Seminars in Colon and Rectal Surgery最新文献

One of the most common fears shared by preoperative intestinal surgery patients is ending up with a stoma. Fear of the stoma often leads patients to delay an inevitable surgery or seek lesser efficacious treatments. How does a surgeon impart their experiential knowledge to a patient reluctant to proceed with stoma creation? A panel of American patients who either had or have a stoma were asked to reflect on their postoperative life with a stoma through the lens of their preoperative concerns to aid future patients considering a stoma.

Stoma formation is a common aspect of general, colorectal, urologic, and oncologic surgical practice. Unfortunately, hernia formation around an ostomy trephine occurs in up to 50% of ostomates. In an era of explosive progress in abdominal wall surgery, parastomal hernia repairs remain plagued with technical challenges, high recurrence rates, and peri-operative morbidity. There is little expert consensus on the ideal operation. Repair type (suture or mesh based), surgical approach (laparoscopic, robotic, hybrid, or open), mesh configuration (cruciate, keyhole, or Sugarbaker), mesh type (permanent synthetic, biologic, or bioabsorbable), mesh location (underlay, sublay, or onlay) vary based on local expertise and patient clinical factors. This article will summarize the current literature on the management of parastomal hernias and provide expert commentary on our preferred practices for parastomal hernia repair.

Stoma creation is an essential tool in the surgeon's armamentarium to treat a variety of surgical conditions. The ability to safely restore intestinal continuity, however, is equally important. Stomal reversal can be considered following an appropriate amount of time and thoughtful assessment of the diverted bowel or anastomosis utilizing radiographic and/or endoscopic evaluation. Despite conscientious and thoughtful preoperative planning, stoma reversal has potential for significant morbidity.

Rectal prolapse occurs when the rectum invaginates and descends into the anal canal or beyond the anal sphincter muscles. Patients often report fecal incontinence, obstructed defecation, pain, and urgency and of patients who present with rectal prolapse, up to 30% will also have anterior or middle compartment prolapse. This review describes the preoperative management of patients with rectal prolapse and principles for determining the operative approach.

All patients should be optimized ahead of surgery with attention to bowel habits, pelvic floor strength and coordination, and baseline nutrition and fitness. If multi-compartment prolapse is identified, those patients should be referred for multidisciplinary management. Determining the best operation for an individual patient is best done through a shared decision-making model weighing the risks and benefits of abdominal versus perineal operations. Many patients can tolerate minimally invasive abdominal operations, but for those who cannot, perineal operations are a safe and effective option.

Rectoceles are a common finding in female patients; they can be asymptomatic, or they can contribute to the sensation of pelvic pain, pressure, and difficulty with evacuation. Rectoceles coexist with anterior and mid compartment pelvic prolapse in up to 50% of patients. Defecatory dysfunction can be secondary to anismus, anatomic abnormalities such as rectocele or intussusception, and often are due to a complex interplay of both structural and functional abnormalities. Hence patients presenting with these symptoms are best evaluated with anorectal physiology testing and dynamic imaging. Nonoperative approaches include pelvic floor physical therapy, biofeedback therapy, and vaginal pessaries. Various operative approaches exist, each with different targets and measurements of successful repair.

Anal incontinence and defecatory difficulties are common and have a considerable impact on quality of life and health cost. Conservative management should be the first line management of anorectal dysfunction because there is minimal risk and a high rate of success with completion of therapy. This article aims to describe the principles of the physiotherapy assessment and the diagnostic process and to summarise published literature focusing on level 1 evidence of the physiotherapy strategies utilised as first-line conservative management of the following anorectal disorders: anal incontinence, defecatory difficulties and functional anorectal pain.

Rectal prolapse is often accompanied by pelvic organ prolapse. The surgeon needs to be astute in order to elicit the symptoms and perform the appropriate exam in order to fully evaluate the pelvic floor. This is often a daunting task, and the immediate response is to refer to our urogynecology colleagues. However, with the knowledge of the individual tests, the purpose of each test, and a systematic approach to performing the comprehensive assessment every provider can and should be able to complete a full pelvic floor exam. In this chapter, we present a stepwise approach to performing a comprehensive multicompartment pelvic floor examination, as well as understanding the common terminology across the treatment team and critical components for the consultation. There is a full consort of physical examinations every patient with pelvic organ or rectal prolapse should undergo, and collaboration across specialties is needed to ensure this comprehensive and complete evaluation is performed. Every surgeon is not expected to perform every test, but significant multicompartment pelvic floor prolapse benefits from a multidisciplinary team to ensure a thorough evaluation is done. But with the information in this chapter, colorectal surgeons should feel comfortable completing the initial examinations, treatment regimens, and eliciting proper referrals for best care of prolapse.

Patients attending the pelvic floor clinic may have symptoms of defaecatory, urinary and sexual dysfunction, including incontinence and prolapse. Pelvic floor dysfunction is multifactorial and multi-compartmental. A holistic approach which addresses all aspects and compartments is essential to achieve optimal assessment and outcomes. The team must be multidisciplinary and cohesive, with open channels of communication and discussion. A multidisciplinary clinic provides a platform to ensure an efficient pathway for the patient and healthcare system, all aspects of care are simultaneously addressed, and patient care is optimised. This section outlines the drivers for, and potential outcomes from, running a multidisciplinary clinic.

The operative management of rectal prolapse has evolved substantially over time. Many patients with rectal prolapse also have concomitant prolapse of their anterior and/or middle compartments. Optimal repair of pelvic organ prolapse will address all of the involved compartments, which often requires close collaboration with a urogynecology or female urology team. This chapter describes our technique for robotic ventral mesh rectopexy with sacrocolpopexy when indicated.

Pelvic floor disorders are common conditions that affects mainly the female population, especially the elderly. Anorectal physiology and imaging tests are important way to assess anal sphincter function and structure of the pelvic floor. Those tests are part of the workup for patients with incontinence, defecatory disorders and pelvic organ prolapse. The most relevant tests will be discussed in this article.