Category Archives: Colorectal Surgery

Management of elective surgery for diverticulitis

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One discussion this week was on the management of elective surgery for acute diverticulitis.

Reference: Wieghard N, Geltzeiler CB, Tsikitis VB. Trends in the surgical management of diverticulitis. Annals of Gastroenterology. 2015 Jan-Mar;28(1):25-30.

Summary: Wieghard et al (2015) state that sigmoid diverticulitis is an increasingly common Western disease associated with a high morbidity and cost of treatment. Improvement in the understanding of the disease process, along with advances in the diagnosis and medical management has led to recent changes in treatment recommendations. The natural history of diverticulitis is more benign than previously thought and despite current recommendations of more restrictive indications for surgery, practice trends indicate an increase in elective operations for the treatment of diverticulitis. Due to diversity in disease presentation, in many cases, optimal surgical treatment of acute diverticulitis remains unclear with regard to patient selection, timing, and technical approach in both elective and urgent settings.

The table below (Wieghard et al, 2015, p.28) provides direct comparison between ASCRS and ACPGBI recommendations for surgical treatment:

diverticulitis 1

diverticulitis 2

Additional Reading: Xai J, Paul Olson TJ, Rosen SA. Robotic-assisted surgery for complicated and uncomplicated diverticulitis: a single-surgeon case series. Journal of Robotic Surgery. 2019 Jan 23. doi: 10.1007/s11701-018-00914-x. [Epub ahead of print]

Risk of acute kidney injury in patients on vancomycin

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One discussion this week included the use of vancomycin in the setting of acute kidney injury (AKI).

Reference: Navalkele B, et al. Risk of acute kidney injury in patients on concomitant vancomycin and piperacillin-tazobactam compared to those on vancomycin and cefepime. Clinical Infectious Diseases. 2017 Jan 15;64(2):116-123. doi:10.1093/cid/ciw709.

Summary: In a retrospective, matched, cohort study of 558 patients, Navlkele et al (2017) compared the incidence of AKI among patients receiving combination therapy with vancomycin + piperacillin-tazobactam (VPT) to a matched group receiving vancomycin + cefepime (VC).

AKI rates were significantly higher in the VPT group than the VC group (81/279 [29%] vs 31/279 [11%]). In multivariate analysis, therapy with VPT was an independent predictor for AKI (hazard ratio = 4.27; 95% confidence interval, 2.73-6.68). Among patients who developed AKI, the median onset was more rapid in the VPT group compared to the VC group (3 vs 5 days P =< .0001).

Types of perirectal abscesses

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One discussion this week involved perirectal abscesses.

Reference: Calandrella C, La Gamma N. Abscess, Perirectal. In StatPearls [NCBI Bookshelf]. Last updated: 2018 Oct 27.

Summary: Although often thought of as the same, perianal abscess and perirectal abscesses differ in both complexity and care options. Except for perianal abscess which can be simply incised and drained as definitive care, all others usually require intravenous antibiotics, surgical evaluation, and drainage. A majority of abscesses are diagnosed clinically based on skin findings and palpitation of the affected area alone, but some require advanced imaging to determine the extent of infiltration.

A perirectal abscess can be further divided into a category based on anatomical location: ischiorectal abscess, intersphincteric abscess, and supralevator abscess. Given the variability in location and severity of the abscess, it is important to consider the presence of fistulas or tracts which may contribute to the spread of the infection. Perianal abscesses are the most common type, followed by ischiorectal, and intersphincteric abscesses.

Alternatively, the Park’s classification system which groups the fistulas into 4 types based on the course of the fistula and the relationship to the anal sphincters.

  • Intersphincteric (70%): Between the internal and external sphincters
  • Trans-sphincteric (25%): Extends thru the external sphincter into the ischiorectal fossa
  • Suprasphincteric (5%): Lasses from the rectum to the skin through the levator ani
  • Extrasphincteric (1%): Extends from the intersphincteric plane through the puborectalis

EPIDEMIOLOGY: The incidence of anorectal abscesses is 1:10,000, resulting in approximately 68,000 to 96,000 cases in the United States per year with a male prevalence of 3:1 during the third and fourth decades of life. The condition is seen more in the summer and spring months. Although often a concern of the patient, data does not support that there is an increased risk from hygiene, anal-receptive intercourse, diabetes, obesity, race, or altered bowel habits.

Laparoscopic entry techniques

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One discussion this week involved laparoscopic entry techniques.

Reference: Ahmad G, et al. Laparoscopic entry techniques. The Cochrane Database of Systematic Reviews. 2019 Jan 18;1:CD006583. doi: 10.1002/14651858.CD006583.pub5

Summary: In their updated systematic review on the topic, Ahmed et al (2019) included 57 RCTs including four multi-arm trials, with a total of 9865 participants, and evaluated 25 different laparoscopic entry techniques.

Overall, evidence was insufficient to support the use of one laparoscopic entry technique over another. Researchers noted an advantage of direct trocar entry over Veress needle entry for failed entry. Most evidence was of very low quality; the main limitations were imprecision (due to small sample sizes and very low event rates) and risk of bias associated with poor reporting of study methods.

Open-entry vs closed-entry: Evidence was insufficient to show whether there were differences between groups for:

  • vascular injury (Peto OR 0.14, 95% CI 0.00 to 6.82; 4 RCTs; n=915; I²=N/A)
  • visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08; 4 RCTs; n=915: I²=0%)
  • failed entry (Peto OR 0.45, 95% CI 0.14 to 1.42; 3 RCTs; n=865; I²=63%)

Direct trocar vs Veress needle entry: Trial results show a reduction in failed entry into the abdomen with the use of a direct trocar in comparison with Veress needle entry (Peto OR 0.24, 95% CI 0.17 to 0.34; 8 RCTs; n=3185; I²=45%; moderate-quality evidence).

Direct vision entry vs Veress needle entry: Evidence was insufficient to show whether there were differences between groups in rates of:

  • vascular injury (Peto OR 0.39, 95% CI 0.05 to 2.85; 1 RCT; n=186)
  • visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34; 2 RCTs; n=380; I²=N/A)

Direct vision entry vs open entry: Evidence was insufficient to show whether there were differences between groups in rates of:

  • visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50; 2 RCTs; n=392; I²=N/A)
  • solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67; 1 RCT; n=60)
  • failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09; 1 RCT; n=60)

Radially expanding (STEP) trocars vs non-expanding trocars: Evidence was insufficient to show whether there were differences between groups in rates of:

  • vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21; 2 RCTs; n=331; I²=0%)
  • visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37; 2 RCTs; n=331)
  • solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91; 1 RCT; n=244)

(Ahmed et al, 2019, p.2)

PROSPER trial: A comparison of treatments for rectal prolapse

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One discussion this week involved the PROSPER trial of treatment for rectal prolapse.

References: Senapati A, et al. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Disease. 2013 Jul;15(7):858-868. doi:10.1111/codi.12177

Summary: The PROSPER randomised control trial is a pragmatic, factorial (2 × 2) design trial in which 293 patients were randomised between abdominal and perineal surgery (i) (n=49), suture vs resection rectopexy for those receiving an abdominal procedure (ii) (n=78), or Altemeier’s vs Delorme’s for those receiving a perineal procedure (iii) (n=213). Primary outcome measures were recurrence of the prolapse, incontinence, bowel function and quality of life scores measured up to 3 years.

Recurrence rates were not significant in any comparisons:

  • abdominal vs perineal surgery: 20% vs 26%
  • suture vs resection rectopexy: 13% vs 26%
  • Altemeier’s vs Delorme’s: 24% vs 31%

It was noted that substantial improvements from baseline in quality of life following all procedures. Additionally, Vaizey, bowel thermometer and EQ-5D scores were not significantly different in any of the comparisons (Senapati et al, 2013).

Additional Reading: Bordeianou L, et al. Clinical practice guidelines for the treatment of rectal prolapse. Diseases of the Colon and Rectum. 2017 Nov;60(11):1121-1131. doi:10.1097/DCR.0000000000000889

Surgical management of Crohn’s Disease

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One discussion this week involved the surgical management of Crohn’s Disease.

Reference: Strong S, et al. Clinical practice guideline for the surgical management of Crohn’s Disease. Diseases of the Colon and Rectum. 2015 Nov;58(11):1021-1036. doi:10.1097/DCR.0000000000000450

Summary: The authors state “these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient” (p.1021).

OPERATIVE INDICATIONS

Failed Medical Therapy

  1. Patients who demonstrate an inadequate response to, develop complications from, or are noncompliant with medical therapy should be considered for surgery. Grade of Recommendation: Strong  based on low-or very low-quality evidence, 1C.
  2. Patients receiving therapy with anti-TNFs, high-dose glucocorticoids and/or cyclosporine may warrant staged procedures because of concerns about postoperative complications; however, decisions should be individualized based on the patient’s risk stratification, overall clinical status, and surgeon judgment. Grady of Recommendation: Weak based on low- or very low-quality evidence, 2C.

Inflammation

  1. Patient with acute colitis who have symptoms or signs of impending or actual perforation should typically undergo surgery. Grade of Recommendation: Strong based on low- or very low-quality evidence, 1C.

Stricture

  1. Endoscopic dilation may be considered for patients with symptomatic small-bowel or anastomotic strictures that are not amenable to medical therapy. Grade of Recommendation: Strong based on low- or very low-quality evidence, 1C.
  2. Surgery is indicated for patients with symptomatic small-bowel or anastomotic strictures that are not amenable to medical therapy and/or dilation. Grade of Recommendation: Strong based on low- or very low-quality evidence, 1C.
  3. Patients with strictures of the colon that cannot be adequately surveyed endoscopically should be considered for resection. Grade of Recommendation: Strong based on low- or very-low quality evidence, 1C.

Penetrating Disease

  1. Patients with a free perforation should undergo surgery. Grade of Recommendation: Strong based on moderate-quality evidence, 1B.
  2. Patients with enteroparietal, interloop, intramesenteric, or retroperitoneal abscesses may be managed by antibiotics with or without percutaneous drainage. Surgical drainage with or without resection should be considered when this is not successful. Grade of Recommendation: Weak based on moderate-quality evidence, 2B.
  3. Patients with enteric fistulas and symptoms or signs of localized or systemic sepsis that persist despite appropriate medical therapy should be considered for surgery. Grade of Recommendation: Strong based on low- or very low-quality evidence, 1C.

Hemorrhage

  1. Stable patients with significant GI heomrrhage may be evaluated and treated by endoscopic and/or interventional radiological techniques. Unstable patients should typically undergo operative exploration. Grade of Recommendation: STrong based on low- or very low-quality evidence, 1C.

Growth Retardation

  1. Prepubertal patients with significant growth retardation despite appropriate medical therapy should be considered for surgery. Grade of Recommendation: STrong based on moderate-quality evidence, 1B.

Neoplasia

  1. Patients with long-standing Crohn’s disease of the ileocolic region or colon should have endoscopic surveillance of the large bowel. Grade of Recommendation: Strong based on moderate-quality evidence, 1B.
  2. Total proctocolectomy should be considered for patients with carcinoma, a nonadenoma-like dysplasi-associated lesion or mass (DALM), high-grade dysplasia, or multifocal low-grade dysplasia of the colon or rectum. Grade of Recommendation: Strong based on moderate-quality evidence, 1B.
  3. Suspicious lesions (mass, ulcer) identified in patients with Crohn’s should typically be biopsied, especially when considering a small-bowel strictureplasty. Grade of Recommendation: Strong based on low- or very low-quality evidence.

For complete guidelines (site-specific operations, technical considerations), methodologies, and definition of GRADE system-grading recommendations, see full text article.

Simultaneous vs staged colorectal and hepatic resections

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One discussion this week involved the comparison of simultaneous and staged resections of colorectal cancer and synchronous colorectal liver metastases (SCRLM).

Reference: Reddy SK, et al. Simultaneous resections of colorectal cancer and synchronous liver metastases: a multi-institutional analysis. Annals of Surgical Oncology. 2007 Dec;14(12):3481-3491. doi:10.1245/s10434-007-9522-5

Summary: In a retrospective study of 610 patients at three institutions between 1985 and 2006, the authors compared postoperative morbidity and mortality after simultaneous and staged resections of colorectal cancer and SCRLM.

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