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388
H. Abcarian and G.R. Orangio
and chronic infection. Finally, occasionally retained rectal
mucosa after a diffi cult pelvic dissection in either UC or CD
will perpetuate purulent drainage and non healing. This will
need to be removed.
Nonoperative Treatment
Key Concept : You do not always need to perform aggressive
surgical revisions and fl aps for chronic wounds . Sometimes
you can start with the nonoperative “ easy ” things that may
lead to closure .
Several tips are worth noting prior to going to the operating room. Aggressive debridement (chemical cauterization,
wet-to-dry dressings, etc.) is important to remove all granulation tissue. Look also for retained foreign material (i.e.,
suture) that may be the source of a chronic wound. If there is
an active fi stula that must be addressed prior to any perineal
reconstruction, especially in patients with CD, institute the
appropriate directed medication or even surgical therapy to
provide adequate closure or drainage. As stated previously,
consider utilization of negative pressure wound care (NPWC/
VAC) in patients with open perineal wounds for both the
acute and chronic settings [ 31 ]. I ( GO ) have utilized these
devices even during the acute phase, with open perineal
wounds and extensive infection; though I agree with Dr.
Abcarian that it is very diffi cult to “keep” a vacuum seal in
this area. If your patient is immobile or has extensive pain
with vacuum device dressing changes, consider the operating room or recovery unit with conscious sedation to allow
for careful inspection of the wound and dressing change. I
must admit that I have been impressed with the early results
when utilized in a contaminated perineal wound. Remember
that the patient is at higher risk of other complications
because of their immobility, whether it is pneumonia, deep
vein thrombosis, or pulmonary embolus, and should have the
proper prophylaxis. I will also limit my utilization of the
VAC wound therapy to 5–7 days. I have no experience with
long-term home usage of this type of wound therapy for
chronic perineal wounds; however, there is some literature
that recommends utilization of VAC therapy following APR
for cancer or pelvic exenteration [ 32 ]. Finally, only to men-
tion the use of hyperbaric oxygen therapy, it has not shown
any statistically signifi cant benefi t in the management of
chronic perineal wounds in patients with CD [ 33 ], but I have
little personal experience.
to fi nd yourself in a situation where you cannot close the
wound and have not properly prepared .
In patients with a COPW, operative debridement of all
granulation and scar tissue must be excised to the level of
bleeding tissue. In some cases you may fi nd a deep presacral
infected space or sinus, and it has been resistant to conventional therapy, and a coccygectomy may be required. This
will allow the tissue to collapse into the sinus tract or defect
in order to facilitate closure. The use of myocutaneous fl aps
in both the acute and the chronic perineal wounds has led to
a multidisciplinary approach to these patients: the primary
surgeon, plastic reconstructive surgeon, and wound ostomy
nurses. You need to each understand the other’s role to ensure
you do not “stray” into problems (i.e., too wide excision and
understand the fl ap boundaries). Plastic surgery will usually
mark the patient prior to the surgery, which will aid in avoiding this error. The three most common myocutaneous fl aps
utilized are the vertical rectus abdominis fl ap (VRAM), gracilis muscle fl aps (GM), and the inferior gluteal artery fl ap
(IGAF) [ 34 – 38 ]. These myocutaneous fl aps have been asso-
ciated with a reduced length of hospital stay and a low perineal wound complication rate [ 34 – 37 ]. Unfortunately the
VRAM fl ap has not been shown to be suitable for laparoscopic APR, with a failure rate of 2–10 % and overall complication rates of 15–22 % [ 39 , 40 ].
Most surgeons can predict in advance a large wound at
completion of major operations and the need for “coverage.”
Female patients with extensive perineal disease involving the
posterior vagina and/or the vulva and who had neoadjuvant
therapy for LRC or patients with ACC who failed therapy or
developed recurrent disease and an APR with posterior vaginectomy with or without vulvectomy are candidates for
myocutaneous fl aps at the initial surgery (Fig. 24.23 ). Many
Operative Management
Key Concept : Anticipate the possibility of large perineal
wounds occurring and get a multidisciplinary team available well in advance . It is better to not need them at all than
Fig. 24.23 Perineal reconstruction with a multidisciplinary approach
(Courtesy of Justin A. Maykel, MD)
24 Complex Pilonidal Disease and Acute and Chronic Perineal Wounds: Point – Counterpoint
389
women will desire vaginal reconstruction because of the
desire to remain sexually active postoperatively, and plastic
surgery will be critical in helping plan this out accordingly.
In the situation when an APR is combined with a posterior
vaginectomy, there is a residual wound that has been radiated, but reconstruction is still desired. The gracilis myocutaneous fl ap is especially suitable for this type of
reconstruction. The well-vascularized muscle is placed in the
defect, and the overlying vaginal mucosa and skin are tailored and sutured in place to form the posterior vaginal wall.
In morbidly obese women with very deep, wide perineal
wounds, bilateral gracilis myocutaneous fl aps may also be
utilized. Of note, the same fl ap may be used in a male patient
by transferring the gracilis muscle to fi ll the defect and the
attached skin to close the cutaneous defect.
Depending on size (both depth and width), location, and
complexity of the perineal wound, it is occasionally possible
to use omental pedicle fl aps in combination with gracilis
muscle or myocutaneous fl aps: gluteus maximus or VRAM
fl aps. Using the VRAM fl ap requires a well-vascularized
rectus abdominis, and it is important that one rectus muscle
is kept intact and you do not utilize both rectus muscles. In
general, one side is usually a site for the stoma. For example,
if a patient had a diverting colostomy in the LLQ and subsequently a coloanal pull-through procedure (coloanal anastomosis) is done, this typically requires a proximal stoma to
protect the anastomosis. You should then ensure that the ileostomy is brought out through the LLQ site in order to maintain the vascularity of the right rectus abdominis muscle.
In the case of a pelvic exenteration needing VRAM fl ap
for perineal wounds, both the colostomy and urostomy
should be placed on the left side and maintain the right rectus
intact for VRAM fl ap. We ( GO / HA ) both agree about the
increased possibility of a peristomal hernia and the need to
relocate the ostomy to the contralateral side or same side
along the rectus abdominis, if needed. However, with the
advent of biologic material, there is less concern regarding
inability to close the abdomen or repair peristomal hernias.
Finally, it is important to note that if the muscle transfer
procedures fail, the result will inevitably be a larger wound
that typically requires prolonged wound care. In many cases,
this often means reverting back to wet-to-dry dressings or
negative pressure therapy. You should remember, however,
that long before wound VAC therapy and the multidisciplinary closures came into play, Dr. Abcarian reported on
perianal wound healing after proctectomy and proctocolectomy. Large wounds left open using wet-to-dry dressing
healed in 12–16 weeks in almost all cases [
25 ]. So a visit to
“back to the future” may be required if all else fails.
For smaller nonhealing chronic perineal wounds, and
those associated with anal stenosis or other perianal processes, a sliding fl ap anoplasty may be required for healing
(Video 24.1 ). Results are generally good, though care is
needed to avoid one that is superfi cial, poorly mobilized, narrow based, and has inadequate blood supply. This is doomed
to fail from the beginning and will simply leave you with a
more complex wound than you or your patient will care for
and one that is extremely diffi cult to manage.
Summary Pearls
There is no doubt that you will be faced with this unfortunate
situation of dealing with chronic nonhealing pilonidal and
perineal wounds if you are practicing colorectal surgery long
enough. Hopefully the tips and tricks we talked about here
will be useful and also point out that there are different
approaches to these wounds. Have realistic expectations, and
ensure your patients and their families do as well. Most
importantly, do not keep trying the same thing over and over
again if it is failing. Never miss out on an opportunity to talk
with someone else or have another colleague examine the
patient when things are not going well. You likely will be
glad you did.
References
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N Engl J Med. 1953;249(23):926–30.
2. Mayo OH. Observations on injuries and disease of rectum. London:
Burgess and Hill; 1833. p. 45–6 (Quoted from da Silva JH. Pilonidal
cyst: cause and treatment. Dis Colon Rectum 2000;43:1146–56).
3. Hodge RM. Pilonidal sinus. Boston Med Surg J. 1880;103:485–6
(Quoted from da Silva JH. Pilonidal cyst: cause and treatment. Dis
Colon Rectum. 2000;43:1146–56).
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6. Urhan MK, Kucukel F, Topgul K, Ozer I, Sari S. Rhomboid excision and Limberg fl ap for managing pilonidal sinus: results of 102
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new operation leading to cures. Arch Surg. 2002;137:114650.
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advancement fl ap. Dis Colon Rectum. 2009;52(12):2036–40.
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Proctol Soc. 1936;36:166.
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H. Abcarian and G.R. Orangio
14. Gabriel WB. The principles and practice of rectal surgery.
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perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis
Colon Rectum. 2005;48:438–43.
17. Gazzaz GE, Kiran RP, Lavery I. Wound complications in rectal cancer patients undergoing primary closure of the perineal wound after
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Bleday R. Risk factors for perineal wound complications following
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19. Nilsson PJ, Svensson C, Goldman S, Glimelius B. Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg. 2002;
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26. Alpsan K, Singh A, Ahmad A. Clinical comparison of perineal
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27. Lubbers Evert JC. Healing of the perineal wound after proctectomy
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Easley K. Management of the perineal wound after rectal excision
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29. Turnbull RB, Fazio V. Advances in the surgical technique of ulcerative colitis surgery: endoanal proctectomy and two-directional
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30. Lyttle JA, Parks AG. Intersphincteric excision of the rectum.
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31. Schaffzin DM, Douglas JM, Stahl TJ, Smith LE. Vacuum-assisted
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B, Consentino B, Sastre B. Advantage of vacuum assisted closure
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Quandalle P, Cortot A. Hyperbaric oxygenation in severe perineal
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34. Chan S, Miller M, Ng R, Ross D, Roblin P, Carapeti E, Williams
AB, George ML. Use of myocutaneous fl aps for perineal closure
following abdominoperineal excision of the rectum for adenocarcinoma. Colorectal Dis. 2009;12:555–60.
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ML. Perineal reconstruction after abdominoperineal excision using
inferior gluteal artery perforator fl aps. Br J Surg. 2012;99:584–8.
36. Buchel EW, Finical S, Johnson C. Pelvic reconstruction using rectus abdominis musculocutaneous fl aps. Ann Plast Surg. 2004;52:
22–6.
37. Chessin DB, Hatley J, Cohen AM, et al. Rectus fl ap reconstruction
decreases perineal wound complications after pelvic chemoradiation: a cohort study. Ann Surg Oncol. 2005;12:14–110.
38. Lefevre JH, Parc Y, Kemeis S, et al. Abdomino-perineal resection
for anal cancer: impact of vertical rectus abdominis myocutaneous
fl ap on survival, recurrence, morbidity and wound healing. Ann
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Surg. 2006;118:1389–400.
Part V
Special Situations
Joshua I. S. Bleier and Robert D. Fry
Key Points
• Preoperative risk assessment is based on identifying
key cardiac and other comorbid risk factors.
• Management of common anorectal problems is different in the elderly because of the likelihood of
relative sphincter dysfunction.
• Certain abdominal diagnoses are more common in
the elderly and appropriate management is based on
prompt diagnosis and effective management.
• Colonoscopy screening guidelines are null after age
85.
• Informed consent is more complex in the elderly,
and patient autonomy, competency, and support
systems must be considered.
• Laparoscopic surgery is safe and appropriate for
select colorectal operations in the elderly.
Key Concept : George Burns once said , “ You can ’ t help get-
ting older , but you don ’ t have to get old .” Aging is most often
defi ned objectively by years since birth , but subjectively ,
physiologically , and medically , it is more often a function of
“ how old you feel .”
J. I. S. Bleier , MD, FACS, FASCRS (*)
Division of Colon and Rectal Surgery, Department of Surgery ,
Pennsylvania Hospital/Hospital of the University of Pennsylvania,
University of Pennsylvania , 8th and Walnut, 20th Floor ,
Philadelphia , PA 19106 , USA
e-mail: joshua.bleier@uphs.upenn.edu
R. D. Fry , MD, FACS, FASCRS
Division of Colon and Rectal Surgery, Department of Surgery ,
Pennsylvania Hospital, University of Pennsylvania ,
8th and Walnut, 20th Floor , Philadelphia , PA 19106 , USA
e-mail: robert.fry@uphs.upenn.edu
To a large degree, management of colorectal issues,
whether benign or malignant, are pathology-driven. In most
instances, colon cancers that are resectable should be
resected; metastatic disease is an indication for adjuvant
therapy; multiply recurrent attacks of diverticulitis indicate
resection; mixed hemorrhoids refractory to the best conservative management may require hemorrhoidectomy; hematochezia or a change in bowel habits require endoscopic
evaluation; screening colonoscopy reduces the risk of colon
cancer; and low rectal cancers that don’t involve the sphincters may be treated by sphincter-sparing operations, including colo-anal anastomoses. However, you as the surgeon
know that indications are only part of the decision process.
Pathology alone may provide the indication for surgery, but
not necessarily the decision for it. Patient factors must be
taken into consideration. Every assessment of the potential
surgical patient takes into account fi tness for surgery, as well
the assessment of tolerating the outcome. But where does
age play into this equation? Age is a nonspecifi c factor that
may provide predictive information about how well a patient
will tolerate a procedure. In general, the older the patient, the
more comorbidities, the higher the risk for healing problems,
the worse the baseline continence and sphincter function,
and the higher the risk for cardiovascular disease.
Chronological age is indisputable, but physiologic age is
variable. Consider the unfortunate condition of progeria, in
which children succumb to the physiologic maladies of
advanced age such as heart attack, stroke, and atherosclerotic
disease – and rarely live past the age of 13. Now contrast that
with the 100-year-old man who completed a marathon in
Toronto in 2011 (although it took him 8 h to do it!). The concept of physiologic age supersedes that of chronologic age in
the assessment of the elderly patient. Determination of the
physiologic age of the patient is an amalgam of all of the
physiologic parameters that will be affected by the operation
The online version of this chapter (doi: 10.1007/978-1-4614-9022-
) contains supplementary material, which is available to
7_25
authorized users.
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_25, © Springer Science+Business Media New York 2014
393
394
J.I.S. Bleier and R.D. Fry
and its recovery. Prior dogma dictating age alone as a relative
contraindication to surgery has been replaced by determination of fi tness, a proxy for physiologic age. Advances in perioperative management have demonstrated that mere
chronological age does not directly determine fi tness and the
ability to recover from surgery; it merely informs us of the
increased possible risks, and overall fi tness for intervention
is determined by factors that are projected to be affected by
the surgery. In this chapter, we will deal with these issues and
the factors that affect them.
Key Concept : Rather than relying on age , use a systems -
based evaluation to determine a perioperative risk profi le for
your patient .
The World Health Organization has broadly defi ned
“elderly” as any patient who is eligible for pension benefi ts.
However, given the varied standards across the world, anyone over the age of 50 may be loosely defi ned as “elderly.”
In the USA, this defi nition is likely inappropriate, as the
retirement age is 65, and health risks do not substantially
increase in the 6th decade of life. Nevertheless, most screening standards do change in the age group over 50. After 50, it
is recommended that all patients receive a preoperative chest
X-ray and laboratory work. There is no mandatory age indicating the requirement for preoperative cardiovascular testing; rather, this decision is the responsibility of the operating
surgeon.
undergo evaluation and treatment before noncardiac surgery
Condition Examples
Unstable coronary syndromes Unstable or severe angina (CCS
class III or IV)
Recent MI
Decompensated heart failure
(NYHA functional class IV;
worsening or new-onset HF)
Signifi cant arrhythmias High-grade AV block
Mobitz II AV block
Third-degree AV block
Symptomatic ventricular
arrhythmias
Supraventricular arrhythmias
(including atrial fi brillation) with
uncontrolled ventricular rate
(HR > 100 bpm at rest)
Symptomatic bradycardia
Newly recognized ventricular
tachycardia
Severe valvular disease Sever aortic stenosis (mean pressure
gradient greater than 40 mmHg,
aortic valve area < 1.0 cm
symptomatic)
Symptomatic mitral stenosis
(progressive dyspnea on exertion,
exertional presyncope, or HF)
Adapted with permission from Fleisher et al. [
of Cardiology
CCS Canadian Cardiovascular Society, HF heart failure, HR heart rate,
MI myocardial infarction, NYHA New York Heart Association
a
May include stable angina in patients who are unusually sedentary
b
The American College of Cardiology National Database Library
defi nes recent MI as more than 7 days but less than or equal to 1 month
(within 30 days)
a
b
2
, or
1 ] © American College
Key Concept : Appropriate preoperative risk assessment is
the surgeon ’ s responsibility when planning for surgery of
any kind . This is even more important in the elderly patient
given the increased incidence of signifi cant comorbidities
associated with age .
The most recent American Heart Association guidelines
[ 1 ] help to delineate the approach to risk stratifi cation. An
appropriate history and physical examination provides information that will identify risk factors. The initial decision process should be aimed at identifying any cardiac condition
that would increase the risk of an adverse cardiac event in the
perioperative period. In general, any patient with active cardiac disease, such as unstable coronary syndrome, decompensated or worsening congestive heart failure (CHF),
signifi cant arrhythmia, or signifi cant valvular disease should
receive cardiology evaluation and baseline cardiac testing
25.1 ) [ 1 ].
(Table
In the absence of serious comorbidities, a rough assessment of exercise tolerance may be all that is needed to determine if further testing should be pursued. This is especially
true when taken in context of the type of surgery you are
performing. Anorectal surgery is considered a low-risk operation, regardless of anesthetic technique, and elective
abdominal operations are considered intermediate risk operations. Age, as a sole criterion, defi nes only the need for
EKG and chest X-ray for patients over 50. Advanced age
alone is not an indication for further cardiac testing. In fact,
for patients with good exercise tolerance (>4 METS)
(Table
25.2 ) [ 2 ], further testing for any elective procedure is
usually unnecessary.
Other signifi cant clinical risk factors should be assessed.
A history of ischemic heart disease, compensated or prior
CHF, diabetes mellitus, renal insuffi ciency, or cerebrovascular disease all represent signifi cant comorbidities that may
require preoperative evaluation.
Exercise tolerance is an excellent overall assessment of
fi tness. In the setting of good exercise tolerance, even with
25 Considerations in the Elderly
Metabolic equivalent
(MET) Activity
1 MET Eat, dress, use the toilet
Walk indoors around the house
Walk a block or 2 on level ground at
2–3 mph?
4 MET Do light housework (dusting, washing
dishes)
Climb a fl ight of stairs or walk up a hill?
Walk on level ground at 4 mph?
Run a short distance
Do heavy housework (scrubbing fl oors,
lifting/moving furniture)
Participate in moderate recreational
activities (golf, bowling, dancing, double
tennis, baseball or football catch)
>10 METS Participate in strenuous sports (swimming,
single tennis, football, basketball, skiing)
Adapted with permission from Fleisher et al. [
of Cardiology
1 ] © American College
multiple clinical risk factors described above, intermediate
risk surgery can often be undertaken with acceptable risk.
Perioperative heart rate control with beta-blockade should be
considered mandatory in anyone with any of the above risk
factors, since this has been shown to reduce cardiac morbidity and mortality [ 3 ].
When a patient has some of these other signifi cant comorbidities, specifi c workup may be indicated as per the AHA
guidelines [ 2 ]:
The presence of restrictive or obstructive pulmonary disease
signifi cantly increases the risk of perioperative pulmonary
complications. In these cases, preoperative pulmonary testing to determine volume and diffusion capacity, response to
bronchodilators, and a baseline blood gas will help guide
postoperative therapy.
This is the most common metabolic disease associated with
advanced age and is often associated with coronary disease.
The presence of insulin-dependent DM increases the risk of
perioperative myocardial ischemia and heart failure. Careful
attention (both intraoperatively and postoperatively) to glucose management with insulin infusions and tight glycemic
control has been found to signifi cantly reduce postoperative
wound infection in CABG patients, and this paradigm can be
applied to major abdominal surgery.
Renal failure is associated with an increased risk of perioperative cardiac morbidity [ 4 ]. In addition, preoperative levels
395
of creatinine >1.5–2 mg/dl is associated with an increased
risk of postoperative renal failure, cardiac complications,
and increased mortality.
Preoperative anemia can impose cardiac stress, worsen ischemia, and exacerbate preexisting CHF. In one study looking
at patients undergoing prostate and major vascular surgery, a
hematocrit <28 % was associated with an increased risk of
perioperative ischemia and postoperative complications.
Key Concept : In any patient with anorectal complaints , base-
line function of the sphincter complex should be taken in to
account when considering surgical options .
Examining and documenting sphincter tone and determining whether alterations in continence are present are
imperative when evaluating older patients with anorectal
complaints. Laurberg showed that in the elderly, there is signifi cantly decreased baseline sphincter tone [ 5 ], decreased
rectal sensation and distensibility, and increased perineal
laxity in women [ 6 ]. Unfortunately, there has been no data
showing any consistently reproducible predictive factors for
postoperative changes in continence based on preoperative
examination or physiologic testing.
Yet, there are some major points you should keep in mind
when evaluating older patients with anorectal complaints:
(a) When considering hemorrhoidectomy in the elderly, as
with younger patients, initial management should be
conservative when possible.
(b) In the elderly, anorectal complaints are often centered on
mucus seepage and soilage. Though dietary changes,
bowel management (i.e., fi ber, Imodium), and skin protection are successful fi rst-line treatments, in most cases,
patients with prolapse or large hemorrhoids will likely
benefi t from surgery.
(c) In our experience, the best predictor of postoperative
function after surgery is preoperative function.
(d) A careful history, with special attention to bowel habits
and continence, is crucial. If preoperative soilage or
seepage is the major complaint, it is important to ascertain whether this is due to mucosal prolapse or true
sphincter dysfunction.
Key Concept : FI occurs much more commonly than thought .
While a full evaluation is helpful , most often by simply focus-
ing on medical management in the elderly patient , you will
provide the most benefi t .
396
J.I.S. Bleier and R.D. Fry
Fecal incontinence (FI) is a socially disabling disorder,
which is far more prevalent in the elderly. Estimates at the
rate of FI ranged from 2 to 17 % in a community setting, but
these are likely underreported. A more recent HMOpopulation based study found reported rates of FI as high as
36 %. In the elderly, rates of FI are signifi cantly higher, especially in the nursing home setting, where rates range from
33 % to as high as 65 % [
7 ].
Management of FI depends on the etiology. A complete
history, focusing on the details of bowel habits, diet and medication, as well as prior anorectal surgical and obstetric history,
will often elucidate the etiology of the disorder and guide
treatment. In the elderly, the differential diagnosis is quite
long, including cognitive and neurologic diseases, chronic
constipation with overfl ow, senescent physiologic changes,
rectal prolapse, or iatrogenic or obstetric injury. Treatment is
almost always geared towards the underlying condition, and
optimization of bowel habits is crucially important in this
population. It is also important to protect the perineal skin, as
seepage of intestinal contents can often lead to severe maceration and breakdown if not properly attended too.
Key Concept : Procidentia , or true rectal prolapse , when
encountered as an etiology for FI , is probably best treated
surgically with a perineal approach .
Oftentimes, patients with FI will have diminished sphincter control due to long-standing (and previously unreported
and undiagnosed) full-thickness rectal prolapse (Fig. 25.1 ).
We advocate a perineal proctectomy in the elderly as this is
well tolerated and avoids the morbidity of an abdominal
operation (Fig. 25.2 ). In patients with signifi cant comorbidi-
ties, it can even be performed under a spinal anesthetic or in
the left lateral decubitus position to minimize intraoperative
complications.
Key Concept : SNS has an evolving role in FI for failed medi-
cal management and with its good preliminary results and
trial period to confi rm effi cacy , may soon be a fi rst - line treatment modality in this cohort .
Ultimately, symptoms of FI should be managed conservatively when possible. Considerations for surgery in the elderly
have changed signifi cantly in recent times. Historically, once
conservative measures and biofeedback fail, and the patient
was considered a suitable candidate for surgery, few options
remained. Often, in men with profound FI, in the absence of a
sphincter injury, fecal diversion remained the only option. In
women with known sphincter injuries, sphincteroplasty was
an option. However, this is a signifi cantly morbid procedure
with a diffi cult recovery and has fairly poor long-term results.
More recently, the paradigm has undergone a signifi cant shift.
Sacral nerve stimulation, a modality that has had a decade of
known effi cacy in urinary incontinence, was recently approved
for use by the FDA for fecal incontinence (Fig. 25.3 ). The
indication included fecal incontinence in the presence of
known sphincter injuries of up to 60°. Although the effi cacy of
SNS in treating FI has been known since it has been used for
urinary incontinence for more than a decade, it was not until
2011 when the FDA fi nally approved FI as an independent
indication for treatment. The initial studies showed signifi cant
success rates, defi ned as at least a 50 % reduction in fecal
incontinence symptoms, in 60–100 % of patients. In the initial
publication of the SNS study group, 133 patients underwent
test simulation with a 90 % success rate. Even at 3 years of
follow-up, 86 % of patients reported a greater than 50 %
reduction in the number of incontinent episodes per week, and
perfect continence was achieved in 40 % of the patients [ 8 ].
There are several advantages of this new approach – it is
low risk, with a reported infection rate of less than 10 %, and
no major morbidities reported. It works even in patients with
sphincter defects, so that there is no further need to subject
them to high risk of morbidity and poor long-term results with
sphincteroplasty. Finally, because there is a test phase built
into the implantation process, patients will know whether or
not it works before they ever have a permanent implant placed.
We suspect that this will have a long-term effect on the paradigm of treatment for fecal incontinence and that sacral nerve
stimulation will become fi rst-line therapy after conservative
measures and behavioral modifi cation have failed.
Ultimately, although not likely greeted warmly, you
should always consider diversion as an option for patients
nonresponsive to more conservative therapies that present
with more severe leakage.
25 Considerations in the Elderly
sacral level
Key Concept : With the increasing availability and expertise
in minimally invasive approaches to more common colorectal disease processes , an abdominal approach can be
performed with minimal morbidity , faster return to preoperative functional status , and improved quality of life .
397
Key Concept : Elderly patients without signifi cant comorbidities can be managed similar to younger patients , including
nonoperative treatment , though colostomy may often be the
best option for those with poor baseline continence .
Recurrent diverticulitis has traditionally been treated
with a dogmatic approach, based on few early data in the
pre- interventional radiology era, without the benefi t of modern antibiotics, critical care management, and advanced
imaging techniques [ 9 ]. The last decade has seen a major
paradigm shift in the management of recurrent diverticulitis.
Newer approaches, based on the effectiveness of interventional radiology techniques and modern antibiotics, have
demonstrated that in many cases, nonoperative management
is appropriate. Newer reports have shown effi cacy of innovative management with peritoneal lavage, as well as the
safety of more prolonged antibiotic management for recurrent attacks. In the elderly, this may be important considering the signifi cant morbidity associated with an abdominal
operation. A review of patients treated by surgery demonstrated that if an emergent operation was done, it was usually required for the fi rst attack [ 10 ]. In the elderly, the risk
of mortality with emergent surgery for diverticulitis is signifi cant. In octogenarians, the risk of mortality is increased
up to sixfold [ 11 , 12 ]. Complicated diverticulitis, especially
an attack that requires either prolonged hospitalization for
parenteral antibiotics or interventional radiologic drainage,
is still an indication for elective surgery once the patient has
recovered. This allows the surgeon the opportunity to optimize the patient for surgery based on the above-stated
guidelines from the AHA. It is important for these patients
to also have a preoperative colonoscopy to rule-out synchronous pathology. We still advocate operative intervention in
the setting of recurrent attacks that are increasing in frequency or for symptoms that do not completely resolve.
However, there is no set number of attacks that mandate
intervention.
From a functional standpoint, although it is important to
consider changes in bowel habits after resection, there should
be little long-term signifi cant effects on continence after sigmoid resection. It is important to ensure that the distal resection margin is at the proximal rectum to minimize the risk of
recurrence. In elderly patients with compromised sphincter
function or prior pelvic surgery, consideration should be
given to fashioning a permanent colostomy. Given the higher
incidence of signifi cant comorbidities with advancing age,
the use of diverting ileostomy after primary anastomosis
should be considered, as this offers protection of a distal
anastomosis and may avoid the signifi cant morbidity of a
second major abdominal operation needed to close a
colostomy.
398
J.I.S. Bleier and R.D. Fry
W. Brian Sweeny, MD)
such patients would benefi t from further treatment [
15 ].
When a resection will result in the high morbidity associated
with abdominal perineal resection, more consideration is
given to watchful waiting in these cases in the elderly. We
wait with great interest the results of the recent ACOSOG
Z6041 trial looking at neoadjuvant chemoradiation followed
by transanal excision for T2 rectal cancers [
16 ].
Along these same lines, there should be increased consideration for avoiding major colon resections for advanced
polyps with the use of advanced endoscopic techniques such
as endoscopic mucosal resection (EMR) (Video 25.1 ,
Courtesy of Conor Delaney, MD) as well as the possibility of
laparoscopic assisted-polypectomy. These modalities allow
the possibility for avoiding unnecessary segmental colectomy. Similarly, in cases of large defi ant polyps in the elderly
patient with a poor operative risk, consideration should be
given to repeated debulking procedures rather than radical
resection. These discussions need to be fl eshed out with the
patient, and in the case of the elderly patient with the possibility of poor comprehension, it is important to make sure
family is involved and to identify the appropriate healthcare
proxy, so that all parties understand the reason for the decision and the risk-benefi t ratio is well explained.
Key Concept : Considerations for proctectomy in the elderly
must take into account the profound functional changes that
accompany the operation . The appropriate indications for
rectal resection for malignancy do not change based on age ,
but we must not place restoration of intestinal continuity as
paramount .
In patients who have early rectal cancers, in whom primary operative therapy is indicated, strong consideration
should be given to the wisdom of a low rectal anastomosis.
The low anterior resection syndrome may result in signifi cant alterations in bowel function, and in the elderly patient
with borderline sphincter function, a low anastomosis may
essentially create a perineal colostomy. In these cases, we
recommend a permanent colostomy, as this will allow for
more satisfactory bowel control. In the setting of locally
advanced or node-positive malignancy (Fig. 25.4 ), the effect
of radiation on the sphincter will dramatically increase the
risk of postoperative continence disturbances. There is a
well-established deleterious effect on sphincter function as a
result of radiation [ 13 ], so alternative approaches should be
considered. Local excision for early rectal malignancies may
be a reasonable option with acceptable local and long-term
recurrence rates. The use of transanal endoscopic microsurgery (TEM) has been shown to signifi cantly increase the
chance of cure after local resection alone in early rectal cancer [
14 ]. It is becoming evident that some rectal cancers
treated by chemoradiation will have a complete clinical
response – and it becomes a matter of judgment as to whether
Key Concept : In the elderly , the incidence of volvulus is sig-
nifi cantly increased , and appropriate and timely diagnosis
and management can make a signifi cant impact at minimizing complications and preserving function .
Volvulus can present with a wide variety of symptoms in
the elderly patient, ranging from mild abdominal pain and
constipation to abdominal distension, obstipation, and sepsis. Prompt diagnosis of volvulus can usually be made by
abdominal plain fi lm (Fig. 25.5a, b ) or CT scan in the elderly
patient who presents with symptoms of large bowel obstruction. In sigmoid volvulus, the diagnosis on CT is usually evident, and on plain fi lm, the characteristic “bent inner-tube”
sign is pathognomonic. Initial management should be resuscitative, but with expeditious proceeding to a decompressive
procedure, either via rigid or fl exible sigmoidoscopy. Once
this is accomplished, a large-bore rectal tube or chest tube
should be placed to prevent immediate recurrence. Once the
large bowel has been decompressed, plans should be made
for sigmoid resection at the same hospitalization. Effective
decompression will give the surgeon time to perform risk
assessment and medical optimization. At the time of operation, resection of the redundant sigmoid should be done
expeditiously, with the decision for reanastomosis made with
assessment of risk and quality of life issues.
Cecal volvulus is also more common in the elderly,
although not as common as sigmoid volvulus. The diagnosis
is made, either on CT scan, on plain fi lm showing
the characteristic “coffee-bean” sign. If the patient is stable,