The principal aims of providing a colorectal surgery serv-ice are to make a diagnosis, to counsel the patient with allavailable information and support, to treat the disorder andto liaise with primary care physicians regarding surveil-lance, education and follow-up. The manner in which thisis achieved has a profound effect on a persons attitude totheir disorder, on their ability to cope with illness and ontheir quality of life. The delivery of this process involves thedissemination of information, education and teaching(Goligher, 1996).

PRINCIPLES

COLLABORATIVE APPROACHIn the past, surgery and medicine existed in separate campsand there were structural, political and economic barriersseparating the medical personnel who would be needed toprovide a colorectal surgery service. Now, however, system-based medical services involving the integration of sur-geons, physicians, radiologists, histopathologists, nursesand counsellors are standard in many hospitals.

In leading hospitals and clinics groups of committedgastroenterologists, colorectal surgeons, radiologists,histopathologists, nurses, nutritionists and counsellorshave created colorectal surgery units, working closelywith basic sciences and oncology. There are separate ward,

theatre, outpatient and endoscopy components. If theseactivities are able to be planned together enormous savingscan be made but most colorectal surgical services havebeen developed within the context of established hospitals.

Prior to setting up a colorectal surgical service it is vitalto determine a vision and a plan for the service. A set ofbasic requirements should be developed and extra servicesadded over time if it is not possible to provide these initially.In tertiary referral hospitals all of the components men-tioned in this chapter should be provided. For smaller units,sharing of resources across a city or region may be anappropriate way to function if not all of the componentscan be put together on one site. For example, multidiscipli-nary meetings are possible by clinicians travelling on a reg-ular basis to central sites. The same is true for Journal Clubsand other educational meetings. Creative use of moderntechnology such as video-conferencing can make these sortof activities practical when travel is difficult and can saveneedless duplication of resources.

Having said this, it is not the bricks and mortar but thepeople that work together to create the right environmentthat make a colorectal surgery unit. Industry, compassion,sensitivity, enthusiasm, teamwork and enquiring minds aresome of the attributes needed to make this venture succeed.Most clinicians trained in colorectal surgery are endo-scopists, physiologists and diagnosticians; some aresurgeons with an emphasis on therapy, while others

2RUNNING A COLORECTALSURGERY SERVICE

Principles 47Collaborative approach 47The doctorpatient relationship 48Dissemination of information 48Teaching 48Assessment 48Information systems 48Colorectal surgery and the law 49

Audit 50Diagnosis 50

History 50Examination 50Proctosigmoidoscopy 51Proctoscopy, vaginal speculum

examination and outpatienttherapy 52

Physiology 54Manometry 54Electromyography 54Sensory parameters 54

Evacuatory assessment 54Anorectal imaging 54

Endoscopy 55Flexible sigmoidoscopy 55Colonoscopy 55Endoscopic ultrasound 56Laparoscopy 58Capsule endoscopy 58

Radiology 58Contrast radiology 58Ultrasonography 59Computerised tomography 59Magnetic resonance imaging 59Angiography 59Videoproctography 59

Nuclear medicine 59Oncology 60Histopathology and

cytopathology 60Multidisciplinary team approach 60

Screening 60Facilities 60

Outpatient area 61Endoscopy 61Ward 61Operating theatres 61Day-case unit 61Emergency admission 62

Stoma care 62History 62Function 62Physical needs 62Records 63Personnel 63Emergency cover 63Ethical considerations and open

access clinics 63Voluntary organisations 63

References 64

are trained as physicians who play a greater role inendoscopy. Within colorectal surgery we now see focused,multidisciplinary teams providing specialist oncology care,services for inflammatory bowel disease, counselling forfunctional bowel disease and screening in patients at riskof familial colorectal cancer. These teams also includenurse specialists (Moshakis et al, 1996), physiotherapists,dietitians (Wright and Scott, 1997), stoma care nurses,audit clerks, those involved with nutrition therapy, radiol-ogists, specialist histopathologists, counsellors (Wiig et al,1996; Gerson and Gerson, 2003), anaesthetists and paincontrol experts (Kamm, 1997).

THE DOCTORPATIENT RELATIONSHIPThere are few other fields of practice where communica-tion between the doctor and the patient is more important.Many patients are terrified that their symptoms are due tocancer growing in the anorectum, which will necessitatethe construction of a stoma (Bass et al, 1997). The thoughtof cancer is bad enough, but the concept of treatmentinvolving a stoma that uncontrollably discharges wind andwaste, that smells and can be seen, is completely shatter-ing to self-esteem. Patients will probably be aware of theimpact of colorectal disease and its treatment on sexualbehaviour and function, which may be devastating (Rapkinet al, 1990; Wood et al, 1990; Brook, 1991; Black, 2004).Many also have gynaecological or urological symptoms(Farquhar et al, 1990; Steege and Stout, 1991).

Before seeing the colorectal surgeon, a patient may notonly have been suffering from pain, diarrhoea or bleedingbut may have had episodes of incontinence. Clearly it isinappropriate to treat a patient even with a minor colorec-tal disorder in the same manner as, for instance, a patientwith a hernia or gallstones. Patients referred with colorec-tal symptoms, however minor, must be adequately assessedso that they may be reassured that they do not have amalignancy. If malignancy is identified, an honestappraisal of the clinical outcome and its natural historyshould be provided in collaboration with oncology coun-sellors. Most patients will require information and dietaryadvice. It may be necessary to trace members of a family;most patients will need some form of endoscopy involvinga bowel preparation, some will be offered outpatient or day-case surgery. Access to a dedicated psychologist is essentialto assess and advise on treatment, especially in functionalbowel disease but also in those with malignancy andinflammatory disease (American GastroenterologicalAssociation, 2002; Sewitch, 2001). For all these reasons,the method, attitude taken and extent of the communica-tion between the doctor and the patient are crucial to thesuccess or failure of treating the whole person (Svedlundet al, 1983; Whorwell et al, 1987; Peters et al, 1991).

DISSEMINATION OF INFORMATIONPatients should understand why they may have developedtheir disease, what is known about the condition, the avail-able therapeutic options and the consequences of treat-ment. Booklets and DVDs should be available on all thecommon colorectal disorders and their treatment, partic-ularly on subjects such as haemorrhoids, fissure, fistula,pilonidal sinus, warts, the irritable bowel syndrome,

colostomy, ileostomy, Crohns disease, ulcerative colitis,Kock and pelvic pouches, bowel cancer and hereditarybowel cancer. In certain circumstances DVDs are useful inreinforcing the information provided, particularly as booksare often not read or fully understood. Today the public cangain up-to-the-minute information through the Internet.A departmental Web page, perhaps as part of the hospitalsWeb site, is a useful source of information for patients, espe-cially if linked to other organisations and providing specificinformation on common conditions.

TEACHINGTeaching of undergraduates and particularly of postgrad-uate medical staff can be conducted in a stimulating andinformative way in the right environment. An undergrad-uate can assess a symptom complex; he or she can then betaken through the most cost-effective process of diagnosisusing radiological and endoscopic techniques, and assess-ment of the histopathology, before deciding on the opti-mum evidence-based therapy and follow-up, all in the oneclinical environment. Colorectal surgeons have a respon-sibility to educate students from other disciplines, particu-larly nurses, nutritionists, physiotherapists and stoma carenurses. Postgraduate education can take place at variouslevels: regular ward management rounds with case pre-sentations, audit, surgical skills workshops, logbook-basedactivity and joint weekly meetings with histopathologists,radiologists and physicians in oncology, inflammatory andfunctional bowel disease.

Continued Medical Education (CME) approval foraccreditation and credentialling purposes for the licensingbodies to monitor professional standards is essential inmodern surgical practice. Regular multidisciplinary casepresentations and journal clubs are important to keep cli-nicians abreast with the latest developments and technol-ogy (Ziemer, 1983; Bartlett, 1986; Karam et al, 1986;Kreps et al, 1987). Access to online journals, colorectal dis-cussion forums and other Internet resources is part of themodern tools of the trade for the colorectal surgeon.

ASSESSMENTA great deal of treatment can be delivered on an outpatientor day-case basis. However, because not all patients aresuitable for this, due to coexisting pathology, unsatisfac-tory home circumstances or incompatible personality, athorough assessment of the patient and the patients envi-ronment is needed. Special forms for determining suitabil-ity for day-case management have been devised (Table 2.1).The patients are then screened by the day-case nursingteam and if necessary are reviewed by the anaesthetist toensure that they are suitable for this form of treatment.

INFORMATION SYSTEMSInformation retrieval is necessary both for financialand auditing purposes. Appropriate software will providea fail-safe follow-up procedure (Kjeldsen et al, 1997) andwill generate information for hospital staff, the patient,the general practitioner and medical colleagues. Computerprograms will provide admission dates, identify operatingtheatre facilities, screen for day-case suitability, code forcost and generate files for research. For these reasons, data

Chapter 2 Running a Colorectal Surgery Service48

sheets must be completed and updated regularly.Networked terminals should be available in outpatientdepartments, the stoma care suite, endoscopy, the operat-ing theatre and the ward for updating and extractingpatient information.

Much of the information required for computer pur-poses can be derived from a patient questionnaire, com-pleted by the patient, a research fellow, a junior doctor ora member of the nursing staff. This provides a checklist forthe surgeon, logs data for audit and ensures that severityof illness indices, ethnic variables and coding are accuratefor financial purposes.

COLORECTAL SURGERY AND THE LAWIncreasingly we live in a world dominated by litigation. Theprincipal areas of potential negligence in colorectal sur-gery seem to be: (a) inadequate counselling leading tounacceptable informed consent, (b) delayed diagnosis ofcolonic perforation, anastomotic leak or malignancy lead-ing to complications or reduced life expectancy, (c) iatro-genic bowel perforation at colonoscopy, laparoscopy orlaparotomy, (d) failure of diagnosis by clinical acumen,endoscopy or radiology, (e) iatrogenic incontinence fol-lowing inappropriate colorectal excision or sphincter dam-age during anal surgery, and (f) inadequate training orexperience of certain procedures such as laparoscopy,pouch surgery or low rectal excision. We are frequently

involved, though not directly liable for postobstetric incon-tinence or fistulas, and for bowel damage leading to sepsis,fistulas and sometimes death caused by our colleagues inurology or gynaecology.

Few physicians would ascribe to defensive medicine, butall of us should be aware of potential pitfalls that can beminimised or avoided. Complex surgery should not be del-egated to trainees unless they can be properly supervised.Availability and appropriate supervision of emergency pro-cedures is mandatory. Proper accreditation and continuedmonitoring of performance is necessary; hence a personalaudit of workload and outcome has become essential todeflect criticism and claims of incompetence. Attendanceat regular meetings for CME accreditation is now essentialin all areas of clinical practice.

Thorough counselling and explanation of proceduresmust now become a part of preoperative assessment, andinformation on likely outcome and risks must be explained.Booklets, DVDs and handouts can be useful. Many practi-tioners regularly send patients copies of the correspon-dence to their referring clinician. In this correspondencean estimate of risk and likely outcome is stated. Patientsrequiring more information must be offered further con-sultations, preferably with a family member or support per-son, before embarking on surgical operations. The consentform should signify that the patient understands what isproposed in the statement that he or she is asked to sign.

Principles 49

TABLE 2.1 QUESTIONNAIRE USED TO ASSESS SUITABILITY FOR DAY SURGERY (TO BE COMPLETED BY THE DSU STAFF)

Physiological assessment1. Have you had an operation before? YES NO

Specify:2. Have you had any problems with anaesthetics? YES NO

Specify:3. Have any of your relatives had any problems with anaesthetics? YES NO

Specify:4. Have you any allergies? YES NO

Specify:5. Have you had any serious illness in the past? YES NO

Specify:6. Do you have blackouts or faint easily? YES NO7. Have you ever had a convulsion or fit? YES NO8. Do you have high blood pressure? YES NO9. Do you get chest pain, indigestion or heartburn? YES NO10. Do you get breathless easily? YES NO11. Do you have asthma or bronchitis? YES NO12. Do you have anaemia or other blood disorders? YES NO13. Do you know your sickle status (if relevant) YES NO

Specify:14. Have you been jaundiced? YES NO15. Do you have diabetes? YES NO16. Are you taking any medicines? YES NO

Specify:17. Are you taking the contraceptive pill or hormone replacement therapy? YES NO18. Do you smoke? YES NO19. Do you drink alcohol? Regularly Rarely Never

ObservationsBP: Pulse: Weight (kg) UrinalysisIf the patient is found to be unsuitable, please state the reason and refer back to the referring doctor.

AUDIT

Audit is essential in monitoring standards and providinginformation for planning future structures, resource man-agement and education (Holm et al, 1997; Kjeldsen et al,1997; Singh et al, 1997). It also facilitates greater linkswith primary care. Audit may be undertaken globally or ata local level. Total activity audits are generally fairly super-ficial but essential for resource management and serviceallocation. More detailed local audit may be undertakenshort term to examine specific events or therapies; forinstance an audit may be taken on the efficacy of glyceryltrinitrate in anal fissure or on the outcome of seton fistu-lotomy. Some specific local audits will necessitate financialinformation, for instance to examine the cost effectivenessof surgical treatments for bowel incontinence or to assessthe cost benefits of stapling low coloanal anastomoses.Other local audits may be deliberately short term so as toprovide education to other groups.

There may be more robust local audits to cover areas ofparticular interest, for instance outcome after pouch oper-ations or recurrence rates in Crohns disease. These spe-cialist audits provide much more information than theresource management package and are important for post-graduate education.

National audits organised through training bodies reg-ularly examine specific areas of practice. These are cur-rently voluntary and do not necessarily capture totalpractice since the information is derived from enthusiastsand specialists. Subjects recently scrutinised have includedoperations for rectal prolapse, treatments of anal fissure,stapled anopexy, laparoscopic colorectal surgery andrestorative proctocolectomy.

Most local and national trials require a robust databasethat provides extremely useful information for audit pur-poses (Fielding et al, 1978; Umpleby et al, 1984; McArdleand Hole, 1991; Gordon et al, 1993; Ubhi and Kent, 1995;Kapiteijn et al, 2003).

DIAGNOSIS

HISTORYA comprehensive history, paying particular attention to thepatients own description of symptoms, is essential. A briefobstetric, gynaecological and urinary tract history should betaken. Details of the key proctological symptomspain,bleeding, altered bowel habit, incontinence, swelling, dis-charge and irritationshould be obtained. A family historyis essential. Thorough documentation of previous gynaeco-logical, urological, abdominal and anal operations must berecorded. A list of risk factors for anaesthesia and con-traindications for day-case surgery should be checked: hyper-tension, diabetes, angina, chronic renal disease, valvularheart disease, previous myocardial infarction and cerebro-vascular accident, epilepsy and others. Coexisting medicaltherapy, especially anticoagulants, diabetic therapy, anticon-vulsants, antihypertensives and immunosuppressants shouldbe recorded. Social circumstances should also be assessed.

Some symptoms must be explored in some depth.Abdominal pain is an important symptom and the clini-

cian will need to know its site, whether it is meal related,what relieving factors there are, whether the pain is con-stant or colicky, and whether there is relief from posture,defecation or medication. Duration of symptoms must berecorded but severity is difficult to quantify. Anal and per-ineal pain may be related to defecation, posture or sexualactivity, and may radiate.

Details of bowel habit are best ascertained by encourag-ing the patient to provide the history spontaneously. Normalperiodicity and factors influencing frequency are noted.Details of consistency, characteristics of the stool and defe-catory difficulty must be sought. A history of straining, self-digitation, rectal sensation, urgency, assisted defecation byperineal or vaginal pressure may provide valuable infor-mation about the pathophysiological problem.

Bleeding is always worrying to the patient. The rela-tionship between bleeding, defecation, straining, scratch-ing, prolapse, constipation and diarrhoea is noted, as is thecolour of the blood loss and its presence in relation tothe stool. Whether blood is on the surface or mixed with thefaeces provides a pointer to the pathology. Other importantsymptomatic clues can be gained by ascertaining whetherblood is on the paper only, drips into the pan on strainingor is lost as clots. The relationship of blood loss to pain oraltered bowel habit needs to be sought.

Information on incontinence must be asked as it is rarelyvolunteered. A distinction must be made between thepatient being truly unaware of passing stool and urgency.Similarly, it is essential to distinguish soiling from trueincontinence. Frequency of incontinence and the rela-tionship between it and stool consistency and lifestyle helpsto define the severity of the problem. An incontinencegrade widely used is outlined in Table 2.2. The relationshipof symptoms due to obstetric, gynaecological and urinarytract symptoms and their treatment must be included.

Other specific proctological symptoms that will needto be explored include discharge, soiling, irritation andprolapse.

The interview may involve relatives and friends; somequestions are extremely personal and should only bediscussed on a one-to-one basis. Above all, this conversa-tion must be undertaken in a place where there is privacy,available counselling and a relaxed environment.

EXAMINATIONGeneral considerationsThe way in which the history, and particularly the exami-nation, is conducted often sets a seal on the entire futurecommunication process. The patient must be made to feelat ease. The room should be clean but not too clinical, wellventilated and warm with adequate lighting, providedpreferably by a fibreoptic cord light. The couch should haveheight and backrest adjustment, and there should be astool on which the doctor can sit during the examination.A handbasin for the patient and doctor is necessary. Thereshould be separate examination and treatment trollies. Thepatient should be left alone to undress behind a curtainand, if possible, given a light bathrobe to wear. He or shemust be covered when lying on the couch. If there is anyconcern a chaperone should be present during the exami-nation.

Chapter 2 Running a Colorectal Surgery Service50

The first part of the examination should help to reassurethe patient while general clinical information is obtained.The clinician should make the patient feel at ease whilechecking for malnutrition, anaemia, cyanosis, clubbing,jaundice and lymphadenopathy and inspecting andpalpating the abdomen.

PositionViews differ about the best position for the anorectal assess-ment. It could be argued that more information can beobtained in the knee-elbow position; however, mostpatients find this position undignified and will not readilyallow the examination to be repeated. By contrast, the leftlateral position enables most conditions to be diagnosedwith all except the patients perineum covered.

The patient lies on the left side on the examining tableor bed with buttocks protruding over the edge, hips flexed,knees slightly extended, and right shoulder rotated anteri-orly. The examiner may sit or stand depending on theheight of the table or bed. Although this position is the eas-iest for the patient, it is not as convenient for the examineras the prone position. There is no evidence to suggest thatposition influences the ability to pass a sigmoidoscope toits full length.

InspectionInspection is critical and may reveal scars, a fistula, a fis-sure, tags, a patulous anus, vaginal and rectal prolapse ordermatological problems (including pruritic changes). Theposition of the perineum at rest is noted, as is the move-ment of the perineum in relationship to the ischialtuberosities during pelvic floor contraction and straining.During straining a rectocele, haemorrhoids and analpolyps, intra-anal warts or a rectal prolapse may becomevisible. Parting of the buttocks may reveal an anal fissure.If the clinician suspects a rectal prolapse it may be neces-sary to examine the patient during straining on a toilet.

Rectal examinationIf a satisfactory and reasonably comfortable examinationis to be achieved, thereby obtaining the maximum infor-mation, it is essential to inform the patient continually of

what is to be expected and what is happening. Rectal exam-ination may be a frustratingly unsuccessful experience ifproper explanation is not provided, particularly in view ofthe patients understandable reluctance to submit to suchan unpleasant intrusion. Having applied a water-solublelubricant to the gloved index finger, the pulp of the fingershould be placed gently over the anal orifice and pressureexerted until the sphincter relaxes, allowing the finger toenter the anal canal and rectum. The anal canal and rec-tum and their surrounding structures should then beexamined in an organised manner. This examinationshould usually be combined with a vaginal examination inwomen.

First, the resting tone of the anal sphincters is assessed,then the presence of scars, induration, local pain and dis-charge. The patient is then asked to contract the sphinc-ters and pelvic floor maximally to gauge their activity,degree of movement and position in relation to the rectalampulla and vagina. The rectovaginal septum must becarefully palpated from both sides. Deeper palpation isneeded to feel for the prostate and most rectal tumours.The clinician should then sweep the examining fingerfrom anterior to posterior, consciously thinking of a pos-sible lesion that might be present. The conscious thoughtprocess is emphasised because too often this phase of theexamination is simply performed as a routine. In the caseof a tumour, its position, size and characteristics, espe-cially whether it is polypoidal, sessile or ulcerated, togetherwith its depth of bowel wall involvement, mobility, fixityand relationship to local anatomy, must be recorded,preferably on a chart. Finally, as the finger is withdrawn,the presence of additional anal pathology is noted(e.g. hypertrophied papilla, thrombosed haemorrhoid,stenosis, scarring).

PROCTOSIGMOIDOSCOPYA rigid sigmoidoscopy will usually be performed at thecompletion of the digital examination in the unpreparedpatient provided there is no painful anal lesion. Disposableinstruments are standard in many practices due to the riskof transmissible disease. The limit of the 25-cm instrumentcan usually be reached in 40% of examinations and in

Diagnosis 51

TABLE 2.2 SCORE OF INCONTINENCE (CLEVELAND CLINIC) (020)

FrequencyType of incontinence Never Rarelya Sometimesb Usuallyc Alwaysd

Solid 0 1 2 3 4Liquid 0 1 2 3 4Gas 0 1 2 3 4Requires pad 0 1 2 3 4Lifestyle 0 1 2 3 4

From Oliveira et al (1996).aLess than once a month.bMore than once a month; less than once a week.cMore than once a week; less than every day.dEvery day.

over half of these the presence of stool does not preventadequate inspection of the anorectum. The rigid sigmoi-doscope is the best instrument available for evaluation ofthe rectum. The purpose of the examination is to identifypolyps, benign strictures, vascular abnormalities, malig-nancy and proctitis. Any visible lesion or abnormalityshould be biopsied, any palpable lesion should be scrapedfor cytopathology and biopsied and in patients withdiarrhoea the stool should be cultured.

EquipmentThere are numerous rigid sigmoidoscopes available:reusable and disposable; with proximal or distal lighting;with and without fibreoptics (Figure 2.1). If only a fewexaminations a day are performed, the reusable instrumentmay be most appropriate. If many examinations are under-taken every day, unless one can afford the luxury of hav-ing a number of instruments and can justify the labour andexpense of cleansing them, the disposable instrument isusually preferred. When using plastic disposable instru-ments be generous with the lubricant gelthey do notglide like cold steel.

Instruments are available in a number of diametersranging from 1.1 to 2.7 cm; the 1.9-cm instrument isan excellent compromise. The large-bore instrumentis less useful for screening because of greater patientdiscomfort but may be invaluable for removing largepolyps. The narrow sigmoidoscope is a good screeningtool and is particularly useful if an anal stricture pre-cludes the use of the larger diameter instrument or if thepatient has had a previous anal anastomosis. In additionto the tube itself, the instrumentation includes a lightsource, a proximal magnifying lens, and an attachmentfor the insufflation of air. Suction facilities should beavailable for banding of haemorrhoids and removal ofliquid stool.

MethodBowel preparation is not normally necessary, although adigital rectal examination should always precede instru-mentation. The well-lubricated, warmed sigmoidoscope isinserted and passed to the maximum height under visionas quickly as possible without causing discomfort. Airinsufflation is of value in demonstrating the lumen and isof even greater benefit in visualising the mucosa, but itshould be kept to a minimum because it tends to causepain. Most information is obtained as the sigmoidoscope iswithdrawn, when the entire circumference of the bowelwall can be inspected.

BiopsyVarious biopsy forceps are available (Figure 2.2) (Siegelet al, 1983; Yang et al, 1990). Some instruments are elec-trified for biopsy and coagulation. The lesion is graspedwith the forceps, which are then rotated to prevent bleed-ing when shearing the mucosa. Cytology smears may beprepared from potentially malignant lesions to gain animmediate diagnosis (Wiig et al, 1996). Random biopsiesfor inflammatory bowel disease should always be per-formed on the posterior rectal wall and from the valve ofHouston where possible.

PROCTOSCOPY, VAGINAL SPECULUMEXAMINATION AND OUTPATIENT THERAPYProctoscopyProctoscopy allows thorough inspection of the anal canalat rest and during straining to exclude an internal openingof a fistula, a discharging intersphincteric abscess, haem-orrhoids, condylomata acuminata and a chronic fissure.

There are a number of proctoscopes, most of which havefittings for a fibreoptic light source. A bivalve speculum is

Chapter 2 Running a Colorectal Surgery Service52

Figure 2.1 (a) A Lloyd-Davies rigid sigmoidoscope withobturator and eyepiece. (b) A Welsh Allen rigidsigmoidoscope with bellows, eyepiece, obturator and lightsource. (c) A disposable transparent Perspex rigidsigmoidoscope.

a

b

c

Diagnosis 53

sometimes preferred to the tubular proctoscope of theGoligher or Eisenhammer design. Proctoscopes with a seg-ment removed from one side of the instrument to allow aside view of the anal canal are available (Figure 2.3a).These instruments have been used in the past for cryother-apy but are rarely used in diagnosis. When rotating theanoscope around the circumference of the anal cavity it ishelpful to reinsert the obturator. The site of any pathologyshould be recorded.

Vaginal speculum examinationA speculum examination of the vagina is often carried outto exclude a fistula, to assess uterine descent, to evaluate acystocele or rectocele and to swab a chronic discharge toexclude specific causes of vaginitis.

Outpatient therapyAfter a complete clinical assessment, certain disorders canbe treated at the same time as the initial consultation, pro-vided the patient has been informed and is agreeable. Thusrapid outpatient therapy is eminently feasible at the firstconsultation. Outpatient or office procedures includepolypectomy, photocoagulation, cryotherapy, injection orrubber-band ligation of haemorrhoids, application ofpodophyllin for condylomata and curettage of a pilonidalsinus.

Different organisations have their own specific facilities.Thus in institutions offering office diagnosis and therapy

there is often a well-equipped minor operating theatre adja-cent to the office with specialised nursing personnel whoare able to provide a wider range of outpatient therapy. Inother institutions the culture is geared to day-case surgi-cal procedures usually not undertaken at the time of thefirst consultation but booked on a minor or day-case list.With the provision of a minor operating theatre equippedfor colorectal surgery, the range of outpatient therapeuticoptions increases considerably. In these circumstances,internal anal sphincterotomy as either an open or closedtechnique may be practised under local or regional anaes-thesia. Likewise, an office facility enables the clinician todrain anorectal sepsis under local or regional anaesthesia;furthermore, low-lying anorectal fistulas may be laid open

Figure 2.2 (a) Long alligator forceps used for swabbing outthe bowel during sigmoidoscopy. (b) Lloyd-Davies biopsyforceps. (c) Cutting biopsy forceps (Mueller design).

Figure 2.3 (a) Rigid proctoscope with light source of the St Marks variety. (b) Proctoscopes widely used in clinicalpractice. (c) Welsh Allen fibreoptic proctoscope with anoblique tip.

Continued

a

b

c

a

b

c

sometimes under local anaesthesia or encircled with aseton as an outpatient procedure. Certainly skin tags canbe excised and minor operations such as the Bascomb oper-ation for pilonidal sinus are feasible.

PHYSIOLOGY

There are certain conditions, notably faecal incontinence,previous anorectal fistula surgery, prolapse, constipation,rectovaginal fistula, solitary ulcer and megarectum, inwhich physiological assessment is necessary for assessmentand diagnosis. In other disorders selective physiologicaltesting is needed to determine optimum therapy, parti-cularly sphincter preservation in colitis, cancer or Crohnsdisease, or the avoidance of sphincter damage in thetreatment of fissure, fistula and haemorrhoids.

Physiological assessment is performed in a separateroom; hence the patient needs to stay in the bathrobe andbe transferred to the physiology laboratory. However, ifsufficient information can be derived from measurementof sphincter pressures alone, it may be possible to use amobile unit for this purpose so that transfer of the patientis unnecessary.

Details of anorectal physiological investigation aredescribed in Chapter 1. The organisational aspects areincluded here only to describe the running of a colorectalsurgery service. Physiological systems were initially drivenby research staff who were engaged in measurementin functional disease. Thus in many units different, oftenhomemade, systems have been developed and used forresearch purposes only. Over the years, many tests havebecome essential for clinical assessment; hence equipmenthas become more standardised and physiology personnelundertake many of the routine investigations. The physi-ologists often have a nursing background and see theirrole in measurement, counselling, research and psycho-logical support. There are organisations and courses for

these individuals who have now established a recognisedprofessional role with links to stoma therapy, psychology,medical physics and clinical colorectal surgery.

MANOMETRYMost systems are modular and fully computerised so thatthey can be used for ambulatory measurement, biofeed-back and static diagnostic purposes. The essential mano-metric assessments include resting and squeeze anal canalpressures, rectomanometry with station pull-through tech-niques using circumferential perfusion channels, combinedanal and rectal manometry during pelvic floor contractionand defecation and motility measurements in the colon (orileum in the case of pouch patients) to evaluate evacuationdisorders (Loening-Baucke and Anuras, 1984; Mathesonand Keighley, 1981; McHugh and Diamant, 1987).

ELECTROMYOGRAPHYSurface electromyography may be used for biofeedback.Pudendal nerve conduction studies may be used in incon-tinent and constipated patients and may help to predictoutcome. Fine wire needle electrodes may be used tomeasure internal anal sphincter EMG activity, externalanal sphincter and puborectalis activity in incontinenceand in patients with evacuatory disorders. Fibre densityis still used by some to quantify the extent of sphincterand pelvic floor neuropathy (Kiff and Swash, 1984;Swash et al, 1985; Snooks et al, 1986; Birnbaum et al,1996).

SENSORY PARAMETERSAnorectal anaesthesia is a feature of pudendal neuropathythat has a major impact on function and that may help topredict outcome.

Rectal sensibility can be evaluated by balloon distensionor by electrosensitivity. Likewise anal sensation to an elec-trical or temperature stimulus may identify anaesthesiainvolving the anal transition zone (Rao et al, 1997).

EVACUATORY ASSESSMENTMost evacuatory measurements are now performed withisotopic techniques in nuclear medicine or by evacuatoryproctography in the X-ray suite. It is possible to integrateEMG measurements and manometry as part of videoproc-tography, a technique that is particularly useful in assess-ing rectal evacuatory disorders, but there is a potentiallyhigh radiation dose in these studies, which are often neededin young women. Simple physical assessment by evacua-tion of cellulose paste from the rectum may be performedin the physiology laboratory. Administration of markers fortransit studies are also arranged through the physiologynurse (Ryhammer et al, 1996).

ANORECTAL IMAGINGIt is largely a matter of logistics where anal and rectal ultra-sound is performed. The authors believe that these investi-gations should be performed by medical staff. Analultrasound allows imaging of the internal and externalsphincter to detect injury, fistulas or abscess. Rectal ultra-sound is available for imaging and staging rectal polyps andtumours (Sultan et al, 1993; Bipat et al, 2004).

Chapter 2 Running a Colorectal Surgery Service54

Figure 2.3, contd (d) Bivalve anal speculum withattachable third blade for intra-anal surgery.

d

ENDOSCOPY

Most endoscopies are planned to be performed at a sepa-rate session but there are certain situations where anurgent assessment is needed, particularly where rigid sig-moidoscopy has been unsatisfactory. In these circum-stances a disposable phosphate enema is given at the endof the examination; the patient uses the lavatory 1020minutes later and the bowel is then usually sufficiently wellprepared to allow a flexible sigmoidoscopy to be performedwithout sedation in the endoscopy suite. This policy hasproved useful in distinguishing ulcerative colitis fromCrohns disease, has helped in the quick assessment of pou-chitis so that treatment can be started and, most impor-tantly, has provided a means of biopsying a tumour thatcould not be adequately seen on rigid sigmoidoscopy.

All other endoscopies are performed on fully preparedpatients who have been booked in for total colonoscopyor small bowel endoscopy under sedation. These patientstherefore require transport after recovery from the exami-nation.

There is an unresolved debate concerning the staffingof endoscopy facilities. The increasing emphasis on screen-ing programmes, surveillance of polyps and individuals atrisk of cancer with a much greater use of endoscopy overcontrast radiology has highlighted a manpower problemin some countries (Achkar, 2004; UK Colorectal CancerScreening Pilot Group, 2004). Nurse endoscopists are lessexpensive than medical staff. Issues identified as importantare legal, adequate training and tight clinical audit(Goodfellow et al, 2003; Kneebone et al, 2003). A robustrisk analysis will be needed before agreed policies on staffingof colonoscopy services is resolved (British Society ofGastroenterology, 1994; Moshakis et al, 1996). Eventuallyacceptance of the nurse practitioner role may lead todevelopment and more general acceptance of the nurseendoscopist (Basnyat et al, 2002).

FLEXIBLE SIGMOIDOSCOPYFlexible fibreoptic sigmoidoscopy has developed as an off-shoot of colonoscopy in order to simplify the former pro-cedure and yet permit more bowel to be examined than ispossible with a rigid instrument (Figure 2.4). The exami-nation requires skill and patience. The lateral Sims posi-tion is preferred for patient comfort and the examinationtakes 25 minutes (Atkins et al, 1993; British Society ofGastroenterology, 1994; Vipond and Moshakis, 1996).

Complications such as haemorrhage or perforationoccur more frequently with the flexible instrument thanwith the rigid (see Chapter 48); thus care is required when-ever the procedure is undertaken in the presence of boweldisease, especially active inflammatory disease. Minimalair should be used in these circumstances and no attemptshould be made to force the instrument into the sigmoidcolon. The limited bowel preparation combined with aclosed system provides a potential hazard for explosion.Biopsies should be carried out only with cold forceps butbrush cytology may provide additional information in sus-picious lesions that are difficult to biopsy. Flexible sigmoi-doscopy may prove to be a useful relatively cost-effectivescreening tool in the asymptomatic population and is the

subject of rigorous scrutiny at this time (Achkar, 2004).Flexible sigmoidoscopy is not the procedure of choice forevaluating the colon in symptomatic patients or in thoseknown to have polyps or a family history of colon cancer.

The examination requires only a limited bowel prepa-ration such as a single disposable phosphate enema. A well-lubricated finger is passed into the rectum, the instrumentis then inserted and passed under direct vision. The tip ofthe instrument is deflected by rotation of the larger dial ineach direction. The small dial deflects the tip from side toside. If passage is impeded, the instrument is withdrawnslightly, the lumen is searched out by dial manipulation androtation and the instrument is advanced again. Negotiationof the sigmoid colon is the most difficult part of the proce-dure. Anticlockwise rotation of the instrument producesthe so-called alpha loop. Clockwise rotation results in rel-ative straightening of the sigmoid colon and the opportu-nity to advance the instrument into the descending colon.Another means of proceeding up the descending colonwhen the sigmoid loop has already been traversed is towithdraw the instrument while rotating clockwise.

After the instrument has been passed to its full length,or as far as is possible, it is carefully and slowly withdrawn.It is important to remember that flexible sigmoidoscopyand colonoscopy are poor tools for evaluation of rectalpathology.

COLONOSCOPYAs with barium enema examination, the importance of anadequately cleansed colon cannot be overemphasised.Sedation is advised whenever total colonoscopy is contem-plated. The insufflation of air and traction on the bowelfrom the instrument may cause considerable discomfortand anxiety. We use a combination of fentanyl and

Endoscopy 55

a

b

Figure 2.4 (a) Flexible fibreoptic sigmoidoscope (ACMIpattern). (b) Close-up of the bending section of a flexiblesigmoidoscope with biopsy forceps.

midazolam for analgesia and sedation. All patients aremonitored with a pulse oximeter.

Most instruments now use video imaging, which greatlyfacilitates training. It also enables patients to observe theircolon if they wish, tapes may be created to prove that theexamination of the colon is complete for legal purposes.Video recordings are useful in assessing polyp density inpolyposis syndromes and as a means of comparing theappearances of the colon before and after therapy forinflammatory bowel disease.

The left lateral decubitus position is recommended bymost endoscopists for commencing the examination. Thewell-lubricated end of the colonoscope (Figure 2.5) ispressed gently but firmly against the anal orifice and thescope passes into the rectum. A little air is now introducedand viewing starts. It is better to continue the advancementof the instrument under vision. The important principle isto keep the lumen constantly in view by a certain amountof inflation combined with angulation and rotation of theinstrument. If a so-called red-out develops and a clearview of the lumen and mucosa is lost, it can always beregained by withdrawing the scope slightly. By the judicious

use of these manoeuvres the rectosigmoid flexure can usu-ally be negotiated and the scope passed along the sigmoidloop into the descending colon and round the splenic flex-ure to the transverse and right colon and caecum.

One of the most difficult areas in colonoscopy is the sig-moid loop, and particularly the angle that it makes with thedescending colon. There are two ways of dealing with thisdifficulty. One is to try to fix the distal end of the scope bystrong angulation of it in the upper end of the sigmoid andthen under X-ray control to withdraw the shaft of theinstrument so as to straighten and shorten the sigmoid loop.If the tip of the instrument is then unhooked, it can oftenbe advanced. The other plan for dealing with an initiallyimpassable sigmoido-descending angle is to employ what isknown as the alpha manoeuvre. The scope is withdrawnto approximately 25 cm from the anus and the distal end isangulated to the patients left. Then, while the instrumentis strongly rotated approximately 180 in an anticlockwisedirection, to turn the tip to the patients right, it is againadvanced. If the manoeuvre is successful the scope makesa loop to the patients right and proceeds from below up thedescending colon. Once the tip of the instrument hasreached the upper descending colon or beyond the splenicflexure, the alpha loop in the sigmoid can be undone by acombination of slight withdrawal and clockwise rotation.

Another way in which the sigmoid may give rise to dif-ficulty during colonoscopy is by its forming a very largeloop, which uses up a certain amount of the length of thecolonoscope and gives rise to considerable discomfort to thepatient. The loop can be undone by fixing the distal end ofthe instrument in the descending colon by forcibly flexingit and then withdrawing the shaft of the scope. When thesigmoid has thus been straightened out, it may be possible,by undoing the terminal loop, to advance the instrumentalong the descending and transverse colon and from thereround to the caecum (Figures 2.62.10).

The really detailed and comprehensive survey of the lin-ing of the bowel is reserved until after the colonoscopist hasreached what is considered to be the limit of the examina-tion, which should be the caecum or terminal ileum. Then,during the phase of slow withdrawal, every effort is madeby bending and rotating the scope to view the mucosa ofall parts of the circumference of the bowel throughout thelength examined. Fluoroscopy is quite useful but is notmandatory.

There are many articles that describe in detail thetechniques for passage of the colonoscope (Macraeet al, 1983; Greenstein and Sachar, 1989; Kavin et al,1992) and the reader is referred to specific texts on thissubject (Hunt and Way, 1981). The role of therapeuticcolonoscopy is discussed in the section on colorectal polyps(Chapter 25).

ENDOSCOPIC ULTRASOUNDEndoscopic ultrasound may be helpful in scrutinising fill-ing defects, staging malignancies and assessing strictures(Ramirez et al, 1994; Novell et al, 1997). The rotatingprobe will provide images that define the extent of bowelwall and extraluminal involvement and may provide infor-mation on the pericolonic lymph nodes (Hunerbein andSchlag, 1997).

Chapter 2 Running a Colorectal Surgery Service56

a

b

Figure 2.5 (a) Olympus colonoscope. (b) Distal extremity ofthe Olympus two-channel colonoscope with biopsy forcepsand snare projecting from the channels.

Endoscopy 57

a b c d

Figure 2.6 The configuration of the colonoscope that may occur at the junction of the descending colon with the sigmoidcolon. Advancement is achieved by wriggling and jiggling into the lower descending colon followed by withdrawal withclockwise torque. Straightening of the instrument allows advancement into the descending colon.

a b

Figure 2.7 Looping in the mid-transverse colon. When thetip has not reached the hepatic flexure this may be resolvedby hooking the tip against the bowel wall and withdrawing.On straightening of the tip a paradoxical advance towardsthe hepatic flexure is achieved.

a b c d e f

Figure 2.8 The alpha loop may be created by withdrawal of the instrument tip to the apex of the sigmoid colon. Initialanticlockwise rotation through 180 is followed by advance of the instrument with torque. Once the colonoscope tip is insertedwell into the descending colon the instrument is straightened by clockwise rotation and simultaneous withdrawal before furtheradvancement.

Chapter 2 Running a Colorectal Surgery Service58

LAPAROSCOPYDiagnostic laparoscopy may be invaluable in staging sometumours, in identifying serosal and peritoneal deposits fromgynaecological malignancy and for the diagnosis and treat-ment of endometriosis involving the bowel. Increasinglylaparoscopy is becoming established in the treatment ofcolorectal disease including both benign and malignant dis-orders. Details of laparoscopy are provided in Chapter 4.

CAPSULE ENDOSCOPYCapsule endoscopy is a recent development and is provingto be useful in investigating the small bowel in patients withobscure GI bleeding and may play a role in assessing theextent of Crohns disease. At the present time its wide-spread use is limited by the cost of the capsules and thelabour-intensive nature of viewing the study but there isno doubt that it has a role in Crohns disease and assessingobscure gastrointestinal blood loss. (Levinthal et al, 2003;Mylonaki et al, 2003; Adler et al, 2004).

RADIOLOGY

Details of radiological diagnosis and management areprovided in each section; this merely provides an overviewof requirements for the provision of colorectal surgeryservices.

CONTRAST RADIOLOGYBarium enema examination is still widely used as the pri-mary diagnostic facility in bowel disease. Barium enemaprovides hard copy evidence of pathology, which can bedigitised for storage and transmission to other centres. Bothbarium enema and colonoscopy depend on rigorous bowelpreparation. Barium enema provides information on pan-mural pathology and is thus particularly useful in distin-guishing ulcerative colitis from Crohns colitis, evaluatingcomplicated diverticular disease and assessing the extent ofmalignancy. Colonoscopy, on the other hand, allows biopsyand polypectomy and does not involve ionising radiation(Simpkins and Young, 1971; Nolan and Gourtsoyiannis,1980; Joffe, 1981; Hooyman et al, 1987).

a b c

Figure 2.9 Negotiation of the splenic flexure. Insertion ofthe colonoscope with the tip at the splenic flexure maystretch both the flexure and the sigmoid colon. In order tonegotiate the flexure the instrument is withdrawn withclockwise torque and reintroduction of the instrument.Further advance is achieved by bringing the acutely angledflexure downward with each withdrawal and reducing flexionon the tip with each reinsertion. Clockwise torque ismaintained with each advance to prevent recurrence ofloops in the sigmoid.

Figure 2.10 At the hepatic flexurecareful steering to avoid the prominentfolds will usually allow the ascendingcolon to be seen. Withdrawal to reducethe transverse loop produces aparadoxical advance.

d e f

a b c

Small bowel enema or barium follow-through is veryuseful for diagnosing and assessing small bowel Crohnsdisease, but after the first resection, barium enema isusually preferred (Herlinger, 1978; Maglinte et al, 1987;Jabra et al, 1991).

Contrast radiology is helpful in assessing enterocuta-neous fistulas by fistulography or gut radiology. Likewiseperineal sinograms will define the extent and ramificationsof a persistent perineal sinus. Pouchography providesinvaluable information in pouch dysfunction or pouch-related fistulas, but the perianal catheter should beremoved before imaging the pouch anal anastomosis.Cystograms and tubograms are sometimes used whenthere is urinary involvement from disease or following col-orectal surgery. Retrograde ileograms are the best way ofidentifying recurrent Crohns disease and pathologyin the ileum after ileostomy. Kock pouchography is use-ful for assessing the integrity of the nipple valve and pouch-related complications.

ULTRASONOGRAPHYAbdominal ultrasound is the most cost-effective methodof detecting hepatic metastases in asymptomatic patientsafter potentially curative bowel resection. The examina-tion is cheap, non-invasive and repeatable; hence its valuein detecting postoperative sepsis, pelvic cysts, gynaeco-logical pathology and liver disease, as well as facilitatingbiopsy of a tumour or drainage of an inflammatory mass.Vaginal ultrasound is helpful in excluding gynaecologi-cal pathology. Surface hepatic ultrasonography may pro-vide better definition and anatomical location of hepaticdeposits.

Endoscopic and rectal ultrasonography is extremelyaccurate in terms of staging the bowel involvementin malignancy but is less sensitive for identifying perirec-tal or pericolonic lymph node metastases. Rectal ultra-sonography is operator dependent in terms of accuracy.It is more useful for smaller lesions rather than circumfer-ential involvement and cannot be used for obstructinglesions (Dubbins, 1984; Kimi et al, 1990; Khaw et al,1991).

COMPUTERISED TOMOGRAPHYComputerised tomography (CT) is still the best method ofstaging colon cancer, providing information on the pri-mary tumour as well as any hepatic metastases. It is prob-ably still the best investigation for detecting locoregionaland distant recurrence, although differentiation betweeninflammatory reaction or postoperative fibrosis andtumour recurrence is still unresolved. Positron emissiontomography (PET) when combined with CT scanning hasbeen shown to be very useful in this group of patients andin those being considered for hepatic resection (Fernandezet al, 2004; Delbeke and Martin, 2004) Increasingly, CTscanning is used for assessing inflammatory bowel diseaseand recurrent Crohns in particular (Ambrosetti et al,1997).

Cross-sectional imaging with contrast provides evi-dence of panmural involvement, which can be very help-ful in distinguishing Crohns disease from ulcerative colitis.CT can demonstrate fistulating disease and localise

paraenteric abscess, thus facilitating preoperative percu-taneous drainage. CT remains the most useful imagingtechnique for diagnosis and localisation of postoperativesepsis (Frager et al, 1983; Goldberg et al, 1983; Halvorsenet al, 1984).

CT colonography may play a role in colorectal cancerscreening in the future and in the patient in whomcolonoscopy is contraindicated or not possible. This is not amethod that is fully established as yet but with improvementsin technology and training it may well find a place in thefuture and possibly replace the barium enema (Pickhardtet al, 2003; Cotton et al, 2004; van Gelder et al, 2004).

MAGNETIC RESONANCE IMAGINGMagnetic resonance imaging (MRI) has a specific role incolorectal surgery. It is the imaging investigation of choicein defining septic conditions in the pelvis, pelvic floorand peritoneum, particularly in distinguishing them fromneurological abnormalities such as meningocele. Thus MRIhas a unique role in imaging complex anorectal fistulas.It may provide better imaging of desmoids or of recurrentmalignancy than CT. MRI provides exclusive anatomicdetail of the pelvic floor and perineum. Functional studiesfor delineating the anatomy of the pelvis and perineum infunctional bowel disease are being developed. IntrarectalMRI coils for staging rectal carcinoma as well as providingfunctional imaging have been developed (Frager et al,1983; Koelber et al, 1989; de Souza et al, 1996; Hadfieldet al, 1997). Increasingly all rectal cancers in Europe arenow staged by MRI and this influences our use of preoper-ative chemoradiotherapy (Kwok et al, 2000; Bissett et al,2001).

ANGIOGRAPHYAngiography is the best method for preoperative localisa-tion of arteriovenous malformations involving the largebowel (Van der Vliet et al, 1985; Browder et al, 1986;Pennoyer et al, 1996; Ng et al, 1997). Angiography mayalso play a therapeutic role in colorectal haemorrhage(Burgess and Evans, 2004).

VIDEOPROCTOGRAPHYPelvic floor studies with conventional radiology involvequite high radiation exposure as high penetration of theperineum is necessary. Furthermore, many patients areyoung women. Contrast can be introduced into the vagina,bladder, small bowel and the peritoneum if necessary toprovide greater anatomical information in the investiga-tion of defecatory disorders, especially enterocele, sig-moidocele, intussusception and associated gynaecologicalprolapse (Bartolo et al, 1985). Videoproctography may becombined with simultaneous sphincter EMG and manom-etry in patients with evacuatory disorders.

NUCLEAR MEDICINE

Dynamic isotope measurements of the colon give more pre-cise information on disordered transit than marker stud-ies. Likewise isotopic rectal or pouch emptying providesobjective measurement of the speed of evacuation and

Nuclear Medicine 59

residual volume (Krevsky et al, 1986; Pemberton et al,1991).

Isotopic imaging of bone and the liver may be useful instaging or defining advanced malignancy. Labelling ofautologous blood products may help to localise the sourceof bleeding from the gut.

Leucocyte scans with indium or technetium can be help-ful in assessing disease activity in Crohns disease and indistinguishing bowel disease from abscess.

Positron emission tomography is still being evaluated incolorectal surgery. It may have a role in staging malignancyand appears to be useful in distinguishing recurrence ofcancer from postoperative fibrosis.

ONCOLOGY

Colorectal surgery may be a standalone subject, but thereare great advantages to patients if they are in close prox-imity to chemotherapy services and radiotherapy, particu-larly as these disciplines are usually supported by palliativecare, chemotherapy personnel, first-class imaging, basicscience laboratories and national databanks. Quality assur-ance, appraisal and rigorous audit of diagnostic facilitiesalso enhances high standards and a multidisciplinaryapproach to clinical services for patients with colorectalcancer (Davies et al, 1984; Jarvinen et al, 1988; Lopez andMonafo, 1993).

HISTOPATHOLOGY ANDCYTOPATHOLOGY

Most outpatient histopathology is obtained from biopsiesthat are fixed, embedded, sectioned and stained in thelaboratories. There is a small call for cryostat sections,particularly in tumours of uncertain origin. If an urgentoncological diagnosis is required, scrape cytology or frozensection diagnosis may be employed. Alternatively, multiplebiopsies are obtained, one of which is transected for smearor imprint cytology; the glass slide is then fixed in alcoholand stained by the Papanicolaou technique and instantlyreported while the remainder is examined by conventionalhistopathology. Likewise, fine needle aspiration cytologyis used for subcutaneous, hepatic and perineal lesions(Bemvenuti et al, 1974; Mortensen et al, 1984; Ehya andOHara, 1990; Farouk et al, 1996, 1997).

Histology and cytopathology reporting should be con-fined to personnel who are committed to oncology proto-cols for accurate staging and who have a special interest ininflammatory bowel disease (Winawer et al, 1978; Daneshet al, 1985; Jeevanandam et al, 1987; Lessells et al, 1994).

MULTIDISCIPLINARY TEAMAPPROACH

One of the most exciting outcomes of a cancer servicesappraisal process in the UK has been the development of arapid access team approach for the early diagnosis of col-orectal disease. One of the essential components of desig-

nated cancer units and central referral cancer centres hasbeen a multidisciplinary approach to patient care that isclosely scrutinised by external quality assurance. Ideally amultidisciplinary team should consist of surgeons, gas-troenterologists, dedicated histopathologists, radiologists,two oncologists (one majoring in radiotherapy, the otherin chemotherapy), colorectal nurses, cancer counsellors,nutritionists and a psychologist, with audit and secretarialsupport. The colorectal cancer team should provide rapidaccess consultation (within a week). Visible malignancy isbiopsied and staged by CT and MRI in the week; probablemalignancy is endoscoped or X-rayed for diagnosis. Lesionsrequiring more detailed evaluation are examined underanaesthesia and biopsied on a dedicated day-case list.

Each week, all the pathology and radiology results frompatients seen in the previous clinic should be reviewed bythe team. This alerts staff to particular patients return-ing for review who may need additional investigation orcounselling.

The majority of patients with colorectal symptoms donot have malignant disease. Many have minor anal condi-tions that can be treated in the clinic or in the day unit. Themajority of patients with these conditions are treated anddischarged.

All follow-up is undertaken in parallel clinics. Thusknown malignancy, once initially treated by surgery withor without chemotherapy or radiotherapy, is followed upin specific oncology clinics. There should be multidiscipli-nary parallel clinics for patients with established inflam-matory bowel disease and a separate clinic for patients withfunctional bowel disease (incontinence, prolapse and con-stipation) that might be amenable to surgical treatment.

SCREENING

Screening of high-risk patients with a family history ofcolorectal cancer is undertaken through special familycancer screening clinics. Screening of patients at risk ofcolorectal cancer with longstanding colitis is undertakenthrough an inflammatory bowel disease clinic by regularcolonoscopy (Hardcastle et al, 1989; Lieberman, 1990;Jatzko et al, 1992; Atkins et al, 1993).

Guidelines for screening in the asymptomatic popula-tion should be made available to the local community. Inthe UK it has been demonstrated that there is clear benefitfrom colorectal cancer screening with faecal occult bloodtesting but it is recommended that introduction of screen-ing must be matched by improvements in provision ofendoscopy resources (UK Colorectal Cancer Screening PilotGroup, 2004). From 2006 population-based colorectalcancer screening using faecal occult blood is to be startedin the UK for those over 60 years of age.

FACILITIES

Ideally there should be a single, self-contained unit com-prising an outpatient facility, counselling rooms, follow-upand screening areas, adjacent to an endoscopy suite, radi-ology, oncology and anorectal physiology rooms. There

Chapter 2 Running a Colorectal Surgery Service60

should be purpose-built recovery and waiting areas, a ded-icated day-case unit and theatre offices, a single theatresuite and the ward. The entire network should be linked bytelephone and computers. The colorectal surgery unitshould incorporate changing areas, toilets and teach-ing and seminar rooms. The plan should provide officesfor physicians, surgeons, nursing staff, stoma carenurses, dietitians and, if possible, dedicated radiologists,histopathologists and a psychologist.

OUTPATIENT AREAThere should be sufficient waiting room space and plentyof examination cubicles. Separate rooms are needed to layup trolleys, a sluice, a pathology laboratory, a linen room,a sterilising room, counselling rooms, rooms for stomatherapy and follow-up, with a booking clerk who entersand extracts information from the computer. There shouldbe a good seminar room fully equipped for teaching.Booklets should be available, preferably in a reading roomwith DVD and information technology facilities. Theremust be plenty of good changing and lavatory facilities.

Diagnostic and therapeutic trolleys must contain a lightsource, anal and vaginal specula, a sigmoidoscope withbiopsy forceps, local anaesthetic agents and syringes, acataract blade, dressings, rubber-band ligators, photoco-agulation and injection sclerosants. There must be micro-scope slides, cytology fixative, bottles of formaldehyde,culture swabs, stool culture bottles, haematology and bio-chemistry tubes, as well as lubricant jelly, skin preparationand gloves.

ENDOSCOPYThere must be a large waiting area, two or three endoscopysuites, good changing, washing and lavatory facilities, asterilisation area, a room for bowel preparation, a sluice,linen cupboards, a patient trolley store and a recovery area.Video teaching bays should be a part of the facility sinceexplanatory video programmes are useful for those patientswho have never had an endoscopy before. Reporting facil-ities and computer linkage are now features of mostmodern endoscopy suites.

WARDThe ward area should be bright, light and attractively dec-orated. Ideally this zone should include the data managersoffice, the admissions unit and the secretarial and academicoffices with a library, a small lecture theatre and severalseminar rooms. There should be office space for stoma carenurses, the nursing staff and other paramedical staff. Thereshould be a room in which the staff can relax. Hard copiesof patients notes should also be easily available and stor-age facilities for appliances, stationery, linen and toiletrequisites should be supplied. The patients will need awaiting area and a reading room. There should be an areafor preadmission registration and clerking. There shouldbe a small kitchen and easy access to a coffee shop.

It is wise to incorporate some flexibility over the use ofbeds. Substantial financial savings can be made if somebeds are staffed only from Monday to Friday. This providesa useful buffer for emergency admissions and allows oper-ations to be performed on patients who would not be suit-

able candidates for day-case surgery. Many intra-anal pro-cedures, complex anal fistulas, stoma resitings, perinealproctectomies and laparoscopic procedures can beperformed from 5-day units. In our institution there is aseparate facility for elective surgery and this has manypractical advantages. In several units fast-track rehabilita-tion, or enhanced recovery, is practised and with majorsurgery being performed early in the week the ward can belargely emptied by the weekend. The combination of anenhanced recovery programme with laparoscopic surgerycan lead to substantial savings for many hospitals and ear-lier return to useful activity for patients (Wilmore andKehlet, 2001; Kehlet and Wilmore, 2002).

The main ward area will need a central nursing station,plenty of lavatories, showers, baths, bidets and washingfacilities. Most beds will be in single- or four-bedded cubi-cles. Most units need a small high-dependency unit in casethere are patients who require intensive care monitoringor high-dependency nursing care. There is also an argu-ment for placing all patients needing parenteral nutritionin a specific area. There should be close access to an inten-sive care unit to accommodate those patients needingventilation or cardiovascular support. In most hospitalsemergencies are admitted to a triage unit for resuscitation,investigation and observation; many can be discharged thefollowing day, whereas those needing operation or admis-sion are transferred to the colorectal unit.

OPERATING THEATRESThere should be separate day theatre, emergency theatreand elective theatre suites. In many larger hospitals andclinics dedicated colorectal theatres adjacent to the wardwith specialised instruments, stapling devices, leg poles,Allan stirrups, trays and a purpose-built operating tableare available. Furthermore, staff should be trained specif-ically in the disciplines of colorectal procedures. Thereshould be a computer terminal in the office. Separateanaesthetic and recovery bays, stores and offices are incor-porated into the theatre suite. Many hospitals are less for-tunate and in this situation it is vital to develop theatrenurses who take a special interest in colorectal surgery.Instruments and equipment should be kept in one area andlooked after by a small group of dedicated staff.

DAY-CASE UNITThere should be a dedicated day-case unit, which mustinclude its own operating theatre, anaesthetic room andrecovery area and have space for prepacked instrumenttrays, patient changing facilities with lockers and a kitchenwith an adjacent sitting room. This allows patients to havea meal and a drink once they have recovered and are readyto return home. There should be public telephones. Thereis considerable teaching potential in a day-case unit. A sys-tem must be incorporated into a day-case unit to provideprimary care physicians and nurses with informationabout the procedures.

Patients should only be booked into the day unit afterthey have been carefully screened by the medical and nurs-ing staff to ensure that they are fit for day-case surgery andthat their home facilities are adequate for recovery pur-poses. A drug history is crucial, since diabetics, those on

Facilities 61

anticoagulants, patients receiving antihypertensives andcardiotropic agents may not be suitable. Patients withunstable epilepsy or those suffering from asthma will needto be carefully screened. Thus there must be a preadmis-sion assessment unit as well as the day ward. Details of theday-case assessment are shown in Table 2.1. The followingprocedures can be performed as day-case procedures onselected patients: ileostomy refashioning, haemorrhoidec-tomy (conventional or stapled), sphincterotomy, layingopen of low anal fistula and pilonidal sinus, excision of skintags and warts, drainage of abscess and examination underanaesthesia.

EMERGENCY ADMISSIONA third of colorectal cancers still present as emergen-cies with obstructive symptoms, pain, advanced disease orperforation. The outlook in such patients is poor and thefacilities for rapid resuscitation, early imaging and rapidsurgical treatment is often suboptimal (Irvin and Greaney,1977; Phillips et al, 1985; Chester and Britton, 1989;Serpell et al, 1989; Rumkel et al, 1991; Anderson et al,1992). Likewise the majority of patients with diverticulardisease present with sepsis or obstruction. At least a thirdof all inflammatory bowel disease presents acutely. A smallnumber of patients with lower gastrointestinal bleedingwill require urgent admission and investigation. Civil vio-lence when it affects the large bowel will also need to bemanaged through the emergency admission unit. Thus itis essential that a colorectal unit should be in close prox-imity to emergency facilities with a dedicated intensive careunit and an emergency operating theatre suite.

STOMA CARE

Stoma care is a recognised component of colorectal sur-gery. Despite this, the need for appropriately trained nurs-ing personnel to supervise the management of stomas inhospital and the rehabilitation of patients into the com-munity is still threatened by funding constraints (IAETStandards Committee, 1983; Londono-Schimmer et al,1994; Cheung, 1995). The role of the stoma care nurseincludes fistula management, counselling patients withincontinence and colitics being considered for pouchsurgery, as well as care of patients with colorectal cancerirrespective of their stoma requirements.

HISTORYStoma care really began in the late 1950s when Norma Gillat the Cleveland Clinic envisioned a proper service to sup-port patients who were having to adjust to life with a per-manent colostomy or ileostomy. She realised that there wasa need not only for the provision of a counselling and advi-sory service, but for a proper training programme to teachthe essential skills of stoma management (Devlin, 1982).Later, Barbara Saunders and Josephine Plant establishedtraining programmes in the UK (Plant and Devlin, 1968).

FUNCTIONThe function of an enterostomal therapy service is to advisepatients about the management of any intestinal stoma.

In practical terms this involves preoperative counselling ofpatients (in the community if possible), marking a stomasite, interviewing relatives and arranging for someone witha stoma to visit the patient. In the immediate postoperativeperiod, the stoma care nurse will be involved in teachingthe patient to look after their stoma, whilst providing adviceon the management of any complications and the choiceof appliance. When patients are confident in changing andemptying their appliance and are ready to be dischargedfrom hospital, they will need to know where they can seekadvice if there are difficulties in the future. They will alsorequire advice on diet, medication and skin care.

Patients with any additional disability, such as a paral-ysed patient with spina bifida, may need the support of thestoma care nurse in their home, particularly if there aresocial and housing problems. The stoma care nurse mayneed to liaise with the social services, employment agen-cies and pharmacies as well as the primary care physicianand district nursing services. Stoma care nurses will needto establish close links with all intestinal surgeons,medical gastroenterologists, appliance manufacturers andvoluntary stoma organisations.

Stoma care nurses have now expanded their role beyondthe management of the stoma patient to the care ofpatients with an intestinal fistula, colorectal cancer, inflam-matory bowel disease and incontinence. They are invalu-able to help with counselling patients before pouchconstruction, resections for malignancy and operations forincontinence.

An experienced stoma care nurse will need to fulfil therole of a psychologist in the assessment of factors that willinfluence the attitude of a patient to a stoma, such as age,personality, intelligence and marital status. Psychologicaladjustment will depend on sexual attitudes, emotional sta-bility and psychosomatic illness as well as on whether thestoma is permanent or temporary (Black, 2004). The reac-tion of the patient will also be influenced by the underly-ing disorder, particularly malignant disease. Potentialphysical disorders causing management problems includearthritis, neurological disease, poor eyesight, scars and obe-sity (Bierman, 1966; Druss et al, 1969; Prudden, 1971;Rowbotham, 1971; Breckman, 1977; Briggs et al, 1977;Burnham et al, 1977).

PHYSICAL NEEDSA stoma care service will need a consultation suite, eitherin an outpatient department or adjacent to a surgical ward.This facility must be easily accessible to patients within thehospital and to patients attending from the community.There must be good access by public transport and park-ing facilities nearby for ambulances and private vehicles.Physical links within the hospital to the gastrointesti-nal unit, as well as to patients attending other outpatientclinics, are essential. A stoma care nurse may have toprovide advice for children with anorectal agenesis andHirschsprungs disease.

There should be an examination suite and a teachingroom for seminars where local courses can be conducted.There must be a room for private discussion and coun-selling with facilities for preparing beverages. There mustbe space for patients who are waiting and space for storage.

Chapter 2 Running a Colorectal Surgery Service62

The entire area should be well ventilated with regularwaste disposal and with hot and cold water. The areashould have adequate lighting, particularly for removal ofsutures and examination of perineal wounds. A lavatoryand sluice is clearly essential. It is desirable to be able tomodify the area so that patients may be taught colostomyirrigation techniques, management of a reservoir ileostomyand wound management.

The consultation room should have a wide variety of lit-erature. There are useful booklets produced by the patientsupport associations, and the pharmaceutical industry onlife with a stoma. Written advice is also available regardingsexual adjustment, stoma management during pregnancyand advice for the elderly. It may be helpful to displaywallcharts in the teaching area.

RECORDSIt is essential to have some simple yet reliable way of keep-ing essential independent records on stoma patients. It isquite unsatisfactory to request hospital notes every time apatient with a stoma problem seeks advice. The record sys-tem devised by Devlin (1983) is particularly useful in thisregard. A computer database records name, address andtelephone number of the patient, the name and address ofthe primary care physician and the names of the hospitalconsultants who have been involved in management.A record is kept of the hospital registration number, thediagnosis and the date and type of surgical procedure per-formed. The record identifies the type of stoma (ileostomy,colostomy, ileal conduit and whether it is a loop or endstoma) and its site. The type of appliance used is recorded,with the prescription given to the patient on discharge sincethe dispensing of supplies is undertaken by our stoma carenurse and not the pharmacy staff. Any problems encoun-tered with the stoma are identified with a note of theirmanagement. Psychological and sexual problems associ-ated with the stoma as well as the attitude of the patient tothe appliance should also be recorded. Physical disabilitiesand problems associated with the perineal wound arealso noted. The database will be needed for counselling pur-poses so that potential ostomates can be put in touch withappropriate patients who have a stoma.

PERSONNELA senior stoma care nurse should be a person with experi-ence in teaching, administration and who can achieveclose liaison between senior medical and nursing staff inthe outpatient, ward and theatre environment of the hos-pital and in the community. The person concerned shouldhave experience of looking after patients with inflamma-tory bowel disease and malignancy of the colon and rec-tum, as well as having served on a surgical unit. Someexperience and training in physiology, sociology, psychol-ogy and therapeutics, counselling, dermatology, oncologyand nutrition is desirable. There is potential for research.A successful stoma care nurse needs to have basic knowl-edge and training in a variety of areas.

It is important that the person in charge of a stoma careservice, apart from commanding respect and being a goodcommunicator, should also be a teacher. There will be aneed to educate ward staff, theatre personnel and district

nurses about stoma care and to run courses. Hence, knowl-edge of anatomy as well as physiology and surgery will berequired.

It is usually necessary to have other members of staff inthe team. The number depends upon the size of the hospi-tal and its community. Indeed, it is probably never desirableto have one person working in isolation unless the personconcerned does so in close liaison with other groups. Oftenpart-time staff help with outpatient clinics and they maybe supplemented by personnel from industry.

If the organisation is responsible for running courses,trainees may provide some help with the care of patientsbut they cannot and should not be relied upon to providethe clinic services. Trainees must be properly supervised;therefore, rather than needing less staff, a training unit willneed more personnel in order to provide the level of super-vision and teaching needed to fulfil the daily functions of aunit. Teaching of stoma care to medical and nursing staffand attending surgical and gastroenterological coursesmay be required. There may even be a place for teaching inthe primary care environment.

Some secretarial help will also be required, both to organ-ise course curricula and to furnish reports and letters.

Although not core members of a service, patients witha stoma and employees of stoma appliance manufacturersoften compose important members of the team.

EMERGENCY COVERProvision of a 24-hour service is an ideal that few stomacare services can offer. Arrangements must thereforebe made to provide for patients who present with stomacomplications out of hours. One way to overcome theseproblems is to have a cohort of nursing staff on the gas-troenterology, surgery and urology units who have beentrained in counselling and the siting of a stoma. These indi-viduals should have access to the database of patients witha stoma who would be prepared to visit patients facing anemergency operation.

In most major cities several hospitals each providecolorectal services, each with their own stoma service.Creative approaches of working together across a city maymake it possible to provide much needed support for nursesin individual institutions and could perhaps be developedinto a 24-hour service that could not be provided by stafffrom any one institution.

ETHICAL CONSIDERATIONS AND OPEN ACCESS CLINICSApart from the follow-up of their own patients, most stomacare nurses provide an open access clinic for anybody inthe community with a stoma. One in four of all ostomateshave had their operations performed elsewhere, havingsince moved for various reasons to a different area. Thesepatients may experience stoma complications or needadvice. For this reason, attendance at stoma clinics is oftenby open access; this explains the need for a separate systemfor clinical information on patients, as already described.

VOLUNTARY ORGANISATIONSThere are a number of voluntary organisations through-out the world extremely supportive to patients with a

Stoma Care 63

stoma. The principal organisations in the UK are the IA:Ileostomy and Internal Pouch Support Group and theColostomy Welfare Group. There is also a Urinary DiversionGroup (Urostomy Association). The reasons for the exis-tence of three separate organisations are largely historical.For instance, many patients having a colostomy havemalignant disease where long-term prognosis is poor. Forthese patients annual meetings are inappropriate since thefall-off of supporters only reinforces to the others the nat-ural history of their disease. By contrast, the IA caters foryoung patients with inflammatory bowel disease who mayhave metabolic problems and psychological readjustments,which they may find helpful to discuss with others. Regularmeetings are therefore supportive and appropriate forpatients with an ileostomy or a pouch.

In North America, the stoma associations have amal-gamated to become the United Ostomy Association.This organisation caters for all patients and is closelyaffiliated to the International Ostomy Association, aninternational organisation aimed at supporting national

societies in disseminating information and stoma devel-opment.

The voluntary organisations are invaluable agencies forencouraging early rehabilitation after operation. Much ofthe information produced by the United Ostomy Associationand its sister organisations in the UK is of the highest stan-dard and extremely practical, having been prepared by peo-ple who have first-hand experience of life with a stoma(Bartlett et al, 1994). These organisations also provide use-ful consumer audit on new appliances. They may also iden-tify individuals who might be recruited as visitors. Theseindividuals are carefully selected and trained to visitpatients before operation. All are patients who are chosenbecause they take a positive attitude towards their stomaand usually provide valuable support to patients who areabout to face the prospect of a stoma.

The voluntary organisations provide guidance to osto-mates who are seeking employment or retraining. Theyalso provide advice on legal and insurance matters thatseem to be unfair to the ostomate.

Chapter 2 Running a Colorectal Surgery Service64

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