Improved Outcomes in Colon and Rectal Surgery part 1 ppsx

Improved Outcomes in
Colon and
Rectal Surgery
Edited by
Charles B Whitlow
David E Beck
David A Margolin
Terry C Hicks
Alan E Timmcke
Improved Outcomes in
Colon and Rectal Surgery
Whitlow • Beck • Margolin
Hicks • Timmcke
www.informahealthcare.com
Telephone House, 69-77 Paul Street,
London EC2A 4LQ, UK
52 Vanderbilt Avenue, New York, NY 10017
Improved Outcomes in Colon
and Rectal Surgery
About the book
Written by many of the world’s leading colorectal surgeons, this evidence-based text investigates the
risks and benets of colorectal surgeries. By using clinical pathways, algorithms, and case discussions,
the authors identify the best practices for patient safety and positive outcomes to ensure that
physicians correctly recognize potential problems and carefully manage complications.
Improved Outcomes in Colon and Rectal Surgery is an essential reference for all colorectal surgeons,
fellows and residents, as well as those working in gastroenterology and the medico-legal profession.
About the editors
Charles B Whitlow MD, Program Director, Colon and Rectal Surgery Fellowship Program, Ochsner
Medical Center, New Orleans, Louisiana, USA.
David E Beck MD, Chairman, Department of Colon and Rectal Surgery, Ochsner Medical Center, New
Orleans, Louisiana, USA. He is President-Elect of the American Society of Colon and Rectal Surgeons

and Editor-in-Chief of Clinics in Colon and Rectal Surgery and the Ochsner Journal.
David A Margolin MD, Colon and Rectal Research Director, Ochsner Medical Center, New Orleans,
Louisiana, USA. He is an Associate Editor of Diseases of the Colon and Rectum.
Terry C Hicks MD, Associate Chairman, Department of Colon & Rectal Surgery, Ochsner Medical Center,
New Orleans, Louisiana, USA. He is President of the American Board of Colon and Rectal Surgeons
Alan E Timmcke, Sta Colon and Rectal Surgeon, Ochsner Medical Center, New Orleans, Louisiana, USA.
Also available
Ambulatory Colorectal Surgery
Edited by Laurence R Sands and Dana R Sands (ISBN: 9780824727925)
Gastrointestinal Oncology: Evidence and Analysis
Edited by Peter McCulloch, Martin S Karpeh, David J Kerr and Jaer Ajani (ISBN: 9780849398650)
Neoplasms of the Colon, Rectum, and Anus, Second Edition
Authored by Philip H Gordon and Santhat Nivatvongs (ISBN: 9780824729615)
Improved Outcomes in Colon
and Rectal Surgery
Edited by
Charles B Whitlow MD
Program Director
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
David E Beck MD
Chairman
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
David A Margolin MD
Research Director

Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Terry C Hicks MD
Associate Chairman
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Alan E Timmcke MD
Staff Surgeon
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
© 2010 Informa UK
First published in 2010 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ. Informa Healthcare is a trading division of
Informa UK Ltd. Registered Office: 37/41 Mortimer Street, London W1T 3JH. Registered in England and Wales number 1072954.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright,
Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court
Road, London W1P 0LP.
Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to
acknowledge in subsequent reprints or editions any omissions brought to our attention.
A CIP record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Data available on application
ISBN-13: 9781920071528
Orders

Informa Healthcare
Sheepen Place
Colchester
Essex CO3 3LP
UK
Telephone: +44 (0)20 7017 5540
Email:
Typeset by C&M Digitals (P) Ltd, Chennai, India
Printed and bound in Great Britain by CPI, Antony Rowe, Chippenham, Wiltshire

Contents
List of Contributors v
Preface ix
Foreword xi
1 Preexisting conditions 1
Eric L Marderstein, Siyamek Neragi-Miandoab, and Conor P Delaney
2 Preoperative bowel preparation 14
David A Margolin and Sean Mayfield
3 Anesthesia and intraoperative positioning 19
Lebron Cooper and Larry R Hutson
4 Sepsis 27
Steven Mills and Michael J Stamos
5 Intraoperative anastomotic challenges 33
David E Beck
6 Other intraoperative challenges 44
James T McCormick and Sharon G Gregorcyk
7 Postoperative anastomotic complications 56
Daniel L Feingold
8 General postoperative complications 67
Scott R Steele and Clifford L Simmang

9 Care paths and optimal postop management 79
Surya P M Nalamati and Eric J Szilagy
10 Limitations of anorectal physiology testing 87
Thomas E Cataldo and Syed G Husain
11 Limitations of colorectal imaging studies 97
Travis J Blanchard, Wilson B Altmeyer, and Charles C Matthews
12 Transanal endoscopy 132
Terry C Hicks
13 Laparoscopic colorectal surgery 140
James W Fleshman and Jonathan S Chun
14 Medical legal issues 148
Charles F Gay Jr and Terry C Hicks
15 Miscellanous conditions 154
M Benjamin Hopkins and Alan E Timmcke
16 Quality and outcome measures 159
Janak A Parikh, Sushma Jain, Marcia L McGory, and Clifford Y Ko
17 Hemorrhoidal surgery 168
Dan R Metcalf and Anthony J Senagore
18 Nonoperative therapy for hemorrhoid disease 178
Kerry Hammond and Charles B Whitlow
contents
19 Surgery and nonoperative therapy of perirectal abscesses and anal fistulas 183
Brian R Kann and Charles B Whitlow
20 Surgery and nonoperative therapy of anal fissure 199
Jaime L Bohl and Alan J Herline
21 Surgery for pilonidal disease and hidradenitis suppurativa 215
Paula I Denoya and Eric G Weiss
22 Surgical treatment of fecal incontinence 226
Ann C Lowry and Dimitrios Christoforidis
23 Surgery for rectal prolapse 239

Steven R Hunt
24 Operative and nonoperative therapy for diverticular disease 249
R Scott Nelson and Alan G Thorson
25 Abdominal surgery for colorectal cancer 263
Jason Hall and Rocco Ricciardi
26 Transanal approaches to rectal cancer 271
Sachin S Kukreja and Theodore J Saclarides
27 Abdominoperineal resection 278
W Brian Perry, Fia Yi, Clarence Clark, and Danny Kim
28 Indications and outcomes for treatment of recurrent rectal cancer and colorectal
liver and lung metastasis 286
Harry L Reynolds Jr, Christopher T Siegel, and Jason Robke
29 Chemotherapy for colon and rectal cancer 300
Liliana Bordeianou and Judith L Trudel
30 Radiation therapy: Acute and late toxicity 306
Roland Hawkins
31 Surgery for ulcerative colitis 318
Patricia L Roberts
32 Surgery for Crohn’s disease 331
Jorge Canedo, Tolga Erim, and Steven D Wexner
33 Ostomies 349
Vance Y Sohn and Scott R Steele
34 Operative and nonoperative therapy for chronic constipation 361
Harry T Papaconstantinou
35 Colorectal trauma 375
S David Cho, Sharon L Wright, and Martin A Schreiber
36 Urologic complications of colorectal surgery 395
Scott Delacroix Jr and J Christian Winters
Index 405


List of Contributors
Wilson B Altmeyer MD
Department of Radiology
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
David E Beck MD
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Travis J Blanchard MD
Department of Radiology
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Jaime L Bohl MD
Department of Surgery
Vanderbilt University
Nashville, Tennessee
USA
Liliana Bordeianou MD
Department of Surgery
Division of General and Gastrointestinal Surgery
Massachusetts General Hospital
Boston, Massachusetts
USA
Jorge Canedo MD
Department of Colorectal Surgery
Cleveland Clinic Florida

Weston, Florida
USA
Thomas E Cataldo MD
Warren Alpert Medical School of Brown University
Brown Program in Colon and Rectal Surgery
Rhode Island Hospital/Lifespan Health System
Providence, Rhode Island
USA
S David Cho MD
Department of Surgery
Oregon Health and Science University
Portland, Oregon
USA
Dimitrios Christoforidis MD
Department of Visceral Surgery,
CHUV-University of Lausanne
Lausanne, Switzerland
Jonathan S Chun MD
Section of Colon and Rectal Surgery
Washington University School of Medicine
St Louis, Missouri
USA
Clarence Clark MD
Department of General Surgery
Wilford Hall Medical Center and the University of Texas Health
Science Center, San Antonio
Lackland AFB, Texas
USA
Lebron Cooper MD
Department of Anesthiology

Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Scott E Delacroix, Jr., MD
Department of Urology
Louisiana State University Health Sciences Center
New Orleans, Louisiana
University of Texas, MD Anderson Cancer Center
Houston, Texas
USA
Conor P Delaney MD MCh PhD
Department of Surgery
Division of Colorectal Surgery
University Hospitals Case Medical Center
Cleveland, Ohio
USA
Paula I Denoya MD
Department of Colorectal Surgery
Cleveland Clinic Florida
Weston, Florida
USA
Tolga Erim MD
Department of Colorectal Surgery
Cleveland Clinic Florida
Weston, Florida
USA

lst of contrbutors
Daniel L Feingold MD
Section of Colorectal Surgery

Columbia University
New York, New York
USA
James W Fleshman MD
Section of Colon and Rectal Surgery
Washington University School of Medicine
St Louis, Missouri
USA
Charles F Gay Jr
Adams and Reeds Attorneys and Counselors at Law
New Orleans, Louisiana
USA
Sharon G Gregorcyk MD
Texas Colon and Rectal Specialists
Dallas, Texas
USA
Jason Hall MD
Department of Colon and Rectal Surgery
Lahey Clinic
Tufts University
Burlington, Massachusetts
USA
Roland Hawkins MD
Radiation Oncology
Ochsner Cancer Institute
New Orleans, Louisiana
USA
Kerry Hammond MD
Division of General Surgery
Medical University of South Carolina

Charleston, South Carolina
USA
Alan J Herline MD
Department of Surgery
Vanderbilt University
Nashville, Tennessee
USA
Terry C Hicks MD
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
M Benjamin Hopkins MD
Department of Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Steven R Hunt MD
Colon and Rectal Surgery Section
Division of General Surgery
Washington University
St. Louis, Missouri
USA
Syed G Husain MD
Brown Program in Colon and Rectal Surgery
Warren Alpert Medical School of Brown University
Rhode Island Hospital/Lifespan Health System
Providence, Rhode Island
USA
Larry R Hutson MD

Department of Anesthiology
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Sushma Jain MBBS MPH
David Geffen School of Medicine at UCLA
Department of Surgery
Los Angeles, California
USA
Brian R Kann MD
Cooper University Hospital
UMDNJ-Robert Wood Johnson Medical School-Camden
Department of Surgery
Camden, New Jersey
USA
Danny Kim MD
Department of General Surgery
Wilford Hall Medical Center and the University of Texas Health
Science Center, San Antonio
Lackland AFB, Texas
USA
Clifford Y Ko MD MS MSHS
David Geffen School of Medicine at UCLA
Department of Surgery
Los Angeles, California
USA
Sachin S Kukreja MD
Section of Colon and Rectal Surgery
Department of General Surgery
Rush University Medical Center

Chicago, Illinois
USA
Ann C Lowry MD
Colon & Rectal Surgery Associates Ltd
St Paul, Minnesota
USA

lst of contrbutors
James T McCormick DO
Department of Surgery
Division of Colon and Rectal Surgery
Western Pennsylvania Hospital and the Forbes Regional Campus
Temple University School of Medicine
Philadelphia, Pennsylvania
USA
Marcia L McGory MD PhD
David Geffen School of Medicine at UCLA
Department of Surgery
Los Angeles, California
USA
Eric L Marderstein MD MPH
Division of Colorectal Surgery,
Department of Surgery,
University Hospitals Case Medical Center,
Cleveland, Ohio
USA
David A Margolin MD
Colon and Rectal Surgery
The Ochsner Clinic Foundation
New Orleans, Louisiana

USA
Charles C Matthews MD
Department of Radiology
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Sean Mayfield MD
Colon and Rectal Surgery
The Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Dan R Metcalf MD
SMDC Health System
Department of Surgery
Duluth, Minnesota
USA
Steven Mills MD
University of California
Irvine, California
USA
Surya PM Nalamati
Division of Colon and Rectal Surgery
Henry Ford Health System
Department of Surgery/Colon & Rectal Group
Detroit, Michigan
USA
R Scott Nelson DO
Colon & Rectal Surgery, Inc
Omaha, Nebraska
USA

Siyamek Neragi-Miandoab MD
Division of Colorectal Surgery,
Department of Surgery,
University Hospitals Case Medical Center,
Cleveland, Ohio
USA
Harry T Papaconstantinou MD
Department of Surgery
Scott & White Hospital and Clinic
Texas A&M University System Health Science Center
Temple, Texas
USA
Janak A Parikh MD
David Geffen School of Medicine at UCLA
Department of Surgery
Los Angeles, California
USA
W Brian Perry MD
Department of General Surgery
Wilford Hall Medical Center and the University
of Texas Health Science Center, San Antonio
Lackland AFB, Texas
USA
Harry L Reynolds Jr MD
University Hospital of Cleveland
Cleveland, Ohio
USA
Rocco Ricciardi MD MPH
Department of Colon and Rectal Surgery
Lahey Clinic

Tufts University
Burlington, Massachusetts
USA
Patricia L Roberts MD
Department of Colon and Rectal Surgery
Lahey Clinic Medical Center
Burlington, and
Tufts University School of Medicine
Boston, Massachusetts
USA
J Robke MD
University Hospital of Cleveland
Cleveland, Ohio
USA

lst of contrbutors
Theodore J Saclarides MD
Section of Colon and Rectal Surgery
Department of General Surgery
Rush University Medical Center
Chicago, Illinois
USA
Martin A Schreiber MD
Division of Trauma and Critical Care
Oregon Health and Science University
Portland, Oregon
USA
Christopher T Siegel MD
University Hospital of Cleveland
Cleveland, Ohio

USA
Anthony J Senagore MD MS MBA
Spectrum Health System
Grand Rapids, Michigan
USA
Clifford L Simmang MD
Texas Colon and Rectal Surgeons
Dallas, Texas
USA
Vance Y Sohn MD
Department of Surgery
Madigan Army Medical Center
Tacoma, Washington
USA
Michael J Stamos MD
University of California
Irvine, California
USA
Scott R Steele MD
Department of Surgery
Madigan Army Medical Center
Tacoma, Washington
USA
Eric J Szilagy MD
Department of Surgery/Colon & Rectal Group
Division of Colon and Rectal Surgery
Henry Ford Health System
Detroit, Michigan
USA
Alan G Thorson MD

Colon & Rectal Surgery, Inc
Omaha, Nebraska
USA
Alan E Timmcke MD
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Judith L Trudel MD, MSc, MHPE
University of Minnesota
St Paul, Minnesota
USA
Eric G Weiss MD
Department of Colorectal Surgery
Cleveland Clinic Florida
Weston, Florida
USA
Steven D Wexner MD
Department of Colorectal Surgery
Ohio State University and
Department of Surgery, Division of General Surgery
University of South Florida College of Medicine
Cleveland Clinic Florida
Weston, Florida
USA
Charles B Whitlow MD
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA

J Christian Winters MD FACS
Department of Urology
Female Pelvic Medicine and Reconstructive Surgery
Louisiana State University Health Sciences Center
New Orleans, Louisiana
USA
Sharon L Wright MD
Department of Surgery
Oregon Health and Science University
Portland, Oregon
USA
Fia Yi MD
Department of General Surgery
Wilford Hall Medical Center and the University of Texas Health
Science Center, San Antonio
Lackland AFB, Texas
USA

Preface
Quality measures and outcomes are receiving greater attention
by the lay and medical communities. The occurrence or mis-
management of complications often results in poor outcomes,
increased cost, and significant morbidity. Answering the call for
transparency and improvement requires action by all involved
in the care of patients. Collection of objective data and quality
measures allows documentation of optimal care and desired out-
comes while identifying areas for improvement.
The goal of this text is to present the current knowledge of
outcomes, as well as the techniques for minimizing and managing
complications from the common diseases and procedures of this

specialty. This information will aid providers in optimizing care
and encourage research in outcome and quality measurement.
Improved Outcomes of Colon and Rectal Surgery represents
the collaborative efforts of many individuals. The contributing
authors were selected for their knowledge of colorectal surgery and
ability to present their surgical judgment and experience in written
form. They represent a spectrum of experienced providers who
have made significant contributions to younger individuals who
will shape the future of their specialty. In addition to reviewing the
available literature, they have described their personal approach
to complications in colorectal surgery. Numerous technical
descriptions and highlights from multiple discussions held in
surgical locker rooms, morbidity and mortality conferences, and
the hallways of conferences and symposiums have been included.
Using this approach, we hope this text will provide initial guidance
to the less experienced provider and stimulate additional thought
and research to the more experienced provider.
The editors gratefully acknowledge the efforts of the many
individuals who made this book possible. This text carries on
the vision of previous editors and contributors to the first two
editions of Complications in Colon and Rectal Surgery.
Charles B Whitlow, MD
David E Beck, MD
David A Margolin, MD
Terry C Hicks, MD
Alan E Timmcke, MD