Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Medical Documentation and Coding for the Colorectal Surgeon

Introduction One of the most essential and least understood issues affecting colorectal surgeons is accurate medical documentation and coding via the current procedural terminology (CPT) coding system. This coding system encompasses a broad framework for capturing the components of physician work and requires use of specific descriptors of the work performed to ensure transformation of the encounter into reimbursement via the various physician payment systems. In…

Measuring Outcomes

Introduction Outcome measurement can be defined various ways. One definition is “a measure of the quality of medical care, the standard against which the end result of an intervention is assessed.” Another definition is “the determination and evaluation of the results of an activity, plan, process or program and the comparison with the intended or projected results.” Although these definitions differ somewhat, both measure some level…

Stoma and Wound Considerations: Nursing Management

Rehabilitation of the patient with a stoma or complicated wound is the responsibility of the entire health care team, and thus it is important that all members understand the principles and techniques of ostomy and wound management. As Dr. Rupert B. Turnbull, Jr., discovered in the 1950s, collaboration between the surgeon, the floor and clinic nurse, and the wound, ostomy, and continence nurse (previously known as…

Prevention and Management of Ostomy Complications

Introduction The term ostomy originates from the Latin word stoma, meaning “opening” or “origin,” and from the Greek word stomat, meaning “mouth.” Historically it is unclear when and how the first ostomies were created, although evidence suggests that the earliest use of fecal diversion was probably related to traumatic fecal fistulas. The first mention of stomas in the surgical literature is by Littre in the early…

Prevention and Treatment of Complications of Laparoscopic Colorectal Surgery

Introduction Laparoscopic colorectal surgery is complex and more technically demanding than many common laparoscopic procedures performed by general surgeons. Advanced laparoscopic skills are required to manipulate and mobilize sections of bowel, control and divide large mesenteric vessels, extract large specimens, and create an anastomosis. The degree of dissection performed can be extensive because of the broad attachments of the colon and rectum. The technical difficulty of…

Urologic Issues in Colorectal Surgery

Introduction Urologic issues pertaining to colorectal surgery can be broadly categorized according to the organ involved: the ureter, bladder, or urethra and their associated nerves and vessels. Because both colorectal surgeons and urologists have become more familiar with laparoscopic techniques, urologic issues encountered in colorectal surgery often may be addressed in a minimally invasive fashion without conversion to an open surgery. In this chapter we will…

Management of Hemorrhage during Pelvic Surgery

Introduction Pelvic dissection is inherent to the management of many rectal, urologic, and gynecologic conditions, and operating deep in the pelvis requires an intimate knowledge of the anatomy of this region. Whether performed in an open, laparoscopic, or robotic manner, surgery must be precise to avoid violating cancer planes and to prevent nerve damage and pelvic bleeding. The greatest challenges are posed by reoperative pelvic surgery…

Complications of Colonoscopy

Introduction Colonoscopy remains the gold standard for colonic investigation. It is a sensitive diagnostic tool and provides a nonsurgical approach for the removal of colonic and rectal polyps. However, colonoscopy is invasive. It can be a challenging procedure to perform and is associated with infrequent but potentially serious complications. Most of these complications occur after therapeutic procedures have been performed. Potential complications are listed in Box…

Management of Anastomotic Leak

Introduction Although significant improvements in oncologic outcomes after surgery for colorectal cancer have been achieved, the issue of anastomotic leaks remains a challenge. In fact, an anastomotic leak is one of the most serious complications of any restorative colon or rectal resection. Leaks account for a quarter of all postoperative deaths after colorectal surgery and up to one third of all deaths after low anterior resection.…

Prevention and Management of Sepsis

Background Sepsis is uncontrolled infection—a potentially fatal condition manifested by tachycardia, leukocytosis, fever, and hypotension. In the United States, the overall incidence is estimated to be more than 1.1 million cases per year at an annual cost of $24.3 billion. More than 70% of septic patients have associated comorbidities, and more than 60% of episodes occur in persons aged 65 years and older. Despite advances in…

Nutritional Support in Colorectal Surgery

Acknowledgment We gratefully acknowledge Maureen E. Rombeau, MA, for editorial assistance. Introduction Surgeons are justifiably proud of their seminal contributions to nutritional care of the hospitalized patient. These contributions include quantifying the prevalence of malnutrition, confirming the association of malnutrition with adverse clinical outcomes, discovering parenteral nutrition (PN), and demonstrating, in selected groups of patients, that providing nutritional support (NS) may either prevent or correct malnutrition-associated…

Reoperative Pelvic Surgery

Introduction Reoperative pelvic surgery is one of the most difficult challenges a colon and rectal surgeon can face. Anatomic, postsurgical, and disease-specific factors combine to present unique challenges with significant potential for major morbidity and even mortality. This is not the occasion for hubris or poor judgment. However, with a thorough understanding of normal and postsurgical anatomy, experience in operating in the pelvis, appropriate planning, sound…

Colorectal Surgery in the High-Risk Patient

Introduction Increasing life expectancy coupled with the growing incidence of both benign and malignant colorectal disease has resulted in a greater need for surgeons to operate on patients with a variety of comorbidities. It has been estimated that elderly persons require surgery four times more often than the remainder of the population. This elderly group has a high incidence of cardiac and pulmonary disease, and other…

Radiation Enteritis and Proctocolitis

Background Radiation was first used as a treatment modality for breast cancer in 1896, and a year later Dr. David Walsh, a physician at the Western Skin Hospital, London, described the first case of radiation enteritis. A “practical worker” had “gastric symptoms, such as pain, tenderness on pressure, flatulency, colic, and diarrhea” after 2 hours of daily exposure to radiation. The symptoms resolved after the worker…

Acute and Chronic Mesenteric Ischemia

Introduction Mesenteric ischemia can be either acute or chronic. The acute variant is a life-threatening disease of sudden onset and has several distinctly different causes. Most patients who are diagnosed with acute visceral ischemia have progressed to the point of bowel necrosis. Early recognition of acute ischemia is essential to permit timely intervention prior to bowel necrosis, irreversible multisystem organ failure, and death. It occurs in…

Enterocutaneous Fistulas

Introduction Enterocutaneous fistulas, defined as an abnormal communication between the small bowel and skin, are among the most daunting problems for an intestinal surgeon. The impact of an enterocutaneous fistula on a patient varies from a minor inconvenience to fatal malnutrition and dehydration. Depending on the cause and output of the fistula and the comorbidity of the patient, enterocutaneous fistulas can be very challenging to manage.…

Neuroendocrine Tumors of the Small and Large Intestine

Definition Neuroendocrine tumors (NETs) derive from neuroendocrine cells (also called enterochromaffin cells or enterochromaffin-like cells) of the endoderm of the fore-, mid-, and hindgut. These cells are diffusely distributed in the epithelium of the gastroenteropancreatic system, the bronchial system, and the thymus and produce peptide hormones or neurotransmitters, such as serotonin, tachykinin, kallikrein, histamine, insulin, gastrin, vasoactive intestinal polypeptide, glucagon, somatostatin, growth hormone–releasing hormone, corticotropin-releasing hormone,…

Small Bowel Neoplasms

Acknowledgment I thank Cory Sandone for her artwork on small bowel neoplasms. Introduction Neoplasms of the small intestine are rare, accounting for 3% to 6% of gastrointestinal neoplasms overall and 1% to 3% of primary gastrointestinal cancers. The incidence of small bowel cancer is higher in North American and Western European men compared with Asian men and women, and a higher incidence also has been noted…

Management of Small Bowel Crohn Disease

Introduction Crohn disease is described according to age of onset, disease location, and disease behavior. The disease location usually remains constant throughout a patient’s lifetime and is categorized as disease of the terminal ileum with or without cecal disease, disease of the colon, or disease of the ileocolon. Further involvement of the intestine proximal to the terminal ileum (i.e., the upper gastrointestinal tract) can coexist with…

Crohn Disease of the Duodenum, Stomach, and Esophagus

Introduction Crohn disease (CD) has a propensity for involvement of the terminal ileum and colon but also can occur throughout the gastrointestinal tract. When it occurs in the esophagus, stomach, and duodenum, it presents challenges in diagnosis and management. The type of detailed assessment of the upper gastrointestinal (UGI) tract by endoscopy and histology that is now widely available suggests that asymptomatic synchronous UGI involvement occurs…