Coloproctology: A Practical Guide

323 Pages·2017·6.755 MB·English

by  John Beynon, Dean Anthony Harris, Mark Davies, Martyn Evans (eds.)

John Beynon
Dean Anthony Harris
Mark Davies
Martyn Evans Editors
Coloproctology
A Practical Guide
123
Coloproctology
John Beynon • Dean Anthony Harris
Mark Davies • Martyn Evans
Editors
Coloproctology
A Practical Guide
Senior Editor
John Beynon
Department of Colorectal Surgery
Singleton Hospital
Swansea
United Kingdom
Editors
Dean Anthony Harris Martyn Evans
Department of Colorectal Surgery Department of Colorectal Surgery
Singleton Hospital Singleton Hospital
Swansea Swansea
United Kingdom United Kingdom
Mark Davies
Department of Colorectal Surgery
Singleton Hospital
Swansea
United Kingdom
ISBN 978-3-319-55955-1 ISBN 978-3-319-55957-5 (eBook)
DOI 10.1007/978-3-319-55957-5
Library of Congress Control Number: 2017941722
© Springer International Publishing AG 2017
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Contents
1 Management of Perianal Crohn’s Disease in the Biologic Era . . . . . . . 1
Samuel O. Adegbola, Kapil Sahnan, Philip J. Tozer, Omar Faiz,
and Ailsa Hart
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3 Anal Skin Tags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 Anal Fissure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.5 Anal Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.6 Anal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.7 Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.8 F istula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.9 R ectovaginal Fistulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.10 P regnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.11 A nal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
1.12 Scoring Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.13 Prognosis of pCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2 The Catastrophic Abdominal Wall—Management
and Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Iain David Anderson and Jonathan Epstein
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2.2 The Open Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.3 Managing the Open Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.4 Management of the Open Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.5 Management Steps in Maturing
Enterocutaneous Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.6 Procedure (Surgery) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2.7 Principles of Gastrointestinal Component
of Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.8 Cases with Infected Mesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.9 Principles of Abdominal Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.10 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
v
vi Contents
3 Colorectal Complications of Radiotherapy . . . . . . . . . . . . . . . . . . . . . 51
Malcolm S. Wilson and Omer Aziz
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.2 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.3 Acute Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
3.4 C hronic Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.5 L ife Threatening Problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.6 R isk of Further Pathology—Second Malignancy . . . . . . . . . . . . . . . 60
3.7 Risk of Further Pathology—Skeletal Problems . . . . . . . . . . . . . . . . . . 61
3.8 Treatment Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4 Robotics in Colorectal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
David Jayne
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
4.2 Robotic Rectal Cancer Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
4.3 Robotic Right Hemicolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.4 Robotic Surgery for Benign Disease . . . . . . . . . . . . . . . . . . . . . . . . . 79
4.5 Training in Robotic Colorectal Surgery . . . . . . . . . . . . . . . . . . . . . . . . 80
4.6 Future Robotic Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
4.7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
5 The Dysfunctional Pouch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Laura Hancock and Peter Sagar
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
5.2 Aetiology of Pouch Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
5.3 Assessment of Ileoanal Pouch Dysfunction . . . . . . . . . . . . . . . . . . . . . 99
5.4 Salvage Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
5.5 P ouch Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
6 T he Iatrogenic Complications of Pelvic Cancer Surgery . . . . . . . . . 107
Alexander G. Heriot and J. Alastair D. Simpson
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
6.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
6.3 Haemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6.4 Sepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
6.5 Neurological Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
6.6 Urological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
6.7 Perineal Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.8 Small Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
6.9 E arly Postoperative Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . 125
6.10 R eoperative Pelvic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
6.11 M inimising Complications in Reoperative Pelvic Surgery . . . . . . . . 126
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Contents vii
7 Assessment of Bowel Vascularity and Adjuncts
to Anastomotic Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Matthew Cassar, Ghazi Yahya Ismael, and Ronan A. Cahill
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
7.2 Central Vascular Ligation (CVL) for Complete
Mesocolic Excision (CME) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
7.3 Vascular Anatomy Versus Vascular Physiology . . . . . . . . . . . . . . . . 137
7.4 Preoperative Vascularity Assessment Methods . . . . . . . . . . . . . . . . 137
7.5 Near Future Applications and Next Step Advances . . . . . . . . . . . . . 139
7.6 Intraoperative Vascularity Assessment Methods . . . . . . . . . . . . . . . 140
7.7 Postoperative Vascularity Assessment Methods . . . . . . . . . . . . . . . . 153
7.8 Intramucosal pH Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
7.9 Microdialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
7.10 Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
8 Transanal Total Mesorectal Excision . . . . . . . . . . . . . . . . . . . . . . . . . 161
F. Borja DeLacy, Marta Jiménez-Toscano, and Antonio M. Lacy
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
8.2 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
8.3 Technical Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
8.4 Operative Morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
8.5 S hort Term and Functional Results . . . . . . . . . . . . . . . . . . . . . . . . . . 174
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
9 A nal Cancer and Sentinel Node Biopsy . . . . . . . . . . . . . . . . . . . . . . . 179
Jonathan Morton and Justin Davies
9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
9.2 Anatomy of the Anal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
9.3 A etiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
9.4 P re-cancerous Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
9.5 A nal Intraepithelial Neoplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
9.6 B uschke-Lowenstein Tumours/Giant Condyloma Acuminatum . . . 184
9.7 Squamous Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
9.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
9.9 Sentinel Lymph Node Biopsy and Anal Cancer . . . . . . . . . . . . . . . . 190
9.10 Basal Cell Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
9.11 Anal Adenocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
9.12 Anal Melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
9.13 Anal Neuroendocrine Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
9.14 S arcomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
10 Rectal Cancer That Responds to Radiotherapy . . . . . . . . . . . . . . . . . 209
Ben Creavin and Desmond Winter
10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
viii Contents
10.2 Assessing Complete Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
10.3 Clinical and Endoscopic Assessment . . . . . . . . . . . . . . . . . . . . . . . 212
10.4 Short Course Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
10.5 R adiation Dose Escalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
10.6 D elaying the Interval to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 217
10.7 Induction Chemotherapy as an Alternative
to Adjuvant Chemotherapy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
10.8 Can Neoadjuvant Radiotherapy Be Omitted? . . . . . . . . . . . . . . . . . 221
10.9 Biological Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
10.10 Local Excision for Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . 222
10.11 Quality of Life and Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
10.12 Predictive Markers: The Future of Rectal Cancer? . . . . . . . . . . . . . 226
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
11 The Advanced Primary or Recurrent
Rectal Cancer: Pushing the Boundaries . . . . . . . . . . . . . . . . . . . . . . . 241
Andrew J. Herd and Michael J. Solomon
11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
11.2 Preoperative Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
11.3 Anatomical Compartments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
11.4 S urgical Techniques for Compartment Resections . . . . . . . . . . . . 245
11.5 P ostoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
12 P ersonalised Genomics and Molecular Profiles
in Colorectal Cancer: Towards Precision Cancer Care. . . . . . . . . . . 261
Kjetil Søreide and Dordi Lea
12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
12.2 A Personalised Approach to Treatment
and Prognostication in CRC? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
12.3 Evolving Understanding of Cancer Biology Points
to Heterogeneity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
12.4 Evolving Multidisciplinary Care . . . . . . . . . . . . . . . . . . . . . . . . . . 264
12.5 L imitations in Current TNM Staging . . . . . . . . . . . . . . . . . . . . . . . 265
12.6 C urrent Understanding of Colorectal Carcinogenesis . . . . . . . . . . 266
12.7 C hromosomal Instability (CIN) Pathway . . . . . . . . . . . . . . . . . . . 269
12.8 Microsatellite Instability (MSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
12.9 Epigenetics (CIMP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
12.10 EMAST—The New Kid on the Block . . . . . . . . . . . . . . . . . . . . . . 269
12.11 The Cancer Genomic Landscape . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
12.12 Genome Wide Association Studies in Populations . . . . . . . . . . . . . 271
12.13 C olorectal Cancer Models and Classifications . . . . . . . . . . . . . . . . 272
12.14 New Suggested Classification: Consensus
Molecular Subtypes (CMSs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
12.15 Mutation Pathways with Treatment Implications:
The EGFR Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Contents ix
12.16 Extended RAS Testing for Targeted Therapy . . . . . . . . . . . . . . . . . 274
12.17 Role of the Immune System in Future Precision Therapy . . . . . . . . 275
12.18 Role of Infiltrating T-Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
12.19 Role of Foxp3 and Tregs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
12.20 Development of an ‘Immunoscore’ . . . . . . . . . . . . . . . . . . . . . . . . . 276
12.21 N ovel (Non-Invasive) Biomarkers (Blood, Faeces,
Urine, Volatile Markers) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
12.22 I mproved and Innovative Trial Design . . . . . . . . . . . . . . . . . . . . . . . 279
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
13 A ssessing Outcomes in Colorectal Cancer Surgery . . . . . . . . . . . . . . 287
Abigail Vallance and James Hill
13.1 I ntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
13.2 W hy Should We Assess and Report Outcomes? . . . . . . . . . . . . . . 288
13.3 Outcome Measures Used in Assessment . . . . . . . . . . . . . . . . . . . . 288
13.4 Post-Operative Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
13.5 Long-Term Disease Free Survival and Overall Survival . . . . . . . . 290
13.6 Quality Indicators and Surrogate Outcome Measures . . . . . . . . . . 290
13.7 Outcome Reporting Through Large Clinical Databases . . . . . . . . 294
13.8 Individual Consultant and Unit Outcome Reporting . . . . . . . . . . . . 297
13.9 Patient Reported Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
List of Contributors
Samuel Adegbola, BSc (Hons), MBBS, MRCS Department of Colorectal
Surgery, St. Mark’s Hospital, London, UK
Iain David Anderson, MD, FRCS, BSc Hope Hospital, Manchester, UK
Department of General Surgery and Colorectal Surgery, Spire Manchester Hospital,
University of Manchester, Manchester, UK
Omer Aziz, BSc, MBBS, PhD, FRCS Colorectal and Peritoneal Oncology Centre,
The Christie NHS Foundation Trust, Manchester, UK
Ronan A. Cahill, MB, BAO, BCh, MD, FRCS Section of Surgery and Surgical
Specialties, Department of Surgery, School of Medicine, Mater Misericordiae
Universtiy Hospital, University College Dublin, Dublin, Ireland
Matthew Cassar, MD MRCS (Edin) ChM (Edin) FRCSEd Section of Surgery
and Surgical Specialities, Department of Surgery, Mater Misericordiae University
Hospital, University College Dublin,, Dublin, Ireland
Ben Creavin, MD, BAO, BCH Department of Colorectal, St. Vincent’s University
Hospital, Dublin, Ireland
Justin Davies, MChir LRCP FRCS (Gen) EBSQ Cambridge Colorectal Unit,
Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,
Cambridge, UK
Jonathan Epstein, MBChB, MD, FRCS Department of General and Colorectal
Surgery, Spire Medical Hospital, Salford Royal Foundation Trust, Manchester, UK
Omar Faiz, MBBS, FRCS, MS Department of Colorectal Surgery, St. Mark’s
Hospital, London, UK
Laura Hancock, BSc, MD, FRCS Department of Colorectal Surgery,
Leeds Teaching Hospital NHS Trust, Leeds, UK
Ailsa Hart, BM Bch, FRCP, PhD IBD Unit, St Mark’s Hospital, London, UK
Andrew J. Herd, BSc, MB, ChB, FRACS Department of Colorectal Surgery,
Royal Prince Albert Hospital, Sydney, NSW, Australia
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