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Ambulatory Surgery. Ambulatory Colorectal Surgery. Edited by Laurence R. Sands Dana R. Sands. Sands. Sands. Gastroenterology and Hepatology

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Gastroenterology and Hepatology A great single-source reference encompassing all aspects of colorectal surgery, Ambulatory Colorectal Surgery covers topics: patient evaluation anorectal anatomy anorectal
Gastroenterology and Hepatology A great single-source reference encompassing all aspects of colorectal surgery, Ambulatory Colorectal Surgery covers topics: patient evaluation anorectal anatomy anorectal ultrasound biofeedback techniques fecal incontinence evaluation and management wound management stoma management pain management anal fissure anorectal abscess proctalgia fugax about the editors... LAURENCE R. SANDS is Associate Professor of Surgery and Chief of the Division of Colon and Rectal Surgery at the University of Miami Miller School of Medicine, Miami, Florida, USA. He received his M.D. from Northwestern University, Chicago, Illinois, USA. Subsequently, he completed his general surgery residency at the Albert Einstein Medical Center in Philadelphia, Pennsylvania, USA. He then went on to do his colon and rectal surgery training at the Cleveland Clinic Florida, Weston, Florida, USA. He has worked at the University of Miami for 11 years and now serves as Chief of the Division of Colon and Rectal Surgery. Dr. Sands is a fellow of both the American College of Surgeons and the American Society of Colon and Rectal Surgeons. In addition, he has served as President of the South Florida Chapter of the American College of Surgeons and now serves as a Governor of the Chapter. DANA R. SANDS is a staff colorectal surgeon and Director of the Colorectal Physiology Center at the Cleveland Clinic Florida in the Department of Colon and Rectal Surgery in Weston, Florida, USA. Dr. Sands received her M.D. from Hahneman University, Philadelphia, Pennsylvania, USA. She completed her general surgery residency at the University of Miami/Jackson Memorial Hospital, Miami, Florida, USA. She completed her colon and rectal surgery training at the Cleveland Clinic Florida, Weston, Florida, USA. Dr. Sands then joined the busy the Cleveland Clinic Florida practice and was appointed a staff surgeon. She assumed the role as Director of the Colorectal Physiology Center and cares for patients with a broad spectrum of colorectal diseases and complex pelvic floor pathology. She is a fellow of both the American College of Surgeons and the American Society of Colon and Rectal Surgeons. Printed in the United States of America DK3420 Ambulatory Colorectal Surgery about the book Sands Sands Ambulatory Colorectal Surgery Edited by Laurence R. Sands Dana R. Sands Ambulatory Colorectal Surgery Ambulatory Colorectal Surgery Edited by Laurence R. Sands University of Miami Medical Center Miami, Florida, USA Dana R. Sands Cleveland Clinic Florida Weston, Florida, USA Informa Healthcare USA, Inc. 52 Vanderbilt Avenue New York, NY C 2009 by Informa Healthcare USA, Inc. Informa Healthcare is an Informa business No claim to original U.S. Government works Printed in the United States of America on acid-free paper International Standard Book Number-10: (Hardcover) International Standard Book Number-13: (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequence of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access ( or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Ambulatory colorectal surgery / edited by Laurence R. Sands, Dana R. Sands. p.;cm. Includes bibliographical references and index. ISBN-13: (hardcover : alk. paper) ISBN-10: (hardcover : alk. paper) 1. Colon (Anatomy) Surgery. 2. Rectum Surgery. 3. Ambulatory surgery. I. Sands, Laurence R. II. Sands, Dana R. [DNLM: 1. Colon surgery. 2. Ambulatory Surgical Procedures methods. 3. Digestive System Surgical Procedures methods. 4. Rectum surgery. WI 520 A ] RD544.A dc For Corporate Sales and Reprint Permissions call or write to: Sales Department, 52 Vanderbilt Avenue, 16th floor, New York, NY Visit the Informa Web site at and the Informa Healthcare Web site at Foreword The Editors are to be congratulated on their collaborative effort to provide colon and rectal surgeons and their trainees with an excellent resource for the management of anorectal and outpatient problems in colon and rectal diseases. The table of contents is comprehensive and contemporary. The chapters have been authored by young colon and rectal surgeons with experienced senior surgeons as coauthors in certain circumstances. The approach to each topic is well organized with adequate historical comment to provide background to modern therapy. This is a rapidly changing field and the authors have provided evidence for the use of each physiologic test, imagining technique, and therapeutic maneuver (medical or surgical). This is a concise, detailed, and practical treatise, which will be easily used as a reference in the clinic, physiology lab, and outpatient operating room. James W. Fleshman, M.D. Washington University School of Medicine, St. Louis, Missouri, U.S.A. Preface The face of medicine has changed significantly in the 21st century. Emphasis is placed on minimally invasive techniques and shorter hospitalization. This medical climate has challenged physicians to provide excellent care of increasingly complex problems often in the outpatient setting and frequently using multidisciplinary approaches. As such, we have been motivated to write a new colon and rectal surgery textbook capitalizing on the shifting practices of medicine in the 21st century. This book represents a compilation of office-based diagnoses, conditions, and treatments that are commonly encountered in general and colon and rectal surgical practices. Attention is paid to all facets of outpatient colorectal surgery including the evaluation and treatment of complex pelvic floor pathology. Many office-based outpatient conditions and anorectal diseases in general are often poorly understood. This disease spectrum is frequently glossed over in surgical training programs. Most surgical trainees today have limited access to the outpatient office setting, especially within the confines of the restricted working hours of residents. Conditions such as the ones reviewed in this book make up the core of many surgical practices. Therefore, we believe that this book will be useful to all practicing colon and rectal surgeons, general surgeons with an interest in anorectal disease, and particularly those young surgeons just completing their surgical training and starting in practice. The chapters are listed by condition and include a comprehensive review of the disease entity followed by the available diagnostic modalities and treatment options. The perioperative care is also included in order to provide the reader with a guide to the complete management of these patients. A review of the literature, both classic and new, will help the reader to gain a thorough understanding of each disease process. Prominent authors who have expertise in these areas have been brought together in this effort to bring some simplicity to the treatment of a group of common conditions, which are often ineffectively managed by physicians. Our hope is that this book will give surgeons the ability to manage the spectrum of diseases encountered in the outpatient setting and make a strong contribution to the welfare of all patients. The editors are especially thankful to the contributors who have taken time from their busy clinical practices to help in this endeavor and to Elektra McDermott, without whom, this project would not have been possible. We also wish to acknowledge and dedicate this book to our dear children, Ryan and Cory, from whom we have taken much time in the preparation of this project. Laurence R. Sands Dana R. Sands Contents Foreword James W. Fleshman... iii Preface.... v Contributors... ix Section I: Evaluation Tools 1. Patient Evaluation 1 Sanjay Jobanputra, T. Cristina Sardinha, and Marc E. Sher 2. Anatomy of the Rectum and Anus 7 José Marcio Neves Jorge and Newton Luiz T. Gasparetti, Jr. 3. Anorectal Physiology 21 Sherief Shawki and Dana R. Sands 4. Anorectal Ultrasound 45 Tracy Hull and Massarat Zutshi 5. Biofeedback Treatment for Functional Anorectal Disorders 55 Dawn Vickers Section II: Functional Disorders 6. Hemorrhoids: Office-Based Management 79 Dean C. Koh and Martin A. Luchtefeld 7. Hemorrhoids: Surgical Treatment 87 David J. Maron and Steven D. Wexner 8. Anal Fissure 103 Miguel del Mazo and Laurence R. Sands 9. Fecal Incontinence: Evaluation 109 Jaime L. Bohl and Roberta L. Muldoon 10. Fecal Incontinence: Office-Based Management 121 Tisha Lunsford and Jonathan Efron 11. Fecal Incontinence: Surgical Management 135 Juan J. Nogueras and Anne Y. Lin 12. Constipation: Evaluation and Management 141 Badma Bashankaev, Marat Khaikin, and Eric G. Weiss viii Contents 13. Urogynecologic Pelvic Floor Dysfunction 163 Vivian C. Aguilar and G. Willy Davila 14. Anorectal Pain 181 Jill C. Genua and David A. Vivas Section III: Septic Disorders 15. Anorectal Abscess 187 Orit Kaidar-Person and Benjamin Person 16. Fistula-in-Ano 203 Rodrigo Ambar Pinto, Cesar Omar Reategui Sanchez, and Mari A. Madsen 17. Pilonidal Disease 217 Jorge A. Lagares-Garcia and Matthew Vrees 18. Perianal Crohn s Disease 225 Marat Khaikin and Oded Zmora 19. Pruritis Ani 239 Eliad Karin and Shmuel Avital Section IV: Infectious Diseases 20. Viral Sexually Transmitted Diseases 245 Peter M. Kaye and Mitchell Bernstein 21. Bacterial Sexually Transmitted Diseases 251 David E. Beck and Johnny B. Green 22. Anal Intraepithelial Neoplasia 259 Patrick Colquhoun Section V: Perioperative Care Postoperative Care 23. Wound Management 267 Hao Wang, Badma Bashankaev, and Helen Marquez 24. Ostomy Management 283 Mary Lou Boyer 25. Perioperative Pain Management 305 Lawrence Frank 26. Perioperative Counseling 321 Norma Daniel and Arlene Segura Index Contributors Vivian C. Aguilar Section of Urogynecology, Department of Gynecology, Cleveland Clinic Florida, Weston, Florida, U.S.A. Shmuel Avital Department of Surgery A, Sourasky Medical Center, Tel Aviv, Israel Badma Bashankaev Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. David E. Beck Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana, U.S.A. Mitchell Bernstein Columbia University College of Physicians and Surgeons, and St. Luke s/roosevelt Hospital Center, New York, New York, U.S.A. Jaime L. Bohl Department of Surgery, Colon and Rectal Surgery Program, Vanderbilt University, Nashville, Tennessee, U.S.A. Mary Lou Boyer Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Patrick Colquhoun Department of Surgery, University of Western Ontario, London, Ontario, Canada Norma Daniel Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. G. Willy Davila Section of Urogynecology, Department of Gynecology, Cleveland Clinic Florida, Weston, Florida, U.S.A. Miguel del Mazo University of Miami Medical Center, Miami, Florida, U.S.A. Jonathan Efron Division of Colorectal Surgery, Mayo Clinic Arizona, Scottsdale, Arizona, U.S.A. Lawrence Frank Division of Anesthesiology, Cleveland Clinic Florida, Weston, Florida, U.S.A. Newton Luiz T. Gasparetti, Jr. Department of Gastroenterology, Colorectal Unit, Hospital das Clínicas, University of Sao Paulo, Sao Paulo, Brazil Jill C. Genua Colon and Rectal Surgeons of Connecticut, Stamford, Connecticut, U.S.A. Johnny B. Green Kitsap Colorectal Surgery, Bremerton, Washington, U.S.A. Tracy Hull Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A. Sanjay Jobanputra North Shore-Long Island Jewish Medical System, New Hyde Park, New York, U.S.A. José Marcio Neves Jorge Department of Gastroenterology, Colorectal Unit, Hospital das Clínicas, University of Sao Paulo, Sao Paulo, Brazil Orit Kaidar-Person Department of General Surgery B, Rambam Healthcare Campus, Haifa, Israel Eliad Karin Department of Surgery A, Sourasky Medical Center, Tel Aviv, Israel Peter M. Kaye Department of Surgery, St. Luke s/roosevelt Hospital Center, New York, New York, U.S.A. Marat Khaikin Department of Surgery and Transplantation, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel x Contributors Dean C. Koh The Ferguson Clinic, MMPC, Grand Rapids, Michigan, U.S.A. and Colorectal Unit, Department of Surgery, Tan Tock Seng Hospital, Singapore Jorge A. Lagares-Garcia R.I. Colorectal Clinic, LLC, Pawtucket, Rhode Island, U.S.A. Anne Y. Lin Department of Surgery, Division of Colorectal Surgery, Washington University, St. Louis, Missouri, U.S.A. Martin A. Luchtefeld The Ferguson Clinic, MMPC, Grand Rapids, Michigan, U.S.A. Tisha Lunsford Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, U.S.A. Mari A. Madsen Department of Colon and Rectal Surgery, Cedars Sinai Medical Center, Los Angeles, California, U.S.A. David J. Maron Department of Colon and Rectal Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A. Helen Marquez Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Roberta L. Muldoon Department of Surgery, Colon and Rectal Surgery Program, Vanderbilt University, Nashville, Tennessee, U.S.A. Juan J. Nogueras Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Benjamin Person Department of General Surgery B, Rambam Healthcare Campus, Haifa, Israel Rodrigo Ambar Pinto Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Arlene Segura Surgical Services, Cleveland Clinic Florida, Weston, Florida, U.S.A. Cesar Omar Reategui Sanchez Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Dana R. Sands Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Laurence R. Sands University of Miami Medical Center, Miami, Florida, U.S.A. T. Cristina Sardinha North Shore-Long Island Jewish Medical System, New Hyde Park, New York, U.S.A. Sherief Shawki Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Marc E. Sher North Shore-Long Island Jewish Medical System, New Hyde Park, and Albert Einstein College of Medicine, Bronx, New York, U.S.A. Dawn Vickers GI-GU Functional Diagnostics, Fort Lauderdale, Florida, U.S.A. David A. Vivas Cleveland Clinic Florida, Weston, Florida, U.S.A. Matthew Vrees R.I. Colorectal Clinic, LLC, Pawtucket, Rhode Island, U.S.A. Hao Wang Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Eric G. Weiss Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida, U.S.A. Steven D. Wexner Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida; Ohio State University Health Sciences Center, Columbus, Ohio; University of South Florida College of Medicine, Tampa, Florida, U.S.A. Oded Zmora Department of Surgery and Transplantation, Sheba Medical Center, Sackler School of Medicine, Tel Aviv, Israel Massarat Zutshi Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A. 1 Patient Evaluation Sanjay Jobanputra and T. Cristina Sardinha North Shore-Long Island Jewish Medical System, New Hyde Park, New York, U.S.A. Marc E. Sher North Shore-Long Island Jewish Medical System, New Hyde Park, Albert Einstein College of Medicine, Bronx, New York, U.S.A. INTRODUCTION Over the past few decades, there have been vast changes in the practice of surgery. Sutures and sewing have been ever increasingly replaced by stapling devices. Generous incisions are being replaced by small port sites. These advances have also been accompanied by cost-reducing measures. Elective inguinal hernia repair is no longer a three day hospital stay, but rather a three hour experience. During this time period, the concept of ambulatory surgery, surgery not requiring in-patient hospitalization, has become a reality. This includes patients who undergo surgery where they are admitted a few hours prior to surgery and discharged a few hours after surgery, or patients who are admitted for a 23-hour stay. The field of colorectal surgery, especially anorectal surgery, has accepted and welcomed this change. Ambulatory colorectal surgery has proven to be both safe and cost-effective (1). However, careful preoperative patient assessment and optimization, along with proper surgical planning, are required to ensure a safe outcome. In addition to a thorough history and physical examination, appropriate laboratory, radiologic, and endoscopic tests are part of the preoperative armamentarium. Moreover, anesthetic and surgical technique must be individualized for every patient and explained to the patient during the office consultation. During this evaluation, a risk-assessment system is also used to better predict the outcome of the procedure to be performed. Furthermore, adequate preoperative education to be provided by the colorectal surgeon or by a member of the surgical team familiar with the procedure will provide comfort and minimize the patient s anxiety. CHOICE OF PROCEDURE Despite a growing number of procedures being safely performed at ambulatory centers, there are still limitations. Therefore, the choice of the procedure must be carefully made by the colorectal surgeon prior to determining the setting of the surgery. In the realm of colorectal surgical procedures, ambulatory surgery is limited predominantly to anal and rectal surgery. Although not comprehensive, a list of acceptable ambulatory procedures is outlined in Table 1. Intra-abdominal colorectal surgery, whether by conventional laparotomy or laparoscopic approach, has not yet made its way to the ambulatory setting. Postoperative issues such as prolonged ileus, intravenous fluid requirements, and postoperative pain management continue to require inpatient care after intra-abdominal colorectal surgery. Table 2 lists some of the relative contraindications to ambulatory surgery. PATIENT EVALUATION Patient evaluation for ambulatory surgery begins with a thorough history and physical examination. The history should first focus on the nature of the disease process to assist in making the correct diagnosis. The history should also elicit information that would be important for planning different treatment options. From the history, the physician should be able to assess 2 JOBANPUTRA ET AL. Table 1 Acceptable Ambulatory Procedures Examination under anesthesia Incision and drainage of peri-rectal abscess Treatment of anal fistula Treatment of anal fissure Treatment of pilonidal sinus Treatment of anal condyloma Treatment of hemorrhoidal disease Transanal excision of rectal lesions Endoscopy what type of surgery the patient will require, and also based on the patient s condition and proposed procedure, the appropriate setting for the planned procedure. For example, a 25- year-old healthy female undergoing an elective hemorrhoidectomy will differ greatly from a 65-year-old male with a history of congestive heart failure, recent myocardial infarction, and
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