CONTROVERSIES IN GI SURGERY
| OVERVIEW OF THE CONTROVERSIES IN THE MANAGEMENT OF COMPLEX ANAL FISTULAS —Brett T.
Gemlo, MD, Adjunct Assistant Professor of Surgery, University of Minnesota Medical School, Minneapolis
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| Presentation: multiple draining tracts; associated tags; coexisting disease; postoperative changes
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| Definition of complex anal fistula: most involve significant amount of sphincter muscle (internal and external
sphincter); transsphincteric, suprasphincteric, and extrasphincteric fistulas extremely challenging; often have multiple
openings or tracts; single internal orifice, perhaps multiple external orifices; unhealed wounds; recurrent fistulas after
previous treatment; often associated with disease (Crohn’s disease [CD], immunosuppressive disorders, or tuberculosis);
not simple intersphincteric or low sphincteric fistula repaired by simple lay-open procedure; often high transsphincteric
fistulas with high blind tract, complicating surgical approach
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| Clinical approach: includes confirming diagnosis, excluding other associated pathology, and defining exact anatomy of
fistula (especially with previous surgery; must document continence when patient first seen, because excellent chance that
continence negatively affected by treatment); minimize recurrence with definitive procedure, but not at expense of continence;
2 alternatives—divide sphincter or close primary tract; division of sphincter—simple fistulotomy with seton or
fistulotomy with sphincter reconstruction traditional approach; alternative options—long-term draining setons, rerouting
fistula, removing fistula, flaps, and glue; not amenable to simple lay-open procedure without change in continence; use seton
(silk, vessel loop, or silastic tubing) for marking (establish tract for fistula) or for draining (noncutting seton to allow good
drainage from internal and external orifice to control sepsis); irritating fistula seton (causes fibrosis and allows return at second
stage to perform simple lay-open fistulotomy); cutting seton—placed tightly around muscle (cuts through slowly by
strangulation); lower squeeze pressures; guttered appearance to canal or anorectal ring (higher incidence of defective continence);
scar interferes with closing or sealing of anal canal (those with hard scars have higher incidence of fecal incontinence);
results of number of series with both cutting and staged setons, or cutting or staged seton alone show unacceptably
high risk for incontinence; closure of primary tract—options include use of advancement flaps, installation of fibrin glue,
and fistula plug to obliterate fistula tract; alternative procedures do not involve cutting of sphincter muscle; result recurrence
rates higher
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| FLAPS FOR FISTULAS —Ann C. Lowry, MD, Adjunct Professor, Department of Surgery, University of Minnesota Medical
School, Minneapolis
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| Three types of advancement flaps: all types have in common timing of surgery; important, before flap procedure
done, to treat any local infection (drain associated abscess or place seton to allow cavity to close down to straighter tract and
allow inflammation in surrounding tissue to subside); endorectal advancement flap—most common; principles of surgery
same in all flap procedures; anocutaneous flap—principle for flap formation same but indication different; used to
avoid mobilizing rectal wall (eg, fistula with low internal opening, patient with significant anal stenosis, or patient who has
had multiple repairs with scarring in distal rectum); endorectal advancement flaps alone—success rate ≈80%, range
70% to 98%; core fistulectomy—average 85%; anocutaneous flaps—small studies with varying follow-up; success
rates good, with exception of Zimmerman study; in Zimmerman’s study of patients who had first repair with this method,
success rates as good as other studies; follow-up—most recurrences occur within 6 to 15 mo; favorable factors—older
patients do better; patients with previous incision and drainage or seton; unfavorable factors—inflammatory bowel disease
(IBD), number of previous repairs, and smoking; number of previous repairs affects success rate, regardless of flap
type; Zimmerman found that success rate in nonsmokers significantly better than in smokers; in smokers, success rate correlated
with number of cigarettes smoked per day (possibly due to blood flow); functional results for endorectal advancement
flaps—technique, number of patients, investigation of incontinence varied; frequency of incontinence not reported;
incontinence to solid stool not reported, only gas or liquid stool; overall, patients showed 50% decrease in incontinence;
functional results for anocutaneous flaps—results varied; improved to worsened incontinence; physiologic testing—
performed before procedure and 3 mo after; no change in parameters (resting squeeze pressures and rectal compliance)
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| ANAL AND PERIANAL NEOPLASIA —Robert D. Madoff, MD, Professor of Surgery, University of Minnesota Medical
School, Minneapolis
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| Background: 2% of gastrointestinal (GI) malignancies; 4-fold increase in men who have sex with men (MSM) without
HIV; doubled or tripled in MSM with HIV
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| Causation and classification: caused by human papillomavirus (HPV); sexually transmitted oncogenic virus that resides
intraepithelially; causes cervical cancer; initially cervical intraepithelial neoplasia (CIN), advanced CIN, then cancer;
see similar progression in vulvar intraepithelial neoplasia (VIN) and anal intraepithelial neoplasia (AIN); AIN, CIN,
and VIN rated from 1 to 3, with 3 being premalignant
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| Risk factors: cervical dysplasia or cancer, HIV (men and women), low CD4 counts, high-risk HPV serotypes, multiple
serotypes, anal-receptive intercourse, immunosuppression, cigarette smoking, healing flaps, fixing fissures, and AIN; invasive
anal cancers—85% variant of squamous cell, 10% adenocarcinoma, and 5% mixed types; epidermoid anal cancers
(squamous cell anal cancers) and transition cell (cloacogenic) cancers treated same way; anal canal cancer cannot be
seen on visual inspection, anal margin cancer can; Bowen’s disease—squamous cell carcinoma in situ (AIN 3 or high-grade
dysplasia); Paget’s disease—adenocarcinoma in situ; Buschke-Lowenstein tumor—giant condyloma accuminata
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| Treatment: invasive anal margin cancers—wide local excision; anal canal cancers (squamous cell)—in past, abdominoperineal
resection (APR) with colostomy; substantial procedure with 40% to 70% survival rate; now, 5-fluorouracil,
mitomycin C, and radiation therapy (neoadjunctive chemoradiation) with 70% to 80% 5-yr survival rate; verrucous
carcinoma—synonymous to Buschke-Lowenstein tumor; giant wart; benign but aggressive invasion locally; deadly; APR
with colostomy and probable chemoradiation therapy (depending on size and extent of tumor); anal adenocarcinoma—
think of them as low-lying rectal carcinoma; aggressive; neoadjuvant chemoradiation (no data); melanoma—uncommon;
poor prognosis; most patients present with systemic disease; local resection instead of APR; radical surgery has little impact
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| PERSISTENT AND RECURRENT ANAL CANCER —Judith L. Trudel, MD, Adjunct Associate Professor of Surgery,
University of Minnesota Medical School, Minneapolis
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| Chemoradiation: primary treatment; cisplatin most recent addition to regimen, also used for recurrence; majority of patients
respond well; 10% to 35% of patients have persistent disease (present 6 mo after initiating treatment); chemoradiation
exerts effect for 6 mo); recurrent disease if tumor and lymph nodes have responded, then reappeared
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| Treatment for recurrent disease: surgery carries heavy burden of morbidity and condemns patient to colostomy;
salvage APR minimal operation; pelvic exenteration if there is pelvic disease invading local organs, or radiation therapy
to level of tissue tolerance; radiation—originally 3000 rads, now using 4500 rads; salvage chemotherapy or combination
chemotherapy/radiation therapy to tissue tolerance—no data; recommendations anecdotal; combination—
neoadjuvant chemoradiation therapy to tissue tolerance, then APR or start with APR and use additional therapy as
needed
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| Abdominoperineal resection: first series—delayed perineal wound healing with APR postchemoradiation therapy
main issue in mortality; large proportion of patients had delayed healing at 3 mo; 33% of patients had no wound healing
or persistent sinus at 6 mo; 56% of patients died by 120 mo; remainder of patients survived for 10 yr; patients with persistent
disease had worse prognosis with APR than those with recurrent disease; second series—failure rate 82% with salvage
APR; patients died promptly after surgery; patients who failed had residual disease after APR; third series—APR
with different modes of closing perineum; half with primary closure, half with wound packed open; no difference in
wound healing, morbidity remained; no statistically significant difference in persistent and recurrent disease due to small
numbers of patients; common factors in all series—small numbers, short follow-up, and average survival ≈50%
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| BEST PRACTICES FOR RADIATION PROCTITIS —Eric G. Weiss, MD, Director of Surgical Endoscopy and Residency
Program, Cleveland Clinic Florida, Weston
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| Two types of radiation proctitis: acute—typically occurs during or within 3 mo of radiotherapy; rectal bleeding,
rectal pain, bleeding, mucus, discharge, diarrhea, incontinence, and tenesmus; chronic—more typical form seen; can be
continuation of acute form; typically occurs 90 days after end of therapy; mostly bleeding, can see ulcerations, fistulas,
and strictures; can get radiation proctitis within 10 yr after radiation therapy
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| Radiation injury: 90% of rectal injuries occur following pelvic radiotherapy (prostate, cervix, rectum, and anus); acute
form—limited to mucosa, no deeper structures involved; chronic form—distortion of blood vessels, intimal fibrosis with
fibrin thrombi, telangiectasias with bleeding, and ischemic changes resulting in submucosal fibrosis and ulceration
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| Risk factors for radiation proctitis: dose-dependent phenomenon; almost definite with high doses of radiation; depends
on how dose fractionated, mode of delivery, types of fields used (whether intracavitary, seed, or external beam),
use of radiosensitizers, and patient comorbidities
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| Disease course and diagnosis: mild or acute disease (nontransfusion-dependent)—bleeding without significant
anemia; 70% spontaneous remission rate within 2 yr; severe disease (transfusion-dependent or with significant alterations
due to fibrosis)—typically do not have spontaneous remission and requires treatment; diagnosis—history of irradiation
to pelvis; endoscopic evaluation to rule out other pathology (recurrent and secondary malignancies) and to evaluate
telangiectasias, ulcerations, and inflammation; biopsies and histologic correlation
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| Treatment: prevention—positioning of patient; filling bladder to displace small bowel and act as buffer for radiation; inserting
omental pedicles or mesh exclusion during surgery to keep small bowel out of pelvis before irradiation; possible role
of antioxidants during radiation therapy; symptomatic therapy—stool-bulking agents, stool softners, antispasmodics, and
antidiarrheals, depending on symptoms; mesalamine or steroids (gels, suppositories, enemas, or foam) used as first-line
treatment (no scientific data on use); sucralfate enemas bid shown effective in 93% of patients at 16 wk; however, symptoms
recur with stopping but respond again when medication restarted; short-chain fatty acid enemas show variable results; significant
improvement with 400 IU of vitamin E tid and 500 mg of vitamin C tid; hyperbaric oxygen has angiogenic effect (8-
to 9-fold increase in vascular density and tissue oxygenation) and stimulates collagen formation (helps form new blood vessels
destroyed by radiation therapy); variable effect, expensive, takes long time, and some side effects (ear perforations and
visual issues); topical formalin applied as aliquots via protoscope or applied directly to areas using sponge stick or cotton-tip
applicator; commonly use 4%; seals fragile telangiectasias; 70% to 100% response rate; variety of endoscopic techniques
(laser, bipolar, argon beam coagulators) successful but numbers small; argon beam coagulator most common, with response
rates of almost 100%; if patient diagnosed at time of endoscopy, recommend use of argon beam coagulator; if diagnosed in
office, recommend use of formalin; if severe complications present, resection or interposition-type surgery; stomas if unsuccessful
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| HOW SHOULD WE TREAT INDETERMINATE COLITIS ?—Scott A. Strong, MD, Department of Colorectal Surgery,
Cleveland Clinic, Cleveland, OH
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| Clinical features of patients: young age at onset; disease more extensive in nature; greater likelihood of family history of
inflammatory bowel disease (IBD); higher risk for severe first attack, mandating resection; higher risk for colorectal neoplasia
compared to patients with CD or ulcerative colitis (UC)
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| Diagnosis and treatment: 3 diagnostic scenarios—first is diagnosis based on biopsies, radiographic findings, and
clinical course; second is transmural lesions in colectomy specimen from elective surgery; last is surgical specimen obtained
at resection for fulminant disease; in 2000, started using serologic markers; if anti-Saccharomyces cerevisiae antibody
(ASCA) positive and perinuclear antineutrophil cytoplasmic antibody (pANCA) negative, then CD; if ASCA
negative and pANCA positive, then UC; if ASCA negative, whether pANCA positive or negative, most remain diagnosed
as indeterminate colitis; if negative for both markers, unlikely that they would be reclassified as CD; serologic markers
have value in these patients; review results and pathology slides; get serologic testing; for ASCA-positive patient (more
likely to be CD), do initial colectomy, then ileoproctostomy or ileostomy, and definitive procedure if patient does not show
signs of CD or if pathology of excised specimen does not show signs of CD; in one study, if review of excised specimen in
nontoxic state showing indeterminate colitis, only 1% reclassified as CD; in patients with toxic colitis specimen, diagnosis
of CD remains consistent, diagnosis of UC remains same, and indeterminate colitis reclassified to CD in 4 of 9 patients;
macroscopic features (dilatation, skip lesions, linear ulceration) used to discriminate between CD and UC useless in toxic
colitis specimen; in toxic colitis, histologic features associated with CD are granulomas and transmural lymphoid aggregates
not associated with mucosal ulcerations; 5% of rectal excisions show CD; small bowel or anoperineal CD develops
in 10%; in toxic colitis, review specimen slides and perform proctoscopy and extensive biopsy of rectum (granulomas and
lymphoid aggregates); consider serologic testing (ASCA status can change with time, pANCA does not); use results to
counsel patients on surgery; usually opt for restorative proctectomy with ileal pouch-anal anastomosis
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Educational Objectives
| The goal of this activity is to discuss controversies in gastrointestinal (GI) surgery. After hearing and assimilating this program,
the clinician will be able to:
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 | 1. Describe the clinical approach to complex anal fistulas.
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| 2. Discuss the use of advancement flaps for correcting fistulas.
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| 3. Review the treatment options for anal and perianal neoplasias, including persistent and recurrent anal cancers
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| 4. Recognize radiation proctitis and know its treatment options.
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| 5. Discuss the diagnosis and evaluation of indeterminate colitis.
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Suggested Reading
Cisplatin (CDDP) [Platinol-AQ]
Fluorouracil (5-fluorouracil, 5-FU) [Adrucil, Carac, Efudex, Fluoroplex]
Mesalamine (5-aminosalicylic acid; 5-ASA) [Asacol, Pentasa, Rowasa]
Mitomycin (mitomycin-C; MTC) [Mutamycin]
Sucralfate [Carafate]
Discussed on this Program
Cullen SN et al: Treatment of haemorrhagic radiation-induced protopathy using small volume topical formalin instillation.
Aliment Pharmacol Ther 23:1575, June 2006; Edelman S, Johnstone PA: Combined modality therapy for HIV-
infected patient with squamous cell carcinoma of the anus: outcomes and toxicities. Int J Radiat Oncol Biol Phys 66:206,
Sep 2006; Henriksen M et al: Change of diagnosis during the first five years after onset of inflammatory bowel disease:
results of a prospective follow-up study (the IBSEN Study). Scand J Gastroenterol 41:1037, Sep 2006; Hung A et al:
Cisplatin-based combined modality therapy for anal carcinoma: a wider therapeutic index. Cancer 97:1195, Mar 2003;
Jhawer M et al: Phase II study of mitomycin-C, adriamycin, cisplatin (MAP)and Bleomycin-CCNU in patients with advanced
cancer of the anal canal: an eastern cooperative oncology group study E7282. Invest New Drugs 24:447, Sep 2006;
Sandborn WJ: Serologic markers in inflammatory bowel disease: state of art. Rev Gastroenterol Disord 4:167, Fall
2004: Sanguineti G et al: Sucralfate versus mesalasine versus hydrocortisone in the prevention of acute radiation proctitis
during conformal radiotherapy for prostate carcinoma. A randomized study. Strahlenther Onkol 179:464, Jul 2003;
Sonoda T et al: Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement
flap. Dis Colon Rectum 45:1622, Dec 2002; Zimmerman DD et al: Smoking impairs rectal mucosal bloodflow-a pilot
study: possible implications for transanal advancement flap repair. Dis Colon Rectum 48:1228, Jun 2005; Zimmerman
DD et al: Anocutaneous advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 44:1474, Oct 2001.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reported nothing to disclose.
Drs. Gemlo, Lowry, Madoff, and Trudel were recorded at Colon and Rectal Surgery: Conundrums and Controversies
held September 8-10, 2005, in Minnepolis, MN, and sponsored by the University of Minnesota Medical School, Division
of Colon and Rectal Surgery, Department of Surgery, Continuing Medical Education, Colon and Rectal Associates,
Ltd., and the Minnesota Colon and Rectal Foundation. Drs. Weiss and Strong were recorded at the 17th Annual
International Colorectal Disease Symposium held February 16-19, 2006, in Fort Lauderdale, FL, sponsored by the
Cleveland Clinic Florida. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in
the production of this program.
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