Seminars in Colon and Rectal Surgery最新文献

Advancements in the surgical and medical care of anorectal malformation (ARMs) have led to greater life expectancy and improved quality of life. Patients with ARM frequently experience fecal incontinence (17–77 %), constipation (23–87 %), and rectal prolapse (4–60 %). Upper urinary tract abnormalities occur in 40-83 %, leading to end-stage renal disease in 5–18 % and kidney transplantation in 2–8 %. Urinary incontinence occurs in 0–41 % of patients. Mullerian anomalies occur in up to 60 % of patients, and 36–41 % present with hematometra, which may impact fertility. Cryptorchidism is seen in 19 % and may lead to reduced paternity rates. Sexual dysfunction impacts 6–66 % of patients and coital debut is delayed, often due to fear of flatus or soiling. While fertility rates vary, childbirth is still possible. However, pregnancies carry a higher risk of miscarriage and premature delivery, and delivery via Cesarean section is recommended. Malignancy is uncommon, but patient anatomy is imperative to consider when assessing cancer risk, screening needs, and the impact of cancer treatment. Depression and anxiety occur in 80 %, with up to 15 % reporting suicidal ideation, yet only 12–40 % receive treatment. The high prevalence of ongoing complications highlights the need for continued multidisciplinary care after index ARM repair.

Development of enterocutaneous fistula (ECF) remains a challenging complication of gastrointestinal surgery and fistulizing disease processes. Successful management of ECF is dependent on timely diagnosis, effective treatment of resulting intra-abdominal sepsis, wound/nutrition management, and supporting the patient though the perioperative optimization period. When approached in multi-disciplinary setting with teams specializing in ECF/intestinal failure, care is optimized and can allow for patients to have greater independence even with complex wounds. While resolution of the ECF remains the overarching goal, a methodical and stepwise approach to management remains paramount both before and after surgical intervention. This chapter outlines ECF management from initial diagnosis to intra-operative decision making after a patient is deemed a candidate for surgery. Further, it highlights patient-specific considerations that can be overlooked in the big picture view of ECF management. While ECF treatment is challenging, the chance to cure a patient of their fistula is a rewarding experience for the patient and ECF/intestinal failure team members alike.

Anorectal mucosal melanoma accounts for less than 1 % of all anorectal malignant tumors and a tendency for delayed diagnosis leads to advanced disease at presentation.^1,2 Due to the rarity of the disease, there are limited prospective trials exploring the optimal treatment strategies. Generally, tumors are surgically excised, with a preference for conservative management with wide local excision. In the past decade, there have been advances with immunotherapy and other targeted therapies. Multiple clinical trials continue exploring neoadjuvant/adjuvant combination treatments in the setting of advanced or unresectable disease.

The indications for colorectal surgery in cirrhotic patients have recently been broadened, mostly due to a better understanding and multidisciplinary management of cirrhosis. However, anesthesia and colorectal surgery may both exacerbate deteriorations in liver function in a patient with chronic liver disease such that careful preoperative patient selection remains mandatory. Four scores (i.e., Child-Turcotte-Pugh, the Model for End-Stage Liver Disease, Mayo Risk Score, and (VOCAL)-Penn cirrhosis surgical risk score) are currently available to assess the severity of cirrhosis, determine the risk of decompensation, and to estimate postoperative mortality. For colorectal resection to be safely performed electively in patients with compensated liver disease, optimization of the patient is mandatory in the preoperative setting. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is a promising strategy in patients with portal hypertension, but it requires further evaluation. Similarly, further studies are needed to validate both the feasibility and safety of the laparoscopic approach to colorectal surgery in cirrhotic patients. In summary, preoperative identification and optimization combined with meticulous postoperative care are essential for optimum outcomes in patients with chronic liver disease undergoing colorectal surgery.

Disease recurrence after surgery for ileocolic Crohn's is common, and repeat surgery is necessary for approximately one-third of patients within ten years. This recurrence rate is influenced by many factors, some of which relate to the disease phenotype. Others may be influenced by the patient (i.e., smoking) or the gastroenterologist with careful disease monitoring and the judicious use of adjuvant medication. The surgeon may also be able to reduce recurrence in the both preoperative preparation of the patient, the timing of surgery, and the intra-operative surgical technique. Evidence of how the surgeon can influence recurrence is discussed in this manuscript, considering current definitions, pathophysiology, and risk factors for recurrence.

Colorectal cancer is associated with distant metastases in 19–26% of patients at initial presentation. Local tumor complications such as obstruction, perforation, and hemorrhage may be identified at initial presentation or may develop during treatment for those that were initially asymptomatic. Optimal management in these situations is dependent on rapid recognition and assessment of the patient's clinical condition, a thorough understanding of oncologic principles, and a multidisciplinary approach to treatment. Given the the reliance on systemic therapy for the management of metastatic disease, it is essential to minimize potential morbidity and mortality to avoid unnecessary treatment delays in this subset of patients. This review highlights the most common local tumor complications seen in the setting of stage IV colorectal cancer and approaches to each.

Approximately 25-30% of patients with colorectal cancer develop hepatic metastases. For patients diagnosed with resectable colorectal hepatic metastases, variation exists regarding the timing of resection of the colorectal primary and the hepatic metastases including three approaches: (1) the “classical” colorectal-first staged approach, (2) the “combined” or simultaneous/synchronous approach, and (3) the “reverse” or liver-first staged approach. The purpose of this chapter is to review the current literature regarding the timing of colorectal and hepatic resection in patients with surgically treatable colorectal adenocarcinoma hepatic metastases. There are inadequate data at the current time to provide definitive recommendations as to the optimal timing and sequence of surgery. Our recommendations based on existing data favor delivery of neoadjuvant therapy followed by either: (1) the combined approach for low-risk resections, (2) the liver-first staged strategy for high-risk hepatic resections or mid- to distal rectal tumors that may benefit from total neoadjuvant therapy, or (3) the colorectal-first approach for symptomatic primary colon tumors.

Colorectal cancer is the second leading cause of cancer related death in the United States. Approximately 25% of patients are diagnosed with metastatic colorectal cancer (mCRC) and the 5-year survival rate in mCRC is low at 14%. Primary treatment for mCRC is systemic therapy, which includes chemotherapy, immunotherapy, and targeted agents. With advances in genomic profiling, we can now tailor treatment to unique patient populations and improve overall survival. In this review, we discuss treatment strategies for mCRC patients based on tumor sidedness, KRAS/BRAF wild-type versus mutant tumors, and review the benefit of immunotherapy in microsatellite unstable and mismatch repair deficient tumors.

Epidemiological trends in stage IV colorectal cancer are concerning. As older adults in highly developed countries enjoy decreasing colorectal cancer incidence and mortality, younger patients are developing metastatic disease with increasing frequency, and profound systemic disparities persist in screening, treatment, and survival. Globally, the young populations of low- and middle-income countries are exposed to ever higher levels of colorectal cancer risk factors without colorectal cancer screening systems in place or ability to provide care, leading to an impending crisis. Scientific discoveries reveal the complex interplay between inherent, tumor-specific, and environmental risks, but the most profound factor underlying the epidemiology of metastatic colorectal cancer is inequality, globally and within the United States.

Many patients with synchronous metastatic colorectal cancer (CRC) are asymptomatic from the primary tumor. While primary tumor resection is indicated for symptoms including bleeding, obstruction, and perforation, the role for asymptomatic primary tumor resection has been debated. Studies in favor of and against primary tumor resection are reviewed. Unlike previously published non-randomized studies, whose results may have been strongly influenced by selection bias, recently published randomized controlled trials suggest that primary tumor resection in Stage IV CRC with an asymptomatic primary and unresectable metastatic disease does not provide a survival benefit to the patient.