49. Graham SM, Ballantyne GH. Cecal diverticulitis. A review of the American experience. Dis Colon

Rectum 1987;30(10):821–826.

50. Gouge TH, Coppa GF, Eng K, et al. Management of diverticulitis of the ascending colon. 10 years’

experience. Am J Surg 1983;145(3):387–391.

51. Hayward MW, Hayward C, Ennis WP, et al. A pilot evaluation of radiography of the acute

abdomen. Clin Radiol 1984;35(4):289–291.

52. Field S, Guy PJ, Upsdell SM, et al. The erect abdominal radiograph in the acute abdomen: should its

routine use be abandoned? Br Med J (Clin Res Ed) 1985;290(6486):1934–1936.

53. Ambrosetti P, Jenny A, Becker C, et al. Acute left colonic diverticulitis–compared performance of

computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients.

Dis Colon Rectum 2000;43(10):1363–1367.

54. Rao PM, Rhea JT, Novelline RA, et al. Helical CT with only colonic contrast material for diagnosing

diverticulitis: prospective evaluation of 150 patients. AJR Am J Roentgenol 1998;170(6):1445–1449.

55. Rao PM, Rhea JT, Novelline RA. Helical CT of appendicitis and diverticulitis. Radiol Clin North Am

1999;37(5):895–910.

56. Ambrosetti P, Grossholz M, Becker C, et al. Computed tomography in acute left colonic

diverticulitis. Br J Surg 1997;84(4):532–534.

57. Sudakoff GS, Lundeen SJ, Otterson MF. Transrectal and transvaginal sonographic intervention of

infected pelvic fluid collections: a complete approach. Ultrasound Q 2005;21(3):175–185.

58. Lewis M. Bleeding colonic diverticula. J Clin Gastroenterol 2008;42(10):1156–1158.

59. McGuire HH Jr. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann

Surg 1994;220(5):653–656.

60. Drapanas T, Pennington DG, Kappelman M, et al. Emergency subtotal colectomy: preferred

approach to management of massively bleeding diverticular disease. Ann Surg 1973;177(5):519–

526.

61. Rafferty J, Shellito P, Hyman NH, et al. Practice parameters for sigmoid diverticulitis. Dis Colon

Rectum 2006;49(7):939–944.

62. Ambrosetti P, Chautems R, Soravia C, et al. Long-term outcome of mesocolic and pelvic diverticular

abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 2005;48(4):787–791.

63. Chautems RC, Ambrosetti P, Ludwig A, et al. Long-term follow-up after first acute episode of

sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients. Dis Colon Rectum

2002;45(7):962–966.

64. Aydin HN, Remzi FH, Tekkis PP, et al. Hartmann’s reversal is associated with high postoperative

adverse events. Dis Colon Rectum 2005;48(11):2117–2126.

65. Constantinides VA, Heriot A, Remzi F, et al. Operative strategies for diverticular peritonitis: a

decision analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann

Surg 2007;245(1):94–103.

66. Salem L, Flum DR. Primary anastomosis or Hartmann’s procedure for patients with diverticular

peritonitis? A systematic review. Dis Colon Rectum 2004;47(11):1953–1964.

67. Reissfelder C, Buhr HJ, Ritz JP. What is the optimal time of surgical intervention after an acute

attack of sigmoid diverticulitis: early or late elective laparoscopic resection? Dis Colon Rectum

2006;49(12):1842–1848.

68. Purkayastha S, Constantinides VA, Tekkis PP, et al. Laparoscopic vs. open surgery for diverticular

disease: a meta-analysis of nonrandomized studies. Dis Colon Rectum 2006;49(4):446–463.

69. Zingg U, Pasternak I, Guertler L, et al. Early vs. delayed elective laparoscopic-assisted colectomy in

sigmoid diverticulitis: timing of surgery in relation to the acute attack. Dis Colon Rectum

2007;50(11):1911–1917.

70. Lee SW, Yoo J, Dujovny N, et al. Laparoscopic vs. hand-assisted laparoscopic sigmoidectomy for

diverticulitis. Dis Colon Rectum 2006;49(4):464–469.

71. Parks TG. Natural history of diverticular disease of the colon. Clin Gastroenterol 1975;4(1):53–69.

72. Farmakis N, Tudor RG, Keighley MR. The 5-year natural history of complicated diverticular disease.

Br J Surg 1994;81(5):733–735.

73. Makela J, Vuolio S, Kiviniemi H, et al. Natural history of diverticular disease: when to operate? Dis

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Colon Rectum 1998;41(12):1523–1528.

74. Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J

1969;4(5684):639–642.

75. Makela J, Kiviniemi H, Laitinen S. Prevalence of perforated sigmoid diverticulitis is increasing. Dis

Colon Rectum 2002;45(7):955–961.

76. Zaidi E, Daly B. CT and clinical features of acute diverticulitis in an urban U.S. population: rising

frequency in young, obese adults. AJR Am J Roentgenol 2006;187(3):689–694.

77. Pautrat K, Bretagnol F, Huten N, et al. Acute diverticulitis in very young patients: a frequent

surgical management. Dis Colon Rectum 2007;50(4):472–477.

78. Nelson RS, Velasco A, Mukesh BN. Management of diverticulitis in younger patients. Dis Colon

Rectum 2006;49(9):1341–1345.

79. Spivak H, Weinrauch S, Harvey JC, et al. Acute colonic diverticulitis in the young. Dis Colon Rectum

1997;40(5):570–574.

80. Guzzo J, Hyman N. Diverticulitis in young patients: is resection after a single attack always

warranted? Dis Colon Rectum 2004;47(7):1187–1190; discussion 1190–1191.

81. Vignati PV, Welch JP, Cohen JL. Long-term management of diverticulitis in young patients. Dis

Colon Rectum 1995;38(6):627–629.

82. Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular

disease. Arch Surg 2005;140(7):681–685.

83. West SD, Robinson EK, Delu AN, et al. Diverticulitis in the younger patient. Am J Surg

2003;186(6):743–746.

84. Sachar DB. Diverticulitis in immunosuppressed patients. J Clin Gastroenterol 2008;42(10):1154–

1155.

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Chapter 70

Anorectal Disorders

David J. Maron and Steven D. Wexner

Key Points

1 The most common manifestation of internal hemorrhoids is painless, bright red rectal bleeding

associated with bowel movements. A high-fiber diet supplemented with bulk-forming agents may

reduce symptoms of hemorrhoids and is ideal for first- and second-degree hemorrhoids.

2 Rubber band ligation is suitable for symptomatic first- and second- and some third-degree internal

hemorrhoids that do not respond to bulk-forming agents.

3 Hemorrhoidectomy is required in only a few patients with symptomatic hemorrhoids. It should be

considered when conservative therapy has failed, or when hemorrhoids are complicated by

associated pathology such as ulceration, fissures, fistulas, large hypertrophied anal papillae, or

extensive skin tags.

4 Anal fissure is an ischemic ulcer in the lower portion of the anal canal; its treatment, both medical

and surgical, involves relaxing the internal anal sphincter.

5 Anal fistula is a chronic form of perianal abscess, spontaneously or surgically drained, in which the

tract persists, with an internal opening at the dentate line and an external opening on the perianal

skin.

6 Rectal prolapse results from intussusception that extends beyond the anal verge. Fit patients are best

treated with transabdominal rectopexy. Patients with significant medical comorbidities are best

treated using a perineal approach.

7 Anal condylomata acuminata are caused by human papillomavirus, as are anal intraepithelial

neoplasia and anal cancers.

8 Palpable lesions of the anal canal are not hemorrhoids and may be cancers; examination under

anesthesia and biopsy allow for correct diagnosis.

ANATOMY AND PHYSIOLOGY

A detailed understanding of the anatomy and physiology of the rectum and anus is critical to accurate

diagnosis and management of anorectal disorders.

The Rectum

The rectum begins at the level of the sacral promontory and measures approximately 15 cm in length. It

descends along the curvature of the sacrum and passes through the levator ani muscles, where it

becomes the anal canal. Although the rectum develops from the hindgut in conjunction with the sigmoid

and left colon, it differs from the colon in that the outer muscular layer is continuous, characterized by

the merging of the three taenia bands. The rectum has three lateral curves whose infoldings form

submucosal folds in the lumen, known as the valves of Houston. Because of these curves, the rectum

may gain 5 cm in length when straightened during resection.

The posterior aspect of the rectum lacks peritoneum and is directly adherent to the mesorectum.

Anteriorly, the upper two-thirds of the rectum are covered by peritoneum; the lower third has no

peritoneal covering. The level of the anterior peritoneal reflection (also referred to as the pouch of

Douglas) is variable, but is usually 7 to 9 cm from the anal verge in men and 5 to 7 cm in women. The

mesorectum is covered with a thin layer of investing fascia (fascia propria), which is distinct from the

fascia overlying the sacrum. It is in this plane between these two fascial layers that a “total mesorectal

excision” for rectal cancer is performed. The endopelvic fascia that covers the sacrum posterior to the

rectum is also referred to as Waldeyer fascia; anteriorly, Denonvilliers fascia lies between the rectum

and the vagina in females and the seminal vesicles in males (Fig. 70-1).1

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