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RECTAL AND PARARECTAL REGION
161
Ferenschild FT, Vermaas M, Verhoef C, et al. Total pelvic exenteration for
primary and recurrent malignancies. World J Surg. 2009;33:1502–1508.
Guillem JG, Chessin DB, Cohen AM, et al. Long-term oncologic outcome
following preoperative combined modality therapy and total mesorectal
excision of locally advanced rectal cancer. Ann Surg. 2005;241:829–836.
discussion 836–838.
Heriot AG, Byrne CM, Lee P, etal. Extended radical resection: the choice for
locally recurrent rectal cancer. Dis Colon Rectum. 2008;51:284–291.
Jimenez RE, Shoup M, Cohen AM, etal. Contemporary outcomes of total pel-
vic exenteration in the treatment of colorectal cancer. Dis Colon Rectum.
2003;46:1619–1625.
Kanemitsu Y, Hirai T, Komori K, Kato T. Prediction of residual disease or dis-
tant metastasis aer resection of locally recurrent rectal cancer. Dis Colon
Rectum. 2010;53:779–789.
Kusters M, Dresen RC, Martijn H, etal. Radicality of resection and survival
aer multimodality treatment is inuenced by subsite of locally recurrent
rectal cancer. Int J Radiat Oncol Biol Phys. 2009;75:1444–1449.
Melton GB, Paty PB, Boland PJ, et al. Sacral resection for recurrent rectal
cancer: analysis of morbidity and treatment results. Dis Colon Rectum.
2006;49:1099–1107.
Milne T, Solomon MJ, Lee P, etal. Assessing the impact of a sacral resection
on morbidity and survival aer extended radical surgery for locally recurrent rectal cancer. Ann Surg. 2013;258:1007–1013.
Moore HG, Shoup M, Riedel E, etal. Colorectal cancer pelvic recurrences:
determinants of resectability. Dis Colon Rectum. 2004;47:1599–1606.
Morikawa LK, Zelefsky MJ, Cohen GN, etal. Intraoperative high-dose-rate
brachytherapy using dose painting technique: evaluation of safety and
preliminary clinical outcomes. Brachytherapy. 2013;12:1–7.
Pacelli F, Tortorelli AP, Rosa F, etal. Locally recurrent rectal cancer: prog-
nostic factors and long-term outcomes of multimodal therapy. Ann Surg
Oncol. 2010;17:152–162.
Rahbari NN, Ulrich AB, Bruckner T, etal. Surgery for locally recurrent rectal
cancer in the era of total mesorectal excision: is there still a chance for
cure? Ann Surg. 2011;253:522–533.
Sagar PM, Gonsalves S, Heath RM, etal. Composite abdominosacral resection
for recurrent rectal cancer. Br J Surg. 2009;96:191–196.
Shoup M, Guillem JG, Alektiar KM, etal. Predictors of survival in recurrent
rectal cancer aer resection and intraoperative radiotherapy. Dis Colon
Rectum. 2002;45:585–592.
Wells BJ, Stotland P, Ko MA, etal. Results of an aggressive approach to resec-
tion of locally recurrent rectal cancer. Ann Surg Oncol. 2007;14:390–395.
You Y N, Habiba H, Chang GJ, etal. Prognostic value of quality of life and
pain in patients with locally recurrent rectal cancer. Ann Surg Oncol.
2011;18:989–996.
P
H
Da
vid E. Beck
ODUCTION
INTR
A
bdominoperineal resection (standard and extralevator) and
pelvic exenteration are frequently performed operations. During follow-up, many patients demonstrate a perineal bulging with
increases in abdominal pressure (especially during coughing,
straining, or a Valsalva maneuver). This perineal hernia develops because a large portion of the pelvic floor has been removed.
If an extended resection (extralevator abdominoperineal or
exenteration) is performed, the defect can be particularly large,
allowing the small bowel to descend into and through the pelvis.
Although postoperative perineal hernias are common, they are
usually asymptomatic. Symptoms that occur vary from a painless
but noticeable perineal bulge to a painful bulge, bowel or urinary
obstruction, and even an ischemic breakdown of the perineal
skin. The incidence of hernias requiring repair has been estimated to be 1% to 7% of abdominoperineal resections and 10%
of pelvic exenterations; however, the condition is under-reported,
with fewer than 75 cases included in the literature. This chapter discusses evaluation, treatment, and prevention of perineal
hernias.
THERAPY
Patient Selection
R
epair of a perineal hernia is a major surgical procedure and
should be reserved for symptomatic patients who are reasonable
operative candidates. Patients are evaluated preoperatively for
operative risks and to exclude the possibility of recurrent cancer.
The evaluation includes a complete history and physical examination, routine blood studies, contrast radiology or endoscopy of the
intestine and urinary tract, and computed tomography or magnetic resonance imaging scans of the abdomen and pelvis. Upright
anteroposterior and lateral films of the pelvis during a small bowel
follow-through study demonstrate loops of small bowel herniating into the pelvis.
As with all procedures, the potential benets of symptom relief
must be balanced against the risks of surgery. A history of pelvic irradiation increases the potential risks of hernia repair.
eoperative Preparation
Pr
atients undergo limited oral mechanical bowel preparation (e.g.,
P
with use of polyethylene glycol) and receive systemic prophylactic
intravenous antibiotics. Patients also receive venous thromboembolic
prophylaxis, as well as multimodality pain management.
Procedures
Th
e hernia can be repaired via either an abdominal or perineal
approach, using primary repair, mesh (synthetic or biologic), or
flaps.
The patient is positioned in a modified Lloyd-Davies position,
which allows access to the perineum if a combined approach is
required and room for a second assistant to provide retraction
in the pelvis. In addition, this position allows easy preoperative placement of ureteric stents. The pelvis is explored through
a lower midline incision. If no recurrent tumor is present, the
loops of small bowel in the hernia sac (Fig. 33-1, A) are freed of
their adhesions by lysis. Care is taken to identify and protect the
ureters.
e pelvic oor is reconstructed using a single or double layer
of prosthetic material (synthetic or biologic). Although several types
of material have been described, early descriptions were of a double
layer of Marlex mesh (C.R. Bard, Inc, Murray Hill, N.J.). is material
is permanent and allows for good tissue ingrowth. Other synthetic
materials that have been used include absorbable mesh (e.g., Vicryl,
Ethicon, Inc., Somerville, N.J., or Dexon, Davis & Geck, Sugarland,
Tex.) and Gore-Tex (W. L. Gore & Associates, Inc., Flagsta, Ariz.).
Because of the potential of synthetic material to cause infection or
erosion into the bowel, more recent reports are of the use of biologic
mesh. Disadvantages of biologic mesh include its cost, diculty in
handling, and limited data on durability of the repair.
The edges of the mesh are sutured to the edges of the pelvic outlet with interrupted nonabsorbable suture (2-0 Ethibond
or Prolene [Ethicon, Inc.]). Posteriorly, the mesh is attached to
Waldeyer’s fascia and the sacral periosteum at or below the level
of S3; anteriorly, it is sutured to the vagina or prostatic capsule
(Fig. 33-1, B). An overlap of the mesh aids in fixation and limits
the potential morbidity of suture placement. The bladder base
is avoided because posterior fixation may cause urinary retention. Laterally, the fasciae of the pelvic side wall and ligamentous
structures are used to anchor the mesh (Fig. 33-1, C). In placing these sutures, care is taken to avoid the large pelvic vessels.
The attachment of the mesh is below the level of the ureters. An
obturator may be placed into the vagina via the perineum to aid
in identifying the vaginal cuff. The edges of the mesh are marked
with small metallic clips, which allows easy documentation of
the mesh position on a plain abdominal radiograph film postoperatively. If sufficient omentum is present in the abdomen, a
pedicle flap is constructed and placed between the mesh and the
small bowel. This procedure reduces the chance that the bowel
will adhere to or erode into the mesh. If a significant dead space
is created below the mesh, a closed suction drain (such as a Jackson-Pratt drain) is placed below the mesh to aid in obliteration
of the space. It is brought out of the abdomen through a separate
incision.
162
RECTAL AND PARARECTAL REGION
163
Mesh
A
B
Mesh
C
FIGURE 33-1
mesh in place. C, View of the pelvis from above with mesh in place. (Courtesy Barbara Siede, Oschner Foundation, New Orleans, La.)
Alternativ
arly reports recommended a perineal approach for repair of these
E
hernias. Although this method was believed to cause less morbidity, it
had several disadvantages. If the genitourinary structures are present,
the pelvic inlet cannot be reached from the perineum and the mesh
must be sutured to the perineal diaphragm (the weak point in such a
repair). It is dicult to separate the adherent small bowel loops in the
hernial sac, and if bowel or a vascular structure is injured, it is very
dicult to repair because the exposure from the perineum is limited.
Finally, the ability to exclude recurrent tumor is limited with such an
approach.
e abdominal approach allows conrmation of the absence of
recurrent tumor and mobilization of the small bowel under direct
vision. e mesh can be attached at an appropriate level in the pelvis, and the chance of injury to other pelvic structures is reduced.
It also allows mobilization of the omentum. A combined approach
(abdominal and perineal) provides the advantages of the abdominal
method and the ability to resect the attenuated skin of the perineum.
I prefer this method. For patients with minimal symptoms or for
those in whom the risks of an operation are thought to be prohibitive,
a support garment (e.g., a girdle or Jobst pantyhose [BSN Medical,
Charlotte, N.C.]) may provide palliation.
Various aps have been recommended to close the peritoneal
defect. Although autogenous tissue is less commonly chosen for primary repair, it may be considered for recurrent hernias or when irradiated tissue or infection is present. Flap tissue may be obtained from the
A, Sagittal section of the pelvis demonstrating a perineal hernia with incar
e Methods
gluteus maximus, gracilis, and rectus abdominis. Flap closure is a more
complicated procedure that usually requires the assistance of a plastic
surgeon. In addition, the morbidity related to the donor site and the
potential of ischemia or necrosis add to possible complications.
Laparoscopy has also been described for intra-abdominal and
perineal repair of perineal hernias using meshes of various types.
Limitations include the presence of adhesions and the challenge of
mesh attachment with laparoscopic techniques.
ostoperative Care
P
P
ostoperative care is similar to that for other patients undergoing
a laparotomy. e patient’s diet is advanced when bowel function
returns. If a drain is used, it is removed when the output has diminished to approximately 50 mL per day.
Complications
n addition to the usual complications that might attend any lapa-
I
rotomy, the placement of the prosthetic material to reconstruct the
perineal diaphragm carries the potential risk of detachment of the
mesh from the pelvic wall, leading to recurrence. e resultant defect
around the mesh is likely to be smaller and much more prone to
strangulate the herniating bowel, and thus this situation demands
cerated small bowel. B, Sagittal section of the pelvis with
164
ur
gent repeat exploration and repair of the defect. A pooled analysis
Perineal Hernia
of perineal hernia repairs aer abdominoperineal resection demonstrated a primary recurrence in 13 of 43 patients (30%) and a secondary recurrence in 3 patients (23%). e recurrence rate was lower for
mesh or ap repair than for primary closure.
A second and potentially more serious problem is a pelvic infection. An infection in or near the mesh requires its removal. e most
common source of contamination is spillage from the bowel. If multiple enterotomies or signicant fecal spillage or contamination occur,
either biologic mesh is used or the planned repair is abandoned.
PREVENTION
ecause of the challenges of repairing perineal hernias, eorts have
B
been directed toward prevention. Prevention is especially relevant to
patients undergoing extended pelvic resections. Both ap reconstruction and the use of biologic repairs have been advocated. A systemic
review of patients undergoing an extralevator approach to abdominoperineal resection from 1995 to 2011 identied 255 patients who
underwent ap reconstruction and 85 who underwent a biologic
mesh repair. e procedures are similar to those described in this
chapter. e analysis showed no signicant dierence in rates of perineal wound complications or perineal hernia formation.
SUMMARY
A p
erineal hernia may occur aer perineal resections. If the patient
is symptomatic, the hernia can be repaired using one of a variety of
techniques. Evidence-based recommendations are dicult to make
because of the lack of a signicant amount of published data.
S
u
g g e
B
eck DE, Fazio VW, Jagelman DG. Postoperative perineal hernia. Dis Colon
Rectum. 1987;30:21–24.
Buchsbaum HJ, Christopherson W, Lifshitz S, Bernstein S. Vicryl
pelvic oor reconstruction. Arch Surg. 1985;120:1389–1391.
Douglas SR, Longo WE, Narayan D. A novel technique for perineal hernia
repair. BMJ Case Rep. 2013. April 10;2013.
Foster JD, Pathak S, Smart NJ, etal. Reconstruction of the perineum following
extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Colorect Dis. 2112;14:1052–1059.
Mjoli M, Sloothaak DA, Buskens CJ, et al. Perineal hernia repair aer abdomi-
noperineal resection: a pooled analysis. Colorect Dis. 2013;14:400–406.
S t
e d
e
R
a d i n g
®
m
esh in
COLON
3
34. Preoperative Preparation of the Patient for Colon and
Rectal Surgery 167
35.
Medical Treatment of Ulcerative Colitis and Other
Colitides 174
36.
Chronic Ulcerative Colitis: Surgical Options 186
37.
Management of Acute Toxic Colitis and Megacolon 191
38.
Pelvic Pouch: Complications and Their Management 197
39.
Pouchitis and Functional Complications of the Pelvic
Pouch 201
40.
Continent Ileostomy 204
41.
Unhealed Perineal Wound 209
42.
Medical Management of Crohn Disease 213
43.
Management of Crohn Colitis 217
44.
Management of Perianal Crohn Disease 222
45.
Cecal Ulcer 226
46.
Pseudomembranous Clostridium Difficile Colitis 228
47.
Cytomegalovirus Ileocolitis and Kaposi Sarcoma in
HIV/AIDS 231
48.
Diagnosis and Management of Acute Colonic
Diverticulitis 234
49.
Surgical Treatment of Diverticulitis and Its
Complications 239
50.
Lower Gastrointestinal Hemorrhage 244
Large Bowel Obstruction 249
51.
52.
Colonic Volvulus 255
53.
Colonic Pseudo-obstruction (Ogilvie Syndrome) 260
54.
Management of the Malignant Polyp 264
55.
Colorectal Cancer Screening and Surveillance 267
56.
Molecular Genetics of Colorectal Cancer 273
57.
Polyposis Syndromes 275
58.
Desmoid Disease 281
59.
Hereditary Nonpolyposis Colorectal Cancer and Lynch
Syndrome 285
60.
Cancer of the Appendix and Pseudomyxoma Peritonei
Syndrome 292
61.
Surgical Management of Cancer of the Colon 301
62.
Management of Metastatic Colorectal Cancer 309
63.
Management of Colorectal Liver Metastasis 314
64.
Colorectal Metastases to the Lung 320
65.
Nonepithelial Colorectal Tumors 323
66.
Management of Colonic Ischemia 328
67.
Colon and Rectal Trauma 334
68.
Endometriosis of the Colon and Rectum 341
69.
Pneumatosis Cystoides Intestinalis 345
70.
Constipation 349
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P
P
P C
Danielle M.
INTR
ODUCTION
e goal of preoperative assessment and preparation for a patient
undergoing colon and rectal surgery is to minimize the risk of perioperative complications and optimize outcomes. Advancing age,
obesity, and comorbidities such as cardiopulmonary disease and
malnutrition are all factors that contribute to perioperative risk and
are becoming more prevalent. Although these factors do not preclude
surgery, they complicate preoperative assessment and increase the
risk of postsurgical complications. Understanding the impact of these
conditions on outcomes and tailoring interventions that optimize a
patient’s health status prior to surgery are important steps in preparing for surgery. is chapter will cover common concerns critical to
the preparation of a patient for colon and rectal surgery.
RISK ASSESSMENT
M
any screening instruments have been designed to assist surgeons in
classifying a patient’s overall surgical risk. e following three tools
are commonly used in colon and rectal surgery: American Society
of Anesthesiologists (ASA) grade, Physiologic and Operative Severity Score for enumeration of Mortality and Morbidity (POSSUM),
and the Association of Coloproctology of Great Britain and Ireland
(ACPGBI) tool. Each tool has proven benets and limitations.
e ASA Physical Status Classication, which was introduced
in 1941 by Saklad, is now commonly referred to as the ASA grade.
is simple stratication was intended to describe a patient’s preoperative condition rather than estimate operative risk. e ve
grades (Table 34-1) have been shown to correlate with intraopera-
tive factors (such as blood loss) and outcomes, such as duration of
intensive care unit stay, necessity of postoperative ventilation, and
perioperative mortality and morbidity. Although it is simple to use,
the ASA grade is limited by its subjectivity.
POSSUM was introduced by Copeland in 1991 as a format for auditing quality of surgical care. is scoring system assigns numeric weights
to 12 physiologic parameters and 6 operative factors (Table 34-2); the
total score predicts morbidity and mortality. To reduce overestimates
in mortality and to address the risk specic to patients undergoing
colon and rectal surgery, the instrument was modied as the Colorectal
POSSUM (CR-POSSUM). In addition to the eight original parameters
(age, cardiac signs, pulse, systolic blood pressure, urea concentration,
operative severity, peritoneal soiling, and malignancy), assessment of
the operative urgency and preoperative hemoglobin are also included
(Table 34-3). CR-POSSUM has been shown to accurately predict mor-
tality aer colon and rectal surgery, although it continues to overestimate it, especially with laparoscopic procedures and in patients with
colon cancer.
In a further eort to address surgical risk in patients with colon
and rectal cancer, the ACPGBI released its own scoring system in
R S
Pickham, Terrell C. Hicks, and David A. Margolin
2010 a
s an online tool. e ACPGBI, which is the simplest of the
three tools, uses ve variables: age, ASA grade, Duke’s Stage, surgical
urgency, and operative procedure (formerly cancer resection status).
It has been shown to be a more accurate predictor of surgical mortality than both CR-POSSUM and ASA grade, especially for elective
cases, with consistent performance for elderly patients and emergency cases as well.
In 2013, the American College of Surgeons (ACS) developed the
ACS NSQIP Surgical Risk Calculator. is online decision support
tool (http://riskcalculator.facs.org/) utilizes 21 patient predictors to
estimate the risk of 9 potential complications occurring within 30
days aer surgery. ese complications include death, cardiac events,
pulmonary events, renal failure, surgical site and deep organ space
infections, urinary tract infection, and thromboembolic complications, including pulmonary embolism (PE) and stroke. Not only are
patient factors entered into the equation, but the magnitude of the
surgery is included in the algorithm. e tool also provides a predicted length of stay based on specic Current Procedural Terminology (CPT) codes, allowing both the surgeon and the patient to have
realistic expectations of the planned surgery.
Although no single tool can substitute for sound clinical acumen,
these tools can help the surgeon and the patient manage expectations
and potentially improve outcomes.
C
ARDIOVASCULAR ASSESSMENT AND
PREOPERATIVE MANAGEMENT
I
nduction of anesthesia and the patient’s autonomic response to surgery can cause signicant cardiac stress resulting in arrhythmias,
ischemia, or infarction in the intra- and postoperative periods.
Consequently, cardiovascular comorbidity is an important contributor to perioperative morbidity and mortality. Estimates of
cardiac complication rates are between 1% and 5% for colorectal
abdominal operations, equating to an intermediate cardiac risk.
This risk is higher in elderly persons. As the number of elderly
patients presenting for colon and rectal surgery continues to rise,
understanding how to assess cardiac fitness and minimize perioperative risk is important. To this end, The American College of
Cardiology (ACC) and the American Heart Association (AHA)
have established practice guidelines for preoperative cardiac
assessment in noncardiac surgery.
The goal of the preoperative cardiac assessment is to evaluate
the patient’s current medical status and “provide a clinical risk profile” that “can [be] used to make treatment decisions that influence
the patients’ short and long term outcomes.” The Revised Cardiac
Risk Index is a scoring system to help guide this assessment. The
index awards one point each to six factors: high-risk surgery, history of ischemic heart disease, history of congestive heart failure,
history of cerebrovascular disease, insulin-dependent diabetes,
167
168
PreoPera
tive Pre
Para
tion of the Patient for Colon and
reCt
al Surgery
TABLE 34-1: American Society of Anesthesiologists
Physical Status Classification
ASA Grade Definition
I N
II Mild systemic disease that does not limit activity
III Severe systemic disease that limits activity but is
IV Incapacitating systemic disease that is constantly
ormal, healthy individual
not incapacitating
life threatening
TABLE 34-2: Physiologic and Operative Severity
Score for Enumeration of Mortality and Morbidity
(POSSUM) Variables to Predict Morbidity and
Mortality
ysiologic Parameters Operative Parameters
Ph
A
ge (yr)
Cardiac symptoms
Respiratory symptoms
Pulse (beats/min)
Systolic blood pressure (mm Hg)
Glasgow Coma Scale score
Hemoglobin (g/dL)
V Moribund; not expected to survive 24 hr with or
without surgery
E Emergency
A
SA, American Society of Anesthesiologists.
T
ABLE 34-3:
Morbidity (CR-POSSUM)
Variable Score
ysiologic
Ph
Ag
e 1 2 3 4 8
Color
ectal Physiologic and Operative Severity Score for Enumeration of Mortality and
Variables and Scoring to Estimate Mortality
White blood cell count
Urea concentration (mmol/L)
Sodium level (mmol/L)
Potassium level (mmol/L)
Electrocardiogram
Operative severity
Multiple procedures
Total blood loss (mL)
Peritoneal soiling
Presence of malignancy
Mode of surgery
Cardiac failure None/mild Moderate Severe
Systolic BP (mm Hg) 100-170 90-99 or >170 <90
≤60 61-70 71-80 >80
Pulse (beats/min) 40-100 101-120 <40 or >120
Urea (mmol/L) ≤10 10.1-15 >15
Hemoglobin (g/dL) 13-16 10-12.9 or 16.1-18 <10 or >18
Operativ
O
e
perative severity Minor Intermediate Major Major +
Peritoneal soiling None/serous Local pus Free pus or feces
Operative urgency Elective Urgent Emergent
Cancer staging None or Duke A/B Duke C Duke D
Equation used to calculate risk (R) of mortality:
Log[R/(R − 1)] = −9.167 + (0.33 × Physiologic score) + (0.3 × Operative Score)
B P, Blood pressure; Duke, Duke Activity Status Index.
and renal insuciency (creatinine >2.0 mg/dL). e total number of
points correlates to predictive rates of major cardiac complications
(Table 34-4).
During this assessment, it is important to dierentiate clinical
risk factors from active disease. Active disease is dened as unstable
coronary syndrome, including unstable or severe angina or recent (<1
month) myocardial infarction, decompensated heart failure, signicant
arrhythmias, and severe valvular disease. ese conditions mandate
further investigation prior to surgery. If an intervention is required,
elective surgery should be postponed up to 4 to 6 weeks in patients
with acute myocardial infarction or stent placement. If placement of a
cardiac stent is required, use of a drug-eluting stent should be avoided,
because these stents have shown higher rates of thrombosis when antiplatelet therapy is withheld within 1 year of placement.
Functional capacity is another important aspect of cardiac risk
assessment. e Duke Activity Status Index quanties common daily
activities into metabolic equivalents (METs), with scale ranges from 1
(eat or dress) to greater than 10 (strenuous activity). Surgeons can use
METs as units of measure to identify cardiac disease or cardiac intolerance. For example, the inability to perform a minimum of 4 METs
(e.g., light housework, such as dusting and washing dishes) should
prompt additional cardiovascular consultation.
TABLE 34-4: Revised Cardiac Risk Index and
Associated Cardiac Risk Estimates
. of Risk
No
Risk Factors
H
igh-risk surgery 1 0.5
Factors
Ischemic heart disease 2 1.3
Congestive heart failure 3 3.6
Cerebrovascular disease ≥4 9.1
Insulin-dependent diabetes 1 0.9
Predicted Rate of
Cardiac Complication, %
COLON
BO
X 34-2: Preoperative Treatment Options to Reduce
Car
diac Risk
locker
β-B
ndicated in:
I
atientscurrentlyreceiving
•P
•P
atientswith
r
isk surgery
tatin
S
I
ndicated in:
>1r
isk
fac
locker therapy
β-b
torwhowill
un
dergo
in
termediate-
• Patientscurrentlyreceivingstatintherapy
•P
atientswith
isk factor who will undergo intermediate-
≥1 r
risk surgery
169
Creatinine >2.0 1 0.9
BOX 34-1: Indications for Preoperative Diagnostic
diac Tests
Car
E
lectrocardiogram
I
ndicated in:
•P
atientswithknown
who will undergo intermediate-risk surgery
atientswith
•P
CAD,P
linical risk factor
≥1 c
AD,or
cer
ebrovascular
di
†
sease
Not indicated in:
symptomaticpatients
•A
A
ssess LV Function
ndicated in:
I
•P
atientswithdyspneaof
•P
atientswithheart
m
o) echocardiogram AND who have a change in clinical
dergoing
un
un
fa
ilurewhohavenothad
lo
knownorigin
w-risksurgery
ar
ecent
*
(<12
status
N
oninvasive Stress Testing
ndicated in:
I
atientswith
•P
atientswith
•P
apacity who will undergo intermediate-risk surgery
c
ot indicated in:
N
•P
atientswithnorisk
•P
atients
* L
ow-risk surgery (<1% cardiac risk): endoscopy, ophthalmologic procedure, breast.
†
ntermediate risk surgery (1%-5% cardiac risk): intra-abdominal procedures, carotid,
I
ead and neck, orthopedic, prostate.
h
CAD, Coronary artery disease; LV, le ventricle; PAD, peripheral arterial disease.
tivecardiac
ac
linicalrisk
>1c
fac
under
going low-risk surgery
nditions
co
torandpoorfunctional
fac
tors
†
pha-2 Agonist
Al
an be used for control of hypertension in patients with ≥1 clini-
C
cal risk factor
oronary Revascularization
C
ndicated in:
I
•P
atientswith
infa
•P
rction
atientswithstableanginaandoneofthefollowing:
Signicant le main coronary disease
un
stableanginaornon-STelevatedmyocardial
3-vessel disease
2-vessel disease with signicant proximal le anterior
descending artery stenosis and ejection fraction <0.50 or
ischemia on a noninvasive test
Not recommended:
•P
rophylactically
e
ase
tent*
S
B
alloon angioplasty or bare-metal stent:
inp
atientswithstable
co
ronaryartery
dis-
• Patientswhomustundergoanurgentoperationthatwould
equire discontinuation of clopidogrel (Plavix)
r
Drug-eluting stent indicated:
atientswhoneedelective,noncardiacsurgery
•P
12 m
o
ins
ubsequent
deally, defer surgery 6 weeks aer bare-metal stent placement and 6 months aer
* I
ug-eluting stent placement. In patients who require surgery within these time inter-
dr
vals, dual antiplatelet therapy should be continued around the time of surgery.
p
erioperative β-blockade should not be routine. A typical indication
would be a major, abdominal, colorectal procedure in a patient with
a history of coronary artery disease who is already taking β-blockers
or who is at high cardiac risk.
A
lthough most pertinent information can be obtained through
a thorough history and physical examination, other tests, including
an electrocardiogram, echocardiogram, or noninvasive stress test,
can be important. Box 34-1 details recommendations from the ACC/
AHA practice guidelines for cardiac diagnostic tests.
A goal of preoperative cardiac assessment and treatment is to
reduce risk. Medications such as β-blockers, statins, or alpha agonists
and interventional therapies such as cardiac revascularization or cardiac stenting are used in select cases to accomplish risk reduction.
Recommendations for the use of these modalities are summarized
in Box 34-2. Of the drug therapies, perioperative beta-blockade was
the most promising at one point, with reports of reduction in overall
mortality of 55%. In addition, beta blockade can result in a reduction
in cardiac mortality and decrease the risk of myocardial infarction.
However, recent studies have raised a concern regarding the safety
of this practice because of increased rates of bradycardia and hypotension, especially in patients with low cardiac risk. Increased risk of
stroke and overall mortality have also been reported. For this reason,
PREOPERATIVE PULMONARY ASSESSMENT AND MANAGEMENT
Pu
lmonary complications are as common as cardiac complications
aer noncardiac surgery and have been shown to increase cost and
account for an increased length of stay in the hospital. For this reason, accurate assessment of the patient’s preoperative pulmonary status is critical.
Patients at highest risk for postoperative pulmonary complications (Table 34-5) include those who have chronic obstructive pul-
monary disease; are older than 60 years; have an ASA score greater
than 2; have functional dependency; and have congestive heart failure. e location of the surgical incision has the greatest impact on
the risk of postoperative pulmonary complications, with incisions
closest to the diaphragm having the highest risk. Laparoscopic surgery, with its smaller incisions, has been shown to reduce pulmonary
complications.
170
PreoPera
tive Pre
Para
tion of the Patient for Colon and
TABLE 34-5: Risk Factors for Postoperative
Pulmonary Complications
Patient Factor Pr
Str
ong Evidence
A
dvanced age
ASA >2
Congestive heart failure
Functional dependency
Chronic obstructive
pulmonary disease
W
eak Evidence
W
eight loss
Impaired sensorium
Cigarette use
Alcohol use
Abnormal chest
examination
Insufficient Data
bstructive sleep apnea
O
Poor exercise tolerance
Good Evidence
W
ell-controlled asthma
AGAINST Being a Risk Factor
Obesity
SA, American Society of Anesthesiologists.
A
Modied from Smetana GW. Postoperative pulmonary complications. Cleve
Clin Med J. 76:s600-65, 2009.
e Respiratory Risk Index was described in 2007 to predict post-
operative respiratory failure. is comprehensive assessment tool
uses 28 independent predictors of postoperative respiratory complications to categorize patients into three groups. Predicted rates of
respiratory failure correlate with these categories and are 0.2%, 1%,
and 6.5% for patients at low, medium, and high risk, respectively.
In 2006 the American College of Physicians published guidelines
for Preoperative Pulmonary Assessment. A serum albumin level should
be obtained for all patients with one or more risk factors, because low
serum albumin (<3.5 g/dL) has been identied as a positive marker for
increased pulmonary risk. Although chest radiographs and pulmonary
function tests (PFTs) can be considered, they are not routinely recommended. e Royal College of Radiologists states that a preoperative
chest radiograph is only indicated in patients with acute respiratory
symptoms or in patients older than 70 years with established cardiorespiratory disease who had not undergone a chest radiograph in the
prior 6 months. A chest radiograph also should be obtained in a patient
with colorectal cancer or suspected metastatic disease. Although use
of PFTs is well established in patients undergoing thoracic surgery,
currently there are no recommendations regarding the utility of PFT
assessment in patients undergoing abdominal surgery.
Once risk status is dened, risk-reduction strategies can be implemented. Standard postoperative pulmonary care involves breathing
exercises, early ambulation, and preoperative incentive spirometry
teaching to minimize atelectasis. Continuous positive airway pressure, which uses a more invasive approach, has been shown to
ocedural Factor
Aortic aneurysm repair
oracic surgery
Abdominal surgery
Neurosurgery
Prolonged surgery (>3 hr)
Head and neck surgery
Emergent surgery
Vascular surgery
Induction of general anesthesia
Perioperative transfusion
Esophageal surgery
Hip surgery
Genitourinary or gynecologic
surgery
reCt
al Surgery
nicantly reduce the risk of pulmonary complications, including
sig
atelectasis and pneumonia, and should be considered in patients who
are unable to comply with deep breathing or incentive spirometry. In
the presence of vomiting or abdominal distention, it is also appropriate to insert a nasogastric tube for gastric decompression, thus reducing the risk for gastric-related pulmonary compromise.
Controlled asthma alone is not a risk factor for pulmonary complications but can be exacerbated by surgery. e National Asthma
Education and Prevention Program (2002) recommends preoperative optimization of lung function, which may require the administration of steroids to reduce a postoperative inammatory response.
Finally, although it is well established that smoking leads to increased
rates of pulmonary complications, quitting smoking in the immediate
preoperative period does not reduce the risk for postoperative pulmonary
complications. In fact, smoking cessation in close proximity to surgery
increases complications because of a transient increase in mucus production and a reduction in coughing, possibly because of decreased airway
irritation. Nonetheless, with overwhelming evidence demonstrating the
negative health outcomes associated with smoking, it is the surgeon’s
responsibility to encourage smoking cessation in all patient encounters.
MANAGEMENT OF PATIENTS RECEIVING ANTITHROMBOTIC THERAPY
ach year approximately 250,000 patients who are receiving anti-
E
coagulation or antiplatelet therapy require surgery. Ideally, anticoagulation therapy is withheld to minimize the risk of bleeding in the
perioperative period, but withholding therapy may put the patient
at increased risk for thromboembolic complications such as stroke,
cardiac infarct, or a PE. erefore, management of anticoagulation is
an important aspect of the preoperative assessment.
When determining the best strategy for dealing with antithrombotic therapy, two important factors need to be balanced: the underlying risk for thromboembolic complications versus the risk of
bleeding complications associated with the intended surgery.
Common indications for antithrombotic therapy include venous
thromboembolic disease (deep venous thrombosis); PE; antithrombin III, protein C, and protein S deciency; arterial thromboembolism
(cardiac valve prosthesis and arrhythmia); cerebrovascular disease;
stenting; or vascular graing. e risk of perioperative thrombotic
complications varies greatly among patients with these indications.
To assess risk, the American College of Chest Physicians (ACCP)
guidelines stratify patients into risk categories based on their indication for antithrombotic therapy (Table 34-6). Special mention needs
to be made regarding the management of patients with atrial brillation. Atrial brillation has its own stroke risk assessment score,
the CHADS
increase the weighting associated with age and a history of stroke,
and it is now referred to as the CHA
been shown to correlate with the risk of PE, as well as stroke.
e preoperative management of patients with colon and rectal
surgery will vary depending on a particular patient’s predicted risk
of thromboembolic complications, but it must also take into account
the risk of bleeding. Although no evidence-based risk stratication
exists for all surgical procedures, many professional organizations
have published guidelines to assist in evaluating the risk of bleeding
for specic procedures. For colon and rectal procedures, the ACCP
denes resection of large (>1 to 2 cm) sessile polyps, bowel resection,
and cancer operations as having an increased risk for perioperative
bleeding. e American Society of Gastrointestinal Endoscopy published guidelines in 2009 dividing endoscopic procedures into lowand high-risk procedures (Table 34-8).
Aer dening the relative risks of clotting and bleeding, the surgeon
must decide whether to withhold antithrombotic therapy and if bridging therapy is necessary. Preoperative use of warfarin should be discontinued for all persons undergoing major operations or procedures who
S
core (Table 34-7). In 2010 this score was revised to
2
2DS2
.
e CHA
2DS2
score has