RECTAL SURGERY PLUS
| RECURRENT RECTAL CANCER —Robert W. Beart Jr, MD, Chair, Department of Colorectal Surgery, Keck School of
Medicine of the University of Southern California, Los Angeles
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| Management of colorectal cancer (CRC): includes staging, screening, and epidemiology; treatment alternatives;
adjuvant therapy; follow-up and recurrence management; meaningful recurrence management improves survival and
cures 30% of patients with recurrent disease
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| Follow-up: if following patients with CRC, 85% present with symptoms at earliest point of detectable disease by any
test; other tests (eg, physical findings, abnormal chest x-rays) positive but relatively low-yield, even for recurrent pelvic
cancer; liver scans and computed tomography (CT) of value but expensive (relegated to confirmatory testing only);
carcinoembryonic antigen (CEA)—next most sensitive to history; blood test positive in ≈67% of patients with recurrent
disease at earliest point of detectable disease by any test; all colon cancer detectable with history or CEA at earliest
point of detectable disease by any test; more likely to be positive for right-sided colon cancer than left-sided colon
cancer or rectal cancer; better for following colon cancers than rectal cancers; transiently elevated in ≈30% of patients;
should be <10 ng/mL; if 5 to 10 ng/mL (intermediate range), confirmatory testing 1 to 2 mo later appropriate; if >10
ng/mL, assume recurrent disease present; history, physical examination, and CEA simplest way to determine recurrent
disease; highly sensitive and must be done every 3 to 4 mo; of 100 cases of CRC, ≈35 have recurrent disease; by doing
nothing and waiting for symptoms to occur, only 2% to 3% of cases cured; following patients results in 12% of cases
cured; management for palliation also important; study by Ovaska—507 participants; 5-yr survival 72% in those followed,
and 62% in those not followed; curative operation rate increased 3-fold; in both groups, cancer-specific survival
after surgery for recurrent CRC, 41%; speaker’s meta-analysis—intense follow-up resulted in 3.62-fold
improvement in 5-yr survival rate and 2.5 times more curative resections (highly significant); other studies also show
follow-up appropriate and results in improved survival; CT and positron emission tomography (PET) benchmarks for
follow-up; PET—changes disease evaluation and assessment; changes management potentially in ≈40% of patients;
problem with false-positive results, particularly in pelvis with previous anastomotic complications
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| Recurrences: can occur in solid organ; repeat resections for solid organs appropriate; peritoneal carcinomatosis more
difficult to treat, but prospective randomized studies looking at hyperthermic mitomycin perfusion with postoperative
chemotherapy; if patients left with minimal or little disease (nodules <5 mm), mean survival close to 2 yr (with more
gross disease, mean survival ≈6 mo); recurrent cancer in pelvis more complex and difficult problem; technically difficult
because of limitation in radial margins; 5-yr survival with central pelvic recurrence ≈35%; sacral involvement—
another pattern of recurrence; if sacrum resected, long-term survival 33% or 34%; positive margin one of adverse prognostic
indicators; blood loss possibly great; mortality rate significant; pelvic exenteration—standard for most common
form of recurrence (usually along lateral pelvic side wall); often includes some urologic structures (bladder and rectum
must be removed); performed as continence-preserving procedure; significant perioperative mortality and morbidity, but
substantial survival achieved if able to maneuver around tumor; if unable to maneuver around tumor and lateral pelvic
side wall remains positive, intraoperative irradiation recommended; long-term survival 25%, but failure rates rarely in
central field or local field (30%-40% local recurrence); most common pattern of recurrence disseminated metastasis and
peritoneal seeding; ongoing chemotherapy appropriate; brachytherapy—preoperatively position 8 catheters and absorbable
mesh; easy to place with endoscopic stapler at time of surgery around any area in pelvis, sacrum, or lateral pelvic
side wall that remains positive; radium used postoperatively in high doses, and catheters removed before patient goes
home; mortality zero and morbidity ≈30%; local control ≈64% and long-term survival ≈25%; also used intraoperatively
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| RESISTANT RECTOVAGINAL AND RECTOURETHRAL FISTULAE —Steven D. Wexner, MD, Chief of Staff and
Chair, Department of Colorectal Surgery, Cleveland Clinic Florida, Weston; Professor of Surgery, Cleveland Clinic, Health
Sciences Center of Ohio State University; and Clinical Professor of Surgery, University of South Florida, Tampa
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| Classification: congenital or acquired; simple or complex; simple defined as low simple fistulae secondary to trauma or
sepsis; complex defined as higher or larger fistulae, possibly associated with inflammatory bowel disease, irradiation, or
neoplasia; fistulae due to multiple previous failed repairs also considered complex; success rates high (85%-100%) with
traditional treatment for first fistula; little data looking at effects of failed repair; repeat repairs have reasonable success
rates but not well quantified; higher failure rate after 2 procedures
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| Surgical management of rectovaginal fistulae: retrospective chart review—28 had persistent fistulae, largely
secondary to obstetric injury; most healed; when complex fistulae reviewed, only 40% healed; 17 patients underwent 23
advancement flaps; sphincter repair successful in 86%; coloanal anastomosis in 67%; graciloplasty worked well; difficult
to manage persistent rectovaginal fistula; operation tailored to underlying pathology; advancement flap not preferred
treatment; study—57 procedures performed in 35 women with recurrent rectovaginal fistulae; obstetric problems often
main cause, followed by Crohn’s disease; repair tended to be advancement flap, followed by sphincter repair; no muscle
transpositions in series; healing still possible even after 5 repairs; after median of 2 more operations, 79% healed, and delayed
repair (≥3 mo) thought to improve outcome; study—persistent and recurrent fistulae; 14 of 16 patients had previous
attempted repairs (mean of almost 3 previous repairs); almost all patients without Crohn’s disease healed; in those
with Crohn’s disease, just over 50% initially healed, with some requiring more operations; success rate for those with
Crohn’s disease, 1 in 3 (mean of almost 3 previous repairs)
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| Rectourethral fistulae: most patients have undergone external beam radiation therapy, brachytherapy with seeds, prostatectomy,
or robotic prostatectomy; other etiologies include Crohn’s disease; management—similar to rectovaginal fistula
with diversion (generally laparoscopic) plus, unlike rectovaginal fistulae, urinary diversion (bladder or suprapubic
catheter, depending on how well bladder catheter drains area); repairs include transabdominal, transanal, perineal, Kraske
approach, transanal endoscopic microsurgery (TEM; possible role), or simply excision (cystectomy and ileal conduit)
with permanent fecal diversion; if performing transabdominal repair, probably necessary to perform sleeve pull-through
as coloanal anastomosis with omental interposition (if any omentum left) or transanal repair with closure of urethral defect;
speaker favors perineal approach of interposition of healthy muscle using gracilis muscle; study by Rabau—10 patients
(6 women) with rectovaginal or rectourethral fistulae treated with graciloplasty; 3 of 4 men developed fistulae after
radical prostatectomy; 5 of 6 women had radiotherapy or Crohn’s disease; success rate 90%; fecal and urinary diversion
should be initial management in patients with recurrent rectovaginal and rectourethral fistulae, followed by graciloplasty
(success rate ≈90% and morbidity low); better results after radiation (worse after Crohn’s disease)
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| AN ALGORITHM FOR THE MANAGEMENT OF ANAL FISSURES —Dr. Beart
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| Etiology: somewhat obscure; anal trauma implied; also associated with diarrhea; anatomic considerations—
decussation of sphincter muscle posteriorly thought to result in relatively weak area (subjected to trauma more easily,
with poor healing); patients with high anal tone also thought more likely to have anal fissures; suspected that blood flow
poor, particularly posteriorly in midline (predisposes to poor healing and infection); unclear why patients develop sentinel
piles and hypertrophy of anal papillae; more common in men; ≈90% of time, occurs in posterior midline; does not occur
off midline; not caused by diet
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| Diagnosis: important not to cause pain; spreading of anal cheeks with patient in knee-chest position allows visualization
of fissure in >80% of cases; if unable to visualize, diagnosis made by rectal examination; applying pressure on anal canal
anteriorly while inserting well lubricated finger minimizes pain; if irregularity in midline (anteriorly or posteriorly) felt
without mass effect, diagnosis certain; lesion off midline considered ulcer; culture atypical ulcers or fissures for bacteria
and viruses; look for actinomycosis, tuberculosis, herpes, and Chlamydia; also suspect immunologic causes, eg, HIV
(atypical ulcer first presentation in 15% of patients with HIV)
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| Treatment: historically, surgical therapy; acute fissure defined as present for few weeks; chronic anal fissure—present
≥3 mo; traditionally treated conservatively (eg, change in diet, topical agents); treatment usually fails and surgery required;
alternatives include open fissurectomy and closed lateral internal sphincterotomy (LIS); long-term anal
incontinence—rare; seen after LIS; characterized by anal seepage; usually responds to repair of LIS; recurrence rates for
fissure low after LIS; complications include bleeding and abscesses, but usually not major long-term problems; study
found incontinent patients tend to have bigger sphincterotomy, and muscles tended to pull more widely apart after
sphincterotomy; nonsurgical alternatives—medical sphincterotomy designed to lower sphincter pressures and allow
fissure to heal; includes nitroglycerin, nifedipine, calcium channel blockers, and botulinum toxin type A (Botox); symptomatic
relief occurs within days; algorithm—for truly chronic anal fissure (>3 mo), topical nitroglycerin cream or diltiazem;
if relief achieved in 2 wk, treat for total of 12 wk to have substantial healing of fissure; if unsuccessful with
nitroglycerin, give 20 U Botox on each side of anal fissure; if pain relief present at 2 wk, continue to observe; if no relief,
surgery (fissurectomy or LIS)
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| SURGICAL TREATMENT OF RECTAL PROLAPSE —Sonia Ramamoorthy, MD, Assistant Professor of Surgery, University
of California, San Diego, School of Medicine, UCSD Medical Center
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| Definition: full-thickness prolapse of circumferential rectal tissue through anus; mucosal prolapse—involves hemorrhoidal
or redundant mucosal tissue through anus; partial or complete; lacks circular muscle of rectum; internal
intussusception—diagnosis made on defecography; rectal prolapse occurs within pelvis (no extrusion of tissue through
anus); also diagnosed by endoscopy (may find solitary rectal ulcer)
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| Epidemiology: not entirely known in United States; predominance in men to women 10:1; majority >50 yr of age; >50%
of patients complain of constipation or some form of obstructive defecation; 40% to 60% complain of fecal incontinence;
20% to 30% associated with pelvic organ prolapse (obtain defecography; often see, eg, cystocele, vaginal prolapse); associated
with adults and children with cognitive disorders (eg, autism, Asperger’s syndrome, cystic fibrosis); historically
thought mental illness; more modern etiologies for rectal prolapse include pelvic floor disorders (some believe actually
sliding hernia through defect in pelvic fascia); high recurrence rates; initially, symptoms begin with obstructive defecation
(constipation), leading to internal intussusception (worsening obstructive defecation); pain and blood in stools, with
solitary rectal ulcer syndrome on sigmoidoscopy; some eventually develop rectal prolapse (first described as anal lump,
leading to progressive incontinence as rectum stays extruded outside anal canal); long term, causes pudendal nerve damage
(demonstrated on manometry studies); patients also experience blood per rectum, mucosal discharge, and if left untreated,
permanent pelvic floor damage
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| Diagnosis: obtain good history of bowel habits, protrusion of tissue, amount of tissue extruded, whether it spontaneously
reduces, duration of symptoms (longer duration of prolapse leads to reduced likelihood of improvement of incontinence),
and presence of incontinence; on physical examination, flat perineum, patulous anus, and lax sphincter seen; may often
prolapse with straining in clinic; defecography—radiolucent toilets; barium paste injected into rectum; patient asked to
strain; other diagnoses made as well, eg, if oral contrast added, can diagnose enterocele, with contrast to bladder, cystocele;
anal manometry and ultrasonography (US)—performed as needed; for incontinent patients, anal manometry
helps to determine whether long-term damage to nerves present; speaker performs US if woman had traumatic delivery
with sphincter injury and rectal prolapse; if patient >50 yr of age, colonoscopy indicated to ensure no other reason for constipation
or blood per rectum; defecography can demonstrate prolapse, internal intussuception, and other organ prolapses;
reduced internal and external pressures common in rectal prolapse; usually prolonged pudendal nerve latencies observed
(questionable whether improvement seen after repair of prolapse); commonly recto-anal inhibitory reflex absent
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| Surgical management: perineal procedure (eg, Altemeier procedure, Delorme repair, Thiersch wire)—
uncommon; performed when abdominal procedure contraindicated (eg, debilitated high-risk patient); low morbidity;
performed under regional block; short hospital stay; can be repeated; disadvantages include high recurrence rates and perianal
pain; Altemeier procedure—involves prolapsing rectum, division of tissue ≈3 cm above dentate line, and resection
without tension (pulling rectum and sigmoid down as far as possible, with adequate tension); can perform
levatorplasty; Delorme procedure—technically more difficult than Altemeier and less commonly performed; some
submucosal stripping and plication of circular muscle (adds more strength to sphincter and helps symptoms); abdominal
procedures—advantages include lower recurrence rates; in low anterior resection or resection rectopexy, address constipation
by removing part of sigmoid; usually medical therapy added to rectopexy to alleviate risk for recurrence and
straining; performed laparoscopically or robotically; disadvantages include related complications and less improvement
in incontinence; rectopexy involves rectal mobilization, plus or minus division of lateral ligaments; advantages include
reduced hospital stay, early mobilization, less pain, minimal invasiveness, earlier return of bowel function, and lower
cost; outcomes with open rectopexy and laparoscopic rectopexy similar; slightly higher complication rate with mesh repair;
resection rectopexy—low anterior resection with addition of posterior fixation with sutures; treats constipation and
prolapse in theory; recommended for otherwise healthy patients; recurrence rate even lower than with rectopexy alone;
low rate of complications; sexual dysfunction complication, particularly in men; infection leak rate added; increased morbidity
with repeated abdominal procedures (concern about blood supply); recurrence leads to more recurrence
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Suggested Reading
Brisinda G et al: Randomized clinical trial comparing botulinum toxin injections with 0.2 percent nitroglycerin ointment
for chronic anal fissure. Br J Surg 94:162, 2007; Brown AJ et al: Prospective study of the effect of rectopexy on
colonic motility in patients with rectal prolapse. Br J Surg 92:1417, 2005; D'Hoore A et al: Long-term outcome of laparoscopic
ventral rectopexy for total rectal prolapse. Br J Surg 91:1500, 2004; Gupta PJ: Internal anal sphincterolysis
for chronic anal fissure: a prospective, clinical, and manometric study. Am J Surg 194:13, 2007; Hahnloser D et al:
Curative potential of multimodality therapy for locally recurrent rectal cancer. Ann Surg 237:502, 2003; Hetzer FH et
al: MR defecography in patients with fecal incontinence: imaging findings and their effect on surgical management. Radiology
240:449, 2006; Epub 2006 Jun 26. Kosugi C et al: Rectovaginal fistulas after rectal cancer surgery: Incidence and
operative repair by gluteal-fold flap repair. Surgery 137:329, 2005; Lane BR et al: Management of radiotherapy induced
rectourethral fistula. J Urol 175:1382, 2006; Lindsey I et al: Chronic anal fissure. Br J Surg 91:270, 2004;
Madiba TE et al: Surgical management of rectal prolapse. Arch Surg 140:63, 2005; Patel S et al: Appearance of the
rectum on barium enema examination after the Delorme procedure. AJR Am J Roentgenol 188:W396, 2007; Rex DK et
al: Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and
US Multi-Society Task Force on Colorectal Cancer. CA Cancer J Clin 56:160, 2006; Salkeld G et al: Economic impact
of laparoscopic versus open abdominal rectopexy. Br J Surg 91:1188, 2004; Singh B et al: Perianal Crohn's disease. Br
J Surg 91:801, 2004; Slawson D: Topical nifedipine plus lidocaine gel effective for anal fissures. Am Fam Physician
67:1781, 2003; Titu LV et al: Routine follow-up by magnetic resonance imaging does not improve detection of resectable
local recurrences from colorectal cancer. Ann Surg 243:348, 2006; Zmora O et al: Gracilis muscle transposition for
iatrogenic rectourethral fistula. Ann Surg 237:483, 2003.
Educational Objectives
| The goal of this program is to improve the surgical management of recurrent rectal cancer, persistent rectovaginal
and rectourethral fistulae, anal fissures, and rectal prolapse. After hearing and assimilating this program, the
clinician will be better able to:
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 | 1. Demonstrate the value of follow-up in managing patients with colorectal cancer.
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| 2. Review the surgical options for management of persistent rectovaginal and rectourethral fistulae.
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| 3. Describe the surgical and nonsurgical alternatives in treatment of anal fissures.
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| 4. Utilize various tests to diagnose rectal prolapse.
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| 5. Differentiate the various perineal and abdominal procedures for managing rectal prolapse.
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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.
Acknowledgments
Drs. Beart and Wexner were recorded at the 18th Annual International Colorectal Disease Symposium, held
February 15-17, 2007, in Fort Lauderdale, FL, and sponsored by Cleveland Clinic, FL. 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 University of California, San Diego, School of Medicine,
Department of Surgery. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
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