GI Surgery

Educational Objectives

The goals of this program are to improve the management of complex anal fistulas and gastroesophageal reflux dis­ease (GERD), and to ensure appropriate utilization of mechanical bowel preparation for elective colorectal surgery. After hearing and assimilating this program, the clinician will be better able to:

1.   Distinguish between simple and complex fistulas.

2.   Describe techniques for the management of complex fistulas and determine their appropriate use.

3.   Identify instances in which mechanical bowel preparation for colorectal surgery is appropriate.

4.   Describe the efficacy of new techniques in the surgical management of GERD.

5.   Explain the appropriate use of pH monitoring of patients with GERD.

Faculty Disclosure

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 following has been disclosed: Dr. Stamos is an adviser for Covidien, Ethicon, and Olympus and has received fellowship grants from Co­vidien and Ethicon.  Drs. Sternberg and Easter and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Sternberg was recorded at Postgraduate Course in General Surgery, held March 27-29, 2008, in San Francisco, CA, and sponsored by the University of California, San Francisco, School of Medicine, Department of Surgery. Drs. Stamos and Easter were recorded at the Kaiser Permanente 4th Annual National Surgical Symposium, held April 2-4, 2008, in Ojai, CA, and sponsored by Kaiser Perma-nente. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Complex Fistula-in-Ano: To Clog or Cloak?

Jeffrey A. Sternberg, MD, Surgical Director, Center for Inflammatory Bowel Diseases, Department of Colon and Rectal Surgery, California Pacific Medical Center, San Francisco, CA

Classification of fistulas: Parks classification  —  most commonly used; based on relationship of fistula tract to anal sphincter muscles; fistula starts as intersphincteric abscess between internal sphincter muscle and external sphinc­ter muscle; generally formed from cryptoglandular infection; simple fistulas  —intersphincteric (expressed directly to perianal skin through intersphincteric groove) or low transsphincteric (go through external sphincter muscle); complex fistulas  —  high transsphincteric fistula; suprasphincteric fistula (above external sphincter muscle); iatro­genic or traumatic fistula  —   extrasphincteric fistula, caused by penetration of rectal wall through to perianal skin

Goals of treatment: drain infection; eradicate fistula and preserve continence; control symptoms; key to success identification of primary opening (difficult and challenging, even for experienced surgeon); mistaken identification of internal opening and false passage of fistula probe most common cause of fistulas; no single technique appropri­ate for treatment of all fistulas; issues to consider  —  type of fistula, amount of muscle involved, and willingness of patient to tolerate alteration in continence; fistulotomy gold standard of treatment, but has significant risk for im­pairment of continence, even with simple fistulas

Management: complexity refers to type of management required, not necessarily anatomy; higher risk for impair­ment of continence if fistulotomy performed; anterior fistulas in women  —  women have thinner anterior sphincter muscles subject to  injury during childbirth; other complex fistulas  —  those with multiple tracts;  patients with pre­vious fistula surgery; those with preexisting incontinence in fistula; history of inflammatory bowel disease; history of irradiation for prostate or anal cancer; if external opening far from anal verge, consider complex fistula; addi­tional studies performed only when internal opening not located; division of approximately one-third to one-half of external sphincter results in some functional deficit; easy to underestimate extent of external sphincter cut because many tracts pass obliquely upward from internal opening

Surgical techniques: fistulotomy of complex fistulas does not yield better results than primary fistulotomy;  speaker’s practice to perform sphincter-sparing techniques (eg, fibrin glue advancement flap, anal fistula plug, long-term draining seton) for complex fistulas; procedures best performed after infection eradicated; initially managed with draining seton (controls sepsis); secondary tract opened and allowed to heal, and long primary tract shortened

Fibrin glue: easy to apply; minimal trauma and discomfort; long-term studies poor, and demonstrate significant variability in efficacy; no benefit with addition of antibiotics to sealant; studies report only 14% healing rate; low morbidity; because of simplicity, considered first-line treatment

Endorectal advancement flap: “u”-shaped incision in anoderm distal to fistula, extending up into proximal rectum; includes inner table of internal sphincter muscle on circular fibers of rectal wall; twice as wide at base as at tip; covers internal opening, with no complete division of sphincter mechanism; technically more difficult than fibrin glue injection; like fibrin glue, repeatable; healing rates 60% to 85%; incontinence still reported; peculiar in de­velopment of mucosal ectropion in many patients (mucus-secreting rectal mucosa present at anal verge after pro­cedure); not ideal in active Crohn’s disease (CD), in patients previously irradiated, and those with large rectovaginal fistulas; necessary that fistulas mature; unclear whether additional fibrin sealant beneficial; possible reasons for incontinence  —retraction during procedure, seepage from ectropion, or thinning of internal sphincter muscle

Anal fistula plug: made from freeze-dried pig intestine that serves as scaffold for connective tissue ingrowth; initial study showed 85% closure rate; simple to perform; low morbidity; minimal pain associated with procedure; min­imal risk; no risk for incontinence; tremendous variability in data (healing rate ranges from 14%-80%); median follow-up 5 mo, with healing rate of 56%; not for simple fistulas; consensus of practitioners  — perform only in mature tracts without inflammation, with or without bowel preparation; exercise caution with choice of tract irri­gant; only gentle debridement for tract; should be sutured to internal sphincter; if plug extruded within 1 wk, pro­cedure considered failure; external opening kept open for drainage; patient should not strain or engage in sexual activity for several weeks after procedure (arbitrary recommendation); requires few months to determine effi­cacy; often have intermittent serous drainage from external opening (not indicative of failure); success rate should reach 50%; conclusions  —  short-term results acceptable; requires long-term studies and trials comparing plug to flap

Long-term draining seton: therapeutic strategy in its own right; ideal choice for patients with CD, preexisting in­continence, diarrhea, previous irradiation, and in women planning future pregnancy; problems seen in one-third of patients

Speaker’s approach: offers luer plug to patients (little disadvantage); repeat luer plug or perform flap procedure if first plug fails; if second luer plug fails, flap or long-term draining seton recommended; in CD  —  fistulotomy for superficial fistulas only; long-term draining seton excellent choice; flap procedure only if no proctitis; if fistula asymptomatic and patient medically well-managed, only observation necessary

Bowel Preparation for Elective Colorectal Surgery: Helpful or Harmful?

Michael J. Stamos, MD, Professor of Surgery, and Vice Chair, Clinical Affairs, Department of Surgery, Univer­sity of California, Irvine, School of Medicine

Introduction: bowel preparation  —  standard for 2 decades; most common preparations include sodium biphosphate and sodium phosphate (Fleet phospho-soda), biphosphate and sodium phosphate with oral antibiotics, and polyeth­ylene glycol (PEG; GoLYTELY) with or without antibiotics; no commonly accepted standard; in perforated diver­ticulitis (Hinchey stages I, II, and III), can perform primary anastomosis without diversion; in trauma, routine to perform primary colonic repair or primary colocolonic anastomosis in unprepped bowel

Advantages: decreases fecal flora burden; easier to palpate and visualize  small intraluminal tumors (tattooing not al­ways reliable); decreases proximal fecal load; may reduce risk for septic complications (controversial)

Disadvantages: poorly tolerated by many patients; creates electrolyte imbalances; theoretic and animal models show increased translocation of bacteria due to bowel preparation; may increase intraoperative fecal spillage (solid stools less likely to leak); removes fuel substrate for colonocytes; recent studies show increased complication rates with bowel preparations

Antibiotics: oral  —  erythromycin, neomycin, or metronidazole (Flagyl); erythromycin (macrolide antibiotic) has po­tential for significant side effects; neomycin has more side effects, especially nausea and vomiting; dizziness, gas­trointestinal (GI) pain, nausea, and vomiting fairly common with metronidazole; parenteral  —  becoming standard; ideally given within 30 min of incision; many surgeons using single-drug therapy; based on recent data, ertapenem possibly optimal drug; approved by Surgical Care Improvement Program (SCIP) as one of treatment choices; long half-life; unclear whether advances in intravenous (IV) antibiotics negate need for bowel preparation

Literature: recent studies, athough inadequate in size, suggested fewer complications in those who received no me­chanical bowel preparation; meta-analysis  —  from Cochrane Database; studies had methodologic flaws, but all show trend toward better outcome when mechanical bowel preparation omitted; also suggest, to almost statistically significant level, lower leak rates without mechanical bowel preparations; lower wound infection rate also noted, athough not statistically significant; no difference in mortality rates; conclusions  —no proven value of prophylactic mechanical bowel preparation before colorectal surgery; controversely, may lead to more anastomotic leakage; other meta-analyses came to same conclusions; recent randomized controlled trials   (RTCs) —Swedish study of elective colon resection and Netherlands study of elective colorectal surgery concluded surgery performed safely without mechanical bowel preparation

Speaker’s conclusions:  both studies separated leak rate from abscess rate; by combining data, leak and abscess rates increase from <5% to 7.2%; speaker believes strong indications remain for necessity of bowel preparations, eg, in laparoscopy, with small, difficult-to-palpate lesions, and in rectal surgery; recommends continued use of mechani­cal bowel preparation, except in selected patients in whom risk outweighs benefit (eg, colectomy in patient with congestive heart failure; in renal failure); biphosphate and sodium phosphate recommended if tolerated (lower leak and abscess rates, compared to PEG)

What’s New in Gerd Therapy

David W. Easter, MD, Professor of Surgery, University of California, San Diego, School of Medicine

Radiofrequency ablation (RFA): less than ideal, but promising option for treatment of gastroesophageal reflux dis­ease (GERD); not tested in RCTs; speaker skeptical about its use at esophagogastric (EG) junction

Endoluminal procedures: hybrid technique; endoluminal augmentation of lower esophageal sphincter (LES) or en­doluminal suturing to achieve same principles as procedures performed extraluminally, laparoscopically, or at open surgery

Laparoscopic Nissen fundoplication: standard treatment; adopted with rigorous controlled studies; done identically to open procedure; less trauma and pain; study of database of laparoscopic antireflux surgery (mostly Nissen)  —  improved heartburn in 90% of participants (resolved in 67%) and regurgitation improved in 97% (77% resolved); less favorable results for dysphagia, cough, and hoarseness; 10% required resumption of proton pump inhibitors (PPIs); 40% required antacids intermittently; 3% required reoperation; young men with dysphagia had best results; RCT  —compared fundoplication to PPIs; found LES pressures improved with fundoplication, but not with PPIs; DeMeester score for acid exposure and GI symptom rating scale better at 12 mo with fundoplication; no difference in patient satisfaction; fewer GERD symptoms and better quality of life reported with fundoplication vs PPIs; fun­doplication more expensive at 1 yr; however, cost of medical therapy continues to increase over lifetime; crossover of medical and surgical therapy costs at »6 yr

New techniques: useful with atypical symptoms of GERD, including globus hystericus, hoarseness, and cough; pH testing does not correlate with symptoms; impedance manometry  —when combined with 24-hr pH test, diagnostic rate increased by 61%; capsule endoscopy  —  not acceptable for surveillance (detecting Barret’s esophagus [BE]); robotic procedures  —  found acceptable in one pediatric study; learning curve short and steep; speaker believes pos­sibly useful for paraesophageal hernias, but not for fundoplication; speaker’s recommendations  —  if considering fundoplication, ensure that esophagitis not present; if present, biopsy for BE or high-grade dysplasia (carcinoma in situ); latter requires esophagectomy rather than fundoplication; determine whether patient’s symptoms match acid exposure; if match present, 90% of patients improve; if no match, limiting acid exposure may not improve symp­toms; if acid exposure picture confusing, consider impedance manometry; speaker prefers performing motility studies and manometry on all patients; abnormal stomach emptying (eg, diabetic patient) may necessitate motility agent (not fundoplication); endoluminal procedures  —  development driven by possibly incorrect description of how LES works and concept of transient LES relaxations; study of patients with known GERD and those with hia­tal hernias found more acid exposure with hiatal hernia, but no difference seen in transient relaxations

Approaches for augmenting LES: Stretta RFA treatment  —resulted in better heartburn scores than sham, although acid exposure same; similar study found 61% of patients heartburn-free initially when Stretta procedure used, but found no difference in PPI usage and acid exposure at 6 mo; speaker concludes that Stretta procedure and pla­cebo give comparable benefit; collagen injections  —  absorbed; no lasting effect in dogs or humans; silicone injections  —absorbed; polymer injections  —  also absorbed; led to punctures of aorta, and taken off market; hy­drogel prosthesis  —  not absorbed, but transient benefit, so no longer on market; magnets  —  in pig models, de­crease transient relaxations; improve LES pressures; stronger magnets resulted in better pressures; crossover point in costs for augmentation vs medication approaches 4 to 5 yr, but results not long-lasting, procedures ex­pensive, and reinstatement of PPIs required

Gastroplasty: allows upward suction of tissue in flexible endoscope channel; some studies show depth attained only at mucosa or submucosa (requires deeper bites to catch and plicate); later models better and capable of achieving full-thickness plications; study showed that at 5 yr, 20 of 30 patients off PPIs; no adverse effects; may prove more economical than PPIs

Endoluminal fundoplication: creates internal ridge of tissue and valve; study at 12 mo showed 82% of patients off PPIs and 63% had normal pH studies; RCTs needed

Hybrid technique: peg-type incision; trocar placed through stomach and suture within stomach using endoscope, with visual control through laparoscope; no data yet

Full-thickness plication device: allows for full-thickness suture capability without laparoscope

Obesity: obese patients have more complications after fundoplication, with recurrence rates of £40%; BE correlates with abdominal girth; continuous positive airway pressure (CPAP) improves LES pressure; stimulation (pace­maker-type device) of stomach improves LES symptoms in obese patients (due to clearance of acid in stomach and transient LES increase of baseline pressure)

Suggested Reading

Bretagnol F et al: Rectal cancer surgery without mechanical bowel preparation. Br J Surg 94:1266, 2007; Bucher P et al: Ran­domized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery. Br J Surg 92:409, 2005; Erratum in Br J Surg 92:1051, 2005; Contant CM et al: Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial. Lancet 22;370, 2007; Erratum in Lancet 17;371, 2008; Csendes A: Re: does Barrett's esophagus impact outcome after laparoscopic Nissen fundoplication?. Am J Surg 196:618, 2008; Gee DW et al: Measuring the effectiveness of laparoscopic antireflux surgery: long-term results. Arch Surg 143:482, 2008; Itani KM et al: Polyethylene glycol versus sodium phosphate mechanical bowel preparation in elective colorectal surgery. Am J Surg 193:190, 2007; Jacobson BC et al: The skinny on obesity and reflux. Gastroenterology 130:1925, 2006; Jeansonne LO 4th et al: Endoluminal full-thickness pli­cation and radiofrequency treatments for GERD: an outcomes comparison. Arch Surg 144:19, 2009; Kelly JJ et al: Laparoscopic Nissen fundoplication: clinical outcomes at 10 years. J Am Coll Surg 205:570, 2007; Ortiz H et al: Length of follow-up after fis­tulotomy and fistulectomy associated with endorectal advancement flap repair for fistula in ano. Br J Surg 95:484, 2008; Perez F et al: Randomized clinical and manometric study of advancement flap versus fistulotomy with sphincter reconstruction in the management of complex fistula-in-ano. Am J Surg 192:34, 2006; Ram E et al: Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch Surg 140:285, 2005; Rantanen TK et al: Complications in antire­flux surgery: national-based analysis of laparoscopic and open fundoplications. Arch Surg 143:359, 2008; Vatansev C et al: A new seton type for the treatment of anal fistula. Dig Dis Sci 52:1920, 2007.