Seminars in Colon and Rectal Surgery最新文献

Anastomotic leak after colorectal resection is a feared complication that dramatically worsens mortality and anastomotic survival. In this chapter, we describe the evolving field of endoscopic management of anastomotic leaks. Endoscopic management of anastomotic leaks is suitable for a minority of leaks that meet the following criteria: 1) the patient is clinically well; 2) the leak is contained; 3) the leak has no drainable component, and; 4) the leak has failed clinical observation. Distinguishing a chronic abscess from a well-drained, chronic sinus is paramount to selection for safe use of endoscopic approaches. Endoscopic techniques for appropriate anastomotic leaks include marsupialization of the tract, over-the-scope endoclips, covered stents, and vacuum-assisted closure. The use of each technique can be supported when selecting for the appropriate anatomic circumstances.

Anastomotic leak is a feared complication of any bowel surgery. While the technical aspects of this complication and its management are often studied, the emotional implications on the patient and surgeon should not be overlooked. There is a growing body of literature on the management of the emotional toll complications can have on the surgeon and team. Open communication with the patient, leaning on colleagues for support, and a blame free surgical culture can be helpful for surgeons facing these dreaded outcomes. Institutional resources are scarcely utilized, but may be available as well. Patients and their families should be informed of the consequences of the complication and the potential for further sequelae to follow. By being available, truthful, and taking care of one's own response to the trauma, the surgeon can lead all involved through a difficult course.

After the initial period of source control and treating sepsis, the pervasive long-term effects of anastomotic failure become clear. Most of these produce some form of debility, require prolonged treatment with multiple procedures and operations and for some, even shorten survival. Regardless of the complication, it is imperative that the surgeon remain patient and create a treatment plan that is measured and safe. This may involve as little as a single operation for reversal of diverting stoma, the time-consuming and labor-intensive management of enterocutaneous fistulas (ECFs), serial dilations of an anastomotic stricture or managing and guiding patients through poor functional and oncologic outcomes.

Intestinal anastomotic tissue follows a similar pattern of healing that is seen in all tissues with characteristic inflammatory, proliferative, and remodeling phases. Several aspects of intestinal healing are distinct from other tissues, however, including its time course and interaction with the environment of the gastrointestinal tract. As the anastomosis progresses through each stage, initial inflammatory cells are replaced by collagen-producing fibroblasts that generate the anastomosis’ strength. A complex network of cell-to-cell signaling mediates this process through the release of cytokines and growth factors including platelet-derived growth factor (PDGF), transforming growth factor-β (TGF-β), and vascular endothelial growth factor (VEGF). Interventions based on these signaling pathways have been shown to improve anastomotic strength in animals, though methods for improving anastomotic healing in human patients remain unclear. Given the risks associated with anastomotic failure in patients, there is value in monitoring inflammatory markers and cytokines that can indicate the presence of a leak.

Anastomotic leak can be a devastating complication. Early recognition is the most important step in avoiding mortality and significant morbidity. Once identified, the surgeon must decide how to best mitigate the problem. A variety of options are available and should be tailored to the unique characteristics of the patient. Choosing between operative and non-operative intervention will be guided by the presentation. Early presentation with septic complications will typically be treated with a more invasive approach, while a delayed or insidious presentation can often be managed with a non-operative approach.

This chapter is focused on the timely diagnosis of anastomotic leak (AL). The general approach emphasizes the recognition of early symptoms of AL to expedite diagnosis and treatment. We will begin with a brief background on known risk factors for developing AL, followed by a review of common presenting symptoms and diagnostic tools. We will review clinical, laboratory, imaging, and endoscopic assessments that may be used to facilitate early diagnosis. We will discuss novel, evidence-based laboratory studies used to detect early AL. We will also discuss whether imaging studies are needed and the pros and cons of various imaging and endoscopic modalities for different types of AL. This chapter is intended to be a succinct reference to guide clinical practice.

Many factors go into the decision to make an anastomosis in colorectal surgery. Emergency surgery is inherently higher risk than elective surgery, but patient factors, such as comorbidities and clinical status, and situational factors, such as contamination can increase the risk of anastomotic complications. Evidence has demonstrated the relative safety of anastomosis and diversion in the setting of feculent or purulent peritonitis, which is somewhat contradictory to previous surgical dictum. Anastomosis in the setting of large bowel obstruction has been extensively studied, and its safety varies widely depending on the cause of the obstruction, location of the obstruction and the type of anastomosis required. In traumatic injuries, data suggests that anastomosis is not necessarily riskier than diversion.

For decades, surgery has been a dependable mainstay in the treatment of inflammatory bowel disease, particularly for ulcerative colitis. Surgical techniques and approaches have evolved over time, but the ultimate goals of surgery for ulcerative colitis have remained constant: that is, to alleviate symptoms and mitigate cancer risk while achieving the highest possible quality of life. A structured surgical approach to the patient with ulcerative colitis is required whereby the complexities of surgical decision-making and several commonly debated topics must be considered.

Inflammatory bowel diseases are a group of chronic, relapsing disorders of the gastrointestinal tract. The initially limited therapy options were significantly expanded with the advent of biologics and small molecules. Biologics and small molecules can be divided into four categories based on their immunologic targets – anti-tumor necrosis factor, anti-interleukin, anti-integrin, and janus kinase pathway inhibitor. Each class of medication functions through a particular mechanism of action that dictates its indications for use, rate of efficacy, and safety profile.

Crohns disease (CD) is a chronic inflammatory condition that can affect any portion of the intestinal tract. The disease presents with myriad symptoms and signs and is best diagnosed and staged through a combination of laboratory tests, endoscopic procedures, and radiographic studies. Appropriate medical therapy is based upon the disease behavior, location, and severity and may require use of one or more classes of medications in an attempt to achieve endoscopic remission as well as histologic normalization. Several clinical scenarios require special consideration and it is important for the gastroenterologist to work with the patient, surgeon, and other healthcare providers to achieve optimal outcomes.