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Surgery for Gut Failure: Auto-Reconstruction and Allo-Transplantation

Introduction The successful clinical introduction of intestinal and multivisceral transplantation in the 1990s fueled a great interest in the management of patients with short gut syndrome (SGS) and gastrointestinal failure. With the early restricted utilization of transplantation as a rescue therapy, the concept of gut rehabilitation was introduced as a new therapeutic dimension to restore the nutritional autonomy of the native digestive system. These nontransplant rehabilitative…

Medical Management of Short Bowel Syndrome

Introduction Short bowel syndrome (SBS) is a form of intestinal failure that most often results from surgical resection related to Crohn disease, mesenteric infarction, radiation enteritis, or surgery for recurrent bowel obstructions. It is characterized by the inability to absorb protein/energy requirements or to maintain fluid, electrolyte, or micronutrient balance when consuming a normal diet. After surgical resection, the remaining small intestine undergoes structural and functional…

Small Bowel Obstruction

Extent of the Problem Small bowel obstruction is a common problem that is responsible for more than 1 million inpatient hospital days and more than $1 billion in health care costs per year in the United States. In some European countries, medical expenses for small bowel obstruction exceed those for gastric cancer and almost parallel those for colon cancer. The most common cause of small bowel…

Constipation

Introduction Constipation is the most common bowel complaint in the United States, with an estimated prevalence of 2% to 27%. The wide range is attributed to the variety of definitions of constipation used by patients and physicians. The Rome Criteria, which were developed to provide a standardized definition, require two or more of the following conditions for at least 3 months: straining more than 25% of…

Pneumatosis Cystoides Intestinalis

Introduction Pneumatosis cystoides intestinalis (PCI) is a condition in which multiple gas-filled cysts occur under the serosa or mucosa of the gastrointestinal tract. PCI is uncommon but increasingly is being recognized and reported. PCI was described by Du Vernoi in 1730 during cadaver dissection, and it has long been noted in animals. PCI occurs in two clinical settings: fulminant, which usually requires immediate surgery, and benign,…

Endometriosis of the Colon and Rectum

Introduction Endometriosis is a disease characterized by the presence of endometrial glands and stroma outside the uterine cavity. A chronic inflammatory reaction induces scar tissue and adhesion formation that may distort a woman’s pelvic anatomy and cause disabling pelvic pain and intractable infertility. Although the cause of this disease is unknown, the most likely explanation involves the implantation of viable endometrial cells from retrograde menstruation through…

Colon and Rectal Trauma

Introduction It seems as if surgeons have always debated the “proper” treatment of colorectal injuries, including the following issues: When should continuity be restored, and when should diversion be implemented? Should left-sided colon injuries be treated differently from right-sided colon injuries? Are drains useful in rectal injuries? Should direct repair be a standard component of surgical management of rectal trauma? Is rectal washout a helpful or…

Management of Colonic Ischemia

Introduction Intestinal ischemia produces a spectrum of diseases affecting the gastrointestinal tract. These syndromes, which can be acute or chronic, can affect the upper abdominal viscera, as well as the small intestine, colon, and rectum. They account for significant morbidity and mortality and continue to be the subject of clinical and laboratory investigation. The most common form of intestinal ischemia is ischemic colitis, accounting for 50%…

Nonepithelial Colorectal Tumors

Introduction Nonepithelial tumors of the colon and rectum are rare and represent fewer than 1% of all neoplasms of the colon and the rectum. They can be categorized as benign or malignant. In this chapter we will briefly discuss benign lymphoid hyperplasia, lipomas, and leiomyomas, as well as leiomyosarcoma and the primary lymphomas of the colon and rectum. A large portion of the chapter will address…

Colorectal Metastases to the Lung

Introduction Colorectal carcinoma metastasizes to the lung in 10% to 15% of patients. The decision about whether to perform surgery for a patient with lung metastasis must take into account the patient’s ability to tolerate surgery, as well as the likelihood of achieving long-term survival. Most reports detailing the treatment of lung metastases are single-center retrospective reviews that have used overall survival as the endpoint. During…

Management of Colorectal Liver Metastasis

Introduction The liver is the most common site for colorectal cancer (CRC) metastases; 15% to 20% of patients present with synchronous lesions, and metachronous metastases occur in 40% to 50% of patients. Liver metastases are present in 60% to 70% of all patients who die of colorectal cancer. However, management of colorectal liver metastases (CRLM) has changed a lot during the past decade, and overall survival…

Management of Metastatic Colorectal Cancer

Acknowledgments Dr. Khorana acknowledges research support from the Sondra and Stephen Hardis Endowed Chair in Oncology Research, the Scott Hamilton CARES Initiative, the Porter Family Fund for Biliary Genomics Research, and the National Heart, Lung and Blood Institute (1R34HL127156). Dr. Noel serves on the speakers bureau for Taiho Pharmaceutical. Introduction Colorectal cancer is currently the third most common cancer in the United States, and in 2015…

Surgical Management of Cancer of the Colon

Introduction Surgical resection is the primary curative treatment for patients with localized colorectal cancer. The most accurate prognostic indicator of colon cancer is its stage at diagnosis, and in patients with locally advanced disease, chemotherapy has a role in decreasing the risk for recurrence or metastasis. Staging of colorectal cancer is based on the depth of penetration of the tumor into the bowel wall, the involvement…

Cancer of the Appendix and Pseudomyxoma Peritonei Syndrome

Introduction Malignant tumors of the appendix are rare, making up approximately 0.4% of all intestinal neoplasms. About 1% of all large bowel cancers arise from the appendix. The histopathology of appendiceal malignancy has been confusing, and the approach to therapy is complex. Many of the tumors have perforated at the time of definitive surgical treatment, and thus the physician is required to manage both the primary…

Hereditary Nonpolyposis Colorectal Cancer and Lynch Syndrome

Introduction Approximately 5% of all colorectal cancers (CRCs) are associated with a hereditary syndrome, where a germline mutation in a key tumor suppressor or DNA repair gene produces a cancer predisposition that can be inherited. Hereditary nonpolyposis colorectal cancer (HNPCC) is the most common of the hereditary CRC syndromes, accounting for about 3% of all CRC cases. HNPCC includes many families affected by Lynch syndrome, but…

Desmoid Disease

Introduction Desmoid disease is a benign proliferation of fibroblasts that produces a spectrum of manifestations from rapidly growing tumors to indolent nodules and flat sheets of tissue that distort surrounding organs. Although desmoid disease occurs in the general population, it is rare and generally affects limbs and limb girdles. Colorectal surgeons encounter it in the abdomen, where it is usually associated with familial adenomatous polyposis (FAP).…

Polyposis Syndromes

Introduction Hereditary colorectal cancer syndromes account for approximately 5% of all colorectal cancers. Traditionally they have been categorized according to the number and histologic features of colorectal polyps in affected patients, although there is significant blurring of the distinction between “polyposis” and “nonpolyposis” syndromes. The most common hereditary syndrome of colorectal cancer (Lynch syndrome) is not usually associated with polyposis and is the subject of a…

Molecular Genetics of Colorectal Cancer

Introduction Cancer is a disorder of cellular growth and differentiation that is due to a loss of function of regulatory pathways and feedback loops. Colorectal cancer is an excellent example of this mechanism because access via colonoscopy to the spectrum of premalignant lesions in the colon and rectum allows demonstration and study of the process. Sporadic colorectal cancer arises from pre-existing benign lesions that begin small…

Colorectal Cancer Screening and Surveillance

Screening for Colorectal Cancer In the United States, colorectal cancer (CRC) is the second most commonly diagnosed cancer in males and females. The age-adjusted incidence rate during the period 2006-2010 was 52.2 per 100,000 men and 39.3 per 100,000 women per year, according to data from the Surveillance, Epidemiology, and End Results (SEER) population-based cancer registries. The projected number of new cases in 2014 is 136,830,…

Management of the Malignant Polyp

Introduction Malignant polyps of the large intestine can be divided into polypoid cancers, which are largely cancerous lesions with a polypoid shape, and polyps that are mostly benign but have a focus of cancer. Polypoid cancers are generally unsuited to endoscopic treatment and are resected along with the segment of bowel in which they lie. Malignant polyps that are mostly benign but have a focus of…