Complex Anorectal Disorders
Steven D. Wexner, MD, FACS, FRACS, FRCS(Ed) Andrew P. Zbar, MD, FRCS, FRACS
Mario Pescatori, MD, FRCS, EBSQ
Complex Anorectal Disorders
Investigation and Management
With 162 Illustrations
With a Foreword by Robin Phillips
Steven D. Wexner
MD, FACS, FRACS, FRCS(Ed) Chairman and Residency
Hospital Program Director Department of Colorectal Surgery Cleveland Clinic Florida
Weston, FL USA
Andrew P. Zbar MD, FRCS, FRACS
Department of Clinical Medicine and Research
University of the West Indies Queen Elizabeth Hospital Cave Hill Campus Barbados
British Library Cataloguing in Publication Data
Complex anorectal disorders: investigation and management 1. Anorectal function tests 2. Defecation disorders—Treatment I. Wexner, Steven D. II. Zbar, Andrew P., 1955– III. Pescatori, Mario 616.3¢42
ISBN 1852336900
Apart from any fair dealing for the purposes of research or private study, or criticism, or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduc- tion outside those terms should be sent to the publishers.
ISBN 1-85233-690-0
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© Springer-Verlag London Limited 2005
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Printed in the United States of America. (BS/EB) Printed on acid-free paper SPIN 10882535 Mario Pescatori
MD, FRCS, EBSQ Coloproctology Unit Villa Flaminia Hospital Rome, Italy
Honorary President Italian Society of
Colo-Rectal Surgery (SICCR)
This book is dedicated to my wife, Nicolette, for all of her love, support, and wisdom.
SDW
As always, to my parents for their constant inspiration to strive for intellectual betterment.
APZ
To my father, Alan Parks, and Vic Fazio, who taught me honesty, surgery, and science.
MP
Foreword
A large cross-section of the world’s great and good in colorectal surgery have been enticed, inveigled, I suspect at times brow-beaten, to produce this tour de force. The editors, themselves famous for their own extensive contributions in this area, must be congratulated for their fine achievements.
Every card-carrying specialist needs a reference book of this sort. My own are well worn by many years’ reference, for when confronted by big problems, big issues, senior clinicians must be able to lay their hands on a well-thumbed old favourite: not a small, “where are we now” sort of book, or an exam crammer, but on one that is large, sedate and of “traditional build.”
Rather than being a supergiant covering all of colorectal surgery, this book has focused on the broad structural investigation of the anorectum and on the focused management of largely “functional” problems. And it has done so in style. For this is a core area of specialist practice; your more general colleagues may think twice before referring you new cases of cancer and inflammatory bowel disease (both also central areas in colorectal surgery), but they will not hesitate in referring the patients whose investi- gation and management are described here. And they will expect you to know how to deal with them.
These are some of the most challenging patients to manage. Rightly have the editors covered the physiological areas, rightly the psychological issues, rightly the medicolegal aspects: here is the making of a specialist—the sword and the shield.
Robin Phillips St Mark’s Hospital Harrow, Middlesex
vii
Preface
The recent profusion of colorectal and anal surgical techniques and inves- tigative procedures has made it comparatively difficult for both the general surgeon with a colorectal interest and the specialist coloproctologist to keep up with the body of new literature and the regular appearance of new sur- gical procedures. The introduction of capital-intensive imaging modalities discussed in this book (including endoanal ultrasonography, 3-dimensional reconstructed axial anal sonography, thin-slice high spatial-resolution magnetic resonance imaging and endoanal MR imaging), has rendered the management and research of some complex anorectal disorders within the perview of a few specialized colorectal centers. Balanced against this, the standardization of rectal cancer resection has shown that workshop prac- tices can readily be translated into noncolorectal environments and has high- lighted the improvement in cancer-specific outcomes for specialists trained specifically in these techniques.We felt that this book was timely to condense these complex disorders into a workable format for the colorectal clinician.
This book is divided into two main sections. Section 1 discusses the inves- tigative aspects of specialist proctological practice with heavy emphasis on the complex physiology of the region in health and disease. The abundance of literature here makes the subject somewhat difficult to comprehend for the busy colorectal surgeon and the aim is to précis relevant physiology which defines anorectal pathology and which may be clinically useful in referrals to a tertiary practice. Here, there is detailed discussion of conventional (and vectorvolume) anorectal manometry, the nuances of rectoanal inhibition (and its clinical significance), the research role of ambulatory anorectal manometry, mucosal electrosensitivity, and the new field of impedance planimetry. The complex subject of rectal biome- chanics is deliberately highlighted in an effort to show the pitfalls (and meaning) of simple rectal compliance measurement. The selected use of colonic (and rectal) transit assessment in the patient presenting with intractable constipation and evacuatory difficulty is discussed along with the ever diminishing place (in view of endoanal sonography), of elec- tromyography and other neurophysiologic testing.
ix
Here too, there is discussion of the expanded role of endoanal sono- graphy and its extensions, (namely 3-dimensional reconstructed axial endosonography and dynamic transperineal sonography), along with an outline of defecography as it is clinically used in two different European centers. The importance in functional disorders of dynamic sequence MR imaging and its endoanal counterpart is included for the assessment of patients with pelvic floor disorders along with the place of surface pelvic phased-array MR imaging which has become the “gold standard” for selected use in recurrent and specific perirectal sepsis and for the pre- operative determination of rectal cancer stage. In the latter circumstance, accurate staging before surgery defines those patients who will benefit from definitive downstaging neoadjuvant chemoradiation and those likely to benefit in terms of reduced locoregional recurrence and enhanced cancer-specific survival from pre- and postoperative adjuvant radiotherapy.
This section continues with an extensive discussion of internal anal sphincter neurotransmission and pharmacology; a burgeoning field for the topical therapy of passive fecal incontinence and chronic anal fissure.
Finally there is consideration of the specialized histopathology of the anus and anal canal and the newer area of cytology and “high-resolution anoscopy” of the region; an important field with limited longitudinal data for human papillomavirus (HPV) -associated preinvasive anal intraepithe- lial neoplasia. This latter disease is becoming increasingly recognized in the HIV-positive population and in other immunosuppressed patients.
Section 2 assesses the specific management decisions of importance in particular proctological practice, as recommended from many renowned units throughout the world dedicated to complex anorectal disorders.
It begins with an overview of the surgical approach towards patients presenting with intractable constipation, examining the importance of paradoxical puborectalis contraction and its management, colectomy, biofeedback therapies and the coloproctological approach to symptomatic rectocele. Fecal incontinence is broadly reviewed along with its prevention, surgical management, biofeedback strategies, quality of life considerations and the place of new operative procedures including dynamic electrically- stimulated graciloplasty, artificial anal sphincter replacement (either as a primary procedure or in total anorectal reconstruction) and the exciting developments in sacral neuromodulation.
The gynecological perspective of patients with complex postoperative evacuatory dysfunction, rectocele and enterocele and mixed fecal and urinary incontinence, is covered as well as the technical clinical problems encountered after failed sphincteroplasty, graciloplasty, artificial bowel sphincter deployment and following construction of a neorectal reservoir.
When patients present with functional problems following these surgeries, management is particularly difficult and renowned units present their experience in this book of these discrete specialized problems. There is discussion of the functional problems encountered in patients with x Preface
particular neurological disorders as well as consideration of the specific psy- chological problems in patients with defecation difficulty along with the psychologist’s approach and integration within the dedicated colorectal unit. Finally, our authors outline the “nuts and bolts” of setting up an anorectal laboratory and the medicolegal issues entailed in the assessment and management of these complex patients; many of whom present after failed surgeries and treatments. It is hoped that this textbook will serve as a useful resource reference for the busy coloproctologist faced with a range of complicated and challenging patients who present with complex procto- logical disorders.
The production of our textbook could not have been possible without the unwavering assistance of Elektra McDermott whose constant cajoling of authors to complete their chapters on time was the difference between whether the product would be finished or simply just remain on the drawing board. Both Melissa Morton and Eva Senior of the medical editorial staff of Springer in London were also essential for the project to come to fruition and their tireless efforts, organization and energy made the task an editor’s joy.
Steven D. Wexner, MD Andrew P. Zbar, MD Mario Pescatori, MD Preface xi
Contents
Foreword by Robin Phillips . . . . vii Preface . . . ix Contributors . . . xvii
SECTION 1 ANORECTAL TESTING 1. Anorectal Anatomy: The Contribution of
New Technology . . . 3 Andrew P. Zbar
2. Anorectal Physiology . . . 17 2.1 History, Clinical Examination and Basic Physiology . . . 18
J. Marcio N. Jorge
2.2 Rectoanal Inhibition . . . 39 Patricia L. Roberts
2.3 Vectorvolume Manometry . . . 48 Andrew P. Zbar
2.4 Clinical Rectal Compliance Measurement . . . 63 Robert D. Madoff and Andrew A. Shelton
2.5(i) Impedance Planimetry: Application for
Studies of Rectal Function . . . 72 Hans Gregersen
2.5(ii) Impedance Planimetry: Clinical
Impedance Planimetry . . . 105 Graeme S. Duthie and Angela B. Gardiner
2.6 Ambulatory Manometry . . . 114 Andrew P. Zbar
xiii
2.7 The Use of Colonic Motility and Transit Studies . . . 120 Nancy Baxter and John H. Pemberton
2.8 Anorectal Sensitivity . . . 137 Richelle J.F. Felt-Bersma
2.9 Neurophysiology in Pelvic Floor Disorders . . . 153 Guillermo O. Rosato and Carlos M. Lumi
3. Anorectal Imaging . . . 170 3.1(i) Evacuation Proctography . . . 171
Philip J. Shorvon and Michelle M. Marshall
3.1(ii) Defecography: A Swedish Perspective . . . 199 Annika López, Jan Zetterström,
and Anders F. Mellgren
3.2(i) Ultrasound in Coloproctologic Practice:
Endorectal/Endoanal Ultrasound . . . 217 Ponnandai J. Arumugam, Bharat Patel,
and John Beynon
3.2(ii) Ultrasound in Coloproctologic Practice:
Dynamic Transperineal Ultrasound
and Transvaginal Sonography . . . 246 Marc Beer-Gabel, Andrea Frudinger,
and Andrew P. Zbar
3.2(iii) Three-Dimensional Endoanal Ultrasound in
Proctological Practice . . . 263 Andrew P. Zbar and Andrea Frudinger
3.3(i) MRI in Colorectal Surgery: Surface Magnetic
Resonance Imaging in Anorectal Practice . . . 275 Gina Brown and Andrew P. Zbar
3.3(ii) MRI in Colorectal Surgery: Endoluminal MR
Imaging of Anorectal Diseases . . . 298 Jaap Stoker
3.3(iii) MRI in Colorectal Surgery: Dynamic Magnetic
Resonance Imaging . . . 322 Andreas Lienemann and Tanja Fischer
4. Sphincter Pharmacology and Pharmacotherapy . . . 351 Thanesan Ramalingam and Neil J. McC Mortensen
5. Anal and Perianal Pathology . . . 370 5.1 Anal Histopathology . . . 371
Claus Fenger xiv Contents
5.2 Anal Intraepithelial Neoplasia (AIN) . . . 389 John H. Scholefield
SECTION 2 CLINICAL ANORECTAL ASSESSMENT
6. Assessment of the Constipated Patient . . . 411 6.1 An Overview . . . 412
Michelle J. Thornton and David Z. Lubowski
6.2 Managing Slow-Transit Constipation . . . 429 Johann Pfeifer
6.3 Rectocele . . . 446 Anders F. Mellgren, Jan Zetterström, and Annika López
6.4 Anismus . . . 461 Kim F. Rhoads and Julio Garcia-Aguilar
6.5 Biofeedback for Constipation and Fecal Incontinence . . . . 494 Dawn E. Vickers
6.6 Evacuatory Dysfunction Following
Gynecologic Surgery . . . 532 Theodore J. Saclarides and Linda Brubaker
7. Assessing the Patient with Fecal Incontinence . . . 546 7.1 An Overview . . . 547
Marc A. Gladman, S. Mark Scott, and Norman S. Williams
7.2 Quality of Life Issues . . . 595 Lucia Oliveira
7.3 Fecal and Urinary Incontinence: Epidemiology
and Etiology . . . 606 Dana R. Sands and Minda Neimark
7.4 Sacral Neuromodulation . . . 620 Ezio Ganio
8. Urogynecological Assessment and Perspective in
Patients Presenting with Evacuatory Dysfunction . . . 636 Jennifer T. Pollak and G. Willy Davila
9. Assessing the Postoperative Patient with
Evacuatory Dysfunction . . . 654 Contents xv
xvi Contents
9.1 Disordered Defecation of the Neorectum and
Neorectal Reservoir . . . 655 Tracy L. Hull
9.2 Evaluation and Management of Postoperative
Fecal Incontinence . . . 670 Homayoon Akbari and Mitchell Bernstein
10. Postoperative Assessment of the Neosphincter . . . 693 10.1 An Overview . . . 694
Donato F. Altomare, Marcella Rinaldi, and Altomarino Guglielmi
10.2 Managing Functional Problems Following
Dynamic Graciloplasty . . . 706 Cornelius G.M.I. Baeten and Mart J. Rongen
10.3 Assessing the Functional Results of the Artificial
Bowel Sphincter . . . 714 T. Cristina Sardinha and Juan J. Nogueras
11. Functional Problems in the Patient with a
Neurological Disorder . . . 725 Jeanette Gaw and Walter E. Longo
12. Psychological Assessment of Patients with
Proctological Disorders . . . 747 Annalisa Russo and Mario Pescatori
13. A Practical Guide to Running an Anorectal Laboratory . . . 761 Joseph T. Gallagher, Sergio W. Larach, and Andrea Ferrara
14. Medicolegal Aspects of Coloproctologic Practice . . . 767 David E. Beck
Index . . . 779
Contributors
Homayoon Akbari, MD, PhD
Department of Colorectal Surgery, St Luke’s/Roosevelt Hospital Center, New York, NY, USA
Donato F. Altomare, MD
Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Unit, University of Bari, Italy
Ponnandai J. Arumugam, MS, FRCS
Department of Colorectal Surgery, Royal Cornwall Hospital, Truro, UK
Cornelius G.M.I. Baeten, MD, PhD
Department of General Surgery, Academic Hospital Maastricht, The Netherlands
Nancy Baxter, MD
University of Minnesota, Minneapolis, MN, USA David E. Beck, MD
Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA
Marc Beer-Gabel, MD
Gastroenterology Institute, Kaplan Medical Center, Rehovot, Israel Mitchell Bernstein, MD, FACS
Center for Pelvic Floor Disorders, St Luke’s/Roosevelt Hospital Center, New York, NY, USA
John Beynon, BSc, MS, FRCS
Department of Colorectal Surgery, Singleton Hospital, Swansea, UK
xvii
Gina Brown, MBBS, MD, MRCP, FRCR
Department of Radiology, Royal Marsden Hospital, Sutton, UK Linda Brubaker, MD
Departments of Obstetrics and Gynecology and Urology, Female Pelvic Medicine and Reconstructive Surgery, Loyola University Medical Center, Maywood, IL, USA
G. Willy Davila, MD
Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, FL, USA
Graeme S. Duthie, MD, FRCS
Academic Department of Colorectal Surgery, University of Hull, Castle Hill Hospital, Cottingham, UK
Richelle J.F. Felt-Bersma, MD, PhD
Department of Gastroenterology, Erasmus University Medical Center, Rotterdam, The Netherlands
Claus Fenger, MD, DrMSci
Department of Pathology, Odense University Hospital, Denmark Andrea Ferrara, MD, FACS, FASCRS
Colon and Rectal Disease Center, Orlando, FL, USA Tanja Fischer, MD
Department of Diagnostic Radiology, Ludwig-Maximilians-Universität, Munich, Germany
Andrea Frudinger, MD
Department of Obstetrics and Gynecology, Medical University Graz, Austria
Joseph T. Gallagher, MD, FASCRS
Colon and Rectal Disease Center, Orlando, FL, USA Ezio Ganio, MD
Colorectal Eporediensis Center, Ivrea, Italy Julio Garcia-Aguilar, MD, PhD
Section of Colon and Rectal Surgery, Department of Surgery, University of California, San Francisco, CA, USA
xviii Contributors
Angela B. Gardiner, MPhil
Academic Department of Colorectal Surgery, University of Hull, Castle Hill Hospital, Cottingham, UK
Jeanette Gaw, MD
Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
Marc A. Gladman, MBBS, MRCOG, MRCS
Academic Department of Surgery and Gastrointestinal Physiology Unit, Barts & The London, Queen Mary School of Medicine and Dentistry, The Royal London Hospital, London, UK
Hans Gregersen, MD, DrMSci, MPM
Center of Excellence in Visceral Biomechanics and Pain, Aalborg Hospital and Center for Sensory-Motor Interaction, Aalborg University, Denmark Altomarino Guglielmi, MD
Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Unit, University of Bari, Italy
Tracy L. Hull, MD, FACS
Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
J. Marcio N. Jorge, MD
Department of Coloproctology, Anorectal Physiology Laboratory, University of São Paulo, Brazil
Sergio W. Larach, MD, FACS, FASCRS
Colon and Rectal Disease Center, Orlando, FL, USA Andreas Lienemann, MD
Department of Diagnostic Radiology, Ludwig-Maximilians-Universität, Munich, Germany
Walter E. Longo, MD, MBA, FACS, FASCRS
Department of Surgery, Section of Gastrointestinal Surgery, Yale University School of Medicine, New Haven, CT, USA
Annika López, MD, PhD
Department of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
Contributors xix
David Z. Lubowski, MB BCh, FRACS
Department of Colorectal Surgery, St. George Hospital, Sydney, Australia Carlos M. Lumi, MD, MAAC, MASCRS
Department of Proctology, Hospital Enrrique Erill, Buenos Aires, Argentina
Robert D. Madoff, MD
Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
Michelle M. Marshall, MB BS, BSc, MRCP
Department of Intestinal Imaging, St. Mark’s Hospital, Harrow, UK Anders F. Mellgren, MD, PhD
Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
Neil J. McC Mortensen, MD, FRCS
Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, UK Minda Neimark, MD
Department of Gynecology, Cleveland Clinic Florida, Weston, FL, USA Juan J. Nogueras, MD
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
Lucia Oliveira, MD
Department of Anorectal Physiology, Policlínica Geral do Rio de Janeiro, Brazil
Bharat Patel, MB BCh, FRCR
Department of Radiology, Singleton Hospital, Swansea, UK John H. Pemberton, MD
Division of Colon and Rectal Surgery, Mayo Graduate School of Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
Mario Pescatori, MD, FRCS, EBSQ
Coloproctology Unit, Villa Flaminia Hospital, Rome, Italy Johann Pfeifer, MD
Department of General Surgery, University Clinic Medical School Graz, Karl-Franzens University School of Medicine, Graz, Austria
xx Contributors
Jennifer T. Pollak, MD
Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, FL, USA
Thanesan Ramalingam, BSc, FRCS
University Department of Pharmacology, University of Oxford, UK Kim F. Rhoads, MD
Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
Marcella Rinaldi, MD
Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Unit, University of Bari, Italy
Patricia L. Roberts, MD
Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, MA, USA
Mart J. Rongen, MD
Department of General Surgery, Academic Hospital Maastricht, The Netherlands
Guillermo O. Rosato, MD, MAAC, FASCRS
Department of Proctology, Hospital Enrrique Erill, Buenos Aires, Argentina
Annalisa Russo, PhD
Coloproctology Unit, Villa Flaminia Hospital, Rome, Italy Theodore J. Saclarides, MD
Section of Colon and Rectal Surgery, Rush Medical College, Chicago, IL, USA
Dana R. Sands, MD
Anorectal Physiology Laboratory, Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
T. Cristina Sardinha, MD
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
John H. Scholefield, MB ChB, ChM, FRCS
Department of Surgery, Division of GI Surgery, University Hospital, Nottingham, UK
Contributors xxi
S. Mark Scott, PhD
Academic Department of Surgery and Gastrointestinal Physiology Unit, Barts & The London, Queen Mary School of Medicine and Dentistry, The Royal London Hospital, London, UK
Andrew A. Shelton, MD
Department of Colorectal Surgery, Stanford University School of Medicine, Stanford University Medical Center, Stanford, CA, USA
Philip J. Shorvon, MB BS, MA, MRCP, FRCR
Department of Radiology, Central Middlesex Hospital, London, UK Jaap Stoker, MD, PhD
Department of Radiology, Academic Medical Center, University of Amsterdam, The Netherlands
Michelle J. Thornton, FRACS, LLB
Department of Colorectal Surgery, St. George Hospital, Sydney, NSW, Australia
Dawn E. Vickers, RN
Department of Gastroenterology, Cleveland Clinic Florida, Weston, FL, USA
Steven D. Wexner, MD, FACS, FRACS, FRCSED
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
Norman S. Williams, MS, FRCS
Academic Department of Surgery and Gastrointestinal Physiology Unit, Barts & The London, Queen Mary School of Medicine and Dentistry, The Royal London Hospital, London, UK
Andrew P. Zbar, MD, FRCS, FRACS
Department of Clinical Medicine and Research, University of the West Indies, Queen Elizabeth Hospital, Cave Hill Campus, Barbados
Jan Zetterström, MD, PhD
Department of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
xxii Contributors