Corman 39;s Colon And Rectal Surgery

[Imelda Matchett]

Theseventh edition has been edited and fully revised by respected experts in their fields, and provides a full list of current references and relevant resources. It includes recent developments in colorectal surgery, including changes to colorectal cancer screening, multimodal therapy for rectal cancer and changes to the terminology and management of anal neoplasia. Several new authors and co-authors have joined the expert team.

This volume is part of the Companion to Specialist Surgical Practice series, the pre-eminent reference for trainees in general surgery and those preparing for the FRCS examinations. Each volume summarises key issues within each surgical sub-specialty and provides evidence-based recommendations to support practice.

PURPOSE:

The Colon Rectal Subspecialty would place the student in an environment where an average of 5 inpatients are treated at any one time, and in two patient clinics servicing 60-120 patients per week. There are also daily colonoscopy procedures totaling over 700 per year.

INSTRUCTIONAL FEATURES:

The operative experience is primarily outpatient three days per week with 1-3 major procedures per week. The educational experience includes formal Attending Rounds a minimum of twice a week, four major teaching conferences per week by general surgery, and a weekly Journal Club for Colon and Rectal. There is constant teaching from the fellow who is at least a PG-6 in training.

Roberto Bergamaschi, MD, Ph.D., FRCS, FASCRS, FACS, is Professor and Vice-Chair of Surgery at New York Medical College, Valhalla, New York, and Chief of Colon & Rectal Surgery at Westchester Medical Center and MidHudson Regional Hospital. He specializes in surgery for colorectal cancer, inflammatory and benign diseases of the colon and rectum.

Dr. Bergamaschi obtained an MD degree in Milan, Italy, and completed a surgery residency at Strasbourg University, France, and at Middlesex Hospital, in London, UK where he obtained his FRCS (Engl.). Dr. Bergamaschi completed his training in colorectal surgery at the Norwegian University of Science and Technology (NTNU) in Trondheim, Norway, and was awarded a Ph.D. degree in colorectal cancer at Bergen University, Norway. The Ph.D. dissertation was included in the reference file used by the U.S. Army Institute of Surgical Research, Houston, TX by Commander Colonel Basil A. Pruitt, MD. Dr. Bergamaschi was director of the Minimally Invasive Surgery (MIS) Center and program director of the MIS fellowship at Allegheny General Hospital in Pittsburgh, as well as professor of surgery at Hahnemann University in Philadelphia, PA. Dr. Bergamaschi was the Indru Khubchandani Endowed Chair in Colon & Rectal Surgery at Penn State University. Dr. Bergamaschi was a tenured professor and chief of the Division of Colorectal Surgery at the State University of New York, Stony Brook, NY. Dr. Bergamaschi was nominated fellow of the American Surgical Association (ASA).

Dr. Roberto Bergamaschi is a colorectal surgery specialist, Chief of Colorectal Surgery Department at Westchester Medical Center, previously Professor of Division of Colorectal Surgery at State University of New York in Stony Brook, NY

Dr. Roberto Bergamaschi was born in Sicily and grew up in Milan, Italy, where he obtained his MD degree.[1] He completed his surgery residency at Strasbourg University in France and at Middlesex Hospital in London, where he also obtained his FRCS ad eundem.[2] He continued his training in colorectal surgery in Trondheim, Norway under professor Helge Myrvold. Bergamaschi completed his PhD in colorectal cancer at Bergen University in Norway under the guidance of professor Odd Sreide. He was there appointed as associate professor, then elevated to full professor and student clerkship director in 1997.[3][4]

In 2001, Bergamaschi obtained his FASCRS [5] in San Diego and moved to the United States in 2003 to become program director of the MIS fellowship and MIS Center director at Allegheny General Hospital in Pittsburgh, Pennsylvania. as well as professor of surgery at Hahnemann University in Philadelphia, Pennsylvania. After obtaining his FACS in New Orleans in 2004, Bergamaschi accepted in 2005 the Indru Khubchandani Endowed Chair in Colorectal surgery at Penn State University [6] and was appointed in 2006 as associate editor of Diseases of the Colon & Rectum, official journal of the ASCRS.[7]

In 2008, Bergamaschi accepted a position as tenured professor and chief of the Division of Colorectal Surgery at State University of New York in Stony Brook, NY.[1][8] Dr. Bergamaschi served as Chairman of the Education and Training Committee for the European Association for Endoscopic Surgery (EAES) from 2012 through 2015.[9][10] Currently, Bergamaschi is editor of the Colorectal Disease journal [11] and past president of the New York Society of Colon & Rectal Surgeons, where he was elected in 2016.[12][13] In 2017 Dr Bergamaschi accepted a position as Chief of Colorectal Surgery at Westchester Medical Center and tenured professor of surgery at New York Medical College.[14][15] In 2023 Dr Bergamaschi accepted a position as Chief of Surgical Oncology and Colorectal Surgery at Jacobi Medical Center, New York City Health Hospitals.

On average, the surgical anal canal is estimated to be longer in males than in females. Intraoperative measurements of the posterior anal canal have estimated the surgical anal canal to be 4.4 cm in men compared with 4.0 cm in women[4]. In addition, the anal canal was shown to be a unique muscular unit in that its length did not change with age. However, when using MRI, the anatomy of the anal canal has been characterized differently. MR imaging did not show a difference in the length of the posterior anal canal in men and women but did show that the anterior and posterior external anal sphincter length (not including puborectalis) was significantly shorter in women[5].

The dentate line represents a true division between embryonic endoderm and ectoderm. Proximal to the dentate line, the innervation is via the sympathetic and parasympathetic systems, with venous, arterial, and lymphatic drainage associated with the hypogastric vessels. Distal to the dentate line, the innervation is via somatic nerves with blood supply and drainage from the inferior hemorrhoidal system.

The internal anal sphincter (IAS) is the downward continuation of the circular smooth muscle of the rectum and terminates with a rounded edge approximately 1 cm proximal to the distal aspect of the external anal sphincter. 3D imaging studies of this muscle demonstrate the overall volume does not vary according to gender, but the distribution is different with women tending to have a thicker medial/distal internal anal sphincter[11]. Overall, the IAS was found to be approximately 2 mm in thickness and 35 mm in length. The authors note that on any study, it is difficult to identify the proximal portion of the IAS as it is a continuation of the wall of the lower rectum.

The external anal sphincter (EAS) is composed of striated muscle that forms an elliptical tube around the internal anal sphincter and conjoined longitudinal muscle. As it extends beyond the distal most aspect of the internal anal sphincter, the intersphincteric groove is formed. At its distal most aspect, corrugator cutis ani muscle fibers from the conjoined longitudinal muscle traverse the external anal sphincter and insert into the perianal skin. Milligan and Morgan described the external anal sphincter as having three distinct divisions from proximal to distal that were termed sphincter ani externus profundus, superficialis, and subcutaneous[1]. With time, this theory of three distinct divisions was proven invalid by Goligher who demonstrated that the external anal sphincter was truly a continuous sheet of skeletal muscle extending up to the puborectalis and levator ani muscles[16]. While the external anal sphincter does not have three distinct anatomic layers, it is common to see the proximal portion of the EAS referred to as deep EAS, the midportion as the superficial EAS, and the most distal aspect as the subcutaneous EAS. The mid EAS has posterior attachment to the coccyx via the anococcygeal ligament, and the proximal EAS becomes continuous with the puborectalis muscle. Anteriorly, the proximal EAS forms a portion of the perineal body with the transverse perineal muscle. There are clear differences in the morphology of the anterior external anal sphincter that have been demonstrated on both MRI and three-dimensional endoanal ultrasound studies in normal male and female volunteers[17],[18]. The normal female external anal sphincter has a variable natural defect occurring along its proximal anterior length below the level of the puborectalis sling that was demonstrated in 75 percent of nulliparous volunteers. This defect correlated with findings on anal manometry, and the authors noted that it can make interpretation of an isolated endoanal ultrasound difficult resulting in overreporting of obstetric sphincter defects[17]. This natural defect of the anterior anal sphincter provides some justification as to why anterior anal sphincterotomy is not routinely recommended in women.

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