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While accidental anal and rectal trauma is relatively rare, iatrogenic injuries to this region – particularly the anus – are quite common. This chapter describes the most frequent etiologies of anal/rectal trauma and the basic clinical and instrumental investigations necessary to provide the most appropriate treatment, particularly in emergencies, when saving patient’s life is a surgeon’s primary concern.

The surgical management of anal and rectal trauma and retention of foreign bodies in the rectum is discussed using a dedicate algorithm. Finally, the possible functional consequences of these traumas are reviewed and how to preserve fecal continence and normal evacuation is described.

Colonic/rectal obstruction, also known as large-bowel obstruction, is a serious condition that needs careful and prompt diagnostic and therapeutic measures to obviate harmful complications and even death. Colorectal cancer is the main cause of this obstruction in Western countries. Recent technological innovations (on-table lavage, colonic stents) have changed the therapeutic strategy, with a marked benefit for patient outcomes. Understanding the various etiological hypotheses, as well as the clinical presentation and the use of appropriate tests, make selecting the best treatment option possible. The preferred approach should be determined on an individual basis and tailored to the particular situation.

Lower gastrointestinal (GI) hemorrhage refers to bleeding that originates distal to the Treitz ligament. Although more than 80 % of these hemorrhages spontaneously resolve or respond to medical and/or endoscopic treatment, acute and massive hemorrhage may represent a life-threatening condition with a 5–10 % mortality. The colon is the first site of bleeding, and common causes include diverticula and angiodysplasia. In the case of occult or self-limited hemorrhage, the potential source is identified using endoscopy of a well-prepared bowel. For acute and massive lower GI bleeding, because colonoscopy may be hampered by the absence of preparation or poor visualization of the intestinal wall, multidetector computed tomography angiography (MDCTa) has progressively emerged as a highly efficient and useful triaging tool. MDCTa could become the investigation used first to identify the location and cause of lower GI bleeding and orient patients according to the different available therapeutic options, including endoscopy, transcatheter embolization, and surgery. Superselective embolization is highly successful and safe, with high technical and clinical success rates. Surgery is a last-resort option for uncontrolled bleeding. It requires a thorough examination of the bowel, including intraoperative enteroscopy with transillumination when the location of the bleed is unknown, which represents the worst situation. The use of segmental versus subtotal colectomy, both of which are associated with significant mortality, is debated depending on the certainty of the location and cause of the bleeding.

Chronic perineal pain is a common condition in patients suffering from pelvic floor disorders. Their management remains challenging and usually requires a long follow-up period and several therapeutic approaches to alleviate the symptoms. The first step is to make sure no organic lesions underlie this situation; imaging is mandatory to avoid any tumor or inflammatory disorder. In a second step, patients’ history and the characteristics of the pain must be precisely defined to offer appropriate therapeutic options. Finally, treatment should be adapted and carefully supervised for a long time to improve the situation.

New technologies and increasing surgical specialization have allowed surgeons to push the limits and perform increasingly complex surgical procedures even in elderly and frail patients. Recent improvements in perioperative care aim to reduce postoperative complications and thus to ameliorate and accelerate postoperative recovery.

Seemingly simple measures such as proper administration of antibiotic prophylaxis and skin disinfection have lowered surgical site infection rates. Perioperative nutritional support has been shown to reduce (infectious) complications, duration of hospital stay, and costs.

The underlying mechanism of many individual measures is to attenuate excessive postsurgical stress response. The best prevention is no doubt the reduction of surgical trauma; this explains the impressive results of minimally invasive surgery.

A comprehensive combination of multiple useful measures is an appealing approach to optimize perioperative care and hence postoperative outcomes. This idea has been realized and developed over the past decade with the advent of enhanced recovery pathways.

Standardization and improvement of perioperative management was followed by a reduction of the surgical stress response and consecutively a tremendous reduction of postoperative complications (by 50 %). The most welcome side effects were a shortened hospital stay and reduced health care costs.

Intestinal failure (IF) describes a clinical state in which parenteral administration of nutrition, fluids, and electrolytes is essential to maintain health. This encompasses acute alterations of intestinal function in the setting of perioperative and critical care (e.g., postoperative ileus and intestinal obstruction) and more severe and prolonged conditions often associated with severe abdominal sepsis and intestinal fistulation. IF may also occur in the chronic setting of short bowel syndrome, for which life-long parenteral nutritional support, intestinal lengthening, or transplant surgery may be appropriate.

Mild acute IF almost always settles quickly and can usually be managed simply with parenteral nutrition and fluid therapy; however, severe acute IF remains a considerable challenge associated with a high mortality. This is largely attributable to the challenge of managing severe abdominal sepsis. Early and aggressive diagnosis and management of abdominal infection by maintaining a high index of clinical suspicion, promptly applying cross-sectional imaging, and effectively controlling the source, supported by appropriate and timely antibiotic therapy and supportive critical care, are essential to a good outcome. Effective source control can be achieved via radiological or surgical means, depending on the location of the abdominal infection. Although radiological drainage is often possible and is usually preferable, surgical intervention is frequently required in the presence of extensive tissue necrosis and/or intestinal discontinuity. In such cases, exteriorization of the bowel is almost always needed. When peritoneal contamination is severe and there are concerns regarding intra-abdominal hypertension (abdominal compartment syndrome), the abdomen may need to be left open, often for prolonged periods, and allowed to heal by secondary intention (unlike in trauma surgery). The aim in all cases should be to preserve the remaining gastrointestinal tract, if possible, especially in patients with inflammatory bowel disease. Sepsis control and care of the wound or fistula sites are followed by nutritional support, usually via the parenteral route, which should be meticulous and uncomplicated.

With effective management of sepsis and nutritional support, severe acute IF may resolve right away or after reconstructive surgery performed when the patient’s condition permits. Reconstructive procedures can be complex and technically demanding, involving surgery in a hostile abdomen and reconstruction of both the gastrointestinal tract and abdominal wall. These procedures may require considerable expertise and judgement if refistulation or considerable loss of intestine (resulting in chronic intestinal failure) is to be avoided. The support of an adequately resourced multidisciplinary team for the management of patients with IF is essential if optimum outcomes are to be achieved.

Incisional hernia following abdominal surgery is a common complication with a multifactorial etiology and has been defined as “any abdominal wall gap with or without bulge in the area of a postoperative scar perceptible or palpable by clinical examination or imaging.” This broad definition encompasses a range of hernia defect sizes, patients, and clinical situations. Consequently, the differentiation between incisional hernia repair and abdominal wall reconstruction is vague. This chapter covers the perioperative management of patients with incisional herniae, operative strategies for hernia repair, and choice of mesh. Adjuncts for tissue expansion and the management of excess adipose tissue in the most complex cases are also reviewed. No single hernia repair technique is suitable for all patients, and tailored approaches are advocated. Preoperative patient optimization in terms of diabetic control, smoking cessation, and obesity management are associated with significant improvements in recurrence and complication rates and should be considered the most important determinants of a good outcome.

The Division of Coloproctology was formed in 1998. It is one of several subspecialties constituting the Section of Surgery within the Union Européenne des Médecins Spécialistes. Its aim is to develop, through the European Board of Surgery Qualification Examination (EBSQ), a diploma acceptable across Europe as a whole. The EBSQ (Coloproctology) Diploma remains the only recognized pan-European certification in the specialty of coloproctology and one of the few outside the USA and Canada. Its acceptance has grown over the years, with 336 surgeons from 22 countries holding the diploma by 2015.

As part of taTME month, ESCP were delighted to hear from Manish Chand, University College London, on the outlook for taTME. 

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A video by Marc Possover