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Scott R. Steele
Justin A. Maykel
Bradley J. Champagne
Guy R. Orangio
Editors
Complexities in
Colorectal Surgery
Decision-Making and
Management
123
Complexities in Colorectal Surgery
Scott R. Steele • Justin A. Maykel
Bradley J. Champagne • Guy R. Orangio
Editors
Complexities in Colorectal
Surgery
Decision-Making and Management
Editors
Scott R. Steele, MD
Division of Colon and Rectal Surgery
Department of Surgery
Madigan Army Medical Center
Fort Lewis, WA
USA
Justin A. Maykel, MD
Division of Colorectal Surgery
Department of Surgery
UMass Memorial Medical Center
University of Massachusetts Medical School
Worcester , MA
USA
Bradley J. Champagne, MD
Division of Colon and Rectal Surgery
Department of Surgery
Case Western Reserve University
School of Medicine
University Hospitals
Cleveland, OH
USA
Guy R. Orangio, MD
Division of Colon and Rectal Surgery
Department of Surgery
Louisiana State University Health Science Center
LSU School of Medicine
New Orleans , LA
USA
ISBN 978-1-4614-9021-0 ISBN 978-1-4614-9022-7 (eBook)
DOI 10.1007/978-1-4614-9022-7
Springer New York Heidelberg Dordrecht London
Library of Congress Control Number: 2014930571
© Springer Science+Business Media New York 2014
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
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Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the
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under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of publication, neither
the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may
be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (www.springer.com)
Foreword
Fifty years ago, with the publication of Surgery of the Anus, Rectum and Colon , John Goligher
set the modern standard for textbooks of colorectal surgery. Several outstanding textbooks in
the Goligher mold have followed, and a few of these have become classics in their own right.
So it is fair to ask: why one more?
The answer becomes evident with the present work. Complexities in Colorectal Surgery:
Decision-Making and Management in many ways starts where standard texts begin to leave
off: with an up-to-date view of some of the most vexing problems in intestinal surgery. A quick
review of the chapters provides the general idea. It’s not “Diverticular Disease” but
“Diverticulitis: Beyond the Basics;” not “Rectal Cancer” but “Recurrent Rectal Cancer;” not
“The Ileal Pouch” but “Ileal Pouch Complications.” Diffi cult problems such as the failed anastomosis, pelvic bleeding, and chronic pain are addressed head on. There is a strong focus on
technical advances, such as TEMS and TAMIS for the local treatment of rectal cancer and
robotics, SILS and CLER approaches to abdominal surgery. Finally, there is material to address
the diffi cult personal and social aspects of surgery that traditionally receive little or no discussion in textbooks: facing our failures, balancing clinical and research practice, medicolegal and
ethical dilemmas, economic considerations, and knowing when to say “when.”
The editors are to be commended for assembling a truly outstanding roster of authors, each
a recognized authority at the cutting edge of his or her fi eld. As for the editorial team itself,
Scott Steele, Justin Maykel, Brad Champagne, and Guy Orangio are exceptional surgeons and
surgical educators, representative of the new generation of innovative colorectal surgical leaders who stand ready to challenge conventional wisdom and push our fi eld boldly into the
future. With this book, they take a giant step in that direction.
Minneapolis, MN, USA Robert D. Madoff, MD
v
Pref ace
There is a simplicity that exists on the far side of complexity….
–P. Buchanan
Merriam-Webster’s Dictionary defi nes complex as “a whole made up of complicated or
interrelated parts.” For surgeons, this could not be more accurate, as there remains a seemingly
never-ending assortment of complex patient disease processes and complications that permeate
colorectal surgery and precisely illustrate this defi nition. Even when the technical challenges
of surgery are managed successfully, the preoperative evaluation and decision-making can be
demanding, and postoperative functional changes may impact short- and long-term quality of
life. Furthermore, the economic implications of care for the patient, family, and the healthcare
system must be considered.
Despite extensive training and a wealth of clinical experience, surgeons are often consumed
with an internal struggle over how to provide the best patient-centered care and formulate
optimal approaches for complex clinical scenarios. Beyond the simple application of knowledge lie deeper questions about the ideal “next step” in patient management, especially for
those who have experienced postoperative complications. Unfortunately, in many situations
algorithms of care do not exist or are not founded in reliable evidence-based recommendations.
Rather, we rely on experience and pragmatic advice from experts who have spent a career
discerning their “best” approach. Hence, our goal with Complexities is to provide a unique,
practical guide that covers the strategic evaluation, specifi c approaches, and detailed management techniques utilized by expert colorectal surgeons caring for patients with complex
problems.
With Complexities we sought to understand the intricate thought process behind each
author’s proposed approach and treatment strategy. When possible, this involved incorporating
evidence-based recommendations. Our experts also lend their personal insight into situations
where data is sparse, yet their individual but extensive experience becomes the cornerstone of
making sound decisions and optimizing patient outcomes. What is the optimal algorithm for
patients with fecal incontinence with or without a sphincter injury? How do we manage and
time surgery for the patient with metastatic cancer? When do we operate on smoldering diverticulitis? What is the best option for a failing J-pouch or low rectal anastomosis? Surgery is an
art rooted in scientifi c principles. This book attempts to bridge that gap.
Not every surgeon can independently accrue the years and volume of experience that result
from a specialty practice at a high-volume referral center. Therefore, by covering all aspects
from the assessment of risk to the medical and surgical treatment for abdominal, pelvic, and
anorectal disease, the authors focus on the details that make these situations challenging.
Additionally, beyond the clinical aspects of colorectal surgery, we have highlighted aspects
that pertain to the true essence of being a surgeon, from the importance of the fi rst encounter
to the medical-legal, ethical, and economic challenges surgeons face. In these situations, there
is little evidence but abundant practical advice to guide us. Furthermore, while disease and
complications of treatment infl ict a tremendous physical and emotional burden on patients, we
examine something rarely discussed among providers—the psychological and emotional
impact complications have on surgeons, and how they may impact subsequent care. Finally,
vii
viii
we confront one of the most diffi cult personal decisions surgeons will face—knowing when to
say “when”—and dealing with our transition out of clinical medicine.
Since inception, it has been our privilege and pleasure to work with this tremendous gathering of authors, as their unique contributions have come together to make this textbook a reality.
We would like to personally thank each one of them for their invaluable insights. It is our wish
that Complexities serves as a resource for this and future generations of surgeons who fi nd
themselves faced with complex clinical and professional challenges.
Olympia, WA, USA Scott R. Steele, MD
Worcester, MA, USA Justin A. Maykel, MD
Cleveland, OH, USA Bradley J. Champagne, MD
New Orleans, LA, USA Guy R. Orangio, MD
Preface
Acknowledgments
Scott Steele, MD
We would fi rst like to thank our outstanding Developmental Editor, Elektra McDermott, for
her extraordinary efforts in overseeing this edition and ensuring its timely completion and
thoroughness. I personally would like to thank my fellow editors for their tremendous vision
and hard work throughout this entire process, as well as all of my mentors in colorectal surgery
for guiding me and giving me such incredible opportunities. Finally, and most importantly,
thank you to my family for supporting and encouraging me throughout this endeavor.
Justin Maykel, MD
I would like to thank all of the teachers at Tufts Medical School who introduced me to the fi eld
of surgery, the attendings at Beth Israel Deaconess Medical Center who shared their skills and
passion for surgery, and my mentors at the University of Minnesota who helped shape my
independence as a surgeon. Finally, thank you to my family for supporting me through this
entire process.
Bradley Champagne, MD
I would like to thank my mentors at Albany Medical Center and Georgia Colorectal Surgical
Associates for their incredible teaching and patience during my training. I would also like to
thank my wife, Christina, for providing balance in my life and for her exceptional support in
all of my endeavors.
Guy Orangio, MD
I want to express my gratitude and appreciation to Drs. Victor Fazio, Ian Lavery, and David
Jagelman. I had the privilege and honor to be trained by probably the greatest master colon and
rectal surgeons in the world. Thank you for setting a standard as a surgeon, physician, and
professional that I strive toward every day. To all of the fellows that I had the privilege of training at Georgia Colon and Rectal Surgical Associates, you have given me more than I could
have ever given to you. Thank you all.
ix