As we have done since 2010, for our annual On the Spot that focuses on colorectal surgery debates, Steven Wexner, MD, and I collaborated on the annual “Dueling Debates in Colorectal Surgery.” Different from the typical On the Spot format, these contributors each weigh in on only one topic.
With a special thanks to Dr. Wexner for lending his time and expertise—and his opinion on each topic—I present some of the most current debates in colorectal surgery, including prevention of anastomotic leaks with fluorescence imaging, the ligation of the intersphincteric fistula tract (LIFT) procedure for anal fistulas, robotics in colorectal surgery, and whether or not transanal total mesorectal excision (TaTME) is the best approach for rectal cancer.
Read on, take a side, access On the Spot online, and share your view with a comment. Feel free to send me any ideas for column topics at colleen@cmhadvisors.com. Happy reading!
—Colleen Hutchinson
Overview of the Debates
I am appreciative of Colleen Hutchinson for inviting me to again edit the pro/con series of colorectal debates for the annual Dueling Debates in Colorectal Surgery.
The first topic, “Fluorescence imaging assessment of anastomotic leaks” is debated by Dr. Manish Chand, from University College London and Dr. Sean Langenfeld from the University of Nebraska. Dr. Manish takes the view that fluorescein improves perfusion assessment, thereby decreasing anastomotic leaks, while Sean assumes the position that fluorescence remains an unproven technology.
The second debate, “Transanal total mesorectal excision is the best approach for rectal cancer” pits two Cleveland Clinic colorectal surgeons against each other. Dr. Dana Sands offers cogent logic for why she feels taTME is the best approach whereas Dr. Hermann Kessler offers some very sage counsel on this new and, as he notes, still unproven approach.
The third debate, “Robotic colorectal surgery is clearly superior” has Dr. Lisa McLemore taking the position that the various robotic improvements on surgery facilitate the operation thereby improving outcomes. The opposing view is taken by Dr. Patricia Sylla from Mount Sinai Medical School in New York. She offers some data to support her view.
The fourth and final debate, “The best treatment for fistula is ligation of intersphincteric fistula tract (LIFT)” has Sthela Murad-Regadas, MD, president elect of the Brazilian Society of Colorectal Surgeons, offering data on why this statement is true. Dr. Massarat Zutshi disagrees, and offers her opinion that the advancement flap is actually a better option.
My disclosures are that I was formerly a paid consultant for Novadaq, Inc. and remain as both paid consultant and royalties recipient from Karl Storz Endoscopy and Intuitive Surgical. Given those disclosures, I feel that fluorescence imaging does offer a more objective means of perfusion assessment, although there certainly has been no proof of concept within a randomized controlled trial. I am a tremendous proponent of taTME and try to perform all of my laparoscopy rectal cancer procedures to include the transanal approach. While I do not personally use the robot, I do recognize it as a tool by which surgeons who do not perform laparoscopic colorectal surgery can perhaps more comfortably and quickly learn minimally invasive surgery by robotic facilitation. My personal opinion is that any form of minimally invasive surgery, robotic or laparoscopic, is superior to open or hand-assisted surgery. Although I think that the LIFT is one of the best treatments for fistula-in-ano, I do think that the advancement flap still plays a significant role.
I am grateful to each of my colleagues for providing cogent, compelling arguments to support their respective viewpoints. I hope that the readers of General Surgery News enjoy this article.
—Steven Wexner, MD
P A R T I C I P A N T S | |
 | Manish Chand, MD Associate professor of surgery, a consultant colorectal surgeon and the director of the Advanced Minimally-Invasive Surgery program at University College London. |
 | Sean Langenfeld, MD Associate professor of surgery at University of Nebraska Medical Center, in Omaha. |
 | Lisa McLemore, MD Chief of colorectal surgery and the director of the Minimally Invasive Surgery Center at Kaiser Permanente Los Angeles Medical Center. |
 | Sthela Murad-Regadas, MD, PhD Associate professor of surgery and the head of the Anorectal Physiology and Pelvic Floor Unit of the Federal University of Ceara Medical School, Sao Carlos Hospital, in Ceara, Brazil. |
 | Sowsan Rasheid, MD Assistant professor of surgery at the University of S. Florida Morsani College of Medicine and associate program director of colorectal surgery residency. Disclosure: Principal investigator for PILAR III: A Randomized, Controlled, Parallel, Multicenter Study Assessing Perfusion Outcomes with PINPOINT® Near Infrared Fluorescence Imaging in Low Anterior Resection. |
 | Dana Sands, MD Staff surgeon in the Department of Colorectal Surgery and the director of the Colorectal Physiology Center of the Digestive Disease and Surgery Institute at Cleveland Clinic Florida, in Weston. |
 | Steven Wexner, MD Director of the Digestive Disease Center and chairman of the Department of Colorectal Surgery at Cleveland Clinic Florida, in Weston. |
 | Hermann Kessler, MD, PhD Professor of surgery and the section head of minimally invasive surgery in the Department of Colorectal Surgery of the Digestive Disease and Surgery Institute at the Cleveland Clinic, in Ohio. |
 | Massarat Zutshi, MD Associate professor of surgery at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and a colorectal surgeon in the Department of Colorectal Surgery of the Digestive Disease and Surgery Institute at the Cleveland Clinic, in Ohio. |
 | Patricia Sylla, MD Associate professor of surgery in the Division of Colon and Rectal Surgery at Icahn School of Medicine at Mount Sinai, in New York City. Disclosure: Ethicon, Medrobotics, Medtronic and Olympus. |
1. Fluorescence imaging prevents anastomotic leaks.
Dr. Chand: Agree. Fluorescence imaging provides surgeons with a new perspective on intraoperative anatomy by allowing them to operate outside the white light visible spectrum. While other surgical disciplines have been using this technology for some time, it has been popularized in colorectal surgery using a dye called indocyanine green (ICG), which shows bowel and anastomotic perfusion when given intravenously.
The main determinant of a successful anastomosis is the blood supply, and if using ICG—one can more objectively assess this than with more traditional and subjective techniques like cutting the nearby mesentery and waiting for a spurt of blood—then it seems like a sensible thing to do. Although randomized controlled trials are still in progress (InTact in the United Kingdom), the current phase 2 evidence from the PILLAR II trial (J Am Coll Surg 2015;220[1]:82-91.e1) and European equivalents shows that leak rates are reduced to less than 2% when using ICG to assess the anastomosis. In these reports, there have been cases where the resection margins have been changed based on the ICG assessment. Fluorescence imaging will be used more widely throughout surgery, and its utility for assessment of bowel perfusion seems particularly useful.
Dr. Langenfeld: Disagree. Fluorescence imaging hypothetically ensures adequate perfusion to a new anastomosis, but there aren’t any high-level data to support the hypothesis. It may be helpful for selected patients where perfusion is uncertain, but I’m not sure one could support routine use at this time. With so many patient factors and technical factors affecting leak rate, it’s difficult to determine what percentage of the variability in anastomotic leaks is truly determined by such a test.
In the PILLAR II trial, fluorescence angiography changed surgical plans in 8% of patients, but there’s really no way of knowing if this altered surgical plan actually affected leak rates, especially considering that the cohort’s overall leak rate was only 1.4%. I was hopeful that the PILLAR III randomized controlled trial would answer this question, but it was unfortunately closed prematurely due to poor patient accrual.
Dr. Rasheid: On the fence, but mostly agree. Anastomotic leaks are one of the most feared complications of colorectal surgery. To date, there has not been a definitive method of preventing this complication, even when every basic tenet of surgery is applied during the making of an anastomosis. The uses of intraoperative Doppler and fluorescein have been the poor man’s tools to evaluate blood flow, but that has not correlated with end organ oxygenation and subsequent healing.
Fluorescence imaging is a great idea in theory as it evaluates the blood flow in the microvasculature. There is significant evidence that the use of fluorescence imaging is effective for identifying varying degrees of blood flow in the bowel. Confirmation of adequate bowel vascularization has been shown to decrease the rates of anastomotic leaks significantly. However, even with confirmation of blood flow using fluorescence imaging, there remain patients who experience anastomotic leaks, and full prevention of leaks has yet to be achieved. Thus, there appear to be factors that affect anastomotic healing, such as the bowel microbiome and various inflammatory mediators that have yet to be defined. In short, the available fluorescence imaging technology has been demonstrated to be effective at evaluating blood flow to anastomoses and should be routinely included in the evaluation of a newly constructed anastomosis to lessen the possibility of an anastomotic leak.
2. TaTME is the best approach for rectal cancer.
Dr. Sands: Agree. TaTME was first introduced in 2010. Initially, a few surgeons pushed the envelope in the realm of transanal surgery. Since that time, numerous publications have shown feasibility of the technique in larger series. In addition, case–control series have shown improved mesorectal completeness, reduced circumferential margin positivity and increased distal margin with TaTME.
Several aspects of the procedure make it an excellent option in treating rectal cancer patients. From the beginning, the distal margin is controlled under direct vision, thereby removing any uncertainty of the location when coming from above with the lack of tactile sensation. All colorectal surgeons are familiar with the challenges of pelvic dissection in an obese patient with a narrow pelvis. Lack of visualization, poor angulation capability of the instruments, and inability to gain proper traction can compromise the dissection and lead to an incomplete specimen in the most important oncologic portion of TME in laparoscopic and open proctectomy. The transanal approach to TME affords the operating surgeon excellent visualization and a straight-line approach to the distal pelvis, providing a superior specimen quality.
Instrument angulation again plays a role in reconstruction after TME. Laparoscopic staplers are often unable to transect the distal rectum with a single fire. It is well known that multiple firings are associated with higher leak rates. The double purse-string technique for anastomosis in TaTME completely avoids crossing staple lines, potentially decreasing the anastomotic leak rate.
As enrollment in U.S. and international registries mounts, the safety and feasibility of TaTME is being ensured. The U.S. multicenter trial also will provide large-scale prospective data. Proper training and familiarity with the “old” dissection planes from a new direction are a must.
Dr. Kessler: Disagree. The best surgical technique for rectal cancer is the one in which total mesorectal excision is achieved best. Whoever performs open surgery with adequate retraction instruments, assistance and expertise will hardly ever have problems to reach the pelvic floor without compromising TME quality. In laparoscopic TME, even with excellent expertise, patient-, tumor- and instrument-related factors play a much more important role. It has been proven that results equivalent to open surgery may be achieved; however, the anatomy and mesorectum with bulky tumors in (mainly male) narrow pelvises located in the middle to lower third are sometimes difficult to visualize and stapling devices difficult to apply. In certain cases, robotic surgery may facilitate dissection by overcoming the rigidity of instruments and improving visualization, but distal stapling still poses problems.
For many years, intersphincteric resection or the transabdominal transanal procedure have been established techniques that could help out in these situations and in tumors within 1 cm of the dentate line to achieve complete TME, equivalent to transabdominal access. After gaining experience with transanal minimally invasive surgery techniques, TaTME was introduced in this context as a standardized approach from below using special devices and instruments. After a learning curve of still unclear duration, probably the same results as in open and expert laparoscopic TME surgery are achievable, but it still needs to be definitely proven. Also, we are still lacking long-term quality-of-life results. In those cases described above, where laparoscopy is hitting its limits and the surgeon does not want to convert to an open procedure, TaTME may make it easier to achieve complete TME. It also needs to be proven that TaTME is not performed at the expense of more complications like urethral, vessel or nerve injuries; and in times of limited resources, cost factors regarding duration of surgery and double-team approach are also part of the equation.
3. Robotic colorectal surgery is clearly the superior approach.
Dr. McLemore: Agree. Robotic technology is revolutionizing our world more rapidly than any other technological advances. This revolution is palpable in the world of colon and rectal surgery. In addition to the superhuman degrees of rotation and motion, the robotic instrumentation can provide retraction with greater force and with longer, more sustainable and stable positioning than the MIS and open equivalent retraction tools and techniques. The stability and proximity of a robotic camera providing and enhancing our visibility intraoperatively also are superior to the MIS and open alternatives. Direct pressure can be applied to presacral bleeding, when encountered, with the option of electrocautery or bipolar energy to assist with obtaining hemostasis. The robotic technology is providing us access to areas previously only accessible by “feel.” The endoluminal robotic frontier has arrived and will further provide us with improved access, visibility and precision, and continue to advance natural orifice colon and rectal surgical management options for our patients.
Dr. Sylla: Disagree. Once the excitement over a new technology settles, one must set aside anecdotes and personal biases and reflect on the best evidence to determine superiority over existing technologies. If defined by a lower risk-to-benefit ratio, the ROLARR trial failed to demonstrate superiority of robotic TME over the laparoscopic approach (JAMA 2017;318[16]:1560-1580). It demonstrated lower conversion rates in male and obese patients, albeit not significantly. The same cohort of patients might be better served by TaTME, the latest development in rectal cancer surgery, with published conversion rates well below 5%. If defined by a shorter learning curve, that of laparoscopic experts in ROLARR was a sobering 60 to 90 robotic TME cases—an unrealistic goal outside of high-volume centers. If defined by increased adoption of MIS techniques, including intracorporeal anastomosis for right colectomies, it might be to the detriment of our trainees’ laparoscopic surgery skill acquisition.
4. The best treatment for a fistula is LIFT.
Dr. Murad-Regadas: Agree. Anal fistulas are classified as simple or complex according to the involvement of the sphincter muscles by the tract, as well as associated factors like female gender, position of the tract, age, previous vaginal delivery with or without sphincter defect, radiation, previous fecal incontinence symptoms and inflammatory bowel disorders. So it’s important to choose a technique that preserves the sphincter muscles and avoids fecal incontinence symptoms, as the risk for incontinence is related to associated factors, as previously mentioned.
LIFT is a technique for treatment of anal fistulas, preserving the sphincter muscles (without anal sphincter division), and has been adopted as a first-line sphincter-sparing repair by many surgeons. The main advantage of LIFT is the preservation of sphincter integrity, with a high rate of primary healing between 65% and 94% (Dis Colon Rectum 2015;58[6]:604-612). On the other hand, the complications of LIFT are simple and well tolerated, like wound hematoma, anal fissure and external hemorrhoid thrombosis. The patterns of failures following the LIFT technique, defined as no healing of the surgical wound or fistulous tract preservation, have been described and can be identified using digital exam or anal ultrasound (Dis Colon Rectum 2011;54[11]:1368-1372). In those cases of recurrence, the LIFT technique is still a good option.
Therefore, the complete clinical and image assessment of anal fistula is mandatory in order to choose the best technique to preserve the sphincter muscles, as LIFT, avoiding the worst complication, fecal incontinence or increased risk for developing late-onset fecal incontinence when associated risk factors such as menopause, age, de novo sphincter surgery division are present.
Dr. Zutshi: Disagree. The LIFT procedure can only be used in limited indications. In subcutaneous fistulas, a fistulotomy is the best option. In most intersphincteric and transsphincteric fistulas, the anal advancement flap has a healing rate of about 76%.
The LIFT procedure is done in a relatively small operating room area, and requires technical skill to be able to evaluate and excise the fistula tract as well as ensure that the cut ends of the fistula tract are ligated. Multiple recent advances, such as the fistula plug, the laser procedure and video endoscopy, are other options that can be offered to patients. The anal advancement flap, however, has the best healing rate of all the procedures, including the LIFT procedure. Even in Crohn’s fistulas, the anal advancement flap can be used in the rectum if it is relatively spared.
Repeated procedures, when needed to repair a fistula after a LIFT procedure, are a repeat LIFT or an anal advancement flap. This indicates that the advancement flap is more suited to almost every fistula.
| Gut Reaction | ||||||
 Most critical new advance in my area of medicine |  FDA approval process for medical devices/drugs | Most challenging issue my counterparts and I face today | My mentor | Best part of my job | Tool or device in my clinical arsenal I can’t live without | |
|---|---|---|---|---|---|---|
| Dana Sands, MD | Transanal total mesorectal excision (TaTME) | Lengthy | Creating a work–life balance | Lucky to have many | Satisfaction of providing excellent care | Always have a Plan B |
| Hermann Kessler, MD, PhD | Complete mesocolic excision | Thorough but sometimes takes too long | Cost reduction | On several continents | Liberty | Knife |
| Patricia Sylla, MD | Transanal endoscopic surgery and TaTME | Lengthy and costly | Centralizing and standardizing rectal cancer care across hospital systems | Steven Wexner, MD | Achieving sphincter salvage without compromising oncologic outcomes | Transanal Endoscopic Operations (KARL STORZ) transanal platform |
| Massarat Zutshi, MD | Sacral neuromodulation | Tedious | Funding for investigator-initiated research for devices | Victor Fazio, MD | The ability to view and offer different possibilities for treatment from holistic to surgical | My support staff |
| Manish Chand, MD | Artificial intelligence | Lengthy and often too bureaucratic | Mastering all the novel techniques in surgery | Brendan Moran, MD | Being able to spitball novel ideas with colleagues | Laparoscope |
| Lisa McLemore, MD | “Watch and wait” surveillance options for patients with rectal cancer who develop a complete clinical response | Is outdated | Less time built into the schedule to develop rapport and establish trust with our patients | Steven Wexner, MD | Witnessing the miracles of postoperative recovery and patients returning to restored health | Circular staplers |
| Sthela Murad-Regadas, MD, PhD | Diagnosis and treatment of pelvic floor dysfunctions | Not applicable—from Brazil | Pelvic floor dysfunctions | Sergio Regadas, PhD | Surgery and 3-D ultrasound | Laparoscopic set/3-D/ultrasound/ sacral nerve stimulation |
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