Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Persistent fecal incontinence options: conservative management (scheduled enemas, antidiarrheals, etc), implantation of
artificial bowel sphincter, MACE procedure, colostomy.
Cross-Reference
Incontinence (Ch. 1)
Anophysiology studies (Ch. 2)
Embryologic colorectal development (Ch. 3)
Fecal incontinence (787.6) (Ch. 4)
Pediatrics—congenital agangliotic megacolon (Hirschsprung disease, 751.3) (Ch. 4)
Implantation of artificial bowel sphincter (ABS) (Ch. 5)
PEDIATRICS—ACQUIRED COLORECTAL PROBLEMS
Overview
In addition to the problems of and around congenital anorectal malformations, children may present with a number of
specific pediatric colorectal conditions, as well as with a wide array of colorectal problems that are known from but not limited
to adult patients, eg, fissure, fistula/abscess, constipation. Most of these problems are dealt with in similar fashion, adjusted
to the patient's age and ability to understand and participate in the treatment plan.
1. Constipation/encopresis:
a. Dietary, social, and psychological issues.
b. Rarely: morphologic problems.
2. Skin pathology:
a. Diaper rash: toxic effect of stool/urine within occlusive confinement of diapers.
b. Contact dermatitis: to ointments, creams, soap, etc.
c. Candidiasis: inflammatory rash, frequently with enhanced margins.
d. Erythrasma: bacterial infection (Corynebacterium minutissimum)
diagnosis made using the Wood lamp.
e. Mollusca contagiosa: clusters of small round papulous lesions, viral infection (molluscum contagiosum virus,
belongs to DNA Poxviridae).
3. Parasites:
a. Pinworm infection (Enterobius vermicularis): perianal pruritus, particularly at night
tape test.
b. Other worm/parasite infestation.
4. Anal pain/bleeding:
a. Anal fissure: most commonly acute (constipation, transition to potty training)
resolution with stool
management, glycerin suppositories, milk of magnesia.
b. Hemorrhoids: rare in children but not impossible.
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
c. Perirectal abscess/-fistula.
d. Anal irritation: secondary to diarrhea, fissure, prolapse, etc.
5. Rectal prolapse:
a. Risk factors: malnutrition, cystic fibrosis, chronic constipation.
6. GI/colonic pathology:
a. Intussusception.
b. Meckel diverticulum:
bleeding, pain, intussusception.
c. Necrotizing enterocolitis.
d. Intestinal malrotation.
e. Polyps:
(1) Hamartomatous polyps: juvenile polyps, Peutz-Jeghers, juvenile polyposis, etc.
(2) Hyperplastic polyps.
(3) Inflammatory polyps.
(4) Adenomatous polyps.
7. Sexual abuse:
a. Anal canal trauma.
b. Condyloma acuminata?
Cross-Reference
Bleeding per rectum (Ch. 1)
Constipation (Ch. 1)
Skin rash (Ch. 1)
Embryologic colorectal development (Ch. 3)
Anal fissure (565.0) (Ch. 4)
Trauma (803.X) (Ch. 4)
Functional disorders—chronic constipation (564.0X) (Ch. 4)
Pediatrics—congenital aganglionic megacolon (Hirschsprung disease, 751.3) (Ch. 4)
Pediatrics—congenital malformations (751.2) (Ch. 4)
Medications for GI tract (App. 1)
COMPLICATIONS—URETERAL INJURY (997.5)
Complication
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Injury to the ureter may be recognized either during surgery or in the postoperative period (urine leak, urinoma, uremia,
hydronephrosis, etc). Incidence ~0.2%.
Typical sites of the injury:
Retroperitoneal in proximity to left colonic vascular stalk.
Entry to the pelvis, crossing iliac vessels.
Pelvis at anterolateral entry to the bladder.
Differential Diagnosis
Bladder injury, urethral injury.
Causes
Inadequate visualization of course of the ureter, lack of verification of ureteral position prior to transecting the
vascular stalk, scarred retroperitoneum after previous surgery or inflammatory process (eg, severe diverticulitis).
Injury mechanism: transection, segmental resection, ligation or crushing with clamp (imprecise bleeding control),
denudation of the ureter.
Preventive measures: ureteral stent placement for anticipated intraoperative difficulties, lighted stents available for
laparoscopic procedures.
Not discussed here: intentional transection of the ureter because of disease involvement (eg, cancer).
Evaluation
REQUIRED MINIMAL STANDARD
Intraoperative suspicion/recognition: verification with indigo carmine extravasation surgical clarification of
anatomy, urology consult (if available).
Recognition in postoperative period:
– Drain with suspicious output:
IV indigo carmine, elevation of creatinine in drain fluid (compared with
serum).
– No drain and further investigation:
imaging studies to confirm and localize injury: ultrasound, CT, IV
urogram, retrograde ureteropyelography.
Cofactors for Decision-Making Process
Intra- or postoperative recognition? time since last exploration: hostile abdomen?
Retrospectoscope on intraoperative difficulties clue about location of injury.
Current patient condition: sepsis, hemodynamic stability?
Management
TIMING
Intraoperative: immediate repair.
Postoperative early (< 7 days postoperatively): reexploration and post-primary repair.
Postoperative late (> 7 days): temporizing measures (eg, percutaneous nephrostomy tubes, stent, etc) secondary
repair/reconstruction (either through laparotomy or through extraperitoneal access) after 6–12 weeks.
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
OPERATIVE APPROACH
Ureteral stenting alone: if minor injury without stenosis reevaluation after 3–6 weeks.
Ureteroureterostomy with/without limited ureteral resection: direct spatulated watertight ureteral anastomosis over
double J-stent
removal of stent after 3–6 weeks.
Ureteroneocystostomy: resection and reimplantation of ureter with appropriate antireflux technique into bladder.
Ureteroneocystostomy with psoas hitch: transverse incision of ipsilaterally mobilized bladder dome vertical closure
to result in elongation of bladder, fixation of bladder in place by nonabsorbable sutures to tendinous part of psoas
muscle, reimplantation of ureter.
Transureteroureterostomy: if insufficient length to reach bladder transposition and anastomosis of injured ureter to
contralateral ureter.
Further techniques: Boari flap (creation of conduit from bladder dome flap), intestinal conduit.
Cross-Reference
Liability in colorectal surgery (Ch. 2)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
Proctocolectomy, ileal J-pouch anal anastomosis (open) (Ch. 5)
Low anterior resection (LAR)/total mesorectal excision (TME) (Ch. 5)
COMPLICATIONS—POSTOPERATIVE ILEUS (546.3)
Complication
Postoperative ileus is an expected motility disorder of the intestinal tract after an operation and general anesthesia.
Prolonged postoperative ileus, however, is a dysmotility persisting beyond this expected time frame.
1. Delayed recovery of upper GI function (small bowel, stomach: normal 24–48 hours):
a. Lack of appetite, inability to tolerate or advance oral intake, epigastric fullness or pressure, heartburn,
burping, later progression to nausea and vomiting.
b. If NGT already in correct position: persistent high output.
2. Delayed recovery of lower GI function (colon: normal 2–4 days):
a. Increasing abdominal distention, diffuse rather than colicky discomfort, lack of passage of flatus or stool:
progression to nausea and vomiting as late symptoms of lower GI dysfunction.
b. It is not possible that upper GI function initially recovers timely, but that the patient subsequently
experiences setback secondary to delayed recovery of lower GI function.
3. Systemic effects of prolonged postoperative ileus:
a. Loss and third-spacing of fluids, electrolyte and acid-base abnormalities, tachycardia, later hypotension.
b. Malnutrition if ileus persists beyond 5 days.
Differential Diagnosis
Local problem: anastomotic leaks, mechanical bowel obstruction (eg, kinking, volvulus, internal hernia, adhesions), persistent
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
ischemia, interloop abscess, aspiration, etc.
Systemic problem: congestive heart failure; steroid deficiency
ileus may be the first and subtle symptom of a relative
deficiency (particularly in patients with history of steroid medication, eg, IBD).
Causes
Exact pathogenesis for postoperative ileus unclear. Speculations: intrinsic vs extrinsic factors (Table 4–13):
Any condition interfering with normal and relatively labile equilibrium of intestinal motility and propulsion activation
of central nervous system reflex pathways and sympathetic system
disorganized irregular electrical activity
paralysis of particular bowel segment.
Focal morphologic alteration of bowel (injury, disease or inflammation) interruption/reversal of antegrade
propagation of coordinated contractions.
Inflammatory cascade: release of active mediators (eg, nitric oxide) and proinflammatory cytokines which inhibit
intestinal motility.
Opiate-mediated (
2
receptors) inhibition of intestinal smooth muscle contractility.
Table 4–13. Triggers of Postoperative Ileus.
Category Conditions
Peritoneal impact Laparotomy, blunt/penetrating abdominal trauma
Infection Peritonitis, sepsis, SIRS
Drugs Anesthesia, exogenous/endogenous opiates, psychotropics, anticholinergics
Cardiopulmonary failure Right ventricular failure, low cardiac output, hypoxia
Vascular Underperfusion, portal hypertension, portal vein thrombosis
Retroperitoneal/mediastinal pathology Hematoma, infection
Spinal disorder Vertebral fracture, spinal cord injury
Metabolic disorders Hyponatremia, hypokalemia, hypomagnesemia, uremia, diabetic coma
Endocrine disorders Adrenal insufficiency, diabetes, hypothyroidism
SIRS, systemic immune response syndrome.
Evaluation
REQUIRED MINIMAL STANDARD
Rule out evidence of leak: overall condition, tachycardia (may initially be the only symptom), fever, sepsis with organ
dysfunction, hemodynamic stability, nutritional status, disproportional pain, etc.
Abdominal exam: diffuse peritoneal signs, wound infection.
Imaging studies:
– Abdominal series and chest x-ray: evidence of increasing rather than decreasing extraluminal air?
– Water-soluble contrast enema: leak?
– CT scan: abscess, fluid collection, transition point?
Cofactors for Decision-Making Process
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Retrospectoscope on nature of the disease, intraoperative findings and difficulties.
Current patient condition (general, local)?
Index of suspicion for problem other than dysmotility?
Chance to surgically improve condition?
Timing since last exploration?
Management
PREVENTION DURING INDEX OPERATION
Emergency indication: aggressive and timely management to minimize exposure time of bowels to negative impacts
(eg, fecal or purulent contamination).
Elective surgery: optimization of patient's general condition and nutritional status.
Surgeon- and surgery-related factors:
– Minimize extent and duration of intraoperative trauma, exposure to room air, lower body temperature.
– Need for adhesiolysis, enterotomies, devascularization, blood loss.
– Laparoscopic rather than open approach if feasible.
Pain management:
– Exogenous opiates or endogenous opiate pathways
inhibitory effect on smooth muscle contractility.
– Preferential use of nonopiate drugs (eg, NSAIDs)
reduce opiate consumption, positive effect on ileus
resolution by inhibition of prostaglandin-mediated inflammation and depression of smooth muscle contractility.
– Opiate antagonists reverse intestinal dysmotility: naloxone
unspecific (increased pain); alvimopan,
methylnaltrexone
specific competitive -receptor antagonists not crossing blood-brain barrier.
– Thoracic epidural anesthesia: analgesia without intestinal/respiratory depression, pharmacologic
sympathectomy
promoting intestinal motility.
Fast-track postoperative management.
CONSERVATIVE MANAGEMENT
Correction of electrolyte and acid-base imbalances, fluid resuscitation.
History of steroid medication stress dose of 100 mg hydrocortisone IV.
Placement of NGT for decompression, prevention of repeated vomiting, and to reduce aspiration risk.
Optimization of underlying comorbidities, eg, cardiopulmonary function, renal function, diabetes, adrenal insufficiency,
hypothyroidism.
Ileus > 5 days or preexisting malnutrition parenteral nutrition.
Pharmacologic treatment:
– Nausea
metoclopramide, odansetron.
– Prokinetics
erythromycin (no proven benefit), neostigmine, metoclopramide, tegaserod maleate (currently
not available)?
OPERATIVE APPROACH
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Early abdominal reexploration:
– Evidence of surgical complication within 7–10 days.
– Suspicion of mechanical SBO within 7–10 days.
Late abdominal exploration:
– Persistent ileus/SBO after 4 weeks.
Cross-Reference
Pain, abdominal (Ch. 1)
Small bowel obstruction (SBO) (Ch. 1)
Liability in colorectal surgery (Ch. 2)
Small bowel follow-through (SBFT) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Complications—leak (997.4) (Ch. 4)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
COMPLICATIONS—LEAK (997.4)
Complication
Postsurgical evidence (abscess, fistula, sepsis) for extravasation of enteric content or contrast from intestines, either from
anastomotic dehiscence or unrecognized enterotomy. Diagnosis based on clinical symptoms (eg, peritonitis, sepsis), clinical
suspicion (low-grade fever, elevated WBCs, unexplained tachycardia, persistent bowel dysfunction), or radiologic
documentation in otherwise asymptomatic patient (eg, if proximally diverted). Incidence: rectum 5–10%, colon 2%, small
bowel 1%, IPAA 4–5%, continent ileostomy 12%.
Differential Diagnosis
Abscess not in connection to intestines (eg, infected hematoma, postdiffuse peritonitis).
Causes
Technical error, insufficient blood supply, tension, poor tissue quality (postradiation, malnutrition, active infection), drug
effect (steroids, bevacizumab, other chemotherapy agents), smoking.
Prophylactic proximal diversion does not prevent a leak but reduces septic sequelae.
Evaluation
REQUIRED MINIMAL STANDARD
Assessment of patient's overall condition: tachycardia (may initially be the only symptom), sepsis with organ dysfunction,
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
hemodynamic stability, nutritional status, etc.
Abdominal exam: diffuse peritonitis, enterocutaneous fistula, wound condition.
Leak suspected but not confirmed: water-soluble contrast enema, CT scan.
Cofactors for Decision-Making Process
Retrospectoscope on intraoperative difficulties.
Current patient condition (general, local)?
Leak confined or causing diffuse peritonitis?
Chance for a better surgical anastomosis?
Timing since last exploration?
Management
CONSERVATIVE
Confined leak CT-guided abscess drainage confined fistula.
Diverted leak reassessment after 6–12 weeks.
Leak with sepsis supportive measures in conjunction to surgery: NGT, antibiotics, cardiopulmonary optimization.
OPERATIVE APPROACH
Early symptomatic leak (< 7–10 days) abdominal reexploration for damage control:
– Diversion and drainage.
– Takedown of anastomosis and ostomy (Hartmann type).
– Redo-anastomosis (with/without diversion).
– Often bowels rigid from inflammation
neither resection nor stoma possible repair/drainage or placement
of drain into the leak with goal to create confined fistula.
Later recognition of leak (> 10 days) hostile abdomen:
– Proximal diversion (if possible).
– Attempt to control sepsis CT-guided or open drain placements attempt to create confined fistula.
– Diffuse peritonitis/sepsis
damage control laparotomy with wide drainage.
Cross-Reference
Pain, abdominal (Ch. 1)
Small bowel obstruction (SBO) (Ch. 1)
Sepsis (Ch. 1)
Liability in colorectal surgery (Ch. 2)
Small bowel follow-through (SBFT) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
Enterocutaneous fistula (569.81) (Ch. 4)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
COMPLICATIONS—STOMA NECROSIS (569.60)
Complication
Dusky appearance of newly created ostomy.
Differential Diagnosis
Traumatized stoma, hematoma, mucosal sloughing only.
Causes
Inadequate blood supply: insufficient mobilization of the intestine, inadequate opening in the abdominal wall (
strangulation), internal wrapping of bowel around stoma ( strangulation), morbid obesity with huge abdominal pannus and
thickened mesentery, independent ischemic event (embolus, thrombus).
Evaluation
REQUIRED MINIMAL STANDARD
Assessment of patient's overall condition: septic, hemodynamic stability, etc.
Assessment of the extent of necrosis: insertion of test tube + illumination with flashlight:
Dark mucosa limited to epifascial segment, pink mucosa visible below.
Dark mucosa extending below the fascia level.
Cofactors for Decision-Making Process
Retrospectoscope on intraoperative difficulties.
Current patient condition?
Ostomy intended as temporary or permanent? initially intended time frame for reversal?
Onset of complication compared with its creation: if > 2 weeks postoperatively has the distal site (eg,
anastomosis) already healed?
Management
TIMING
Subfascial urgent revision, otherwise risk of intraperitoneal perforation: abscess, enterocutaneous fistula, sepsis.
Epifascial acceptance of stricture elective stoma revision or takedown.
OPERATIVE APPROACH
Acute:
– Early after stoma creation: reexploration better mobilization of intestine, wider abdominal wall opening, thinning of
abdominal pannus, possible relocation, possible selection of different bowel segment (eg, transverse colon instead of
AccessSurgery | Print: Chapter 4. Diseases and Problems
file:///C|/...RIANA/McGrawHillManual%20ColorectalSurgery%201stEdition/Chapter%204_%20Diseases%20and%20Problems.htm[9/5/2009 19:15:58]
ileum).
– > 2 weeks after stoma creation: consider exploration with definitive takedown of temporary ostomy, if healing of
distal site confirmed (clinical, endoscopic, contrast enema).
Elective: stoma revision or relocation vs stoma takedown.
Cross-Reference
Large bowel obstruction (LBO) (Ch. 1)
Small bowel obstruction (SBO) (Ch. 1)
Liability in colorectal surgery (Ch. 2)
Contrast enemas (Ch. 2)
Small bowel follow-through (SBFT) (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
"Stomatology"—the science of ostomies (V44.2) (Ch. 4)
Complications—postoperative ileus (546.3) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
Creation of end-ileostomy or -colostomy (Ch. 5)
Ileostomy takedown (Ch. 5)
General perioperative management—abdominal (Ch. 7)
Fast-track recovery (Ch. 7)
COMPLICATIONS—DELAYED WOUND HEALING (998.3)
Complication
Failure of a wound to close in a timely manner, either defined by persistently unfavorable wound appearance or a time frame
> 3 months.
Differential Diagnosis
Perirectal or enterocutaneous fistula, suture granulomata, decubitus ulcer.
Causes
Wound infection (5–10% incidence, particularly if multidrug-resistant bacteria involved, eg, MRSA, pseudomonas, etc),
inadequate blood supply (eg, flaps), tension, formation of deeper pockets, persistent feeding of the wound from deeper
abscess or fistula, continued fecal contamination, obesity, infected foreign body (eg, mesh), neglected wound care, diabetes,
immunosuppression, malnutrition, immobility, drug effect (steroids, infliximab, bevacizumab, other chemotherapy agents).
Evaluation
REQUIRED MINIMAL STANDARD