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CHAPTER 11 Colorectal surgery
402
Restorative pelvic surgery
Low/ultralow anterior resection
Anterior resection = removal of part or all of the rectum and anastomosis
of the left colon to the remaining stump of tissue.
• Low anterior resection refers to a join that takes place below the level
of the peritoneal refl ection. i.e. to a short stump of rectum.
• Ultralow anterior resection refers to a join that takes place on to the
top of the anal canal, i.e. no native rectum remains. The anastomosis
may be stapled or sewn by hand.
The lower the level of the anastomosis, the higher the risk of complications of anastomosis, particularly anastomotic leakage (see b p. 420).
Most low and almost every ultralow anastomosis will have a temporary
loop ileostomy formed to reduce the risk of major septic complications
and consequences of leakage, but cannot prevent them.
Indications
• Rectal carcinoma.
• Rectal adenoma untreatable by other means (very rare with transanal
endoscopic microsurgery (TEMS).
• Severe or complex anorectal sepsis (including rectovaginal fi stula).
Ileoanal pouch formation
For operations that remove all the colon and rectum, but do not require
removal of the anus, a permanent stoma can be avoided by the formation of
an ileal pouch. Formed from a side-to-side double fold of ileum (‘J’ pouch) or
three folds sewn together (‘W’ pouch), joined either by hand or by staples to
the upper anal canal (ileoanal anastomosis). A temporary loop ileostomy is
often formed for the same reasons as for a low anterior resection (above).
Indications
• Ulcerative colitis not responding to medical management.
• FAP or multiple colorectal polyposis.
• Crohn’s disease of the colon (controversial).
• Multiple colonic tumours including the rectum.
Complications of pelvic anastomosis (anterior resection
and ileoanal pouch)
• Leakage. Occurs in up to 15% of cases; highest in the lowest
anastomosis. Typically presents as fever, abdominal pain, and
tachycardia (see b p. 420).
• Bleeding. Uncommon; usually settles with supportive treatment.
• Ischaemia. The proximal bowel involved in the anastomosis may
become ischaemic. This may present as a leak, bleeding PR, or fever
and tachycardia. Diagnosis is by careful fl exible sigmoidoscopy. May
resolve spontaneously; progressive ischaemia results in perforation and
death if not corrected by surgery.
• Stenosis. Narrowing of the anastomosis or bowel used to form it is
an occasional late complication. Presents with diffi culty in defecation
and small volume frequent stools. Treatment is dilatation under
anaesthetic; very rarely requires re-operation.
MINIMALLY-INVASIVE COLORECTAL SURGERY
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Minimally-invasive colorectal surgery
Transanal endoscopic microsurgery (TEMS)
Large calibre operating protoscope with operating microscope allows
microsurgery within the rectum.
Indications
• Excision of large adenomas of the rectum (up to the rectosigmoid
junction) in a single specimen either by mucosectomy (or occasionally
full thickness).
• Excision of early rectal carcinoma (only if <3cm size, early tumour
(T1), no adverse features or in elderly/comorbid patients) by single
specimen full thickness excision.
• Repair of a rectovaginal fi stula.
Advantages Include entirely endoscopic technique, very low risk of pararectal/pelvic sepsis, single complete specimen for histological assessment,
may avoid more radical surgery.
Complications Include bleeding (rarely requires active treatment), infection in the pelvic tissues (rare, presents with deep pelvic pain, fever, tachycardia, and disturbance of bowel habit; treat with IV antibiotics).
Laparoscopic surgery
Several variants now exist. All use the same principles: minimal incisions,
avoidance of exposure of viscera, light anaesthetic techniques with minimal opiates, and often enhanced recovery post-operatively.
Typical Indications
• Any colorectal resection can be performed by laparoscopic surgery.
• Rectopexy for prolapse.
• Combined treatment of large/extensive colonic polyps.
• Formation of some stomas.
Two newer variants have been used:
• SILS. Single incision laparoscopic surgery; one larger port for camera
and instruments used at the umbilicus.
• LESS. Combined laparoscopic and endoscopic single site surgery;
combines laparoscopic mobilization and handling with endoluminal
endoscopic techniques to remove very large lesions.
Advanced polypectomy
Several advanced endoscopic techniques are used to remove large and
often sessile colonic polyps.
• EMR. Endoscopic mucosal resection; excision (usually piecemeal)
of (presumed) adenoma with use of submucosal fl uid injection to
facilitate snaring of the polyp.
• ESD. Endoscopic submucosal dissection; attempted complete excision
of (presumed) adenoma using submucosal injection and endoscopic
diathermy ‘knife’.
403
CHAPTER 11 Colorectal surgery
404
Diverticular disease of the colon
Key facts
Colonic diverticula are acquired outpouchings of colonic mucosa and
overlying connective tissue through the colonic wall.
• Tend to occur along the lines where the penetrating colonic arteries
traverse the colonic wall between the taenia coli.
• Associated with hypertrophy of the surrounding colonic muscle
with thickening of the colonic mucosa. This is probably due to the
underlying pathological process, which is high pressure contractions of
the colon, causing chronic pressure on the colonic wall.
• Peak age of presentation is 50–70y, but diverticular disease is
increasing in frequency and occurring at a progressively younger age.
Clinical and pathological features
Asymptomatic
The majority of diverticular disease is found incidentally on barium enema
examination.
Painful diverticular disease
Intermittent LIF pain may be due to diverticular disease, but irritable bowel
syndrome commonly coexists and may be the cause of symptoms.
Acute diverticulitis
Rapid onset of LIF pain, nausea, fever, frequently with loose stools. Usually
febrile with moderate tachycardia and LIF tenderness. Colonic wall shows
acute neutrophil infi ltration around the infl amed diverticulum and in the
subserosal tissues.
Bleeding diverticular disease
Usually spontaneous in onset with no prodromal symptoms. Presenting
with large volume dark red, clotted rectal blood. Due to rupture of a
peridiverticular submucosal blood vessel. Not typically associated with
infl ammation.
Complications
Pericolic/paracolic mass/abscess
Acute diverticulitis may progress to persistent pericolic infection with
thickening of surrounding tissues and the formation of a mass. If this suppurates, a pericolic abscess forms. Enlargement and extension of this into
the paracolic area leads to a paracolic abscess. The features are those of
acute diverticulitis with a swinging fever, fl uctuating tachycardia, unresolving abdominal pain, and a tender LIF mass.
Peritonitis
Perforation of a pericolic or paracolic abscess usually leads to purulent
peritonitis. Direct perforation of the acute diverticular segment leads to
faeculent peritonitis. The features are of acute diverticulitis with high fever,
severe abdominal pain, and generalized guarding and rigidity.
DIVERTICULAR DISEASE OF THE COLON
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Diverticular fi stula
Acute infection with paracolic sepsis may drain by perforation into
adjacent structures. This is typically the posterior vaginal vault in women or
the bladder in either sex. Colovesical fi stula leads to recurrent UTI caused
by enteric organisms with bubbles and debris in the urine. Colovaginal
fi stula leads to faeculent per vagina (PV) discharge.
Stricture formation
Chronic or repetitive infl ammatory episodes may lead to fi brosis and narrowing of the colon. A history of recurrent diverticulitis with recurrent colicky abdominal pain, distension, and bloating suggests stricture formation.
Diagnosis and investigations
• Elective diagnosis is usually by double contrast barium enema.
Colonoscopy is a relatively poor investigation to assess number and
extent of diverticula.
• Hb, WCC, CRP during acute episodes of infl ammation.
• CT scanning is the test of choice to identify complications, including
abscess formation and perforation.
• Double contrast barium enema is used to assess for possible stricture
formation.
• Colonoscopy is indicated if there is any suggestion of coexistent
malignancy.
Treatment
Medical treatment
• High fi bre diet, high fl uid intake, and stool softeners to reduce
intracolonic pressure.
• IV antibiotics (amoxycillin 500mg IV tds, metronidazole 500mg IV tds,
gentamicin IV od) during acute infective exacerbations.
• Recurrent infective episodes may be prevented by a 6-week course of
oral antibiotics (e.g. ciprofl oxacin 500mg PO od).
• Signifi cant paracolic abscesses may be drained by radiological guidance.
Surgical treatment
• Resection is indicated for:
Acute infl ammation failing to respond to medical management.•
Undrainable paracolic sepsis.•
Free perforation.•
The affected region should be resected (segmental colectomy). The ends
may be re-anastomosed if they are healthy and the patient’s general condition is suitable. If not, a proximal end colostomy and oversewing of the
distal end is usual (Hartmann’s type resection).
• Stricture may be treated by elective resection or balloon dilatation.
• Diverticular fi stula may be treated by elective resection to prevent
recurrent infections.
405
CHAPTER 11 Colorectal surgery
406
Rectal prolapse
Key facts
Rectal prolapse may be partial thickness (usually just mucosa) or full
thickness involving all the layers of the rectal wall. Full thickness may
be contained within the rectum (internal prolapse also called intussusception). Commonest in post-menopausal women, multiple vaginal deliveries, associated with chronic straining and chronic disorders of defecation
(which cause weakness of the pelvic fl oor and sphincter complex), and
slow transit constipation. Occasionally occurs in children suffering constipation (usually self-limiting).
Pathological features
Mucosa involved in prolapse undergoes chronic changes.
• Typically glandular branching and occasional gland misplacement.
• Thickening of the muscularis mucosae and excess submucosal collagen
deposition.
• Mucosal infl ammation and focal ulceration may also occur. Extensive
mucosal ulceration associated with mucosal prolapse may result in an
appearance called ‘solitary rectal ulcer’.
Clinical features
• Mucosal prolapse. Discharge of mucus and small volume faecal staining,
pruritus ani, and occasionally small volume bright red rectal bleeding.
• Internal full thickness prolapse. Sensation of rectal fullness/mass,
incomplete defecation, dissatisfaction after defecation and repeated
defecation.
• External full thickness prolapse. External prolapsing mass after
defecation (usually requiring manual reduction), mucus and faecal
soiling, occasional bright red rectal bleeding (may be large volume if
prolapse becomes ulcerated).
Diagnosis and investigations
• Rigid sigmoidoscopy may show features of mucosal infl ammation,
particularly the anterior rectal mucosa.
• Prolapse may be demonstrable on straining in clinic.
• Defecating proctogram may be performed to confi rm the diagnosis
if it is unclear and surgery is contemplated. Proctogram required
to confi rm the diagnosis of internal prolapse if suspected. May also
demonstrate associated problems of pelvic fl oor and rectocele.
• Colonic transit studies may be used if there is suspected slow transit
constipation and resection is possible.
Treatment
Medical treatment
• Avoidance of straining and adaptation of defecatory habit (bio-
feedback).
• Avoidance of constipation (stool softeners and bulking agents, rather
than stimulants).
RECTAL PROLAPSE
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Surgical treatment
Mucosal prolapse
• Recurrent banding or dilute phenol injection of excess mucosa.
• Mucosal excision.
• Stapled anopexy (also called procedure for prolapse and haemorrhoids
(PPH)) sometimes used.
Full thickness prolapse (internal or external)
Surgery indicated for failure of control of symptoms. Choice of operation
depends on age and extent of prolapse.
• Delorme’s perineal rectopexy (mucosal excision with sutured plication
of the excessively long rectal muscle tube in an effort to shorten it to
prevent prolapse). Ideal for very frail and elderly, but least successful
with highest recurrence rate of all surgical procedures.
• Altmeier’s perineal rectal resection (mucosal and rectal muscle
tube excision with sutured perineal anastomosis). Avoids abdominal
operation, but has increased morbidity due to perineal anastomosis.
• Transabdominal rectopexy (mobilization of the rectum and suturing to
the presacral fascia). May be done via a laparotomy or laparoscopically.
May be just to ventral surface of the rectum with suspensory mesh
(ventral mesh rectopexy). Highest success rate for prevention of
recurrence of prolapse. May be combined with a sigmoid resection if
there is marked associated constipation on transit studies.
Key revision points—anorectal physiology
• The internal anal sphincter is smooth muscle and under involuntary
control of the pelvic autonomic system. Relaxants include nitric
oxide donors (e.g. GTN) and calcium antagonists (e.g. diltiazem).
• The external anal sphincter is skeletal muscle and under voluntary
control of the pudendal nerve (S2, 3, 4). Relaxation (by temporary
partial paralysis) may be achieved by botulinum toxin injection.
• Defecation is a complex sensorimotor process that requires intact
pelvic autonomics, sacral spinal nerves, and pelvic fl oor muscle
function.
407
CHAPTER 11 Colorectal surgery
408
Pilonidal sinus disease
Key facts
Single or multiple sinuses (‘pits’) that exist in the midline of the buttock
clefts. Usually contain hair, inspissated secretions, and debris. Commonest
in men, dark-haired, hirsute people, especially eastern Mediterranean
races. Probably caused by local trauma, causing retention of hairs within
initially normal midline pits. May be precipitated by long periods seated,
e.g. lorry drivers, computer operators.
Pathological features
Typifi ed by chronic infl ammation. Once infl ammation has started, sinuses
often extend and may become interlinked. Lateral tracks may run out into
the neighbouring buttock tissue.
Clinical features
• Irritative features. Intermittent discharge and infl ammation with pain
• Acute sepsis. Acute abscess formation is common with swelling, pain,
and erythema; may discharge spontaneously or may cause fi stulation
with sinuses appearing in the lateral buttock tissue.
• Chronic sepsis. Usually follows unresolved acute sepsis either after
spontaneous discharge or surgical drainage.
Diagnosis and investigations
• Ensure the patient is tested for occult diabetes mellitus.
• Very extensive sinus formation and fi stulation may be assessed by MRI
scanning of the natal cleft and buttocks.
Treatment
Medical/non-surgical
• Shaving of local hairs and washing of accessible cavities (usually by a
partner or family member) may control local symptoms.
• Intermittent courses of antibiotics may be required for septic episodes.
• Formed pilonidal abscess or collection requires surgical drainage
(under local or general anaesthetic).
• Recurrent acute sepsis or persistently symptomatic chronic sepsis
usually requires surgical treatment.
Surgical
Principles of surgical treatments are:
• Excision of all sinus openings.
• Obliteration of all infected or chronically infl amed tissue.
• Obliteration of the natal cleft by fl attening (thought to be most
important in the prevention of recurrence by reducing the risk of
further hair implantation).
PILONIDAL SINUS DISEASE
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Surgical options are:
• Primary excision with laying open of wound and closure by secondary
intention is very rarely used, except in extensive recurrent disease; it
requires daily dressings for many weeks or months.
• Tension-free apposition of the skin edges (may be by lateral fl aps,
e.g. Karyadakis or Bascom procedures, or by plastic surgical fl aps, e.g.
rhomboid, rotational, or Z plasty fl aps).
Key revision points—anatomy of the large bowel
• Main features of large intestine structure:
Complete layer of circular smooth muscle throughout, but •
incomplete bands of longitudinal muscle (taeniae coli) in colon
(complete in rectum).
Fatty appendages along taeniae (appendices epiploicae).•
Folded internal mucosal appearances (haustrations).•
‘Segmented’ external appearances (sacculations).•
• Four main arterial (and lymph node) territories (used for resections):
Ileocolic and right colic arteries (from SMA): last terminal ileal •
loop, caecum, and ascending colon.
Middle colic artery (from SMA): transverse colon up to the •
splenic fl exure.
Left colic (from IMA): splenic fl exure and descending colon.•
Superior rectal artery (from IMA): rectum and upper anal canal.•
• Autonomic nerve supply:
Sympathetic, mainly from greater splanchnic nerves via SMA and •
IMA plexuses.
Parasympathetic, from vagus via SMA and IMA plexus from •
caecum to splenic fl exure and from pelvic parasympathetics (S2,
3, 4) via hypogastric plexuses and retroperitoneal nerves from
splenic fl exure to upper anal canal.
409
CHAPTER 11 Colorectal surgery
410
Fistula-in-ano
Key facts
A fi stula is an abnormal connection of two epithelial surfaces and the two
surfaces joined in fi stula in ano are the anorectal lining and the perineal or
vaginal skin. Very common, especially in otherwise fi t young adults. May
occur in the presence of Crohn’s disease; minor association with obesity
and diabetes mellitus, very rarely due to trauma or ulceration of anorectal
tumours.
Pathological features
Commonest cause is sepsis arising in an anal gland that forces its way out
through the anal tissues to appear in the perianal or in women, vaginal
skin (cryptoglandular theory of fi stula in ano). Often presents initially as
an acute perianal abscess. The tissues through which the track pushes
determines the classifi cation of fi stulas (see Fig. 11.1).
Clinical features
• Acute perianal abscess. Rapid onset of severe perianal or perineal pain.
Swelling and erythema of the perianal skin with fever and tachycardia.
• Recurrent perianal sepsis. Recurrent intermittent sepsis typifi ed by
gradual build-up of ‘pressure’ sensation and swelling in the perianal skin
and eventual discharge of bloodstained purulent fl uid.
• Chronic perianal discharge. Persistent low grade sepsis of the track with
chronic discharge of seropurulent fl uid via a punctum that is usually
clearly identifi ed by the patient.
Diagnosis and investigations
Diagnosis and investigation should aim to confi rm the presence of
a fi stula and identify the course of the track to determine the type of
fi stula:
• Examination of the perineum and rectal examination may reveal a
palpable fi brous track.
• EUA with probing of any external opening to aid identifi cation of the
course of the track.
• Endoanal ultrasound (sometimes with hydrogen peroxide injected into
the track) identifi es the course of the track.
• MRI scanning is probably the most sensitive method of determining the
course of the track and identifying any occult perianal or pelvic sepsis.
• Flexible sigmoidoscopy if associated colorectal disease, e.g. Crohn’s
disease, is suspected.
Treatment
Medical treatment
• Antibiotics may reduce symptoms from recurrent sepsis, but cannot
treat the underlying fi stula.
• Medical treatment of infl ammatory bowel disease may dramatically
reduce symptoms from associated fi stulas.
FISTULA-IN-ANO
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Surgical treatment
Principles of surgical treatment are as follows:
• Drainage of any acute sepsis if present.
• Prevention of recurrent sepsis. Usually by insertion of a loose seton
suture, e.g. silastic sling.
• Low fi stula in ano. Lay open track, remove all chronic granulation
tissue, and allow to heal spontaneously (fi stulotomy); little risk of
impairment of continence due to minimal division of sphincter tissues.
• High fi stula in ano:
Remove fi stula track and close the internal opening (core •
fi stulectomy and endorectal fl ap advancement).
Slowly divide the sphincter tissue between the fi stula and the •
perianal skin (cutting seton); low risk of incontinence.
Fill the fi stula with fi brin glue.•
Rectum
Pelvic
floor
Submucosal
Low
Anus
transphincteric
High
fistulae
Extrasphincteric
Suprasphincteric
High
Sphincter
muscle
Low
transphincteric
Intersphincteric
fistulae
Fig. 11.1 Classifi cation of fi stula-in-ano.
411
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