1324 SECTION X Abdomen
normokalemic while ingesting a normal amount of potassium
before requiring dialysis. This phenomenon is associated with a
compensatory increase in colonic secretion and fecal excretion of
potassium. This effect is blocked by spironolactone, which illus-
trates the effect of aldosterone on colonic potassium secretion.
Potassium secretion requires both Na+,K+-ATPase and Na+-K+-
2Cl− cotransport on the basolateral membrane and an apical
potassium channel.
Many forms of colitis are associated with increased potassium
secretion, such as inflammatory bowel disease (IBD), cholera, and
shigellosis. In addition, some forms of colitis impair colonic
absorption or produce secretion of chloride, such as collagenous
and microscopic colitis and congenital chloridorrhea. Chloride is
secreted by colonic epithelium at a basal rate, which is increased
in pathologic conditions such as cystic fibrosis and secretory diar-
rhea. Secretion of chloride also requires the coupling of Na+,K+-
ATPase and Na+-K+-2Cl− cotransport to exit passively through the
apical membrane. Calcium and cyclic adenosine monophosphate
both stimulate chloride secretion, whereas bicarbonate and SCFAs
inhibit chloride secretion.
Colonic secretion of H+ and bicarbonate is coupled to the
absorption of Na+ and Cl−, respectively. It is through these
exchangers that the colon is linked to systemic acid-base metabo-
lism. The supply of H+ and bicarbonate for these exchangers
is maintained by the hydration of CO2, catalyzed by colonic
carbonic anhydrase. Changes in systemic pH induce changes
in the activity of carbonic anhydrase, eliciting elimination of
H+ or bicarbonate as needed to bring the systemic pH back to
normal.
Motility
Colonic motility is a highly complex process, made difficult to
investigate by a lack of standardized terminology and measure-
ments. In addition, movement through the colon is relatively slow
compared with the proximal GI tract, and studies require pro-
longed observation.
Colonic motility patterns may be more simply divided into
two primary patterns, segmental activity and propagated activity.
Segmental activity consists of single contractions or rhythmic
bursts of contractions. The purpose of these segmental contrac-
tions is to propel fecal matter distally through a directed pressure
gradient toward the rectum in discrete distances and to allow
mixing, which promotes optimal absorption. The second pattern
is propagated activity, commonly classified on the basis of
amplitude as low-amplitude or high-amplitude propagated con-
tractions. High-amplitude propagated contractions have been
historically referred to as mass movements, or migrating motor
complexes, whose role is shifting large quantities of contents
through the colon. These have an important role in defecation,
with mass movements propelling larger volumes of fecal matter
to the distal colon and emptying of the descending colon into the
sigmoid colon and rectum. Little is known about low-amplitude
propagated contractions, but they are associated with distention
of the viscus and passage of flatus.5
There seems to be a circadian rhythm to colonic motility, with
maximum peaks of activity immediately after waking and after
meals. Sleep is associated with a decrease in colonic motility.
Not surprisingly, food ingestion results in an increase of overall
colonic motility for approximately 2 hours. This reflex is stimu-
lated not only by gastric distention but also by the central nervous
system, initiated by visualization of food. In addition, meal com-
position affects colonic responses. Increased activity in response
to carbohydrate meals is fairly short-lived, whereas fatty meals
elicit longer term responses.
Ultimately, transit in the colon is controlled by the autonomic
nervous system. Parasympathetic innervation reaches the colon
through the vagus and pelvic nerves. The enteric nervous system
in the colon is arranged in several plexuses—subserosal, myenteric
(Auerbach), submucosal (Meissner), and mucosal plexuses. Sym-
pathetic innervation originates in the superior and inferior mesen-
teric ganglia and reaches the colon through perivascular plexuses.
Formation of Stool
The frequency of defecation is just as variable among individuals
as is their perception of abnormal stool frequency. An individual
who passes more than three loose stools daily is considered to have
diarrhea, whereas fewer than three weekly stools is considered
constipation. Any frequency within that range is considered
normal, although many individuals will still seek medical atten-
tion for what they perceive as diarrhea or constipation. Many
factors influence colonic transit rate. Colonic transit is longer in
women than in men and longer in premenopausal than in post-
menopausal women. Conversely, colonic transit time is shortened
in smokers. In normal subjects, supplementation with NSPs does
not shorten colonic transit time, although it does increase fecal
weight. In patients with idiopathic constipation, however, NSPs,
in the form of psyllium seeds, shorten colonic transit time and
increase stool weight.
Defecation
Normal defecation requires adequate colonic transit time, stool
consistency, and fecal continence. Fecal continence implies defer-
ment of stool elimination; discrimination among gas, liquid, and
solid stool; and selective elimination of gas without stool. There
is some controversy about the actual role of the rectum under
resting conditions. Some have proposed that the rectum is simply
a conduit, which under resting conditions should be empty. If
stool arrives at the rectum, the anorectal inhibitory reflex is trig-
gered, forcing the subject to hold defecation by voluntary contrac-
tion of the external sphincter. However, any surgeon who performs
routine rigid proctosigmoidoscopies in the office is well aware that
a patient can have a rectum full of stool without any awareness.
This leads to the opposing view, which regards the rectum as a
reservoir. Just as stool triggers the anorectal inhibitory reflex, it
also triggers a rectocolic reflex. This reflex allows continuous filling
of the rectum with fecal material until the colon is emptied.
The mechanisms involved in fecal continence are not fully
understood. A certain reservoir capacity is needed to achieve fecal
continence. A stiff nondistensible rectum, such as in radiation
proctitis, may produce incontinence, even when the sphincter
muscles are competent. Some of the internal and external sphinc-
ter muscle fibers are necessary for adequate continence, although
many patients have part of the sphincter severed during a fistu-
lotomy and are still continent. Probably the only factor needed
for fecal continence is innervation of the sphincter. The motor
nerve fibers, which produce contraction of the sphincter fibers,
and also all the sensory innervation are important to empty the
rectum adequately.
PREOPERATIVE WORKUP AND STOMA PLANNING
Today, routine preoperative testing guidelines exist to streamline
the process to elective surgery. They are dependent on the planned

procedure, the patient’s comorbidities, and the American Society
of Anesthesiologists class of the patient. Detailed description of
preoperative management and workup for surgical patients is
discussed elsewhere. However, additional preoperative evaluation
specific to major colon and rectal procedures may also include the
following considerations:
• Evaluation of nutritional status
• Use of a preoperative mechanical bowel preparation (MBP) or
oral antibiotics
• Preoperative counseling for stoma care, education, and marking
• Colonoscopy to exclude synchronous lesions
• Postoperative fluid and pain management
Nutritional Assessment
Preoperative malnutrition is an important predictor of poor clini-
cal outcomes in patients undergoing major colorectal operations.
The additional stress of a major abdominal surgery further induces
a catabolic response and insulin resistance. Therefore, nutritional
parameters for chronically ill patients and especially those with
IBD should be assessed before consideration for elective surgery.
Serum albumin is an indicator of long-term nutrition (21 days),
whereas serum prealbumin can gauge short-term nutritional
status (3 to 5 days). Low preoperative albumin (<3.5 g/dL) has
been further shown to be a risk factor for anastomotic leak after
colorectal surgery. These two indices may also identify patients
who may benefit from preoperative supplemental nutrition, such
as total parenteral nutrition. The decision to initiate total paren-
teral nutrition should also be judicious because of its known albeit
low association with infectious complications. Nonetheless, elec-
tive operations should be delayed if possible until the patient is
nutritionally replete.
Preoperative Bowel Preparation
Purging the feces and reducing the concentration of colonic intra-
luminal bacteria before operations on the colon is a practice that
has been challenged in recent years. The normal, or autochtho-
nous, microbial organisms in the colon compose up to 90% of
the dry weight of feces, reaching concentrations of up to 109
organisms/mL of feces. The anaerobic Bacteroides is the most
common colonic microbe, whereas Escherichia coli is the most
common aerobe. Pseudomonas, Enterococcus, Proteus, Klebsiella,
and Streptococcus spp. are also present in large numbers.
The process of preparing the colon for an elective operation
has traditionally involved two factors, purging of the fecal con-
tents (mechanical preparation) and administration of antibiotics
effective against colonic bacteria. Tradition has held that an unpre-
pared colon (i.e., one that contains intraluminal feces) poses an
unacceptably high rate of failure of the anastomosis to heal.
However, experience with primary repair of traumatic colonic
injuries, along with reports from Europe describing elective opera-
tions conducted safely without the use of preoperative purging,
has led to reconsideration of the true value of purging the colon
before colonic surgery. Because the colonocytes receive nutrition
from intraluminal free fatty acids produced by fermentation from
colonic bacteria, there are concerns that purging may actually be
detrimental to healing of a colonic anastomosis. In the United
States at present, the addition of a preoperative MBP with or
without oral antibiotics is controversial and is left to the surgeon’s
discretion. Nonetheless, a variety of MBP regimens and antibiotic
combinations are in current use. A clear superiority of one over
another has not been found; however, for some patients, certain
bowel preparations may have adverse physiologic consequences.
CHAPTER 51 Colon and Rectum 1325
Knowledge of the history of bowel preparation practices, current
controversies, and data is useful.
Complete bowel obstruction and free perforation are absolute
contraindications to bowel preparation. For colonoscopy, proper-
ties of preparations are judged by safety, tolerance of the patient,
and efficacy or preparation quality. In the past, 4 to 5 days of
clear liquids along with laxatives (such as senna, castor oil, and
bisacodyl), whole bowel nasogastric irrigation, mannitol irriga-
tion, and repeated enemas were among the regimens used. Toler-
ance of patients of these methods is poor; they are associated
with dehydration, electrolyte abnormalities, and severe abdomi-
nal cramping and are generally not well tolerated by older or
infirm patients.
In the 1980s, polyethylene glycol–electrolyte solution, a non-
absorbed, sodium sulfate–based liquid, was developed as an oral
MBP. Patients are required to drink at least 2 to 4 liters of the
solution, along with additional fluids. Abdominal cramping,
nausea, and vomiting are common side effects of the preparation,
and prophylactic antiemetics are often administered routinely. In
the 1990s, oral sodium phosphate solutions and pills were devel-
oped in response to dissatisfaction of patients with the large fluid
volume required for polyethylene glycol preparation, and these
preparations have been found in most trials to be more tolerable,
with higher rates of satisfaction and compliance of patients.
Sodium phosphate, in liquid or pill form, has been linked more
frequently than polyethylene glycol to rare but serious electrolyte
imbalances. In patients with impaired renal function, hyperphos-
phatemia, hypernatremia, hypokalemia, and hypocalcemia can
occur. In response to concerns about toxicity, the Food and Drug
Administration removed oral sodium phosphate bowel prepara-
tions from the market in 2008; however, they are still available as
over-the-counter medications in other countries. Thus, polyethyl-
ene glycol–electrolyte solution is the recommended bowel prepa-
ration in patients with renal insufficiency, cirrhosis, ascites, or
congestive heart failure as well as physiologically in normal
patients. Ultimately, comfort of the patient and economic factors
may determine MBP practices if the efficacy is similar. Patients
favor preparations that are low in volume, are palatable, have easy
to complete regimens, and are either reimbursed by health insur-
ance or are inexpensive. Physicians are advised to select a prepara-
tion that is safe to administer in light of existing comorbid
conditions and those preparations that will not interact with
previously prescribed medications. The ideal bowel preparation
has to balance the intraoperative expectations of the surgeon with
the safety profile and comfort of the patient.
For patients undergoing colonoscopy, the quality of the bowel
preparation is essential for performing an accurate examination.
However, for patients undergoing surgical resection, the necessity
of mechanical bowel preparation has been questioned. In a 2011
update to the initial Cochrane review from 2005, Guenaga and
colleagues evaluated 13 randomized controlled studies that com-
pared MBP versus no preparation during elective colorectal
surgery while looking at the primary outcome of anastomotic
leakage.6 The overall anastomotic leakage rate was 4.4% in the
group with MBP (101 of 2275 participants) compared with 4.5%
in the group without MBP (103 of 2258 participants) and was
not statistically significant. Before conclusions are drawn, it is
important to note that although the goals of many of these studies
appear the same, there is significant heterogeneity in their meth-
odology. There is significant variability among the populations of
patients, and more pertinent prognostic factors for anastomotic
leakage may include the indications for surgery, the patient’s
1326 SECTION X Abdomen

comorbidities and acuity, the surgeon’s experience, the surgical were also less likely to have a prolonged ileus (3.9% versus 8.6%;
technique, and the location of intestinal anastomosis. P = .011) and had similar rates of C. difficile colitis (1.3% versus
Antibiotic use in colorectal surgery is a well-established prac- 1.8%; P = .58).5 Thus, it seems there are reliable data supporting
tice that reduces infectious complications. Elective colorectal cases the use of oral antibiotics as an adjunct to a preoperative MBP as
are classified as clean contaminated and, as such, benefit from a means of reducing postoperative SSI.
routine single-dose administration of parenteral antibiotics 30
minutes before an incision to reduce rates of superficial and deep Planning Intestinal Stomas
wound infection. It has been shown that when operative times are The techniques of fashioning a stoma have been developed to
prolonged, additional doses at 4-hour intervals are required. provide diversion of waste until conditions are attained that
When the operation is completed, postoperative administration permit the restoration of normal intestinal continuity. If it is
of antibiotics for a clean contaminated case, such as a routine anticipated that the creation of a stoma will be part of an opera-
segmental resection, does not reduce infectious complications tion, appropriate preparations should be made to optimize the
further and may promote C. difficile colitis, Candida infection, outcome of the procedure. Preoperative consultation with an
and the emergence of bacterial antibiotic resistance. Polk and enterostomal therapist is helpful in most circumstances. This con-
Lopez-Mayer showed a reduction in postoperative infection rates sultation provides the opportunity for education, counseling, and
from 30% to 8% with the routine use of preoperative parenteral appropriate stoma site selection and marking. Such preparation
antibiotics. Gomez-Alonzo and colleagues repeated these results, significantly increases the patient’s satisfaction and quality of life
showing a decrease from 39% to 9%. Antibiotics active against scores of patients who require permanent or temporary stomas.9
both aerobes and anaerobes are ideal; a second- or third-generation The preferred location of a stoma should be in an area of the
cephalosporin alone or a combination of a fluoroquinolone plus anterior abdominal wall where there are no creases that could
metronidazole or clindamycin is typical. prohibit the satisfactory seal of the appliance to the peristomal
The efforts to reduce surgical site infections (SSIs) have recently skin. The stoma should be visible to the patient—not on the
included the implementation of the Surgical Care Improvement underside of a large pannus in an obese individual—and easily
Project guidelines and the push to incorporate standardized pro- accessible. Most surgeons think that it is desirable to bring the
phylactic parenteral antibiotic measures. The correct and timely stoma through the rectus muscle, traversing an appropriately sized
administration of antibiotics has now become a performance aperture (2 cm) that does not constrict the blood supply to the
measure for quality improvement projects nationwide. The role stoma but does not result in a peristomal hernia. In a normal-sized
of appropriate parenteral antibiotics before incision is well estab- patient, the preferred site for stoma location is through the rectus
lished in reducing SSI. However, the role of oral antibiotics in muscle, slightly inferior to the umbilicus at the apex of the natu-
conjunction with preoperative mechanical bowel preparation has rally occurring tissue mound of the abdomen (Fig. 51-14).
been recently questioned. Despite the current trends among sur-
geons to omit oral nonabsorbable antibiotics, the data suggest that Stoma Types
this omission may be premature. The use of additional oral anti- A colostomy is an anastomosis fashioned between the colon and
biotics, theoretically to reduce the bacterial load further, is widely skin of the abdominal wall. Colostomies may be temporary or
accepted but not as well validated. In a survey of colon and rectal permanent, depending on the disease and conditions for which
surgeons, 87% indicated that both oral and parenteral antibiotic they are created. However, appropriate planning and careful
use is part of their routine preparation for elective colon opera-
tions. A typical preparation consists of erythromycin base (1 g)
and neomycin (1 g) given in three preoperative doses the day
before surgery. However, this regimen is associated with a high
incidence of nausea and abdominal cramps, and some surgeons
prefer to prescribe oral ciprofloxacin or metronidazole.
In a 2002 meta-analysis by Lewis (N = 215), the study showed
a significant reduction in SSIs for patients with MBP plus oral
antibiotics (from 17% to 5%); all patients received a standard
preoperative parenteral antibiotic regimen.7 Similarly, a 2012 ret-
rospective study conducted by Cannon and colleagues showed a
57% decrease in SSIs when MBP and oral antibiotics were used
in elective colon resections (N = 9940).8 These results were echoed
by Bellows and colleagues, who showed in their 2011 meta-
analysis that the combination of oral antibiotics and MBP reduced
the incidence of SSI after colorectal surgery by 43% compared
with parenteral antibiotics alone. In 2011, the Michigan Surgical
Quality Collaborative evaluated 2011 elective colectomies per-
formed during 16 months; MBP without oral antibiotics was
administered to 49.6% of patients, whereas 36.4% received MBP
and oral antibiotics. In this large, well-designed study, patients
receiving oral antibiotics were significantly less likely to have any
SSI (4.5% versus 11.8%; P = .0001), to have an organ space
infection (1.8% versus 4.2%; P = .044), or to have a superficial
SSI (2.6% versus 7.6%; P = .001). Interestingly, they also found
that patients receiving bowel preparation with oral antibiotics FIGURE 51-14 Selecting a site.

FIGURE 51-15 Hartmann operation.
technical considerations should be given to the creation of any
colostomy because history has shown that even colostomies
intended to be temporary may prove to be permanent in a sig-
nificant number of patients.10
A colostomy may be indicated to divert colonic contents tem-
porarily from a pathologic process in the distal colon or rectum,
such as an obstructing rectal cancer or phlegmon of the sigmoid
colon associated with diverticulitis. A loop colostomy using the
sigmoid or the transverse colon can be useful for this, expedient,
and able to be completed laparoscopically. Other circumstances
are more appropriately treated by an end colostomy, in which the
end of the sigmoid or, more commonly, descending colon is
brought out the abdominal wall. An end colostomy is an essential
component of an abdominal perineal proctectomy performed for
rectal cancer. Resection of the sigmoid colon with closure of the
rectal stump and fashioning of a descending colon is usually
referred to as a Hartmann operation (Fig. 51-15). An ileostomy
is the union of the terminal ileum to the skin of the abdominal
wall. As described for colostomy, an ileostomy may also be fash-
ioned as a loop or an end stoma. A temporary loop ileostomy may
be fashioned to protect a distal anastomosis, such as a coloanal
anastomosis in a patient who has received preoperative chemora-
diation for rectal cancer, or to protect an ileal pouch–anal anas-
tomosis (IPAA) in a patient treated with restorative proctocolectomy
for ulcerative colitis. An end ileostomy is required if the colon and
rectum must be removed and the anal sphincter cannot be
preserved.
Physiologic Considerations and Practical Implications
Colostomy
For practical purposes, the dominant physiologic properties of the
proximal colon are the completion of digestion of complex car-
bohydrates by fermentation, retention of electrolytes, and absorp-
tion of water. The more distal colon participates to less of an
extent in these processes and serves as a reservoir for the waste
products of digestion pending elimination. In some cases, the
collateral communication through the marginal artery is not suf-
ficient to sustain the sigmoid colon, so it is generally preferred to
fashion a distal colostomy from the descending colon, which has
CHAPTER 51 Colon and Rectum 1327
a more reliable blood supply than the sigmoid colon (especially if
the IMA has been divided). In addition, the sigmoid colon is often
afflicted with diverticulosis and the thickening of the colonic wall
associated with that disease process, so the more pliable and capa-
cious descending colon is the preferred choice for a left-sided
colostomy.
The more proximal the site of the colon that is selected to
fashion a colostomy, the more likely it is that the effluent will be
liquid and foul-smelling. Descending colostomies that pass
formed feces are relatively easy to care for with a well-fitting
enterostomal appliance, whereas transverse colostomies that expel
significant amounts of feculent liquid are difficult to care for and
frequently leak and prolapse. Colostomies from the right colon
are particularly troublesome because there is a copious amount of
liquid foul-smelling effluent that is difficult to contain with an
appliance. In addition, the motility characteristics of the colon are
such that the more proximal the site of the colon selected to
fashion a colostomy, the higher is the likelihood of prolapse
through the stoma. This is distressing to the patient and makes
maintenance of the stoma exceedingly difficult. As a general rule,
with modern enterostomal techniques, it is much easier to care
for an ileostomy than to care for a wet colostomy or a colostomy
fashioned from the proximal colon.
Transverse colostomies, although at times useful to protect a
distal anastomosis or to divert colonic contents from a distal
obstruction, should almost always be considered a temporary
diversion to a transient problem. A transverse loop colostomy
fashioned at skin level will completely divert the fecal stream for
a period of at least 6 weeks, but with the passage of time and the
natural maturation of the colostomy, the spur, or posterior wall
of the colostomy, will retract and the stoma will no longer divert
completely. In addition, the incidence of significant prolapse from
a transverse loop colostomy is high and increases over time. It is
usually (but not always) the distal limb of the loop colostomy that
prolapses through the stoma site.
Ileostomy
The terminal ileum normally delivers up to 2 liters of succus
entericus to the cecum during a 24-hour period. There is a remark-
able adaptation following the construction of a stoma from the
very distal ileum in that after several weeks, the absorptive capacity
of the ileum increases to the extent that approximately 900 mL
of effluent will be expected to be produced by the ileum during
a 24-hour period. However, the intestinal adaptation cannot com-
pletely compensate for the loss of the absorptive capacity of the
colon, and ileostomy patients need to recognize the need to
increase their intake of fluid. Supplemental sodium chloride may
often be necessary for ileostomates, although liberal addition of
salt to the daily diet usually will suffice.
The ileal chyme is liquid and contains digestive substances that
are normally inactivated in the colon. If the skin adjacent to the
ileostomy is exposed to the effluent, significant erosion of the
peristomal skin can occur. Therefore, the ileostomy is fashioned
to protrude above the skin surface as a spigot that pours the ileal
contents into an enterostomal appliance fitted to the abdominal
skin at the base of the ileostomy to protect the skin from the
corrosive properties of the ileal effluent.
Technical Considerations
End Descending Colostomy
As noted, it is generally preferable to use the descending colon,
rather than the sigmoid colon, for the creation of a colostomy.
1328 SECTION X Abdomen
FIGURE 51-16 End colostomy.
The most common indication for an end descending colostomy
is abdominal perineal resection for rectal cancer. In this case, we
recommend dividing the IMA close to the aorta (for oncologic
and anatomic reasons; see later). The sigmoid colon should be
resected with the rectum, with care taken to preserve the mesen-
tery to the descending colon. The blood supply to the descending
colon will be maintained through the collateral circulation from
the marginal artery, and this collateral circulation is better main-
tained by dividing the IMA close to its origin. The colon is then
mobilized from the posterior abdominal wall and the prerenal
(Gerota) fascia in such a manner that the entire descending colon
and its mesentery lie anterior to the small bowel (Fig. 51-16).
With use of this technique, there is no remaining lateral attach-
ment of the colonic mesentery for the small intestine to twist
around, and it is not necessary to approximate the mesentery of
the descending colon to the lateral peritoneum to prevent an
internal hernia.
The closed end of the descending colon is brought through an
abdominal wall aperture created through the left rectus muscle at
the site selected and marked before the operation. The colostomy
is matured by approximating the wall of the colon to the skin
with interrupted absorbable sutures. Some surgeons place the
sutures in such a fashion to elevate the colostomy above skin level
slightly, but this is not necessary with a descending colon because
the effluent is formed and noncorrosive, and maintaining an
appliance does not require eversion of the stoma.
Loop Colostomy
A loop colostomy may provide diversion from a distal obstruction
(e.g., rectal cancer, diverticulitis) while simultaneously decom-
pressing the limb of the colon leading to the obstruction. The
most commonly performed type of loop colostomy is the trans-
verse loop colostomy, but as noted, this stoma has the disadvan-
tages of liquid effluent, eventual prolapse, and only temporary
complete diversion. Although a loop transverse colostomy is cer-
tainly indicated in certain circumstances, consideration should be
given to a loop ileostomy or loop descending colostomy. The loop
ileostomy is easier to care for and to maintain an appliance, and
the effluent of the loop descending colostomy is thicker, with less
fluid loss and less chance of prolapse of the more distally placed
colostomy. The technique of fashioning the descending loop
FIGURE 51-17 Loop colostomy.
colostomy is essentially the same as for the transverse loop colos-
tomy; the transverse loop is often technically easier because it is
mobile and more easily accessible in the midabdomen.
The transverse colon is brought through an abdominal wall
aperture, usually selected in the midline well cephalad to the
umbilicus and well above a midline incision if the operation is
conducted through such an incision. The exteriorized loop of
colon is supported over a plastic stoma rod (Fig. 51-17). The
antimesenteric surface of the colon is incised in a longitudinal
incision, and the edges of the resulting colostomy are sutured to
the skin of the abdominal wall with absorbable sutures. The sup-
porting rod is removed after the fifth postoperative day. This
stoma will provide complete diversion of the feces and gas from
the proximal colon while simultaneously venting the distal colon.
However, after a period of approximately 6 weeks, the posterior
wall of the stoma (spur) will retract, and feces from the proximal
colon can spill over into the distal limb.
Ileostomy
In forming an ileostomy, the ileum is brought through the
abdominal wall at a site selected before the operation to ensure
that the location is ideal for maintaining the seal of an appliance
(i.e., away from natural abdominal wall creases, scars, hernias). A
disc of skin is excised, the dissection is carried longitudinally
through the center of the rectus muscle, and the posterior fascia
is divided (Fig. 51-18). The abdominal wall aperture should be
approximately 2.5 cm in diameter, thus admitting two fingers
(Fig. 51-19). Sufficient length of well-vascularized ileum is
brought through the abdominal wall to permit creation of a spigot
that will protrude well above skin level (Brooke configuration),
allowing the ileal contents to pour into an appliance sealed to the
adjacent skin (Fig. 51-20). The ileostomy is completed by approx-
imating the full thickness of the divided wall of the ileum to the
subcuticular tissue of the abdominal skin of the stoma site, placing
sutures in so as to maintain the everted configuration of the stoma
(Figs. 51-21 and 51-22).
By use of these same principles, a loop ileostomy may be fash-
ioned (Figs. 51-23 and 51-24). The loop ileostomy can be fash-
ioned over an ileostomy rod, but a rod is not necessary to maintain
the configuration of the stoma. Some surgeons prefer not to use
a supporting rod because it may interfere with maintaining the

FIGURE 51-18 Dividing fascia for ileostomy.
FIGURE 51-19 Aperture for ileostomy.
seal of the appliance. If an ileostomy rod is used, it can be removed
on the fifth postoperative day.
Postoperative Management Protocols
Major colon and rectal procedures are commonly performed in
the United States, and therefore the postoperative management
of these patients has come under scrutiny with the focus
on decreasing morbidity, mortality, and health care cost.
Evidence-based studies have now generated standardized fast-
track protocols or enhanced recovery pathways to streamline the
postoperative management of these patients, to limit complica-
tions, and to limit length of stay by enhancing early recovery of
bowel function. These protocols include several of the following
key elements:
• Appropriate selection of patients
• Minimally invasive surgery
• Perioperative fluid management
• Early enteric feeding
CHAPTER 51 Colon and Rectum 1329
FIGURE 51-20 Ileum brought through aperture.
FIGURE 51-21 Maturing ileostomy.
• Early ambulation
• Multimodality postoperative analgesia
Patients selected for inclusion in enhanced recovery pathways
should understand the goals of the protocol and be able to physi-
ologically tolerate reduced fluids and narcotics. Even so, participa-
tion in some but not all of the elements of an enhanced recovery
pathway may still confer benefit. The cornerstones of the concept
include intraoperative and postoperative fluid restriction as well
as limitation of opiates and use of alternative pain control strate-
gies. Acetaminophen, nonsteroidal anti-inflammatory drugs, gaba-
pentin, and use of epidurals and cutaneous analgesic approaches
have all been incorporated into various enhanced recovery
protocols.
In a comprehensive meta-analysis, 13 randomized controlled
studies (1910 patients) were analyzed, and in comparison with
traditional care, enhanced recovery after surgery programs were
associated with significantly decreased primary hospital stay
1330 SECTION X Abdomen
FIGURE 51-22 Creating ileostomy spigot.
FIGURE 51-23 Completing loop ileostomy.
(weighted mean difference, −2.44 days; 95% confidence interval
[CI], −3.06 to −1.83 days; P < .00001), total hospital stay
(weighted mean difference, −2.39 days; 95% CI, −3.70 to −1.09
days; P = .0003), total complications (relative risk, 0.71; 95% CI,
0.58-0.86; P = .0006), and general complications (relative risk,
0.68; 95% CI, 0.56-0.82; P < .0001).11 No significant differences
were found for readmission rates, surgical complications, and
mortality. However, despite these favorable initial results, proto-
cols for enhanced recovery after surgery have not been widely
implemented. This is not unexpected as most protocols incorpo-
rate 8 to 20 elements and require the persistence and involvement
of a multidisciplinary team of surgeons, anesthesiologist, nurses,
stoma therapist, and hospital administration.
More recent adjuncts to the postoperative management in
major colon and rectal surgery include the abandonment of naso-
gastric tubes and administration of early enteral feeding. A
Cochrane review in 2007 revealed that patients without a naso-
gastric tube after undergoing lower GI surgery experience early
return of bowel function, fewer primary complications, and
decreased length of stay. In addition, randomized controlled
trials have shown that early postoperative enteral feeding in
patients undergoing elective colorectal surgery is safe and effective
Proximal Distal
Terminal
ileum
FIGURE 51-24 Loop ileostomy in continuity.
and decreases both postoperative complications and hospital
length of stay with no differences to the risk of anesthetic anasto-
motic dehiscence, pneumonia, wound infection, vomiting, and
mortality.
Clearly, the implementation of enhanced recovery after surgery
protocols and the contemporary evolution of postoperative man-
agement for elective colorectal surgery have significant benefits to
the patient and health care costs.
DIVERTICULAR DISEASE
Background
Diverticular disease encompasses a range of signs and symptoms
directly related to the presence of diverticula in the colon wall.
These include infection, perforation, bleeding, fistula, and occa-
sionally obstruction due to chronic inflammation. Diverticulosis
was first described in the mid-19th century and appears to be an
unfortunate product of the Industrial Revolution, which brought
with it marked changes in diet. The incidence has been noted to
increase with age and has been largely on the rise in the United
States and other Western societies. Approximately 30% of those
older than 60 years and roughly 60% to 80% of those older than
80 years may be affected. Only 10% to 20% of people with
diverticula develop symptoms, which in the United States accounts
for roughly 300,000 hospitalizations annually and 1.5 million
outpatient visits, all of which comes at a considerable annual cost
estimated to exceed $2 billion.12
Pathophysiology
Diverticula are abnormal outpouchings or sacs of the colon wall
that occur most commonly because of interactions of high intra-
luminal pressures, disordered motility, alterations in colonic struc-
ture, and diets low in fiber. Diverticula are formed on the
mesenteric side of the antimesenteric taeniae coli in areas of rela-
tive weakness in the bowel where small arterioles (vasa recta)