Improved Outcomes in Colon and Rectal Surgery part 42 pot

Bladder dYsFUnCtiOn The reported incidence of difficulty in reestablishing micturation ranges from 15 to 25% after low anterior resection and up to 50% after abdominoperineal resection.3

can be used to aid in diagnosis of ureteral injury by retrograde

injection of methylene blue through the ureteral catheter They

can also be used to place a retrograde wire under fluoroscopic

guidance for placement of an indwelling ureteral double-J stent

after a ligation/crush injury

Types of Injury

Laceration

A laceration or transection of the ureter can usually be repaired

with primary anastamosis (ureteroureterostomy with spatulated

ends), ureteral stent, and placement of a closed suction drain in

the area of the repair (Figure 36.3)

Ligation

If a ligation injury is apparent intraoperativly, the clamp or tie can

be removed followed by ureteral stent placement for up to one

month The patient should undergo repeat imaging either with a

renal ultrasound or intravenous pyelogram (IVP) at 3 months to

ensure a ureteral stricture has not developed If the injury is not

identified until post operatively, a retrograde ureterogram and

stent placement or percutaneous nephrostomy tube placement

may be needed before surgical correction

Devascularization

A devascularization injury will not be evident intraoperatively

and results from the sacrifice of the segmental ureteral blood supply

Intraoperativley a devascularized ureter may appear discolored,

lack peristalsis, and may not bleed at a transected site The irradi-ated ureter is especially susceptible to this type of injury, as the normal healthy ureter has numerous collaterals and is very resist-ant to devascularization, even with extensive dissection The anat-omy of the blood supply to the ureter (as previously described) should be known as the surgeon is carrying his dissection over the pelvic brim

Thermal

Thermal injuries will usually present in the early postoperative period with either fistula or stricture formation These injuries are repaired

in the same fashion as above depending on the location of the injury Many laparoscopic surgeons use alternatives to monopolar dissec-tors because of the risk of thermal injury and delayed presentation of injuries Even with these newer technologies, collateral tissue dam-age can be produced depending on the energy level and duration of exposure In animal models, use of the ultrasonic dissector (Ethicon

or USSC) at a level of 3 for <10 seconds per burst resulted in little to

no collateral tissue damage.(27) When using an ultrasonic dissector

at levels of 4 or 5, energy time should be reduced to <5 seconds to prevent collateral damage due to spread of thermal.(27)

lOCatiOn dePendent rePair OF the iatrOgeniC Ureteral injUrY

Repair of the injured ureter does not necessitate open conversion

if a urologist is available with advanced laparoscopic skills The basic principles of a ureteral anastamosis: a tension free anasta-mosis; well-vascularized spatulated ends anastamosed over an indwelling ureteral stent ; use of an absorbable suture material 4–0 or 5–0; and placement of a closed drain near the area of the repair Do not use nonabsorbable suture, as stone formation is inherent with these nonabsorbable materials

Proximal One Third

The boundaries of the proximal one-third ureter is from the ure-teropelvic junction (level of the kidney) to the pelvic brim (sac-roiliac joint on KUB) Repairs of injuries to the proximal ureter depend on the length of the damaged segment Simple spatulated ureteroureterostomy with ureteral stent placement is the pre-ferred method of repair if there is significant length of the unin-jured ureter A nephropexy can be performed to bring the kidney caudad to allow a tension free anastamosis In cases with long segments of damaged ureters, a bowel interposition with tapered ileum or an apendiceal interposition can be used (Figure 36.4)

At specialized centers, autotransplantation with reanastamosis to the iliac vessels, and native more distal ureter can be performed

Middle One Third

The preferred technique for mid-ureteral repair is ureteroureter-ostomy, either laparoscopically or through the open technique

Distal One Third

The procedure of choice for the lower one-third ureteral injury is the ureteroneocystotomy This may be accomplished primarily for very distal ureteral injuries or may require a Psoas hitch or Boari flap for patients with small capacity bladders and injuries near the iliac vessels.(24) Care must be taken to maintain a tension free

Figure 36.3 Ureteroureterostomy (A) Spatulation of ureteral margins and placement

of running locked sutures Preferred technique (B) Oblique anastomosis.

(A)

(B)

anastamosis This can usually be accomplished with a Psoas Hitch

(Figure 36.5) The bladder is mobilized by ligating the superior

vesical pedicle on the contralateral side of the injury It is prudent

to locate the contralateral ureter and ensure its integrity before

this maneuver The bladder can then be opened through an

ante-rior cystotomy and then secured to the Psoas muscle and tendon

using several 0–0 SAS sutures through the seromuscular layer of

the bladder Care must be taken not to include the genitofemoral

nerve which is located within the belly of the Psaos muscle Suture

should be placed in a linear fashion inline with the fascicles of the

muscle to prevent underlying nerve entrapment The ureter can then

be tunneled by passing a clamp from the lumen through all layers of

the bladder and then withdrawn with the distal aspect of the

proxi-mal salvaged ureter The ureter should then be widely spatulated and

interrupted mucosal stitches (4–0 SAS) should be used

circumferen-tially to create the neo-orifice A ureteral stent can also be placed The

anterior cystotomy is then closed as previously described A closed

suction drain and foley catheter is then left in place

The Boari flap is another effective yet more complex method

for replacing an extensive loss of the distal and mid-ureter A flap

of the anterior bladder wall is raised in a rectangular fashion and

affixed to the Psoas muscle in same fashion as a Psoas hitch The

ureter is tunneled through the most proximal portion of the flap and a neo-orifice is created as previously described The bladder flap is then tabularized and closed in a two-layer fashion using running 3–0 SAS to close the mucosa followed by closure of the seromuscular layer using 2–0 SAS (Figure 36.6)

The final option is the transureteroureterostomy The surgeon tunnels the injured ureter under the posterior peritoneum over-lying the great vessels The allows a spatulated end to side anasta-mosis of the injured ureter to the patient’s native uninjured ureter (Figure 36.7)

renal injUries

Direct renal injury is a rare occurrence in colorectal surgery McAnich et al have reported that 90% of renal injuries can be managed without nephrectomy.(28) Though this work does not

Figure 36.4 Ureteral replacement by ileum Left colon retracted medially Ileum

brought through a hiatus in the colonic mesentary Ileal ureter is in retroperitoneal

position.

Figure 36.5 Psoas bladder hitch Mobilized bladder being anchored to psoas

muscle and the ureter is reimplanted.

address iatrogenic injuries, the principle of renal salvage should

be applied Every attempt to evaluate the extent of the injury as

well as an assessment of the entire genitourinary tract should be

done before undertaking repair A one shot IVP can confirm

con-tralateral renal function This can be done by giving the patient

2 ml of contrast per kg up to a maximal of 150 ml IV An on the

table KUB is then done 10 minutes later Simple palpation of the

contralateral kidney does not ensure function The literature is

full of anomalous solitary kidneys which were removed

neces-sitating dialysis or transplantation.(29, 30) Pelvic kidneys have an

anomalous blood supply generally arising from multiple arteries

along the aorta and iliac vessels A total of 10% are solitary and

may easily be taken for a pelvic mass as they are not reniform

and have a discoid shape.(23) If caliceal or renal pelvis injury is

suspected, intravenous methylene blue or indigo carmine can be

administered

Once the injury is well defined, repair can be decided Minor

renal lacerations or penetrating injuries may be repaired primarily

with absorbable sutures and retroperitonealized with perinephric

fat, omentum, or hemostatic materials Hilar control is paramount

if an attempt at repair is to be performed If the injury is to the

collecting system or renal parenchyma and the ensuing blood loss

is able to be managed by pressure and hemostatic agents alone, a

ureteral stent and foley catheter can be placed from below and the

area drained with a closed suction to prevent urinoma formation

Conservative management is optimal as renorraphy and

explora-tion can lead to unnecessary nephrectomy If a major vascular

injury occurs and the patient’s intraoperative condition permits,

every attempt should be made to reestablish vascular integrity

Bladder dYsFUnCtiOn

The reported incidence of difficulty in reestablishing micturation

ranges from 15 to 25% after low anterior resection and up to 50%

after abdominoperineal resection.(31) A thorough

understand-ing of the neuroanatomy of the pelvis and the technique of total

mesorectal excision (TME) and autonomic nerve preservation

(ANP) can enable both local tumor control and preservation of

autonomic nerve structures thus reducing the risk of urogenital

dysfunction.(34, 35) Favorable oncologic outcomes have been

Figure 36.6 Boari or bladder

flap procedure (A) Creation

of tapered bladder flap, based posteriorly (B) Submucosal ureteral reimplantation (C) Closure of bladder flap.

Figure 36.7 Transureteroureterostomy Right-to-left, showing retroperitoneal

tunnel anterior to the great vessels.

reported for these nerve sparing techniques.(35–39) APR, when performed in accordance with the principles of TME and ANP, ensures the greatest likelihood of resecting all regional disease

while preserving both urinary and sexual function.(39) Locally

advanced tumors and preoperative chemotherapy and

radia-tion can make identificaradia-tion of the autonomic nerves and plexus

more difficult and sometime impossible.(34) The most common

sequela from autonomic nerve damage during surgery of the

colon and rectum is detrusor denervation and areflexia This

nor-mally requires clean intermittent catheterization, foley catheter

placement, or suprapubic tube placement depending on the

over-all dexterity and functional status of the patient Damage to the

pudendal nerve or its branches from Alcocks canal can result in

weakening of the striated urinary sphincter with resultant stress

urinary incontinence and intrinsic sphincter deficiency

Detrusor function (bladder contractility) is predominantly

mediated by the parasympathetic nervous system, namely the

pelvic nerve.(33) These parasympathetic fibers originate from

the spinal cord at the S2–S4 level Pelvic nerve branches are

redundant within the pelvis The main trunks to the bladder and

proximal urethra course in the visceral pelvic fascia, also called

the posterior endopelvic fascia.(33) These preganglionic

auto-nomic fibers course alongside the superior vesical vasculature to

synapse with postganglionic autonomic fibers within the bladder

wall Multiple pelvic preganglionic nerves pass laterally from the

pelvic floor over the rectal fascia investments en route medially to

the bladder (Figure 36.8).(33)

Sympathetic innervation to the bladder arises at the level of

L2–L4 with a presynaptic fiber to the sympathetic ganglion

adja-cent to the spinal cord Synapse occurs in the ganglion and a long

post ganglionic fibers travels through the pelvis to innervate the

bladder Through different end receptors located within the

blad-der, the sympathetic component of the autonomic nervous

sys-tem helps to cause relaxation of the bladder body (compliance

for storage) and contraction of the trigone and bladder neck at

resting/storage states

Somatic motor innervation to the striated pelvic floor

muscu-lature and sphincter arises from the S2–S4 level and travels via

the pudendal nerve through Alcocks canal The perineal branches

of the pudendal nerve follow the perineal artery into the

super-ficial pouch to supply the ischiocavernosus, bulbospongiosus,

and transverse perinei muscles Some branches continue

anteri-orly to supply sensation to the posterior scrotum and perineum

Additional perineal branches pass deep to the perineal membrane

to supply the levator ani and striated urethral spincter.(40)

In the study by Junginger on total mesorectal excision (TME), identification of the pelvic autonomic nerves was complete in 72%, partial identification in 10.7%, and not at all in 17.3% of patients.(34) Univariate analysis showed that the case number (experience), gender (males > females), and T stage (T1-2 vs T3-4) exerted an independent influence on the achievement of complete pelvic nerve identification In this series of 150 patients with adenocarcinoma of the rectum, identification and preser-vation of the autonomic nerves was achieved in a majority of patients and led to the prevention of urinary dysfunction (4.5%

vs 38.5%; p < 0.001).(34)

Management of the postoperative patient with bladder dys-function after colorectal surgery includes teaching clean inter-mittent catheterization (CIC) and having the patient return for full urodynamic evaluation around 2–3 months postoperatively Urodynamics can be a combination of fluoroscopic pressure/flow studies with EMG tracings and sometimes urethral pressure profil-ing It may take up to 6 months for bladder function to return to its new baseline and CIC may be a lifelong therapy CIC is performed with a 12–14 french low friction catheter every 4–6 hours and the duration can be adjusted based on the storage pressures and bladder capacity at the time of urodynamic evaluation There are no drugs with acceptable pharmacokinetics and side-effect profiles that have been shown to clinically increase contractility in the bladder

In a meta-analysis, Branagan et al., reviewed the colorectal surgery literature on suprapubic catheter placement followed

by voiding trial versus urethral catheter placement and standard trial of voiding postoperatively.(31) They found favorable results for the suprapubic catheter in terms of incidence of urinary tract infection, and a shorter magnitude and duration of pain and dis-comfort The ability to simply clamp and unclamp the suprapubic catheter makes management and voiding trials relatively simple especially in patients unable to perform CIC or those at especially high risk for postoperative bladder dysfunction Suprapubic catheters are particularly useful if autonomic nerves have to be removed during radical pelvic surgery, because normal voiding may be difficult to reestablish and may take several months to recover In the select patient with voiding dysfunction and delayed recovery, suprapubic catheter placement results in less morbidity and patient discomfort than urethral catheterization.(32)

seXUal dYsFUnCtiOn

In the urologic community, an emphasis on postoperative sexual function has arisen from studies by Walsh on the anatomic ret-ropubic prostatectomy with preservation of the neurovascular bundles that contribute to erectile function.(41) Most recently, post operative penile rehabilitation is being performed in mul-tiple settings with a theoretical benefit of reducing the time of neuropraxia to the penis and prevention of apoptosis induced atrophy Although no standardization exists with these rehabili-tation programs, patients are very interested and at the authors’ institution this is discussed preoperatively Sexual dysfunction has long been associated with rectal surgery in both male and female patients In male patients, erectile dysfunction is reported

in 5 to 65% of patients and ejaculatory dysfunction is reported in

Figure 36.8 Innervation of lower urinary tract

14 to 69%.(43) Damage to the sacral splanchnic nerve

(parasym-pathetic) or the hypogastric nerve (sym(parasym-pathetic) during surgery

is the propsed mechanism of injury.(43)

Sexual dysfunction is a broad term that encompasses failure of

arousal, erection, orgasm, ejaculation, and emission Complaints

from patients after radical pelvic surgery are usually mixed

Erection is parasympathetically mediated and is governed by

impulses traveling along the nervi ergentes (S2–S4).(41) The

pel-vic plexus is located retroperitoneally on the lateral surface of the

rectum 5–11 cm from the anal verge with its midpoint located at

the tip of the seminal vesicles The preganglionic fibers from the

nervi ergentes coalesce on the pelvic wall with contributions from

the sympathetic fibers and from the hypogastric plexus (T10–L4)

Damage to the sympathetic plexus will result in problems with

ejaculation including retrograde ejaculation or anejaculation

In a study by Henderson et al., eighty one women and 99 men

that had undergone curative rectal cancer surgery were given a

validated sexual function questionnaire.(42) Thirty-two percent

of women and 50% of men were sexually active compared with

61% and 91% preoperatively Twenty-nine percent of women

and 49% of men reported that “surgery made their sexual lives

worse” Specific sexual problems in women were libido 41%,

arousal 29%, lubrication 56%, orgasm 35%, and dyspareunia

46% In men complaints were impotence/erectile dysfunction

84%, libido 47%, orgasm difficulty 41%, and ejaculation

diffi-culties 43% Patients seldom remembered discussing sexual risks

preoperatively and were seldom referred or treated for symptoms

postoperatively Sexual dysfunction should be discussed with

rec-tal cancer patients, and when appropriate, efforts to prevent and

treat sexual dysfunction should be instituted.(42)

In a study of patients by Nam et al., on patients undergoing TME

and ANP for rectal carcinoma, factors that most affected

postop-erative sexual dysfunction were age older than 60 (sexual desire, p =

0.019), time period within 6 months of surgery (erectile function,

p = 0.04), and lower rectal cancer (erectile function p = 0.02).(43)

In the urologic literature, penile rehabilitation is started at

approxi-mately 1 month postoperatively with evidence suggesting that lack

of natural erections during this period of time produces

cavern-osal hypoxia.(44) Prolonged periods of caverncavern-osal hypoxia induce

fibrosis, which later increases the incidence of venous leak and thus

potentiates long-term or permanent erectile dysfunction

In consultation with a urologist, sexual dysfunction in the man

can be treated with many different modalities For erectile

dys-function, oral phosphodiesterase inhibitors, intraurethral

vasoac-tive suppositories, intracavernosal injections, vacuum errection

devices, and implantable devices are all options For ejaculatory

dysfunction in a patient desiring pregnancy, semen may be

col-lected from the bladder in the case of retrograde ejaculation

Sympathomimetic agents may also be used For refractory cases,

electro-vibratory ejaculation can be performed at specialized

cent-ers It is important to discuss sexual function with the patient both

pre and postoperatively as there are many therapeutic options that

have been shown to be very satisfactory for both partners

artiFiCial deViCes

Thousands of artificial urinary sphincters (AUS) and inflatable

penile prosthesis (IPP) have been implanted worldwide for the

treatment of stress urinary incontinence and erectile dysfunction, respectively (Figure 36.9) The IPP has one to three components, while the AUS has three components The three component sys-tems have a reservoir, pump, and cuff or prosthesis that is inter-connected with reinforced tubing These devices are silicone but develop a capsule around them after implantation The reservoir

is typically placed suprapubically in the space of Retzius One should make every attempt to refrain from entering this capsule and to prevent contamination of these silicone devices If con-tamination occurs, either device removal or salvage therapy with copious antibiotic irrigation is recommended, preferably the lat-ter The risk of device contamination, post operative infection, and damage to the tubing necessitating device removal or reop-eration should be discussed with the patient preoperatively It is the authors practice to be very conservative in patients with AUS, and we recommend all patients have their device de-activated by

a urologist familiar with the AUS before placement of a urethral catheter There are numerous reports of patients “turning off” their own AUS when in reality they only cycle them, followed by urethral catheterization at the time of surgery and the result is a device ero-sion through the urethra This is a medico-legal issue that usually can be averted with a preoperative consultation with a urologist The FDA approved sacral neuromodualtor is the Interstim device manufactured by Medtronic Corp.(45) It is approved for use in patients with refractory urgency and frequency or nonob-structive nonneurogenic urinary retention A tined lead is placed through the S3 foramen and an implanted generator is placed in

a pocket created in the gluteal area/upper hip The manufacturer recommends against using electrocautery near the generator and

to not perform a MRI on any patients with the Interstim device

Figure 36.9 Artificial urinary sphincter (AVS-800); American Medical Systems

Inc, Minnetonka, MN (A) reservoir (B) cuff (C) pump.

(A)

(B)

(C)

It is the authors practice to turn off the device with a Medtronic

supplied magnet before any radical pelvic operation In small

patients, appropriate padding must be applied to the area of the

implanted generator MRI is contraindicated although there has

been at least one study to show deactivation of the device before

MRI to be safe.(46, 47)

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5-Aminosalicylates (5-ASA) 336–7

5-FU 300

Bevacizumab 301

Cetuximab 301

indications for 301

Irinotecan-Containing Regimens 301

with leucovorin 300

with levamisole 300

Oxaliplatin-Containing Regimens 300–1

see also chemotherapy

6-methyl-mercaptopurine (6-MMP) 337–8

6-methylprednisolone 337

6-Thioguanine Nucleotide (6-TGN) 337–8

AAST grades 378

abdominal colectomy

ileorectal anastomosis with 322

abdominal CT 377

abdominal discomfort 367

abdominal radiography 97

bowel obstruction and dilatation 97–8

cecal volvulus 99

pneumoperitoneum 97

sigmoid volvulus 98–9

toxic megacolon 98

abdominal surgery 263

functional outcomes 267

oncologic outcomes 263

preoperative evaluation 263–4

surgical technique 264

patient-centered outcomes 267–8

surgical outcomes

anastomotic bleeding 265–6

anastomotic complications 264

anastomotic leak 264–5

anastomotic stricture 265

autonomic nerves injury 267

pelvic hemorrhage 266

splenic injury 266–7

ureteral injuries 267

abdominal trauma

colostomy closure

outcomes of 384

antibiotic therapy 385–6

blunt colon injury 383

diagnosis 376

epidemiology 375

military perspective 384–5

physical exam

computed tomography 377

diagnostic peritoneal lavage (DPL) 376

injury scale 377–8

laparoscopy 377

peritoneal sign 376

seat belt sign 376

ultrasound 376–7

preoperative assessment 375–6

retained fragments 386–7 World War I 375 World War II 375 abdominal wall contouring 356–7 caring 356–7

flap dissection 356, 357 abdominoperineal resection (APR) 278 closure, methods of 280–1

complications 281 abscess 281 intraoperativ hemorrhage 281 non-healing wound and perineal sinus 282 perineal wound complications 282 postoperative hemorrhage 281–2 epidemiology 278

evisceration 283 operative technique 278–80 perineal hernia 283 positioning 278

leg positioning 279

preparation 278 risk factors 282–3 carcinoma 282 fecal contamination 282–3 radiation therapy 282 sexual and urinary function 280 treatment 283

abscess 340 absorbable regenerated cellulose 266 Acticon TM Neosphincter device 231 acute anal fissure 200

calcium channel antagonists versus nitrates acute pilonidal disease 216

Adalimumab 338 adhesions 47–9

grading system for bowel 47, 47

adjuvant chemotherapy for T3 302–3 stage II and IV colon cancer 301–2 stage III colon cancer 302 Advanced Trauma Life Support principles 375 adynamic ileus 110

Agency for Healthcare Research and Quality (AHRQ) 164 aging 8

Altmeier procedure 241–2 alvimopan 367

American College of Surgeons (ACS) 3, 164 American Heart Association (AHA) 134

American Joint Committee on Cancer (AJCC) 301

American Society of Anesthesiologists (ASA) 2, 19 classification 2

American Society of Clinical Oncology (ASCO) 164, 165

American Society of Colon and Rectal Surgeons (ASCRS) 14, 15, 27,

164, 200, 251, 253 aminosalicylates 336 anal dilation 207

anal encirclement 242, 243–4

anal fissure

acute 200–1

chronic 201

classification 199

conservative therapy 200

diagnosis 200

pathophysiology 199

posterior and anterior 199

surgery therapy 206–8

see also acute anal fissure; chronic anal fissure

anal fistula 174

Crohn’s disease 192

diagnosis 184–5

etiology 183–4

HIV-positive patient 193

incontinence 190–1

non-surgical management 192–3

recurrence 189–90

surgical therapy

advancement flap 186–7

anal fistula plug 188–9

extrasphincteric fistulas 186

fibrin glue 187–8

fistulotomy 186

incision and drainage 185–6

seton placement 186

anal fistula plug 188–9

Anal Fistula Plug™ (AFP) 188

anal skin tags 175

anal sphincter 226–7

anal sphincter injury 389

life-threatening injuries 389

anal sphincteroplasty 229

anal stenosis 174, 208–210

anal ultrasonography 91–2

anastomosis 380

anastomotic complications, postoperative 56

bowel preparation , mechanical 58

case management 56

clinical presentation 59–60

considerations 56–7

dehiscence 56

diagnosis 60

diagnosis 64–5

management 60–2

asymptomatic 60–1

colocutaneous fistula 62

leak with associated abscess 61–2

leak without abscess 61

peritonitis 62

omental pedicle 58

operative intervention 62–3

colostomy creation 62

leaking anastomosis

@4:exteriorization of 63

@4:leaving, in place 63

@4:repeat anastomosis after resection 63

@4:resection of 62

@4:short and long-term implications of 63

pelvic drains 59

proximal diversion 57–8

radiation 58–9

stricture 63–4 techniques 58 treatment 64–5 anastomotic leak 264, 324 anemia 1

anesthesia 1 awareness 23 local anesthesia 19 Monitored Anesthetic Care (MAC) 20–1 regional anesthesia 21–3

anoderm 172 anorectal foreign bodies bedside extraction 389 initial assessment 388–9 operative removal 389 sexual implements 388 anorectal manometry 117, 364 anorectal physiology tests (ARP) 228–9 limitations of 87

case management 87 anal ultrasonography 91–2 constipation 92

balloon expulsion test 94 biofeedback 94

colonic transit studies 93 defecography 93 MRI 94 small bowel transit 94 electromyography concentric needle 89–90 single fiber 90

surface 90 fecal continence 87 fecal incontinence, investigations for biofeedback 92

electomyography 91

manometry 87–8, 88

ultrasound 92

pudendal nerve terminal motor latency 90, 90

rectal capacity and sensation 89 Recto-Anal inhibitory reflex 89 sphincter pressure measurement 88–89 anorectal sexually transmitted disease 156–7 anorectal varices 175

antegrade colonic enema 233–4 anthraquinones 367

antibiotic prophylaxis 14 antibiotic therapy abdominal trauma 385–6

anti-Saccharomyces cerevisiae mannan antibodies (ASCA) 332 anti-Saccharomyces cerevisiae 327

apocrine sweat glands 221

appendicitis 117

areflexia 401 argon plasma coagulation 306 arteriovenous sinusoids 178 artificial bowel sphincter 231 artificial urinary sphincters (AUS) components 402

traumatic foley catheter placement 395 ASA Closed Claims Project 21

ASCRS see American Society of Colon and Rectal Surgery

Aspirin 135

ATLS principles see Advanced Trauma Life Support principles

AUS see artificial urinary sphincters

Australian Safety and Efficacy Register of New Interventional

Procedures-Surgical 232

autonomic nerves injury 267

AVASTIN® 301

azathioprine (AZA) 337

Babcock clamp 140

bacteremia 22

bacterium Clostridium botulinum see botulinum toxin

Bacteroides 386

balloon expulsion test 94, 364

balloon proctography 117

balsalazide 337

barium enema 112–15, 367

Crohn’s disease 114–15

diverticulitis 115

diverticulosis 115

double contrast 112–13

limitations of 113–14

lymphoma 115

single contrast 112–13

ulcerative colitis 114

Bascom II procedure 220

Bascom operation 219

bedside extraction 389

benzodiazepines 133

Bevacizumab (AVASTIN®) 301

biofeedback therapy

failure of 368

for constipation 94

for fecal incontinence 92

limitations 92

pelvic floor dyssynergia

dyssynergic-type constipation 368

treatment of 367–8

on slow-transit constipation 368

Bioplastique® 233

bispectral index (BIS) 23

bladder dysfunction

autonomic nerve structures 400

innervations 401

oncologic outcomes 400–1

postoperative patient

clean intermittent catheterization (CIC) 401

resection 400

total mesorectal excision 401

bladder flap see Boari flap

bladder injury

delayed bladder injury 396

iatrogenic injury

stages 396

risk factor 396

two layer technique 396

bleeding complications 69

bleeding 178, 265–6

blunt colon injury (BCI) 383

Boari flap 399

body temperature and oxygenation 28

botulinum toxin (BT) 205

vs nitrates 206

vs placebo 205–6

randomized controlled trials 205

sphincterotomy 206 bowel function

adhesions, grading system for 47, 47

preparation 33–4 mechanical 58 status 34 bowel obstruction and dilatation 97–8 Bridgewater 135

brooke ileostomy proctocolectomy with 319–20 budesonide 337

bupivicaine 19 calcium channel antagonists 203–5

vs nitrates 204

vs placebo 203–4

vs sphincterotomy 204 calcium polycarbophil 179 Cancer Care Outcomes Research and Surveillance Consortium” (CanCORS) 165

cardiovascular disease 3–4 functional status, assessment of 4 preoperative cardiac evaluation Goldman risk model 3 Lee index 3

care paths benefits of 80 case management 79 challenges and concerns 83–4

in colon and rectal surgery 79 development of 80–3 fast track surgery 84–5 guidelines 79

implementation of 80–3 institutional experience 83 objectives of 79

outcome measures, defining and improving 80 realistic expectations 84

cathartic colon” 367 caudal anesthetic 21 cecal volvulus 99

Centers of Medicare and Medicaid Services (CMS) 161, 162

central nervous system (CNS) 20, 227 central neuraxial blockade 21–2 caudal 21

contraindications 22 epidural 21–2 heparin 22 spinal 21 cerebrospinal fluid (CSF) 21 cerebrovascular accidents (CVA) 8 Cetuximab (ERBITUX®) 301 Chance fractures” 376 chemotherapy 287, 300, 314 with colorectal cancer 300–1 future directions 303–4 indications and timing 301–3 side effects 303

chlamydia trachomatis infections 157 chronic anal fissure 201

botulinum toxin (BT) 205

vs nitrates 206