Bass and associates (16) reviewed a
single institution’s stoma complication rate in 593 patients over
an 18-year period. The study compared 292 patients who under-
went preoperative marking by an enterostomal therapist to the
remaining 301 remaining patients who did not undergo pre-
operative marking. The endpoints of their study, early and late
complications, were favorable for the patients who underwent
preoperative marking with a 23% versus 43% early complication
rate (p < 0.03) and 9% versus 31% late complication rate (p =
NS). This study, and the joint statement by ASCRS and WOCN,
highlights the importance of proper preoperative stoma marking
for decreasing complication rates.
STOMAL TYPES
End ostomies
End ostomies, either permanent or temporary, are most often
placed in the left lower quadrant of the abdominal wall using
the left colon or in the right lower quadrant when utilizing the
ileum. The indication for stoma creation is important, as this
 ostomies
often dictates whether gastrointestinal continuity can be reestab-
lished. For instance, in patients undergoing an abdominoperineal
resection (APR) for rectal cancer, a permanent end colostomy is
the only option as the anorectum and surrounding musculature
are removed. Similarly, patients who undergo a proctocolec-
tomy, usually for inflammatory bowel disease (IBD) or Familial
Adenomatous Polyposis (FAP), are candidates for an end ileos-
tomy. For patients wanting more fecal control, a continent ileos-
tomy may be offered.
Ostomies remain permanent when the altered anatomy pro-
hibits reestablishment of gastrointestinal continuity, the risks of
undergoing another surgery are prohibitive due to comorbidi-
ties, or the functional results of a reanastomosis would adversely
impact quality of life. This latter point is common with reanasto-
mosis of the ileum with the mid- or distal rectum or anus (since
the large absorptive capacity of the colon or the storage ability
of the compliant rectum is lost), or when the patient has poor
sphincter function. Barring the aforementioned contraindica-
tions, most ostomies can be reversed and thus, are temporary.
A common temporary end ostomy performed routinely by sur-
geons is the Hartmann’s procedure. Initially described by Henri
Hartmann in 1921 for rectal cancer, this versatile procedure is
indicated for a variety of benign and malignant scenarios where
primary resection of colon and reanastomosis is unsafe or not
possible. As discussed later, reversal is associated with complica-
tions and the benefits of stoma reversal must be balanced with
the potential risks to the surgery. Ideal candidates for reversal are
young, healthy patients with preserved sphincter mechanisms.
The optimal time for this colostomy reversal has been controver-
sial. Some have found that reversals after 4 months were associ-
ated with a higher complication rate; after this time, the rectal
stump was less readily accessible and therefore, led to increased
complications.(17) Others have found no outcome differences
between early or late reversals and considered the timing an insig-
nificant factor.(18)
The benefits of an end ileostomy with immediate maturation,
initially described by Brooke in 1952, have decreased the incidence
of stenosis, dysfunction, retraction, and serositis associated with
an ileostomy.(19, 20) Since that time, this has become the standard
technique for ileostomy and most colostomy formations. Despite
increasing experience with restorative continuity procedures
such as the ileal pouch-anal anastomosis (IPAA), an end ileos-
tomy remains an important part of the surgical armamentarium.
For instance, in patients with toxic megacolon undergoing total
abdominal colectomy, when the principles of “damage control”
surgery are paramount, an end ileostomy following abdominal
colectomy remains the procedure of choice. Additionally, an end
ileostomy would be preferred over an IPAA or an ileal-rectal
anastomosis (IRA) for patients with poor anal sphincter mecha-
nisms where continence is questionable. Alternatively, in young
healthy patients with inflammatory bowel disease or FAP requir-
ing proctocolectomy, IPAA should be considered, or IRA when
the rectum is spared. Purported benefits of an IPAA compared
to the end ileostomy revolve around the maintenance of conti-
nuity and thus, a more psychologically favorable outcome for
the patient. Pemberton et al. (21) evaluated this relationship by
comparing quality of life for 298 patients with IPAAs and 406
patients with end-ileostomies. Greater than 93% of patients in
both groups were satisfied with their surgeries, although 39% in
the end ileostomy group would have preferred an IPAA. After anal-
ysis, the authors concluded that patients who underwent an IPAA
experienced significant advantages in performing daily activities
with resultant improved quality of life. While the benefits of IPAA
are beyond the scope of this chapter, this procedure should be
considered as a viable alternative for patients considered for end
ileostomy. It should be noted, however, that a significant portion
of IPAA patients require a temporary stoma, with an additional
~10% developing pouch failure that requires either pouch exci-
sion with permanent stoma or permanent pouch diversion.(22)
Thus even in this select cohort, education regarding stoma care
and outcome is of utmost importance.
Continent ileostomy
Continent ileostomy, first reported by Nils Kock in 1969, is a less
frequently performed procedure due to the technical expertise
required, the significant complication rate associated with its
nipple-valve mechanism, and the preference for creation of ileoa-
nal pouches.(20) Occasionally, the continent ileostomy remains a
useful option for patients undergoing proctocolectomy for FAP or
IBD, or in those patients who develop IPAA failure. In 2006, Nessar
et al. (23) reported the long-term outcomes of patients undergo-
ing continent ileostomy at the Cleveland Clinic Foundation. Their
study population included 181 patients with continent ileostomies,
69 of whom previously had an end ileostomy, and 35 patients who
had an end ileostomy after excision of a continent ileostomy. With
a median follow-up of 11 years, 17% of patients had their conti-
nent ileostomy excised; there was only a 7 month complication-
free interval, and a 14 month revision-free interval. Long-term
complications were common, with 30% experiencing valve slip-
page, 26% developing pouchitis, 25% with fistula formation, and
15% with parastomal herniation. Other complications included
valve prolapse, difficult intubation, stoma stricture, and pouch
bleeding. Importantly, even in centers with significant experience,
the complication profile remains considerable. Similarly, in a study
by Kohler et al. (24) comparing outcomes in patients between end
ileostomy, continent ileostomy, and ileal pouch-anal anastomosis
(IPAA), those patients with IPAA had fewer restrictions in sport
and sexual activities when compared to patients with continent
ileostomy. Patients with end ileostomy fared the best with regards
to the travel capabilities when compared to the other two. In our
practice, continent ileostomies are seldom performed. Due to the
aforementioned complication profile, patients are counseled for
either an IPAA, IRA, or an end ileostomy. Yet, despite our reluc-
tance to perform this procedure, select institutions well-versed in
this procedure report excellent outcomes and overall high patient
satisfaction.(25–27)
Loop End Stomas
A loop end stoma is a variation in which a section of the bowel
several inches proximal to the divided end of the bowel is
brought through the abdominal opening (Figure 33.2). The
loop can be supported with a rod and the bowel is opened
and matured in a fashion similar to a loop stoma. This type of
stoma is helpful in challenging situations such as thick shortened

 improved outcomes in colon and rectal surgery
Figure 33.2  Z-Plasty repair for stenosis. A, incisions in skin and bowel. B, completed repair.
mesentery, tenuous blood supply, or friable bowel. Its advantage
is that no blood vessels are divided and with a rod, the tension
is on the back wall of the bowel rather than the mucocutane-
ous anastomosis. This type of stoma is slightly more difficult to
pouch as it is slightly oval and may not have the protrusion of a
well-formed end stoma.
Diverting or loop ostomies
The ultimate purpose when creating a diverting stoma is to pre-
vent the fecal stream from reaching a distal segment of distal
small bowel or large intestine for the purpose of either treat-
ing or preventing a leak. To that end, either a loop colostomy
or ileostomy will suffice. However, an ileostomy is often pre-
ferred due to its perceived ease of closure. Proponents of a loop
colostomy cite the lower risk of high stomal output leading to
fluid and electrolyte abnormalities occasionally seen with a loop
ileostomy. The common indications for concomitant proximal
fecal diversion include protection of distal at-risk anastomo-
sis, especially low-lying colo-anal anastomosis and ileal pouch
anal-anastomosis (IPAA), complicated diverticulitis, treatment
of anastomotic leaks and pelvic sepsis, large bowel obstruction,
trauma, extensive perianal Crohn’s disease, and less commonly,
fecal incontinence.
The indication for a concomitant proximal fecal diversion for
low lying anastomosis, most commonly performed for rectal cancer,
has been intensely studied. Wong and Eu (28) reported the results
from a prospective, comparative study of 1,078 patients undergo-
ing elective low or ultra-low (defined as colonic anastomosis to the
anal canal) anterior resections from 1994 to 2004. In the diverted
group, 28% developed a clinically significant leak while of the non-
diverted group, 13% had a clinically significant leak (p = 0.86). 95%
of these leaks required a salvage operation, and analysis revealed
no statistical difference between anastomotic leak complications
between patients undergoing and not undergoing fecal diversion.
These authors concluded that a defunctioning ileostomy did not
influence the complication rate of a rectal anastomosis, rather it
minimized the clinical sequela of leaks in high risk patients. They
recommended that proximal diversion should be used on a selected
basis. In another prospective study from Sweden, the Rectal Cancer

Trial On Defunctioning Stoma (RECTODES) randomized 234
patients undergoing low rectal (<15 cm from the anal verge) anas-
tomosis to fecal diversion versus no diversion.(29) Their primary
endpoint was to assess whether there was a difference in the rate
of symptomatic anastomotic leakage in patients between the two
arms of the study. While there was a disproportionate number
of patients (72%) not undergoing ­randomization due to various
factors including intraoperative concerns requiring diversion, the
total number of patients with and without diversion were simi-
lar (116 pts vs 118 pts). Patient characteristics were similar with
increased operative times for those undergoing stoma placement as
the only statistically significant difference between the two patient
cohorts. In their analysis, patients without a defunctioning stoma
had ­significantly more symptomatic leakages (28%) when com-
pared to those without proximal diversion (10%). The group not
undergoing diversion consequently constituted 75% of all urgent
reoperations. Of the 28 out of 33 patients without initial fecal
diversion who developed a leak, urgent reoperation was accom-
panied with either a loop ileostomy or permanent end colostomy.
Consequently, these investigators recommended routine defunc-
tioning loop stoma in low anterior resections for rectal cancer.
Based on these and other studies, it is now generally acknowledged
that a proximal defunctioning stoma does not abolish the risk of
leakage, but certainly mitigates the consequences. In our practice,
defunctioning stomas are almost always placed for any anastomo-
sis within 5 cm of the anal verge, although exceptions such as the
one stage IPAA occurs occasionally. Furthermore, patient factors
such as previous irradiation, intraoperative hemodynamic insta-
bility, poor nutrition, and chronic steroid use lead us to liberally
“protect” the distal anastomosis.
When deciding to perform a proximal fecal diversion or a
defunctioning stoma, the two traditional options include a trans-
verse loop colostomy or a loop ileostomy. These two options were
compared in a prospective randomized study by Williams et al.
for elective protection of distal anastomoses.(30) In their analysis,
nearly all complications were twice as common with transverse
colostomies than ileostomies and included infection at the time
of creation and at takedown, odor, leakage, and skin problems.
Additionally, multiple visits to the stoma therapist were needed
 ostomies
in 58% of colostomy patients versus 18% of ileostomy patients.
In another prospective randomized study by Edwards et al., there
was no difference in operating time required to construct either
stoma, and in fact, reversing the colostomy was easier due to the
larger fascial opening.(31) This larger defect however, resulted
in worse complications manifested as parastomal hernias, pro-
lapse, fecal fistula, and in the follow-up period, incisional hernias.
These increased rates of complications with loop colostomy and
increased rate of hernia formation at the ostomy closure site, and
has led to an almost universal preference of loop ileostomy for
diverting stoma.(31, 32) Should one choose to perform a loop
transverse colostomy, choosing a point in the colon adjacent to
the flexures may decrease the risk of prolapse to a small extent.
COMPLICATIONS WITH OSTOMIES
The incidence of stoma complications varies in surgical literature
from 10–70%, and can range from minor skin irritation to parasto-
mal herniation requiring operation.(33–35) The wide variance in
complication rates is due to the definition of complication and the
length of follow-up in the studies. Furthermore, there are a multi-
tude of factors that influence complication rates, including the type
and location of the ostomy, patient factors such as gender, BMI,
diagnosis, and urgency in which the procedure is performed. In a
study from Cook County Hospital, the incidence of stoma com-
plications was 34% in a review of 1,616 patients, with 28% hav-
ing an early complication (<30 days from time of surgery) and 7%
late complication (>30 days).(36) In a national audit, Cottam and
associates identified 1,329 (34%) patients out of a cohort of 3,970
stomal patients that developed early complications (<3 weeks from
times of surgery) defined as stoma retraction, necrosis, ischemia,
muco-cutaneous separation, and dehiscence.(37) Statistically sig-
nificant factors increasing postoperative complications were stoma
height (<20 mm for ileostomy and <7 mm for colostomy), female
gender, loop ileostomy, advanced BMI, younger age, malignant
diagnosis, and emergent procedures. Similarly, in a prospective
study of 97 patients, Arumugam et al. found elevated BMI, diabetes,
and emergency surgery as significant risk factors for the develop-
ment of stoma complications.(38) In yet another study evaluating
risk factors for stoma complications, Saghir and colleagues identi-
fied advanced age, advanced American Society of Anesthesiologists
(ASA) grade, and noncolorectal specialty-trained surgeons per-
forming the ostomy as risk factors for stoma complications.(39)
As evident in these studies, various patient and surgeon factors can
increase the risk of developing complications. Thus, it is impera-
tive for the surgeon caring for these patients to be well aware of
not only the things they can do to prevent these complications, but
also how do deal with any complications should they arise. In the
following section, the presentation and management of common
complications will be addressed.
Skin Complications
Skin conditions are common among patients living with stomas and
are more prevalent in patients with ileostomies than colostomies.
(5) Common causes include fungal or bacterial infections, irrita-
tion from the ostomy effluent, folliculitis, contact dermatitis from
the appliance, a manifestation of IBD such as pyoderma gangreno-
sum, or simple skin excoriation from frequent appliance changing.
To a certain degree, minor skin irritation is unavoidable. However,
preoperative stoma marking, precise ostomy creation, involvement
of an enterostomal therapist, and diligent postoperative care may
prevent some of the more severe complications. Proper location of
an ostomy diminishes leaking from the appliance and entails avoid-
ing previous incisions, scars, natural skin folds, and belt lines that
prevent circumferential adhesion of the appliance. Leaking around
the appliance and can lead to social embarrassment and dramatic
skin irritation. These problems can occasionally be mitigated by
careful appliance fitting which entails minimizing unprotected
skin and sealing leaks from the caustic effluent. Various commer-
cially produced barriers, powders, ointments, and creams are avail-
able especially for this purpose and should be applied with the help
of an enterostomal therapist. If skin excoriation, maceration, and
irritation persist despite these conservative measures, consider-
ation should be given for ostomy reversal, revision or repositioning
the ostomy, or if possible, converting a high output ileostomy to a
lower output colostomy.
Retraction
Stoma retraction occurs in up to 15% of patients and is most
often the result of a technical error from improper construction
and/or tension.(40–42) Postoperatively, complete retraction of
the stoma into the abdomen mandates immediate re-exploration
and re-creation of the ostomy. Fortunately, this potentially cata-
strophic complication is extremely rare. Partial stoma retraction
occurs more frequently and is more problematic for an ileostomy
than a colostomy. In ileostomies, retraction leads to difficulties
with appliance placement and subsequent skin irritation. In the
thicker viscous colostomy effluent, skin irritation is less of an issue
and can often be conservatively managed. In severe cases, opera-
tive stoma revision may be required. The principles of ­revision
include tension free ostomy and adequate eversion emphasizing
the Brooke method.
Ischemia and Stenosis
Ostomy necrosis, due to either arterial insufficiency or venous
engorgement, presents in the early postoperative period and is
first recognized by mucosal ischemia. Arterial insufficiency is a
complication of overaggressive mesenteric mobilization with
resultant lack of small vessel collateralization to the mucosa.
It can also be seen in patients with foreshortened or thickened
mesenteries, in obese patients with thick abdominal walls, or
after an inadequate fascial opening. Likewise, stoma necrosis
from venous engorgement as the etiology ultimately leads to the
same end result. Clinically, differentiating the etiology of necro-
sis is not important as management is the same regardless of the
cause. When both considering and managing stoma necrosis, it is
imperative to identify the proximal extent of ischemia. This can be
done by a simple bedside “test-tube test” in which a clear test tube
is inserted into the stoma and then trans-illuminated or direct
visualization is obtained via a pediatric anoscope or proctoscope.
Necrosis seen below the fascia mandates re-exploration and revi-
sion while necrosis isolated above the fascia can be conservatively
managed. Surgically, principles of revision include excision back
to healthy, viable bowel, and recreation of the stoma. This may
entail a more thorough intraabdominal mobilization to reduce

 improved outcomes in colon and rectal surgery
(A) (B)
(C)
tension through the abdominal wall, revision of the fascial open-
ing, or ensuring no kinking of the blood supply. In very difficult
cases, consideration for a loop-end ostomy is advised since less
mesenteric mobilization is required.
Conservative management of stoma necrosis is possible when
the necrosis is isolated above the level of the fascia. Simple mea-
sures, such as maintaining an adequate blood pressure for stoma
perfusion and awaiting edema resolution after bowel manipula-
tion can avoid the morbidity of a re-exploration. Even with frank
necrosis, conservative measures with local wound care should be
attempted. However, conservative management of stoma isch-
emia is a risk factor for ostomy stenosis which occurs in 2–9%
of patients.(34, 40, 41) Stoma stenosis is described as narrowing
of the lumen of the ostomy at the skin or fascia level and is due
to luminal contraction from scar tissue formation. In addition
to ischemia, stenosis can occur due to insufficient skin excision
at the stoma site, peristomal abscess, or mucocutaneous separa-
tion. Stenosis, easily diagnosed by visual inspection and digital
exam of the stoma, is rarely clinically significant and can be man-
aged with a low residue diet and stool softeners. In refractory and
symptomatic cases, dilation, excision of scar tissue, or stoma revi-
sion can be performed. A local type of revision involves a Z-plasty
repair (Figure 33.3).(43, 44)
Parastomal Hernias
By definition, a stoma is a hernia in the anterior abdominal wall,
thus leading Goligher to state that the true rate of parastomal
hernias is 100%. As such, parastomal hernias are a well-known
complication of stomal surgery, and can be a major source of
morbidity (Figure 33.4).(45) The incidence of hernias ranges
from 5–10% of stomal patients with colostomies more prone

Figure 33.3  Loop end colostomy. A, loop of
bowel brought through abdominal wall opening.
B, stoma rod is placed through the mesenteric
opening to support the loop on the skin and the
bowel is opened. C, Completed loop colostomy.
to herniate than ileostomies.(34, 46) Fortunately, most are well
tolerated and manageable nonoperatively. However, approxi-
mately 30% of hernias require operative repair for symptoms
that include bleeding, obstruction, abdominal masses, poor
­fitting appliances, and leakage.(47, 48) Surgical therapy has cen-
tered on stomal relocation, primary fascial repair, and prosthetic
mesh—alone, or in combination. Each of these has been widely
touted; however, significant morbidity and complication rates up
to 88% have left surgeons searching for a better answer to this
difficult problem.(49–52) Equally frustrating is the high rate of
recurrence following initial repair. Rubin et al. found an initial
recurrence rate of 60%, with approximately 70% having subse-
quent failures following additional surgery for both primary fas-
cial repair alone and stomal relocation.(51) Although prosthetic
mesh has shown improved results over stomal relocation and
primary fascial repair, these reports are hindered by low patient
numbers and lack of long-term follow-up to draw meaningful
conclusions regarding complications and recurrences.(49–51,
53–56) A variety of surgical mesh repair techniques exist, includ-
ing a circumferential onlay mesh, two separate intraperitoneal
pieces placed lateral to the stoma, one large piece placed via a
midline approach, and an incomplete mesh ring.(49, 53, 57, 58)
Additionally, both open and laparoscopic approaches have been
used.(59, 60) Yet, fear of mesh infection and erosion has led to
concerns regarding mesh use, and the perceived need to avoid any
contact between the bowel and mesh.(57)
At our institution, one operative approach to symptomatic
parastomal hernias commonly used is primary fascial repair with
nonabsorbable suture and placement of mesh via a “stove-pipe”
hat repair (Figure 33.5). In this technique, one piece of mesh is
placed overlying the fascial repair, the stoma is then pulled through
 ostomies
Figure 33.4  Computed tomography image of a patient with a parastomal hernia.
The arrowhead represents a herniated portion of small bowel adjacent to the
ileostomy (arrow). Also note the large midline incisional hernia.
Figure 33.5  “Stove-pipe” hat repair: Parastomal hernia repair with mesh
demonstrating the onlay piece of mesh in as well as circumferential component
overlying the fascial repair. An additional piece (not shown) may be placed in the
sub-fascial location as well. (Courtesy of Patrick Y. Lee, M.D.)
the center of the mesh, thus creating a 360-degree repair. An addi-
tional piece of mesh is then tacked to both the bowel circumfer-
entially and to the onlay mesh. Once constructed, this creates the
“stove-pipe hat” appearance. In selected cases, an additional piece
of mesh is placed beneath the fascia to provide additional sup-
port. Drains are routinely placed at the time of surgery.
In a recent review of our experience, we analyzed 58 patients
that underwent parastomal hernia repair with polypropylene
mesh.(64) With a mean follow-up of 50.6 + 40.1 months, the
overall complication rate related to the polypropylene mesh was
36.2%, and occurred at a mean of 27.2 months. Complications
encountered included recurrence (25.8%), surgical bowel
obstruction (8.6%), prolapse (3.4%), wound infection (3.4%),
fistula (3.4%), and mesh erosion (1.7%). No patients required
extirpation of the mesh. Data analysis demonstrated that stomas
placed for underlying colorectal cancer were associated with a
decreased rate of complications while increased complications
were significantly associated with younger age (59.6 vs. 67 years,
p < 0.05). With the increased availability and use of the biologic
mesh products, fear of contact between mesh and bowel with
subsequent erosion and infection have allowed for increased use
of these products using a similar technique. In addition, while
not extensively studied, we have periodically placed mesh dur-
ing the primary creation of a stoma in select cases, such as for
those patients with diminished fascia, prolonged steroid use, and
­re-siting of stoma from prior failures. Future data on this practice
awaits further recommendations.
Prolapse
Ostomy prolapse is the telescoping of the intestine through the
stoma and can be a source of discomfort and anxiety for the patient.
Causes include a large fascial opening in the abdominal muscula-
ture, redundancy of the intestine through the abdomen, failure to
place the stoma through the rectus muscle, insufficient suturing to
the abdominal wall, distended abdomen, and increased abdominal
pressure. Prolapses are most commonly seen in loop stomas with
the distal loop more prone to prolapse. The diagnosis is easily con-
firmed by inspection and the treatment depends on the severity of
the prolapse. In severe prolapse, stoma obstruction and ischemia
may result from excessive tension on the underlying mesentery.
Ischemic changes manifested as ulceration or dusky appearance of
the bowel mandates expeditious surgical intervention and resto-
ration of blood flow. In the more chronic setting, prolapse can be
managed conservatively with manual reduction and symptomatic
relief of discomfort or pain. The application of the ostomy appli-
ance is important for patients who suffer from prolapse. The skin
barrier opening should be cut to accommodate the stoma at its larg-
est size and two piece pouching systems with plastic rings should be
avoided to prevent strangulation. Surgery may ultimately be neces-
sary to resect the prolapse and revise the stoma if symptoms persist.
Again, especially in the setting of loop colostomies, using a portion
of bowel near the flexures where it tends to be more tethered, may
aid in decreasing the incidence of prolapse.
Special Consideration
Morbidly Obese Patients
Morbid obesity, defined as a body mass index >35 kg/m2, is a pub-
lic health epidemic in the United States with the prevalence in the
adult population ranging from 2.8–5.1%.(62, 63) The impact of
obesity on the complication profile of patients undergoing col-
orectal surgeries have been well documented and include a higher
incidence of wound infection, dehiscence, wound herniation,
anastomotic, pulmonary, cardiovascular, thromboembolic com-
plications, increased operative time and length of hospital stay,
and overall increased morbidity and mortality.(61) Additionally,
morbid obesity has been found to increase the complication rates
associated with stomas. A prospective risk factor analysis of 97
patients for stoma complications found that elevated BMI was
independently associated with an increased rate of ostomy retrac-
tion, early skin excoriation, and overflow.(36) Furthermore, in a
retrospective review of 156 patients undergoing stoma formation,
Duchesne et al. found obesity, defined as a BMI > 30 kg/m2, was
significantly associated with stoma complications, most com-
monly, stoma necrosis, prolapse, and skin irritation.(65) Similarly,
Leenan and Kuypers found that obese patients had a significantly
higher percentage of overall stoma complication (47 vs 36%)

 improved outcomes in colon and rectal surgery
(A) (B)
(A) (B)
Figure 33.7  Redundant abdominal wall folds of skin associated with ileostomy
retraction. (A) Frontal view. (B) Sagittal section demonstrating skin and subcutaneous
fat incisions.
including a higher incidence of stoma necrosis.(40) Cottam’s
group, in a nationwide audit of stoma complications, found that
increasing BMI, even that not meeting criteria for “morbid obe-
sity”, was associated with more stoma problems.(37)
Various reasons for a higher complication rate in the obese
include a relatively shortened and fatty mesentery, thicker abdomi-
nal wall through which the stoma must traverse, poor small ves-
sel circulation associated with comorbidities of obesity, and the
physical difficulties of stoma appliance application in the redun-
dant pannus. Ultimately, these factors predispose obese patients
to undergo increased mesenteric mobilization so that the bowel
reaches the skin, with the end result being arterial insufficiency to
the super-fascial stoma. Additionally, an inadequate fascial opening
or physical compression of the abdominal wall on the stoma as it
traverses the abdominal wall may lead to constriction of venous
return with resultant stoma engorgement, stenosis, or necrosis.
In morbidly obese patients undergoing stoma formation in an
elective setting, preoperative weight loss should be encouraged.
Realistically however, sufficient weight loss to favorably impact the
complication profile is unlikely. There may be a unique subset of
patients who can defer abdominal surgery requiring stoma forma-
tion until after undergoing bariatric surgery. In these cases, stoma
formation should be delayed until massive weight loss has stabilized
as significant changes on the abdominal wall may require ostomy
revision if the order of surgery is reversed. In addition to timing
of surgery, the preoperative preparation of the morbidly obese
patient is critical. This high risk patient population should undergo
age appropriate and comorbidity appropriate risk stratification and
work-up as they are at increased risk for perioperative complications.

(C)
Figure 36.6  Loop ileostomy in an obese patient. It
is important to consider stoma placement in the
lying (A), seated (B), and standing (C) positions.
Note the placement of the ostomy with relation
to the pannus and mid-line incision. Improper
cutting of the stoma appliance cause peristomal
skin excoriations. This patient was preoperatively
marked by an enterostomal therapist with good
postoperative functional outcome.
In regards to ostomy complications, preoperative stoma marking is
important in all patients undergoing stoma formation, but is argu-
ably even more important in this patient population already at
increased risk for local skin complications. Large skin creases prone
to superficial fungal infections in the obese should be avoided, as
well as low lying ostomies which may be difficult for the patient to
adequately visualize and properly maintain (Figure 33.6).
Technically, a sufficient fascial opening should be made to
easily accommodate the bowel through the abdominal wall.
Conservative mesenteric mobilization is encouraged, with mini-
mal length required for the bowel to reach the skin without ten-
sion for proper maturation the ultimate goal. In patients with
foreshortened mesenteries or those with significant abdominal
wall thickness, a loop ostomy, or end-loop stoma in which a
loop of bowel is brought through the fascia and the distal por-
tion closed allowing a few additional centimeters of bowel length
for construction, should be considered as these are less prone
to complications associated with vascular insufficiency. Finally,
removal of some local adipose tissue through which the stoma
will traverse is reasonable, although over-aggressive “de-fatting”
may lead to skin necrosis.
Additional options include a modified abdominoplasty (abdom-
inal wall countering), localized flaps with skin or fat removal, or
liposuction. Although frequently successful, these techniques
have potential for significant morbidity. Patients who may ben-
efit from these techniques include those with stomal retraction
(especially those who have bowel limitations [e.g., continent ileo-
stomies, dense intraabdoninal adhesions or short gut], prolapse,
large peristomal hernias, abdominal wall laxity (usually resulting
from major weight loss), and peristomal skin problems such as
pyodermia. In many of these patients stomal relocation may not
be the best option.
A modified abdominoplasty or abdominal wall contouring
is similar to the technique employed by plastic surgeons.(66,
67) A low curvilinear transverse incision is made at the inferior
abdominal fold or 2–3 cm above the pubis and anterior superior
iliac spines and carried down to the fascia (Figure 33.7). A flap
of skin and subcutaneous tissue is created by electrocautery dis-
section in a cranial direction, just above the fascia. Perforating
vessels are identified and ligated or cauterized. As the dissection
continues the stoma will be encountered. With the flap on trac-
tion, the intestine is separated from the skin and subcutaneous
tissue. Care is taken to avoid injury to the bowel or its blood sup-
ply. The dissection should err on leaving additional subcutane-
ous fat attached to the intestine. This can be carefully resected
later. A similar maneuver may be performed at the umbilicus if
 ostomies
(A) (B)
Figure 33.8  Excess skin and subcutaneous fat have been excised. (A) Frontal view,
(B).Sagittal section.
(A) (B)
Figure 33.9  Ileostomy relocated through upper flap and skin incisions closed.
Closed suction drains placed below flaps. (A) Frontal view, (B) Sagittal section.
the surgeon and patient prefer to preserve it in its normal loca-
tion. Again care is taken to preserve the tissue’s blood supply. If
the umbilicus is not to be maintained, it can be amputated at the
fascial level. The flap dissection is continued cranially just above
the fascia until enough laxity or length is obtained in the upper
flap for the upper edge of the previous stomal opening to reach
the inferior portion of the incision without excessive tension or
to the costal margins. Any associated peristomal hernia can be
repaired at this time with suture repair of the fascia and/or mesh
(synthetic or biologic) reinforcement.
As the flap is retracted inferiorly, new sites for the ostomy and,
if desired, the umbilicus are selected and openings created in the
flap. Excess subcutaneous fat can be carefully removed to thin
the flap. Fortunately, there is usually less subcutaneous fat above
the umbilicus compared to below it. The excess, distal portion
of the flap is excised (Figure 33.8). The intestine and umbilicus
are brought through the respective flap openings and matured
with interrupted absorbable sutures (Figure 33.9). Excess bowel
or umbilical tissue can be carefully excised. Closed suction drains
are placed below the flap to avoid seromas and the inferior inci-
sion is closed in layers. As intraabdominal dissections are avoided
with this technique, patients usually recover quickly. Morbidity
is usually associated with infection, flap ischemia, or seromas.
These are managed with wound care.
(A) (B)
(C)
Figure 33.10  Medial approach. (A) Frontal view with skin incision marked,
(B) Cross section demonstrating midline incision and areas of subcutaneous fat
excision, (C) After removal of excess subcutaneous tissue, incision is closed, flaps
attached to fascia, and stoma matured with adequate eversion.
A more localized procedure involves the use of flaps to modify
the abdominal wall around the stomas. Most involve peristomal
dissections and removal of skin and subcutaneous fat. This can be
performed via a medial or inferolateral approach (Figure 33.10).
An incision is made down to the fascia and advanced toward the
stoma. The ostomy is dissected free of the skin and subcutaneous
tissue as described above. After the stoma is freed, lateral or cra-
nial dissection will provide enough laxity to advance the previous
stoma site to the incision (advancement flap). As above, a new
ostomy opening, in fresh skin, is created. Excess fat may be excised
around the stoma and redundant midline skin is resected.
If the skin flap is not redundant enough to advance the origi-
nal ostomy opening to the midline, the subcutaneous fat can
be excised and the stoma returned to its original skin opening
through the thinned flap. Either method is performed in such a
manner to leave a smooth, flat, thinned flap that provides a flat
surface to site the appliance. The stoma is matured and the inci-
sion is closed. Subcutaneous closed suction drains are placed
above and below the stoma.
The circumstomal approach starts with an incision around the
stoma at the mucocutaneous junction. With careful dissection,
the bowel is separated from the subcutaneous tissue down to the
fascia. The subcutaneous tissue is then separated from the fascia
with electrocautery in a circumferential manner to a point 7–8 cm
out from the stoma. A wedge of subcutaneous tissue is circumfer-
entially created from the upper skin edge to meet the outer edge
of the extrafascial dissection. Small closed suction drains may be
placed and the ostomy is matured to the skin edges. If there was
a preoperative stenosis, the skin opening may be enlarged or the
bowel may be matured with a Z-plasty technique.(43, 68) If the
preoperative stomal opening was too large or it becomes too large
from the dissection, the diameter of the opening can be reduced
with interrupted sutures (Figure 33.11). This type of closure has
been referred to a “Mercedes technique”.(69)
Rapid and significant weight gain in ostomy patients may pro-
duce stomal retraction. If attempts at weight loss have not been
successful and stomal revision is not desirable or feasible (e.g., con-
tinent ileostomy or short gut patients), liposuction is an excellent
option. This method is preferred if there is no associated stomal

 improved outcomes in colon and rectal surgery
(A) (B)
Figure 33.11 Mercedes or triangular closure. A. Stoma site with fascia closed, B. Initial approximation of skin and subcutaneous fat, C. Completed closure with small
area in center left open for drainage and secondary healing.
stenosis or hernia. Experienced plastic surgeons can carefully use
liposuction techniques to remove subcutaneous fat around the
stoma. Obviously, care must be taken to not injure the stoma
­during the procedure and to leave a flat smooth peristomal skin
surface for the ostomy faceplate. Once the fatty tissue is removed,
it will not be redeposited despite additional weight gain.
Ostomy Reversal
Reversal of temporary stomas should be undertaken as soon as
physiologically feasible to reestablish gastrointestinal continuity
and for psychological improvement. This of course implies that
the purposes of the stoma placement has been met and the patient
is capable and a candidate for another operative procedure. There
are two main operative approaches to ostomy reversal, local or via
a laparotomy. While both approaches are associated with inadver-
tent enterotomies, bleeding, wound infections, and anastomotic
complications, the biggest advantages of the laparotomy approach
is improved exposure and the ability to reexplore the abdomen.
Certainly, the type of ostomy is important to consider when plan-
ning the operative approach as loop ileostomies are technically
the least challenging to reverse and often amenable to local rever-
sal. Although a local approach is preferred, patients with a prior
Hartmann’s procedure or those in which the distal remnant is not
available via a local approach are obviously forced to undergo a
repeat laparotomy. Surprisingly, there is a paucity of recent data
that highlights the potential perils of this seemingly benign opera-
tion. The most recent study, published in 2005, was a retrospective
review of 533 patients undergoing stoma closure at the University
Hospital of Vienna.(70) The majority of the patients (51%) under-
went reversal of a colostomy, 44% had closure of an ileostomy, and
5% had combined reversals of both a colostomy and an ileostomy.
All patients underwent a laparotomy using the intraperitoneal
approach. Their 30-day mortality was 3% (15 patients) with rates
similar for either ileostomy or colostomy reversal. Causes of death
were multisystem organ ­failure after nonsurgical complications in
nine patients, and anastomotic leakage, missed small bowel injury,
and cecal perforation in the remaining six patients. Overall com-
plications were 20%, with anastomotic leakage (5%), ileus (4%),
postoperative bleeding (2%), and wound infection (2%). When
analyzing patient related factors between survivor and nonsur-
vivors, only advanced patient age was found to be statistically
­significant. This study, which highlights the potential morbidity

(C)
of stoma reversal, also emphasizes the importance of meticulous
surgical technique required in these challenging patients with
reoperative abdomens.
Our approach to ostomy reversal begins with a thorough pre-
operative evaluation which includes interrogation of the distal
colon with either a barium enema and/or endoscopy. The primary
reason for which sentinel procedure was performed is important
to consider since it may reveal if the purposes of the ostomy has
been met and potentially alter the decision on reversal. An obvi-
ous but sometimes overlooked step should also be the evaluation
of the patient’s sphincter tone and ability to control fecal stream
once continuity has been restored. This may require not only
clinical evaluation, but formal documentation through anorectal
physiology testing including manometry. Baseline poor sphincter
tone or incontinence should be considered a contraindication for
ostomy reversal in all but the rarest of cases. Finally, additional
patient factors which can be altered, such as nutritional status,
steroid use, and tobacco abuse, should be optimized before sur-
gery. When planning the operative approach for end colostomy
reversals, additional factors to consider before embarking on the
operation should include the expected amount of adhesive disease
likely to be encountered or previously encountered (i.e., review
prior operative notes), whether there is a history of prior abdomi-
nal or pelvic radiation, concomitant pathology such as the pres-
ence of incisional hernias, and the type of ostomy. For instance,
patients with multiple prior surgeries and a history of radiation
will most likely benefit from a laparotomy approach that includes
preoperative ureteral stent placement, while those patients with
loop ostomies without any other comorbidities can be managed
with a local approach. Whether a stapled or hand-sewn anasto-
mosis is performed is up to the surgeon’s discretion. Key technical
points in each method, however, is to ensure adequate mobiliza-
tion and visualization of the distal colonic or rectal stump with
resection of both the exteriorized bowel or end stump back to
normal healthy bowel before the anastomosis. Finally, delayed
primary closure is performed for the area in which the stoma was
placed and drains are not routinely placed.
Conclusion
Beyond bringing a loop of bowel to the skin surface, there are a
wide variety of issues that a surgeon needs to consider when creat-
ing a stoma. Having a thorough understanding of the indications
 ostomies
for stoma placement, the technical details for the various ostomies,
and the physical and psychological impact of living with an ostomy
will aid the surgeon in caring for these unique patients. Finally,
understanding the potential complications from ostomy place-
ment and having the knowledge to correctly deal with them is an
essential tool for all providers and emphasizes the importance of a
multidisciplinary team of specialists.
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34 Operative and nonoperative therapy for chronic constipation
Harry T Papaconstantinou
Challenging Case
A 33-year-old women presents with constipation of 8 years dura-
tion. She goes 7–10 days between bowel movements, despite tak-
ing multiple laxatives. She tried extra dietary fiber, polyethylene
glycol, and lubiprostone, all without relief. Her lack of bowel
activity is significantly impacting on her life style.
Case Management
A barium enema demonstrates normal anatomy. A colonic transit
study demonstrates 20 markers evenly distributed throughout
the colon on day 5. A balloon expulsion test and anal manometry
were normal. A diagnosis of colonic inertia is made and the
patient is offered a total abdominal colectomy with an ileorectal
anastomosis.
INTRODUCTION
Constipation is a common medical complaint resulting in over
2.5 million physician visits in the United States each year.(1)
Reports have indicated that constipation is a significant problem
with its prevalence ranging from 2 to 27%, and associated medica-
tion costs of over $500 million each year.(2) Stool weight, transit
time, and frequency of defecation correlate strongly with dietary
fiber intake. It is estimated that the average daily consumption of
fiber in the United States is <20 grams, therefore, the prevalence
of constipation should be no surprise.(3, 4) Furthermore, con-
stipation adversely affects work-related productivity, educational
performance, and results in significantly lower quality of life and
higher psychological distress.(5, 6)
Constipation is not a specific disease, but rather a constellation
of symptoms. Physicians typically define constipation in objective
terms of bowel movement frequency, specifically fewer than three
bowel movements per week. However, constipation has different
meaning to individual patients, and may be described as the need
to strain to defecate, having hard stools, the inability to defecate
at will, incomplete evacuation, or the infrequent passage of stool.
Regardless of the ambiguity of defining constipation, patients fre-
quently perceive the need for treatment due to advertising por-
traying “regularity” as the secret to health and well-being.(7, 8)
Therefore, it is important for the physicians to clarify patient’s
intended meaning, and to establish a more objective definition
for this subjective symptom. Recently, a consensus of parameters
has been created and updated to more clearly define constipation
and is known as the Rome III criteria (Table 34.1).(9) The estab-
lishment of these parameters has provided more uniform defini-
tion of constipation, and is a valuable tool to identify patients
that require treatment.
Successful treatment of constipation requires the accurate iden-
tification of the underlying etiology of the symptom. In most
patients, constipation is the direct result of specific medical condi-
tions (Table 34.2) or side effect of medications (Table 34.3). These
Table 34.1  Rome III diagnostic criteria for constipation.
Criteria must be fulfilled for the last 3 months.
Symptom onset at least 6 months before diagnosis .
1) Must include 2 or more of the following.
a. Straining ≥25% of defecation.
b. Lumpy or hard bowel movements ≥25% of defecation.
c. Sensation of incomplete evacuation ≥25% of defecation.
d. Sensation of anorectal obstruction ≥25% of defecation.
e. Manual maneuvers to facilitate bowel movement ≥25% of defecation.
f. Fewer than 3 defecations per week.
2. Loose stools are rarely present without the use of laxatives.
3. Insufficient criteria for irritable bowel syndrome
Table 34.2  Medical conditions causing constipation.
Collagen Vascular and
Endocrine and Metabolic Neurogenic Musculoskeletal
Chronic renal failure Autonomic neuropathy Amyloidosis
Diabetes mellitus Cerebrovascular disease Dermatomyositis
Hypothyroidism Dementia Myotonic dystrophy
Hypercalcemia Depression Systemic sclerosis
Hypokalemia Multiple sclerosis Scleroderma
Pregnancy Muscular dystrophy
Milk-alkali syndrome Parkinson’s disease
Porphyria Spinal chord lesions
Carcinomatosis Hirschsprung’s disease
Chaga’s disease
extracolonic causes can be easily identified in a careful and complete
history and physical examination. Constipation for these patients
is treated through medical management including alteration of
their medications, prescription of laxatives, or dietary and lifestyle
modifications. A small group of patients will have a functional dis-
order of the colon and anorectum resulting in constipation. It is
within this group of patients that colon and rectal surgeons can
make the greatest impact, and is the focus of this chapter.
Functional constipation can be divided into three groups:
1) slow-transit constipation, 2) pelvic floor dysfunction, and
3) combined slow-transit constipation and pelvic floor dysfunc-
tion. Slow-transit constipation, also known as colonic inertia,
is characterized by prolonged length of time for stool to pass
through the colon.(10) Delay in stool transit is thought to be a
primary dysfunction of the colonic smooth muscle (myopathy)
or innervation (neuropathy). Pelvic floor dysfunction results in
evacuation disorders, and is characterized by either difficulty or
inability to expel stool from the anorectum.(11) Common disor-
ders of pelvic floor dysfunction include obstructive defecation,
pelvic floor dyssynergia, outlet obstruction, or anismus.(11–13)

 improved outcomes in colon and rectal surgery
Table 34.3  Drugs associated with constipation.
Antidepressants
Anticholinergics
Antipsychotics
Aluminum (antacids, sucralfate)
Bismuth
Cation-containing agents
Calcium (antacids, supplements)
Iron supplements
Opiates
Antihypertensives
Neurally active agents Ganglionic blockers
Vinca alkaloids
Calcium channel blockers
Antihistamines
Antiparkinsonian drugs
Others
Diuretics
Nonsteroidal anti-inflammatory drugs
Recent advances in the analysis of colonic motility and pelvic floor
physiology have allowed for the identification and classification of
these two subtypes. This is important as treatment modalities are
different. Surgery is indicated for patients with slow-transit consti-
pation, while nonoperative treatment modalities, such as biofeed-
back therapy, are effective in patients with pelvic floor dysfunction.
Patients with mixed conditions require correction of the pelvic
floor abnormality before undergoing an operation for slow-transit
constipation. Patient selection is critical for treatment success.
EVALUATION AND DIAGNOSTIC STUDIES
Initial evaluation of patients with constipation is a complex task
and starts with a careful history and physical examination. Most
patients are reluctant to discuss these issues, and establishing a
trustworthy relationship is important to define the nature of bowel
dysfunction. Constipated patients present with a constellation of
symptoms that include excessive straining to defecate, passage of
hard stools, the inability to defecate at will, digital disimpaction,
vaginal splinting, feeling of blockage at the anal opening, incom-
plete evacuation, and/or the infrequent passage of stool. Details
of defecatory characteristics and habits are helpful and should
include stool frequency, stool consistency, stool size, and degree of
straining during defecation. These patients should be asked about
precipitating events and the duration and severity of the problem.
A dietary history should be obtained to assess of the amount of
daily fiber ingested and fluids consumed, as stool transit time and
frequency of defecation correlate strongly with dietary fiber intake.
(3, 4) If the patient has already been treated by a referring phy-
sician it is important to know the number and types of laxatives
used, patient compliance, and whether there was any improvement
in symptoms. A long history of constipation refractory to dietary
measures and laxative use is suggestive of functional constipation,
while a history of recent onset should alert the physician to seek
and exclude an organic cause such as neoplastic disease or stricture.
A complete medical history will provide evidence of extracolonic
causes of constipation such as diabetes, hypothyroidism, or cer-
ebrovascular disease (Table 34.2). Detailed review of the patient’s
medication list will identify specific medications that are known to
cause constipation (Table 34.3).

A complete physical exam with specific emphasis on the abdo-
men and perineum are important. A normal physical exam is
not uncommon. A detailed anorectal exam starts with inspec-
tion of the perianal skin. Perineal sensation and the anocutane-
ous reflex are assessed by gently stroking the perineal skin with a
cotton-tipped applicator stick. Absence of a reflex contraction of
the external anal sphincter indicates the presence of neuropathy.
A digital rectal examination is performed to identify the presence
of an anorectal stricture, distal rectal mass, and the presence of
stool or blood within the rectal vault. Positive findings require
further aggressive evaluation including colonoscopy. During dig-
ital examination, sphincter tone is assessed at rest and voluntary
squeeze. It is important to ask the patient to bear down as if to
defecate. This maneuver allows the examiner to determine relaxa-
tion of the external anal sphincter and the presence of perineal
descent. Absence of these features is suggestive of pelvic floor
dysfunction or dyssynergic defecation.(11) Vaginal and biman-
ual examination should be performed to rule out rectocoele as a
cause of outlet obstruction constipation.
Routine evaluation of the colon is performed when there is a
lack of identifiable causes of constipation. This can be performed
by colonoscopy, barium enema, or CT colonography. Although it
has been reported that there is no increased incidence of colon or
rectal neoplasia in patients with chronic constipation (14), rou-
tine anatomic evaluation of the colon is performed to exclude
tumors, strictures, and large bowel disease. Endoscopic evalua-
tion of the colon may reveal evidence of chronic laxative abuse
(melanosis coli), diverticular disease with stricture, malignancy,
or colitis cystica profunda (internal rectal prolapse). Further
work-up and treatment is dependent on the findings. However, in
the absence of anatomic causes of constipation, patients should
be initially treated with dietary and lifestyle modifications with
or without medications. If initial treatment of constipation fails
to improve the patient’s symptoms, further investigational stud-
ies are required to differentiate between functional constipation
types. It may seem intuitive that patients with slow-transit con-
stipation would complain of infrequent bowel movements, while
patients with pelvic floor dysfunction would report feelings of
incomplete evacuation and excessive straining. However, recent
reports show that symptoms alone do not differentiate between
the subgroups of functional constipation.(6, 15, 16) In fact, up
to 62% of patients with pelvic floor dysfunction report stool
frequency of less than three bowel movements per week.(6) For
this reason symptom assessment should be combined with objec-
tive testing to better assess the nature of a patient’s complaint.
Physiologic studies of the colon (colonic transit study) and pelvic
floor (anorectal manometry, balloon expulsion test, defecogram,
and electromyography) are required to differentiate between
slow-transit constipation, pelvic floor dysfunction, and patients
with mixed features, and accurate diagnosis is critical for treat-
ment success.
Colonic Transit Studies
Self-reported stool frequencies correlate poorly with colonic
transit, and patient’s recall of stool habits is often inaccurate indi-
cating that subjective complaints are not sufficient to determine
diagnosis. Colonic transit studies provide objective assessment of
 operative and nonoperative therapy for chronic constipation
(A)
Figure 34.1 Colonic transit study using single capsule radiopaque markers. Abdominal radiographs shown were taken 5 days after capsule ingestion. The presence of
>6 marks scattered throughout the colon is diagnostic for slow colonic transit (A). Retention of markers within the rectum and rectosigmoid region suggests pelvic
outlet obstruction (B).
stool movement through the colon, and are critical tests to iden-
tify patients that will benefit from colectomy. Two methods are
commonly used to measure colonic transit time and include radi-
opaque marker methods and scintigraphic techniques. Studies
have shown that that these two tests correlate well to each other
and are sensitive for identifying colonic transit delays in patients
with slow-transit constipation.(17, 18) Objective documentation
of slow-transit constipation is critical for patient selection for
surgery, and has been shown to significantly improve outcomes
after colectomy (90% vs. 67%).(19, 20)
Radiopaque Marker Test. The most common and widely used
study of colonic transit time is the radiopaque marker method.
This test was first described by Hinton et al. in 1969, and since that
time several modifications have been described including single
and multiple capsule techniques.(21–23) This study is performed
by having the patient swallow a single capsule (Stizmarks; Konsyl®
Pharmaceuticles, Ft. Worth, Texas) containing 24 radiopaque mark-
ers, and then tracking the markers by abdominal radiographs at
3 days and 5 days. Patients are instructed to stop laxatives, cathartics,
and enemas for 2–7 days before ingestion of the capsule, and dur-
ing the test period to prevent false results. In patients with normal
colonic motility, by day 5 of the test 19 (80%) or more of the mark-
ers will have passed through the colon and are either completely
evacuated or found in the rectum. Patients with slow colonic transit
show the presence of 6 or more markers scattered throughout the
colon (Figure 34.1A). Patients with pelvic floor dysfunction such as
functional obstructive or dyssynergic defecation, exhibit retention
of 6 or more markers in the rectum or rectosigmoid region with a
near normal transit of markers through the colon (Figure 34.1B).
(B)
Although this test has been shown to be highly reproducible, when
considering total abdominal colectomy for colonic inertia, it has
been shown that patients have more favorable results if two marker
studies have demonstrated slow-colonic transit times to confirm
the diagnosis.(24)
Scintigraphic technique. Scintigraphic defecography is another
modality available to study colonic transit. Delayed-release cap-
sules containing charcoal or polystyrene pellets radiolabeled with
technetium-99m or indium-111 are coated with a pH-sensitive
polymer methacrylate. The coating dissolves in an alkaline pH
within the terminal ileum and cecum. Colonic distribution of the
radioisotope is determined on scans taken 24 and 48 hours after
capsule ingestion, and is highly sensitive and specific for identi-
fying slow colon transit.(25, 26) Colon transit measurements by
radiopaque markers and scintigraphic techniques correlate well
with each other, and are sensitive for identifying colonic transit
delays in patients with slow transit constipation.(18)
When a diagnosis of slow-transit constipation is made, the
physician must be aware of specific conditions that may be asso-
ciated with this functional disorder and adversely affect surgical
treatment with colectomy. First, slow-colonic transit constipation
may be a component of a generalized gastrointestinal disorder
such as panenteric intertia. A recent review has suggested that
patients with this generalized gastrointestinal motility disorder
have significantly diminished long-term success rate after colec-
tomy for slow-transit constipation.(27) This is supported by the
high rate of recurrent small-bowel obstruction (70%) in patients
with panenteric intertia.(28) Collectively, these data suggest that
whole gut transit studies should be considered before colectomy

 improved outcomes in colon and rectal surgery
for slow-transit constipation, and include gastric emptying,
upper gastrointestinal small bowel follow-trough, and choly-
cystokinnin hepatic dimethyliminodiacetic acid (CCK-HIDA)
scan. Colectomy in patients with a global gastrointestinal motility
disorder is not likely to improve their symptoms and is discour-
aged. Second, in patients with findings suggestive of pelvic floor
dysfunction, up to two-thirds will exhibit mixed pattern consti-
pation with both slow transit and obstructive delay.(29) Further
pelvic floor physiology testing and treatment of the pelvic floor
dysfunction is required before colectomy to improve outcomes
and avoid treatment failure.
Pelvic Floor Physiology Tests
Patients with functional constipation due to pelvic floor dysfunc-
tion and obstructive defecation have difficulty with evacuation
of rectal contents. Normal evacuation requires the involuntary
relaxation of the internal anal sphincter as well as the voluntary
relaxation of the external anal sphincter and pelvic floor mus-
cles. Failure of this coordinated effort results in outlet obstructive
symptoms. Pelvic floor physiology testing can identify specific
disorders such as blunting of the rectal anal inhibitory reflex
(RAIR), paradoxical puborectalis contraction, and anatomic
abnormalities that cause outlet obstruction. Common tests used
to identify these disorders include anorectal manometry, balloon
expulsion test, defecography, and electromyography.
Anorectal Manometry. Anorectal manometry provides a
comprehensive assessment of anal sphincter muscle tone and
the anorectal sensory response to different stimuli. This test is
useful in the evaluation of patients with obstructive defecation,
and helps to detect abnormalities during attempted defecation
such as pelvic floor dyssynergia or anismus.(30) The complete
manometric evaluation of the anorectum includes determination
of the resting pressure, squeeze pressure, length of the high-pres-
sure zone, rectal compliance, RAIR, and the ability of the internal
anal sphincter to relax with straining. In normal defecation, as
rectal pressure rises there is a synchronized fall in the internal
anal sphincter pressure. A blunted rectal sensation is a common
finding in patients with functional obstructive defecation.(31)
Absence of the RAIR suggests secondary causes of constipation
such as Hirschsprung’s disease, Chagas disease, or previous sur-
gery.(32–34) External sphincter muscle relaxation for the elimina-
tion of stool is a learned response that is under voluntary control.
Inability to perform this coordinated movement represents the
chief pathophysiologic abnormality in patients with dyssynergic
defecation and anismus, and may be due to impaired rectal con-
traction, paradoxical puborectalis contraction, or impaired anal
relaxation.(11, 35) Anorectal manometry has been shown to be
inaccurate in the diagnosis of paradoxical puborectalis and dys-
synergic defecation, and further testing with balloon expulsion
test and electromyography should be performed to assist in diag-
nosis.(36)
Balloon Expulsion Test. The balloon expulsion test is a func-
tional evaluation of the patient’s ability to defecate. In this test,
a latex balloon is filled with 60 ml of warm water or air within
the rectum. The patient is asked to expel the balloon in a pri-
vate bathroom while sitting on the toilet. The physiologic posi-
tion and privacy allow this method to more closely approximate

normal evacuation. Normal subjects can expel the balloon within
1 minute.(37) While seeming trivial, it is important that patients
do not flush the balloon as it can severely damage the plumbing.
Inability to expel the balloon is suggestive of functional outlet
obstruction such as paradoxical puborectalis contraction and
dyssynergic defecation. The balloon expulsion test is a simple and
accurate test that has been shown to have a high specificity (89%)
and negative predictive value (97%) for excluding pelvic floor
dyssynergia as a cause of constipation.(36, 38, 39)
Defecography. Defecography is the real time imaging of
patient defecation, and provides dynamic characterization of the
interaction between the anal sphincter complex and the rectum
in an attempt to define abnormalities in the pelvic floor. It pro-
vides information on the anatomic and functional changes of the
anorectum during defecation, and is effective in differentiating
between anatomic and functional causes of obstructive defeca-
tion. Before the test is performed, the patient is cleansed of stool
using an enema. Barium paste is placed into the rectum, and with
the aid of fluoroscopy the process of defecation is video-recorded.
Static and real-time dynamic radiographic images are obtained
during the process of defecation. Specific measurements such
as the anorectal angle, perineal descent, and puborectalis length
during stages of squeeze and push are calculated.(40) Patients
with paradoxical puborectalis contraction and dyssynergic def-
ecation will exhibit failure of the anorectal angle to open, per-
sistence of the puborectalis impression on the rectum, and poor
rectal emptying of the barium paste.(41–43) It has been shown
that patients with a diagnosis of paradoxical puborectalis on
defecography have a high frequency of constipation symptoms.
(44) Defecography is reported to be too sensitive for paradoxical
puborectalis contraction and dyssynergic defecation leading to a
high false-positive diagnosis, but this test does have the advantage
of evaluating any coexistent pelvic floor pathology.(45) Anatomic
causes of obstructive defecation are readily identifiable during
defecography and include internal intussusception of the rec-
tum, rectocoele, enterocoele, and sigmoidocoele. The physiologic
importance of these findings is often unclear, and the surgeon
must determine their significance to individual patient symp-
toms and complaints to determine need for surgical repair.
Electromyography. Surface electromyography (EMG) can be
performed by anal plug, intraanal sponge, or concentric needle
technique to diagnose patterns of anal sphincter and pelvic floor
muscle dysfunction. Electrodes are used to record action potentials
derived from motor units within contracting muscles. Recordings
are taken at rest, squeeze, and push. In normal patients, the act
of defecation and push is accompanied by a decrease in motor
unit activity signifying relaxation of the anal sphincter complex
(Figure 34.2A). Patients with dyssynergic defecation and para-
doxical puborectalis contraction exhibit increased motor unit
activity during push indicating an increase in anal sphincter
complex contraction during defecation (Figure 34.2B). Studies
have shown that the negative predictive value for this test is high
(91%) indicating EMG can accurately rule out paradoxical pub-
orectalis contraction; however, the positive predictive value is
quite low when compared with defecography.(46–48) This sug-
gests the need for comprehensive physiologic testing to accurately
diagnose paradoxical puborectalis contraction.
 operative and nonoperative therapy for chronic constipation
(A)
MEDICAL TREATMENT OF CONSTIPATION
Initial treatment of functional constipation regardless of type
is patient education, dietary and lifestyle modifications, and a
trial of medical management. Education of the patient is criti-
cal and should include explanation of normal physiologic bowel
patterns.(49) It is important to communicate to the patient that
their symptoms will not be corrected overnight, and modifica-
tions of the treatment regimen may be required. In many patients
a dietary and medication log can be helpful to accurately iden-
tify fiber and water consumption, and medication compliance.
A daily diary to record bowel movements, stool characteristics,
and associated abdominal symptoms is useful when assessing
responses to treatment. Patients should be encouraged to recog-
nize and respond to the urge to defecate. Most patients who have
a normal bowel pattern usually empty stools at approximately
the same time every day suggesting this is in part a conditioned
reflex.(50) Ritualizing bowel habits may be useful to establish a
regular pattern of bowel movement and should be coordinated
with physiologic events that stimulate colonic motility (walking
and postprandial gastrocolic response).(11) General measures
such as adequate hydration and regular exercise has overall health
benefit; however, there is no evidence to support success in the
treatment of chronic constipation, except in situations of dehy-
dration.(51, 52) Indirect evidence exists, as epidemiologic stud-
ies suggest that sedentary people are three times more likely to
report constipation.(53)
A diet high in fiber content increases stool weight and accelerates
colonic transit time.(54) In contrast, a diet that is deficient in fiber
may lead to constipation.(54, 55) Consensus exists that empiric
treatment for constipation with a high-fiber diet is inexpensive
and effective therapeutic intervention for addressing constipation-
related bowel dysfunction.(56, 57) There is a clear dose response
between daily fiber intake and fecal output that is enhanced by
increased fluid intake. Dietary supplements such as bran may cause
significant amounts of abdominal bloating and discomfort, which
may decrease patient compliance. Gradual increase in dose may
(B)
Figure 34.2  Electromyographic tracings in a patient with normal defecation (A)
and paradoxical puborectalis contraction (B). Black arrows indicate push phase
that normally corresponds with muscle relaxation and lower amplitude waves. (R
rest; S strain; P push).
minimize these symptoms. Psyllium seed, methylcellulose, and cal-
cium polycarbophil are bulk-forming laxatives that absorb water
into the colonic lumen and increases fecal mass, which in turn
stimulates motility and reduces colon transit time.(58) A literature
review of articles dealing with 18 double-blind studies related to
constipation found that dietary fiber supplements or bulk laxa-
tives resulted in an average increase of 1.4 (95% CI, 0.6–2.2) bowel
movements per week, while laxative agents other than bulk showed
an increase of 1.5 (95% CI, 1.1–1.8) bowel movements per week.
(59) Others have shown that fiber has limited value in patients with
slow-transit constipation and pelvic floor dysfunction as patients
with these conditions did not respond effectively to dietary sup-
plementation with 30 grams of fiber per day.(56) Conversely,
patients without an underlying motility disorder either improved
or became asymptomatic with fiber therapy. Collectively, these
data suggest that therapeutic trial of dietary fiber should be con-
sidered as initial treatment for patients with constipation, although
fiber supplements administered alone are probably more effective
in normal transit or fiber deficiency constipation than slow transit
constipation or pelvic floor dysfunction.(27)
Failure of fiber therapy requires alternative choices of laxative
medications. A list of common medications used to treat consti-
pation is shown in Table 34.4. With so many potential options
available, the choice of laxative therapy is subject to patient pref-
erence, and physician opinion and consensus.(60, 61) Although
there are a variety of preparations available, the laxatives that are
frequently recommended include milk of magnesia, lactulose,
sorbitol, senna compounds, bisacodyl, and polyethylene glycol
preparations.
Milk of magnesia, magnesium citrate, and sodium phosphate
are saline laxatives that are poorly absorbed or nonabsorbed
osmotic preparations that result in secretion of water in the
intestines to maintain isotonicity with plasma.(62) Use of these
agents is not recommended in patients with cardiac and renal
dysfunction because excessive absorption may lead to electrolyte
abnormalities and volume overload. When ingested as hypertonic

 improved outcomes in colon and rectal surgery

Table 34.4  Medications commonly used for constipation.

Type Generic Name Trade Name Dosage Mechanism of action

Bran – 1 cup/day
Increase stool bulk
Fiber Psyllium Metamucil 1 tsp up to tid Decrease colonic transit
Methylcellulose Citrucel 1–2 tsp up to tid Increase gastrointestinal motility
Calcium polycarbophil Fibercon 2–4 tabs qd
Stool Softener Docusate Sodium Colace 100 mg bid Ineffective for constipation

Sorbitol 15–30 mL qd or bid Nonabsorbable disaccharides

Osmotic
Lactulose Chronulac 15–30 mL qd or bid Accelerate colonic transit
agents
Polyethylene glycol Miralax 17 g/d Osmotic increase in intraluminal fluid

Suppository Glycerine Up to daily Rectal stimulation

Bisacodyl Dulcolax 10 mg daily
Bisacodyl Dulcolax 10 mg po up to 3x/wk Increase intraluminal fluid

Stimulants Antraquinones Senokot 2 tabs qd to 4 tabs bid Stimulation myenteric plexus

Peri-colace 1–2 tabs qd Increase motility

Milk of Magnesia 15–30 mL qd or bidn Osmotic increase fluid small bowel

Saline
Magnesium Haley’s M-O 15–30 mL qd or bid Stimulate CCK
laxatives
Decrease colon transit time
Magnesium citrate 1 bottle
Lubricant Mineral oil 15–45 mL Stool lubricantn

Mineral oil retention 100–250 mL qd Stool softened and lubricated

Enemas Tap water 500 mL

Evacuation induced by distended
Phosphate Fleet 1 unit colon; mechanical lavage
Soapsuds 1500 mL
Secretory agents Lubiprostone Amitiza 24 mg bid Stimulation of Chloride channels

tid = three times a day; qd = daily; bid = twice a day.

solutions, there is a rapid osmotic equilibration that occurs, and
overuse may result in significant dehydration.(62)
Lactulose and sorbitol are nonabsorbable disaccharides that are
effective osmotic laxative agents. Lactulose is a known substrate
for colonic bacterial fermentation with resultant production of
hydrogen, methane, carbon dioxide, water, acid and short-chain
or volatile fatty acids.(63) These products act as osmotic agents
and also stimulate intestinal motility and secretion. Lactulose has
been shown to increase stool frequency in chronically constipated
patients (64); however, abdominal bloating, discomfort, and
flatulence are common side effects of this medication and may
decrease patient compliance. Sorbitol is a poorly absorbed sugar
alcohol that produces similar effects. In a trial of constipated men
over the age of 65, sorbitol administered as a 70% syrup (10.5 g/15
mL; 15 to 60 mL daily) was equivalent to lactulose in improving
symptoms.(65) Furthermore, it was cheaper and better tolerated
during a 4-week trial.
High-molecular-weight polyethylene glycol (PEG) is a large poly-
mer with substantial osmotic activity that obligates intraluminal
water.(66) It is routinely used with a balanced electrolyte solution
for colon cleansing as polyethylene glycol electrolyte lavage solution
(PEG-ELS). These solutions are safe and effective, and are routinely
used for bowel preparations for colonoscopy and bowel surgery.
(67) Other forms have been effectively used as laxatives for the treat-
ment of constipation. PEG 3350 (MiraLax, Braintree Laboratories,
Braintree, MA) is a large chemically inert polymer that also functions
as an osmotic laxative. It does not contain salts that can be absorbed,
and has been shown not to change measured electrolytes, calcium,
glucose, blood urea nitrogen (BUN), creatinine, or serum osmolal-
ity.(68) A recent randomized controlled multicenter trial has shown
effectiveness of 17g of PEG 3350 laxative over a dextrose placebo,
with greatest efficacy during the second week of the therapy.(69) An
8-week, double blind, placebo-controlled study showed that PEG
3350 administered to patients with chronic constipation increased
stool frequency and accelerated left colonic transit, without induc-
ing abdominal cramps or bloating. In a long-term multicenter study
of PEG 4000, 14.6 g twice a day improved stool frequency, reduced
straining effort, softened stools, and decreased the need for oral laxa-
tives and enemas when compared with placebo (70); however, there
was a high dropout rate (30% PEG 4000 and 60% placebo) which
raises concerns about efficacy and tolerance.
Stimulant laxatives. The stimulant laxatives have effects on
mucosal electrolyte transport and gut motility. Commonly used
laxatives in this category include bisacodyl and senna. Abdominal
discomfort and cramping are common side effects of these agents.
Bisacodyl produces defecation within 6 to 8 hours of taking the


 operative and nonoperative therapy for chronic constipation
tablet, or 15 to 30 minutes after the suppository. It is believed
to exert its effect by inducing high amplitude propagated con-
tractions of the bowel, and is an effective rescue medication for
chronic constipation.(27) Senna is member of the anthraquinone
family of laxatives that are common constituents of herbal and
over-the-counter laxatives. They are metabolized in the colon by
bacteria into their active forms. In a trial of elderly nursing home
residents (n = 77), a senna and fiber combination was reported
to be better than lactulose in improving stool frequency, stool
consistency, and ease of passage.(71) Furthermore, the senna and
fiber combination was 40% cheaper than lactulose therapy.
Side effects of these laxatives include allergic reactions, electro-
lyte imbalance, melanosis coli, and “cathartic colon”. Melanosis
coli is a result of chronic ingestion of anthraquinone-containing
laxatives. This condition is an abnormal pigmentation of the
colonic mucosa that is caused by the accumulation of apop-
totic epithelial cells that are phagocytosed by macrophages.(72)
“Cathartic colon” is an alteration of colon anatomy that was
believed to be associated with chronic stimulant laxative use.
Barium enema findings included colonic dilation, loss of haus-
tral folds, strictures, colonic redundancy, and wide gaping of the
ileocecal valve.(73) Initially, it was attributed to the destruction of
myenteric plexus neurons by laxatives (74); however, more recent
studies do not confirm those findings.(75) Current evidence sup-
ports the safety of currently available laxatives at recommended
doses for long-term use. Finally, anthraquinones have been pro-
posed to have mutagenic effects and produce tumors in animal
models. Several cohort studies and one case-control study failed
to find an association between anthraquinones and colorectal
adenomas or carcinoma.(76)
Other drugs. Patients with severe slow-transit constipation
may not respond to medical therapies described above. Ideally,
slow-transit constipation should be treated with an agent that
restores normal colonic function. Medications such as secretago-
gues (lobiprostone, cholchicine, and misoprostol) and prokinetic
agents (tegaserod, alvimopan, linaclotide) are currently under
clinical trials for the treatment of constipation, and show promise
for patients with slow-transit constipation.
Lubiprostone is an oral bicyclic fatty acid that activates the type
2 chloride channels that are located on the intestinal epithelial
cell leading to an active secretion of chloride in the intestinal
lumen.(77) In healthy humans, this drug has been shown to slow
gastric emptying, but accelerated small bowel and colonic transit
time at 24 hours.(78) In a randomized control study with intent
to treat analysis, lubiprostone significantly increased the number
of spontaneous bowel movements per week, improved straining
effort, improved overall satisfaction with bowel habits, and pro-
duced softer stools when compared with placebo.(79)
Colchicine is a microtubule formation inhibitor that is com-
monly used to treat gouty arthritis. A significant side effect of
colchicine is diarrhea. In an open labeled study of 7 patients with
normal transit constipation, colchicine (0.6 mg orally 3 times
per day) increased stool frequency and accelerated colon tran-
sit time.(80) Furthermore, patients reported reduced symptoms
of abdominal pain, nausea, and bloating. However, long-term
use may be associated with neuromyopathy, and its use for
chronic constipation is not supported. The prostaglandin E1
analog misoprostol (1200 µg/d) has been shown to increase stool
frequency and accelerate colonic transit (81); however, the drug is
expensive and its beneficial effects appear to decline over time.
Tegaserod is a serotonin 5-HT4 receptor partial agonist that
has been shown to increase gastic emptying and colonic transit
time.(82) Large randomized controlled trials in the United States
and Europe have reported that tegaserod increases the number
of complete spontaneous bowel movements per week, relieves
constipation-related symptoms, and improves overall bowel sat-
isfaction.(79, 83) However, recent reports of 0.01% incidence
of coronary and cerebrovascular events have suspended sales
of tegaserod. Another drug, alvimopan, is a peripherally acting
µ-opioid receptor antagonist. This drug does not cross the blood-
brain barrier, and therefore, does not inhibit the analgesic effect
of opioids. A physiologic study of alvimopan has shown that this
drug reverses opioid-induced delayed colonic transit in healthy
subjects.(84) These data were verified in another randomized
trial of opioid-induced bowel dysfunction, and has been shown
to be effective in the treatment of acute postoperative ileus.(85,
86) Further studies are necessary to determine efficacy of alvimo-
pan on chronic constipation.
BIOFEEDBACK THERAPY
In patients with constipation due to pelvic floor dyssynergia, bio-
feedback therapy is frequently recommended after failure of con-
servative management described above.(87) Biofeedback therapy
uses electronically amplified recordings of pelvic floor mus-
cle contractions (EMG) or anorectal pressure tracings to teach
patients how to relax pelvic floor muscles and to strain more
effectively when they defecate.(12) The purpose of this therapeu-
tic modality is to restore a normal pattern of defecation by using
an instrument-based education program. The primary goals are
to correct the underlying dyssynergy that affects the abdominal,
rectal, and anal sphincter muscles, and to improve the rectal sen-
sory perception. A series of training sessions are used to teach
diaphragmatic breathing techniques to improve abdominal push-
ing effort and to synchronize this with anal relaxation. Visual or
auditory feedback is used to provide the patent input regarding
performance during attempted defecation maneuvers.
Studies on biofeedback therapy for the treatment of pelvic
floor dyssynergia have been reviewed extensively.(88, 89) These
reviews suggest that two-thirds of these patients benefit from
biofeedback training, with individual studies reporting a 30 to
100% success rate; however, attempts to draw definitive conclu-
sions about the usefulness and effectiveness of biofeedback for
the treatment of pelvic floor dyssynergia-type constipation are
difficult due to the lack of adequately controlled trials of suffi-
cient sample size.(87) In a recent review of biofeedback therapy
for pelvic floor dyssynergia, 4 of 27 (<15%) studies in the adult
population were controlled, and only one well-controlled study
had a sample size that was sufficient to provide meaningful statis-
tical conclusions.(87)
Biofeedback therapy for dyssynergic-type constipation is directed
at coordinating pelvic floor muscle relaxation with intraabdominal
pressure to generate an effective propulsive force. Instrumentation
protocols in these patients require either EMG monitoring of
muscle tone or anorectal pressures for biofeedback training. To

 improved outcomes in colon and rectal surgery
determine which method is superior, a recent meta-analysis of
the available literature was used to compare the treatment out-
come using EMG vs. pressure biofeedback.(87) EMG biofeed-
back was primarily used in 18 studies (442 subjects) with a mean
success rate (improved symptoms) of 70%. Pressure biofeedback
training was used in 13 studies (275 subjects) with a mean success
rate of 78%. These results showed a significantly better outcome
in patients with pressure biofeedback protocols. Further analy-
sis compared intraanal to perianal EMG biofeedback and their
results showed no significant difference between the two sub-
groups (69% vs. 72%, respectively). Overall, these data show suc-
cess rates ranging from 69 to 78%, regardless of which protocol or
what instrumentation is used; however, without controlled trials,
the optimal protocol for subjects with dyssynergic-type constipa-
tion remains unclear.
The role of other factors on the outcome of biofeedback therapy
in patients with pelvic dyssynergy has been studied. In one study,
the only predictor of successful outcome was the number of ses-
sions attended (5 or more) and whether the therapist discharged
the patient (63% success rate) rather than the patient terminating
treatment prematurely (25% success rate).(90) To date, research-
ers have not been able to identify any physiologic (manometry
and balloon expulsion test), anatomic (rectocele, intussusception,
or abnormal perineal descent), or demographic (age, gender,
duration of symptoms) variables that influence treatment out-
come; however, many investigators do suggest that psychopathol-
ogy may influence biofeedback treatment outcome. Anxiety and
psychological distress are commonly associated with pelvic floor
dyssynergy. One study showed that patients with pelvic floor dys-
synergic-type constipation or rectal pain showed a tendency to
use somatization as a defense mechanism to manage psychologi-
cal distress.(91) This pattern was not seen in a comparison group
of patients with fecal incontinence. Others have suggested that
there may be a psychosomatic basis for chronic idiopathic con-
stipation, including pelvic floor dyssynergy.(92, 93) Studies have
reported up to 65% of constipated subjects were diagnosed with
various psychological disorders (94); however, there is significant
debate whether the psychopathology is a cause or a consequence
of dyssynergic constipation. In a study of patients with slow-tran-
sit constipation without pelvic dyssynergy 60% of subjects had a
concurrent affective disorder, with 66% reporting having a previous
affective disorder.(95) Others have shown a high incidence of
sexual or physical abuse in patients suffering from constipation.
Given these results, it is of no surprise that psychological treatment
for subjects with constipation is frequently recommended in addi-
tion to biofeedback therapy. Establishment of an effective psycho-
therapeutic relationship may be critical for success.
Biofeedback therapy has been used for the treatment of slow-
transit constipation. A single case series reported the successful
treatment of 4 patients with slow-transit constipation without
pelvic floor dyssynergy using biofeedback therapy (96); how-
ever, two of the four patients continued to require laxative use
despite improved symptoms, and there was no objective confirm-
atory evidence (repeat colonic transit study) to support physi-
ologic improvement. A recent study has compared the benefits
of biofeedback therapy in patients with slow-transit constipa-
tion to those with pelvic dyssynergia-type constipation.(97) At

6 months, the dyssynergic group had greater satisfaction (71%
vs. 8%), and more frequently reported ≥ 3 bowel movements
per week (76% vs. 8%) than the slow-transit group following a
5 weekly biofeedback sessions. These data indicate that pelvic
floor biofeedback benefits patients with pelvic floor dyssyner-
gia, but not patients with slow transit constipation. Biofeedback
therapy has been suggested as the initial therapy for patients with
outlet obstruction associated with pelvic floor dyssynergy. This
concept is supported by a recent randomized, controlled trial
of patients with pelvic floor dyssynergy where biofeedback was
shown to be more effective than laxative therapy with PEG.(98)
Further well designed prospective randomized controlled trials
are necessary to establish biofeedback therapy as the primary
treatment for patients with this condition.
Failure of biofeedback therapy poses a significant treatment
problem as most patients do not improve with surgical interven-
tion. Division of the puborectalis muscle in the posterior midline
has been reported in patients with intractable pelvic dyssynergy.
However, results are disappointing with very few patients obtain-
ing any benefit from the procedure.(99) These data suggest that
this procedure has no role in the treatment of patients with this
condition. Botulinum toxin injection has been proposed as an
alternative therapeutic modality for these patients with refrac-
tory pelvic floor dyssynergy. Injection of the toxin is directed into
the puborectalis muscle and external anal sphincter. Symptom
improvement was reported in up to 75% of patients with benefit
lasting from 1 to 3 months. Fecal incontinence was reported in
25% of patients, and was transient lasting only 1 to 3 months
after injection.(100–101) Others have reported similar beneficial
effects of botulinum toxin injection for dyssynergic-type con-
stipation.(102) However, because the effects of the toxin wear
off within 3 months of administration, repeated injections are
necessary to maintain symptomatic improvement. Furthermore,
given the expense of this drug, this treatment modality should be
reserved for those patients with severe symptomatic pelvic dys-
synergia that has failed all other therapies.
SURGERY OPTIONS
Surgical intervention for functional constipation is limited to
patients with documented severe slow-transit constipation that
is refractory to medical management. Patient selection is criti-
cal for success. Minimal evaluation requires colon transit studies
to document slow-transit constipation, and pelvic floor physiol-
ogy testing to rule out pelvic floor dysfunction. Operative proce-
dures performed for the treatment of slow-transit constipation
include segmental colectomy, subtotal colectomy with ileosig-
moid anastamosis, and total abdominal colectomy with ileorec-
tal anastamosis. Each procedure has its champions; however, the
overwhelming body of literature indicates superiority of total
abdominal colectomy with ileorectal anastamosis.
Total abdominal colectomy with ileorectal anastamosis is the
treatment of choice for patients with slow-transit constipation.
The anastamosis is usually performed in the proximal rectum
at or near the sacral promontory. At this level, the anastamosis
is easier to perform, eliminates the risks associated with rectal
mobilization, and bowel diameter does not limit the size of the
anastomotic lumen.(103)
 operative and nonoperative therapy for chronic constipation
Timing of surgery is best decided by the patient, as this sur-
gery is an irreversible step in the treatment of constipation. Most
patients are accepting of surgical intervention when all conserva-
tive measures have failed to result in an acceptable quality of life.
In addition to standard operative risk for colectomy, patients
should be counseled that abdominal pain and bloating may
persist postoperatively even after normalization of bowel fre-
quency. This is significant as a recent report showed that persist-
ent abdominal pain had the strongest correlation with quality of
life scores following colectomy in these patients.(104) Standard
bowel preparations may not be sufficient as many patients with
slow-transit constipation have one bowel-movement per week
and are already taking PEG products to assist with bowel func-
tion. A clear liquid diet for 48 hours along with multiple enemas
and laxatives may be necessary to adequately evacuate the colon
and rectum of stool. Perioperative antibiotics are given accord-
ing to current standards (intravenous) and physician preference
(oral) as described in Chapter 2.
Overall success of total abdominal colectomy with ileorectal anas-
tamosis for slow-transit constipation is approximately 90%, and
reported rates of symptomatic improvement ranges from 50% to
100%.(104, 105) This variability may be the direct result of how suc-
cess after surgery is defined.(104) Many studies use patient satisfaction
as criteria for success; however, patient derived subjective assessment
is an inaccurate measurement of surgical outcome and likely varies
between patients and studies. In a review of the literature evaluating
subtotal colectomy for slow-transit constipation, Knowles et al. found
that only half of the 31 studies that documented success or satisfaction
reported the method of data acquisition.(19) Furthermore, in these
studies success rate was based on patient judgment in 14, on function
in 6, and on a combination of both in 5. Criteria used to assess suc-
cess or satisfaction was not reported in 6 studies. Patient satisfaction
and gastrointestinal functional outcomes (i.e. bowel-movement fre-
quency) do not correlate with quality of life.(104, 106) A recent report
showed a significant increase in bowel-movement frequency after
subtotal colectomy; however, the persistence of abdominal pain and
the development of postoperative incontinence or diarrhea adversely
affected quality of life scores.(104) The authors concluded that bowel
movement frequency alone does not provide an accurate assessment
of patient’s outcome. This has led investigators to suggest the use of
standardized outcome measures such as questionnaire-based proto-
cols that assess quality of life.(106) These instruments should be used
along with postoperative complications, functional outcome measures
as well as gastrointestinal function to provide more uniform outcomes
measurement of operative success in these patients.
Acute and long-term complications are significant and include
prolonged postoperative ileus, recurrent bowel obstruction,
abdominal pain and bloating, diarrhea, incontinence, and recur-
rent constipation, and are addressed in detail below. These fac-
tors all affect quality of life scores with incontinence having the
greatest negative impact.(104) In fact, postoperative quality of
life assessment after total abdominal colectomy and ileorectal
anastamosis showed significantly decreased scores compared to
those of the general population (107); however, 93% of patients
that met selection criteria for total abdominal colectomy with ile-
orectal anastamosis for slow-transit constipation would undergo
colectomy again given the chance.(104)
Early reports found that if the whole intraabdominal colon
was not removed, symptoms often recurred.(108) In fact, results
of segmental colectomy have been disappointing with small
series reporting up to 100% failure rate.(19) Reports of subtotal
colectomy with ileosigmoid anastamosis resulted in an increased
incidence of constipation and conversion to total colectomy
was necessary in 50% of cases.(109) Other authors support this
concept and cite increased incidence of constipation recurrence
and persistence resulting in the need to reoperate to remove the
remaining colon.(107, 110) Removal of the colon with preserva-
tion of the cecum and ileocecal valve has been described; how-
ever, long-term results were poor as maintenance of the cecal
reservoir resulted in dilatation and recurrence of constipation
symptoms.(111) Modifications of colonic transit studies using
multiple ingestible markers and scintigraphic defecography have
been used to determine segmental colonic inertia.(112) Although
the validity of these techniques to determine segmental motility
dysfunction has been questioned (113), these tests have been used
in recent studies to identify and successfully treat patients with
segmental colonic inertia.(105, 114) In one study, 28 patients
were treated with segmental resection with a median follow-up of
50 months.(114) Early failure with persistent or recurrent consti-
pation occurred in 3 (11%) patients and required further surgery.
Patient satisfaction was reported in 23 (82%) patients; however,
outcome was reported as excellent in 10 patients, good in 7, fair
in 7, poor in 4. If successful outcomes were assigned to the excel-
lent and good category, the success rate would fall to 61%. Again,
variability in method to define success may play a factor in these
results. Another study evaluated 15 patients with slow-transit
constipation classifying them into total colonic slow-transit (8
patients) and left slow-transit (7 patients). (105) Total abdominal
colectomy or left colectomy was performed according to this clas-
sification and resulted in improvement in symptoms (increased
daily evacuations) in 8 (100%) and 6 (86%) patients, respectively.
The authors report that patients with left colonic slow-transit all
had prolonged latency times and were treated with percutaneous
nerve evaluation. None received permanent implantation of the
device, but it does raise the question as to whether colon transit
studies were affected in these patients. The weighted finding of
prolonged latency times in patients with left colonic slow-transit
is interesting as sacral nerve stimulation has been successful for
the treatment of slow-transit and dyssynergic-type constipation.
(115) Although segmental colectomy seems promising for the
treatment of segmental colonic inertia, controlled data are lack-
ing and further studies are needed to verify and support its use.
In a small subset of patients with slow-transit constipation ile-
ostomy may be necessary due to poor operative risk or in elderly
patients with impaired continence.
COMMON COMPLICATIONS
Morbidity of colectomy in patients with slow-transit constipation
includes several factors. First, the direct risks of colon resection are
related to the anastamosis (leak, stricture), infections (wound and
intraabdominal abscess), bleeding, and anesthesia. Mortality related
to colectomy in this group has been <1%.(103) Long-term compli-
cations resulting from colectomy in patients with slow-transit con-
stipation are significant, and have been shown to negatively impact

 improved outcomes in colon and rectal surgery
outcomes with decreased quality of life.(104) Common complica-
tions in this group of patients include recurrent bowel obstruction,
abdominal pain, diarrhea, incontinence, and recurrent constipa-
tion, and warrant further discussion. Recurrence of constipation is
addressed in detail in the section to follow.
In patients undergoing total abdominal colectomy with ile-
orectal anastamosis, the most frequently occurring complication
is small bowel obstruction. The reported incidence ranges from
8 to 38% with surgical intervention required in up to 75%.(104,
110, 116) The etiology of obstruction is commonly attributed to
adhesions formed from the extensive colectomy; however, others
have reported findings of small bowel pseudo-obstruction due
to proposed neuropathic disorder of the myenteric plexus affect-
ing overall bowel motility.(104, 117, 118) A retrospective review
examined the incidence of postoperative complications follow-
ing subtotal colectomy with ileorectal anastamosis in 48 patients
with colonic inertia, 30 with Crohn’s disease, and 22 with either
Familial Adenomatous Polyposis, or other neoplasia.(119) Small
bowel obstruction occurred in 10 to 18% of each group, with
no significant difference between groups. Others have reported
intestinal obstruction rates of 35% following total abdominal
colectomy for slow-transit constipation. In this study, 33% of
patients had evidence of a delay in small bowel transit time sug-
gesting this disorder is not limited to the colon, but also affects
the small bowel. Recent reviews have speculated that routine use
of antiadhesive agents such as Seprafilm® may reduce the inci-
dence of adhesion induced small bowel obstruction.(103)
Postoperative persistence of abdominal pain and alteration in
bowel function are significant issues that adversely affect quality
of live. A recent retrospective review on quality of life after subto-
tal colectomy for slow-transit constipation showed that abdomi-
nal pain was persistent in 41% of patients, diarrhea in 52%, and
incontinence in 45%.(104) Collectively, these factors had the
strongest correlation with quality of life survey, and the devel-
opment of incontinence had the most negative impact on the
score. As mentioned above, the high rate of persistent abdominal
pain after surgery warrants detailed counseling of the patients
regarding expectations and outcomes. Patients must be aware
that normalization of bowel frequency may not relieve them of
their pain. Diarrhea following total abdominal colectomy with
ileorectal anastamosis is not uncommon with reported incidence
ranging from 0 to 46%.(104) This is not surprising as the colon
is effective at water absorption and is responsible for desiccating
the stool. Over time intestinal adaptation occurs and normalizes
consistency and frequency of the stool, with more than 90% of
patients having either solid or semisolid stools by 6 months.(120)
During the intestinal adaptation period, diarrhea is treated with
fiber, motility agents (loperamide, diphenoxylate and atropine
sulfate), and binders (cholestyramine) to reduce bowel frequency.
The incidence of postoperative incontinence has been reported
in 0% to 52% of patients with a mean of 14%.(104) Intractable
diarrhea, especially in the setting of fecal incontinence, may
require conversion to a permanent ileostomy.
RECURRENCE
It is clear that colectomy for refractory constipation has demon-
strated successful outcomes for total abdominal colectomy with

ileorectal anastamosis in 89 to 100% after appropriate preop-
erative workup, including colon transit study, defecography, and
anorectal physiology tests.(19) Therefore, the greatest assurance
to success in the operative treatment of constipation starts with
appropriate patient selection.
Recurrence or persistence of constipation following colectomy has
been reported to occur in up to 33% of patients.(104) Patients with
combined slow-transit constipation with pelvic floor dyssynergy are
less likely to result in successful outcomes after surgery. Outcomes
in patients undergoing surgery for slow-transit constipation with or
without pelvic floor dyssynergy have been compared.(121) The pres-
ence of pelvic floor dysfunction significantly decreased success rates
from 78% to 56%. It has been shown that slow-transit constipation
with associated pelvic floor dyssynergia can be treated initially with
biofeedback therapy followed by surgery with similar improvement
in outcomes such as median stool number per day, spontaneous
stools, laxative use, and quality of life.(107)
Patients with slow-transit constipation are believed to have a glo-
bal neuropathic disorder of the myenteric plexus that affects colonic
motility.(117) It has been proposed that this neuropathic disorder
may extend proximal into the small bowel, or even the entire gas-
trointestinal tract resulting in a global gastrointestinal motility dis-
order (panenteric inertia). Failure to identify these patients may be
a reason for early recurrence of constipation or even the high inci-
dence of postoperative bowel obstruction. Preoperative evaluation
of whole gastrointestinal transit should be performed in all patients
undergoing surgery for slow-transit constipation. Successful iden-
tification of these patients should raise question as to whether they
will benefit from colectomy. If this entity is identified after surgery,
conversion to an ileostomy may be required.
Finally, recurrence of constipation may be a direct result of
incomplete colonic resection. Segmental colectomy, ileosigmoid
anastamosis, and preservation of the cecum and ileocecal valve
with cecorectal anastamosis are all associated with a higher inci-
dence of constipation recurrence or persistence. Surgical failure
in these patients frequently requires reoperation for conversion
to ileorectal anastamosis.
In patients with recurrent constipation after colectomy, workup
is directed at the issues addressed above. First, anatomic evalu-
ation of the remaining rectum should be performed. Flexible
signoidoscopy is adequate and can be performed in the office after two
Fleets enemas. Special attention is made to the anastamosis as stric-
ture formation will result in constipation. In the absence of organic
disease, pelvic floor physiology testing is repeated to determine
the presence of pelvic floor dyssynergia. Presence of this condition
requires biofeedback therapy to improve symptoms and outcome.
Upper gastrointestinal small bowel follow trough and other tests of
whole gut transit will determine whether panenteric inertia is present.
In these patients, persistent constipation and pseudo-obstruction
are difficult to manage and may require end ileostomy. A careful
review of the original operative report will provide evidence as to
whether adequate colectomy was performed. Complimentary tests
such as colon transit studies (radiopaque markers or scintigraphy)
and gastrografin enema (avoid barium if constipation is significant)
will help determine if there is residual dysmotile colon remaining.
Persistent constipation with evidence of residual colon may require
completion colectomy with ileorectal anastamosis.
 operative and nonoperative therapy for chronic constipation
SUMMARY  
Constipation is a common and complex polysymptomatic clini-
cal disorder that has multiple etiologies. Successful treatment
requires careful workup and patient selection. A careful history  
and physical exam are the first step. Many medical conditions
and medications can cause constipation, and correction of these  
disorders can improve symptoms. Anatomic evaluation of the
colon to rule out neoplasia, stricture, and other organic disease  
is required. When these secondary causes of constipation are
excluded, a functional chronic constipation exists. Functional
constipation consists of three overlapping subtypes including  
slow-transit constipation, dyssynergic defecation, and mixed dis-
orders. Initial therapy for all patients includes dietary and lifestyle
modification with and without laxatives. Persistent constipation
that is refractory to medical management requires further testing.  
The tests obtained will vary depending on the patients history,
surgeons experience, and testing availability. Colonic motility is  
determined by colon transit studies such as radiopaque markers
or scitigraphic defecography. Pelvic floor function and physiology
is determined by anal manometry, balloon expulsion test, defec-  
ography, and electromyography. Isolated slow-transit constipa-
tion is successfully treated with total abdominal colectomy with  
ileorectostomy. Lesser operations result in poor outcome with a
high incidence of reoperation. Before surgery global gastrointes-
tinal motility should be assessed as the presence of panenteric  
inertia can negatively impact outcomes. Pelvic floor dyssynergia
is treated with biofeedback therapy to improve pelvic muscle  
coordination for defecation. Surgical therapy has poor results
and should be discouraged. The combination of slow-transit
constipation and pelvic floor dyssynergia are more complex.  
Optimal outcomes require successful treatment of pelvic floor
dysfunction with biofeedback therapy before surgery.
 
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35 Colorectal trauma
S David Cho, Sharon L Wright, and Martin A Schreiber
challenging case
A 23-year-old man sustained a through and through gun shot
wound to the left lower abdomen. The patient was mildly hypoten-
sive on arrival to the emergency room, but responded to admin-
istration of 2 L of normal saline. The abdominal exam reveals
the bullet holes and moderate tenderness. The rectal exam was
normal. Chest and abdominal radiographs were normal except
for markers at the gunshot wounds, electrolytes and hemoglobin
levels were normal. After administration of a second generation
cephalosporin and a type and cross for blood, the patient was
taken to the operating room for an abdominal exploration. The
only injury found was a lateral injury to the mid sigmoid colon.
There was minimal stool contamination of the lower abdomen.
case management
The colonic wound edges were debrided and the colon was
repaired primarily with a two layer suture closure. The abdomen
was copiously irrigated. The laparotomy wound was closed and
the patient received one dose of antibiotics postoperatively.
introduction
The management of traumatic colon injury has been the sub-
ject of much debate and has evolved considerably over the past
century. During World War I, primary repair was practiced for
all colon injuries, with a resultant mortality in excess of 60%.
(1, 2) Civilian series reported similar results, with LoCicero and
colleagues reporting a 67% mortality rate from 1927–1942.(3)
The mortality rate dropped to approximately 30% during World
War II (2) at a time when several changes in management were
introduced. Most notably, Ogilvie (4) described exteriorization
of colon injuries, leading to the practice of mandatory colostomy,
which reduced mortality to about 45%.(4) Mortality dropped
further during the Korean and Vietnam conflicts, to about 10%
(1), which many attributed to the standardization of colos-
tomy. The thinking at that time was that diversion of the fecal
stream and avoiding an anastomosis would greatly reduce infec-
tious complications.(5) The specter of infection was particularly
ominous during a time when antibiotics had just been intro-
duced. Many combat surgeons did not have significant training
in managing colon injuries, high-velocity wounds, or operating
under conditions of resource constraint and combat triage, dur-
ing which follow-up of an anastomosis would be difficult.(4, 6)
These concepts became incorporated into civilian settings as well
and became the standard for at least 30 years. Other innovations
during this period included the introduction of antibiotics, and
improvements in transport, surgical devices, critical care, and
resuscitation (2, 5, 7, 8) that may well have been responsible for
the improvements in survival. Despite these factors, colostomy
remained the standard of care for the first three-quarters of the
twentieth century.
This practice was first successfully challenged by the landmark
work of Stone and Fabian (9) in 1979, when they published the
results of their randomized trial of primary repair without diver-
sion versus colostomy in 268 patients with colon injuries. They
noted a similar wound infection rate, and a significantly lower
peritoneal infection rate with primary repair (15% vs. 29%).
Their overall complication rate was 1% for primary repair and
10% for colostomy. Further, they noted an increase in hospital
length of stay of approximately 6 days in the colostomy group.
Although the study excluded more severely injured patients, it
was the first to provide evidence that colostomy was not manda-
tory in all cases. Based on this work, a growing body of evidence
contributed to a shift toward primary repair of traumatic colon
injury during the 1980s and 1990s.
Currently, primary repair, defined as a single-staged operation
establishing bowel continuity (either by direct suture repair or
resection and anastomosis) without proximal diversion, is being
increasingly used for most colon injuries in civilian settings.(10,
11) The military conflict in Iraq and Afghanistan has both rein-
vigorated the debate between primary repair and diversion, and
has brought new perspectives to this issue. Clearly, optimal treat-
ment depends not on the uniform application of one technique
or the other, but depends on sound judgment and an understand-
ing of the current evidence.
epidemiology
Colon injury occurs in 30% of abdominal gunshot wounds
and 5% of stab wounds, and is the second most common
intraabdominal organ injury in civilian penetrating trauma.
(12) Penetrating mechanisms cause 85–95% of colon injuries
in civilian practice.(6, 13–16) In contrast, in a recent review
of colon injuries sustained by American soldiers in Operation
Iraqi Freedom over a 2-year period, 71% of injuries were caused
by improvised explosive devices (IED) and 24% were caused by
gunshot wounds. Blunt injury is rare, with colon involvement
in 0.2% of trauma admissions but 20–30% of blunt hollow
viscus injuries.(17) Motor vehicle crashes and traffic accidents
account for the majority of blunt colorectal injuries.(18, 19)
Approximately 80–90% of colon injuries in civilian settings are
nondestructive.(20)
While mortality has dropped in recent decades to <3% (21,
22), morbidity has remained high. Colon related complications
have been consistently reported in 15–30% of cases since 1979.
(9, 14, 23–27)
preoperative assessment
The initial assessment of any trauma patient always begins with
the ABCs (airway, breathing, and circulation) and adherence to
Advanced Trauma Life Support (ATLS) principles including the
primary and secondary surveys, rapid treatment of immediately

 improved outcomes in colon and rectal surgery
Figure 35.1a  Seat-belt sign. The patient was involved in a roll-over motor vehicle
crash.
life-threatening injuries, establishment of appropriate intrave-
nous access, and administration of fluids or blood products when
appropriate.
In cases of severe injury accompanied by marked physiologic
derangement, most notably the ‘lethal triad’ (acidosis, hypo-
thermia, and coagulopathy) (28) of trauma, the principles of
damage control surgery are applicable. These include rapid tri-
age, abbreviated laparotomy, and return to the intensive care unit
(ICU) for rewarming and correction of acidosis and coagulopa-
thy. Intraoperatively the abdomen is packed, massive hemorrhage
is controlled, and injured bowel is stapled off and left in disconti-
nuity if necessary. In 12 to 24 hours the patient is brought back to
the operating room at least once for reexploration and definitive
repair.(29)
Diagnosis
The diagnosis of bowel injury is notoriously difficult. Colon inju-
ries are primarily diagnosed intraoperatively.(30) However, diag-
nostic techniques warrant a brief discussion.
physical exam
Peritoneal signs in the abdominal trauma victim are most often
caused by hollow viscus injury. However, physical exam may be dif-
ficult to perform in the multisystem trauma patient. Intoxication,
traumatic head injury, or distracting injuries may obviate a reli-
able physical exam.
The “seat belt sign” has been described as a physical exam find-
ing that predicts bowel injury. The classic finding is ecchymosis of
the anterior abdominal wall secondary to the compressive force
of the lap belt (Figure 35.1a). It is associated with a more than
doubled (2.9%) relative risk of bowel injury.(31) Flexion distrac-
tion injuries of the thoracolumbar spine, termed “Chance frac-
tures”, also should raise suspicion for blunt bowel injury.(32)
Diagnostic peritoneal lavage
Diagnostic peritoneal lavage (DPL) is a rapid and inexpensive
test to evaluate the intraperitoneal contents and it remains a

diagnostic option in patients with suspected abdominal injury.
Via an open or closed technique, the abdominal cavity is lavaged
with 1 L of isotonic solution, then aspirated and tested for evi-
dence of intraabdominal injury. In blunt trauma, DPL is con-
sidered positive if 10 mL of blood is aspirated before instillation
of lavage fluid. Microscopic criteria for a positive DPL in blunt
trauma include more than 100,000 red blood cells (RBCs)/mm3
or 500 white blood cells/ mm3. The criteria for a positive DPL
in penetrating trauma are much less standardized and vary from
more than 1,000 RBCs/mm3 to gross aspiration of >10 cc of
blood. In both blunt and penetrating trauma, presence of bile,
amylase, bacteria, or particulate matter should indicate visceral
injury and need for laparotomy. The accuracy of DPL is 92% to
98%, as reported by the Eastern Association for the Surgery of
Trauma guidelines.(33)
Otomo et al. (34) posited new criteria specifically designed to
diagnose intestinal injuries using DPL. Due to the fact that hemo-
peritoneum is not necessarily an indication for operation, they
considered the DPL positive when there was a relative increase in
the WBC count compared to the RBC indicating peritoneal irrita-
tion. They prospectively evaluated 250 patients with blunt abdomi-
nal trauma. In addition to other criteria, when the RBC count in
the lavage fluid was greater than 10 × 104/mm3), then the DPL
was considered positive when the WBC count exceeded the RBC
count/150. They report that these criteria have a diagnostic sensi-
tivity of 96.6% and specificity of 99.4% for intestinal injury.
Advantages of DPL include rapidity, higher sensitivity, lower
cost, and immediate performance and interpretation. Unlike
computed tomography, performance of DPL does not require
transfer to a noncritical area. The major disadvantages are a 1%
to 3% risk of iatrogenic intraperitoneal injury and the high sen-
sitivity of the test, which may lead  to nontherapeutic laparoto-
mies.(33) The utility of DPL has significantly decreased in the
era of nonoperative management of solid organ injuries and it
is primarily used in unstable trauma patients with an unknown
source of hemorrhage. However, DPL may diagnose hollow vis-
cus injuries that are missed by other modalities. There are relative
contraindications to the performance of a DPL which include
pregnancy, obesity, and prior celiotomy. Lastly, DPL is primarily
of value if the abdominal injury is intraperitoneal. If the injury is
confined to the extraperitoneal colon and rectum, DPL may not
identify these injuries.
Ultrasound
Focused abdominal sonography for trauma (FAST) is now a com-
monly used modality in the initial diagnostic management of
abdominal trauma. FAST has been used as a screening modality
for patients with blunt trauma to determine which stable patients
should undergo further diagnostic imaging with CT scanning. It
has also been used in hemodynamically unstable patients to rap-
idly determine presence of intraperitoneal fluid and the need for
immediate surgery analogous to the use of gross blood on DPL.
In FAST, the ultrasound probe is used to serially evaluate the
pericardium, Morison’s pouch (hepatorenal space), splenorenal
recess, and the pouch of Douglas (retrovesical portion of the
intraperitoneal cavity) for free fluid. A small amount of physi-
ologic fluid is occasionally seen in the pelvis, but anything more
 colorectal trauma
Figure 35.1b  CT scan of a patient with colon injury who demonstrated a “seat-
belt” sign. Note the presence of free fluid (arrow) consistent with blood in the
abdominal cavity. Of note, this patient did not have a solid organ injury raising
suspicion of a hollow viscus injury.
should be considered abnormal and should prompt either opera-
tive exploration or further investigation.
FAST has a sensitivity of 42% to 63%, a specificity of 98% to
100%, a positive predictive value of 67% to 100%, negative pre-
dictive value of 93% to 98%, and an accuracy of 92% to 98%.
(33–40) Its advantages include rapidity, easy repeatability, its
noninvasive nature, the absence of radiation exposure, and low
cost. Disadvantages to FAST are interobserver variability and
the fact that hollow viscus injuries may not be associated with
an adequate volume of free intraabdominal fluid to be diagnosed
by FAST.
Computed tomography
Computed tomography (CT) scanning of the abdomen and pel-
vis is the procedure of choice for the evaluation of the hemody-
namically stable blunt trauma patient.(33) It is recommended in
patients with equivocal physical exam findings, multiple injuries,
and neurologic injury.
Abdominal CT has a sensitivity of 64% to 88%, specificity of
97% to 99%, and an accuracy of 82% to 99% for the diagno-
sis of hollow viscus injury.(41, 42) Disadvantages include high
cost, radiation exposure, and the need to transport patients to the
radiology suite.
Signs of bowel trauma seen on CT include mesenteric strand-
ing, free intraperitoneal fluid in the absence of solid organ injury,
extraluminal air or contrast material, and bowel wall thickening.
(43) Figure 35.1b demonstrates these findings. Improvements
in CT technology have led to increasing sensitivity of CT in the
detection of the more subtle signs of injury to the bowel.
Laparoscopy
Laparoscopy has been evaluated in the diagnosis of intraabdomi-
nal injury in a selected group of trauma patients as a method to
evaluate penetrating injuries. Potential advantages include avoid-
ing nontherapeutic laparotomy and diagnosing and treating blunt
bowel injuries that are otherwise missed by imaging techniques.
In patients with penetrating abdominal trauma, stable vital signs,
intact sensorium without evidence of raised intracranial pres-
sure, and absence of contraindications for pneumoperitoneum,
Ahmed et al. found that exploratory laparoscopy is safe and accu-
rate in the diagnosis of penetrating abdominal injuries, and iden-
tified those injuries that necessitated open repair.(44) In their
study, they report avoiding nontherapeutic exploratory laparo-
tomy in 75% of their patients. The authors describe laparoscopy
as having the advantage of identifying injuries to the peritoneum,
diaphragm, mesentery and omentum.
Mitsuhide et al. (45), prospectively evaluated the use of diag-
nostic laparoscopy in conjunction with CT scan in patients with
blunt abdominal injury. Diagnostic laparoscopy was performed
in hemodynamically stable patients who had either local peri-
toneal signs and indirect CT signs (bowel thickening or isolated
intraperitoneal fluid), an increase in abdominal pain or tender-
ness, or intraperitoneal fluid increased on serial CT scan. A total
of 25 laparotomies were performed in 399 patients, 14 based on
physical exam or CT findings and another 11 after laparoscopy.
In total, 17 laparoscopic examinations were completed and 10
injuries were repaired. Thus, in these 399 patients, laparoscopy
detected 1 mesenteric laceration and 7 bowel injuries that were
not diagnosed on CT scan. There were no nontherapeutic lapa-
rotomies, and 7 laparotomies were avoided. They concluded that
laparoscopy can prevent nontherapeutic laparotomy and delayed
diagnosis in patients with suspected blunt bowel injury.
Risks of laparoscopy in trauma patients include tension pneu-
mothorax upon CO2 insufflation, which can be decreased by
limiting initial insufflation pressures to 8 mmHg.(45) Other risks
include hypotension following insufflation secondary to intra-
vascular volume depletion, and gas embolism in patients with
intraabdominal solid viscus injury.
Injury scales
In the effort to standardize assessment of traumatic injuries and
potentially predict outcomes, a number of scoring systems have
been published. While these scales do not attempt to replace
sound judgment, experience and individualization of treatment,
they are useful as a common means of assessment and commu-
nication amongst surgeons caring for patients with these inju-
ries. The three most commonly used in association with colonic
injury are briefly discussed here.
Flint and colleagues (16) described three grades of colonic injury
(Table 35.1), derived from a series of 137 patients. Interestingly,
this report appears to have been at least in part generated by the
discussion begun by Stone and Fabian (9) just 2 years earlier. The
aim of their study was to determine if selection of candidates for
primary repair could be based on the severity of colon injury.
They noted an increase in mortality from 4% to 25% between
injury grades 1 and 3, and no complications for grade 1 versus a
31% complication rate for grade 3 injury. Although no statistics
were reported, the authors concluded that primary repair was safe
for injury grade 1, while colostomy was the procedure of choice
for grades 2 and 3.
Moore and co-workers proposed a Penetrating Abdominal
Trauma Index (PATI) in 1981.(46) These authors cited a need for
an injury severity index that specifically addressed intraabdomi-
nal injury, one that focused on morbidity rather than mortality,

 improved outcomes in colon and rectal surgery
Table 35.1  Flint grades of colonic injury.
Grade Mortality a
Complications
a
1  Isolated colon injury, minimal contamination,   4%   0%
   no shock, minimal delay
2  Through-and-through perforation, lacerations, 20% 20%
   moderate contamination
3  Severe tissue loss, devascularization, heavy 25% 31%
   contamination
a. n = 137.
and that was reliable in the acute postinjury setting as opposed to
other etiologies for critical illness (i.e. sepsis or major operation).
Three hundred sixty patients undergoing laparotomy for pen-
etrating trauma were the basis of this study. Each intraabdominal
organ was assigned a weight in terms of potential for developing
complications, and a sub-grading from 1–5 based on severity of
the injury. A PATI cutoff of 25 separated a substantial increase in
complication rates (17% vs. 50% for stab wounds, and 12% vs.
44% for gunshot wounds). Notably, this scale provided a basis
for the development of the Organ Injury Scale of the American
Association for the Surgery of Trauma (AAST).
In 1987, Dr. Donald Trunkey, the president of the AAST at that
time, appointed the Organ Injury Scaling Committee to derive
an injury scaling system that unified several previously proposed
scoring systems for the purposes of conducting higher-quality
research, and to provide a common parlance amongst centers and
authors (Trunkey, DD, personal communication). This commit-
tee cites the results of 2 prior studies of penetrating colon injuries
(47, 48), in which scoring systems proved useful to guide manage-
ment, as support for creating this scoring system for all abdomi-
nal organs. Their work utilized some of the structure of the PATI
proposed by Moore, as previously discussed. The AAST Colon
Injury Scale is shown in Table 35.2.(49)
management of penetrating colon injury
The argument for primary repair
The management of penetrating colon injury has undergone sig-
nificant changes during the past 50 years. Today, primary repair is
considered the treatment of choice for most colon injuries. Stone
and Fabian’s seminal paper set the stage for this strategy. Earlier
authors recognized that a strategy mandated during wartime,
under combat conditions, and practiced by surgeons with vary-
ing levels of experience may not be applicable to modern civilian
conditions. As an example, Pontius, Creech, and DeBakey (50)
reported their experience with 122 civilian colon injuries in 1957.
They reviewed military series between WWII and the Korean con-
flict, noting a drop in mortality from 53% to 15%, and civilian
series during the same era, noting a drop in mortality from 62% to
14%. These authors primarily repaired 83 colon injuries with 8%
mortality and diverted 36 colon injuries with 25% mortality. They
acknowledge that primary repair was only attempted in patients
without extensive fecal contamination, complete destruction of a
segment of bowel or rectal injuries. In addition, they note that, of
all survivors in both groups, there was a 20% complication rate,
including only 3 intraabdominal abscesses. This complication rate
is similar to rates seen half a century later.

Table 35.2  AAST grades of colon and rectal injury.
Gradea Description ICD-9b
Organ injury scale: Colon
I Hematoma Contusion/hematoma without 863.40 – .44
   devascularization
Laceration Partial thickness, no perforation 863.40 – .44
II Laceration Laceration <50% circumference 863.50 – .54
III Laceration Laceration ≥50% circumference 863.50 – .54
IV Laceration Transection of the colon 863.50 – .54
V Laceration Transection with segmental 863.50 –.54
   tissue loss
Vascular Devascularized segment 863.50 – .54
Organ injury scale: Rectum
I Hematoma Contusion/hematoma without 863.45
   devascularization
Laceration Partial thickness, no perforation 863.45
II Laceration Laceration <50% circumference 863.55
III Laceration Laceration ≥50% circumference 863.55
IV Laceration Full thickness laceration extending 863.55
   into perineum
V Vascular Devascularized segment 863.55
a. Advance one grade for multiple injuries to the same organ.
b. .41 & .51 = Ascending; .42 & .52 = Transverse; .43 & .53 = Descending; .44 &
.54 = Rectum.
The modern era of data supporting primary repair for pen-
etrating colon injuries includes several randomized controlled tri-
als (RCT). The next RCT examining this issue after the work of
Stone and Fabian was not published until 1991 by Chappuis and
colleagues.(14) Although there are several methodological limita-
tions, this study was important in that it excluded only patients
with rectal injuries and attempted to answer the question that Stone
and Fabian did not address, which is whether primary repair was
equivalent in more severely injured patients with a greater degree
of colon injury. Stone and Fabian (9) excluded almost half of the
patients with colon injuries due to preoperative shock, multiple
organs injured, gross contamination, greater than 8 hours from
injury to repair, blood loss >1 L, and destructive injury. Chappuis
and colleagues randomized 56 patients into either a primary repair
or a diversion group, with 28 patients in each group. There were
similar grades of colon injury (primarily grade III), PATI (26 and
23.9), transfusion rates (43% and 39%), complication rates (32%
and 35%), and numbers of intraabdominal abscess (3 and 4) in
the primary repair and diversion groups respectively. However,
the sample size was small, and the authors reported no statistics.
Although the PATI was indicative of severe intraabdominal injury,
only four patients were admitted in hemorrhagic shock (defined as
a systolic blood pressure less than 80 mm Hg). Additionally, only
13 total patients (5 in the primary repair group and 8 in the diver-
sion group) required more than 4 units of packed red blood cells
(PRBC). Thus, although this series represented an unselected pop-
ulation, the sample size was insufficient to conclude that primary
repair is equivalent to diversion in severely injured patients.
Since these two reports, there have been four other RCT
that support primary repair in most situations.(23, 25, 26, 51)
Although Gonzalez and colleagues published the results of their
first 109 patients in 1996 (24), the authors state that this study
was continued in order to assess complication rates associated
 colorectal trauma

Table 35.3  Randomized trials investigating primary repair versus diversion in colon injury.
Complication Mortality

Author(s) Year n PR Div PR Div Exclusion Criteria

d
Comment

Stone (9) 1979 139   1%a 10%a 1.5% 1.4% Preoperative BP < 80/60 PR lower total and
BL > 1000 ml    infectious complication
>2 organs injured    rate.
Gross contamination Excluded group: More
Operation >8 hr post-injury    infectious complications,
Destructive injury    higher mortality.
Loss of abdominal wall
Chappuis (14) 1991 56 32% 35% 0% 0% Extraperitoneal rectal 1st study with broad
   injury    inclusion criteria.
Low N in shock (3 PR,
   1 Div) but PATI scores
   equivalent (26 & 24).
Falcone (51) 1992 22 8/11b 10/9b 9% 0% Death < 24 hr post-injury Used intracolonic bypass.
Admit > 8 hr post-injury
Operation at another
   institution
Deemed inadmissible
Sasaki (23) 1995 71 19%a 36%a NR NR Extraperitoneal rectal PR more shock, gross
   injury    contamination,
   transfusions, left-sided
   injury (p < 0.05).
PATI >25 independent
   risk for complications.
Div OR 1.99 for
   complications vs. PR.
Gonzalez (25) 2000 176 18% 21% 2% 1% Extraperitoneal rectal PATI > 25 subgroup no
   injury    difference PR vs. Div
Kamwendo (26) 2002 240 37% 26% 0% 1.7% Extraperitoneal rectal Equivalent complication
   injury rate PR vs. Div:
•   Overall
•   Early vs. late (cutoff
    12hr post-injury)

Note: PR = Primary repair, Div = Diverted, NR = Not reported, PATI = Penetrating Abdominal Trauma Index.
a. Significantly different.
b. Total number of complications was reported, p = 0.516.
c. Reported as significantly different but no p values reported.
d. Number randomized.

with destructive injuries requiring resection and anastomo-
sis.(25) Table 35.3 summarizes the findings from these studies,
excluding the preliminary 1996 data generated by Gonzalez.
Falcone et al. (51), also had stringent exclusion criteria, and had a
small sample size of 22 patients. The other studies excluded only
extraperitoneal rectal injury.(14, 23, 25, 26) Notably, Sasaki and
colleagues (23) noted more patients in shock defined as a systolic
blood pressure (SBP) <80 mm Hg (28% vs. 4%), a higher degree
of gross contamination (60% moderate or heavy contamination
vs. 25%), and more patients requiring more than 4 units of blood
(16% vs. 4%) in the primary repair group as compared to the
diversion group. The authors report that all of these comparisons
were statistically significant, although p values were not reported.
Despite these differences, and despite similar PATI scores of
25.5 and 23.4 for primary repair and diversion respectively, they
found an increase in the likelihood of complications in the diver-
sion group (odds ratio of 1.99, p = 0.02). Using a multivariate
regression model, they analyzed the exclusion criteria of previous
studies (associated organ injury, shock on admission, fecal con-
tamination, location of colon injury, age, transfusion requirement,
delay of operation, extent of colon injury, abdominal wall loss,
and mechanism of injury) as potential risk factors for complica-
tions. They found that only the PATI score was an independent
predictor for complications but this was regardless of the type of
repair. Gonzalez et al. (25) found no difference in complication
rate, and noted that this lack of difference persisted when patients
with a PATI >25 in each group were compared. Kamwendo and
colleagues (26) randomized 240 patients to diversion or pri-
mary repair, and also further stratified these groups into those
that underwent operation before and after 12 hours postinjury.
They found no differences in overall complication rate, mortality,
number of patients in shock or requiring transfusion, or septic
complications between the primary repair and diversion groups.
Further, they found no difference in complication rate between
the early and late repair groups.
Two meta-analyses have been published on this topic. Singer
and Nelson (22) published a systematic review of the litera-
ture in 2002. They pooled data from five RCTs (9, 14, 23, 25,
51), totaling 467 patients. The following year, the Cochrane
Collaboration (21) pooled data from six RCTs, including five


 improved outcomes in colon and rectal surgery

Table 35.4  Meta-analyses investigating primary repair vs. diversion in colon injury.
Author Singer 2002 (Ref) Nelson 2003 (Ref) Comment

N (patients) 467 705 Patients analyzed in an intention to treat manner

N (trials) 5 6 Nelson added 1 trial to Singer review (REF)
Injury severity by PATI for PR 28.9 28.9 Only 4 trials (REFS) reported PATI
Variance not provided, thus statistical analysis could
Injury severity by PATI for Div 25.8 25.8 not be performed
PR included higher PATI patients
OR (CI) for mortality 1.7 (0.51 – 5.7) 1.22 (0.4 – 3.74) Mortality low for both groups (1.7-2.9%)
Intervention favored Neither Neither No heterogeneity among trials
OR (CI) for all complications 0.28 (0.18 – 0.42) 0.54 (0.39 – 0.76) P value for heterogeneity < 0.01
Intervention favored PR PR
OR (CI) for all complications 0.13 (0.08 – 0.23) 0.13 (0.08 – 0.23) P value for heterogeneity = 0.16
(excluding heterogeneous study) Study by Gonzalez, et al (REF) contributed the
Intervention favored PR PR heterogeneity to the meta-analysis
OR (CI) for all infectious complications 0.41 (0.27 – 0.63) 0.44 (0.17 – 1.1) Including intra-abdominal abscess, anastomotic
Intervention favored PR Neither* leak, peristomal abscess, sepsis, wound infection, and
abdominal wound dehiscence
OR (CI) for abdominal infection (including wound dehiscence) 0.59 (0.38 – 0.94) 0.67 (0.35 – 1.3) Including all of the above except sepsis.
Intervention favored PR Neither Kamwendo study contributed heterogeneity. OR values
OR (CI) for abdominal infection (excluding wound dehiscence) 0.52 (0.31 – 0.86) 0.69 (0.32 – 1.39) same as Singer review favoring PR when this trial
Intervention favored PR Neither excluded
OR (CI) for wound complications 0.55 (0.34 – 0.89) 0.55 (0.34 – 0.9) Including peristomal abscess, wound infection, and
(including wound dehiscence) abdominal wound dehiscence
Intervention favored PR PR No heterogeneity among trials
OR (CI) for wound complications 0.43 (0.25 – 0.76) 0.43 (0.24 – 0.77)
(excluding wound dehiscence)
Intervention favored PR PR

* When the heterogeneous study was excluded, the OR (CI) became 0.24 (0.14 – 0.40), favoring primary repair.
PATI= Penetrating abdominal trauma index, PR= Primary repair, Div= Diversion, OR= Odds Ratio, CI= 95% confidence interval.

of the studies addressed in their prior meta-analysis (9, 14, 23,
25, 26, 51), comparing 361 patients in the primary repair group
with 344 patients in the diversion group. They noted that the
PATI was reported in five of the six trials, and although statisti-
cal analysis could not be performed on this data, the primary
repair group had higher mean PATI scores (29 vs. 26). Their
analysis revealed a lower overall complication rate in patients
undergoing primary repair. The authors conducted a rigorous
analysis in which data that contributed to possible heterogene-
ity were excluded. This resulted in a strengthening of the odds
ratio favoring primary repair. When considering intraabdomi-
nal infection, there were no significant differences between the
two groups, although when sensitivity analysis was performed,
the remaining data generated an odds ratio (OR) that favored
primary repair (0.59, CI 0.37–0.94). Thus, meta-analysis showed
a decreased risk of complications, and an either equivalent or
lower risk of intraabdominal infection with primary repair. Neither
analysis found any differences in mortality between the two groups,
with rates of <3%. A summary of these 2 meta-analyses is pre-
sented in Table 35.4.
Both meta-analyses were authored by Nelson and Singer, and
both were conducted in the same fashion by the authors. The
Cochrane review included the report by Kamwendo (26), and
noted that these were the only data from outside the United States.
Although differences in resources, transport time, and patient
population may have implications for including this data in the
meta-analysis, similar findings amongst such a potentially differ-
ent population support the generalizability of primary repair. In
general, these analyses do not include the complication rate from
subsequent ostomy takedown.
Injuries requiring resection and anastomosis
Current evidence clearly supports primary repair in the set-
ting of uncomplicated colon injury defined as injuries easily
repaired by direct suture, without significant devascularization
or a destructive component. The summary of existing prospec-
tive, randomized data suggests that this is the method of choice
even in the setting of significant hypotension, high transfusion
requirement, associated injury, gross contamination, and delay
to operation. The issue of performing primary repair in the sub-
set of injuries requiring resection and anastomosis is less clear.
The data still favor primary resection and anastomosis without
proximal diversion in the sense that all of the RCTs classified
these repairs as primary repair. A review of these studies finds
only 43 cases of resection and anastomosis without diversion
in 6 randomized studies, which is a potential source of type II
error. The most well-documented data in a randomized set-
ting comes from Sasaki and colleagues (23), who noted patient
characteristics, complications, and outcomes in the subset of
12 patient who underwent resection and anastomosis versus


 colorectal trauma
31 patients who did not require resection, all within their
primary repair group. When these data were independently
extracted and analyzed by chi squared analysis and Fisher’s
exact test, there were no differences between number of organs
injured (p = 1.0), proportion of patients in shock (p = 0.46),
presence of either moderate or heavy gross contamination (p =
0.31), proportion of patients needing more than 4 units of PRBC
(p = 0.38), left-sided injury (p = 0.75), proportion with PATI > 25
(p = 0.17), or number of complications (p = 0.67). As would be
expected, the mean PATI was greater in the resection subgroup,
although this was not statistically significant (29 vs. 24). Also as
expected, the number of patients with Flint grade 3 injury was
higher in the resection subgroup versus the direct repair group
(92% vs. 23%, p < 0.001). In their study, the primary repair group
as a whole was more ill than the diversion group. Despite this, the
diversion group was twice as likely to develop complications as
compared to the primary repair group. Within the primary repair
group, there were no differences between the resection and non-
resection groups. Thus, the analysis above supports resection and
anastomosis without diversion. Two caveats to this statement are
that the numbers of patients are small, and the study was not
powered to make this conclusion definitively.
Demetriades et al. (27), conducted a nonrandomized, multi-
center prospective review of 297 patients who sustained colon
injury that required resection. One-hundred ninety-seven patients
underwent primary anastomosis exclusively and 100 patients
underwent diversion at 19 trauma centers. The method of repair
was left to the discretion of the operating surgeon. The authors
identified severe gross contamination, transfusion >4 units of
PRBC in the first 24 hours, and single agent antibiotic prophy-
laxis as independent risk factors for abdominal complications in
a multivariate regression analysis. The presence of all 3 factors
was associated with a complication rate of 68%, 2 factors with a
rate of 17–38%, one factor with a rate of 17–21%, and none of
these factors with a rate of 13%. Subsequently, two sets of analyses
were then conducted comparing primary repair with diversion,
the first controlling for these 3 independent risk factors, and the
second adjusting for ‘traditional’ risk factors commonly found in
the literature: hypotension (SBP < 90), transfusion >6 units of
PRBC, severe contamination, PATI >25, and delay of operation
>6 hours. The authors found similar rates of abdominal compli-
cations between the 2 groups, no difference in complication rate
by location of repair (e.g. ileocolostomy, colocolostomy, ileos-
tomy, colostomy), and no difference in hospital or ICU stay. They
noted 24% and 22% overall rates of abdominal and extraabdomi-
nal complications respectively.
One major limitation of this study was that the diversion
group had a higher incidence of delayed operation, shock at
admission, left colon injuries, PATI >25, small bowel and liver
injuries, transfusion requirement, and severe fecal contamina-
tion. Further, the diversion group received antibiotics longer
than the primary repair group, although the median duration is
not reported. However, the authors performed a separate analy-
sis controlling for these factors and again found no difference in
abdominal complications, hospital stay, or ICU stay. They did
note an increased colon-related mortality with the diversion
group (4.5% vs. 0%, p = 0.03), which translated to 4 deaths in
this group. Thirteen patients in the primary repair group had an
anastomotic leak, compared to one leak from a Hartmann pouch.
No risk factors could be identified for leak within the primary
repair group, and no patient died as a result of leak. The authors
concluded that method of colon management does not influence
the development of colon-related abdominal complications, and
primary repair should therefore be practiced for all injuries. They
also concluded that transfusion, severe contamination, and single
agent antibiotic prophylaxis are independent risk factors associ-
ated with complications.
On the other side of this argument, several retrospective series
have been published that present a caution to the concept of uni-
form primary repair of all colon injuries. As an example, Stewart
et al. (52), published a follow-up study based on their previous
experience with 95 direct repairs with no suture line complica-
tions and an 11% incidence of abscess.(53) The authors changed
their management strategy and repaired all injuries primarily,
including destructive wounds requiring resection and anasto-
mosis. Forty-three patients undergoing resection and anastomo-
sis and 17 undergoing colostomy were analyzed. They noted no
statistically significant difference in complication rate. However,
when comparing the 6 anastomotic leaks to 37 primary repairs
that did not leak, they noted a 12-fold risk of leak in patients that
had an underlying illness (e.g. diabetes mellitus, cirrhosis, HIV
infection). The need for transfusion was not significantly associ-
ated with increased risk, but the combination of transfusion >6
units of PRBC and medical illness resulted in a 14-fold increased
risk of leak. The sample size was small, but the authors concluded
that a 14% leak rate is excessively high. Other limitations include
a shift in practice toward primary repair during the study period
and inherent problems with determining underlying illness in
the trauma population in general. Although these reports are ret-
rospective reviews of a relatively small number of patients, high
transfusion requirement (commonly 4 or 6 units) consistently
appears as a risk factor for complications.(27, 53) Results of the
randomized trials previously discussed did not identify this as a
risk factor for complications.
Damage Control
Data concerning repair of colon injuries in the setting of damage
control surgery (DCS) are scarce. There are no randomized data,
and literature that specifically describes the management of colon
injury in the context of damage control surgery is limited to three
reports analyzing 34 patients.(54–56)
Miller et al. (54) retrospectively analyzed 17 patients who
underwent DCS and subsequent delayed definitive repair of
colon injury. All patients had destructive colon injury, under-
went abbreviated laparotomy at their initial operation, and
were returned to the operating room after correction of acido-
sis, coagulopathy, and hypothermia in the ICU. Eleven patients
underwent resection and primary anastomosis and 6 under-
went diversion. The authors compared the 11 anastomosis after
DCS patients to 21 controls, who were patients with traumatic
colon injuries undergoing anastomosis at initial operation. There
were no leaks in the DCS group and one in the initial anasto-
mosis group (p = 0.66). The abscess and colon-related mortality
were also similar. As would be expected, the ISS and overall

 improved outcomes in colon and rectal surgery
mortality were higher in the damage control group. The authors
then compared the 11 anastomosis after DCS patients to the other
6 patients, who underwent colostomy after damage control. They
found no differences in ISS, abscess rate, colon-related mortality,
or overall survival.
Chavarria-Aguilar et al. (55) reviewed the management of
destructive bowel injury in the setting of the open abdomen. The
data are heterogeneous, as patients with small bowel injuries are
included in the analysis. Of 104 patients with destructive bowel
injury requiring resection and anastomosis, 29 underwent tem-
porary vacuum closure and the rest primary fascial closure. Eight
patients with colon injuries underwent resection and delayed
anastomosis after initial packing. Two leaks occurred, both from
small bowel anastomoses. There were no differences in rate of
abdominal abscess between the anastomosis and stoma groups
in either the vacuum-closure group or the initial fascial closure
group, with rates of 7–21%. These findings led the authors to
conclude that resection and anastomosis is safe in the face of
destructive injury and an open abdomen and should be consid-
ered in most patients. The retrospective nature of the study did
not allow causality to be established, and the small sample size
did not allow for the identification of risk factors or appropriate
candidates for anastomosis versus ostomy.
Finally, Johnson and colleagues (56) describe general changes
in DCS over an 8-year period and comment on 7 colonic anasto-
moses and 2 primary repairs. They report one leak and 3 abscesses,
but do not specify if this was within the colon resection group or
the 13 small bowel resections performed.
The authors of this chapter recently reviewed data collected
on soldiers undergoing damage control laparotomy in Operation
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
during 2005–2006 (unpublished data). We found a 51% rate of
concomitant colon injury, or 77 of 152 patients. This is more than
twice the number of patients studied than in the existing civil-
ian literature. The early colon-related complication rate (7 days
postinjury) was 14%. These included 5 leaks, 3 abscesses, and
6 cases of ischemia on further evaluation requiring reoperation.
Complications were essentially equally distributed among the
ostomy and anastomosis groups (p = 0.54). Results are summa-
rized in Table 35.5. Further, there were no differences in compli-
cations by location of injury (p = 0.58). There were no differences
in ISS between colostomy and no colostomy (all primary repairs)
and colostomy, direct repair, and resection and anastomosis
groups. The colostomy group was more likely to have a massive
transfusion, but there were no differences in the complication
rate in any comparison. Although follow-up is currently limited
to a mean of 7 days postinjury, data collection is ongoing. These
results support the conclusion of Chavarria-Auguilar and col-
leagues (55), that even in combat settings with massive injury and
tissue loss, primary repair is feasible. However, as discussed later
in this chapter, war injuries in combat situations may require dif-
ferent management than civilian injuries.
Practice patterns
In an attempt to synthesize the diverse conclusions found in the
literature, Miller and colleagues (57) developed a clinical path-
way for destructive colon injuries in 1995 and compared patients

Table 35.5  Colon injuries in the setting of damage control surgery
during Operation Iraqi Freedom 2005–2006.
Colostomy No colostomy
(n = 44) (n = 30) p value
ISSa 24.7 ± 2.2 24.8 ± 3.2 0.98
Massive 25/44 8/30 0.02
   transfusion (56.8%) (26.7%)
Complications 9/44 4/31 0.54
(20.5%) (12.9%)
Colostomy Direct repair Anastomosis
(n = 44) (n = 10) (n = 20) p value
ISS a
24.7 ± 2.2 24.4 ± 3.8 24.9 ± 6.0 1.00
Massive 25/44 3/10 5/20 0.04
   transfusion (56.8%) (30%) (25%)
Complications 9/44 1/10 3/20 0.69
(20.5%) (10.0%) (15%)
a. mean ± standard error of the mean.
treated during this period with their experience before its imple-
mentation. Primary repair was undertaken in all colon injuries
except patients with destructive injuries requiring >6 units of
PRBC pre- or intraoperatively, or patients with significant under-
lying medical illness. These high-risk patients underwent diver-
sion. Two hundred nine patients in the clinical pathway group
were compared to 60 prepathway patients. The authors found no
difference in abscess, anastomotic leak, or colon related mortality
rates between the two time periods. They also found no differ-
ence in leak rates between anastomosis and direct repair groups
after implementation of the clinical pathway, whereas there was
a higher leak rate in the resection group in the prior era. Finally,
they found that there was a reduction in the number of patients
undergoing diversion from 31% to 9%. This translates to a rela-
tive risk reduction of 71%, an absolute risk reduction of 22%, and
a number needed to treat of 4.5. That is, for every five patients
treated according to the pathway, one colostomy and subsequent
takedown was avoided. Further, there were no differences in com-
plications with gross contamination, associated injury, or location
of colon injury. These results suggest that the authors improved
their patient selection for colostomy, and that destructive injury
alone is not a contraindication to primary repair. The notable
corollary to this conclusion is that there was a role for colostomy
in their experience.
summary
The treatment of penetrating colon injury has changed markedly
in the past 50 years. Level I evidence supports primary repair (with-
out diversion) of nondestructive injuries as the method of choice
in nearly all circumstances. Specifically these circumstances include
hypotension, gross contamination, high transfusion requirement,
associated injury, and delay from injury to operative treatment.
Level I data also exists supporting primary repair for destructive
injuries requiring resection and anastomosis but is more limited.
Transfusion requirement, gross contamination, and high penetrat-
ing abdominal trauma index have been independently associated
with infectious complications by a number of authors, but this has
been regardless of the type of management (diversion or primary
repair). Data regarding primary repair in the setting of damage
 colorectal trauma
control is even more limited, and no level I data exists. However,
small series, including a recent large review of military injuries sug-
gests that primary repair is feasible in the damage control setting.
No convincing data exist supporting diversion as superior to pri-
mary repair. In severely injured patients, a reasonable strategy is to
initiate damage control techniques, including leaving the bowel in
discontinuity, and subsequently performing an anastomosis once
normal physiology is restored.
A low threshold of suspicion is the key to diagnosis in most
cases. Most injuries are found intraoperatively, and most are
uncomplicated. Thus, primary repair is appropriate for the major-
ity of colon injuries. As always, sound judgment, skilled resuscita-
tion, and attentive postoperative care are keys to good outcomes.
The complication rate is high regardless of method of manage-
ment, and providers should be aware of this fact. “… it cannot
be emphasized too strongly that the dangers of the abdominal
patient are not over when the last stitch has been put in. Recovery
depends almost as much on the skill and the duration of the after-
care as on the operation itself.” (Ogilvie, 1944) (4)
Blunt colon injury
Colonic injury is uncommon after blunt abdominal trauma,
accounting for only 1–5% of blunt traumatic injury.(58) It is
notoriously difficult to diagnose, but a delay in diagnosis is
associated with significant morbidity including fatal peritonitis,
sepsis, and life-threatening hemorrhage.(59, 60) There are three
primary proposed mechanisms in the pathogenesis of blunt
colonic injury.(61) The first is crush injury between an object
such as a steering wheel, seat belt, or vertebral column. Second,
shear injury occurs at points of fixation, particularly the sigmoid
mesentery. Third, burst injury can occur when a closed loop is
formed at impact. The resultant injury pattern is characteristic
and can include mural and mesenteric hematomas, partial thick-
ness tears, full thickness perforations, and transection at fixation
or contact points.
Blunt colonic injury (BCI) is usually partial thickness, with
rare exceptions (3%) being full-thickness colonic perforations.
(62) The most common cause is motor vehicle crashes, both
restrained and unrestrained.(62) The left colon is the most fre-
quently injured, followed by the right and transverse colon.(62)
The diagnosis of blunt colon injury is a diagnostic dilemma,
and requires a high index of suspicion. In a retrospective multi-
center 5 year review of patients with BCI, the diagnosis was made
preoperatively only 5% of the time.(62) These injuries are often
diagnosed upon laparotomy for other indications, and although
rare, colon injury ranks 4th among injuries found at laparotomy
in blunt trauma patients.(60) Physical exam findings are incon-
sistent or manifest late after injury and the patient may be diffi-
cult to evaluate secondary to traumatic head injury, intoxication,
or distracting extraabdominal traumatic injury. The presence of
a ‘seat-belt’ sign or a Chance fracture, as described previously, are
predictors of hollow viscus injuries. Figure 35.1c demonstrates a
blunt colonic injury. Nance et al. (63) studied solid organ injury
as a predictor of hollow viscus injury in blunt trauma patients.
They found that as the number of solid organ injuries increased,
the likelihood that a hollow viscus injury coexisted increased, up
to 34.4% in patients with three solid organ injuries.
Figure 35.1c  Intraoperative findings in a patient with a “seat-belt sign”. The
patient sustained a hematoma in the cecal mesentery and a serosal tear in the
sigmoid colon which was primarily repaired.
CT scan is currently the most utilized modality for the diagno-
sis of blunt colonic injury.(33, 42) Findings suggestive of BCI on
CT  include evidence of extraluminal air, extraluminal contrast
material, bowel wall thickening, streaking of the mesentery, and
free fluid in the absence of solid organ injury (Figure 35.1b).
Williams et al. (60) studied trauma patients with blunt colonic
injury. They evaluated the ability of physical exam, plain radiogra-
phy, CT scan, FAST, and DPL to accurately detect BCI. They found
that no individual or combination of diagnostic tests was able to
accurately detect BCI. For example, the sensitivity of CT findings
including free air, contrast extravasation, and free fluid had sensi-
tivities ranging from 6–49% and positive predictive values between
50–72%. Ultrasound examination had a sensitivity of 58%, speci-
ficity of 44%, a positive predictive value of 61%, and a negative
predictive value of 41%. Physical examination findings such as the
seat-belt sign, peritoneal signs, and abdominal pain performed
similarly, with sensitivity between 21 and 59% and positive predic-
tive values between 57 and 63%. Diagnostic peritoneal lavage had
a sensitivity of 97% but a specificity of 13%, a positive predictive
value of 55% and a negative predictive value of 80%.
Malhotra et al. (41) evaluated the accuracy of CT scan in the
diagnosis of blunt bowel injury. They found the sensitivity and
specificity of CT for these injuries was 88.3% and 99.4%, respec-
tively, with an accuracy of 99.9%. The positive and negative
predictive values were 53.0% and 99.9%, respectively. The most
common finding they reported associated with BCI was unex-
plained free fluid. Yegiyants and colleagues (64) found 14 cases
of blunt injury with free fluid on CT scan but no evidence of
solid organ injury (0.5% of admissions in their review). Eleven
of these patients (74%) required laparotomy, with hypotension
(3 patients) and peritoneal signs (6 patients) being the two most
common triggers. In their series, physical exam was predictive
in 43% and FAST exam was positive in 50%. It is possible that
the addition of laparoscopy may aid in the management of blunt
colonic injuries. As previously noted, Ahmed (44) and Mitsuhide
(45) report the avoidance of between 21–75% of laparotomies in
blunt abdominal trauma.

 improved outcomes in colon and rectal surgery
summary
The management of blunt small bowel injury is relatively
straightforward, requiring mainly primary repair or resection
and anastomosis.(65) Blunt colonic injury is more complex. In a
comprehensive review of the pathophysiology and management
of blunt bowel and mesenteric injuries, Hughes and Elton (65)
suggest that most blunt colonic injuries should be categorized
as high grade (AAST grade V or Flint grade 3, Tables 35.1 and
35.2) and treated accordingly. A high index of suspicion, experi-
ence, and appropriate follow-up are the cornerstone to the diag-
nosis of this uncommon injury. Currently, physical exam, and
CT scanning appear to be the most used methods of diagnosis.
Laparoscopy may be a useful adjunct to diagnosis. Devascularized
mesentery presents a challenging problem. The viability of the
bowel should be assessed if in question and resected if indicated.
In cases of severe injury a second look may be considered to
assess for progressive ischemia. Once diagnosed, the treatment of
blunt colonic injury should follow the guidelines for penetrating
colonic injury.
Outcomes of colostomy closure
Only one RCT included subsequent colostomy takedown in the
primary analysis. Chappuis et al. (14), reported 22 closures out of
28 patients in the diversion arm of their RCT with one complica-
tion (4.5%), an enterocutanous fistula after ileostomy reversal. The
absence of good follow-up limits the conclusions that can be made
from this study. It is thus debatable whether this is an appropriate
analytical strategy, in that initial management is a separate issue
from colostomy closure. However, the risk of subsequent colostomy
reversal should be considered when the decision to proceed with
diversion is made. This topic is well represented in the literature,
with a wide array of heterogeneous conclusions made. Differences
in conclusions are due to varied definitions of complications and
infections, the inclusion or exclusion of rectal injury, varied indica-
tions for original diversion (trauma, cancer, etc), and the retrospec-
tive nature of published data.(66–70) Mortality as a consequence
of colostomy reversal is sufficiently low (0–3%)(69) that most
authors report infectious complications as their primary endpoint.
Further, infectious complications remain the major source of mor-
bidity after wounding of the abdominal cavity.(71)
Two series reviewing stoma closures after diversion for any
indication found complication rates of 20–36%.(66,69) These
rates are similar despite the reports being separated by 20 years.
Factors associated with increased complications range from
reversal performed in less than 90 days (66), diverting versus loop
colostomy (66), age >55 (69), and use of a silicone drain.(69)
While the data is heterogeneous, conclusions that can be made
are that colostomy reversal is associated with a high complication
rate of approximately 20–30%, and that some retrospective data
seem to suggest an increase in complications with diversion (68,
70) which supports at least consideration of primary repair in
almost all cases and a more selective use of diversion than what
has been taught in previous years.
Military perspective
The recent military conflicts in Iraq and Afghanistan have raised
questions about the applicability of the civilian experience to

combat settings and war injuries. In light of this conflict a brief
overview of the impact that active wartime has had on trauma
surgery—and colon injury specifically—is worthwhile.
There is a long history of the lessons of war having a deep and
lasting impact on civilian surgical management. One of the clas-
sic papers in the trauma literature is Ogilvie’s account of mili-
tary surgery during World War II.(4) Although this is the paper
most often cited as the impetus behind mandatory colostomy, it
describes many classic precepts that were not widely recognized
until much later decades. Ogilvie’s paper is remarkable both
for his foresight but also the number of principles he describes.
These include: the ‘trimodal’ peaks in trauma mortality, damage
control, massive transfusion, ARDS, abdominal compartment
syndrome, and many of the logistical issues later incorporated
into both military and civilian trauma programs.
Ogilvie reports a 60% mortality rate from colon inju-
ries. Direct suture repair resulted in a 44% mortality rate as
opposed to 45–65% for colostomy with and without resection.
However, 2 of 2 patients who underwent resection and anas-
tomosis died. He attributes the lower mortality with suture
repair to less severe injury but nevertheless makes no recom-
mendation about selective repair in these cases. Further, he
acknowledges the beneficial effects that antibiotics, improved
logistics, and liberal use of blood products had on outcomes.
Despite these other factors, he strongly advocates for colos-
tomy in all cases and states that it is “perhaps the greatest sin-
gle factor in the improved results we are able to record”. It is
likely that a mandate and automatic action were preferred in
the face of the challenges involving resources, evacuation, and
ever-changing groups of surgeons of vastly different levels of
training and experience. This can be seen in his assertion that
“the forward surgeon must have good hands, a stout heart, and
not too much philosophy. He is called upon for decision rather
than discussion, for action rather than a knowledge of what
the best writers think should be done”.
Perry and colleagues (2), in a comprehensive review of the
military management of colon injury, describe its evolution
throughout modern history. Before World War I, laparotomy was
discouraged and observation afforded the wounded soldier the
best chance of survival. Laparotomy and rapid evacuation dur-
ing WWI saw a dramatic decrease in mortality from abdominal
injuries from almost 90% to 40%. The changes wrought during
WWII have been detailed previously. During the Korean War,
air superiority led to improvements in evacuation. Further, the
practice of exteriorization, in which the repaired colon was mobi-
lized and brought out above the skin for observation, was largely
abandoned. Finally, some leeway in the primary repair and anas-
tomosis of right colon injuries was allowed. These factors led to
a further decline in colon-related mortality from 35% to 16%.
Aside from well-documented advances in resuscitation and criti-
cal care, the Vietnam War saw improvements in evacuation and
antibiotics, as well as more location-specific trends in colon man-
agement. Left-sided wounds were diverted, while recommenda-
tions for right-sided wounds included resection and primary
anastomosis, exteriorization, and resection, ileostomy and mucus
fistula. During this time mortality dropped to around 10%. Perry
and colleagues stress that the best results with primary repair
 colorectal trauma
are obtained by surgeons experienced in this strategy and when
patients remain under the care of the same surgeon.
Hudolin and Hudolin (72) reviewed their experience during
the Bosnia-Herzegovina conflict in 1992–1995. Two-hundred
fifty-nine patients with colonic injury were treated at a single
receiving facility with no radiologic capability and a single field
generator. Rapid evacuation made long-term follow-up impos-
sible. Roughly equal numbers of patients were treated with pri-
mary repair and colostomy (47% and 53% respectively). Overall
mortality was 7.7% in both treatment groups. There were no dif-
ferences in associated injuries, or mechanism of injury (explo-
sive or gunshot) between groups. Overall complication rate was
similar between groups (27% for primary repair and 30% for
colostomy). The authors did not perform statistical analysis on
individual complications, citing low numbers, but there were
more leaks in the primary repair group (8 vs. 2) and fewer wound
complications (7 vs. 15). These authors also cite surgeon experi-
ence as an important factor in management with primary repair,
but conclude that it is safe even with subsequent rapid evacuation
if treatment is undertaken soon after injury and with administra-
tion of perioperative antibiotics.
Steele and colleagues (73) reviewed the treatment of 175
patients during the 2003–04 period of OIF. Primary repair was
undertaken in 53%, the leak rate was 10%, and overall mortality
was 17.7%. Only 37% of patients were United States or coalition
forces and the rest were local nationals. Mean ISS and AIS were
similar among different regions of the colon. Stomas were more
frequently performed for rectal or anal sphincter injuries than
colonic injuries, and for left-sided versus right-sided or trans-
verse injuries. Leaks after primary repair were equally distributed
throughout the colon. Although the leak rate was higher in the
primary repair group, there was no difference in rate of sepsis
or mortality between groups on multivariate analysis. Only ISS
>15 was associated with an increase in sepsis, while only rectal or
transverse injuries were associated with an increase in mortality.
Follow-up is not reported likely due to rapid evacuation and the
high proportion of local nationals included in the study.
We conducted a review of colon injuries sustained during
OIF during 2005–2006 (unpublished data). One hundred thirty-
three patients with colon injuries were admitted from Iraq and
Afghanistan to Landstuhl Regional Medical Center (LRMC) in
Landstuhl, Germany, the tertiary referral center for combat casu-
alties in this theater. The average time spent in the three echelons
of combat care facilities (battalion aid station, forward surgical
team, and combat hospital) was 2 days and the average time spent
at LRMC was 4.7 days, translating to about 7 days from injury
to echelon V (tertiary US military hospital) care in the United
States. Anatomic distribution of injury is depicted in Table
35.6. Primary repair or resection and anastomosis was the ini-
tial method of treatment in 34%, colostomy in 45%, and dam-
age control consisting of bowel left in discontinuity in 21%. The
complication rate was 12% overall and was not related to type
of management (p = 0.172). Complications were linked to open
abdomen (p = 0.031), increased ICU days (p = 0.015), gunshot
wound (p = 0.021), and number of procedures before admission
at LRMC (p = 0.008), but not LOS, ISS, mechanism, location of
injury, or massive transfusion. These results are limited by the lack
Table 35.6  Anatomic distribution of colon injuries during
Operation Iraqi Freedom 2005–2006.
Location Numbera Percenta
Ascending 28 21%
Transverse 20 15%
Descending 28 21%
Sigmoid 36 27%
Rectum 33 25%
a. Totals exceed 100% due to multiple injuries in some patients.
of long-term follow-up. Data collection from US sites is ongoing,
however, and will be the subject of future publications.
summary
These examples demonstrate that the use of primary repair in
military series is lower than reported in the civilian literature.
(27, 57) Contributing factors include varied training and per-
sonal philosophy of treating surgeons, higher number of dam-
age control procedures performed, and higher incidence of rectal
injury, which in turn results from the contribution of blast and
high-energy mechanisms of injury. These differences in combat
trauma contribute to the active debate on the method of choice,
as is evidenced by recent publications by authors deployed to OIF
calling for an expanded role for diversion.(74, 75) To date, how-
ever, the experience has been limited to small series and expert
opinion. Larger series previously described currently lack long
term follow-up. The bulk of the data seems to support primary
repair.
Antibiotic therapy
As previously mentioned, infectious complications are the major
source of morbidity after abdominal trauma.(71) Infection is a
major contributor to the third peak in the ‘trimodal’ distribution
of trauma mortality, which was recognized by Ogilvie in 1944
(4) and described by Trunkey in 1982.(76) Causes can be sepa-
rated into two broad categories, those related to the patient or the
disease process and those related to treatment. The latter are the
modifiable factors.
A number of disease-related factors have been reported to
contribute to infectious complications. In a recent, comprehen-
sive review of the literature addressing infections in penetrating
abdominal trauma, Fabian (71) describes colon injury, rate of
transfusion, shock (generally SBP < 90 mm Hg), and PATI >25
as well-investigated independent risk factors. Treatment related
factors include careful attention to measures that contribute to
improved outcomes in the trauma and critically ill population in
general; aggressive efforts to achieve normothermia (77), correc-
tion of coagulopathy and acidosis, euglycemia (78), minimiza-
tion of transfusions (79–81), and careful attention to nutrition.
(82–85)
Choice, timing, and duration of antibiotic therapy have been
well studied and deserve a brief comment. The efficacy of prein-
tervention versus posttreatment (postoperative) therapy is well
established.(85, 86) In addition, the choice of antibiotic does not
seem to matter as much as the adequacy of anaerobic and gram-
negative coverage. The only study that appeared to have generated

 improved outcomes in colon and rectal surgery
data favoring multiple agent therapy was the prospective nonran-
domized study of colon injury requiring resection and anastomo-
sis conducted by Demetriades and colleagues that was discussed
previously.(27) In this report, single agent antibiotic therapy was
an independent risk factor for abdominal complications, with an
RR of 1.89 (p = 0.004) and an RR of 1.12 when adjusted for trans-
fusion of 4 or more units of PRBC, severe fecal contamination, or
method of colon injury management. However, the most recent
guidelines published by the Surgical Infection Society in 2002 rec-
ommend 24 hours of organism-specific coverage in instances of
peritoneal contamination due to traumatic bowel injury repaired
within 12 hours.(87) There is sufficient class I evidence to recom-
mend 24 hours of an appropriate antibiotic for the minimization
of infectious morbidity in colon trauma.(88–90)
Bozorgzadeh et al. (88) randomized 300 patients to either
24 hours or 5 days of therapy with cefoxitin after penetrating
abdominal injury. There were no exclusion criteria and patients
with colon injury (32%), shock on admission (31%), and multiple
abdominal organ injuries (19%) were included. The overall infec-
tion rate was 25%, while deep surgical site infections occurred in
6%. There were no differences in complications or length of stay
between groups. In addition, multivariate analysis found only
colon injury to be independently associated with infection and
increased length of stay. One limitation of this study was that the
5 day group had a higher incidence of intraoperative shock, mul-
tiple organ injury, and intraoperative blood loss.
Cornwell and co-workers (89) randomized patients with full-
thickness, penetrating colon injury and one risk factor consisting
of PATI>25, transfusion of 6 or more units of PRBC, or greater
than 4 hours from injury. Sixty three patients were randomized
to either 24 hours or 5 days of cefoxitin therapy. There were no
differences in severity of injury or other baseline characteristics,
infectious complications, length of stay, or mortality. Overall
abdominal infection rate was 29% and overall mortality was
9.5%. Although the sample size was adequate by power analysis,
there were a small number of patients in each group.
Kirton and colleagues (90) performed a multicenter, double
blinded, placebo-controlled RCT in which 317 patients with pen-
etrating hollow viscus injury were randomized to receive either
24 hours of ampicillin/sulbactam followed by 4 days of saline
placebo, or 5 days of antibiotic therapy. The proportion of colon
injuries (50%), AAST grade of colon injury, distributions of solid
organ injury, ISS, PATI, and infection rates were similar in each
group. The overall infection rate was 19%, with 9% surgical site
infections. Mortality was 1.6% overall. On multivariate analy-
sis only total number of PRBC transfused and PATI >25 were
independent contributors to infectious complications. Both the
Cornwell and Kirton studies identified gram-negative bacilli as
the most common isolates.
Although this topic has been well studied, the demonstrated
risk of infection with colon injury may predispose some prac-
titioners to inappropriately prolong the duration of antibiotic
therapy. The rising incidence of resistant bacterial strains makes
this a critical issue. Adherence to evidence-based guidelines and
support on an individual, practice, hospital, and national level is
essential in minimizing the incidence of multiply resistant noso-
comial infections.

Retained fragments
The traditional teaching regarding retained fragments is that they
should be left in place unless they traverse the colon, in which
case they should be removed and the tract debrided. Data regard-
ing this subject is scarce. For example, four reports specifically
addressing infectious complications after missile injury to the
colon have been published since 1990.(91–96) Sarmiento and
colleagues, who report the largest experience on this subject,
reference six other publications on this topic since 1892.(93)
Flint et al. (95) reported a series of seven patients with gun-
shot wounds through the colon who developed abscesses, two of
whom died (28%). They noted that abscess culture revealed E.
Coli, Klebsiella, Bacteroides, and pseudomonal species in every
case, leading to the conclusion that contaminated material was
inoculating the wound tract, and that retained fragments should
be removed. Based on a small series, Flint refuted the belief held
at that time that bullets and missile tracts were sterile due to
the heat and friction generated by the projectile.(91) Poret (91)
reviewed 151 patients with gunshot wounds traversing the colon
and found a 26% rate of septic complications when the bullet or
fragment was retained and a 16% rate when there was no retained
fragment (p = 0.15). Although not statistically significant the
authors note clinical significance, and conclude that the retained
missile is a nidus for infection.
In contrast, Demetriades and Charalambides (92) reviewed their
experience with 84 patients with gunshot wounds to the abdomen
traversing the colon. Bullets were removed only if they were pal-
pable. In 48% of patients the bullet was retained, while in 52% it
was either removed or had exited the body. The two groups were
matched in severity of injury, site of injury, number of colonic per-
forations, and method of repair (primary versus colostomy). The
overall abdominal complication rate was 14% and the incidence of
missile tract infection was 4% with no differences between groups.
Antibiotics were given for 48 hours. The authors concluded that
missiles should only be removed if they are easily palpable. Edwards
et al. (93) studied the effects of low-velocity, small-fragment injury
in a porcine model designed to simulate injury from antipersonnel
devices in combat. They fired steel fragments through the unpre-
pared colons of swine into a gelatin medium, then cultured several
points along the missile tract, as well as the fragment itself. No cul-
ture reached 1 × 105 organisms and average tract size was 5 cm long
by <1 mm in diameter. The authors concluded that small-fragment
removal and debridement of wound tracts would not present an
increased risk of infection if antibiotics were administered soon
after injury.
Sarmiento et al. (93) retrospectively reviewed 185 patients who
sustained gunshot wounds in which the bullet had traversed the
colon and extraperitoneal soft tissue only. The decision to extract
the bullet was according to the discretion of the operating sur-
geon at the time of initial laparotomy. There was a fivefold lower
incidence of infection in those in whom the bullet was extracted
compared to retained (5% vs. 25%, p = 0.06). They also found no
difference in risk of infection for injuries that traversed the right
and transverse colon compared to the left colon and rectum.
In summary, the evidence is sparse on this topic, but seems to sup-
port extraction of bullets, debridement of wound tracts and early
antibiotic administration with retained fragments that traverse the
 colorectal trauma
Table 35.7  High-risk factors for rectal injury.
Gunshot wound to pelvis, buttocks, lower back or abdomen
Wound in which injury tract is directed caudad
Penetrating gluteal injury
Blast injury to perineal area
Complex perineal laceration
Pelvic fracture
Lower genitourinary tract injury
Sexual assault
Erotic anal penetration
Gross blood per rectum
High-energy blunt injury to lower abdomen
colon and embed in soft tissue. This is consistent with the basic gen-
eral surgical principle of not leaving foreign material in the presence
of the open gastrointestinal tract. Small-fragment injury poses an
additional problem, in that debridement of multiple small-diameter
tracks may be a significantly morbid procedure.(94)
Rectal injury
The classic components of managing rectal injury include the
three (or sometimes four) D’s: diversion, presacral drainage, dis-
tal rectal washout, and sometimes direct repair.(30, 96) These
maneuvers were established during WWII and the Vietnam war
(2), and were credited with decreasing mortality from 67% dur-
ing WWI to essentially zero during the Vietnam war, and decreas-
ing morbidity from approximately 70% to 10% during the same
period.(1, 30, 96) Mortality in recent series is low. In a review
of 39 civilian studies, Merlino and Reynolds (96) identified 42
deaths in 1105 patients with rectal injury, 10 of which (0.9%)
were attributed to the rectal injury itself. They also report a range
of 1.3 to 4.5 associated injuries per patient, making associated
injury the rule rather than the exception. Genitourinary injury is
the most commonly associated injury given the anatomic prox-
imity of these organs.
The rectum is protected by the bony pelvis and soft tissue,
which makes injury less frequent, but exposure more difficult. It
is mostly accessible from the anus but is only covered by peri-
toneum along its proximal one-third and anteriorly along the
middle one-third, facilitating both repair and intraperitoneal
contamination. Penetrating injury accounts for 85% of reported
injuries, with the majority of these being gunshot wounds.(96)
A rare source of rectal injury is iatrogenic perforation, which
reportedly occur in approximately 0.1–0.2% of cases.(97, 98)
Diagnosis
Rectal injuries present a diagnostic challenge. Injuries to the
bony pelvis should be rapidly diagnosed, and an unstable pel-
vis should be addressed first. Careful perineal and digital rectal
examination is the next step and should be accompanied by a
high clinical suspicion with risk factors outlined in Table 35.7.
Sphincter tone and injuries to the sphincter complex should be
carefully noted at this point as well. Digital rectal exam has a
reported accuracy of 64–96%.(99–102) Sigmoidoscopy (blood
or lesion visualized) for the diagnosis of rectal perforation
has an accuracy of 89–100%.(99–101, 103, 104) Blood on
digital exam is an indication to further assess the rectum either
by proctoscopy or sigmoidoscopy.(103, 104) Intraluminal hem-
orrhage identified by endoscopy should lead to the presump-
tive diagnosis of rectal injury and management should follow
accordingly.(102–104) Contrast-enhanced CT scan and contrast
studies are useful adjuncts in equivocal cases.(105) Diagnostic
laparoscopy has been described for hemodynamically stable
patients with evidence of extraperitoneal rectal injury (blood
on rectal exam and proctoscopy), no peritonitis, and no intra­
peritoneal injury.(103, 106, 107)
Management
Traditionally, the cornerstone of rectal injury management is fecal
diversion.(96) In distinction to colon injury, diversion is more often
indicated for rectal injury. This is partly due to a lack of class I data
confirming the safety and feasibility of primary repair alone with
rectal injuries, combined with increased difficulty in dissection and
exposure, as well as lack of a serosa for much of its extent.(104)
Overall mortality rates are low, between 0–9% (99–104, 108–111),
including six modern series published since 1996 with a <2% death
rate. The infrequency of this injury makes it unlikely that an RCT
with sufficient power will be performed. The safety of colostomy in
rectal injuries has been documented. In a review of complications
related to colostomy, Berne and colleagues (68) reported a 55% inci-
dence of complications when colostomy was performed for colon
injury versus a 13% incidence when performed for rectal injury.
A number of reports have challenged the routine practice of
distal irrigation and presacral drainage (101, 103, 108, 110–112),
the majority of which cite the differences between civilian and
military penetrating trauma as the primary indication for devia-
tion from the classic teaching.
Only one RCT exists on this topic, conducted by Gonzalez and
colleagues.(110) Forty-eight patients were randomized to diver-
sion and either presacral drainage or no drainage. Distal irriga-
tion was not performed on any patient. There was no mortality
attributable to rectal injury, and complications occurred in two
patients in the drainage group and one in the nondrainage group
(p > 0.05). The authors acknowledge that their study was under-
powered to detect a difference in complication rates. Others have
argued that with unrepaired extraperitoneal injury the risk of
overwhelming pelvic sepsis developing within a closed space is
high, and in this case presacral drainage is indicated.(96, 108) In
the absence of convincing data, this argument represents a rea-
sonable approach.
Distal washout has largely been abandoned, as many authors
have consistently failed to demonstrate any advantage to its use.
Most authors cite the difference between high-energy, military
rectal wounds, and lower-energy civilian injuries as the pri-
mary difference in results between the original reports from the
Vietnam war and contemporary experience (96, 101–104, 108,
110). There may be a role for distal irrigation in wartime and with
injuries resembling combat injuries.
One useful convention is to approach rectal injury along ana-
tomic lines. Intraperitoneal injury can be safely treated in a simi-
lar fashion to colon injury, as several authors have demonstrated
the feasibility of primary repair without proximal diversion.(96,
101, 108) The exception is in the case of extensive contamination
and tissue loss, for which most authors divert the fecal stream.

 improved outcomes in colon and rectal surgery
Table 35.8  Traditional steps in the management of rectal injury.(20)
Perineolithotomy position
Management of concomitant injuries
Debridement
Proximal diversion
Remove foreign bodies
Presacral drainage
Distal rectal washout
Repair injury if possible
Repair sphincters if possible
External wound drainage
Broad spectrum antibiotics
Skin left open
Table 35.9  Modified steps in management of rectal injury.
Perineolithotomy position
Management of concomitant injuries
Debridement
Intraperitoneal injury Extraperitoneal injury
Primary repair Diversion
Diversion if destructive injury (Loop colostomy Selective presacral drainage
   preferred) Repair if easily accessible
Repair sphincters if possible
Selective external wound drainage
Broad spectrum antibiotics
Skin left open
(96, 108) Given the relative ease of the procedure and subse-
quent reversal, a loop colostomy is recommended (100, 102, 103)
if solely for the purpose of diversion in rectal injury, while an
end colostomy is performed if there are other indications, such as
associated colonic injury. Extraperitoneal injuries can be treated
without repair, unless they are easily accessible or uncovered in
the course of treating other injuries.(96, 102, 103, 108) There is
some evidence to support this principle. Gonzalez et al. (111),
implemented a protocol for the management of extraperitoneal
rectal injury without fecal diversion, presacral drainage, or dis-
tal irrigation in patients with nondestructive penetrating injury.
Although they had no mortality or infectious complications, the
series included only 14 patients, making these results difficult to
generalize. Interestingly, in all 14 patients a barium enema was
performed and demonstrated complete healing by postinjury
day 10, demonstrating the rapid healing capacity of the rectum,
likely due to its rich blood supply. Abdominoperineal resec-
tion has been described in the setting of traumatic rectal injury
(102), but should be regarded as an extraordinary measure under
extremely rare circumstances. The steps in the classic, conserva-
tive management of rectal injury have been described by Stewart
and Rosenthal (20) and are summarized in Table 35.8. A modi-
fication to these steps as suggested by modern series is presented
in Table 35.9.
Summary
Rectal injury is uncommon and often accompanied by significant
associated injury, most commonly genitourinary. Data is scarce,
and is mostly limited to retrospective reviews. Diagnosis is chal-
lenging, and is most often made by clinical suspicion, digital exam,

Figure 35.2  Foreign body requiring operative extraction. This patient sustained a
full-thickness rectal injury from the foreign body placement.
and proctoscopy or sigmoidoscopy. Intraperitoneal injury can be
treated with primary repair in a manner analogous to colon injury.
Extensive destructive injury can be diverted with lower expected
complication rates than colon injury. Extraperitoneal injury can be
treated with diversion alone, although selected cases of partial or
nondestructive injury can be treated with nonoperative manage-
ment. Presacral drainage is sometimes recommended in these cases
in order to prevent pelvic sepsis. Presacral drainage and distal rectal
washout are more appropriate in high-velocity injuries similar to
combat injuries but have less efficacy in civilian settings.
Foreign bodies
Anorectal foreign bodies are almost always inserted during sexual
conduct.(113–117) The most common objects found are sexual
implements such as vibrators and dildos (115, 116) (Figure 35.2).
Other, less common causes are ingested material, most often
bones, or iatrogenic causes such as thermometers and enema tips.
(113) A case of a live eel inserted into the anus as a folk remedy for
constipation has been reported, in which the eel migrated proxi-
mally and was found biting the perforated splenic flexure.(118)
The patient presented with peritonitis, which led the clinicians to
note “the shadow of an eel on abdominal radiograph”, confirming
the diagnosis. There is a predominance of males, ranging from
93–100% in the largest series.(114–116, 119)
Goals of initial assessment are to create an atmosphere that
allows the patient to give a detailed history, to recognize the
potential of rape or assault, and to recognize signs of perfora-
tion that require more urgent therapy. Multiple-view plain radio-
graphs should be obtained. Plain films will help localize the
object, although rubber will not be apparent on radiography. Free
air or obvious perforation can be ruled out. Patients with signs
and symptoms of obstruction or perforation should have basic
labs drawn, intravenous fluids initiated, antibiotics started and
proceed to urgent laparotomy with no further attempt at removal
of the object.(117) A perforation should be treated as any trau-
matic rectal injury, with removal of the foreign body, which will
be discussed subsequently.
 colorectal trauma
The majority of rectal foreign bodies can be removed at the
bedside, which is successful in 60–75% of cases.(114, 115, 119)
An attempt at bedside extraction is reasonable in patients without
signs of peritonitis.(113–115, 119) Sedation and local anesthesia
can assist with relaxation and extraction, and an awake patient
can be asked to perform a valsalva maneuver. If these maneuvers
are unsuccessful, a stable patient can be admitted and observed
for 12 hours; during this time the object will often descend into
the rectum.(114) Foreign bodies removed nonoperatively require
a postprocedure sigmoidoscopy to assess the viability of the rec-
tum and rule out perforation.(113–117, 119)
Operative removal can be accomplished with local, regional,
or general anesthesia. Either the lithotomy or prone position
can be used, but one advantage of lithotomy is that pressure
can be applied to the abdomen to move the object distally.(117)
Retractors can be placed and the anus dilated. Obstetric forceps
and balloon-tipped catheters are commonly employed.(113–117,
119) Balloon-tipped catheters are useful in the case of jars or
containers that are positioned with the mouth facing proximally,
where the suction generated can prevent removal. The passage of
a Foley catheter past the object can serve to break the suction and
can be used to aid in extraction.(113)
Rarely, laparotomy is required (0–6% of cases).(114, 115, 119)
Attempts should be made at distally displacing the object with-
out entering the bowel. If this is unsuccessful, an enterotomy
can be made through which the object can be removed.(117,
119) Even more uncommonly, a lateral sphincterotomy may be
required. Lake and colleagues (119) performed a recent review of
93 retained colorectal foreign bodies in 87 patients to determine
predictors of operative intervention. Two patients (2%) presented
with signs of peritonitis and were taken to the operating room.
Seventy five percent of attempts at bedside extraction were suc-
cessful. Of 23 cases requiring operative management, 6 required
laparotomy and 5 (6%) required creation of a colotomy. Size of
object (greater than 10 cm) and time to presentation (greater
than 48 hours) were not associated with an increase in opera-
tive intervention. Only location in the sigmoid was predictive of
failure of nonoperative management (55% versus 24%, p = 0.04),
with an associated OR of 2.25.
Anal sphincter and perineal injury
Anal sphincter injury
Anal sphincter function is extremely complex, and a full dis-
cussion is outside the scope of this discussion. Anal sphincter
trauma is highly unusual due to its protected anatomic location
and abundant blood supply (113). The most common cause of
anal sphincter injury is obstetric trauma, followed by sequelae of
anorectal operations, and uncommonly by etiologies similar to
those causing rectal injuries.(113, 120) Stapling procedures such
as for hemorrhoidectomy have been shown to cause anal sphinc-
ter injuries as well.(113)
Life-threatening injuries should be addressed first in trauma
patients, particularly massive, complex perineal injury (discussed
subsequently). In a comprehensive review, Hellinger (113) out-
lines the initial management of anal sphincter injury. As men-
tioned, documentation of the extent and nature of the sphincter
injury is imperative. Superficial injuries can be debrided and
repaired without proximal diversion and minimal injury iso-
lated to the internal sphincter can be left unrepaired. Destructive
injury requires diversion following the same principles as rectal
injury. In most cases primary repair should be undertaken, com-
monly in an end-to-end or overlapping fashion. Overlapping
repair is accomplished by dissecting out the sphincter muscles
and wrapping them anteriorly around the anus. Although over-
lapping repair increases the surface area of muscular apposition,
this repair is difficult to achieve without tension in the acute
setting, and thus end-to-end repair may be the principal option
in the setting of acute trauma.(113, 120)
Other techniques for repair include muscle transpositions (e.g.
gracilis or gluteal) and artificial sphincters.(113,120) However,
these procedures are best undertaken in the delayed setting and
should be performed by surgeons with extensive experience. For
example, graciloplasty for fecal incontinence has been shown in
several large series to have success rates of 60–66% by various
measures (121–123), but infectious complications in 34–39%
of patients and donor-site morbidity (pain, paresthesias) have
been reported in 22–72%.(121, 123) Artificial anal sphincters
have been associated with success rates of 75–98% by vari-
ous measures, but infection rates range from 13–34%, erosions
from 8–21%, explants in 19–37%, and revisionary procedures in
26–45%.(124, 125)
In the long-term, sphincter repairs tend to degenerate (120),
with rates in the elective population ranging between 2.8–10%.
(126, 127) It is important to arrange appropriate follow-up for
the assessment of anal function in these patients. Physical exam,
myography, manometry, and contrast studies are all routinely
employed to assess sphincter function.(113) In addition, endo-
scopic ultrasound has been shown to be a useful adjunct to visu-
alizing the anal sphincters and predicting defects. A sensitivity of
100% and specificity ranging from 83–100% has been reported
when compared to intraoperative findings in elective operations
for fecal incontinence.(128, 129) Delayed repair has been shown
to have good results in approximately 70% of patients with fecal
incontinence due to nonobstetric trauma.(130)
Complex perineal injury
Kudsk and Hanna (131) have published a complete review of
complex perineal injuries, describing a 15-year experience in the
comprehensive care of these patients. Figures 35.3a–3c illustrate
complex perineal injury. The authors demonstrate the synthe-
sis of the principles of ATLS, damage control, and distal rectal
injury required to manage these potentially devastating injuries.
Their review included only those patients with evidence of severe
degloving (25 total) and the reported mortality was 24% during
the first 2 hours of admission. Two additional patients died for
reasons unrelated to their perineal injury, for an overall mortal-
ity of 32%. Their review of the literature revealed similar mor-
tality rates. Roughly half of the patients were pedestrians hit by
cars, one-third were involved in motor vehicle crashes, and the
remainder sustained industrial accidents.
The second most common cause of mortality after exsan-
guinating hemorrhage is pelvic sepsis. The authors’ review of
the literature revealed a 21–25% death rate from this cause. For

 improved outcomes in colon and rectal surgery
Figure 35.3a  Complex perineal injury. The patient was run over by heavy road-
repair equipment. The patient also sustained urethral injury, sigmoid colon injury,
and severe pelvic fracture.
Figure 35.3b  CT scan of complex perineal injury. Note the large soft-tissue
defect.
example, Maull et al. (132), reported a 25% mortality due to pel-
vic sepsis in their series. Kudsk and Hanna report a 21% pelvic
sepsis rate but no mortality, which they attribute to their aggres-
sive, multisystem approach as described.
Immediate assessment of the ABCs, intravenous access, and lim-
ited radiographic imaging are the initial steps. In cases of severe
injury resuscitation should occur in the operating room. The most
serious and most common associated injury was severe complex
pelvic fracture, which occurred 74% of the time (Figure 35.3c). The

Figure 35.3c  Pelvic fracture associated with complex perineal injury.
authors emphasize that in complex pelvic injuries, lower extremity
central access is contraindicated in that it may contribute to fur-
ther hemorrhage by delivering fluids and blood products directly
into the abdominal cavity through lacerated vessels. Access above
the diaphragm is recommended. Laparotomy should be performed
and intraabdominal injuries addressed. Early pelvic fixation and
hemorrhage control should proceed by packing, direct ligation
or clamping, and angiography as necessary. The lithotomy posi-
tion is essential to appropriate exposure. Associated genitourinary
injuries should be addressed. Debridement should continue only
in the absence of refractory hemorrhage and the patient should
be returned to the ICU for further resuscitation before prolonged
operative interventions.
Following stabilization, fecal diversion should be undertaken
early. Aggressive debridement and irrigation should be under-
taken with frequent return trips to the operating room. Kudsk
and Hanna report an average of 8 trips to the operating room
using pulse-lavage before closure or coverage was attempted.
These principles are similar to the management of Fournier’s
gangrene. Enteral feeding should be initiated as early as possible.
In the delayed setting, coverage can be achieved with skin grafts
and muscle flaps as indicated. Using these techniques, the authors
were able to discharge 17 of 19 patients (89%) to home. Feeding
jejunostomies were placed in 6 patients and enteral nutrition was
initiated in all 6 within 48 hours.
Summary
Anal sphincter and complex perineal injuries are uncommon in
civilian settings. Life-threatening hemorrhage and pelvic fracture
are the first concerns. Documentation of the extent of sphincter
injury is imperative. Genitourinary and rectal injuries should be
suspected until ruled out by careful investigation. Primary repair
of sphincter injury should be undertaken if feasible. Referral
is recommended for cases where complex repair is required.
Follow-up is important for assessment of long-term function, as
 colorectal trauma
functional deterioration is common after repair. Fecal diversion  
may be necessary in cases of massive injury. The primary concern
initially is hemorrhage control, while infection and nutrition are
more important in the next several days. In the longer-term, tis-  
sue coverage and functional issues become more important. With
aggressive, comprehensive management, the majority of patients  
have good outcomes.
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36 Urologic complications of colorectal surgery
Scott Delacroix Jr and J Christian Winters
Challenging Case
A laparoscopic left hemicolectomy was performed for an asympto-
matic 2.0 cm sigmoid adenocarcinoma found on screening colon-
oscopy. Due to her previous three cesarean sections and abdominal
hysterectomy with bilateral oopherectomy, she required extensive
lysis of adhesions in order to mobilize the left colon. The procedure
was uneventful and the patient was discharged home on postoper-
ative day number three. On follow-up at 10 days, patient was doing
well except for a new complaint of left “side pain” rated as a 3 out
of 10. Management was expectant and patient was scheduled for
a follow-up visit. She presented to the emergency room one week
later with significant left flank pain and a fever of 102.1. Her WBC
count was 21,000 and serum creatinine was 1.2 (preop 0.9). A CT
scan of the abdomen and pelvis with and without intravenous con-
trast was ordered and left hydroureteronephrosis was seen down to
the level of the mid-ureter.
Case Management
The patient was admitted and placed on intravenous antibiotics.
Urology was consulted and the patient was taken to the cystos-
copy suite where a cystoscopy and retrograde stent placement was
attempted but unsuccessful. No contrast was seen beyond the level of
the mid-ureter. The patient was taken to the interventional radiology
suite where a percutaneous nephrostomy tube was placed. Patient
improved clinically over the next 48 hours with IV antibiotics. An
anterograde nephrostogram was performed and a 2.0 cm stenotic
segment of ureter was visualized in the middle-third of the left ure-
ter. Iatrogenic injury was presumed and treatment options were dis-
cussed with the patient. After a full treatment course of antibiotics
for her pyelonephritis, the patient underwent a robotic ureteral reim-
plant with Psoas hitch and ureteral stent placement. Her percutane-
ous nephrostomy tube was removed 1 week later (as outpatient). The
ureteral stent was removed at 4 weeks postoperatively and patient
remained asymptomatic thereafter. At 4 months postreimplantation,
her serum creatinine was 0.9 and renal ultrasound showed a normal
left kidney without evidence of obstruction.
urethral injuries
The most common urologic injury in surgery is the traumatic
foley catheter placement. It is essential to adequately lubricate the
entire foley and insert the catheter past the point at which urine
is returned into catheter tubing. Inserting the catheter in a male
to the inflation port can help prevent urethral injury. The usual
preoperative catheter is either a 16 french or 18 french catheter. It
is not necessary to inflate the balloon before placement as this will
increase the size and decrease the rigidity of the distal aspect of the
catheter. If catheter placement is unsuccessful, a trial of passage with
an 18 French coude’ tipped foley catheter is appropriate. Patient
dehydration secondary to bowel preparation can make it difficult
to determine proper placement if one only looks for urine return.
Placement of the entire foley catheter (to port)before inflation will
aid in proper placement. If still unsure, usage of a 60 cc catheter
tipped syringe to irrigate the bladder can confirm placement before
inflation of the balloon. Intraoperative urologic consultation for
cystoscopy and foley catheter placement should be performed if
the above measures fail. If cystoscopy cannot accurately deline-
ate urethral anatomy, a suprapubic catheter can be placed either
through a percutaneous or an open technique.
Artificial urinary sphincters (AUS) must be deactivated before
insertion of a foley catheter. Deactivation is a different mecha-
nism than the normal operating “on” and “off ” cycling. It is
the author’s experience that most patients do not know how to
deactivation their AUS beyond the normal cycling mode. This de-
activation must be performed before placement of a foley cath-
eter. Either a device representative or urologist can deactivate the
sphincter preoperatively as an outpatient or on the day of surgery.
A 12 French foley catheter can then be placed with lubrication
and care to ensure placement in the bladder before inflation of
balloon. Failure to deactivate the AUS can result in erosion of the
urinary sphincter by means of pressure necrosis between the foley
catheter and sphincter device. Removal of the catheter should be
done in standard fashion postoperatively. If unable to obtain uro-
logic consultation before or intraoperatively, a suprapubic cath-
eter can be placed either by open or percutaneous methods. Care
must be taken to avoid intraabdominal prosthetic components,
which are normally placed below the rectus muscle suprapubi-
cally. An inflatable penile prosthesis (IPP) should not pose any
additional difficulty in placing a urethral catheter if lubrication
and the aforementioned guidelines are adhered.
Urethral injuries are associated with extensive rectal neoplasm
or any inflammatory processes that alter surgical planes includ-
ing pelvic radiation. Urethral injuries are usually identified at
the time of surgery secondary to identification of the indwell-
ing foley catheter. Repair of a small urethral laceration can be
performed with absorbable 3–0 or 4–0 synthetic absorbable suture
(SAS) on a tapered needle. If the patient has had prior radiation or
there is poor tissue composition, placement of either an omental flap
or local tissue flap to support coverage of the repair is recommended.
Injuries not identified at surgery can present postoperatively as urine
drainage per rectum, pneumaturia, or fecaluria if fistula is present.
It can also present as a delayed urethral stricture with difficult void-
ing and bladder outlet obstruction. A retrograde urethrogram will
confirm the presence of a urethral stricture but must be done in the
bilateral oblique as well as anterior-posterior views. A retrograde
urethrogram (RUG) can be performed by affixing a 14-gauge angi-
ocatheter to a 60 cc syringe filled with standard water-soluble con-
trast. A RUG should be performed around an indwelling catheter
if already in place. If a radiographic enema is performed, water-
soluble contrast is preferred as it does not form concretions in the
bladder. Spontaneous closure of a urinary fistula is rare but a trial

 improved outcomes in colon and rectal surgery
of conservative urinary diversion (foley catheter) for low-grade fis-
tulas is recommended for 4–6 weeks.
Urinary fistulas are staged according to location, size, and
patient’s history.(1)
•• Stage 1—low (<4 cm from the anal verge and non-irradiated)
•• Stage 2—high (>4 cm for the anal verge and non-irradiated)
•• Stage 3—small (<2 cm irradiated fistula)
•• Stage 4—large (>2 cm irradiated fistula)
•• Stage 5—large (ischial decubitus fistula)
Enteric diversion by means of a diverting colostomy or ileos-
tomy is recommended for Stages 3–5. The choices for repair are
diverse and depend on local tissue integrity and staging. It is rec-
ommended to place a suprapubic catheter at the time of repair in
addition to a foley catheter for maximal drainage.(2) Transanal
rectal flap advancement can be used for Stage 1 fistulas or in com-
bination with other techniques for higher stage fistulas.(3) Other
techniques described include:
•• transanal-transphincteric approach (dorsal lithotomy anterior
sphincterotomy).(4)
•• York Mason/transphincteric with rectal advancement flap (2, 5,
6) (jack-knife posterior sphincterotomy)
•• Perineal approach (Jack knife or dorsal lithotomy).(7, 8)
•• Gracillus and Rectus Abdominus Flaps.(9, 10)
Surgical selection is based on fistula stage and the experience of
the reconstructive surgeon. Higher stage fistulas and recurrences
normally require regional flaps and possibly even urinary diver-
sion.(11) Outcomes for surgically corrected rectourethral fistulas
are overall favorable with recurrences mostly dependent on stage
and appropriate choice in initial surgical treatment. Success rates
vary from >90% for low-grade fistulas to 70% for higher-grade
fistulas.(1–11) A retrograde urethrogram around foley catheter at
4–6 weeks postoperatively should be performed before urethral
catheter removal.
Bladder Injuries
The location of the bladder within the pelvis and its, close prox-
imity to the sigmoid colon and rectum predisposes the bladder to
injury during surgery of the colon and rectum. Iatrogenic injuries
to the bladder can be staged as:(12, 13)
•• Grade 1 : contusion, intramural hematoma, or partial thickness
laceration
•• Grade 2: extraperitoneal bladder wall laceration <2 cm
•• Grade 3: extraperitoneal >2 cm or intraperitoneal <2 cm blad-
der laceration
•• Grade 4: intraperitoneal bladder wall laceration >2 cm
•• Grade 5: intra or extra peritoneal bladder wall laceration extend-
ing into the bladder neck or trigone (near ureteral orifice)
Risk factors for bladder injury include any process that distorts
tissue planes and reduces surgical exposure.(14) This includes adhe-
sions or scarring from prior surgery, radiation, malignant infiltra-
tion, chronic inflammation, or infection. Injuries can be apparent

intraoperatively or present in a delayed fashion. Intra­operative iden-
tification of the injury allows for immediate cystorraphy usually in
a two layer fashion. In open surgery, the mucosa is closed in a run-
ning fashion using a 3–0 SAS suture followed by a seromuscular run-
ning suture of 2–0 SAS. The bladder can then be irrigated to ensure
a watertight closure. In the laparoscopic setting, a running one layer
closure is performed using a 2–0 SAS to close all three layers of the
bladder. Care must be taken to ensure closure of the mucosal layer
in the laparoscopic one layer technique. Again, the bladder should
be irrigated to ensure a watertight closure. Repair can also differ
depending on the location of the injury. Anterior and dome injuries
can be repaired primarily as above. Posterior injuries involving the
trigone or near the ureteral orifices (possible Grade 5) dictate a more
thorough inspection of the bladder and an assurance of ureteral
integrity before closure. This is done through an anterior cystotomy
in the sagittal plane extending down toward the pubic symphisis.
This will allow placement of a Balfour or Bookwalter self-retaining
retractor and placement of bilateral ureteral open-ended catheters.
Giving the patient indigo carmine with Lasix can aid in identifica-
tion of the ureteral orifices. Closure of the posterior bladder injury
can then be done from the bladder lumen—closing the muscular
layer first using 2–0 SAS followed by closure of the mucosal layer
using 3–0 SAS. The anterior cystotomy is then closed as described
above. In cases where neoadjuvant radiotherapy has been used, an
interposition of omentum or perivesical fascia is prudent to decrease
the risk of fistula formation.
A delayed bladder injury will usually manifest in the early postop-
erative period, especially after removal of foley catheter. The injury
can present as drainage from surgical incision; increased output
from surgical drain; vaginal leakage; ileus; apparent oliguria; uri-
nary ascites with increasing BUN and serum creatinine secondary
to reabsorption of urine through parietal peritoneum—in the case
of an unrecognized intraperitoneal injury; pneumaturia or fecaluria
in the cases of an enterovesical or colovesical fistula. Delayed urine
leaks can be diagnosed radiographically by fluoroscopic cystogram
or the CT cystogram.(15) It is important when ordering a CT cysto-
gram that passive filling of the bladder from the upper tracts is not
the sole method of bladder opacification. A foley catheter should be
placed and the bladder filled in a retrograde fashion with 300–400
cc’s of water-soluble contrast before the scan.
The development of a colovesical or enterovesical fistula is a delayed
complication of cystotomy.(16–17) Abdominal-pelvic CT scan with
oral and/or rectal water-soluble contrast has a greater sensitivity than
cystoscopy in diagnosing an enterovesical fistula (Figure 36.1). The
most sensitive test to diagnose an enterovesical or colovesical fistula
is the poppy seed test.(17) A 1.25-ounce container of poppy seed is
mixed into a 12-ounce beverage o r a 6-ounce serving of yogurt and
orally ingested by each patient. Urine was visually inspected during
48 hours, during which identification of poppy seed in the urine was
a positive confirmatory test for gastrointestinal fistula to the urinary
tract. The sensitivity and specificity was 100%.(17) This test does
not provide anatomical information as in the case of the abdominal-
pelvic CT scan but it is a much more cost effective screening test in
patients with equivocal symptoms (5 dollars vs. over 600 dollars).
(17) When using Barium contrast, it is the authors recommendation
to empty the bladder after a fistulae is diagnosed as there have been
reports of Barium concretions within the bladder.
 urologic complications of colorectal surgery
Figure 36.1  Enterovesical fistula (arrow).
URETERAL INJURIES
Injury to the ureter is one of the most common intraoperative
urologic injuries in colorectal surgery. The incidence of iatro-
genic injury to the ureter is reportedly from 1 to 10%.(18–22)
Iatrogenic ureteral injuries are of 4 types: laceration, ligation,
devascularization, and thermal or energy related. Optimal treat-
ment is early recognition and repair of any ureteral injury.
Anatomy
Iatrogenic ureteral injuries in colorectal surgery usually occur in
three distinct locations: at the takeoff of the inferior mesenteric
artery, where the infundibulopelvic ligament/uterine vessels crosses
the pelvic brim, and between the lateral rectal ligaments (Figure
36.2).(23) The course of the ureter begins posterior to the renal
artery and continues along the anterior edge of the psoas muscle.
The gonadal vessels cross the ureter from lateral to medial in this
region. The ureter next passes over the iliac vessels, generally
marking the bifurcation of the common iliac into internal and
external iliac arteries.(24) Of greatest importance to the surgeon
is that arterial branches to the abdominal ureter approach from
the medial direction whereas arterial branches to the pelvic ureter
approach from the lateral direction.(24) For the abdominal ure-
ter, these branches originate from the renal artery, gonadal artery,
abdominal aorta, and common iliac artery. After entering the pel-
vis, additional small arterial branches may arise from the internal
iliac artery or its branches, and also from the middle rectal and
vaginal arteries.(24)
The ureter will tend to adhere to the peritoneum during its
reflection rather than staying adherent to the Psoas muscle and
underlying tissue. The ureter can be identified by visualization
and by its peristaltic activity. Gentle pressure applied to the ureter
will frequently cause peristalsis—termed the Kelly sign. The right
ureter is adjacent to the cecum, terminal ileum, and the appendix.
The left ureter is related to the descending and sigmoid colon and
their mesenteries.
Figure 36.2  Anatomy of the ureter.
Prevention
Ureteral catheterization is used to aid in identification of the
ureters and to help identify ureteral injury, but catheters do not
prevent ureteral injury.
The clinical value of prophylactic ureteral catheter placement
before 162 laparoscopic segmental left and right colectomies was
assessed by Nam et al. There were no complications from place-
ment of ureteral catheters.(18) Postoperative urinary tract infec-
tion was not increased. Total operative time was increased by
11.3 minutes. The ureteral catheter group included more difficult
cases including patients with Crohn’s disease and diverticulitis.
There were no ureteral injuries in any of the one hundred sixty
two patients.(18) An earlier study deemed ureteral catheteriza-
tion necessary in 27.5% of patients when assessed in a stand-
ardized retrospective fashion.(22) There were 4 complications
presumably due to ureteral catheterization which included renal
colic, oliguria, and one case of anuria attributed to ureteral edema
after removal of the ureteral catheters.(20, 25) Chahin et al. stud-
ied lighted ureteral stents/catheters placed before laparoscopic
colectomy in 66 patients.(20) The most common complication
was self-limiting hematuria in 98.4% of patients with an aver-
age duration of 2.5 days for unilateral stenting and 3.3 days with
bilateral stenting.
It is the authors’ opinion that the choice for ureteral stenting is
a surgeon preference and depends on multiple variables includ-
ing complexity of case, anatomy, and experience—especially with
the laparoscopic approach in a hostile abdomen. With greater
experience, iatrogenic injury decreases. In a study by Larach et al.,
the incidence of conversions due to iatrogenic injuries showed a
decline from 7.3% in the early group to 1.4% in the latter expe-
rience group.(26) Once again ureteral catheters have not been
shown to decrease ureteral injuries but aid in identification of
the ureters and any iatrogenic ureteral injury. Ureteral catheters

 improved outcomes in colon and rectal surgery
(A)
(B)
Figure 36.3  Ureteroureterostomy. (A) Spatulation of ureteral margins and placement
of running locked sutures. Preferred technique. (B) Oblique anastomosis.
can be used to aid in diagnosis of ureteral injury by retrograde
injection of methylene blue through the ureteral catheter. They
can also be used to place a retrograde wire under fluoroscopic
guidance for placement of an indwelling ureteral double-J stent
after a ligation/crush injury.
Types of Injury
Laceration
A laceration or transection of the ureter can usually be repaired
with primary anastamosis (ureteroureterostomy with spatulated
ends), ureteral stent, and placement of a closed suction drain in
the area of the repair (Figure 36.3).
Ligation
If a ligation injury is apparent intraoperativly, the clamp or tie can
be removed followed by ureteral stent placement for up to one
month. The patient should undergo repeat imaging either with a
renal ultrasound or intravenous pyelogram (IVP) at 3 months to
ensure a ureteral stricture has not developed. If the injury is not
identified until post operatively, a retrograde ureterogram and
stent placement or percutaneous nephrostomy tube placement
may be needed before surgical correction.
Devascularization
A devascularization injury will not be evident intraoperatively
and results from the sacrifice of the segmental ureteral blood supply.
Intraoperativley a devascularized ureter may appear discolored,

lack peristalsis, and may not bleed at a transected site. The irradi-
ated ureter is especially susceptible to this type of injury, as the
normal healthy ureter has numerous collaterals and is very resist-
ant to devascularization, even with extensive dissection. The anat-
omy of the blood supply to the ureter (as previously described)
should be known as the surgeon is carrying his dissection over
the pelvic brim.
Thermal
Thermal injuries will usually present in the early postoperative period
with either fistula or stricture formation. These injuries are repaired
in the same fashion as above depending on the location of the injury.
Many laparoscopic surgeons use alternatives to monopolar dissec-
tors because of the risk of thermal injury and delayed presentation of
injuries. Even with these newer technologies, collateral tissue dam-
age can be produced depending on the energy level and duration of
exposure. In animal models, use of the ultrasonic dissector (Ethicon
or USSC) at a level of 3 for <10 seconds per burst resulted in little to
no collateral tissue damage.(27) When using an ultrasonic dissector
at levels of 4 or 5, energy time should be reduced to <5 seconds to
prevent collateral damage due to spread of thermal.(27)
LOCATION DEPENDENT REPAIR OF THE
IATROGENIC URETERAL INJURY
Repair of the injured ureter does not necessitate open conversion
if a urologist is available with advanced laparoscopic skills. The
basic principles of a ureteral anastamosis: a tension free anasta-
mosis; well-vascularized spatulated ends anastamosed over an
indwelling ureteral stent ; use of an absorbable suture material
4–0 or 5–0; and placement of a closed drain near the area of the
repair. Do not use nonabsorbable suture, as stone formation is
inherent with these nonabsorbable materials.
Proximal One Third
The boundaries of the proximal one-third ureter is from the ure-
teropelvic junction (level of the kidney) to the pelvic brim (sac-
roiliac joint on KUB). Repairs of injuries to the proximal ureter
depend on the length of the damaged segment. Simple spatulated
ureteroureterostomy with ureteral stent placement is the pre-
ferred method of repair if there is significant length of the unin-
jured ureter. A nephropexy can be performed to bring the kidney
caudad to allow a tension free anastamosis. In cases with long
segments of damaged ureters, a bowel interposition with tapered
ileum or an apendiceal interposition can be used (Figure 36.4).
At specialized centers, autotransplantation with reanastamosis to
the iliac vessels, and native more distal ureter can be performed.
Middle One Third
The preferred technique for mid-ureteral repair is ureteroureter-
ostomy, either laparoscopically or through the open technique.
Distal One Third
The procedure of choice for the lower one-third ureteral injury is
the ureteroneocystotomy. This may be accomplished primarily for
very distal ureteral injuries or may require a Psoas hitch or Boari
flap for patients with small capacity bladders and injuries near the
iliac vessels.(24) Care must be taken to maintain a tension free
 urologic complications of colorectal surgery
Figure 36.4  Ureteral replacement by ileum. Left colon retracted medially. Ileum
brought through a hiatus in the colonic mesentary. Ileal ureter is in retroperitoneal
position.
anastamosis. This can usually be accomplished with a Psoas Hitch
(Figure 36.5). The bladder is mobilized by ligating the superior
vesical pedicle on the contralateral side of the injury. It is prudent
to locate the contralateral ureter and ensure its integrity before
this maneuver. The bladder can then be opened through an ante-
rior cystotomy and then secured to the Psoas muscle and tendon
using several 0–0 SAS sutures through the seromuscular layer of
the bladder. Care must be taken not to include the genitofemoral
nerve which is located within the belly of the Psaos muscle. Suture
should be placed in a linear fashion inline with the fascicles of the
muscle to prevent underlying nerve entrapment. The ureter can then
be tunneled by passing a clamp from the lumen through all layers of
the bladder and then withdrawn with the distal aspect of the proxi-
mal salvaged ureter. The ureter should then be widely spatulated and
interrupted mucosal stitches (4–0 SAS) should be used circumferen-
tially to create the neo-orifice. A ureteral stent can also be placed. The
anterior cystotomy is then closed as previously described. A closed
suction drain and foley catheter is then left in place.
The Boari flap is another effective yet more complex method
for replacing an extensive loss of the distal and mid-ureter. A flap
of the anterior bladder wall is raised in a rectangular fashion and
affixed to the Psoas muscle in same fashion as a Psoas hitch. The
Figure 36.5  Psoas bladder hitch. Mobilized bladder being anchored to psoas
muscle and the ureter is reimplanted.
ureter is tunneled through the most proximal portion of the flap
and a neo-orifice is created as previously described. The bladder
flap is then tabularized and closed in a two-layer fashion using
running 3–0 SAS to close the mucosa followed by closure of the
seromuscular layer using 2–0 SAS (Figure 36.6).
The final option is the transureteroureterostomy. The surgeon
tunnels the injured ureter under the posterior peritoneum over-
lying the great vessels. The allows a spatulated end to side anasta-
mosis of the injured ureter to the patient’s native uninjured ureter
(Figure 36.7).
RENAL INJURIES
Direct renal injury is a rare occurrence in colorectal surgery.
McAnich et al. have reported that 90% of renal injuries can be
managed without nephrectomy.(28) Though this work does not

 improved outcomes in colon and rectal surgery

(A) (B) (C)

Figure 36.6  Boari or bladder

flap procedure. (A) Creation
of tapered bladder flap, based
posteriorly. (B) Submucosal
ureteral reimplantation. (C)
Closure of bladder flap.

address iatrogenic injuries, the principle of renal salvage should

be applied. Every attempt to evaluate the extent of the injury as
well as an assessment of the entire genitourinary tract should be
done before undertaking repair. A one shot IVP can confirm con-
tralateral renal function. This can be done by giving the patient
2 ml of contrast per kg up to a maximal of 150 ml IV. An on the
table KUB is then done 10 minutes later. Simple palpation of the
contralateral kidney does not ensure function. The literature is
full of anomalous solitary kidneys which were removed neces-
sitating dialysis or transplantation.(29, 30) Pelvic kidneys have an
anomalous blood supply generally arising from multiple arteries
along the aorta and iliac vessels. A total of 10% are solitary and
may easily be taken for a pelvic mass as they are not reniform
and have a discoid shape.(23) If caliceal or renal pelvis injury is
suspected, intravenous methylene blue or indigo carmine can be
administered.
Once the injury is well defined, repair can be decided. Minor
renal lacerations or penetrating injuries may be repaired primarily
with absorbable sutures and retroperitonealized with perinephric
fat, omentum, or hemostatic materials. Hilar control is paramount
if an attempt at repair is to be performed. If the injury is to the
collecting system or renal parenchyma and the ensuing blood loss
is able to be managed by pressure and hemostatic agents alone, a
ureteral stent and foley catheter can be placed from below and the
area drained with a closed suction to prevent urinoma formation.
Conservative management is optimal as renorraphy and explora-
tion can lead to unnecessary nephrectomy. If a major vascular
injury occurs and the patient’s intraoperative condition permits,
every attempt should be made to reestablish vascular integrity.

BLADDER DYSFUNCTION
The reported incidence of difficulty in reestablishing micturation
ranges from 15 to 25% after low anterior resection and up to 50%
after abdominoperineal resection.(31) A thorough understand-
Figure 36.7  Transureteroureterostomy. Right-to-left, showing retroperitoneal
ing of the neuroanatomy of the pelvis and the technique of total tunnel anterior to the great vessels.
mesorectal excision (TME) and autonomic nerve preservation
(ANP) can enable both local tumor control and preservation of reported for these nerve sparing techniques.(35–39) APR, when
autonomic nerve structures thus reducing the risk of urogenital performed in accordance with the principles of TME and ANP,
dysfunction.(34, 35) Favorable oncologic outcomes have been ensures the greatest likelihood of resecting all regional disease


 urologic complications of colorectal surgery
Figure 36.8  Innervation of lower urinary tract
while preserving both urinary and sexual function.(39) Locally
advanced tumors and preoperative chemotherapy and radia-
tion can make identification of the autonomic nerves and plexus
more difficult and sometime impossible.(34) The most common
sequela from autonomic nerve damage during surgery of the
colon and rectum is detrusor denervation and areflexia. This nor-
mally requires clean intermittent catheterization, foley catheter
placement, or suprapubic tube placement depending on the over-
all dexterity and functional status of the patient. Damage to the
pudendal nerve or its branches from Alcocks canal can result in
weakening of the striated urinary sphincter with resultant stress
urinary incontinence and intrinsic sphincter deficiency.
Detrusor function (bladder contractility) is predominantly
mediated by the parasympathetic nervous system, namely the
pelvic nerve.(33) These parasympathetic fibers originate from
the spinal cord at the S2–S4 level. Pelvic nerve branches are
redundant within the pelvis. The main trunks to the bladder and
proximal urethra course in the visceral pelvic fascia, also called
the posterior endopelvic fascia.(33) These preganglionic auto-
nomic fibers course alongside the superior vesical vasculature to
synapse with postganglionic autonomic fibers within the bladder
wall. Multiple pelvic preganglionic nerves pass laterally from the
pelvic floor over the rectal fascia investments en route medially to
the bladder (Figure. 36.8).(33)
Sympathetic innervation to the bladder arises at the level of
L2–L4 with a presynaptic fiber to the sympathetic ganglion adja-
cent to the spinal cord. Synapse occurs in the ganglion and a long
post ganglionic fibers travels through the pelvis to innervate the
bladder. Through different end receptors located within the blad-
der, the sympathetic component of the autonomic nervous sys-
tem helps to cause relaxation of the bladder body (compliance
for storage) and contraction of the trigone and bladder neck at
resting/storage states.
Somatic motor innervation to the striated pelvic floor muscu-
lature and sphincter arises from the S2–S4 level and travels via
the pudendal nerve through Alcocks canal. The perineal branches
of the pudendal nerve follow the perineal artery into the super-
ficial pouch to supply the ischiocavernosus, bulbospongiosus,
and transverse perinei muscles. Some branches continue anteri-
orly to supply sensation to the posterior scrotum and perineum.
Additional perineal branches pass deep to the perineal membrane
to supply the levator ani and striated urethral spincter.(40)
In the study by Junginger on total mesorectal excision (TME),
identification of the pelvic autonomic nerves was complete in
72%, partial identification in 10.7%, and not at all in 17.3% of
patients.(34) Univariate analysis showed that the case number
(experience), gender (males > females), and T stage (T1-2 vs.
T3-4) exerted an independent influence on the achievement of
complete pelvic nerve identification. In this series of 150 patients
with adenocarcinoma of the rectum, identification and preser-
vation of the autonomic nerves was achieved in a majority of
patients and led to the prevention of urinary dysfunction (4.5%
vs. 38.5%; p < 0.001).(34)
Management of the postoperative patient with bladder dys-
function after colorectal surgery includes teaching clean inter-
mittent catheterization (CIC) and having the patient return for
full urodynamic evaluation around 2–3 months postoperatively.
Urodynamics can be a combination of fluoroscopic pressure/flow
studies with EMG tracings and sometimes urethral pressure profil-
ing. It may take up to 6 months for bladder function to return to its
new baseline and CIC may be a lifelong therapy. CIC is performed
with a 12–14 french low friction catheter every 4–6 hours and the
duration can be adjusted based on the storage pressures and bladder
capacity at the time of urodynamic evaluation. There are no drugs
with acceptable pharmacokinetics and side-effect profiles that have
been shown to clinically increase contractility in the bladder.
In a meta-analysis, Branagan et al., reviewed the colorectal
surgery literature on suprapubic catheter placement followed
by voiding trial versus urethral catheter placement and standard
trial of voiding postoperatively.(31) They found favorable results
for the suprapubic catheter in terms of incidence of urinary tract
infection, and a shorter magnitude and duration of pain and dis-
comfort. The ability to simply clamp and unclamp the suprapubic
catheter makes management and voiding trials relatively simple
especially in patients unable to perform CIC or those at especially
high risk for postoperative bladder dysfunction. Suprapubic
catheters are particularly useful if autonomic nerves have to be
removed during radical pelvic surgery, because normal voiding
may be difficult to reestablish and may take several months to
recover. In the select patient with voiding dysfunction and delayed
recovery, suprapubic catheter placement results in less morbidity
and patient discomfort than urethral catheterization.(32)
SEXUAL DYSFUNCTION
In the urologic community, an emphasis on postoperative sexual
function has arisen from studies by Walsh on the anatomic ret-
ropubic prostatectomy with preservation of the neurovascular
bundles that contribute to erectile function.(41) Most recently,
post operative penile rehabilitation is being performed in mul-
tiple settings with a theoretical benefit of reducing the time of
neuropraxia to the penis and prevention of apoptosis induced
atrophy. Although no standardization exists with these rehabili-
tation programs, patients are very interested and at the authors’
institution this is discussed preoperatively. Sexual dysfunction
has long been associated with rectal surgery in both male and
female patients. In male patients, erectile dysfunction is reported
in 5 to 65% of patients and ejaculatory dysfunction is reported in

 improved outcomes in colon and rectal surgery

14 to 69%.(43) Damage to the sacral splanchnic nerve (parasym-

pathetic) or the hypogastric nerve (sympathetic) during surgery
is the propsed mechanism of injury.(43)
Sexual dysfunction is a broad term that encompasses failure of
arousal, erection, orgasm, ejaculation, and emission. Complaints
from patients after radical pelvic surgery are usually mixed.
Erection is parasympathetically mediated and is governed by
impulses traveling along the nervi ergentes (S2–S4).(41) The pel-
vic plexus is located retroperitoneally on the lateral surface of the
rectum 5–11 cm from the anal verge with its midpoint located at
the tip of the seminal vesicles. The preganglionic fibers from the
nervi ergentes coalesce on the pelvic wall with contributions from
the sympathetic fibers and from the hypogastric plexus (T10–L4).
Damage to the sympathetic plexus will result in problems with
ejaculation including retrograde ejaculation or anejaculation.
In a study by Henderson et al., eighty one women and 99 men
that had undergone curative rectal cancer surgery were given a
validated sexual function questionnaire.(42) Thirty-two percent
of women and 50% of men were sexually active compared with
61% and 91% preoperatively. Twenty-nine percent of women
and 49% of men reported that “surgery made their sexual lives
worse”. Specific sexual problems in women were libido 41%,
arousal 29%, lubrication 56%, orgasm 35%, and dyspareunia
46%. In men complaints were impotence/erectile dysfunction
84%, libido 47%, orgasm difficulty 41%, and ejaculation diffi-
culties 43%. Patients seldom remembered discussing sexual risks
preoperatively and were seldom referred or treated for symptoms
postoperatively. Sexual dysfunction should be discussed with rec-
tal cancer patients, and when appropriate, efforts to prevent and
treat sexual dysfunction should be instituted.(42)
In a study of patients by Nam et al., on patients undergoing TME
and ANP for rectal carcinoma, factors that most affected postop-
erative sexual dysfunction were age older than 60 (sexual desire, p =
0.019), time period within 6 months of surgery (erectile function,
p = 0.04), and lower rectal cancer (erectile function p = 0.02).(43)
In the urologic literature, penile rehabilitation is started at approxi-
mately 1 month postoperatively with evidence suggesting that lack
of natural erections during this period of time produces cavern-
osal hypoxia.(44) Prolonged periods of cavernosal hypoxia induce
fibrosis, which later increases the incidence of venous leak and thus
potentiates long-term or permanent erectile dysfunction
In consultation with a urologist, sexual dysfunction in the man
can be treated with many different modalities. For erectile dys-
function, oral phosphodiesterase inhibitors, intraurethral vasoac-
tive suppositories, intracavernosal injections, vacuum errection
devices, and implantable devices are all options. For ejaculatory
dysfunction in a patient desiring pregnancy, semen may be col-
lected from the bladder in the case of retrograde ejaculation.
Sympathomimetic agents may also be used. For refractory cases,
electro-vibratory ejaculation can be performed at specialized cent-
ers. It is important to discuss sexual function with the patient both
pre and postoperatively as there are many therapeutic options that
have been shown to be very satisfactory for both partners.
ARTIFICIAL DEVICES
Thousands of artificial urinary sphincters (AUS) and inflatable
penile prosthesis (IPP) have been implanted worldwide for the
(A)
(B)
(C)
Figure 36.9  Artificial urinary sphincter (AVS-800); American Medical Systems
Inc, Minnetonka, MN. (A) reservoir. (B) cuff. (C) pump.
treatment of stress urinary incontinence and erectile dysfunction,
respectively (Figure 36.9). The IPP has one to three components,
while the AUS has three components. The three component sys-
tems have a reservoir, pump, and cuff or prosthesis that is inter-
connected with reinforced tubing. These devices are silicone but
develop a capsule around them after implantation. The reservoir
is typically placed suprapubically in the space of Retzius. One
should make every attempt to refrain from entering this capsule
and to prevent contamination of these silicone devices. If con-
tamination occurs, either device removal or salvage therapy with
copious antibiotic irrigation is recommended, preferably the lat-
ter. The risk of device contamination, post operative infection,
and damage to the tubing necessitating device removal or reop-
eration should be discussed with the patient preoperatively. It is
the authors practice to be very conservative in patients with AUS,
and we recommend all patients have their device de-activated by
a urologist familiar with the AUS before placement of a urethral
catheter. There are numerous reports of patients “turning off” their
own AUS when in reality they only cycle them, followed by urethral
catheterization at the time of surgery and the result is a device ero-
sion through the urethra. This is a medico-legal issue that usually
can be averted with a preoperative consultation with a urologist.
The FDA approved sacral neuromodualtor is the Interstim
device manufactured by Medtronic Corp.(45) It is approved for
use in patients with refractory urgency and frequency or nonob-
structive nonneurogenic urinary retention. A tined lead is placed
through the S3 foramen and an implanted generator is placed in
a pocket created in the gluteal area/upper hip. The manufacturer
recommends against using electrocautery near the generator and
to not perform a MRI on any patients with the Interstim device.


 urologic complications of colorectal surgery
It is the authors practice to turn off the device with a Medtronic
supplied magnet before any radical pelvic operation. In small
patients, appropriate padding must be applied to the area of the
implanted generator. MRI is contraindicated although there has
been at least one study to show deactivation of the device before
MRI to be safe.(46, 47)
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Index

5-Aminosalicylates (5-ASA) 336–7 retained fragments 386–7

5-FU 300 World War I 375
Bevacizumab 301 World War II 375
Cetuximab 301 abdominal wall contouring 356–7
indications for 301 caring 356–7
Irinotecan-Containing Regimens 301 flap dissection 356, 357
with leucovorin 300 abdominoperineal resection (APR) 278
with levamisole 300 closure, methods of 280–1
Oxaliplatin-Containing Regimens 300–1 complications 281
see also chemotherapy abscess 281
6-methyl-mercaptopurine (6-MMP) 337–8 intraoperativ hemorrhage 281
6-methylprednisolone 337 non-healing wound and
6-Thioguanine Nucleotide (6-TGN) 337–8 perineal sinus 282
perineal wound complications 282
AAST grades 378 postoperative hemorrhage 281–2
abdominal colectomy epidemiology 278
ileorectal anastomosis with 322 evisceration 283
abdominal CT 377 operative technique 278–80
abdominal discomfort 367 perineal hernia 283
abdominal radiography 97 positioning 278
bowel obstruction and dilatation 97–8 leg positioning 279
cecal volvulus 99 preparation 278
pneumoperitoneum 97 risk factors 282–3
sigmoid volvulus 98–9 carcinoma 282
toxic megacolon 98 fecal contamination 282–3
abdominal surgery 263 radiation therapy 282
functional outcomes 267 sexual and urinary function 280
oncologic outcomes 263 treatment 283
preoperative evaluation 263–4 abscess 340
surgical technique 264 absorbable regenerated cellulose 266
patient-centered outcomes 267–8 ActiconTM Neosphincter device 231
surgical outcomes acute anal fissure 200
anastomotic bleeding 265–6 calcium channel antagonists versus nitrates
anastomotic complications 264 acute pilonidal disease 216
anastomotic leak 264–5 Adalimumab 338
anastomotic stricture 265 adhesions 47–9
autonomic nerves injury 267 grading system for bowel 47, 47
pelvic hemorrhage 266 adjuvant chemotherapy
splenic injury 266–7 for T3 302–3
ureteral injuries 267 stage II and IV colon cancer 301–2
abdominal trauma stage III colon cancer 302
colostomy closure Advanced Trauma Life Support principles 375
outcomes of 384 adynamic ileus 110
antibiotic therapy 385–6 Agency for Healthcare Research and Quality (AHRQ) 164
blunt colon injury 383 aging 8
diagnosis 376 Altmeier procedure 241–2
epidemiology 375 alvimopan 367
military perspective 384–5 American College of Surgeons (ACS) 3, 164
physical exam American Heart Association (AHA) 134
computed tomography 377 American Joint Committee on Cancer (AJCC) 301
diagnostic peritoneal lavage (DPL) 376 American Society of Anesthesiologists (ASA) 2, 19
injury scale 377–8 classification 2
laparoscopy 377 American Society of Clinical Oncology (ASCO) 164, 165
peritoneal sign 376 American Society of Colon and Rectal Surgeons (ASCRS) 14, 15, 27,
seat belt sign 376 164, 200, 251, 253
ultrasound 376–7 aminosalicylates 336
preoperative assessment 375–6 anal dilation 207


 index

anal encirclement 242, 243–4 stricture 63–4

anal fissure techniques 58
acute 200–1 treatment 64–5
chronic 201 anastomotic leak 264, 324
classification 199 anemia 1
conservative therapy 200 anesthesia 1
diagnosis 200 awareness 23
pathophysiology 199 local anesthesia 19
posterior and anterior 199 Monitored Anesthetic Care (MAC) 20–1
surgery therapy 206–8 regional anesthesia 21–3
see also acute anal fissure; chronic anal fissure anoderm 172
anal fistula 174 anorectal foreign bodies
Crohn’s disease 192 bedside extraction 389
diagnosis 184–5 initial assessment 388–9
etiology 183–4 operative removal 389
HIV-positive patient 193 sexual implements 388
incontinence 190–1 anorectal manometry 117, 364
non-surgical management 192–3 anorectal physiology tests (ARP) 228–9
recurrence 189–90 limitations of 87
surgical therapy case management 87
advancement flap 186–7 anal ultrasonography 91–2
anal fistula plug 188–9 constipation 92
extrasphincteric fistulas 186 balloon expulsion test 94
fibrin glue 187–8 biofeedback 94
fistulotomy 186 colonic transit studies 93
incision and drainage 185–6 defecography 93
seton placement 186 MRI 94
anal fistula plug 188–9 small bowel transit 94
Anal Fistula Plug™ (AFP) 188 electromyography
anal skin tags 175 concentric needle 89–90
anal sphincter 226–7 single fiber 90
anal sphincter injury 389 surface 90
life-threatening injuries 389 fecal continence 87
anal sphincteroplasty 229 fecal incontinence, investigations for
anal stenosis 174, 208–210 biofeedback 92
anal ultrasonography 91–2 electomyography 91
anastomosis 380 manometry 87–8, 88
anastomotic complications, postoperative 56 ultrasound 92
bowel preparation , mechanical 58 pudendal nerve terminal motor latency 90, 90
case management 56 rectal capacity and sensation 89
clinical presentation 59–60 Recto-Anal inhibitory reflex 89
considerations 56–7 sphincter pressure measurement 88–89
dehiscence 56 anorectal sexually transmitted disease 156–7
diagnosis 60 anorectal varices 175
diagnosis 64–5 antegrade colonic enema 233–4
management 60–2 anthraquinones 367
asymptomatic 60–1 antibiotic prophylaxis 14
colocutaneous fistula 62 antibiotic therapy
leak with associated abscess 61–2 abdominal trauma 385–6
leak without abscess 61 anti-Saccharomyces cerevisiae mannan antibodies (ASCA) 332
peritonitis 62 anti-Saccharomyces cerevisiae 327
omental pedicle 58 apocrine sweat glands 221
operative intervention 62–3 appendicitis 117
colostomy creation 62 areflexia 401
leaking anastomosis argon plasma coagulation 306
@4:exteriorization of 63 arteriovenous sinusoids 178
@4:leaving, in place 63 artificial bowel sphincter 231
@4:repeat anastomosis after resection 63 artificial urinary sphincters (AUS)
@4:resection of 62 components 402
@4:short and long-term implications of 63 traumatic foley catheter placement 395
pelvic drains 59 ASA Closed Claims Project 21
proximal diversion 57–8 ASCRS see American Society of Colon and Rectal Surgery
radiation 58–9 Aspirin 135


 index

ATLS principles see Advanced Trauma Life Support principles randomized controlled trials 205
AUS see artificial urinary sphincters sphincterotomy 206
Australian Safety and Efficacy Register of New Interventional bowel function
Procedures-Surgical 232 adhesions, grading system for 47, 47
autonomic nerves injury 267 preparation 33–4
AVASTIN® 301 mechanical 58
azathioprine (AZA) 337 status 34
bowel obstruction and dilatation 97–8
Babcock clamp 140 Bridgewater 135
bacteremia 22 brooke ileostomy
bacterium Clostridium botulinum see botulinum toxin proctocolectomy with 319–20
Bacteroides 386 budesonide 337
balloon expulsion test 94, 364 bupivicaine 19
balloon proctography 117
balsalazide 337 calcium channel antagonists 203–5
barium enema 112–15, 367 vs nitrates 204
Crohn’s disease 114–15 vs placebo 203–4
diverticulitis 115 vs sphincterotomy 204
diverticulosis 115 calcium polycarbophil 179
double contrast 112–13 Cancer Care Outcomes Research and Surveillance Consortium”
limitations of 113–14 (CanCORS) 165
lymphoma 115 cardiovascular disease 3–4
single contrast 112–13 functional status, assessment of 4
ulcerative colitis 114 preoperative cardiac evaluation
Bascom II procedure 220 Goldman risk model 3
Bascom operation 219 Lee index 3
bedside extraction 389 care paths
benzodiazepines 133 benefits of 80
Bevacizumab (AVASTIN®) 301 case management 79
biofeedback therapy challenges and concerns 83–4
failure of 368 in colon and rectal surgery 79
for constipation 94 development of 80–3
for fecal incontinence 92 fast track surgery 84–5
limitations 92 guidelines 79
pelvic floor dyssynergia implementation of 80–3
dyssynergic-type constipation 368 institutional experience 83
treatment of 367–8 objectives of 79
on slow-transit constipation 368 outcome measures, defining and improving 80
Bioplastique® 233 realistic expectations 84
bispectral index (BIS) 23 cathartic colon” 367
bladder dysfunction caudal anesthetic 21
autonomic nerve structures 400 cecal volvulus 99
innervations 401 Centers of Medicare and Medicaid Services (CMS) 161, 162
oncologic outcomes 400–1 central nervous system (CNS) 20, 227
postoperative patient central neuraxial blockade 21–2
clean intermittent catheterization (CIC) 401 caudal 21
resection 400 contraindications 22
total mesorectal excision 401 epidural 21–2
bladder flap see Boari flap heparin 22
bladder injury spinal 21
delayed bladder injury 396 cerebrospinal fluid (CSF) 21
iatrogenic injury cerebrovascular accidents (CVA) 8
stages 396 Cetuximab (ERBITUX®) 301
risk factor 396 Chance fractures” 376
two layer technique 396 chemotherapy 287, 300, 314
bleeding complications 69 with colorectal cancer 300–1
bleeding 178, 265–6 future directions 303–4
blunt colon injury (BCI) 383 indications and timing 301–3
Boari flap 399 side effects 303
body temperature and oxygenation 28 chlamydia trachomatis infections 157
botulinum toxin (BT) 205 chronic anal fissure 201
vs nitrates 206 botulinum toxin (BT) 205
vs placebo 205–6 vs nitrates 206


 index

vs placebo 205–6 colostomy closure

vs sphincterotomy 206 outcomes of 384
calcium channel antagonists 203–5 colostomy 234, 375
medical therapy 201 colovesical fistula 396
nitrates 201–3 Commission on Cancer (CoC) Joint Quality Measures 165
randomized controlled trial complex diverticulitis 255
botulinum toxin 205 complex perineal injury 389–90
calcium channel antagonists 204 computed tomography 390
complications of 208–10 pelvic fracture 390
surgical therapy 206–8 computed tomographic colonography (CTC) 110–12
anal dilation 207 advanced adenoma 110–11
refractory fissures 208 benefits 111
sphincterotomy 207–8 complications 111
chronic constipation see constipation limitations 111–12
chronic diverticulitis 254 optical colonoscopy 112
surgical treatment 254 postoperative surgery 112
best timing 254 technique 111
vs medical treatment 254 computed tomography (CT scan) 99
chronic pilonidal disease appendix 108
surgical therapy 216 bowel trauma 101–2
see also pilonidal disease cecal volvulus 109
Ciprofloxacin 337 colitides 103–4
cisapride 73 colorectal cancer 105–8
Citrucel® 179 contrast enhanced multidector CT 100
clean intermittent catheterization (CIC) 401 diverticulitis 104–5
cleft lift procedure 220 inflammatory bowel disease (IBD) 102–3
Cleveland Clinic Florida 247 pneumatosis 100
Clinical Outcomes of Surgical Therapy (COST) trial 59, 140 pneumoperitoneum 100–1
Clopidogel 135 sigmoid volvulus 109
Clostridium difficile 103 small bowel obstruction
cocaine 19 CT enteroclysis 110
Cochrane Database Review 28 diagnosis and causes 109–10
Colazal 337 ischemia 110
colchicine 367 paralytic/adynamic ileus 110
colectomy 370 tumors 108–9
colocolic intussusception 115 unenhanced multidector CT 99–100
colon cancer 322 Condyloma Acuminatum 155
colon injury condyloma 155
abdominal injury 376–8 congestive heart failure 5
anastomosis 380 conservative therapy 200
diversion 378–80 acute anal fissure 200
meta-analyses investigation 380 constipation 361
primary repair 378, 379, 380 balloon expulsion test 94
arguments of 378 biofeedback therapy 367–8
randomized trials investigation 379 biofeedback 94
resection 379–80 colectomy, successful outcomes 370
colonic inertia see slow-transit constipation colonic transit studies 362–4
colonic transit studies 362–3 colonic transit studies 93
radiopaque marker test 363 complications 370
scintigraphic technique 363–4 defecography 93
colonic transit studies 93 limitations 93
colonoscopy 132 drugs associated with 362
perforation rage 136 functional constipation 361
sedation 133 initial evaluation 362
colorectal cancer 105–7 medical condition 361
diverticulitis medical treatment 365–7
detection and differentiation 105 high-fiber diet 365
metastasis 106 medications 366
postoperative complications 107 stimulant laxatives 367
recurrence 106–7 MRI 94
staging 105–6 limitations 94
Colorectal Quality Measures 165 pelvic floor physiology tests 364
colorectal transit 117 Rome III diagnostic criteria 361


 index

routine evaluation 362 destructive injury 389

small bowel transit 94 detrusor function 401
surgical intervention 368–70 devascularization injury 398
timing 369 diabetes 8
treatment 361 diagnostic laparoscopy 387
Contigen® 233 diagnostic peritoneal lavage (DPL) 376
continent ileostomy 351 dietary modification 178
proctocolectomy with 320–2 Dipentum 337
Coronary Artery Revascularization Prophylaxis (CARP) 4 Diprivan 133
corticosteroids 337 diverticular disease
cramping 367 immunosuppressed patients 254–5
Crohn’s disease incidence of 250
after surgery intra-operative classification 250
health-related quality of life (HRQL) 344 nonoperative therapy 250@
postoperative occurrence 343 operative therapy 249, 255–7
clinical features 331 complications of 257
computed tomography (CT scan) 102 Hartmann reversal 256–8
evaluations of postoperative resection 258–9
blood test 332 procedures of 258–9
double balloon enteroscopy (DBE) 335 timing of closure 259
imaging techniques 332–5 diverticulitis 143–4, 250
PET scan 335–6 acute complicated 253
stool marker 332 outcomes 253
fever 331 recurrence, risk of 253
and indeterminate Colitis 327 surgical intervention 253–4
medical therapy 336 chronic diverticulitis 254
5-Aminosalicylates (5-ASA) 336–7 complex diverticulitis 254
antibiotics 337 diverticulosis 250
biologic response modifiers 338 acute uncomplicated 251
corticosteroids 337 age 251–2
immunomodulators 337–8 outcomes 251
postoperative recurrence, prevention of 338–9 progression, of disease 251
nutritional therapy 339 recurrence, risk of 252
surgical intervention postoperative surgery 258–9
bypass surgery 343 procedures 258
resection 342–3 diverting ostomies 352
stricture biopsy 342 Donabedian model 160
strictureplasty 341–2 double balloon enteroscopy (DBE) 335
surgical treatment doxycycline 157
abscess 340 Duke Activity Status Index 4
bleeding 341 duodenum stricture 343
indications for 339 Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress
obstruction 341 Echocardiography (DECREASE-V) 4
perforation 339–40 DVT prophylaxis 22
perianal crohn’s disease 340–1 DVT see deep venous thrombosis (DVT)
toxic megacolon 341 dynamic graciloplasty 231–2
symptoms of 331 dysplasia 326
cryotherapy 155, 291
CT enteroclysis 110 E. Coli see Escherichia coli
cyclosporine 338 Eastern Cooperative Oncology Group (ECOG) 304
elective colectomy 258
damage control surgery (DCS) 381–2 elective colon resections 14
damage-control laparotomy 46–7, 47 electomyography
deep venous thrombosis (DVT) 71–2 in fecal incontinence with limitations 91
defecography 93, 117, 240, 364 electrocardiogram 4
in constipation, limitations of 93 preoperative baseline 4
scintigraphic 363–4 electrolyte 15
dehiscence 324–5 electromyography (EMG) 364
delayed bladder injury 396 concentric needle 89–90
delayed hemorrhage 135 rectal prolapse 239–40
Delorme’s procedure 241, 242–3 single fiber 90
Denonvilliers’ fascia 267 surface 90
Depositions 151 Elsberg syndrome 157


 index

Emergency Department 249 flexion distraction injury 376

end ileostomy 351 Flint grade 378
end ostomies 350–1 fluoroscopy 112–17
endometriosis 115 barium enema 112–15
endorectal advancement flap 340 physiologic examinations 117
endoscopic ablation therapy 314 anorectal manometry 117
endoscopic ultrasound (EUS) 335 balloon proctography 117
enterovesical fistula 396, 397 colorectal transit 117
EORTC 310 defecography 117
epidural anesthetic 21–2 water-soluble contrast enema 115–17
ERBITUX® 301 focused abdominal sonography for trauma (FAST) 376–7
erythema 28 evaluation 376
erythromycin 73 FOLFIRI 301
Escherichia coli 14, 386 FOLFOX 300
evisceration 283 Frykman-Goldberg procedure 245–6
excisional hemorrhoidectomy 169–72 functional constipation 361
extrasphincteric fistulas 186 see also constipation

fecal bolus 227 gabapentin 68

fecal contamination 282–3 gastrointestinal (GI) bleeding 122
fecal continence 87 gastrointestinal obstruction 341
fecal incontinence, surgery for 87, 174 gastrointestinal scintigraphy 121–2
biofeedback 92 Gastrointestinal Tumor Study Group and North Central Cancer
limitations 92 Treatment Group 308
electromyography, limitations 91 Gatrointestinal Stroma Tumors (GIST) 109
manometry 87–8, 88 German Rectal Cancer Trial 302
limitations 89 glyceryl trinitrate (GTN) 200, 202
ultrasound, limitations 92 Goldman risk model 3
anorectal physiology tests (ARP) 228–9 gracilis transposition 341
epidemiology 226
etiology Hand Assisted Laparoscopic (HAL) Colectomy 255
anal sphincter 226 Harmonic Scalpel® hemorrhoidectomy 172
central nervous system 227 Harmonic Scalpel® 172
fecal bolus 227 Hartmann colostomy
rectum 226–7 outcomes of 256
evaluation reversal 256–7
historical 227–8 healthcare 263
physical 228 Heineke–Mikulicz procedure 341
severity, assessment of 227 hemorrhage 134–5, 281
risk factors 227 anastomosis 41
treatment delayed bleeding 174
antegrade colonic enema 233 intraoperative 281
artificial bowel sphincter 231 intraoperative 44–6
biofeedback 229 postoperative bleeding 173–4
dynamic graciloplasty 231–2 postoperative 281–2
injectable bulking agents (IBA) 233 hemorrhoid
medical therapy 229 anatomy and pathophysiology 178
sacral nerve stimulation 232–3 bleeding 178
sphincteroplasty 229–31 classifications 181
fentanyl 21, 133 clinical evaluation 178
Ferguson hemorrhoidectomy 170, 171 grading system 178
FFCF trial 310 nonoperative therapy for 178
FiberChoice® 179 techniques, comparison of 181–2
Fibercon® 179 treatment
fibrin glue 187–8 conservative management 178–9
Fibrin Glue 340 infrared photocoagulation 181
fibrinclot 340 rubber band ligation 179–80
fissures see anal fissures sclerotherapy 179
fistula 174, 219, 340 hemorrhoidal surgery 168
fistula-in-ano anatomy/etiology 168–9
carcinoma associated with 193 clinical evaluation 169
classifications 184 excisional hemorrhoidectomy 169–72
fistulotomy 186, 340 nonexcisional options 169


 index

postoperative complications abdominalradiography 97–99

anal fistula 174 bowel obstruction and dilatation 97–8
anal stenosis 174 cecal volvulus 99
anal tags 175 pneumoperitoneum 97
constipation and fecal impaction 174 sigmoid volvulus 98–9
fecal incontinence 174 toxic megacolon 98
hemorrhage 173–4 computed tomographic colonography (CTC) 110–12
infection 174 advanced adenoma 110–11
mucosal ectropion 174 benefits 111
pain 172 complications 111
urinary retention 172–3 limitations 111–12
sagical section and anal cushion 168 optical colonoscopy 112
special situation postoperative surgery 112
anorectal varices 175 technique 111
postpartum hemorrhoids 175 computed tomography (CT scan) 99
heparin 22 appendix 108
hepatic artery infusional (HAI) therapy 290–1 bowel trauma 101–2
hepatic disease 6 cecal volvulus 109
hepatic metastasis, chemoembolization of 123 colitides 103–4
herpes simplex virus (HSV) 156–7 colorectal cancer 105–8
hidradenitis suppurativa 215 contrast enhanced multidector CT 100
diagnosis 222 diverticulitis 104–5
nonoperative management 222–3 inflammatory bowel disease (IBD) 102–3
pathophysiology 221–2 pneumatosis 100
surgical management pneumoperitoneum 100–1
excision 223 sigmoid volvulus 109
high-molecular-weight polyethylene glycol (PEG) 366–7 small bowel obstruction 109–10
HIV/AIDS 7 tumors 108–9
human immunodeficiency virus 156 unenhanced multidector CT 99–100
human papillomavirus (HPV) 155 fluoroscopy 112–17
hydrocortisone cream 155 barium enema 112–15
hyperbaric local anesthetic 21 physiologic examinations 117
hyperbaric oxygen 314 water-soluble contrast enema 115–17
hypercoaguable syndromes 9 interventional radiology 122–3
hypersomolar oral saline laxative 15 chemoembolization of hepatic metastasis 123
hypertonic NaP 15 gastrointestinal (GI) bleeding 122
hypobaric local anesthetics 21 image-guided percutaneous biopsy 123
percutaneous abscess drainage (PAD) 122–3
iatrogenic injury 266 radiofrequency ablation (RFA) 123
iatrogenic perforation 144 magnetic resonance imaging (MRI) 119–20
iatrogenic ureteral injuries 397 nuclear medicine imaging
distal one third 398–9 gastrointestinal scintigraphy 121–2
middle one third 398 positron emission tomography 120–1
proximal one third 398 ultrasonography 117–19
idiopathic hypertrophic subaortic stenosis (IHSS) 22 endoluminal ultrasound’s (EUS) 119
IFL 301 intraoperative ultrasound 119
ileal pouch-anal anastomosis (IPAA) 325, 351 transabdominal ultrasound 118
ileal-rectal anastomosis (IRA) 351 imaging techniques
ileocolic resection 342 in crohn’s disease
ileocoloc intussusception 110, 115 colonoscopy 334
ileonal pouch procedure computed tomography scan 334–5
abdominal colectomy 322 double balloon enteroscopy (DBE) 335
complications 323–326 endoscopic ultrasound (EUS) 335
controversies 326–7 enema 332
functional result 323 magnetic resonance imaging 335
proctocolectomy 319–23 scintigraphy 336
ileorectal anastomosis small bowel series 332
with abdominal colectomy 322 transabdominal ultrasound (US) 334
ileostomy 352 upper edoscopy 332–3
selective omission 327 imiquimod 156
ilioinguinal and iliohypogastric nerve block 23 immunocompromise 7
image-guided percutaneous biopsy 123 immunomodulators 337–8
imaging studies 97 immunosuppressed patients 254–5


 index

impaired sensorium 5 intraperitoneal anastomoses 29

infections 69–70 intrathecal blockade see spinal blockade
surgical site 69–70 intravenous antibiotics 15
urinary tract infections 70 effect of 15
inflatable penile prosthesis (IPP) inulin 179
components 402 IPAA 322
Infliximab 193, 338 Irinotecan 303
infrared photocoagulation 181 IROX 301
injectable bulking agents 233 ischemia 353
injection sclerotherapy 179 isobaric local anesthetics 21
interventional radiology 122–3 isosorbide dinitrate (IDN) 200
gastrointestinal (GI) bleeding 122 isosorbide mononitrate (IMN) 200
hepatic metastasis, chemoembolization of 123 Ivalalon sponge rectopexy 244, 245
image-guided percutaneous biopsy 123
percutaneous abscess drainage (PAD) 122–3 jeep disease 215
radiofrequency ablation (RFA) 123
intestinal stomas 349 Kaposi’s sarcoma 156
intraabdominal hemorrhage 323–4 Karydakis flap 200
intraabdominal infections 29 Klebsiella 386
percutaneous drainage 29 Kock pouch 322
intraoperative anastomosis 33 Konsyl® 179
case management 33
challenges 40–1 laceration injury 398
adjuvants and drains 41 lactulose 366
hemorrhage 41 laparoscopic colorectal surgery 140
inadequate anastomotic lumen 40–1 advantages 140–1
leakage 41 colonoscopic perforation 144
proximal protection 41 disadvantages 141
preanastomotic considerations diverticulitis 143–4
bowel preparation 33–4 inflammatory bowel disease
bowel status 34 ulcerative colitis 142–3
exposure 34 instruments 145
obtaining adequate length 35–6 purported benefits 140
operative principles 33 rectal prolapse 144
preoperative discussion and planning 33 stoma 143
staples versus sutures 37 technical considerations 144
double staple 39 treatable conditions
end-to-end 37–9 colon cancer 141–2
end-to-side 39–40 trocar placement 144–5
side-to-side 39–40 vascular control 145
technique 36–7 laparoscopic intraperitoneal surgery 4
test 40 laparoscopic surgery 28
types of 37 laparoscopy 246, 291–2, 377
intraoperative challenges 44 lateral decubitus positioning 24
abdominal wall closure 51 lateral fistula 216–16
adhesive disease 47–9 Leapfrog Group 160–1
biologic meshes 52 criteria 161
case management 44 purchasing principles 160–1
damage control 46–7, 47 Lee index 3
hemorrhage 44–6 leucovorin 300
lesion localization 49–50 levamisole 300
preoperative evaluation 44 lidocaine 19
retention sutures 51 life-threatening injuries 389
suture material 51 LigaSure™ Vessel Sealing System 291
synthetic prostheses 51–2 LigaSure™ 172
technique 51 Ligation of Intersphincteric Fistula Tract
intraoperative positioning (LIFT) 189
lateral decubitus 24 linaclotide 367
lithotomy 24 liposuction 357–8
nerves, at risk 24 lithotomy 389
prone 23–4 positioning 24
supine 23 litigation injury 398
intraoperative radiation therapy (IORT) 287 liver metastasis 289


 index

adjuvant therapy 291 Metronidazole 337

assessing resectability 289–91 microfibrillar collagen 266
operative approach midazolam 133
laparoscopy 291–2 Milligan-Morgan hemorrhoidectomy 169–70, 171
open resection 292 misoprostol 367
outcomes 292 modified abdominoplasty 356–7
treatment of 289 flap dissection 356, 357
local anesthesia 19, 389 caring 356–7
drugs 19 Monitored Anesthetic Care (MAC) 20–1
perianal block 20 morbid obesity 355–8
relative potency 19 preoperative stoma marking 356
systemic toxicity 20 preoperative weight loss 356
loop end stomas 351–2 mucosal ectropion 174
loop ileostomy 327 mucosectomy
loop ostomies 352 vs. double-stapled technique 326–7
loose hair 215 multidector computed tomography (MCDT) 99–110
Lovenox® 135 see also computed tomography
low-molecular weight heparin (LMWH) 22
lubiprostone 367 National Healthcare Safety Network (NHSN) 27
lung metastasis 292 National Cancer Institute (NCI) 165
assessing resectability 293 National Comprehensive Cancer Network (NCCN) 165, 290
operative approach 294 National Initiative on Cancer Care Quality (NICCQ) 164
outcomes 294–5 National Nosocomial Infections Surveillance (NNIS) System 27
treatment of 292 National Quality Forum (NQF) 164, 165
video assisted thoracoscopic surgery (VATS) 294 National Surgery Quality Improvement Project
(NSQIP) 3, 162
magnetic resonance imaging (MRI) 94, 119–20 National VA Surgical Risk Study (NVASRS) 162
in constipation, limitations of 94 nausea 72
malignancy 326 neisseria gonorrhea 157
malnutrition 6–7 neoadjuvant chemoradiotherapy 302
mannitol 15 tumors 302
manometry 87–8, 88 nephropexy 398
for incontinence neurologic system 8–9
value and limitations of 89 Parkinson’s disease 8–9
marsupialization 218 neutropenic colitis 104
mechanical bowel preparation (MBP) 15, 16 Nichols-Condon antibiotic 14
randomized controlled trials 16–17, 28 nifedipine ointment 204
Meckel’s diverticulum 104 nipple valve slippage
medical legal issues 148 manifestations of 322
affordable liability insurance, lack of 148–9 nitrates 200, 201–3
documentation vs calcium channel antagonists 204
chart 150 sphincterotomy 203
high-risk areas 149 nitroglycerin (NTG) 200
informed consent 149–50 nitroglycerin transdermal patch 200
malpractice suit, anatomy of NJ 135
initial phase 150–1 node-positive rectal cancer 302–3
ploys 150–2 neoadjuvant chemoradiotherapy for 302
pretrial discovery 151 T3
testing your memory 151 adjuvant chemotherapy alone for 302–3
trials 152 nonabsorbable disaccharides 366
physician-patient relationship 149 nonbladed trocars 145
medical therapy noncutting Seton 340
chronic anal fissure 199–6 nuclear medicine imaging
fecal incontinence 229 gastrointestinal scintigraphy 121–2
melanosis coli 367 positron emission tomography 120–1
meperidine 133
mepivacaine 19 obesity 7–8
mesh rectopexy 243 olsalazine 337
mesh sling repair 244 omentoplasty 283
metabolic disease 7 open abdominal repairs 244
Metamucil® 179 oral antibiotic prophylaxis 28
methotrexate 338 Oral antibiotics 14
Methylcellulose 179 oral lavage 133


 index

oral preparations 15 perirectal abscesses

polyethylene glycol (PEG) 15 Crohn’s disease 192
sodium phosphate (NaP) 15 diagnosis 184–5
ostomy etiology 183–4
complications with HIV-positive patient 193
ischemia 353 incontinence 190–2
morbid obesity 355–8 non-surgical management 192–3
parastomal hernias 354–5 recurrence 189–90
prolapse 355 surgical therapy
retraction 353 advancement flap 186–7
skin 353 anal fistula plug 188–9
stenosis 353–4 extrasphincteric fistulas 186
dissected free 357 fibrin glue 187–8
preoperative stoma marking 350 fistulotomy 186
psychological impact 349–50 incision and drainage 185–6
reversal 358 seton placement 186
types of 350–3 PET scan see positron emission tomography scan 335–6
ostomy necrosis 353 phenol sclerotherapy 217
outcome measures 161–5 Physician Quality Reporting Initiative (PQRI) 161, 163–4
and quality measures 165 Physiologic and Operative Severity Score for enUmeration of Mortality
overlapping sphincteroplasty 230 and morbidity (POSSUM) 2, 257
Oxaliplatin 303 pilonidal disease 215
acute disease 216
pain management 67–8 advanced procedures for 220
paralytic ileus 110 Bascom operation 219
parastomal hernias 354–5 chronic disease 216
parenteral antibiotic prophylaxis 14 chronic pilonidal disease 217
Parkinson’s disease 8–9 diagnosis 215–16
patient-controlled epidural analgesia historical perspective 215
(PCEA) 21 limited excision 219
pectins 179 marsupialization 218–19
pelvic floor dysfunction 361 nonhealing wounds 220
biofeedback therapy 367–8 nonsurgical treatment 216–17
and slow-transit constipation 362 phenol sclerotherapy 217
pelvic floor physiology tests procedures for 217
anorectal manometry 364 sacral wound 220
balloon expulsion test 364 surgery for 219–20
defecography 364 wide local excision 217–18
electromyography (EMG) 364 plain films 97
pelvic hemorrhage 266 Plavi® 135
pelvic kidneys 400 Plavix 8
pelvic nerve 401 pneumonia 71
pelvic sepsis 29–30, 389–90 pneumoperitoneum 97
manifestations 324 abdominalradiography 97
penetrating colon injury computed tomography (CT scan) 100–1
damage control surgery (DCS) 381–2 podophyllin 155–6
penetrating colon injury 380–1 polyethylene glycol (PEG) 15
practice patterns 382 polyethylene glycol electrolyte lavage solution (PEG-ELS) 366
primary repair versus diversion polypectomy 135
arguments of 378–80 polyvinyl alcohol sponge rectopexy 244, 245
meta-analyses investigation 380 positron emission tomography (PET) scan 120–1, 335–6
randomized trials investigation 379 positron emission tomography with fluorine 18–labeled fluoro-2-
penicillin G 157 deoxy-D-glucose (FDG-PET) 335–6
percutaneous abscess drainage Post Dural Puncture Headache (PDPH) 22
(PAD) 122–3 posterior bladder injury 396
perianal crohn’s disease posterior mesh fixation 244
elective surgery 340 posthemorrhoidectomy pain 172
surgical treatment 340 postoperative complications 67
perineal hernia 283 atelectasis
perineal proctosigmoidectomy 241–2 pneumonia 71
perineal rectosigmoidectomy 240 prevention 71
perineal sinus 282 bleeding 69
perineal wound complications 282 case management 67


 index

deep venous thrombosis 71–2 proctocolectomy

infections with brooke ileostomy
surgical site 69–70 indications 319–20
urinary tract 70 operative technique 320
nausea and vomiting 72 outcomes 320
pain 67–8 with continent ileostomy
prolonged ileus 72–3 operative technique 320
retained foreign bodies 73–5 outcomes 320–2
time out” and sided surgery concerns 75 with ileoanal pouch 322
urinary retention 70–71 indications 322
postoperative hemorrhage 323–4 operative technique 322–3
postoperative ileus 140 outcome 323
postoperative patient prolapse 355
pelvic sepsis 29–30 prone positioning 23–4, 389
with sepsis 27 jack-knife position 21
postoperative pneumonia 25 prophylactic antibiotics 27
postoperative pulmonary complications (PPCs) 5 prophylactic sigmoid resection 255
postpartum hemorrhoids 175 pseudodiverticula 114
postpolypectomy bleeding 135 pseudomonal species 386
anticoagulant recommendations 135 Psoas hitch 399
management of 134 psuedomembranous colitis 103–4
pouch anal fistulas 325 psychiatric evaluation 23
pouch vaginal fistulas 325 psyllium 179
pouchitis 322, 326 PTQ implantsTM 233
prednisone 337 pulmonary disease 5
premenopausal females 2 American College of Physicians 5
preoperative bowel preparation 14 risk factors 5
in elective colon resections 14 purse-string stitch, repair of 38–9, 38
objectives 14
preoperative cardiac disease 3–4 quality measures
ACC 4 assessment and improvement,
hypertension 3 in surgery 159
preoperative medical condition 1 process measures 161, 162, 163–4
aging 8 structural measures 160–1
anesthesia consultation 1 definition 159
cardiovascular disease 3–4 Donabedian model 160
diabetes 8 Leapfrog Group 160–1
documentation 3 criteria 161
hepatic disease 6 purchasing principles 160–1
HIV/AIDS 7 and outcome measures 165
hypercoaguable disorders 9
immuncompromise 7 radiation therapy 306
malnutrition 6–7 acute adverse effects 310–11
metabolic disease 7 adjuvant treatment 307–10
neurologic system 8–9 chronic late adverse effect 312–13
obesity 7 chronic rectal effects 313–14
premenopausal females 2 neoadjuvant treatment 308
prevent postoperative complications 1 surgical complications 311–12
pulmonary disease 5 radiofrequency ablation (RFA) 123
renal disease 5–6 randomized controlled trials 16
using scoring systems 2 mechanical bowel preparation (MBP) 15, 16
preoperative risk assessment rapid plasma regain (RPR) 157
scoring systems 2 rectal carcinoma
prilocaine 19 staging 306
Priritis ani 154 rectal injury
causes of 154–5 classic components of 387
measures 155 foreign bodies 388
soilage 154 high-risk factors of 387
procaine 19 intraperitoneal injury 387–8
procedure for prolapse and hemorrhoids (PPH) 172, 173 management of
proctectomy fecal diversion 387
fecal contamination 282–3 modified steps 388
proctitis 157 traditional steps 388


 index

rectal procidentia 239 sedation 389

rectal prolapse senna 367
abdominal fixation procedures 144 sepsis 27
anal physiology 239–40 intraabdominal infections 28
defecography 240 pelvic sepsis 29–30
evaluation and investigations 239 postoperative patient 27
operative procedures 240–1 surgical site infection 27–8
anal encirclement 243–4 seton placement 186
Delorme’s procedure 242–3 severe diarrhea
laparoscopic approach 246 postoperative radiation therapy 310
mesh sling repair 244 sexual dysfunction 323, 401–2
open abdominal repairs 244 erection 402
perineal proctosigmoidectomy 241 male and female patients 401
perineal repairs 241 modalities 402
posterior mesh fixation 244 short-chain fatty acids (SCFA) 314
resection rectopexy 245–6 sigmoid volvulus 98–9, 115
suture rectopexy 244–5 skin infection 27
physical exam 239 skin 27
recurrent prolapse 246–7 functions 27
surgery for wound infection 27
Recto-Anal inhibitory reflex (RAIR) 89 slow-transit constipation 361
recurrent rectal cancer 286 and pelvic floor dysfunction 362
assessing resectability 286 total abdominal colectomy
chemotherapy and radiation 287 and ileorectal anastamosis 369
operative treatment 287, 289 small bowel crohn’s disease
outcomes 288 imaging techniques 336
refractory fissures 208 small bowel obstruction
regional anesthesia 21–3 small bowel transit constipation 94
central neuraxial blockade 21–2 sodium phosphate (NaP) 15, 133
ilioinguinal and iliohypogastric dosages 15
nerve block 23 soft tissue infection 27
Transversus Abdominis Plane sorbitol 366
(TAP) block 22–3 sphincteroplasty
renal disease 5–6 fecal incontinence 229–30
resection 379–80 functional result
resection rectopexy 245–6 follow-up 230
restorative proctocolectomy 327 sphincterotomy 207
Cesarean sections 323 vs botulinum toxin (BT) 206
with ileoanal pouch 322 vs calcium antagonists 204
indications 322 nitrates 203
operative technique 322–3 spinal blockade 21
outcomes 323 spirochete 157
retrograde urethrogram (RUG) 395 splenic injury 266
Rhomboid flap 200 recognition 266
Ripstein procedure 243, 244 SSI see surgical site infection (SSI)
RTOG 310 Staphylococcus aureus 222
rubber band ligation 179–80 staple anastomosis
vs suture 37
sacral foramina 232 double staple 39
sacral nerve stimulation (SNS) 232 double staple 39
efficacy of 232 double staple 39
functional result 233 double staple 39
indications for 232–3 end-to-end 37–9
selection criteria 232 end-to-side 39–40
sacral neuromodualtor 402 vs sutures 37
sacral wound healing 221 stapled anoplasty 170, 173
sacrococcygeal fascia 217, 220, 221 stenosis 354
Sanofi-Aventic 135 Z-plasty repair 352
scintigraphy 336 stimulant laxatives 367
sclerotherapy 179 side effects 367
seat belt sign” 376 stoma necrosis 353–4
secretagogues 367 stomal retraction 357–8


 index

stomas 143 Teflon® 233

living with 349–50 Tegaserod 367
meshing 354 temperature and oxygenation 28
necrosis test-tube test” 353
conservative management 354 tetracaine 19
site marking 350 therapeutic heparin 22
types thermal injury 398
diverting ostomies 352 Thiersch repair 243–4
end ostomies 350–2 thiopurine methyltransferase (TPMT) 337–8
loop colostomy 352 thrombin 266
stricture biopsy 342 tissue oxygenation 28
stricture 265 TissueLink Endo SH2.0™ Sealing Hook (SH) 291
strictureplasty 341–2 total abdominal colectomy
indication and contraindication 342 with ileorectal anastamosis 369
sucralfate 314 total mesorectal excision (TME) 308, 401
sulfasalazine 336 toxic megacolon 98, 341
superficial injury 389 transabdominal ultrasound (US) 334
supine positioning 23 transanal approach, to rectal cancer
suprapubic catheter 401 benefits 276
Surgical Care Improvement Project (SCIP) 19, 161, 162 complications 275
common and preventable complications 25 imaging techniques 271–2
process and outcome measures 25 local surgery
Surgical Infection Prevention Guideline Writers Workgroup disadvantages 276
(SIPGWW) 14 oncologic advantages of 276
surgical site infection (SSI) 27–8, 69–70 outcomes 276
laparoscopic surgery 28 surgical options 271–2
prophylactic antibiotics 27 Transanal Endoscopic Microsurgery (TEM) 273
scaling 27 comparison with 275–6
skin and soft tissue infection 27 complication of 275
surgical therapy techniques of 274–5
abdominal surgery 264, 265–7 transanal excision 272
advancement flap 186–7 techniques 273
anal fistula plug 188–9 Transanal Endoscopic Microsurgery (TEM)
anal fistula 183, 186–7 comparision with 275, 276–6
chronic anal fissure 201–8 complication of 275
chronic diverticulitis 254 benefits 276
chronic pilonidal disease 216 local surgery
Crohn’s disease 339–41 disadvantages 276
extrasphincteric fistulas 186 oncologic advantages of 276
fecal incontinence 226 outcomes 276
fibrin glue 187–8 and transanal 273, 275–6
fistulotomy 186 techniques of 274–5
hidradenitis suppurativa 215 transanal endoscopy 132
incision and drainage 185–6 colorectal preparation 132–4
perianal crohn’s disease 340 hypertonic electrolyte solutions 133
perirectal abscess 183, 185–9 infectious disease complications 134
pilonidal disease 217 intravenous sedation 133–4
seton placement 186 oral lavage 133
on stoma 354 nontechnical complications 132
Surgisis® 188 postpolypectomy syndrome 136–7
suture anastomosis proctoscopic perforations 137
vs staple 37 technical complications
double staple 39 hemorrhage 134–5
end-to-end 37–9 perforation 135–6
side-to-side 39–40 transanal excision 272
vs sutures 37 transanal rectal flap advancement 396
suture rectopexy 244–5 transcoccygeal Kraske approach 278
laparoscopy 246 transureteroureterostomy 399
Swedish Rectal Cancer Trial 302 Transversus Abdominis Plane (TAP) block 22–3
syphilis 157 Trendelenburg position 23, 246
systemic inflammatory response syndrome (SIRS) 27 Treponema pallidum 157
trichloroacetic acid 155


 index

trocar 144–5 urinary fistula

typhilitis 104 spontaneous closure 395–6
enteric diversion 396
ulcerative colitis, surgery for 103, 142–3 stages 396
abdominal colectomy surgical selection 396
with ileorectal anastomosis 322 urinary retention 70–1, 172–3
complications urinary tract infections 70, 174
anastomotic leak 324–5 urological complication
dysplasia and malignancy 326 artificial devices 402–3
ileal pouch anal anastomosis, stricture at 325 bladder dysfunction 400–1
pelvic sepsis 324 bladder injury 396
postoperative hemorrhage 323–4 fistula 396
pouch anal fistulas 325 iatrogenic ureteral injury 398–9
pouch failure 326 renal injury 399–400
pouch vaginal fistula 325 sexual dysfunction 401–2
pouchitis 326 ureteral injury 397–8
small bowel obstruction 323 urethral injury 395–6
controversies 326–7
Crohn’s Disease and Indeterminate Colitis 327 VAC® 283
ileostomy, omission of Venereal Disease Research Laboratory (VRDL) 157
mucosectomy vs. double-stapled venous thromboembolism (VTE) 9
technique 326–7 Vermont Colorectal Cancer Project 164
reservoir design 326 vertical rectus abdominis myocutaneous (VRAM) flap 281
functional result 323 Veteran Affairs (VA) hospitals 162
indications video assisted thoracoscopic surgery (VATS) 294
acute unresolving colitis 318–19 virtual colonoscopy 110–12
elective procedures 319 Visiport™ 47
proctocolectomy vomiting 72
with brooke ileostomy 319–20
with continent ileostomy 320–2 warfarin therapy 22
with ileoanal pouch 322–3 Warfarin 135
restoration 322 water-soluble contrast enema 115–17
ultrasonography 117–19 anastomotic assessment 116
endoluminal ultrasound’s (EUS) 119 intussusception 115
intraoperative ultrasound 119 postoperative complications 115–16
transabdominal ultrasound 118 volvulus 115
ultrasound Wells operation 244
in fecal incontinence with limitations 92 Whitehead deformity 174
unfractionated subcutaneous heparin 67 Whitehead hemorrhoidectomy 170, 172
ureteral injuries 267, 397 wireless capsule endoscopy (WCE) 335
anatomy 397 wound infection 28
gentle pressure 397 risk 27
prevention 397–8 see also skin
types 398 Wound-Vac (KCI) 28
ureteral stents 144
ureteroneocystotomy 398 XELOX 300
urethral injuries 395 xylocaine toxicity 19


Improved Outcomes in Colon
and Rectal Surgery
About the book
Written by many of the world’s leading colorectal surgeons, this evidence-based text investigates the
risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions,
the authors identify the best practices for patient safety and positive outcomes to ensure that
physicians correctly recognize potential problems and carefully manage complications.

Improved Outcomes in Colon and Rectal Surgery is an essential reference for all colorectal surgeons,
fellows and residents, as well as those working in gastroenterology and the medico-legal profession.

About the editors

Charles B Whitlow MD, Program Director, Colon and Rectal Surgery Fellowship Program, Ochsner
Medical Center, New Orleans, Louisiana, USA.

David E Beck MD, Chairman, Department of Colon and Rectal Surgery, Ochsner Medical Center, New
Orleans, Louisiana, USA. He is President-Elect of the American Society of Colon and Rectal Surgeons
and Editor-in-Chief of Clinics in Colon and Rectal Surgery and the Ochsner Journal.

David A Margolin MD, Colon and Rectal Research Director, Ochsner Medical Center, New Orleans,
Louisiana, USA. He is an Associate Editor of Diseases of the Colon and Rectum.

Terry C Hicks MD, Associate Chairman, Department of Colon & Rectal Surgery, Ochsner Medical Center,
New Orleans, Louisiana, USA. He is President of the American Board of Colon and Rectal Surgeons

Alan E Timmcke, Staff Colon and Rectal Surgeon, Ochsner Medical Center, New Orleans, Louisiana, USA.

Also available
Ambulatory Colorectal Surgery
Edited by Laurence R Sands and Dana R Sands (ISBN: 9780824727925)

Gastrointestinal Oncology: Evidence and Analysis

Edited by Peter McCulloch, Martin S Karpeh, David J Kerr and Jaffer Ajani (ISBN: 9780849398650)

Neoplasms of the Colon, Rectum, and Anus, Second Edition

Authored by Philip H Gordon and Santhat Nivatvongs (ISBN: 9780824729615)

Telephone House, 69-77 Paul Street,

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