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Transanal Approaches to Early Rectal Cancers: Transanal Minimally Invasive Surgery

The realization that local excision may result in equivalent oncologic outcomes for histologically favorable rectal cancer is not a recent development. Conventional transanal excision (TAE) using traditional anorectal retractors has been associated with substantial margin positivity and tumor fragmentation. This has resulted in significantly higher local recurrence rates and worse long-term survival as compared with transabdominal resection for these lesions. The development of advanced endoscopic platforms…

Basic Principles of the Operative Treatment of Colorectal Cancer

Despite recent advances in understanding the biology of cancer that have resulted in new targeted and biological therapies, surgery is still the primary treatment for most patients with colorectal cancer. While the overall treatment plan may be different for colon and rectal cancers, the principles that guide the surgical procedures to treat them are similar. These principles, based on the Halstedian concept of tumor progression from…

Inherited Colorectal Cancer and the Genetics of Colorectal Cancer

Colorectal cancer (CRC) is a complex heterogeneous disease with a variety of factors influencing genetic and epigenetic changes that drive tumor initiation and progression. Alterations in the intricate system of biological checks and balances can lead to a malignant change of the normal colorectal mucosa. The underlying changes, whether inherited or sporadic, influence the genotype and phenotype of that particular cancer and patient. Understanding CRC in…

Appendix

Acute Appendicitis Acute appendicitis is one of the most common problems encountered by a general surgeon, accounting for approximately 1% of all surgical operations. Historically the appendix has been identified as a potential source of right lower quadrant pain and disease for centuries, with a scattering of case reports through the early 19th century describing abscesses and evidence of inflammation of the appendix in autopsies. The…

Surgery for Crohn Disease: Personalizing the Operation

Crohn disease (CD) is a chronic inflammatory disease of the intestinal tract with an unknown etiology and an unknown cure. The characteristic transmural inflammation can progress to refractory inflammatory disease, stricturing disease, and fistulizing disease—all potential indications for surgery when medical management has been exhausted. An important tenet to remember is that surgery is not curative but is rather an adjunct to maximal medical therapy. Thus…

Operative Therapy for Ulcerative Colitis: A Minimally Invasive Approach

Proctocolectomy with ileal pouch–anal anastomosis (IPAA) has become the standard restorative procedure for patients requiring surgery for ulcerative colitis. Since the operation's introduction in 1978 by Sir Alan Parks, several refinements have occurred as new medications and technologies have come into practice. New biologic therapies have become a standard in medical management, and they have forced the surgeon to better understand the physiologic state of the…

Concepts in Inflammatory Bowel Disease Management

The prototypical inflammatory bowel diseases (IBDs), ulcerative colitis (UC), and Crohn disease (CD), are idiopathic inflammatory disorders of the intestinal tract characterized by a chronic, relapsing course. UC and CD have profound effects on the life of patients and create significant challenges for the entire health care system. Research in the genetics, epidemiology, and basic mechanisms of IBD has produced a giant leap in our understanding…

Anal Fistula Management

Anorectal suppurative disease may manifest itself in an acute or a chronic setting. Anal sepsis (abscess) represents the acute manifestation, and anal fistula represents the chronic form of the suppurative process. In its simplest form, an anal fistula represents a communication between an internal opening in the anal canal and an external opening through which an abscess has drained. A fistula and abscess may coexist or…

Fissure-in-Ano

Anal fissure (fissure-in-ano) is a common condition that usually presents as anal pain or bleeding with defecation. It is easily confused with symptomatic hemorrhoids. It can be very troubling because the severity of patient discomfort and extent of disability far exceed that which would be expected from such trivial lesion. Bleeding is a common symptom and is usually scant, bright red, and found on the tissue…

Hemorrhoids and Rectoceles

Hemorrhoids have been referenced in ancient texts dating back 4000 years. Included in many of these Egyptian and Greek writings are multiple recommended treatment regimens including anal dilation, topical ointments, and the intimidating red hot poker. Although few people have died of hemorrhoidal disease, many patients wish they had, particularly after therapy, and this fact led to the sanctification of St. Fiachre, the patron saint of…

Diverticular Disease Management

Diverticulitis is one of the most commonly diagnosed inflammatory conditions of the gastrointestinal (GI) tract. The condition was relatively uncommon a century ago, yet it now results in approximately 300,000 hospital admissions per year, placing it among the top five most costly GI tract diseases in the United States. Yet despite how relatively common it is and the considerable cost to the nation, there remain numerous…

Colonic Bleeding and Ischemia

Colonic Bleeding Lower gastrointestinal (GI) bleeding is defined as bleeding that occurs distal to the ligament of Treitz. Patients typically complain of hematochezia or blood clots per rectum. However, lower GI bleeding can be further subdivided into small bowel and colonic bleeding for diagnostic and therapeutic purposes. Colonic bleeding, whether acute or chronic, is associated with increased health care use, thus resulting in considerable cost to…

Colonic Intussusception and Volvulus

Colonic Intussusception Pathophysiology Colonic intussusception is a rare diagnosis in adults. This process occurs when a proximal segment of intestine (intussusceptum) invaginates into a distal segment of intestine (intussuscipiens) with 86% to 90% associated with a pathologic lesion as the lead point. The exact mechanism of intussusception in adults is not completely understood. It is proposed that the presence of a stimulus in the lumen of…

Emergent Care of the Victim of Colorectal Trauma

Elective surgical philosophies and techniques are often suboptimal in the injured patient. Unlike planned colorectal operations, where hemorrhage and fecal spillage are immediately addressed, the adverse cascades of infection and shock commence at injury. This inherent delay in presentation, obscuration of tissue planes, instability without the luxury of preoperative optimization, and the requirement for impromptu but decisive operation based on minimal information differentiates trauma from elective…

Pilonidal Disease and Perianal Hidradenitis

Pilonidal Disease Sacrococcygeal pilonidal disease (PD) has a calculated incidence of 26 per 100,000 people and is a source of morbidity in young adults due to the chronicity of disease and extent of surgical intervention. The current understanding is that this is an acquired disease resulting in subcutaneous trauma of hair shafts. Treatment of PD ranges from simple incision and drainage to excision with flap reconstruction.…

Current Approaches to Complete Rectal Prolapse and Internal Intussusception

Historical Perspective Evidence of rectal prolapse (rectal procidentia) exists from ancient times. The first described mortality from rectal prolapse was in the 4th century. The initiating cause of prolapse is elusive. The path to rectal prolapse generally occurs slowly over a period of years. Suggested contributing factors include standing, constipation, colic, coughing, sneezing, weak anal sphincters and pelvic floor musculature, an abnormal cul-de-sac, and distal rectal…

Rectovaginal and Rectourethral Fistulas

Fistulas between the genitourinary tract and the digestive tract present a particular conundrum for the surgeon. Not only are they uncommon, but the technical aspects of repair in conjunction with managing etiology appropriately present a multidisciplinary challenge to even the most experienced surgeon. Not only do they present particular issues with respect to quality of life, but also complicated management of septic complications, management of radiated…

Pelvic Floor Dysfunction

The pelvic floor is the anatomic region bounded anteriorly by the pubis, posteriorly by the sacrum, laterally by the ischial and iliac bones, superiorly by the peritoneum, and inferiorly by the levator ani and coccygeus muscles, which form the pelvic diaphragm. Functionally, the pelvic floor supports the pelvic viscera, helps maintain optimal intraabdominal pressure, and provides storage and maintenance of continence as part of the urinary…

Surgical Treatment of Dysmotility Disorders of the Colon

Constipation is one of the most frequently experienced gastrointestinal complaints and one of the most common indications for medical consultation. It is estimated that more than 4 million patients in North America suffer from constipation, and laxatives are annually prescribed for 2 million individuals, at a cost of more than $800 million. In the United States, more than 90,000 patients are hospitalized each year for constipation-related…

Diagnosis and Management of Fecal Incontinence

Fecal incontinence (FI) is the inability to maintain voluntary control of the passage of gas, liquid, or solid stool through the anus. Although FI is not a life-threatening condition, it is certainly a life-altering condition. The associated embarrassment, subsequent coping mechanisms, and behavioral changes can lead to a dramatic decrease in quality of life (QoL) and social isolation. The prevalence of FI is difficult to determine…