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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1125_Библиотеки_им_академика_М_И_Перельмана.pdf
Acknowledgments
I cannot thank the authors enough for taking on the task of writing on topics that
may seem rather simple in their vast experiences, for keeping to deadlines, and for
their patience in all the editing. I have to thank the medical illustrators at Springer
who have done wonderful work with the creation of the artwork for working closely
with the authors. Lastly, there are no words to thank the developmental editor
Margaret Burns for her patience and help with the editing and communication.
xi
Contents
Part I Anatomy and Investigations
1 Anorectal Anatomy and Applied Anatomy ......................................... 3
Alice C. A. Murray and Ravi Pokala Kiran
2 Investigations for Anorectal Disease .................................................... 33
Michael A. Valente
3 CT and MRI of the Pelvis for Anorectal Disease ................................ 51
Myra K. Feldman , Zachary E. Friess , and Joseph C. Veniero
Part II Pathology and Treatment
4 Anorectal Abscess .................................................................................. 79
Nicole M. Saur and Dana R. Sands
5 Anal Fissure ............................................................................................ 95
Glenn Hall Jr. and Brian R. Kann
6 Anal Fistula............................................................................................. 127
Martin Luchtefeld and Tarek Jalouta
7 Pruritus Ani ............................................................................................ 153
Ursula M. Szmulowicz
8 Anal Condyloma Acuminata and Anal Dysplasia............................... 189
Michelle D. Inkster , Ursula M. Szmulowicz ,
Homer O. Wiland , and James S. Wu
9 Anovaginal and Rectovaginal Fistula ................................................... 211
Evie Carchman and Brooke Gurland
10 Hemorrhoids: Anatomy, Physiology, Concerns,
and Treatments ....................................................................................... 225
Ohmar Coughlin and Michael Page
xiii
xiv
Contents
11 Chronic Anal Pain .................................................................................. 243
Alexander T. Hawkins and Liliana Bordeianou
12 Anal Cancer ............................................................................................ 263
A. M. Hogan , M. Sheehan , and M. R. Joyce
13 Pilonidal Disease..................................................................................... 283
Andrea Petrucci , Nancy Morin , and Marylise Boutros
Index ................................................................................................................ 307
Contributors
Liliana Bordeianou , MD, MPH Colorectal Surgery Program and Center for
Pelvic Floor Disorders , Massachusetts General Hospital , Boston , MA , USA
Marylise Boutros , MD, FRCSC McGill University/Jewish General Hospital ,
Montreal , QC , Canada
Evie Carchman , MD Division of Colorectal Surgery, Department of Surgery ,
University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
Ohmar Coughlin , MD General Surgery Residency Program , Iowa Methodist
Medical Center , Des Moines , IA , USA
Myra K. Feldman , MD Imaging Institute, Section of Abdominal Imaging,
Cleveland Clinic , Cleveland , OH , USA
Zachary E. Friess , DO Imaging Institute, Section of Abdominal Imaging,
Cleveland Clinic , Cleveland , OH , USA
Brooke Gurland , MD Associate Professor of Surgery, Lerner College of Medicine
of Case Western Reserve University, Staff Surgeon, Department of Colorectal
Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
Glenn Hall Jr. , MD Department of Colon and Rectal Surgery , University of
Pennsylvania, Perelman School of Medicine , Philadelphia , PA , USA
Alexander T. Hawkins , MD, MPH Division of Surgery , Massachusetts General
Hospital , Boston , MA , USA
A. M. Hogan , MD Department of Colorectal Surgery , University Hospital Galway ,
Galway , Ireland
Michelle D. Inkster , MD Digestive Disease Institute, Cleveland Clinic Foundation ,
Cleveland , OH , USA
Tarek Jalouta , MD Section of Colon and Rectal Surgery , Spectrum Health
Medical Group , Grand Rapids , MI , USA
M. R. Joyce , MB, BCH, BAO, MD, FRCSI Department of Colorectal Surgery ,
University Hospital Galway , Galway , Ireland
xv
xvi
Brian R. Kann , MD, FACS, FASCRS Department of Colon and Rectal Surgery ,
Ochsner Clinic , New Orleans , LA , USA
Ravi Pokala Kiran , MBBS, MS, MSc, FRCS(Eng), FACS Kenneth A. Forde
Professor of Surgery (in Epidemiology), Chief and Program Director, Department
of Colorectal Surgery , Columbia University and Mailman School of Public Health,
New York Presbyterian , New York , NY , USA
Martin Luchtefeld , MD Section of Colon and Rectal Surgery , Spectrum Health
Medical Group , Grand Rapids , MI , USA
Nancy Morin , MD, FRCSC, FACS, FASCRS McGill University/Jewish General
Hospital , Montreal , QC , Canada
Alice C. A. Murray , BSc (Oxon), MBBS, MRCS Division of Colorectal Surgery,
Columbia University, New York Presbyterian Hospital, Herbert Irving Pavilion,
New York, NY, USA
Contributors
Michael Page , MD, FACS, FASCRS
Digestive Disease Center , Clive , IA , USA
Andrea Petrucci , MD, FRCSC
Montreal , QC , Canada
Dana R. Sands , MD Department of Colorectal Surgery , Cleveland Clinic Florida ,
Weston , FL , USA
Nicole M. Saur , MD Department of Colorectal Surgery , Cleveland Clinic Florida ,
Weston , FL , USA
M. Sheehan , MD Department of Histopathology , University Hospital Galway ,
Galway , Ireland
Ursula M. Szmulowicz , MD Retired Staff Surgeon, Department of Colorectal
Surgery , Cleveland Clinic , Cleveland , OH , USA
Michael A. Valente , DO, FACS, FASCRS Assistant Professor of Surgery, Lerner
College of Medicine of Case Western Reserve University. Staff Surgeon, Department
of Colorectal Surgery , Digestive Disease Institute, Cleveland Clinic , Cleveland ,
OH , USA
Joseph C. Veniero , MD, PhD
Cleveland Clinic , Cleveland , OH , USA
Homer O. Wiland , MD
Cleveland Clinic Foundation , Cleveland , OH , USA
Imaging Institute, Section of Abdominal Imaging,
Department of Anatomic and Surgical Pathology ,
Department of Colorectal Surgery , Iowa
McGill University/Jewish General Hospital ,
James S. Wu , MD Digestive Disease Institute, Cleveland Clinic Foundation ,
Hillcrest Hospital, Mayfi eld Heights , OH , USA
P a r t I
Anatomy and Investigations
Anorectal Anatomy and Applied A n a t o m y
Alice C. A. Murray and Ravi Pokala Kiran
1.1 Rectum (Latin: Intestinum Rectum, Straight)
The colon is a distensible tube approximately 150 cm long and of varying diameters
depending on location (2.5–7 cm maximal diameter at the cecum) [ 1 ]. It begins
from the ileocecal junction and comprises the cecum, ascending colon, hepatic fl exure, transverse colon, splenic fl exure, and descending and sigmoid colon, whereby
it ends at the rectosigmoid junction. The anatomical landmark for the rectosigmoid
junction is controversial and considered to be the sacral promontory by surgeons,
but the third sacral vertebra to anatomists. The transition to rectum can be identifi ed
by several changes: the absence of appendices epiploicae and teniae coli and the
lack of a defi ned mesocolon [ 2 ]. The three teniae coli fan out to continue as a com-
plete longitudinal muscular layer around the rectal tube. The rectum continues caudally for approximately 12–15 cm where it becomes the anal canal at the anorectal
junction. At a point just above its termination, the rectal diameter fi lls out to form
the rectal ampulla, and it is here that it provides a distensible reservoir for storage of
feces prior to defecation. The caudal limit of the rectum is again disputed as being
either at the level of the anorectal angle formed by the sling of puborectalis (anorectal ring) or instead at the dentate line.
At its beginning, the rectum courses over the pelvic brim, falling into the pelvic
cavity, lying snug against the sacrococcygeal concavity. Its course within the
1
A. C. A. Murray , BSc (Oxon), MBBS, MRCS (*)
Division of Colorectal Surgery , Columbia University, New York Presbyterian Hospital,
Herbert Irving Pavilion , 161 Fort Washington Avenue , New York , NY 10032 , USA
am4160@cumc.edu;
e-mail:
R. P. Kiran , MBBS, MS, MSc, FRCS(Eng), FACS
Kenneth A. Forde Professor of Surgery (in Epidemiology), Chief and Program Director,
Department of Colorectal Surgery , Columbia University and Mailman School of Public
Health , New York Presbyterian , New York , NY , USA
email: rpk2118@cumc.columbia.edu
© Springer International Publishing Switzerland 2016
M. Zutshi (ed.), Anorectal Disease, DOI 10.1007/978-3-319-23147-1_1
3
4
A.C.A. Murray and R.P. Kiran
Axis of rectum
Puborectalis
Axis of anal
canal
Fig. 1.1 Puborectalis forming the anorectal angle
confi nes of the pelvis is “s-shaped” in sagittal view, with a further anterior tilt of
90–110° at the anorectal angle (Fig. 1.1 ).
Lying posteriorly to the rectum are the sacrum, coccyx, and pelvic diaphragm,
along with the associated presacral venous plexus and roots of the sacral nerve
plexus. Anteriorly lie the rectovesical pouch, prostate and seminal vesicles in men,
and the posterior wall of the vagina and uterine cervix in women.
The rectum traverses the pelvic fl oor, which is the muscular diaphragm separating the pelvis from the perineum and providing support for the abdominal cavity.
The puborectalis slings around the rectum at approximately 5 cm from the anal
verge creating the sharp anorectal angle and attaches anteriorly to the pubis. On
either side of the rectum are the ischiorectal fossae containing loose areolar fat,
branches of the inferior rectal vessel, and nerves which cross the fossae to enter the
wall of the anal canal. These potential spaces allow the rectum to distend during
defecation. The ischial tuberosities form the outer limits of the ischiorectal fossae.
1.1.1 Mesorectum
The “ mesorectum” is a fatty cuff of tissue surrounding the rectum containing perirectal lymph nodes and terminal branches of the inferior mesenteric artery, but no
functionally signifi cant nerves. The mesorectum extends through the entire length
of the rectum; the lower third of the rectum is completely enveloped by the mesorectum, but it begins to narrow caudally from the level of the insertion of the levator
ani muscles [ 3 ]. It is thickest posteriorly and is enclosed by fascia propria. Its
removal is crucial to the treatment of rectal cancer, since it is a site of metastasis.
A total mesorectal excision (TME) is the gold standard for surgery of cancer in the
middle and lower thirds of the rectum and is defi ned as the complete excision of
the visceral mesorectal tissue to the level of the levators (Fig. 1.2 ) [ 4 ]. Technically
the mesorectum is not a mesentery however, as it does not conform to the defi nition
of “two layers of peritoneum that suspend an organ.”