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Coloproctology
A Practical Guide
Martyn Evans
Mark Davies
Rhiannon Harries
John Beynon Editors
SecondEdition
123
Coloproctology
Mart yn Evans · Mark Davies ·
Rhiannon Harries · John Beynon
Editors
Coloproctology
A Practical Guide
Second Edition
Editors
Martyn Evans
Department of Colorectal Surgery
Swansea Bay University Health Board
Swansea, UK
Mark Davies
Department of Colorectal Surgery
Swansea Bay University Health Board
Swansea, UK
Rhiannon Harries
Department of Colorectal Surgery
Swansea Bay University Health Board
Swansea, UK
John Beynon
Department of Colorectal Surgery
Swansea Bay University Health Board
Swansea, UK
ISBN 978-3-031-59629-2 ISBN 978-3-031-59630-8 (eBook)
https://doi.org/10.1007/978-3-031-59630-8
1stedition: © Springer International Publishing AG 2017
nd
edition: © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
2
Nature Switzerland AG 2024
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, 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, 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 affiliations.
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.
Contents
https://t.me/med1917
1 Triage Optimisation in Patients with Symptoms Suspicious
of Colorectal Cancer ................................................ 1
Ian Bissett and Kai Sheng Saw
1.1 Introduction . . . ............................................... 2
1.2 Symptoms Suggestive of Colorectal Cancer .................... 3
1.3 Current Challenges of Diagnosing Colorectal Cancer
Amongst Symptomatic Patients . . ............................. 4
1.3.1 Risks of Invasive Investigations . . . .................... 4
1.3.2 Low Patient Acceptability . . . ......................... 5
1.3.3 Excessive Investigation and Low Value Healthcare . . . . 5
1.3.4 Opportunity Costs Associated with Reliance
on Symptoms for Risk Assessment .................... 6
1.3.5 Supply and Demand Imbalance . . . .................... 7
1.4 The Need for Triaging and Defining Optimum . ................ 8
1.5 An Overview of Current Approaches to Triaging . . . ........... 10
1.6 The Faecal Immunochemical Test (FIT) . . . .................... 15
1.7 Implementing FIT—A Proposed Triaging Approach ........... 22
1.8 Further Questions . . . .......................................... 25
1.9 Conclusions . . . ............................................... 27
References . . ........................................................ 28
2 Total Neoadjuvant Therapy (TNT) in Rectal Cancer; Where
Now, Where Next? .................................................. 35
S. Bedrikovetski and T. Sammour
2.1 Introduction . . . ............................................... 36
2.2 Where Are We Now? . . . ...................................... 37
2.2.1 Induction Chemotherapy . ............................. 37
2.2.2 Consolidation Chemotherapy ......................... 40
2.2.3 Induction Versus Consolidation Chemotherapy
2.2.4 Total Neoadjuvant Therapy Combined
Sequencing . .......................................... 44
with Immunotherapy or Biologics . .................... 46
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2.3 Where Next? . . ............................................... 48
2.3.1 Personalized Total Neoadjuvant Therapy
Sequencing . .......................................... 48
2.3.2 Optimising Chemotherapy Regimen . . . ................ 49
2.3.3 Neoadjuvant Chemotherapy or Immunotherapy
with Selective Omission of Radiotherapy . . . ........... 50
2.3.4 Pushing the Boundaries of Nonoperative
Management . . . ...................................... 51
2.3.5 Quality of Life Implications . ......................... 52
2.4 Conclusion ................................................... 53
References . . ........................................................ 54
3 Quality of Life and Survivorship in Extended Pelvic Resection
for Advanced and Recurrent Malignancy ........................... 61
Deena Harji and Claire Taylor
3.1 Introduction . . . ............................................... 62
3.2 Quality of Life Outcomes ..................................... 62
3.2.1 Physical Function ..................................... 63
3.2.2 Psychological Function . . ............................. 63
3.2.3 Role Function . . ...................................... 64
3.2.4 Sexual Function ...................................... 64
3.2.5 Body Image .......................................... 65
3.2.6 Occupational and Financial Impact .................... 65
3.2.7 Global QoL and General Health . . .................... 66
3.2.8 QoL Assessment ..................................... 66
3.3 Cancer Survivorship .......................................... 67
3.4 After-Care Models . . .......................................... 68
3.5 Symptom Management . . ...................................... 69
3.6 Pain .......................................................... 69
3.7 Stoma Care ................................................... 70
3.8 Empty Pelvis Syndrome . ...................................... 70
3.9 Fatigue ....................................................... 71
3.10 Mobility . . . ................................................... 71
3.11 Conclusion ................................................... 72
References . . ........................................................ 72
4 Lynch Syndrome ................................................... 77
Penelope Edwards and Kevin J. Monahan
4.1 Introduction . . . ............................................... 79
4.2 History and Epidemiology . . . ................................. 83
4.2.1 History of Lynch Syndrome . . ......................... 83
4.2.2 Epidemiology . . ...................................... 84
4.2.3 Gene-Specific Cancer Risk . . . ......................... 85
4.3 Diagnosis of Lynch Syndrome: MMR Testing . ................ 89
4.4 Biology of Lynch Syndrome; Molecular Pathways . . ........... 94
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4.5 Pathways to Carcinogenesis; Adenomatous
and Non-adenomatous . . ...................................... 95
4.5.1 Cancer from pMMR Adenoma ........................ 96
4.5.2 Cancer from dMMR Precursor, Adenoma . . ........... 97
4.5.3 Cancer from dMMR Precursor, ‘Non-Polypous’
Route . ............................................... 97
4.6 Role of Surveillance Colonoscopy ............................. 98
4.6.1 Quality Factors in Colonoscopy . . . .................... 98
4.6.2 Advanced Imaging Techniques ........................ 99
4.6.3 Variables in Sidedness Affecting Risk Reduction ...... 100
4.6.4 Frequency of Colonoscopy . . . ......................... 100
4.6.5 Barriers to Colonoscopy Adherence . . . ................ 101
4.7 Colorectal Surgical Management of Lynch Syndrome . . . ....... 103
4.7.1 Extensive or Segmental Resection? . . . ................ 103
4.8 Prophylactic Surgery and Screening in Gynaecological
Cancer ........................................................ 103
4.8.1 Gene-Specific Risk and Risk Reduction Surgery ....... 103
4.8.2 Considerations Post-surgery . . ......................... 104
4.8.3 Pathological Features of Gynaecologic Cancers
in Lynch Syndrome . . ................................. 105
4.8.4 Gynaecological Surveillance . ......................... 105
4.9 Role of Screening in Other Cancers . . ......................... 105
4.9.1 Upper Gastrointestinal (GI) Cancer Screening . . ....... 105
4.9.2 Urological Cancer Screening; Urothelial
and Prostate .......................................... 107
4.9.3 Pancreatic Screening . ................................. 107
4.9.4 Diagnostic Testing Strategies Pan-Cancer
Approach . . . .......................................... 108
4.10 Lifestyle and Chemoprevention . . . ............................. 108
4.10.1 Environmental/Lifestyle Modifiers in Lynch
Syndrome . . .......................................... 108
4.10.2 Pharmacologic Agents . . . ............................. 110
4.10.3 Endometrial Risk Reducing Agents . . . ................ 113
4.11 Oncological Management: Radical and Advanced . . . ........... 114
4.11.1 CRC . . ............................................... 114
4.11.2 Immunotherapy; the Basics . . ......................... 114
4.11.3 Clinical Trial Data for Use of Immunotherapy
in CRC: Sporadic and Germline . . .................... 114
4.11.4 Targeted Treatments in LS Associated
Gynaecological Cancers . ............................. 118
4.11.5 Toxicities Related to Immune Checkpoint
Blockade . . . .......................................... 118
4.11.6 Vaccine Based Therapies ............................. 118
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4.12 Future Directions . . . .......................................... 119
4.13 Conclusion ................................................... 121
References . . ........................................................ 121
5 Neoadjuvant Therapy in Colon Cancer ............................. 133
Geerard L. Beets
5.1 Introduction . . . ............................................... 134
5.2 Rationale for Neoadjuvant Chemotherapy . .................... 135
5.3 Evidence on Neoadjuvant Chemotherapy . . .................... 136
5.4 Current Status and Remaining Questions on Neoadjuvant
Chemotherapy . ............................................... 138
5.5 Circulating Tumour DNA and Adjuvant Therapy . . . ........... 139
5.6 Immunotherapy—Immune Checkpoint Inhibition (ICI) . . ....... 140
5.6.1 Deficient Mismatch Repair (dMMR)
and Microsatellite Instability (MSI) . . . ................ 140
5.6.2 Neoadjuvant Immunotherapy in Colorectal Cancer . . . . 141
5.7 Conclusions . . . ............................................... 143
References . . ........................................................ 144
6 Appendix Neoplasms ............................................... 147
Paul A. Sutton and Sarah T. O’Dwyer
6.1 The Normal Appendix . . ...................................... 148
6.1.1 Histopathology . ...................................... 149
6.1.2 Function . . . .......................................... 149
6.1.3 Appearances on Imaging . ............................. 150
6.2 Pathology of Appendix Tumours . ............................. 150
6.2.1 Neuroendocrine Neoplasms . . ......................... 151
6.2.2 Appendiceal Mucinous Neoplasms .................... 151
6.2.3 Appendix Adenocarcinoma . . ......................... 153
6.2.4 Goblet Cell Adenocarcinoma ......................... 154
6.3 Appendiceal Neuroendocrine Tumours ........................ 155
6.3.1 Clinical Presentation . ................................. 155
6.3.2 Investigations . . . ...................................... 155
6.3.3 Management . . . ...................................... 155
6.3.4 Surveillance and Outcomes . . ......................... 157
6.4 Appendiceal Mucinous Neoplasms . . . ......................... 157
6.4.1 Clinical Presentation . ................................. 157
6.4.2 Pseudomyxoma Peritonei ............................. 158
6.4.3 Investigations . . . ...................................... 159
6.4.4 Surgical Management ................................. 160
6.4.5 Multi-visceral Transplantation ........................ 163
6.4.6 Systemic Anti-cancer Therapy (SACT) ................ 163
6.4.7 Surveillance and Outcomes . . ......................... 164
6.5 Appendix Adenocarcinoma . . . ................................. 164
6.5.1 Clinical Presentation . ................................. 164
6.5.2 Investigations . . . ...................................... 165
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6.5.3 Surgical Management ................................. 165
6.5.4 Systemic Anti-cancer Therapy ........................ 165
6.5.5 Surveillance and Outcomes . . ......................... 166
6.6 Goblet Cell Adenocarcinoma . ................................. 167
6.6.1 Clinical Presentation . ................................. 167
6.6.2 Investigations . . . ...................................... 167
6.6.3 Surgical Management ................................. 168
6.6.4 Systemic Anti-Cancer Therapy (SACT) ............... 168
6.6.5 Surveillance and Outcomes . . ......................... 169
6.7 Referring to Specialist Services . . ............................. 169
6.8 Current Research and Future Directions . . . .................... 170
6.9 Conclusion ................................................... 171
References . . ........................................................ 171
7 Patient Optimisation for Colorectal Surgery ........................ 179
Carly N. Bisset and Susan J. Moug
7.1 Introduction . . . ............................................... 180
7.2 Definition of Patient Optimisation: Preassessment
and Prehabilitation . . .......................................... 180
7.2.1 Pre-assessment . ...................................... 181
7.2.2 Prehabilitation . . ...................................... 185
7.3 The Evidence for the Effectiveness of Prehabilitation . . . ....... 187
7.3.1 Patient Safety and Feasibility ......................... 187
7.3.2 Assessment of Prehabilitation ......................... 188
7.3.3 Trials, Systematic Reviews and Meta-Analyses . ....... 190
7.3.4 The Future of Prehabilitation ......................... 195
7.4 Conclusion ................................................... 196
References . . ........................................................ 197
8 Empty Pelvis Syndrome Complication Management Following
Pelvic Exenteration ................................................. 205
Martha Quinn and Colin W. Steele
8.1 Introduction . . . ............................................... 206
8.2 Empty Pelvis Syndrome . ...................................... 206
8.3 Prevention Strategies .......................................... 207
8.3.1 Negative Pressure ..................................... 208
8.3.2 Myocutaneous Flap Reconstruction . . . ................ 208
8.3.3 Mesh . . ............................................... 209
8.3.4 Spacers ............................................... 210
8.4 Summary ..................................................... 210
8.5 Complications and Management of Empty Pelvis
Syndrome . ................................................... 211
8.5.1 Pelvic Collection ..................................... 211
8.5.2 Haemorrhagic Complications ......................... 212
8.5.3 Wound Complications . . . ............................. 213
8.5.4 Enteroperineal Fistula . . . ............................. 215
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8.5.5 Perineal Hernia . ...................................... 216
8.5.6 Conclusion . .......................................... 216
References . . ........................................................ 217
9 Contemporary Management of the Open Abdomen ................ 221
Dominic Alexander James Slade
9.1 Introduction . . . ............................................... 222
9.2 Indications for an Open Abdomen ............................. 222
9.2.1 Trauma and the Damage Control Laparotomy . . ....... 224
9.2.2 Intra-Abdominal Hypertension and Abdominal
Compartment Syndrome . ............................. 226
9.2.3 Peritonitis and Intra-Abdominal Sepsis ................ 229
9.2.4 Acute Mesenteric Ischaemia, Pancreatitis,
and Burns Without Abdominal Trauma ................ 233
9.3 Management of the Open Abdomen . . ......................... 234
9.3.1 Temporary Abdominal Closure Dressings . . ........... 234
9.3.2 Static Temporary Abdominal Closure . ................ 235
9.3.3 Dynamic Temporary Abdominal Closure . . . ........... 237
9.3.4 Mixed Techniques . . . ................................. 239
9.3.5 Vacuum-Assisted Wound Closure Using
Mesh-Mediated Fascial Traction . . .................... 240
9.3.6 Immediate Management of an Enteroatmospheric
Fistula ............................................... 243
9.4 Conclusion ................................................... 244
References . . ........................................................ 245
10 Anastomotic Techniques for Crohn’s Surgery ...................... 251
Antonino Spinelli and Elisa Paoluzzi Tomada
10.1 Surgical Principles in Crohn’s Disease ......................... 252
10.2 Restorative Surgery Techniques After Bowel Resection . ....... 255
10.3 Anastomotic Techniques After Ileocaecal Resection . ........... 255
10.3.1 Side-to-Side Ileocolonic Anastomosis . ................ 256
10.3.2 End-to-End Handsewn Ileocolonic Anastomosis ....... 258
10.3.3 End-to-Side and Side-to-End Ileocolonic
Anastomosis .......................................... 259
10.3.4 Antimesenteric Hand-Sewn Functional
End-to-End Anastomosis: Kono-S Anastomosis ....... 260
10.3.5 Additional Anastomotic Techniques . . . ................ 263
10.4 Extracorporeal and Intracorporeal Anastomoses ................ 264
10.5 Restorative Techniques After Colectomy, Proctocolectomy
and Upper Gastrointestinal Surgery . . . ......................... 265
10.5.1 Ileo-Rectal Anastomosis . ............................. 265
10.5.2 Ileal Pouch-Anal Anastomosis and Coloanal
Anastomosis .......................................... 266
10.5.3 Surgical Management of the Upper
Gastrointestinal Crohn’s Disease Manifestations ....... 266
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