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Of patients with newly diagnosed colorectal cancer who undergo surgery with curative intent, approximately 5–12% will have tumors that have spread beyond the anatomic landmarks of a standard resection due to invasion of adjacent organs or structures. The goal of surgery in such cases is a wide, en bloc resection of the tumor and any involved adjacent organ or structure. Of patients who undergo resection...
Anoscopy is the examination of the anal canal. The lower part of the rectal mucosa, upper anal mucosa, anoderm, dentate line, internal and external hemorrhoids can be seen through this examination. There are basically two types of anoscopes: beveled type such as the Buie or Hirschman scope (Fig. 5.1) and the lighted Welch–Allen scope (Fig 5.2) that uses the same light source as the rigid proctosigmoidoscope...
Risks related to surgery are a function of many factors. Patient-related factors include the underlying disease processes and the patient’s physical ability to tolerate the physiologic stress related to the surgical procedure. Increasing amounts of data now show that risk is also affected by the volume of a procedure performed at the medical institution, but perhaps most importantly by the experience,...
Colorectal cancer is the third most common cancer affecting persons in the United States. Overall, approximately 38% of newly diagnosed patients with colorectal cancer in the United States will die of their disease.
It would seem that lifestyle concerns dominate the landscape of resident choice and are at the heart of the reason surgical specialties are losing some of the best and brightest to specialties with a more controlled lifestyle. Further exacerbating this trend is the reality that surgical specialties no longer have a monopoly on interventional procedures, and levels of compensation that have historically...
Normal bowel continence is a complex process that involves the coordinated interaction between multiple different neuronal pathways and the pelvic and perineal musculature. Complicating this are multiple other factors that have a role in normal regulation such as systemic disease, emotional effects, bowel motility, stool consistency, evacuation efficiency, pelvic floor stability, and sphincter integrity...
“Pilonidal disease” refers to a subcutaneous infection occurring in the upper half of the gluteal cleft. It may present as an acute “pilonidal abscess,” or as an indolent wound, resistant to spontaneous healing, and causing drainage and discomfort. It typically presents in the second decade of life, but also occurs in teenagers and in patients in their thirties. It afflicts men more often than women...
Vascular disorders of the midgut and hindgut are extremely morbid conditions. This is because these diseases often afflict elderly individuals with various coexisting morbidities and limited physiologic reserve. This is compounded by the fact that these disorders are often diagnosed late, only after full-thickness intestinal injury has occurred, with perforation or gangrene. Major postoperative complications...
Site and route of infection determine the symptoms caused by Sexually Transmitted Diseases (STDs). Infections of the distal anal canal, anoderm, and perianal skin are similar to lesions in other parts of the genitalia and perineum caused by the same organisms. These are typically the result of anal receptive intercourse but in some instances represent contiguous spread from genital infections. Proctitis...
An anal fissure, or fissure-in-ano, is an oval, ulcer-like, longitudinal tear in the anal canal, distal to the dentate line. Fissures can occur at any age, but are usually seen in younger and middle-aged adults. In almost 90% of cases, fissures are identified in the posterior midline, but can be seen in the anterior midline in up to 25% of affected women and 8% of affected men. Fissures occurring...
Endometriosis is a disease characterized by the presence of endometrial glands and stroma outside the uterine cavity. It is one of the most common conditions requiring surgery for women during their reproductive years. The degree of symptoms varies widely and does not always correspond to the extent of pathology encountered at surgery. Diagnosis is typically made or confirmed at laparoscopy or during...
Professional responsibilities have been a concern of surgeons since antiquity; however, the last 25 years have displayed a dramatic growth of both professional and societal attention to moral and ethical issues involved in the delivery of health care. This increased interest in medical ethics has occurred because of such factors as the greater technologic power of modern medicine, the assigning of...
The word polyp refers to a macroscopically visible lesion or mass projecting from an epithelial surface. Polyps may be classified as neoplastic or nonneoplastic. Neoplastic polyps encompass epithelial tumors such as adenomas, polypoid adenocarcinomas, and carcinoid tumors, as well as nonepithelial lesions such as lipomas, leiomyomas, and lymphomatous polyps. Nonneoplastic polyps include hamartomas,...
The presacral or retrorectal space may be the site of a group of heterogeneous, and rare tumors that are often indolent and produce ill-defined symptoms. Because detection is often difficult and delayed, patients frequently present with tumors that have reached considerable size and involve multiple organ systems, complicating their treatment. The diagnosis and management of these tumors has evolved...
Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited condition caused by mutation of the APC gene, which occurs with a frequency of about 1:10,000. Mutation of this tumor suppressor gene results in a generalized disorder of tissue growth regulation and a range of clinical manifestations, principally the formation of multiple gastrointestinal adenomas and carcinomas, but also a...
Uncontrollable bleeding is one of the most fearsome complications any surgeon may face.[1] Bleeding may present as the patient’s initial problem, or a familiar procedure can rapidly deteriorate into a struggle for survival. Careful preparation and a logical, reasoned approach to hemorrhage are essential to successful management. This chapter discusses the evaluation and management of the patient presenting...
Prolapse, in general, is defined as: “A falling down of an organ or part… from its normal position.” Rectal prolapse is a “falling down” of the rectum so that it is outside the body. Its appearance is that of an erythematous, proboscis-like object and is a true intussusception of the rectum through the sphincters. It is associated with fecal incontinence, and in women, is associated with other pelvic...
Crohn’s disease is a chronic, unremitting, incurable, inflammatory disorder that can affect the entire intestinal tract. The presenting symptoms and signs, medical and operative options, and outcome likely depend on the disease genotype and phenotype. Specifically, the surgical procedures typically utilized in the operative management of Crohn’s disease include nonresectional techniques such as internal...
Hirschsprung’s, disease (congenital megacolon) is an anomaly characterized by functional partial colonic obstruction caused by the absence of ganglion cells. It occurs in approximately 1 in 5,000 births. Boys are more frequently affected than girls and it is more common in Caucasians than in other races. A deletion in the long arm of chromosome 10 has been found. The functional disturbances in this...
The rate of stoma-specific complications in the literature varies quite widely, ranging from 10 to 70% depending on the methodology of the study, the length of follow-up, and the definition of a “complication.” For example, virtually all ostomates will have at least transient episodes of minor peristomal irritation and skin irritation is the most frequently reported stoma complication. Stoma-related...
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