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COLORECTAL SURGERY

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A Companion to Specialist Surgical Practice

Series Editors

O. James Garden Simon Paterson-Brown

COLORECTAL SURGERY

SIXTH EDITION

Edited by

Sue Clark

MA MD FRCS(Gen Surg) EBSQ(Coloproctology)

Consultant Colorectal Surgeon, St Mark's Hospital, Harrow; Adjunct Professor of Surgery, Imperial College, London, UK

For additional online content visit ExpertConsult.com

Edinburgh London New York Oxford Philadelphia St Louis Sydney 2019

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First edition 1997 Second edition 2001 Third edition 2005 Fourth edition 2009 Fifth edition 2014 Sixth edition 2019

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

ISBN: 978-0-7020-7243-7

Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

Content Strategist: Laurence Hunter Content Development Specialist: Lynn Watt Project Manager: Umarani Natarajan Design: Miles Hitchen Illustration Manager: Nichole Beard Illustrator: MPS North America LLC

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Series Editors’ preface

The Companion to Specialist Surgical Practice series has now come of age. This Sixth Edition takes the series to a different level since it was first published in 1997. The intention from the outset was to ensure that we could support the educational needs of those in the later years of specialist surgical training and of consultant surgeons in independent practice who wished for contemporary, evidence-based information on the subspecialist areas relevant to their general surgical practice. Although there still seems to be a role for larger reference surgical textbooks, and having contributed to many of these, we appreciate that it is difficult for them to keep pace with changing surgical practice.

This Sixth Edition continues to keep abreast of the increasing specialisation in general surgery. The rise of minimal access surgery and therapy, and the desire of some subspecialities, such as breast and vascular surgery, to separate away from 'general surgery' may have proved challenging in some countries. However, they also underline the importance for all surgeons of being aware of current developments in their surgical field. This series as a consequence continues to place emphasis on the need for surgeons to deliver a highquality emergency surgical practice. The importance of evidence-based practice remains throughout, and authors have provided recommendations and highlighted key resources within each chapter. The ebook version of the textbook has also enabled improved access to the reference abstracts and links to video content relevant to many of the chapters.

We have recognised in this Sixth Edition that new blood is required to maintain the vitality of content. We are indebted to the volume editors, and

contributors, who have stood down since the last edition and welcome the new leadership on several volumes. The contents have been comprehensively updated by our contributors and editorial team. We remain grateful for the support and encouragement of Laurence Hunter and Lynn Watt at Elsevier. We trust that our original vision of delivering an up-to-date affordable text has been met and that readers, whether in training or independent practice, will find this Sixth Edition an invaluable resource.

We are grateful to Kathryn Rigby and Jonathan Michaels who wrote the guidelines on Evidencebased Practice in Surgery for previous editions of the series. They have been well received and have been retained for this new edition in order to help guide readers in their assessment of the various levels of evidence discussed in each chapter.

O. James Garden, CBE, BSc, MBChB, MD, FRCS (Glas), FRCS(Ed), FRCP(Ed), FRACS(Hon), FRCSC (Hon), FACS(Hon), FCSHK(Hon), FRCSI(Hon), FRCS(Engl)(Hon), FRSE Regius Professor of Clinical Surgery, Clinical Surgery, The University of Edinburgh and Honorary Consultant Surgeon, Royal Infirmary of Edinburgh, Edinburgh, UK

Simon Paterson-Brown, MBBS, MPhil, MS, FRCS(Ed), FRCS(Engl), FCSHK, FFST(RCSEd) Honorary Clinical Senior Lecturer, Clinical Surgery, The University of Edinburgh and Consultant General and Upper Gastrointestinal Surgeon, Royal Infirmary of Edinburgh, Edinburgh, UK

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vii

Editors’ preface

Colorectal surgery continues to evolve, as has this Sixth Edition. In particular, minimally invasive techniques are now part of the repertoire of the majority of colorectal surgeons; rather than being covered in a distinct chapter, this aspect of surgery is now incorporated in the relevant chapters, mirroring the development of surgical practice.

The running order has been changed to provide a more logical flow, and separate chapters have been introduced on colon cancer and on advanced and recurrent colorectal cancer. New techniques, including complete mesocolic excision, transanal TME, TAMIS and LIFT, are covered. Links to videos of procedures have been added for the first time, and will complement the written descriptions and diagrams.

A number of new authors have joined the team, and have helped to ensure that the content is up to date. The aim has been to be clear, concise, authoritative and contemporary, and to emphasise the underlying evidence base. This is achieved using clearly signposted 'expert opinion' (one tick)

and 'strong recommendation' (two tick) panels, together with brief descriptions of the key papers.

This volume provides more than enough information for those preparing for general and colorectal surgical examinations, and to support those in consultant practice. Each print volume has access to the accompanying ebook version which should enhance the overall experience, and ensure that it is enjoyable to read and to use.

Acknowledgements

The editor would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition would not have been possible. Grateful thanks also to the retiring volume editor of all the previous editions, Robin K.S. Phillips, who did a superb job in developing this volume to its current standard.

Sue Clark

Harrow, Middlesex

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Evidence-based practice in surgery

Critical appraisal for developing evidence-based practice can be obtained from a number of sources, the most reliable being randomised controlled clinical trials, systematic literature reviews, metaanalyses and observational studies. For practical purposes three grades of evidence can be used, analogous to the levels of ‘proof’ required in a court of law:

1. Beyond all reasonable doubt. Such evidence is likely to have arisen from high-quality randomised controlled trials, systematic reviews or high-quality synthesised evidence such as decision analysis, cost-effectiveness analysis or large observational datasets. The studies need to be directly applicable to the population of concern and have clear results. The grade is analogous to burden of proof within a criminal court and may be thought of as corresponding to the usual standard of ‘proof’ within the medical literature (i.e. P <0.05).

2. On the balance of probabilities. In many cases a high-quality review of literature may fail to reach firm conclusions due to conflicting or inconclusive results, trials of poor methodological quality or the lack of evidence in the population to which the guidelines apply. In such cases it may still be possible to make a statement as to the best treatment on the ‘balance of probabilities’. This is analogous to the decision in a civil court where all the available evidence will be weighed up and the verdict will depend upon the balance of probabilities.

3. Not proven. Insufficient evidence upon which to base a decision, or contradictory evidence.

Depending on the information available, three

grades of recommendation can be used:

a. Strong recommendation, which should be

followed unless there are compelling reasons to act otherwise.

b. A recommendation based on evidence of

effectiveness, but where there may be other factors to take into account in decisionmaking, for example the user of the guidelines may be expected to take into account patient

preferences, local facilities, local audit results or available resources.

c. A recommendation made where there is no

adequate evidence as to the most effective practice, although there may be reasons for making a recommendation in order to minimise cost or reduce the chance of error through a locally agreed protocol.

Evidence where a conclusion can be reached ‘beyond all reasonable doubt’ and therefore where a strong recommendation can be given.

This will normally be based on evidence levels:

• Ia. Meta-analysis of randomised controlled trials

• Ib. Evidence from at least one randomised

controlled trial

• IIa. Evidence from at least one controlled study

without randomisation

• IIb. Evidence from at least one other type of quasi-

experimental study.

Evidence where a conclusion might be reached ‘on the balance of probabilities’ and where there may be other factors involved which influence the recommendation given. This will normally be based on less conclusive evidence than that represented by the double tick icons:

• III. Evidence from non-experimental descriptive

studies, such as comparative studies and case– control studies

• IV. Evidence from expert committee reports or

opinions or clinical experience of respected authorities, or both.

Evidence that is associated with either a strong

recommendation or expert opinion is highlighted in

the text in panels such as those shown above, and is distinguished by either a double or single tick icon, respectively. The references associated with doubletick evidence are listed as Key References at the end of each chapter, along with a short summary of the paper's conclusions where applicable. The full reference list for each chapter is available in the ebook.

The reader is referred to Chapter 1, ‘Evaluation

of surgical evidence’ in the volume Core Topics in General and Emergency Surgery of this series, for a more detailed description of this topic.

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Contributors

Omer Aziz, MBBS, BSc(Hons), DIC, PhD, FRCS

Consultant Colorectal, General, and Laparoscopic Surgeon, Colorectal and Peritoneal Oncology Centre; Honorary Senior Lecturer, The University of Manchester, Manchester, UK

John Bunni, MBChB(Hons), DipLapSurg, FRCS [ASGBI Medal]

Consultant Colorectal and General Surgeon, Royal United Hospitals Bath NHS Foundation Trust, Bath; Honorary Lecturer, Cardiff University, Cardiff, UK

Sue Clark, MA, MD, FRCS(Gen Surg), EBSQ(Coloproctology)

Consultant Colorectal Surgeon, St Mark's Hospital, Harrow; Adjunct Professor of Surgery, Imperial College, London, UK

Eric J. Dozois, MD, FACS, FACRS

Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA

Anton V. Emmanuel, BSc, MD, FRCP

Department of Gastroenterology (GI Physiology), University College London, UK

Nicola S. Fearnhead, BMBCh, FRCS, DM

Consultant Colorectal Surgeon, Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK

Pasquale Giordano, MD, FRCS

Consultant Surgeon, Department of Colorectal Surgery, Royal London Hospital; Honorary Senior Lecturer Queen Mary University London, London, UK

Simon Gollins, BMBCh, MA, DPhil, MRCP, FRCR

Consultant Clinical Oncologist and Oncology Clinical Director, North Wales Cancer Treatment Centre, Rhyl, UK

Gianpiero Gravante, MBBS, MD, PhD

Surgical Registrar, Colorectal Surgery, Leicester Royal Infirmary, Leicester, UK

Adam Haycock, MBBS, MRCP, BSc, MD

Wolfson Unit for Endoscopy, St Mark's Hospital, London, UK

David J. Humes, BSc, MSc, MBBS, PhD, FRCS

Associate Professor of Surgery, Nottingham Digestive Diseases Biomedical Research Centre, University of Nottingham, Nottingham, UK

Scott R. Kelley, MD, FACS, FASCRS

Assistant Professor of Surgery, Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA

Robin Kennedy, MS, FRCS

Consultant Colorectal Surgeon, StMark's Hospital, Harrow; Adjunct Professor of Surgery and Cancer, Imperial College, London, UK

Andrew Latchford, BSc(Hons), MBBS, FRCP,MD

Consultant Gastroenterologist, St Mark’s Hospital, Harrow, UK

Paul-Antoine Lehur, MD, PhD

Professor, Digestive and Endocrine Surgery, University Hospital, Nantes, France

Brendan J. Moran, MBBCh, FRCS, FRCSI, MCh

Consultant Colorectal Surgeon, Hampshire Hospitals Foundation Trust, Basingstoke, UK

Robin K.S. Phillips, MBBS, MS, FRCS

Professor of Colorectal Surgery, Imperial College London; Consultant Colorectal Surgeon, St Mark's Hospital, Harrow, UK

Eanna Ryan, MBBCh, BAO, MD Candidate

Surgical Professorial Unit, St Vincent’s University Hospital, Dublin, Ireland

Alexis M.P. Schizas, BSc, MBBS, MSc, MD, FRCS(Gen Surg)

Consultant Colorectal Surgeon, Guy's and StThomas' Hospitals, London, UK

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xiii

Contributors

John H. Scholefield, MBChB, FRCS, ChM (Distinction)

Professor of Surgery, Head of Division, Division of GI Surgery, University Hospital, Nottingham, UK

David Sebag-Montefiore, MBBS, FRCP, FRCR

Professor of Clinical Oncology, University of Leeds and Leeds Cancer Centre, St James's University Hospital, Leeds, UK

Robert J.C. Steele, MD, FRCSEd, FRCSEng, FCSHK, FRCPE, MFPH(Hon), FRSE

Professor of Surgery, Head of Department of Surgery, University of Dundee Medical School, Ninewells Hospital, Dundee, UK

Gregory P. Thomas, MBBS, BSc, FRCS, MD

Resident Surgical Officer, St Mark’s Hospital, Harrow, UK

Siwan Thomas-Gibson, MD, FRCP

Consultant Gastroenterologist, Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow; Honorary Senior Lecturer, Surgery, Imperial College, London, UK

Mark W. Thompson-Fawcett, MBChB, MD, FRACS

Associate Professor, Department of Surgical Sciences, University of Otago, Dunedin, New Zealand

Phil Tozer, MBBS, FRCS, MD(Res)

Consultant Colorectal Surgeon, and Lead, Robin Phillips Fistula Research Unit, St Mark’s Hospital, Harrow, UK

Carolynne Vaizey, MBChB, MD, FRCS(Gen), FCS(SA)

Consultant Colorectal Surgeon, St Mark's Hospital, Harrow, UK

Janindra Warusavitarne, BMed, FRACS, PhD

Consultant Colorectal Surgeon, St Mark's Hospital, Harrow, UK

Des Winter, MB, FRCSI, MD, FRCS(Gen)

Consultant Surgeon, Centre for Colorectal Disease, St Vincent's University Hospital and University College, Dublin, Ireland

Andrew B. Williams, MBBS, BSc, MS, FRCS

Consultant Colorectal Surgeon, Director Pelvic Floor Unit, Colorectal Surgery, Guy's and St Thomas' Hospitals, London, UK

xiv

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