Colorectal and Pancreatic Surgery

From the Postgraduate Course in General Surgery, sponsored by the University of California, San Francisco, School of Medicine, March 19-21, 2009

Educational Objectives

The goal of this program is to improve the management of ulcerative colitis and pancreatic cancer. After hearing and assimilating this program, the clinician will be better able to:

1.   Distinguish between appropriate surgical choices for emergency and elective surgery for ulcerative colitis.

2.   Describe the advantages and disadvantages of the ileal pouch and total proctocolectomy.

3.   Discuss variables related to ileostomy surgery, including patient age, pouch creation techniques, and laparo­scopic vs open surgery.

4.   Recognize the long-term morbidities associated with the ileal pouch, including pouchitis, bowel obstruction, and sexual dysfunction.

5.   Explain why early surgery is indicated for pancreatic cancer.

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 faculty and plan­ning committee reported nothing to disclose.

Acknowledgements

Drs. Varma and Kirkwood were recorded at the Postgraduate Course in General Surgery, held March 19-21, 2009, in San Francisco, CA, and sponsored by the University of California, San Francisco, School of Medicine. The Audio-Digest Foun­dation thanks the speakers and the UCSF School of Medicine for their cooperation in the production of this program.

Ulcerative Colitis: Surgical Indications and Controversies

Madhulika G. Varma, MD, Associate Professor of Surgery and Chief, Section of Colorectal Surgery, University of California, San Francisco, School of Medicine

Background: 25% to 30% of patients with ulcerative colitis (UC) require surgery, most commonly for treatment of complications or inadequate disease control; complicating factors include multiple choices of surgery and whether surgery emergency or elective; main goals of surgery eradication of colon and rectal disease and preservation of natural bowel function, if possible

Choice of surgery: urgent or emergent setting  —  patient already hospitalized, has received high-dose steroids or other immunomodulating therapies, and not responding due to bloody diarrhea, severe abdominal pain, or toxic­ity (toxic megacolon); little time for counseling patients; total abdominal colectomy indicated; remove bulk of disease by removing abdominal colon, leaving rectal stump, and creating ileostomy; elective setting  —  total proc­tocolectomy indicated; patients may have toxic colitis without toxic megacolon

Symptom severity: mild  —  normal hemodynamics and pulse; <4 stools per day; intermittent bloody stools; fulmi­nant (patient hospitalized)  —  >10 bloody stools per day; fever, tachycardia, colonic dilatation or toxic megaco­lon; may require transfusion

Elective surgery: indications include partial response to medication (interferes with normal function); severe food restrictions; chronic disability due to abdominal pain or diarrhea; inability to taper from steroids, or unacceptable side effects from other medications; gradual loss of medication efficacy; increased risk for dysplasia or colorectal cancer in patient with otherwise well-controlled, longstanding disease

Surveillance colonoscopy for UC patients: involves ³48 biopsies; risk for colorectal cancer increases when UC has persisted >10 yr; low-grade dysplasia associated with 10% risk for colorectal cancer; high-grade dysplasia asso­ciated with risk of 30% to 40%; with dysplasia-associated lesion or mass, risk >50%

Other reasons for considering surgery: strictures (could be cancer) or extensive pseudopolyposis; consider possibil­ity of Crohn’s disease

Reconstructive options: end ileostomy or ileal or J pouch

Total proctocolectomy: removal of entire colon and anus, with permanent end ileostomy; advantages include com­plete removal of disease and cancer risk, and complete alleviation of problems associated with bowel function; disadvantages include permanent end ileostomy, with associated stoma, psychologic (body image) and quality-of-life issues; best candidates include older patients, individuals with distal rectal cancer, or those with desire for only one operation

Koch pouch (continent ileostomy): developed in 1970s; reservoir created from end of small intestine, nipple valve inserted, and stoma brought flush with skin; patient intubates pouch to drain stool; requires no appliance and does not change body contour; advantages  —  all disease removed without need for stoma bag; disadvantages  —valve slippage and subsequent leakage; pouchitis due to stool stasis; obstructions, fistulas, and retractions, with need for revision; problems with intubation; in study conducted in 2006, 22% of patients ultimately needed pouches excised; warn patients of issues involved

Ileal pouch anal anastomosis (IPAA): currently most popular surgical option; involves removal of colon and rectum down to dentate line; pouch constructed from terminal ileum and connected to anus; proximal diverting loop il­eostomy then performed; main advantage  —  patient can defecate normally through anus; disadvantages  —  preservation of some dentate line and anus, with potential for residual disease or dysplasia and cancer; multi­ple loose stools; skin irritation; incontinence; waking during night to defecate; dietary restrictions to modulate bowel movements; poor candidates include those with pre-existing fecal incontinence or need for emergency surgery (abdominal colectomy with subsequent second-stage proctectomy with pouch creation may be appro­priate)

Controversies associated with ileal pouch

Age: in Cleveland Clinic study, older patients (>65 yr) had more problems with pelvic floor function and greater incidence of incontinence and night seepage; these patients report significantly lower quality of life than those in younger age groups

Staple or sew: stapled anastomosis permits creation of rectal stump, with preservation of tissue; hand sewing al­lows surgeon to strip off rectal mucosa and create anastomosis (may be helpful for patients with familial ade­nomatous polyposis); stapling technically easier, associated with better function, less incontinence, better sampling reflex, and fewer complications; hand sewing associated with higher rates of abscess, leakage, steno­sis, and eventual pouch removal; in meta-analysis of 21 studies involving 4183 patients, hand-sewn anastomo­sis associated with significantly higher risk for pouch failure, night seepage, night pad use and incontinence, and lower sphincter pressure; disadvantages of stapling  —  potential for dysplasia in residual rectal cuff (in study, actual risk small [0%-4.5% at 10 yr]; authors concluded intensive checkups unnecessary unless cancer or dysplasia present within 8 cm of dentate line); cuffitis (persistent or recurrent inflammation in cuff; occurs in 9%-22% of patients, especially if cuff >1 cm; hard to re-resect [may require hand-sewn anastomosis])

Laparoscopic or open surgery: in study of 11 trials involving 607 patients, of whom 253 (41%) had laparoscopic surgery, total complication rates similar; laparoscopic surgery associated with longer operative time but more favorable incision length, shorter hospital stay, and better cosmesis scores; emergency surgery  —  in 2001 study, no difference in complication rates or length of stay with laparoscopic vs open surgery; laparoscopy for emergency surgery now standard; operation usually lasts 3 to 4 hr (but may be as long as 6 -7 hr); if necessary, colon can be extracted through stoma site; patient can avoid longer recovery associated with incision; hand-as­sisted procedure saves time; patients often return to work within 2 to 4 wk, compared to >6 wk with open pro­cedure

Necessity of ileostomy with ileal pouch anastomoses: question arose with advent of double-stapling technique; complication rate associated with ileostomy as high as 30% in some series; pouch leak rate similar with and without ileostomy (5%-15%); arguments for performing ileostomy  —  decreases risk for pelvic infection if leak does occur; also decreases risk for abscess, peritonitis, and need for reoperation; helps maintain pouch func­tion; arguments against performing ileostomy  —patient avoids second procedure and hospitalization, as well as complications of ileostomy; may also avoid bowel obstruction; candidates for ileal pouch anastomosis with­out ileostomy  —  patients in good health (not hospitalized, good nutritional status, not on long-term steroid therapy); reserve option to do ileostomy if surgery leaves patient at risk for leakage

Long-term morbidity associated with ileal pouch: pouchitis  —  »40% of patients develop pouchitis over 10 yr; of­ten misdiagnosed (patient may actually have irritable pouch syndrome, Crohn’s disease, or cuffitis); bowel obstruction  —  cumulative probability 19% over 10 yr; 33% of those patients required laparotomy, »20% of whom had further episodes of small bowel obstruction; obstruction associated with pouch revisions and loop ileostomy; sexual dysfunction  —  few prospective studies; in one study of 122 men, ileal-pouch anal anastomo­sis associated with better sexual function and improved satisfaction (less improvement seen in older patients); in separate study of 1454 men, improvement in sex life reported in 25%, no effect of surgery in 56%, severely restricted sex life in 3%, and retrograde ejaculation in 3%; in review of 22 studies involving 1852 women, 25% reported postoperative sexual dysfunction, compared to 8% preoperatively; in unrelated study, women who un­derwent pouch procedure had lower rate of successful natural pregnancy, compared to women with UC who had not had surgery; pregnancy successfully achieved in surgical patients with assisted fertility; cesarean deliv­ery indicated only for obstetric reasons (pouch procedure does not rule out natural childbirth); no hard data confirm that cesarean delivery prevents future pouch dysfunction; long-term data (>10 yr)  —  in Cleveland Clinic study of 997 patients, pouch excision rate 3%; 82% of patients reported perfect continence; 98% said they would recommend surgery to others or have procedure again; 33% of patients reported functional deterio­ration over time; risk for incontinence, pouchitis, and pouch failure increased with length of follow-up; pouch failure  —  pouch excision rate increases with time; current long-term rates 5% to 10%; common causes include early postoperative complications, poor pouch function over time, and subsequent diagnosis of Crohn’s dis­ease; pouch excision associated with high rate of perineal wounds

Pancreatic Cancer

Kimberly S. Kirkwood, MD, Professor of Surgery, University of California, San Francisco, School of Medicine

Case histories: first patient  —  75-yr-old woman, asymptomatic, undergoing surveillance imaging for history of colon cancer; had 1-cm mass in body of pancreas; underwent distal pancreatectomy and en bloc splenectomy for node-negative pancreatic ductal adenocarcinoma; returned home 8 days later and returned to work <3 wk postopera­tively; patient identified as Ruth Bader Ginsburg (had access to best possible care); second patient  —  41-yr-old woman presented with epigastric discomfort; after several months of treatment with proton pump inhibitors, under­went computed tomography (CT) which showed 5 by 7-cm mass in head of pancreas, with 180^o contact on superior mesenteric vein (SMV); fine needle aspiration biopsy showed adenocarcinoma; patient told tumor unresectable, given poor prognosis; presented to University of California, San Francisco (UCSF); repeat imaging studies showed heterogeneous mass in head of pancreas; clear celiac access on arterial phase; coronal reconstructions of arterial and venous phases showed portal vein entering liver “looked just fine”; duodenum showed large mass in pancreatic head; 180^o of contact at confluence of splenic vein and SMV, but no invasion or thrombosis; SMV below tumor, portal vein above; tumor judged borderline resectable, probably mucinocystadenocarcinoma; no metastases seen on positron emission tomography; made new treatment plan to perform diagnostic laparoscopy during resection sur­gery; resection to include short-segment SMV reconstruction; only one wall at confluence needed removal; venor­rhaphy performed with 20% narrowing; pathology report indicated mucinocystadenocarcinoma with negative margins, and with 1 of 15 lymph nodes positive by direct invasion off superior portion of tumor; patient discharged on postoperative day 8, with no evidence of disease 2.5 yr after surgery

Study on failure to resect early-stage pancreatic cancer: authors reviewed National Cancer Database data from 1995-2004 on nearly 10,000 patients with clinical stage 1 tumors (T1 and T2 lesions confined to gland, with no evidence of lymph node invasion or spread elsewhere); 71.4% of patients did not undergo surgery; 4.2% refused operation; 9.1% excluded due to age; among patients who underwent surgery, 96% had resectable disease; sur­gery dramatically improved survival; among patients not resected, mortality after 2 to 3 yr similar to that associ­ated with more advanced disease; only 5-yr survivors patients who underwent resection; surgery only curative therapy for this population

Characteristics of patients not offered surgery: average age 72 yr, compared to 65 yr among patients offered sur­gery; lower comorbidity scores; tumors mostly at head of pancreas; patients more likely to be black, have lower annual household incomes and lower educational level, and have Medicaid or Medicare rather than private insur­ance; in UCSF study of California during same period, only 37% of patients with localized tumors underwent re­section; those patients also more likely to be black and of lower socioeconomic status; resection associated with median survival of 21 mo, compared to 6 mo among unresected patients; only 5-yr survivors were in resection group

Clinical setting for patients in National Database study: 11% treated at National Cancer Institute-designated cancer centers; of those, 21% not offered surgery; 55% treated at community hospitals; 43% of those patients not of­fered surgery; among hospitals ranking in bottom 3 quartiles for performing pancreatectomy, likelihood of not offering surgery »40%, compared to 28% among hospitals in top quartile; patient refusal rates lower at high-vol­ume hospitals; long-term survival also better at high-volume centers; improvement related to better perioperative systems of care (eg, deep venous thrombosis prophylaxis, b-blocker use, 24-hr availability of interventional radi­ologists and scanning equipment); higher-volume centers had higher rate of negative margins at resection; pa­tients more likely to receive multimodal therapy

Take-home messages: surgeons must educate medical colleagues about benefits of earlier surgery for locoregional disease; consider resecting neuroendocrine tumors; surgeons should evaluate own institutional data about access to current protocols for adjuvant therapy and systems of care that improve survival

Suggested Reading

Ahmed Ali U et al: Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenoma­tous polyposis. Cochrane Database Syst Rev 1:CD006267, January 21, 2009; Bilimoria KY et al: National failure to operate on early stage pancreatic cancer. Ann Surg 246:173, 2007; Birkmeyer JD et al: Effect on hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 125:250, 1999; Casillas S, Delaney P: Laparoscopic surgery for inflammatory bowel disease. Dis Surg 22:135, 2005; Delaney CP et al: Prospective, age-related analysis of surgical results, functional outcome, and quality of life after ileal pouch-anal anastomosis. Ann Surg 238:221, 2003; Karoui M, Cohen R, Nicholls J: Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum 47:869, 2004; Lepistö A et al: Female fertility and childbirth after ileal pouch-anal anastomosis for ulcerative colitis. Br J Surg 94:478, 2007; Lovegrove RE et al: A compari­son of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 pa­tients. Ann Surg 244:18, 2006; Marcello PW et al: Laparoscopic total colectomy for acute colitis: a case-control study. Dis Colon Rectum 44:1441, 2001; Modlin IM et al: Priorities for improving the management of gastroenteropancreatic neuroendo­crine tumors. J Natl Cancer Inst 100:1282, 2008; Nessar G et al: Long-term outcome and quality of life after continent ileos­tomy. Dis Colon Rectum 49:336, 2006; Remzi FH et al: Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years. Dis Colon Rectum 46:6, 2003.