Table Of Content

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 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland 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 xi

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