Improved Outcomes in
Colon and
Rectal Surgery
Edited by
Charles B Whitlow
David E Beck
David A Margolin
Terry C Hicks
Alan E Timmcke
Improved Outcomes in
Colon and Rectal Surgery
Whitlow • Beck • Margolin
Hicks • Timmcke
www.informahealthcare.com
Telephone House, 69-77 Paul Street,
London EC2A 4LQ, UK
52 Vanderbilt Avenue, New York, NY 10017
Improved Outcomes in Colon
and Rectal Surgery
About the book
Written by many of the world’s leading colorectal surgeons, this evidence-based text investigates the
risks and benets of colorectal surgeries. By using clinical pathways, algorithms, and case discussions,
the authors identify the best practices for patient safety and positive outcomes to ensure that
physicians correctly recognize potential problems and carefully manage complications.
Improved Outcomes in Colon and Rectal Surgery is an essential reference for all colorectal surgeons,
fellows and residents, as well as those working in gastroenterology and the medico-legal profession.
About the editors
Charles B Whitlow MD, Program Director, Colon and Rectal Surgery Fellowship Program, Ochsner
Medical Center, New Orleans, Louisiana, USA.
David E Beck MD, Chairman, Department of Colon and Rectal Surgery, Ochsner Medical Center, New
Orleans, Louisiana, USA. He is President-Elect of the American Society of Colon and Rectal Surgeons

Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Terry C Hicks MD
Associate Chairman
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Alan E Timmcke MD
Staff Surgeon
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
© 2010 Informa UK
First published in 2010 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ. Informa Healthcare is a trading division of
Informa UK Ltd. Registered Office: 37/41 Mortimer Street, London W1T 3JH. Registered in England and Wales number 1072954.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright,
Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court
Road, London W1P 0LP.
Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to
acknowledge in subsequent reprints or editions any omissions brought to our attention.
A CIP record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Data available on application
ISBN-13: 9781920071528
Orders

9 Care paths and optimal postop management 79
Surya P M Nalamati and Eric J Szilagy
10 Limitations of anorectal physiology testing 87
Thomas E Cataldo and Syed G Husain
11 Limitations of colorectal imaging studies 97
Travis J Blanchard, Wilson B Altmeyer, and Charles C Matthews
12 Transanal endoscopy 132
Terry C Hicks
13 Laparoscopic colorectal surgery 140
James W Fleshman and Jonathan S Chun
14 Medical legal issues 148
Charles F Gay Jr and Terry C Hicks
15 Miscellanous conditions 154
M Benjamin Hopkins and Alan E Timmcke
16 Quality and outcome measures 159
Janak A Parikh, Sushma Jain, Marcia L McGory, and Clifford Y Ko
17 Hemorrhoidal surgery 168
Dan R Metcalf and Anthony J Senagore
18 Nonoperative therapy for hemorrhoid disease 178
Kerry Hammond and Charles B Whitlow
contents
19 Surgery and nonoperative therapy of perirectal abscesses and anal fistulas 183
Brian R Kann and Charles B Whitlow
20 Surgery and nonoperative therapy of anal fissure 199
Jaime L Bohl and Alan J Herline
21 Surgery for pilonidal disease and hidradenitis suppurativa 215
Paula I Denoya and Eric G Weiss
22 Surgical treatment of fecal incontinence 226
Ann C Lowry and Dimitrios Christoforidis
23 Surgery for rectal prolapse 239

List of Contributors
Wilson B Altmeyer MD
Department of Radiology
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
David E Beck MD
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Travis J Blanchard MD
Department of Radiology
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Jaime L Bohl MD
Department of Surgery
Vanderbilt University
Nashville, Tennessee
USA
Liliana Bordeianou MD
Department of Surgery
Division of General and Gastrointestinal Surgery
Massachusetts General Hospital
Boston, Massachusetts
USA
Jorge Canedo MD
Department of Colorectal Surgery
Cleveland Clinic Florida

Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Scott E Delacroix, Jr., MD
Department of Urology
Louisiana State University Health Sciences Center
New Orleans, Louisiana
University of Texas, MD Anderson Cancer Center
Houston, Texas
USA
Conor P Delaney MD MCh PhD
Department of Surgery
Division of Colorectal Surgery
University Hospitals Case Medical Center
Cleveland, Ohio
USA
Paula I Denoya MD
Department of Colorectal Surgery
Cleveland Clinic Florida
Weston, Florida
USA
Tolga Erim MD
Department of Colorectal Surgery
Cleveland Clinic Florida
Weston, Florida
USA

lst of contrbutors
Daniel L Feingold MD
Section of Colorectal Surgery

Charleston, South Carolina
USA
Alan J Herline MD
Department of Surgery
Vanderbilt University
Nashville, Tennessee
USA
Terry C Hicks MD
Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
M Benjamin Hopkins MD
Department of Colon and Rectal Surgery
Ochsner Clinic Foundation
New Orleans, Louisiana
USA
Steven R Hunt MD
Colon and Rectal Surgery Section
Division of General Surgery
Washington University
St. Louis, Missouri
USA
Syed G Husain MD
Brown Program in Colon and Rectal Surgery
Warren Alpert Medical School of Brown University
Rhode Island Hospital/Lifespan Health System
Providence, Rhode Island
USA
Larry R Hutson MD

Chicago, Illinois
USA
Ann C Lowry MD
Colon & Rectal Surgery Associates Ltd
St Paul, Minnesota
USA

lst of contrbutors
James T McCormick DO
Department of Surgery
Division of Colon and Rectal Surgery
Western Pennsylvania Hospital and the Forbes Regional Campus
Temple University School of Medicine
Philadelphia, Pennsylvania
USA
Marcia L McGory MD PhD
David Geffen School of Medicine at UCLA
Department of Surgery
Los Angeles, California
USA
Eric L Marderstein MD MPH
Division of Colorectal Surgery,
Department of Surgery,
University Hospitals Case Medical Center,
Cleveland, Ohio
USA
David A Margolin MD
Colon and Rectal Surgery
The Ochsner Clinic Foundation
New Orleans, Louisiana

Siyamek Neragi-Miandoab MD
Division of Colorectal Surgery,
Department of Surgery,
University Hospitals Case Medical Center,
Cleveland, Ohio
USA
Harry T Papaconstantinou MD
Department of Surgery
Scott & White Hospital and Clinic
Texas A&M University System Health Science Center
Temple, Texas
USA
Janak A Parikh MD
David Geffen School of Medicine at UCLA
Department of Surgery
Los Angeles, California
USA
W Brian Perry MD
Department of General Surgery
Wilford Hall Medical Center and the University
of Texas Health Science Center, San Antonio
Lackland AFB, Texas
USA
Harry L Reynolds Jr MD
University Hospital of Cleveland
Cleveland, Ohio
USA
Rocco Ricciardi MD MPH
Department of Colon and Rectal Surgery
Lahey Clinic

USA
Anthony J Senagore MD MS MBA
Spectrum Health System
Grand Rapids, Michigan
USA
Clifford L Simmang MD
Texas Colon and Rectal Surgeons
Dallas, Texas
USA
Vance Y Sohn MD
Department of Surgery
Madigan Army Medical Center
Tacoma, Washington
USA
Michael J Stamos MD
University of California
Irvine, California
USA
Scott R Steele MD
Department of Surgery
Madigan Army Medical Center
Tacoma, Washington
USA
Eric J Szilagy MD
Department of Surgery/Colon & Rectal Group
Division of Colon and Rectal Surgery
Henry Ford Health System
Detroit, Michigan
USA
Alan G Thorson MD

J Christian Winters MD FACS
Department of Urology
Female Pelvic Medicine and Reconstructive Surgery
Louisiana State University Health Sciences Center
New Orleans, Louisiana
USA
Sharon L Wright MD
Department of Surgery
Oregon Health and Science University
Portland, Oregon
USA
Fia Yi MD
Department of General Surgery
Wilford Hall Medical Center and the University of Texas Health
Science Center, San Antonio
Lackland AFB, Texas
USA

Preface
Quality measures and outcomes are receiving greater attention
by the lay and medical communities. The occurrence or mis-
management of complications often results in poor outcomes,
increased cost, and significant morbidity. Answering the call for
transparency and improvement requires action by all involved
in the care of patients. Collection of objective data and quality
measures allows documentation of optimal care and desired out-
comes while identifying areas for improvement.
The goal of this text is to present the current knowledge of
outcomes, as well as the techniques for minimizing and managing
complications from the common diseases and procedures of this