Since 2010, Dr. Steven Wexner and I have collaborated on the annual “Dueling Debates in Colorectal Surgery.” Every year, I pay special thanks to Dr. Wexner for lending his time and expertise in the current debates in colorectal surgery. In this year’s issue, I present current debates in colorectal surgery, including parastomal hernia prevention with mesh, whether fluorescence angiography should be used to assess anastomotic perfusion, and whether neoadjuvant chemotherapy should be given to as many patients as possible with colon cancer. Read on, take a side, access On the Spot online and share your view with a comment. Feel free to send me any comments as well at colleen@cmhadvisors.com. Happy reading!
—Colleen Hutchinson
Colleen Hutchinson is a medical communications consultant at CMH Media.
I’m grateful to Colleen Hutchinson for allowing me another opportunity to enlist the support of my colleagues for this edition of “Dueling Debates in Colorectal Surgery.” This year, I have selected five current controversial topics and, in some instances, more than two dueling debaters. I endeavored to select a wide range of dilemmas and have enlisted an equally diverse group of debaters.
I thank the participants in this year’s debates for their time, expertise and succinct cogent comments supporting their views. I am confident that the readers of General Surgery News will find this article both thought-provoking and enjoyable.
—Steven Wexner
Director, Ellen Leifer Shulman & Steven Shulman Digestive Disease Center
Department Chair, Colorectal Surgery, Cleveland Clinic Florida
P A R T I C I P A N T S | |
 | Professor of Surgery, Division of General Surgery Vanderbilt Colorectal Research Center Vanderbilt University Medical Center Nashville, Tenn. |
 | Professor of Surgery Victor W. Fazio Chair in Colorectal Surgery Cleveland Clinic Foundation Cleveland, Ohio |
 | Director of Clinical Research, Department of Surgery Associate Program Director, Colon and Rectal Surgery Weill Cornell Medicine Chief, Colorectal Surgery NewYork-Presbyterian Brooklyn Methodist Hospital New York City |
 | Associate Professor Marks Colorectal Surgical Associates Department of Surgery, Lankenau Medical Center Lankenau Medical Research Institute Lankenau, Pa. |
 | Section Head, GI Medical Oncology Vice Chair, National Accreditation Program for Rectal Cancer Multidisciplinary Team Cleveland Clinic Cleveland |
 | Colorectal Surgeon Angelita & Joaquim Gama Institute Hospital AlemÃo Oswaldo Cruz Hospital BeneficÊncia Portuguesa Sao Paulo, Brazil |
 | Regional Chairman, Digestive Disease Institute Chairman, Department of General Surgery Director, General Surgery Residency Program Director, The Bariatric and Metabolic Institute Co-Director, Advanced GI Surgical Fellowship, Ellen Lifer Shulman and Steven Shulman Digestive Disease Center Cleveland Clinic Florida Weston |
 | Consultant Colorectal Surgeon Royal Devon & Exeter Foundation NHS Trust Honorary Associate Professor University of Exeter Medical School Exeter, England |
 | Clinical Associate Department of Colon and Rectal Surgery Cleveland Clinic Florida Weston |
Prophylactic mesh should be used to prevent parastomal hernias (PSHs).
Mr. Neil Smart: Agree—with conditions! PSHs are very common, with approximately 50% of patients reporting a hernia at three years after their stoma was formed. PSHs cause significant symptoms associated with reduced quality of life. After PSH formation, one-third of patients may require surgical PSH repair over the following seven years; and one-third of these patients may undergo multiple repairs, as there is no gold-standard technique or mesh for PSH repair. “Watchful waiting” has been similarly unrewarding, with one in five patients developing symptoms requiring urgent surgery. Consequently, the focus has been on prevention of PSHs.
No stoma creation technique has been reliably proven to reduce PSH development until prophylactic mesh was first investigated more than 30 years ago. Over the past 20 years, prophylactic mesh placement at the time of index stoma formation has been extensively studied in more than 12 randomized controlled trials (RCTs) and 14 meta-analyses. The relative risk reduction of approximately 60% in PSH formation with retrorectus macroporous permanent synthetic meshes is cost-effective and has an excellent safety profile. The most recent RCTs of better methodological quality and larger sample sizes have failed to demonstrate benefit of mesh placement if considering the presence or absence of PSHs alone at one or two years postoperatively as an outcome. However, some older trials have reported longer follow-up, out to five years postoperatively, and have demonstrated a delay to onset of PSHs and the need for PSH repair with mesh usage—outcomes that are important for many patients.
The caveat is that the data overwhelmingly pertain to permanent end colostomies formed during elective cancer surgery only. Evidence for stomas created for inflammatory bowel disease, functional and diverticular patients is lacking, and ileostomies are almost wholly absent from the literature. The National Institute for Health and Care Research–funded CIPHER study will clarify the patient and intraoperative technical factors that increase the risk development for PSHs and may allow prophylactic measures, such as mesh placement, to be targeted to those individuals at the highest risk (Colorectal Dis 2021;23[7]:1900-1908).
David Beck, MD: Disagree Mesh reinforcement is considered to reduce the incidence of PSHs. The reported incidence has been variable, and not all PSHs need to be treated. While reinforcement can reduce the incidence of PSHs, it does not eliminate them. There is also a significant cost associated with reinforcement and some morbidity. In addition, there is no consensus on the best technique of reinforcement or what is the best material for reinforcement. In the absence of high-quality convincing data, I would favor a selective approach, only reinforcing patients with significantly higher risk for PSHs (large stomas, thin abdominal wall, younger age, with active lifestyles, etc.).
Deborah Keller, MD: Disagree Based on my clinical experience, the answer is no. Even those with prophylactic mesh still get PSHs. Then, they are substantially more difficult to repair when the “prophylactic” mesh fails because the planes have been violated. Mesh may be simply mitigating bad surgery.
Based on the literature, the answer is also no, not because all of the studies have negative outcomes but because the existing studies are poor. There are a multitude of confounding variables that affect the occurrence of a PSH, and no work to date has effectively addressed these. As a result, published works are both pro and against, using the same populations, data sources and methodology. In reality, we still need to define the patient factors that predispose patients to PSHs, the ideal procedure to perform and the ideal platform to perform that procedure on. With the long-term outcome and complication data, then we can examine the question of who should (appropriately) have prophylactic mesh. The CIPHER trial, the most powerful study to date with the longest follow-up and largest sample size, is currently working toward these goals.
Neoadjuvant chemotherapy should be given to as many patients as possible with colon cancer.
Rodrigo Perez, MD: Disagree I believe that neoadjuvant chemotherapy should be offered to patients with colon cancer very selectively based on molecular testing (microsatellite-stable adenocarcinoma) and preoperative staging. Given the limitations in preoperative staging with CT scans, at this point I would restrict it to patients with clear cT4 disease or/and obvious bulky nodal disease. Patients with cT3 disease and visible nodes are still at considerable risk for overtreatment and are probably best treated with surgery first.
Tracy Hull, MD: Agree We rely on surgical resection anchored by technical excellence as the cornerstone to cure our patients with colon cancer. However, even the best surgical treatment can fail. Having a definitive pathology report after resection is endorsed by some caregivers to ensure adjuvant therapy is given to only selected “appropriate” patients postoperatively. However, giving neoadjuvant therapy increases the probability that patients will complete their entire course as they will be in overall better health and not recovering from surgery. Circulating tumor cells may escape from the surgical field of resection, and neoadjuvant chemotherapy before surgery may destroy those cells prior to resection. Large and bulky tumors may have threatened resection margins. Neoadjuvant therapy can shrink a bulky tumor and improve chances for negative margins. A common worry with neoadjuvant therapy is that the tumor will grow and the window for surgical cure could be missed without early surgery. From a different perspective, patients with bad disease biology likely would have had a poor outcome and a very early recurrence with surgery.
Fluorescence angiography should be used to assess anastomotic perfusion.
Peige Zhou, MD: Agree I agree that fluorescence angiography should be used to assess anastomotic perfusion. The intestine is a robust organ and requires time to reveal ischemic change. Factors such as back-bleeding and pulsatile main branch vessels can give a false sense of security. Fluorescence angiography allows the surgeon to quickly assess intestinal perfusion and ensure end vascular tributaries have not been inadvertently divided to remaining intestine.
However, fluorescence angiography must be used with caution, especially with repeated dosing, by ensuring adequate visualization and targeting prior to administration. Perfusion must be identified within the recommended time frame and expected magnitude.
The adjunct use of fluorescence angiography can identify subtle ischemic areas that may lead to decreased anastomotic complications. A recent systemic review and meta-analysis found a significantly decreased odds ratio for anastomotic leaks in usage of indocyanine green (ICG) fluorescence angiography compared with white light (Surg Endosc 2022;36[4]:2245-2257). The ease of administration and low side effect profile make it worthwhile to consider its routine use, especially in high-risk anastomoses.
Mehraneh Dorna Jafari, MD: Disagree I will fully admit that I initially thought the addition of fluorescence angiography to colorectal surgery would be a game changer. Imagine a world where the use of an inexpensive, safe drug and available camera system with no downside would decrease anastomotic leak rates. But alas, this was shortsighted. Despite the promising results from retrospective reviews, the actual benefit was not proven in the only RCT conducted in the United States (PILLAR III). The addition of fluorescence angiography did not decrease leak rates and would not have, even if it had reached power. The two other RCTs show mixed results and include high anastomosis with very low rates of preoperative radiation.
It should also be noted that the change in transection line during perfusion assessment has not been shown to improve leak rates. We really do not understand what the subtle differences mean with ICG fluorescence angiography. Perhaps a more accurate measure of the oxygen saturation will shed some light on this question. Although one of the pillars of anastomotic healing is blood perfusion, it is not the only factor. Anastomotic leaks are caused by a multitude of factors—many of which we do not fully comprehend, such as microbiome. My take is that in experienced hands, the use of ICG does not improve the surgeon’s ability to judge optimally perfused bowel under normal white light. It is possible, by contrast, that less experienced operators may find the use of ICG useful.
| GUT REACTION | ||||
 Most critical new advance in surgery |  Most challenging issue my counterparts and I face today | Tool or device in my clinical arsenal I can’t live without | The robot | |
|---|---|---|---|---|
| Rodrigo Oliva Perez, MD, PhD | Multidisciplinary team interaction for colorectal cancer | Explaining why watch-and-wait is not for all patients | The team I work with | Just another tool |
| Arun Nagarajan, MD | Watch and wait | Documentation burden | iPhone | My brain |
| Peige Zhou, MD | Increasing research-focused, patient-reported outcomes | Imparting the rapid advancement in resources to learners | My left retracting hand | A tool that can improve a surgeon’s dexterity |
| Tracy Hull, MD | Enhanced recovery after surgery (ERAS) | Lack of nurses and support staff | Bovie | An excellent tool/approach in selected circumstances |
| Raul J. Rosenthal, MD | Fluorescence image-guided surgery | Nursing turnover | Staplers and ultrasonic scalpel | An expensive prosthetic device for surgeons who can’t move their hands |
| Mehraneh Dorna Jafari, MD | Augmented reality AI | Variation in care based on socioeconomic disparities in the United States | The laparoscope | Is a tool, not a religion |