*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
Audio-Digest General Surgery
Volume 60, Issue 12
June 21, 2013
Multiple Colonic Adenomas (MCA) José G. Guillem, MD
Reoperative Pelvic Pouch Surgery Feza H. Remzi, MD
Stomal Complications Scott R. Steele, MD
Clostridium difficile Colitis Laurence R. Sands, MD
Highlights From The 24th Annual Jagelman/34th Annual Turnbull International Colorectal Symposium
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
General Surgery Program Info Accreditation InfoCultural & Linguistic Competency Resources
Management of Colorectal Disease
Highlights from the 24th Annual Jagelman/34th Annual Turnbull International Colorectal Symposium
The goal of this program is to improve the surgical management and treatment of patients with colorectal diseases. After hearing and assimilating this program, the clinician will be better able to:
1. Use immunohistochemistry and genetic testing to diagnose patients and families with multiple colonic adenomas.
2. Choose optimal surgical techniques for ileal pouch-anal anastomosis.
3. Diagnose and treat complications of ileal pouch surgery.
4. Evaluate patients with stomal complications and apply surgical and nonsurgical treatments.
5. Select appropriate preventive, surgical, and nonsurgical therapy for patients with Clostridium difficile colitis.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Multiple Colonic Adenomas (MCA)
José G. Guillem, MD, Professor of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
Case 1: 40-yr-old man with altered bowel habits; multiple large adenomas found on colonoscopy; patient’s father diagnosed with rectal cancer (CA) at 79 yr of age; local therapies — multiple polypectomies; endoscopic mucosal resection (EMR); endoscopic submucosal dissection (ESD); flexible sigmoidoscopy; segmental resection more likely than local treatment to remove all CA; definitive treatment — total colectomy with ileorectal anastomosis; study in Diseases of the Colon & Rectum — risk for invasive colorectal cancer (CRC) significantly increased in patients undergoing colectomy due to polyps; malignancy poorly correlated with size of polyps; multivariate analysis shows left colonic polyps and high-grade dysplasia predict colorectal cancer
Diagnosis: phenotype — determine whether family history of CRC meets Amsterdam Criteria; extensive adenomatosis likely due to familial adenomatous polyposis (FAP; caused by mutation on adenomatous polyposis coli [APC] gene); quantify number of polyps on current and past colonoscopies if no family history; FAP and Lynch syndrome (hereditary nonpolyposis CRC) autosomal dominant; MYH-associated polyposis (MAP) autosomal recessive; risk for cancer high in FAP and Lynch syndrome (lower in MAP [≈50%]); family may have multiple members in same generation with early onset of CRC; APC phenotype study — patients with attenuated FAP somewhat older in age; have <100 polyps; basis for disease genetic
Case 2: 23-yr-old woman with no past medical history underwent colonoscopy because brother had stage 4 CRC; large right-sided villous adenoma found; many family members had multiple adenomas and early onset; patient’s adenoma had normal expression of 4 mismatch repair (MMR) proteins on immunohistochemistry (IHC); brother’s tumor showed intact expression on IHC and normal proteins on genetic testing (Lynch syndrome unlikely); FAP and MAP also excluded; patient underwent total colectomy; no other polyps found in specimen; close surveillance of rectum and future follow-up of patient’s children recommended; 20% to 30% of patients with significant family history and early age of onset of MAP or CRC have uninformative results on genetic testing; work-up and treatment driven by patient’s phenotype and family history; data show patients who undergo segmental colectomy have higher rates of subsequent adenoma and cancer than those treated with total abdominal colectomy
Testing: speaker’s institution performs IHC on CRCs of all patients <50 yr of age; work-up generally complete if MMR proteins present; patients with loss of MMR proteins or suspicious family history referred for genetic testing; Shia study — IHC testing of biopsy specimens sufficiently reliable to guide management (positive result likely to be concordant with resected specimen); Guillem Study — single-amplicon testing for A636P mutation of MSH2 gene (in patients of Ashkenazi Jewish descent) inexpensive and can be completed in 2 wk
Case 3: 44-yr-old woman with polyposis and family history of FAP requested germline testing; children tested negative for APC mutation; MAP — age of onset later than with Lynch or FAP; seen in 25% of siblings, but only 1% of offspring, due to autosomal recessive inheritance; total colectomy with ileorectal anastomosis procedure of choice; MAP found in 8% to 13% of patients with multiple adenomas without APC mutation, and 16% to 40% of patients with 15 to 100 adenomas; patients negative for APC mutation who have >10 adenomas (or 5 adenomas and positive family history) should be tested for MAP mutation
Reoperative Pelvic Pouch Surgery
Feza H. Remzi, MD, Professor of Surgery; Chairman and Ed and Joey Story Endowed Chair, Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
Ileal pouch-anal anastomosis (IPAA): transection of rectum — measure distance to anastomosis by inserting finger in anus up to proximal interphalangeal joint; perform double stapling across area at level of fingertip; mobilize bowel as far as duodenum to avoid tension on anastomosis; creation of J-pouch — use most dependant part of ileum; perform 2 firings of staples across, then oversew tip of J-pouch with 3-0 polyglactin 90 (Vicryl) suture; insufflate pouch to check for leakage; check for posterior bleeding; anastomosis — perform bimanual examination; position (circular) staple gun transanally; place trochar posterior to staple line to avoid bladder, vagina, or prostate; check donut (tissue ring) and integrity; insufflate to check for leakage; create ileostomy (in most cases) to aid healing
Misfiring of stapler: avoid mucosectomy (requires that pouch be placed 1-2 in beyond optimal location of anastomosis); attempt transabdominal single-stapled anastomosis if repeat double stapling not possible; place pursestring (to anorectal stump) from above, then staple anastomosis, or evert anorectal stump and place pursestring from below; leave stapled anorectal stump in place if unable to complete procedure; place adhesion barrier film (Seprafilm) and omentum into pelvis to avoid having bladder, vagina, or prostate fall into presacral space; if area mucosectomized or anal canal open, use sutures to close from bottom to avoid creation of presacral sinus; encourage patients to lose as much weight as possible
Complications with pouch: history — determine whether complication due to disease (eg, Crohn disease [CD]) or perioperative sepsis; work-up — order gastrografin enema and magnetic resonance imaging (MRI) of pelvis; perform flexible pouchoscopy under anesthesia; order anal manometry and defecation studies for nonseptic complications; nonhealing postoperative leaks — most common cause of repeat pouch surgery (occurred in 10%-25% of patients in Cleveland Clinic series); advise patient early that closure of ileostomy not possible in original time frame of 3 mo; treatment — placement of mushroom catheter promotes bottom-to-top healing; perform incision and drainage and downsize mushroom (under anesthesia) every 6 to 8 wk until healing occurs; closure of ileostomy usually possible in 6 to 12 mo; persistent drainage indicates incomplete healing; plan repeat pouch surgery if healing does not occur; opening of posterior wall limits reusability of pouch (reusable in 70% of cases)
Redo of IPAA: continue use of diverting ileostomy for 6 mo; obtain consent for permanent ileostomy or Kock ileostomy (K-pouch) in event of unexpected problems; proper healing requires excision of pelvic phlegmon; dissect from known to unknown (have exit strategy if problems occur); dissect caudally, then cranially, around area; excise adhered area last; prepare for blood loss; perform mucosectomy (stapling anastomosis ineffective); reuse old pouch, if possible; repeat IPAA study — 90% of patients required complete disconnection of pouch; quality of life measurements comparable to patients undergoing primary IPAA
Other complications: postsurgical fistulas often attributed to CD, despite lack of preoperative diagnosis; pouch salvaged in 80% of these patients (and in 5 of 7 patients with true CD); leakage from tip of J-pouch — does not heal; must be resewn or stapled; afferent limb syndrome — occurs years after procedure; probably due to elongation and collapse of bowel; requires resection and straightening; preserve blood supply to pouch; efferent limb syndrome — often prevented by making outlet ≤2 cm; requires redo of pouch surgery
Scott R. Steele, MD, Chief of Colon and Rectal Surgery, Madigan Army Medical Center, Fort Lewis, WA
Preoperative siting of stoma: important even in urgent setting; site stoma with patient in standing, sitting, and prone positions; 5 cm of flat skin ideal; position through (or lateral to) rectus muscle; creases and body folds differ with position; consider belt line and location of surgical scars; difficult situations — eg, emergency surgery, obstructed and dilated bowel, thick abdominal wall (maintaining adequate length while preserving blood supply challenging); more difficult situations — postoperative leak and loss of abdominal compartment; concomitant trauma; trauma in obese patient; necrotizing fasciitis; may require innovative solutions; disabled patients — base site of stoma on patient’s usual position (braces should be worn at time of marking); radiation therapy — may necessitate more lateral position; previous stoma — place site at level different relative to first; burn victims — may be unable to wear belt or protective garments
High ileostomy output: administer hydration, replace electrolytes, and monitor input; bismuth, tincture of opium, oral codeine, or depot somatostatin may provide relief; treatments developed for, eg, short bowel or bowel may be tried for slowing of severe output
Parastomal hernias: type I (true type) — located in subcutaneous fascia; type II (intrastomal) — associated with prolapse; extends to opening of hernia; type III (subcutaneous prolapse) — not true hernia; type IV (pseudohernia) — weakness of anterior abdominal wall; no true fascial defect present
Treatment options: include reversal of stoma, nonoperative therapy, and revision; local repair — incision must be outside footprint of appliance; consider possible alternative sites due to high risk for future herniation; translocation — ideally performed with minimal dissection
Mesh options: sublay procedure — rectus fascia remains intact; mesh often placed through keyhole deformity; fixation often not required (however, keyhole may increase in size over time); mesh repair studies — overall, ≈33% of patients experience recurrence (depending on length of follow-up); wide variety of mesh available; repairs increasingly performed via laparoscopic and minimally invasive surgery; recurrence rates equivalent or slightly lower than with open techniques; prophylactic mesh placement — increasingly used during stoma surgery; appears to decrease recurrence rates; randomized studies pending
Other stomal problems: loss of abdominal wall domain — determine whether repair needed; patients tend to have multiple comorbidities and may not tolerate operation; no good surgical options available; cutaneous skin breakdown — relocate and reconstruct stoma; repair abdominal wall defect (often with biologic mesh and component separation); stoma prolapse — consider nonoperative management first; add support belt or truss, if needed; placing sugar on ostomy site may decrease swelling; if surgery required, determine whether parasternal hernia present (if not, attempt local repair, with, eg, Altmeier procedure); parastomal varices — treat underlying cause of portal hypertension; several treatments available for acute bleeding; stomal stenosis — often due to ischemia; problems with bowel more common than cutaneous issues; follow-up alone possibly sufficient if stoma temporary (repair required if permanent); stomal retraction — most common in obese patients who had emergency surgery; protect skin; ensure adequate pouching; may require reoperation
Technical maneuvers: increase reach — create pseudoloop (bring up side of bowel with blind end); fully prepare bowel before creation of trephine (to rule out vascular compromise); sew skin down to level of fascia; use Alexis wound protector; reduction of dilation — decompress bowel well in advance; remove portion of staple line, then mature
Reversal of stoma: speaker’s institution obtained good results with loose stapling and placement of wicks; studies — rate of stomal site infection varies (2%-41%) due to heterogeneity (ie, true primary vs delayed closure); study — good results obtained with subcuticular wound approximation
Clostridium difficile Colitis
Laurence R. Sands, MD, Professor of Clinical Surgery, and Chief, Division of Colon and Rectal Surgery, University of Miami Miller School of Medicine, Miami, FL
Background on C difficile: gram-positive bacillus that causes infectious diarrhea and pseudomembranous colitis; produces toxin A (enterotoxin) and toxin B (cytotoxin); prevalence — by 2008, found in 13.1 per 1000 hospitalized patients in United States; incidence and severity of strains increased in recent years; hypervirulent strain with higher levels of toxin has emerged, and has resulted in increased need for emergent surgery due to severe complications; ≈3 million cases of diarrhea and colitis per year in United States; mortality — 5-fold increase seen in C difficile-associated deaths from 1999 to 2004; costs — overall, >$1 billion/yr in United States; expected to double over next several decades
Diagnosis and transmission: symptoms — diarrhea; abdominal cramps; fever; blood and mucus in stools; abdominal tenderness; systemic toxicity (in severe cases); obtain history of use of antibiotics (fluroquinolones currently most commonly associated); test stool by enzyme immunoassay or tissue culture; 3-hit theory — patients exposed to antimicrobial agent that alters microflora of gastrointestinal (GI) tract; patients then exposed to toxogenic form and highly virulent strain of C difficile; patients possibly immunocompromised or have comorbidities that encourage progression of disease; C difficile transmitted by fecal-oral route; 50% of hospital rooms and 60% of hands of health care workers contaminated
Medical treatment: metronidazole (Flagyl) used to treat mild cases; oral vancomycin used for more severe cases; fidaxomicin (Dificid) recently approved for treatment of C difficile (bactericidal with minimal effect on normal colonic flora); study — fidaxomicin caused 40% greater reduction in recurrence of diarrhea and death, compared to vancomycin; fecal transplantation study — given via enema, feeding tube, or colonoscope; resulted in 87% improvement
Surgical treatment: 3% to 10% of patients develop fulminant colitis, for which treatment of choice total colectomy and ileostomy (usually permanent); recent study showed postsurgical mortality of 57%; meta-analysis — postsurgical mortality of 41%; predictors of mortality (multiple studies) — intubation; acute renal failure; multiorgan failure; use of vasopressors; white blood cell count >50,000/µL and hypoalbuminemia; older age; cardiopulmonary failure; high lactate level; delayed diagnosis of C difficile; colectomy for refractory disease associated with better outcomes than with colectomy for shock, megacolon, or perforation; patients with high lactate levels did not benefit from surgery
Diverting loop ileostomy and colonic lavage: study — associated with significantly lower rate of postoperative death, compared to patients who underwent colectomy; ileostomy later reversed in most patients; may be alternative to colectomy
Prevention: best treatment; limit type and use of antibiotics; adhere to infection control measures; use appropriate cleaning methods; place infected patients in private rooms; select appropriate antibiotic therapy and minimize duration; adhere to strict hand washing (soap and water superior to hand sanitizers); use vinyl gloves and disposable gowns
Drs. Guillem, Remzi, Steele, and Sands were recorded at the 24th Annual Jagelman/34th Annual Turnbull International Colorectal Symposium, held February 13-15, 2013, in Fort Lauderdale, FL, and sponsored by Cleveland Clinic Florida. Information on meetings presented by Cleveland Clinic Florida, can be found at www.ClevelandClinicFloridaCME.org. The Audio-Digest Foundation thanks the speakers and Cleveland Clinic Florida for their cooperation in the production of this program.
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