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Difficult Decisions in Surgery:
An Evidence-Based Approach
KonstantinUmanskiy
NeilHymanEditors
Difficult
Decisions in
Colorectal
Surgery
SecondEdition
Dicult Decisions in Surgery:
An Evidence-Based Approach
Series Editor
MarkK.Ferguson
Department of Surgery
University of Chicago
Chicago,IL,USA
The complexity of decision making in any kind of surgery is growing exponentially.
As new technology is introduced, physicians from nonsurgical specialties offer
alternative and competing therapies for what was once the exclusive province of the
surgeon. In addition, there is increasing knowledge regarding the efcacy of
traditional surgical therapies. How to select among these varied and complex
approaches is becoming increasingly difcult. These multi-authored books will
contain brief chapters, each of which will be devoted to one or two specic questions
or decisions that are difcult or controversial. They are intended as current and
timely reference sources for practicing surgeons, surgeons in training, and educators
that describe the recommended ideal approach, rather than customary care, in
selected clinical situations.
Konstantin Umanskiy • Neil Hyman
Editors
Dicult Decisions in
Colorectal Surgery
Second Edition
Editors
https://t.me/medicina_free
Konstantin Umanskiy
Medical Center
University of Chicago
Chicago, IL, USA
Neil Hyman
Medical Center
University of Chicago
Chicago, IL, USA
ISSN 2198-7750 ISSN 2198-7769 (electronic)
Difcult Decisions in Surgery: An Evidence-Based Approach
ISBN 978-3-031-42302-4 ISBN 978-3-031-42303-1 (eBook)
https://doi.org/10.1007/978-3-031-42303-1
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2023, 2017 Springer International Publishing AG, part of Springer Nature
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microlms 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 specic 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, expressed 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 afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Paper in this product is recyclable.
“To my wife, Regina, and to my daughters,
https://t.me/medicina_free
Tina, Leah, and Ilana:
You are my sparkling fountain of inspiration,
encouragement, and never-ending love.”
–Konstantin Umanskiy
“With love to Naomi, EJ, and Seth—thanks
for making me feel every day like I am the
luckiest guy on the planet”
—Neil Hyman
Preface from First Edition
https://t.me/medicina_free
Colon and rectal surgery may very well be on the cusp of a golden age. Our specialty is thriving and our ACGME approved training programs are extremely popular among the best and brightest general surgery residents. Breathtaking advances in
minimally invasive surgery have occurred over the past quarter century including
laparoscopic bowel resection, robotic surgery, endoscopic techniques such as endoscopic mucosal/submucosal resection, and transanal approaches such as transanal
endoscopic microsurgery and transanal minimally invasive surgery. Innovation in
these areas has made surgery safer for many of our patients, enabled sphincter preservation, and reduced the period of disability that many experience after treatment.
However, in addition to the obvious benets of these disruptive technologies, many
long-standing questions persist and new ones have been raised.
1. What is the most appropriate use of this new and often more expensive technology? Does the evidence really support that notion that everything new is
really better?
2. Considering the primacy of patient safety, how do we decide who should be
credentialed to do what?
3. Should any surgeon be able to use any technique they wish, irrespective of cost,
efcacy, and demonstrated competence?
4. Should these new technologies be evaluated rst by a select group of high volume/experienced surgeons in a controlled and measured environment before
more widespread adoption?
5. Do we really have adequate hypotheses and frameworks of understanding for the
common diseases we treat?
6. Without them, can we really devise rational treatment approaches for these
maladies?
7. As such, are almost all our treatments largely empiric and lacking in the basic
scientic underpinnings that would move us beyond therapeutic “hail Mary’s”?
With this state of affairs, the practice of colon and rectal surgery has largely been
driven by expert opinion and the practice of thought leaders—it is often the best we
have. In this book, we have put together a select and highly respected group of leaders in our eld and asked them both to critically review the evidence in a controversial area which they have typically contributed to and investigated during their
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Preface from First Edition
career. We also asked them to supplement this with their clinical insights and personal experience. This is not a comprehensive textbook of colon and rectal surgery
which attempts to review the basic anatomy and physiology of the vast spectrum of
problems one may encounter in the small intestine, colon rectum, and anus. Many
excellent textbooks like this already exist. Rather, we have selected a broad array of
difcult and often controversial problems that the surgeon who deals with colorectal
disease often encounters. We asked our experts to imagine that they received a
phone call from a busy surgeon in the surgeon’s lounge who wanted to know how a
particular challenging patient management issue should be handled. The goal was
NOT to list every treatment that has ever been described or utilized.
1. What are my best options?
2. What is the best evidence for/against these options in the literature?
3. How do I decide?
4. What do you think and what do you do?
The reader will be able to see what the highest quality evidence available exists to
guide our management decisions. However, it will be evident that there is always
going to be considerable room for alternative opinions and approaches. A different
acknowledged expert with considerable clinical experience and knowledge of the
applicable evidence may see things differently and approach the same problem
using a very different algorithm. Indeed, as much as we like to talk about evidence
based approaches, the “evidence” for much of what we do is often lacking and meager. We hope that the reader will nd real help and a sense of perspective from this
book. We particularly hope that we inspire our trainees and junior colleagues to
uncover new paradigms of care, contribute high quality evidence to the literature,
and advance the scientic underpinnings of our management decisions. Our patients
deserve no less!
Chicago, IL, USA NeilHyman
Preface
https://t.me/medicina_free
It is truly remarkable to reect on how much has changed, yet how much has stayed
the same since our initial edition of this book in 2017. On the one hand, our specialty continues to thrive, and we continue to attract the very best and brightest
general surgery residents to colon and rectal training programs. Technologic
advances make our operations safer, and we are appropriately focusing on a more
rapid recovery and quality of life considerations more generally.
On the other hand, there was COVID.The impact of the pandemic on many
aspects of our personal and professional life was profound. We became even more
siloed and disconnected and yearned for the collegial interactions that make colon
and rectal surgery so special and rewarding. The reader will forgive my indulgence
in what may be considered hyperbole, but I really do consider my professional colleagues to be heroes. No administrator will ever understand what it is like to share
the burdens we take on when we care for our patients and their families. We worry
constantly about their well-being and whether they are recovering properly. Why is
this lab abnormal? How concerned should I be about this imaging nding? Could
this anastomosis be leaking? We cannot and do not walk away from our patients
when things go astray…and there really is no “off switch.” There is an awful lot for
colorectal surgeons to be proud of and we should make sure that our colleagues get
the support and advocacy they richly deserve. Our steadfast commitment to our
patients and professionalism should not be used as weapons against us and taken for
granted.
We were very gratied by the response to the rst edition and pleased to have the
opportunity to work on this second edition, under the very capable leadership of Dr
Konstantin Umanskiy. Best we can tell, this book has been used by many to study
for their colorectal board examinations and by others who seek a clear, concise, and
evidence based approach for the complex/controversial issues that we encounter in
the management of colorectal disease. Again, this book is NOT intended as a comprehensive colorectal textbook that describes routine anatomy, pathophysiology and
provides a complete list of potential treatments. Rather, we asked the expert authors
to imagine that they were sipping coffee between cases in the OR lounge and got a
call from a colleague, asking their opinion on the management of a vexing problem
they have just encountered.
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Preface
How should I be thinking about this case?
What are my options?
What is the best evidence for/against these options in the literature?
How do you decide in this particular circumstance what makes the most sense?
What would you do if this was your patient?
In some cases, there will be good evidence to guide decisions; in others, one
must rely almost entirely on expert opinion. In this light, it is important to understand that we have asked the authors to give their own assessment of the relevance/
value of the literature and what the best approach is. Undoubtedly other experts will
not agree and would provide very different advice on how the situation should be
managed—this is ne and the reader should keep this in mind. We do not always get
the answer we are comfortable with when we “phone a friend”; in the end, each
surgeon needs to decide what is best for their patient in the unique circumstances
that they present.
Indeed, we really hope that readers will be inspired to identify the gaps in our
collective knowledge and choose to dig deeper into the literature and even perhaps
plan their own study to address these gaps. We continue to be awed and amazed at
the brilliance and commitment we see every day from our junior colleagues, fellows, and residents. It is impossible not to be optimistic about the future of our
specialty.
Chicago, IL, USA NeilHyman
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