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Perineal Hernia

Introduction Abdominoperineal resection (standard and extralevator) and pelvic exenteration are frequently performed operations. During follow-up, many patients demonstrate a perineal bulging with increases in abdominal pressure (especially during coughing, straining, or a Valsalva maneuver). This perineal hernia develops because a large portion of the pelvic floor has been removed. If an extended resection (extralevator abdominoperineal or exenteration) is performed, the defect can be particularly large, allowing…

Locally Recurrent Rectal Cancer: Management and Follow-Up

Introduction An estimated 40,000 new cases of rectal cancer were diagnosed in the United States in 2015, encompassing almost one third of all newly diagnosed colorectal cancers. In 4% to 19% of these patients, pelvic recurrence will develop after curative resection. These patients often experience significant pelvic pain, dysesthesia, tenesmus, and other local complications that severely impair quality of life. Early diagnosis and aggressive surgical treatment…

Local Treatment of Rectal Cancer

Introduction The treatment of early rectal cancer has been a controversial subject for several decades. Radical proctectomy with total mesorectal excision (TME) is the gold standard for patients with tumors localized to the bowel wall. The average local recurrence (LR) rate for stage I rectal cancer after TME approximates 2%, and 5-year survival is as high as 95%. However, the morbidity associated with radical proctectomy is…

Cancer of the Rectum: Operative Management

Introduction Two decades ago, surgery for rectal cancer was associated with local recurrence rates as high as 30% and poor long-term overall survival. However, during the past 10 years, survival has significantly improved and the local recurrence rate has decreased. Several important factors have contributed to this increase in overall survival for patients with rectal cancer, including new regimens for radiotherapy/chemotherapy, centralization of surgical practice, and…

Cancer of the Rectum: Neoadjuvant Therapy

Introduction In the era of total mesorectal excision (TME) surgery, preoperative radiotherapy (RT) reduces local recurrence (LR) and can be administered either as long-course RT (LCRT) with a 5-fluorouracil (5-FU)–based regimen or as short-course RT (SCRT). For patients with a positive circumferential resection margin (CRM) at TME, tumor downstaging is highly desirable. In these circumstances, SCRT is not as effective as LCRT in preventing LR. To…

Preoperative Evaluation of the Patient with Rectal Cancer: Staging and Strategy

Introduction The aims of the preoperative evaluation of a patient with rectal cancer are to assess both the patient and the tumor and offer a tailored treatment plan that optimizes both cure and sphincter preservation. Accurate staging of rectal cancer is the foundation upon which the choice of the best therapeutic strategy rests. Locoregional staging assists in selecting patients who can benefit from neoadjuvant chemoradiation treatment…

Management of Rectal Villous Tumors

Introduction The rectum, which is the organ of defecation, is a unique part of the gastrointestinal tract. The anatomic and physiologic characteristics peculiar to this role allow specific and sometimes unique approaches to management of neoplasms of the rectum. This chapter discusses options for the management of benign epithelial neoplasms in the rectum. Rectal Anatomy and Physiology The rectum consists of the lowest 8 inches of…

Diagnosis and Management of Sacral and Retrorectal Tumors

Introduction Tumors of the sacrum and retrorectal space are rare. Two reviews of patients at the Cleveland Clinic found 50 patients between 1928 and 1985 ( Table 26-1 ) and 87 patients between 1981 and 2011, in line with other studies indicating that in major referral centers, 1.4 to 6.3 patients will be diagnosed with these tumors per year. The annual incidence of congenital retrorectal tumors…

Rectal Foreign Bodies

Epidemiology Rectal foreign bodies are a challenging, unique, and commonly seen problem. The true incidence of rectal foreign bodies varies throughout the literature because of patient underreporting. Most patients with rectal foreign bodies are male and range from 30 to 90 years of age. Rectal foreign bodies are most often retained from transanal insertion for the purpose of anal eroticism, but they can also be the…

Rectocele

Definition A rectocele is an abnormal protrusion of the anterior rectal wall into the vagina ( Fig. 24-1 ). It is found in 20% of adult women, and symptoms may develop by the fourth or fifth decade of life. Most rectoceles protrude less than 2 cm into the vagina, are incidental findings, and require no treatment. Rectoceles can be graded according to size. A grade I…

Solitary Rectal Ulcer Syndrome

Introduction Solitary rectal ulcer syndrome (SRUS) is a chronic benign disorder of the rectum and pelvic floor that produces ulcerated and polypoid areas in the rectal wall. Although some patients have a single rectal ulcer, the term is misleading because the ulcers sometimes are multiple and extensive, and at times no ulcers are present but the rectal wall has a polypoid appearance (colitis cystic profunda). The…

Rectal Prolapse

Introduction Rectal prolapse occurs when the full thickness of the rectal wall protrudes through the anal canal. This condition can cause discomfort, bleeding, and incontinence. Rectal prolapse is most commonly seen in older women, but it may occur in both sexes and at any age. Although the condition has fascinated surgeons for many years, the optimal surgical approach to rectal prolapse has not been determined. More…

Management of Fecal Impaction

Introduction Fecal impaction may be defined as a large compacted mass of feces (fecaloma) that becomes stuck in the colon or rectum and cannot be evacuated by the patient. Fecal impaction is common and causes significant morbidity. Although it can occur at all ages, some groups of patients are more susceptible, such as children and institutionalized elderly persons. Others at particular risk include the physically and…

Rectal Stricture: Etiology and Management

Definition A rectal stricture, or stenosis, is a pathologic narrowing or constriction involving the lumen of the rectum. This narrowing can be the result of an intrinsic process that is occurring within the lumen or wall of the rectum, or it can be secondary to an extrinsic process compressing the rectum. A “clinically relevant” rectal stricture is one that is symptomatic and not easily defined by…

Fecal Incontinence

Introduction and Incidence Fecal incontinence may be defined as the inability to voluntarily control the release of flatus or stool until a socially convenient time and place. Fecal continence, which is learned in childhood, is one of the most important social milestones in development, and its loss is a devastating handicap. The prevalence of incontinence varies by gender, age, and definition; however, as many as 2%…

Hirschsprung Disease

Introduction and History Hirschsprung disease represents a common cause of intestinal obstruction in newborns. These patients do not have an actual mechanical obstruction but rather a serious disturbance in normal colonic peristalsis because of a lack of ganglion cells. The disease was named after Dr. Harald Hirschsprung, who presented what is considered a classic description of this condition at the Pediatric Congress in Berlin in 1886.…

Anorectal Congenital Disorders

Anorectal congenital malformations include a wide spectrum of defects, each of which requires a specific treatment and has a different functional prognosis. The main and most feared sequela is fecal incontinence, which is a devastating problem, although anal stenosis also may complicate some repairs. Approximately 70% of all affected patients who are properly treated will have voluntary bowel movements by the age of 3 years, although…

Pelvic Pain

Patients with anorectal and pelvic pain often present to the colorectal surgeon with debilitating symptoms. It is estimated that such symptoms affect as many as 6.6% of the population, but only a third of these patients will seek medical care. Although a diagnosis can usually be made, it is often difficult to completely relieve the patient’s symptoms. Most patients with anorectal pain have organic disease such…

Anal Carcinoma

Introduction Anal cancer is relatively rare, accounting for only 1.5% of gastrointestinal malignancies. However, its incidence is on the rise. Although chemotherapy/radiotherapy is the primary mode of treatment of anal squamous cell cancer (SCC), abdominoperineal resection is still required at times. The cornerstones of successful therapy are timely diagnosis, accurate staging, and routine surveillance. Although major advances have been made in the treatment of anal cancer,…

Anal Melanoma and Basal Cell Cancer of the Perianal Region

Introduction Anorectal melanoma is a rare disease with a poor prognosis. It can be found anywhere in the anal canal or distal rectum and can spread anywhere in the body. Standard chemotherapy and radiation options are not effective, and thus surgery is the primary treatment. Debate is ongoing about whether the treatment of choice is local excision or radical resection. Epidemiology and Risk Factors Anorectal melanoma…