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13. Surgical Management of Constipation 285
A
Abdominoperineal resection, after
failure of radiation, for anal
cancer, 128
Abdominosacrectomy, inoperable
rectal cancer, 183–184
Adenocarcinoma, anal canal, 123
Adenoma, colonoscopic view, 27
Adenomatous polyposis, familial,
38–44
11307K (3920 T to A), 44
clinical features, diagnosis, 39–40
E1317Q (3949 G to C), 44
genetics, genotype-phenotype
correlation, 40–42
management, 42–44
nontruncating variants of APC gene,
44
Adjuvant therapy, benefits of, 199
Advancement flaps, Crohn’s disease,
102–103
Age
diagnostic value of rectal bleeding
and, 12
prevalence of cancer, in patients with
rectal bleeding, 13
symptom profiles and, 10
Amsterdam criteria II, 31
for diagnosis of hereditary non-
polyposis colorectal cancer, 45
Anal canal, 215
endosonographic layers, 228
males, females, variation in anatomy
of, 229
three-dimensional imaging, 231
Anal gland adenocarcinoma, anal
canal, 123
Anal manometry, 218–224
electromyography, 223
pudendal nerve terminal motor
latency, 219, 223–224
rectal compliance, 223
rectal sensation, 222–223
rectoanal inhibitory reflex, 222
test available, 218
vector volume manometry, 222
Anal-canal bulking agents, with faecal
incontinence, 254
Anal-canal tumours, malignant, 115–134
anatomic features, 115–116
chemoradiation salvage after local
resection, 129
classification, 121–122
diagnosis, 120
evaluation after treatment, 129
histology, 122
inguinal lymphadenectomy, 127
local excision, 124–125
location, 121–122
preoperative chemotherapy, 125–127
radiation, 125–127
presentation, 116–117
radiation, 125–127
recurrent disease, 127–128
surgical salvage, 127–128
risk factors, 117–120
cervical cancer and, 118–119
chronic immunosuppression, 120
HIV infection, 119
smoking, 120
Index
287
288 Index
Anal-canal tumours, malignant, (cont.):
screening, 130–131
surgical salvage, 127–128
treatment, 122–127
Anismus, defaecating proctogram,
obstructed defaecation, 274
Anorectal angle, 215–216
Anorectal fistula, 123
Anorectal stricture, Crohn’s disease,
105–106
Antibiotics, in Crohn’s disease, 64–65
Anus, carcinoma of, WHO
classification, 123–124
Artificial anal sphincter, vs. dynamic
graciloplasty, with faecal
incontinence, 252–253
Artificial bowel sphincter, with faecal
incontinence, 251–252
ATZ, anal canal, anal margin, 121
Autonomic injury, 147
Azathioprine, in Crohn’s disease, 63,
108
Azathioprine/6-MP, in Crohn’s disease,
61
B
Barium enema, double-contrast,
carcinoma in sigmoid colon, 27
Basal-cell carcinoma, 123
Basaloid tumour, anal canal, 123
Benign proctectomy, 145–148
autonomic injury, 147
dissection of rectal stump, 145–147
Biofeedback, with faecal incontinence,
247–248
Biological therapies, in Crohn’s disease,
65–76
Bleeding, rectal
cancer risk in community, in primary
care, 9–12
change in bowel habit, 12
with change in bowel habit, 10
characteristics of, 10–12
dark red bleeding, 10–11
delays in treatment, 6
diagnostic value of, 12
earlier diagnosis, survival and, 6–7
for identification of cancer, 1–21
incidence rates, 3
in inoperable rectal cancer, 186–187
with low risk of cancer, 14–15
manifestation of rectal bleeding, 11
palpable rectal mass, 11–12
symptom profiles, 10
Bowen’s disease, 123
Bulking agents, with faecal
incontinence, 254
C
Cancer. See also specific type of
low risk of, patient management and,
9
risk in community, bleeding and,
9–12
WHO classification, anal, 123–124
CDP571, in Crohn’s disease, 68–69
Cervix, cancer of, malignant anal-canal
tumours and, 118–119
Change in bowel habit, rectal bleeding
and, 10, 12
Changes in rectal wall, 216–217
Chemoradiation, in inoperable rectal
cancer, 184–185
Chemotherapy
in colorectal cancer, 191–201
in inoperable rectal cancer, 175–176
in malignant anal-canal tumours,
preoperative, 125–127
Chimeric anti-tumour necrosis-factor
antibody, 60
Cholecystokinin provocation test,
delayed gallbladder emptying,
265
Chronic immunosuppression,
malignant anal-canal tumours,
120
Chronic ulcerative colitis,
predisposition to, 53
Ciprofloxacin, Crohn’s disease, 107–108
CNI-1493, in Crohn’s disease, 70–71
Colitis, ulcerative, chronic,
predisposition to, 53
Collateral damage, in pelvic surgery,
139–145
Colonic carcinoma, 23
Colonic transit studies, 236–239
normal, with rectal bleeding, 5–7
Colonoscope, 25
Index 289
Colorectal cancer
familial, 37–58
chronic ulcerative colitis,
predisposition to, 53
familial adenomatous polyposis,
38–44
family history, 38
future developments, 53–54
hamartomatous polyposis
syndromes, 50–51
hereditary non-polyposis
colorectal cancer, 45–50
inherited syndromes predisposing
to colorectal cancer, 38–52
MYH polyposis, 51–52
risk, in absence of defined genetic
cause, 52–53
family history, surveillance protocols,
43
gene therapy, 204
hereditary non-polyposis, 45–50
age at diagnosis, cancer risk, 47
clinical features, diagnosis, 46–47
genetics, 45–46
management, 47–50
screening, 31–33
immunotherapy, 202–204
inherited risk, 32
mechanistically novel cytotoxics,
195–198
irinotecan, 195–197
oxaliplatin, 198
modulation of, 194–195
new approaches to treatment,
202–204
oncologist’s role, 191–208
radiotherapy, 201–202
recombinant virus vaccines, 204–205
screening for, 22–36
cost effectiveness of, 28
ethical dilemmas in population
screening, 28–29
individuals screened, 26–28
test(s), 23–26
Colorectal surgeon, in pelvic surgery,
137
Coloproctology
with constipation, 262–285
Crohn’s disease
medical treatment of, 59–92
perianal, management of, 93–114
faecal incontinence, innovations in
treatment of, 244–261
familial colorectal cancer, 37–58
functional bowel disorders,
investigation of, 209–243
inoperable rectal cancer,
management of, 171–190
malignant anal-canal tumours,
115–134
oncologist, role of, 191–208
pelvic floor, functional
reconstruction of, 154–170
pelvic surgery, intraoperative
problems, 135–153
perineum, functional reconstruction
of, 154–170
rectal bleeding, for identification of
cancer, 1–21
screening, colorectal cancer, 22–36
Combined chemoradiation, results of,
126
Community, cancer risk in, bleeding
and, 9–12
Computed tomography, in pelvic
surgery, 136
Constipation
delayed colonic transit study
abnormal proctogram, 276
normal proctogram, 264–268
flow chart for investigation of,
264
investigations, 263–277
megabowel, 277–280
normal caliber colon/rectum, severe
constipation and, 263–280
normal colonic transit study
abnormal proctogram, 268–275
normal proctogram, 276–277
surgical management, 262–285
Consultant surgical personnel, in pelvic
surgery, 137
Correlation of position of, 42
Corticosteroids
in Crohn’s disease, 61–63
Cost effectiveness, screening for
colorectal cancer, 28
Cowden syndrome, 51
290 Index
CR07 trial, schematic representation
of, 203
Crohn’s disease, 59–92
abscess, management of, 96–98
antibiotics, 64–65
5-ASAs in Crohn’s disease, 64
azathioprine, 63
biological therapies, 65–76
CDP571, 68–69
CNI-1493, 70–71
corticosteroids, 61–63
cyclosporin, 64
cytokine manipulation, 71–72
anti-IFN-y, 72
anti-IL 12, 72
anti-IL-2 receptor antibodies, 72
anti-IL-18, 72
IFN-y, 72
IL-10, 71–72
dietary therapy, 78–84
efficacious drugs in, comparative
features, 61
enteral nutrition, 80–82
established treatment, 62–65
etanercept, 69
exclusion diets, 83–84
fish oils, 82–83
growth, development, 79
infliximab, 66–68
lymphocyte trafficking inhibition,
72–74
6-mercaptopurine, 63
medical treatment of, 59–92
methotrexate, 76
evidence for efficacy, 76
future questions, 78
side-effect profile, 77
microparticle diets, 83–84
new therapies, 65
nutritional therapies, 78–79
onerecpt, 69–70
perianal, 93–114
classification of, 94–95
initial assessment, 95–96
manifestations of, 93
medical management, 107–109
probiotics, 83
targets for new therapy in, 60
thalidomide, 70
total parental nutrition, 79–80
Crohn’s gracilis, 151
Cyclosporin, Crohn’s disease, 64
Cystoscopy, pelvic surgery, 136
Cytokine manipulation, in Crohn’s
disease, 71–72
anti-IFN-y, 72
anti-IL 12, 72
anti-IL-2 receptor antibodies, 72
anti-IL-18, 72
IFN-y, 72
IL-10, 71–72
Cytotoxics. See also under specific
cytotoxic agent
mechanistically novel, 195–198
D
Dark red bleeding, 10–11
Defaecating proctogram, anismus,
obstructed defaecation, 274
Delayed colonic transit study
abnormal proctogram, surgical
management, 276
normal proctogram, surgical
management, 264–268
Delays in treatment, after rectal
bleeding, 6
Diagnosis of colorectal cancer, early,
survival and, 6–7
Dietary therapy, in Crohn’s disease,
78–84
Discharge, inoperable rectal cancer,
186
DNA, microsatellite instability,
hereditary non-polyposis
colorectal cancer, 46
Double-contrast barium enema,
carcinoma in sigmoid colon, 27
Dynamic graciloplasty, versus artificial
anal sphincter, with faecal
incontinence, 252–253
E
Electromyography, 223
Encirclement procedures, with faecal
incontinence, 249–250
Endo-anal ultrasound, 224–236
combined internal, external sphincter
defect, 232
Index 291
Crohn’s disease, 95–96
faecal incontinence, 230–235
solitary rectal ulcer syndrome,
235–236
technique, instrumentation, 225–230
Endoanal ultrasound scanner, by
Bruel, Kjaer, 225
Endometrial hereditary non-polyposis
colorectal cancer, 47
Endosonographic layers, anal canal,
228
Enteral nutrition, in Crohn’s disease,
80–82
Epithelial tumours, anal canal, 123
Etanercept, in Crohn’s disease, 69
Ethical dilemmas in population
screening, 28–29
Excisional pelvic surgery, mental,
physical consequences, 137
Excisional problems, in pelvic surgery,
145–150
Exclusion diets, in Crohn’s disease,
83–84
Excretion renogram, in pelvic surgery,
136
Exenterative procedures, inoperable
rectal cancer, 182–183
External sphincter defect, endo-anal
ultrasound demonstration of,
232
F
Faecal incontinence, 244–261
anal-canal bulking agents, 254
artificial bowel sphincter, 251–252
biofeedback, 247–248
dynamic graciloplasty versus artificial
anal sphincter, 252–253
encirclement procedures, 249–250
endo-anal ultrasound, 230–235
medical management, pharmacology,
246–247
new techniques, 249–254
sacral nerve stimulation, 253–254
sphincter repair, 248–249
Faecal loading, within
megacolon/megarectum, 278
Familial adenomatous polyposis, 38–44
11307K (3920 T to A), 44
clinical features, diagnosis, 39–40
E1317Q (3949 G to C), 44
genetics, genotype-phenotype
correlation, 40–42
macroscopic appearance of colon, 39
management, 42–44
nontruncating variants of APC gene,
44
screening, 30–31
Familial colorectal cancer, 37–58
chronic ulcerative colitis,
predisposition to, 53
familial adenomatous polyposis,
38–44
11307K (3920 T to A), 44
clinical features, 39–40
E1317Q (3949 G to C), 44
genetics, genotype-phenotype
correlation, 40–42
inherited colorectal cancer risk, 44
management, 42–44
nontruncating variants of APC
gene, 44
family history, 38
future developments, 53–54
hamartomatous polyposis
syndromes, 50–51
Cowden syndrome, 51
juvenile polyposis syndrome,
50–51
Peutz-Jeghers syndrome, 50
hereditary non-polyposis colorectal
cancer, 45–50
clinical features, 46–47
genetics, 45–46
management, 47–50
inherited syndromes predisposing to
colorectal cancer, 38–52
MYH polyposis, 51–52
risk factors, 52
in absence of defined genetic
cause, 52–53
Family history of colorectal cancer,
surveillance protocols, 43
Fish oils, in Crohn’s disease, 82–83
5-fluorouracil, 192–195
mechanism of action of, 193
with other agents, biomodulation,
193–194
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