COLON AND RECTAL SURGERY
| SURGERY FOR INDETERMINATE COLITIS: TO POUCH OR NOT TO POUCH, THAT IS THE QUESTION —
David J. Schoetz Jr, MD, Professor of Surgery, Tufts University School of Medicine, and Tufts Academic Dean at
Lahey Clinic, Boston, MA
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| Evolution and pathology of ileal pouches: in series of 543 patients, preoperative diagnosis in 92% was ulcerative
colitis (UC); <1% diagnosed with Crohn’s disease (CD; median follow-up 8 yr); cases evolved from UC to
indeterminate colitis to CD
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 | Diagnostic evolution: from UC to CD, 3%; from indeterminate colitis to CD, 13% (change statistically significant)
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| Pouch failure rates: 2.3% in patients diagnosed with UC; >37% in patients diagnosed with CD; 12.5% in patients
with indeterminate diagnosis; in era of total proctocolectomy for patients with inflammatory bowel disease (IBD),
recurrence rates low, and incidence of indeterminate disease 5% to 10%; risk for recurrent CD higher when any
type of anastomosis performed; in most series of patients with CD, ≈33% of pouches fail; rates of indeterminate
colitis 2 to 3 times higher than in prepouch era
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| Review of 675 patients with indeterminate diagnosis undergoing surgery for IBD: most reclassified as probable CD
or probable UC, but ≈33% remained indeterminate; indeterminate colitis acted more like UC over time, but radiographic
as well as clinical criteria must be considered (diagnosis clinicopathologic); findings from other series
similar; rates of complications, pelvic sepsis, fistulae, and abscesses higher among patients with
indeterminate colitis; patients diagnosed with indeterminate colitis at speaker’s institution not offered pouches
(in favor of observing clinical behavior), but 5 in 51 patients (10%) with ileal pouches evolved to CD, with
pouch failure in 2; patients whose disease did not evolve did “quite well”
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| Reasons for pouch failure: recurrent obstruction; pouch-vaginal or pouch-perineal fistulae; chronic anastomotic
problems; among patients who kept pouches, function remained good
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| Conclusion: among patients receiving pouches for indeterminate colitis, risk for evolution to CD, complications,
and ultimate pouch loss highest during first 3 yr; after that, long-term functional results excellent; warn patients
with indeterminate disease of high risk for pouch complications and loss
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| ANORECTAL CROHN’S DISEASE— Dr. Schoetz
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| Anal CD: occurs in ≈20% of patients; most patients with CD have colonic rather than small bowel manifestations;
in one-third of patients, first manifestations anal
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| Perianal abscesses: drainage indicated; often complex; long-term drainage may require mushroom catheters or seton;
make incision and drainage area as close as possible to anus (facilitates fistula management); healing may
take as long as 2 yr; risk for recurrence higher in patients who undergo simple incision and have drainage without
seton or mushroom catheter; proctectomy may be necessary if perianal sepsis develops; 6-mercaptopurine
and azathioprine (Imuran) recommended for treating fistulae; infliximab (Remicade), infused at 0, 2, and 6 wk,
also associated with improvement and fistula healing in >50% of patients (active inflammation necessary for
response); good results also obtained with seton drainage plus infliximab infusions
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| Seton removal: advocated by gastroenterologists after disease controlled by infliximab; speaker recommends
leaving it in
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| Fistula management: consider complexity, patient discomfort, activity of proximal disease (especially in rectum),
and surgical history; management goals include minimizing anal wound, preserving continence, and avoiding
stoma; simple fistulotomy recommended for low simple fistula in patient with well-controlled disease; setons,
drains, flaps, proximal fecal diversion, and proximal resection options for high or complex fistulae; fibrin glue—
success rates 31% and 33% in 2 recent series; nevertheless, recommended as first-line therapy (no risk for
sphincter damage); fibrin plug—success rate 80% in one recent study, including healing of 83% of fistulae associated
with CD; however, findings “await confirmation from other investigators”; sliding flaps—associated with
high success rates in 2 series in carefully selected patients; proximal fecal diversion (split ileostomy)—gastrointestinal
tract continuity restored in only 21% of patients studied; “more patients had their rectum out than got their
anus back”; if disease active at time of stoma construction, anal function usually does not recover; presence of
active anal or rectal disease strong predictor of permanent stoma; consider starting with loop ileostomy to accustom
patient to living with ileostomy and to reduce risk for nonhealing perineal wound after proctectomy; rectovaginal
fistulae—develop in 8% to 10% of women with CD; spontaneous healing “extremely rare”; let
symptoms determine treatment (if disease inactive, healing satisfactory in ≈66% of cases, regardless of procedure);
anal fissures—conventional wisdom dictates nonsurgical treatment, but in Tufts study, long-term healing
persisted in 88% of patients who underwent surgery; of patients with active fissures who did not heal, many developed
perianal sepsis; conclusion—if CD otherwise well controlled, use local anal procedure to manage nonhealing
anal fissures
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| Anticipated outcomes in patients undergoing surgery for anal CD: many require incision and drainage; a few will
undergo proctectomy; conservative use of surgery leaves 60% of patients with functional anus; stricture and colonic
disease associated with permanent stoma
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| VOLVULUS OF THE COLON —Sonia Ramamoorthy, MD, Assistant Professor of Surgery, University of California,
San Diego, School of Medicine, UCSD Medical Center
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| Definition: axial rotation of organ on its pedicle
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| Pathology: results from mobile bowel segments; infarction results from torsion of pedicle, cutting off vascular supply
and creating closed-loop obstruction; accounts for ≈10% of colonic obstructions in United States (rate higher in
cultures with diets higher in fiber); sigmoid colon most common site, usually seen in older patients; cecal form second
most common, usually seen in younger patients
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| Causes: patients likely have anatomic predisposition (colon longer relative to mesenteric base); chronic distention
and colonic stasis often present, often resulting from laxative abuse; also associated with very high-fiber diets,
pregnancy, Ogilvie’s syndrome, and megacolon
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| Sigmoid volvulus: may occur at any age but most commonly seen in elderly patients, especially those institutionalized
with psychiatric or neurologic diseases; associated with chronic colonic dysmotility; patients typically have
history of severe chronic constipation, as well as disproportionately long colon
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| Presentation: patients report history of intermittent cramping, abdominal pain, and distention; symptoms may occur
daily; acute symptoms include nausea, vomiting, more severe pain, abdominal tenderness, and distention; rarely,
patients present in very late stages with ischemia, necrosis, and systemic sepsis (may have elevated white blood
cell count, acidosis, and peritonitis)
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| Diagnosis: radiography necessary; many institutions now perform computed tomography
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| Treatment: endoscopic decompression with rigid or flexible sigmoidoscope; ischemic tissue absolutely indicates surgery;
endoscopy permits evacuation of bowel contents proximal to volvulus and simultaneous placement of rectal
tube to prevent recurrence; while patient hospitalized, correct electrolyte balance and perform sigmoid resection
(without surgery, risk for recurrence high)
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| Subtotal colectomy: consider if patient has megacolon and chronic dysmotility; consider colostomy if patient extremely
debilitated with severe dysmotility
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| Emergency surgery: required when patient fails decompression, or presents with sepsis or peritonitis; mortality rate
≈40%; perform open resection of ischemic segments; manipulate gangrenous tissue as little as possible; perform
colostomy if necessary and send patient to intensive care; perform primary anastomosis if possible
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| Cecal volvulus: accounts for 1% of all intestinal obstructions; patients usually women, mean age ≈50 yr; results
from abnormally mobile cecum; failure of mesentery to fuse with posterior parietal peritoneum
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| Cause: 360º rotation of hypermobile cecum on mesenteric pedicle of ileocolic artery, creating closed-loop obstruction
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| Symptoms: abdominal pain, distention, and constipation; progression leads to nausea, vomiting, and, rarely, peritonitis
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| Management: no role for endoscopic decompression; emergency surgery usually necessary, with resection, primary
anastomosis, and right hemicolectomy; cecostomy and cecopexy rare but possibly indicated for patients with severe
comorbidities; ileostomy and mucus fistula other options for patients too sick for primary anastomosis
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| Operative management: if bowel viable, counterclockwise detorsion; if bowel necrotic, resection
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| Outcomes: mortality associated with bowel necrosis; low morbidity and mortality with early diagnosis and treatment
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| Cecal bascule: caused by redundant mesentery and hypofixation of right colon and cecum, causing cecum to obstruct
by folding on itself; produces massive cecal dilation in right lower quadrant; may mimic cecal volvulus;
radiographic findings atypical; manage similarly to cecal volvulus (emergency surgery), although usually associated
with less bowel loss; left untreated, dilated cecum may perforate
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| INCIDENTAL COLORECTAL FINDINGS —Bruce G. Wolff, MD, Professor of Surgery, Mayo Clinic College of
Medicine, Rochester, MN
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| Appendiceal masses: mucocele—simple (appendiceal dilatation with accumulation of mucus due to luminal obstruction);
cystadenoma (dilated mucocele appendix containing adenomatous mucosa); precursor to cystadenocarcinoma
(adenocarcinoma associated with dilated mucus-filled appendix)
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| Signs of malignant mucocele: preoperative symptoms (abdominal pain, mass, and weight loss); preoperative diagnosis
of pseudomyxoma peritonei; mucocele extravasation
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| Size difference: cystadenomas often twice as large as mucoceles; diameter usually >2 cm (should be removed)
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| Carcinoids: account for 0.3% of appendectomies and 85% of appendiceal neoplasms; usually found at appendiceal
tip; 70% to 90% <1 cm in diameter; simple appendectomy sufficient if carcinoid <2 cm, with no mesenteric metastases;
right hemicolectomy indicated for tumors at appendiceal base, tumors >2 cm in diameter, or mesenteric
metastases
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| Adenocarcinomas: account for 14% of appendiceal neoplasms (8% mucinous type, 4% colonic type, 2% adenocarcinoid
[goblet cell]); right hemicolectomy treatment of choice
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| Second primary malignancies: incidence relatively high in one series; included tumors of gastrointestinal or genitourinary
tracts; oophorectomy recommended for postmenopausal women with appendiceal adenocarcinoma;
always look for synchronous primary tumors; close follow-up warranted for metachronous tumors; survival
with stages 3 or 4 adenocarcinoma and adenocarcinoid poor, regardless of treatment; risk for ovarian metastasis
high
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| Incidental cholecystectomy: questionable for asymptomatic patients undergoing nonbiliary surgery; studies of
effects on operative morbidity contradictory; risk for long-term complications in asymptomatic patients with gallstones,
1% to 20%, depending on study; in series of 195 patients who underwent incidental surgery (compared to
110 who did not), no difference in operative morbidity and mortality between groups; no-cholecystectomy patients
followed for mean of 6 yr; 16 (14.5%) developed biliary complications; 5-yr cumulative probability of undergoing
cholecystectomy, 21.6%; similar findings observed on longer (8 yr) follow-up, with cumulative probability of
cholecystectomy >30%; also, slight risk of missing small gallbladder malignancy; conclusion—low-risk patients
with asymptomatic gallstones should undergo concomitant cholecystectomy
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| Incidental Meckel’s diverticulectomy: resection for asymptomatic diverticulum; 1976 study demonstrated 800
procedures necessary to prevent one death; in later study of complications in 58 patients (compared to 87 who underwent
incidental surgery), common presenting symptoms included obstruction, hemorrhage, diverticulitis, and
perforation, with mortality rate of 2% (among patients undergoing incidental diverticulectomy, mortality 1%);
morbidity 12% and 2%, respectively; if diverticulum left in situ, lifetime risk for complications 6.49%
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| Review of ≈1500 cases: most common presentations obstruction (in children) and bleeding (in adults); 75% of
symptomatic cases occurred after 10 yr of age; 75% in boys and men; 75% of patients with bleeding Meckel’s
have ectopic gastric tissue; speaker routinely performs diverticulectomy
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| Colorectal cancer (CRC) with concomitant abdominal aortic aneurysm (AAA): in >15-yr study of
20,000 patients with history of CRC, of nearly 11,000 with AAA, 83 had both simultaneously; AAA <5 cm in 6 patients
(CRC treated); AAA >5 cm in 5 patients (3 underwent treatment for CRC; 1 treated for AAA first, CRC 87
days later; 1 underwent simultaneous treatment); in 2 patients with CRC discovered incidentally during laparotomy
for AAA, CRC treatment delayed 3 mo in both cases; conclusion—size of aneurysm key; small risk for rupture during
CRC treatment if AAA <5 cm; if >5 cm, risk for rupture 10% if CRC treated first
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| Prophylaxis: analysis of 250,000 appendectomies over 15 yr showed that 36 incidental surgeries necessary to prevent
one case of appendicitis; for patients aged 65 to 69 yr, 115 appendectomies needed to prevent one case of appendicitis
(4472 to prevent one death); open surgery cost-effective for patients <35 yr of age; laparoscopic surgery
may miss other abdominal pathology
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| Incidental omentectomy: associated with higher rates of abdominopelvic sepsis than seen in patients not undergoing
procedure
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| Incidental oophorectomy for women with CRC: risk for ovarian metastases 5%; oophorectomy associated
with slightly higher rate of recurrence-free survival, but no other significant differences; question not yet resolved
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Suggested Reading
Aronoff JS et al: Anorectal Crohn’s disease: surgical and medical management. BioDrugs 13:95, 2000; Burakoff
R: Indeterminate colitis: clinical spectrum of disease. J Clin Gastroenterol 38:S41, 2004; Byrn JC et al: Management
of goblet cell carcinoid. J Surg Oncol 94:396, 2006; Consorti ET, Liu TH: Diagnosis and treatment of caecal
volvulus. Postgrad Med J 81:772, 2005; Madiba TE, Thomson SR: The management of cecal volvulus. Dis Colon
Rectum 45:264, 2002; Martland GT, Shepherd NA: Indeterminate colitis: definition, diagnosis, implications and
a plea for nosological sanity. Histopathology 50:83, 2007; Mitchell PJ et al: Indeterminate colitis. Tech Coloproctol
11:91, 2007; Oren D et al: An algorithm for the management of sigmoid colon volvulus and the safety of primary
resection: experience with 827 cases. Dis Colon Rectum 50:489, 2007; Park JJ et al: Repair of chronic anorectal fistulae
using commercial fibrin sealant. Arch Surg 135:166, 2000; Ruiz-Tovar J et al: Mucocele of the appendix.
World J Surg 31:542, 2007; Shen B et al: Risk factors for clinical phenotypes of Crohn’s disease of the ileal pouch.
Am J Gastroenterol 101:2760, 2006.
Educational Objectives
| The goal of this program is to improve management of indeterminate colitis, anorectal Crohn’s disease (CD), and volvulus
of the colon and cecum, and to discuss considerations involved in the decision to perform incidental surgery.
After hearing and assimilating this program, the clinician will be better able to:
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| 1. Identify the best candidates for ileal pouches among patients with indeterminate colitis.
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| 2. Manage anorectal CD.
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| 3. Diagnose and treat colonic and cecal volvulus.
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| 4. Recognize appendiceal masses that indicate incidental appendectomy.
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| 5. Discuss the indications for incidental cholecystectomy, omentectomy, Meckel’s diverticulectomy, and management
of concomitant colorectal cancer and abdominal aortic aneurysm.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members 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.
Acknowledgements
Dr. Schoetz spoke at the 18th Annual International Colorectal Disease Symposium, held February 15-17, 2007, in Fort
Lauderdale, FL, and sponsored by the Cleveland Clinic Florida. Dr. Ramamoorthy was recorded at the 30th Annual
San Diego Postgraduate Assembly in Surgery, held February 26 to March 2, 2007, in San Diego, CA, and sponsored by
the Department of Surgery at the University of California, San Diego, School of Medicine. Dr. Wolff gave his presentation
at The Postgraduate Course in General Surgery, held March 22-24, 2007, in San Francisco, CA, and sponsored
by the Department of Surgery at the University of California, San Francisco. The Audio-Digest Foundation thanks
the speakers and the sponsors for their cooperation in the production of this program.
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