Welcome to First Incision. the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. Welcome to this special guest episode of First Incision. Today, we are lucky enough to be joined by Michael Johnston, a colorectal surgeon from St. Vincent's Hospital in Melbourne.
Today, we're going to talk about operative inflammatory bowel disease topics, specifically what makes inflammatory bowel disease difficult to operate on, some tips and tricks, and how to approach some of the common scenarios you might encounter with these patients. I hope you learn as much as I did. And thanks again, Michael, for joining us on today's episode.
So to start us off, Michael, could you tell us a little bit about yourself? Okay, I'm Michael Johnston. I'm a colorectal surgeon at St. Vincent's in Melbourne. I've been working there for almost 20 years. I have a passionate interest in training as well as inflammatory bowel disease and minimally invasive surgery and a little bit of robotic stuff these days as well. St Vincent's born and bred. I was a student there.
Did a couple of years working down in Geelong as an intern and a second year. And then did my general surgery training at St Vincent's before doing a fellowship year in the colorectal training scheme in Christchurch in New Zealand. And then moving to Brisbane. really around that advent time of laparoscopic surgery when hardly anyone was doing it because that's how old I am now. And I had a special interest at the time in exentrative surgery.
And I did a fellowship in Leeds with Peter Sagar doing redo pelvic surgery, which I still do a little of. But the call for it in this country is not as great as it was in the UK because we're better at doing rectal cancer surgery primarily. Been married for 22 years and I've got three beautiful kids and I have four brothers and my kids have 17 cousins and I love getting all parts of the family together.
We go on trips together and I'm passionate about playing hockey. I still play twice a week and I enjoy surfing and windsurfing and I'm even having a go at foilboarding these days. So I've been trying to pin you down for this podcast episode for a little while. So I've managed to track you down here at the RACS Annual Scientific Conference in 2023 in Adelaide. Thank you so much for giving up your time for us today. Specifically, I wanted you on the podcast to talk to us about IBD.
St Vincent's has a massive referral centre in Victoria for inflammatory bowel disease and your practice has a huge number of inflammatory bowel disease patients. And I learned a lot from you as your trainee in managing patients with Crohn's and ulcerative colitis. So I'm really grateful that you're going to be able to share that knowledge with trainees all around Australia and the world through the podcast.
The first thing I wanted to talk to you about is hopefully a little softer introduction to the topic in terms of complexity because we could go in all sorts of directions here. But let's start by talking a little bit about acute colitis. Specifically, can you talk a little bit about the types of...
presentations patients have when they come in with acute colitis and what factors you use in your decision making about whether a patient does need an operation or not. So most patients are going to present with bloody diarrhoea. varying severities and frequency. The key issues when you're assessing these patients are obviously making sure from the start that you don't fall into the trap of a toxic megacolon that slips by without you operating sooner.
That can be a really tough thing to judge these days, the criteria that we have used in the past, like True Love and Wits criteria, the CRP on day three after intravenous steroid. They don't quite apply in the era of biologics and now even JAK inhibitor use as well as cyclosporine in some centres. So it becomes a real clinical art to looking after these patients and seeing them usually twice a day.
in concert with your gastroenterology colleague it's a real multidisciplinary disease so you are hoping that they'll respond to medical treatment but at the same time you're educating the patient in those first few days about what surgery might entail You'll want to involve your stomal therapist early on from a teaching and counselling perspective as well as many patients still fail their medical therapy even though we have quite a range of different treatments.
and the figures now for a first presentation with colitis are still around 20 to 30 percent may end up with a colectomy if they have severe enough disease so what we'll see these days is three days of treatment with intravenous steroid and predominantly the next drug that the gastroenterologist will use is infliximab as a 10 milligram per kilogram infusion. And that response to that will usually peak on day two at about 48 hours. And if the patient hasn't responded.
and is not getting sicker to the point that you do need to do an operation, then they'll get a second and a third dose, usually three to five days after the first. The things that you'll be looking out for as a surgeon are going to be deterioration.
from a frequency or bleeding perspective temperature and still there is criteria for measuring the transverse colon diameter although i tend to not use that as my key issue as an indication for surgery When the patient stops passing any motions altogether is a real danger sign that megacolon may be imminent.
So if you get sudden silence of the bowel motions, then you need to be sure that that's an improvement in their condition as opposed to the development of megacolon. Not every patient will have pain. Not every patient will have tenderness. In fact, they shouldn't have tenderness unless there is a real problem. Although some people with the colon being quite inflamed will actually have some peritonism locally over that section. But you need to be wary, obviously, of a perforation.
I find the nuance how long to actually wait and see if they're going to get a response to treatment versus when to operate really difficult, especially as a trainee. Yeah, well, that can be a difficult thing even for consultants and we'll often use an expert opinion from... more than one surgeon just to see if the time is now for an operation because as I said before the criteria we've used in the past don't necessarily hold up.
And we still find patients improving on day five after their third dose of infliximab who've been in hospital for three weeks and then suddenly they get better. And that is getting harder and harder to judge. But you will use all of those different. criteria that you have at your disposal the clinical picture in terms of tachycardia and fever the
biochemical markers, including what's happening with their CRP. Although a lot of these patients, after their first lot of infliximab and steroids, you'll find their CRP is 12. Then you'll find someone else who's got a CRP of 140. So it too is not as... clear as it used to be. So you'll use all of those things put together to make the decision, but it's really going to be a deterioration that pushes you in the direction of an operation.
And a failure to thrive after three doses of infliximab should be a really strong indication at that stage that the patient's just not going to get better, although occasionally they will. I haven't got the crystal ball that can tell you exactly which it is for each patient, but you need to do individual assessment and really continuity of care is paramount. So you need to be the same person over that two, three-week course that is seeing the patient because...
You won't be able to pick up on the differences if you come in as a newcomer a lot of the time. So if you do end up operating on these patients, what is the surgery that we should be saying in the exam and in real life that you do? And can you talk us through how you do that operation? So the one correct operation in the exam is a subtotal colectomy with an end ileostomy and a buried mucous fistula or a mature mucous fistula if...
the bowel is too friable to close off. There are the sexy options which don't get included in the exam and they might be that you do it laparoscopically but you have to remember that these colons that you're dealing with can be very fragile and the mortality associated with this operation primarily relates to spillage of fecal content damaging the bowel. So you need to be not doing this as your second or third laparoscopic procedure.
If you're going to do it laparoscopically, you need to be an experienced laparoscopic surgeon to do it that way. And in the exam, you won't do it laparoscopically. And the mucous fistula will get buried in the suprapubic space. And what I... do for the exam is to open that part of the wound, close the laparotomy down to a point where the bowel sits easily within the subcutaneous space without tension and that's how I make the decision as to where I divide the bowel.
And I usually use a GIA or a linear cutter stapler. And then I put some 3OPDS sutures through the serosa of the bowel and into the linear alba on either side, usually three sutures on either side, so that it just sits there. Mostly abdominal pressure will mean it doesn't fall in, but if it does fall in, that's when you get the danger of that rectal stump breaking down and causing perforation within the abdomen and, again, closely linked to mortality.
Sexy options, if we can talk about them. I've tried this a couple of times and I'm not particularly happy with it, but some centres, when you do the laparoscopic procedure, use the ileostomy as the extraction site. And you can use the linear cutter across the bowel where it reaches. to the ileostomy and you can open a corner of it to go into the ileostomy bag with your ironium. I found judging the size of the trephine when you're putting two bits of bowel through it.
One of them, which is inflamed at the time and probably will lose its inflammatory component to some degree later, means that I once made the stomas too tight and it didn't work for quite a long time afterwards. And the dissection for doing the... pouch operation or the proctectomy later was quite difficult to take down whereas often the suprapubic one is really easy to take down so that's next level bringing the mucous fistula out at the ileostomy site the other thing that
you may want to consider which is in the literature is just a diverting ileostomy without a resection for some patients who you were worried about getting through the operation they're that unwell you wouldn't want to do that if the bowel is in a megacolon state because it's going to die and you need to get it out before that happens. But sometimes a diverting ileostomy will be all a patient needs to get through the next few months.
allow their inflammatory change to settle and convert the situation from an emergency operation to an elective one. From the series I've seen in the literature, none of the patients avoid the colectomy when they have a diverting ileostomy, but they... can convert the situation from an emergency one to an elective one in about 90% of cases. That meant that the patient didn't have a three-stage operation but could have, if you like, the first stage is only an aliostomy and the second stage is a...
proctocolectomy and pouch, so they could have that electively. I don't necessarily favour that too much. I quite like the three-stage operation because... the pouch is something that you want this patient to be able to have for the rest of their lives you want the best function out of it you can so when you make the patch you want them in the best shape they can be so that they heal and don't leak
Yes, you can salvage your leak with a diverting ileostomy, but they're still left with a lot of scarring and potentially functional disorder as far as emptying the pouch goes if they've had pelvic sepsis. personally do a laparoscopic resection for a subtotal colectomy. My preferred approach is a personal one. It has some rationale, but it is not something that I make all of my trainees do.
and get disappointed when they choose to do it some other way. But personally, I like to start on the right colon and take the hepatic flexure down first. This has come from a history of doing a lot of terminal allele surgery where... You've got a phlegmon or fistula in the ilium, and so you want to get to that part last. And what I discovered was that I could take the hepatic flexure down first, which required minimal repositioning of the patient, just a little bit of roll.
And so the patient spends less time head down, which potentially is hazardous for limb injuries and barotrauma in the lungs and even cerebral edema that I've seen from people being head down for a long time. hepatic flexure first, expose the duodenum. I personally take the ileocolic pedicle for all of these although i know some people will leave the ileocolic pedicle as a blood supply for the terminal for the pouch but my personal preference is to take it
I think that you have more potential for length without it than you do with it. And the length is what you want when you're trying to create a pouch for people to get that ILM to reach to the anorectal junction. So I'll take that. either with a thunderbeat but sometimes with haemolock clips. And then I extend the window in the hepatic flexure right across to the middle colic vessel and then I stop on the right side and move to the left.
So then the patient rolls the other way. Again, they don't need to go head down too much, although I find doing the sigmoid, it's probably a little bit advantageous. So I'll start at the sigmoid colon, the pelvic brim, and work my way up. And I do mobilise the whole of the colonic mesentery to expose the inferior mesenteric vein. But at the same time, for this operation, I leave the inferior mesenteric artery and vein as a blood supply to my distal.
sigmoid unless the patient's having surgery for bleeding because some patients with colitis will have heavy bleeding where they've ulcerated into reasonable sized vessels and in those patients I take the inferior mesenteric artery. if I think I'm going to get enough length to get the surviving or at least perfused colon up to the surface. That's rare. I've probably only done that twice in my surgical career, so most of the time I'm leaving the inferior mediteric artery and vein.
I take the omentum off. I'm an omentum preserver, and often I'll get into the lesser sac just coming up the left side, but that's probably a bit more next-level surgery. Probably go to the mid-transverse and start taking the omentum off to get the flexure down completely. Get into the lesser sac and then open the window above the infra-mesenteric vein. And then for the transverse colon mesentery, I do that from the patient's left side and work my way across. Once you've got that window, I...
bring the colon down so I can see the middle colic vessels on the pancreas while I'm going across. I don't go too high if it's not a cancer operation but at the same time the higher you go the fewer vessels you have to clip and divide. A lot of people do a close dissection on the mesentery next to the colon for inflammatory bowel disease. I don't like that as a process. It tends to be more in terms of bleeding.
And I don't want to be the one who finds out that there was actually a cancer in the transverse colon or in the splenic flexure when you've done a close dissection on the mesentery and you have to potentially go back and take that mesentery out later. So I've always done the operation. deliberately but as a more cancer type resection because it's more convenient to divide fewer vessels again using either hemox or the thunder beta cross so once you've got the middle colic
vessels divided, you've used that window on the right side as somewhere to aim for because you can get lost coming across in the mesentery. So I'll often lift up the hepatic flexure to know where I'm going to from underneath. and see the mesentery where it's coming off the front of the pancreas. Now once that's complete, I'll go and do the terminal ileo mesentery again using the thunderbeat.
and use a linear cutter stapler across the terminal ILM. At that point, I'll usually bring the ILM up to the surface and extend my suprapubic port site to use as an extraction site with usually a small... rigid alexis some of that mesentery i'll divide on the surface when i've decided how much length i've got and what i'm going to do to staple it off so usually i'll actually ligate
with open surgery on the mesentery after i've lifted the cecum out first and lifted the sigmoid up to the surface and again i use that linear cutter stapler across the bowel and suture the recto sigmoid stump to the fascia now with no closure because it's you've just made an opening that's exactly the right size usually for the bowel to sit there but you can put a couple of sutures of one pds in if you need to close the wound a little bit and then i close the skin over the top of that
I actually put my laparoscope back in to double and triple check that I haven't got any twists in the bowel, either in the distal part or where I'm bringing out the ileostomy. So I usually put a 5mm laparoscope in through one of the ports on the left side of the patient to double check that. Didn't mention my port sites at the beginning. If I'm feeling confident in the patient's reasonable build, I actually use a 12mm port at the stoma site and three 5mms across the bottom.
So you need childlike fossa and a suprapubic. That usually gives me enough room, but you can put an extra 5mm port higher up in the abdomen on either side, depending on how the flexors are coming down. If the patient's bigger...
then I'll just use a central umbilical camera port. And I make the ileostomy in pretty standard fashion, everted brook ileostomy using two omonocryls. So once you've gotten the patient through there... acute colitis episode and you've operated on them, the obvious next question from the patient is what do I do now and what do I do with the rectum?
How do you counsel patients on the next steps in decision making and if a patient's going to choose a pouch, what is your preference in terms of pouch operation? So this is a really big decision for the patient. get over the subtotal colectomy and they have their early ostomy and within a few weeks they're just feeling so much better than they have often for a very long time.
So I actually counsel a lot of my patients just to hold their horses and enjoy being well for a little while before we go on to the next step. I give them some written information about pouches and I have a number of patients who have...
ileostomies and pouches that I get to talk to them so that they can hear from someone else who's been through this that might help them make a decision. For my young female patients, I tell them that they should... really have their families before they make a decision about what they're doing with the rectum because we know that the ability to get pregnant is changed dramatically by having pelvic surgery although most of the data we have comes from
the pre-laparoscopic era. So laparoscopic proctectomy, we'd think, would have less impact. But certainly we'd know that there'd be some impact still. So if they're keen to have children... I tell them to have children before they have the next step. That doesn't mean everybody does that. I've recently done a pouch on someone who's had one child but wants to have more. So they've got one, so that's a good start. I've had another...
patient who's had four children and then decided she actually wanted to keep her ileostomy and didn't want the pouch anyway. Obviously it's different for everybody in different parts of their lives and the way they cope with their body image with a stoma. And I get a lot of help from my stoma therapist and occasionally from an IBD psychologist as well. Certainly the pouch is the pinnacle colorectal operation that there is, and so I quite enjoy doing it.
Also very circumspect with my patients about what their expectations are. I tell them a good result with a pouch is four to eight times going to the toilet per day. So they need to be aware that there's going to be potential for leakage because it's... not solid, and that they are going to have to know where the toilets are everywhere they go, but they won't have a stoma. I tell them that one in 20 pouches fails completely and makes them miserable and will be taken out fairly early on.
and that only a third of people won't experience pouchitis. Now, another third will have pouchitis that's fleeting, but another third will probably have some degree of regular treatment for pouchitis. And whether that extends to immunosuppression is... unusual but most of the time it's going to be antibiotic treatment so i think it's important for the patients to know about pouchitis before they even go down that path it's part of the informed consent process for my patients
If they do decide that they want to have a pouch, I personally make a J pouch for men and a W pouch for women. I've been doing that for some time. It's a little bit of a lost art, the W pouch. But there is data in the literature about potentially better function with a W pouch. And I think that is mostly because it will empty better in a round gynecoid pelvis and fits well there.
whereas a J pouch probably fits better in an Android pelvis. The W pouch is a hand sewn construction and it takes about 30 minutes longer to make than a staple J pouch. There is some evidence that the longer surgery will translate into more thromboembolic complications and that probably is also related to the fact that the W pouch is bigger and rounder and actually may cause a little bit of compression on the pelvic veins.
That's just supposition on my part, not a real proven fact. But in one trial that I was involved in, we did see more PEs on the W arm. My stapled J pouches, I use at least three firings of a... echelon flex 60 stapler i like that stapler for this purpose because it contains a small head that will fit through a small opening in the end of the j pouch i leave the small bow end open
while i'm constructing the pouch because the other quality that the echelon has over the endo gia is it's actually more of a crushing device when you make a pouch with an endo gia the small bowel will continually slide out of the jaws. And so where you started to make it, you might find that you've used anywhere from six firings by the time you get to the tip of the small bowel. That's the...
efferent limb. So I leave it open so that when I've made my pouch length appropriately I can actually use a contour stapler to close off that end and make it really snug with the trouser leg, if you like, of the top of the J. This means you don't have much redundancy in the effrant limb.
where I find that you can get more stagnation, and I don't know whether that truly leads to more pouchitis, but it's possible. After a proctectomy, there is some evidence that it is safe to do a pouch without a diverting ileostomy. I have done that twice in my career and found it very stressful. One of the patients had pain for six weeks after the operation in the perineum, and I thought she must have had a leak, but I couldn't demonstrate anything.
But I sweated over it every day for six weeks until suddenly she woke up one day and the pain was gone. I had been swayed by that patient because she had her 21st birthday coming up and she wanted to have that party without a stoma. Again, my principle is to make the best pouch I can for the long term and I counsel the patients that it's still going to be safer if they were to have a leak to have the diverting stoma in place.
rather than come back and try and clean it out and salvage the situation if they have a leak without a covering stoma. Leaks still occur between 10% and 15% of the time. If you want to keep seeing those patients for the rest of their lives with their pouch dysfunction, you can do it without a diverting ileostomy. I prefer to be very cautious in these circumstances. I also got a little bit confused when I was a trainee about where you actually joined the pouch to.
whether you should be leaving an erectum there, whether you should be stripping the mucosa, whether you're doing a hand-sewn coloanal. What goes into the decision-making for where you do the join and what potential issues do the different options have in the future for the patient? So there are two considerations in this respect. One is the residual disease in the anorectal cuff and the other is the sampling that the anorectal cuff can do of what's coming into the anal canal.
to be passed i prefer to staple both a j or a w and that leaves a cuff of around one to two centimetres of residual mucosa above the dentate line that may still be disease prone. But it doesn't tend to lend itself to causing much of a problem. Certainly anything longer than that will... result in difficulty emptying the pouch and anything shorter than that will have an impact on the ability to sample and continence.
So I only do a hand sign with mucosectomy in patients who've had dysplasia in the rectum or a cancer. And the remaining patients, if it's done purely for inflammatory disease, get a stapled anastomosis done. around two centimeters from any dentate line. If you look at the data on cancer that occurs in pouches, the numbers are very, very low.
Some centres do surveillance pouchoscopy on their patients every 12 months, every two years, depending on the local thinking. The incidence of a pouch cancer in inflammatory bowel disease is around 1 in 15,000 pouches. To me, that doesn't spell a lot for doing regular surveillance, but you may want to be a bit selective about those patients who've had to have a mucosectomy because of the previous cancer or dysplasia.
refer my patients back to their gastroenterologist to do their surveillance and would recommend maybe once every five years unless they're symptomatic of pouchitis. Okay, let's change tack a little bit and talk about Crohn's disease. The first topic I was hoping you could talk to us about is the quote-unquote straightforward ileocolic resection, specifically how you handle the Crohn's mesentry.
what join you do, and also any other tips or tricks you could give trainees for operating on Crohn's patients. All right. Well, first up, we'll talk about what the indication for surgery might be, and that's become a more interesting area. of late because of the potential for doing upfront surgery as opposed to going down a biologic arm. We've got data from the Lyric trial with some long-term follow-up now that really shows that it's a good treatment to have upfront surgery.
If you take all of those patients that were involved in that trial, more than half of the patients that went down the infliximab arm, the non-surgical arm, have had surgery since, and there are more patients taking immunomodulation. in the non-surgical arm than in the surgery arm after eight years of follow-up so you may want to consider an operation as the first line treatment if you have enlightened gastroenterology colleagues other than that then
What it comes down to is the septic indications, and they are penetrating disease that has caused either abscess or fistula. And then there is the stricturing phenotype as well, which will impact on a patient's quality of life. and realistically when you've met someone who's been on treatment for a while you need to make sure that you're doing an operation that is going to impact on their quality of life otherwise what would be the point of doing it
So you'll meet people who've been sick for so long they don't realise that they're actually that sick. People who've been on a liquid diet for months and have been frightened to have an operation. And you've got to take that into account as well.
But realistically, I love food, and I'm hoping that my patients are going to love food too. And if they're losing weight in particular, then you'll want to be doing an operation on them. But at the same time, their quality of life can be majorly impacted by removing a stricture from their terminal arm.
You want to counterbalance that with the length of disease and how much resection you would need to do. And most patients who we see have less than 20 centimetres of disease, certainly less than 50 centimetres. because you will get into that realm of bile salt malabsorption, which again might impact on our quality of life if you're resecting more than that. And certainly if they've had multiple operations before, you're going to be trying to avoid any loss of mucosa.
I tackle an oleocolic resection laparoscopically primarily these days. I don't think it's a great robotic operation and I have a bias as far as my anastomosis is concerned. Crohn's mesentery can be very difficult too. control and some of our instruments are good for dividing Crohn's mesentery and some mesentery will need suture ligation to be happy that you're not going to run into trouble with bleeding.
For the exam you can say that you do an open operation for that reason because of the difficulty handling and dealing with Crohn's mesentery. It's often very thick and friable and when you cut it the vessels will retract into it.
You can then get into trouble with hematomas within the mesentery, which can either rupture later or continue to bleed despite suture ligation. So you want to be very careful about that first division. And, yeah, as I say, use a... an ovicle for thickened pedicles with a transfixion stitch to control the thickness of the meditory and any bleeding from it.
If I get some bleeding from a stump, I'll use a 3OPDS as a fine needle to get into the mesentery and get around vessels. Having said that, we do a laparoscopic approach, and I mentioned previously talking about... colitis surgery that i do a hepatic flexure mobilization first and that really is because you want to stay away from any thickened or inflamed disease process and protect your retroperitoneal structures so i often find that if you've got a phlegmon or a perforation in there
ilium it'll be stuck onto the retroperitoneum so if you can clear the duodenum and even come down on the front of the ureter and the gonadal vessels from above Then you can tackle the attachment to the retroperitoneum from both directions and then you'll have less trouble with damage to something in the retroperitoneum. So I always mobilise the hepatic flexure completely. The argument about...
Total mesocolic excision has been raised with the hypothesis that a lot of the inflammatory drive comes from the mesentery. I tend not to be that vigilant about removing every bit of Crohn's mesentery. I do that mostly because... A lot of patients will have more proximal disease that is not causing strictures that I'm not going to take out and they're going to need some form of therapy post-operatively. We're major contributors to the POCA trial at St Vincent's where we looked at...
the management of patients after their resection and so we will be using both Calprotectin and early colonoscopy to inspect the anastomosis for recurrence fairly early on and a lot of patients will have escalated therapy if they have any disease. So I don't think... that we're saving a lot of people from medical therapy by doing a total mesocolic excision. Once I've mobilised all of the disease and the hepatic flexure, I do an extraction in a super-umbalical space with the...
Middle colic vessels being a rate-limiting step in terms of what I can extract. I like to do a hand-sewn anastomosis end-to-end. I find the information we have following patients over many years that the... side-to-side functional end-to-end anastomosis didn't really save anyone from having redo surgery. And in the last 14 years of doing a hand-sewn end-to-end anastomosis, I've only had to reoperate on one patient.
The big advantage for me as far as the end-to-end is concerned is access endoscopically. So if they do get recurrence, it usually occurs just proximal to the anastomosis, not on the anastomosis itself. That's why the functional end-to-end is still problematic even if you make a 100mm stapled anastomosis. But it's very hard to access that endoscopically where you need to do a 180 degree turn as you're scoping a patient to dilate it.
And we do a lot of dilating of strictures endoscopically that saves a lot of people from redo surgery. So having a straight end-to-end is a real advantage as far as intubating the strictured bowel is concerned. So you will have heard a fair bit about the Kono S anastomosis and seen it talked about at meetings, and indeed there's even some trials going in Australia. This is a hand-sewn anastomosis.
that is done with a buttress between each cut end of the bowel. It does not remove the mesentery. In fact, it preserves the extra mesentery. And in my opinion, it's actually just a hand-sewn side-to-side anastomosis that... The buttress will possibly keep straight for a little while, but once you put it back in the abdomen, I think it'll flop around and become just a side-to-side anastomosis anyway. I haven't seen a lot of endoscopic vision of what it looks like down the track.
But I'm yet to be convinced that it's a useful adjunct despite what the enthusiasts who publish their data might say. The data I've seen on... In terms of recurrent surgery, they do comparisons with historical cohorts that often are pre-biologic era. And certainly my personal experience is that very few patients need redo surgery these days.
So I've got to thank a couple of people for the way I've developed my hand zone in astomosis. Greg Robertson was a surgeon I worked with in Christchurch in my fellowship years who I took a lot of his ideas. and have modified them slightly, but it was one of the greatest surgeons I saw operate and unfortunately it doesn't operate anymore. But I will put a row of held sutures across the mesenteric side as full thickness vertical mattress type sutures.
and then when i've completed the whole mesenteric wall i tie them down and hold the end ones i then use a serum muscular stitch on the outside effectively creating the same vertical mattress from the outside one on each end of the mesentery and then hold one in the middle and make up the sutures in between and hold the sutures without tying down when I get to the last few.
just so I can place them well without getting tied down into a space that's not given me enough room to place them adequately. I've taught a lot of people that anastomosis, a lot of people like it, and it is exceedingly rare that it leaks. For my next question, can I ask you about what you do if there's Crohn's disease fistulating from the small bowel to the sigmoid?
Can you talk a little bit about what you might usually find in these cases and how you actually manage the sigmoid side of the fistula? So the first thing I'm going to mention here is the position of the patient that I put them in for.
all of their surgery and actually had someone point out to me years ago after i had to reposition a patient mid-operation because of this very problem i had a fellow suggest why don't you just put everyone in lithotomy for every operation And so I've done that for the last 20 years now because that repositioning in the middle of finding that you need access to the rectum after mobilising the bowel is a really distressing situation.
I've never had a patient who's had a perineal nerve injury or a traction injury from being in a low Lloyd-Davies lithotomy position. I'm pretty careful about the way I position every patient in that regard, but it just makes...
It's very simple for all of my techs and nursing colleagues. They know the patient's going to be in orthotomy for me for everything. And that way you know that you can control anything that you might not have expected. I guess this came about... from an era before we had MRI scans and could see most fistulas before we operate.
So it's rare to get a surprise these days, but sometimes the phlegmon might be stuck onto something that you are unsure about whether there's true fistula or not, and you may want to scope the patient to check the fistula.
generally occurs on the primary side of the bowel from an abscess or phlegmon that is adjacent to the mesenteric edge of the bowel. And for some reason it seems to often occur at the same place on the sigmoid colon if it's... going into it but it can really occur on any part of the secondary organ that's still
follows the, if you like, the complete mesocolic excision hypothesis that the mesentery is driving the disease and the ulcers, although they might be circumferential, the primary drive and the deepest ulcers will be on the...
mesentery side and that's where the perforation occurs and that's where the fistula links to. When you're mobilising the terminal alium and you think it's stuck on the sigmoid colon, there comes a time when you're going to have to say, all right, we just need to cut through this or get it off.
and usually you can see but sometimes you can't see that there's a hole you'll want to get access endoscopically to the large bowel to have a look and potentially do a leak test like you might for an anastomosis in the pelvis If you have any doubt, I would mobilise the sigmoid colon to the point that you can bring it to the surface and do a wedge resection. You don't need to do a formal resection, you just need a small margin around and often I've done a disc excision.
and just closed it like a pyloroplasty or even just a short segment resection i wouldn't do that with a stapler either i do a hand sewn anastomosis at that level although you could if you are looking at a short segment resection and it's an appropriate level just by luck at the top of the rectum, you might be able to staple that one. What always confused me was, and what I came to realise, is that the primary pathology is usually in the terminal ileum.
basically just remove the fistula and where the fistula is sort of attached to the sigmoid and then you you can deal with the repair you know as required if it's a a small area, you can suture it closed. If it's a larger area and you're going to narrow off the lumen, then you might do a short segment resection, but that you don't have to do a formal bowel resection and typically the sigmoid isn't.
involved with the Crohn's disease. It's just been a side effect of the fistula or the abscess from the small bowel. Yeah, so it is generally the secondary organ, but it can have varying levels of involvement in a phlegmon.
So what you're putting back together needs to be free of inflammation. And whether or not that's a small disc or it's a longer segment is going to individually depend on the pathology. But, you know, you don't need to resect the whole... sigmoid colon if there's a small fistula there without much inflammation around it
One last question before we move on from an ileocolic resection from Crohn's. What margins do you aim for? Where do you decide to stop resecting the bowel with a Crohn's resection? What's the sort of decision making that goes into that? So the Cleveland Clinic in the 1980s and 90s did a trial looking at a 10 centimetre margin and a 2 centimetre margin from what was macroscopically visible in terms of disease and found no difference between the recurrence in either side.
I've tended to use that 20mm margin, although I sometimes will make it less than that depending on what the bowel looks like. One of the advantages with the hand-sewn anastomosis is that you can get a good view into the open end of the bowel that you are...
using for your anastomosis and sometimes you'll see a few extra deep ulcers that you didn't know about a little bit more approximately and obviously you don't really want to put those into your anastomosis so that is a macroscopic level of disease that you can see so
If it's not going to be a lot of resection in terms of length of small bowel, I'll try and clear all the ulcers that I can see within the lumen. But a lot of the time I'll accept that the patient's going to need treatment and ongoing maintenance and just... resolve the stricturing disease if it looks like I'm going to have to take out too much small intestine. I wouldn't take an extra 15 centimetres based on the ulcer appearance.
The fat wrapping and induration of the bowel are the primary indicators of my margin usually for me. And so I'll try and extend about 20mm beyond that, what I can see from the external side. So we're quite lucky at St Vincent's Hospital in Melbourne to have a very diverse and large referral base and a lot of gastroenterologists who are sought out for their expert opinions.
This translates into a lot of referrals for surgery because that is the ultimate destination for a lot of these patients whose medical therapy is not working. It means that our trainees get a lot of exposure to both. perineal in particular, and Illuminal Crohn's disease. And when we looked at our data compared with most of the other centres that are doing colorectal training, an annual experience for one trainee might be what you get in six weeks at St Vincent's.
So you may well be sick of Crohn's disease after spending 12 months at St Vincent's or you might be sick of it after three months really but you'll get a lot of knowledge and exposure if that's what you're looking for. So the last topic I wanted to talk to you about today is strictureplasty. Again, another thing that a lot of trainees may not see during their training.
What strictures would be suitable and what patients would be suitable for stricture aplasty and what are the options and how do you do it? So it's a less common presentation but extensive small bowel Crohn's disease is what we're looking at. when we decide to do strictureplasties. This is a mucosa-preserving operation and basically most of the patients who we're considering in have extensive disease across areas, although you can use it just in an isolated sense.
It doesn't tend to work well across the ileocecal valve or across an ileocolic anastomosis, but you'll find there are patients who have multiple strictures up the bowel, and what you'll do is pick one of the definite strictures that you're going to... operate on and open the lumen longitudinally along the anti-mesenteric border.
And then I tend to take a Foley catheter and concertina the small bowel up over the surface of that with the balloon blown up with around 5 mils and then try and run it through and pick off the strictures and put sutures in to mark where they are. and that will tell you about any other disease in either direction so your first stricture that you pick you may well want to do that in the mid small bowel so you can go easily in either direction
You can use a vascular foggy balloon if you think your length of your catheter is not long enough, but most of the time I tend to just use the usual folly. The open longitudinal cut is then closed with interrupted sutures transversely.
leaving a wider lumen and the same look as a Heineke-Mikulich pyloroplasty, which is what it's generally referred to as. For longer strictures, you can do a finny, but I don't... find a finney is that useful because although you are preserving some disease it will sometimes recur at either end of the entry point to the finney strictoplasty or the exit point and that means that you've ended up with a saccular
sort of dilated bit of small bowel that probably isn't getting any absorption from it and may well result in bacterial overgrowth as well. The strictoplasties are really useful. tool for making sure that you don't have to take out a lot of small bowel when someone's got extensive disease. And you can do it multiple times. And I've done one patient where I did three small resections and 10 strictoplasties.
And I'd rather do a small resection than the Finney Lyme, considering whether the Michelassie operation, which overlaps areas of stricturing disease. in a long anastomosis might be suitable for some of my patients, but I haven't found a need for that the way some other surgeons have. It seems a very elegant operation though, quite like the idea. I think that's enough IBD for today. As our very last topic, I want to ask you about something that's completely unrelated to IBD.
And I saw you do a couple of times at St Vincent's and I thought it was a really elegant approach to what can sometimes be a very unelegant part of colorectal surgery. If you're doing an anastomosis and you want to clear the upstream column of stool, say for a patient, presenting with an obstructing cancer and you're going to do an anastomosis and a covering ileostomy. Can you talk us through your approach to doing a clonic washout intraoperatively? Okay, so I'm not a big fan of...
stomas and I'm not a big fan of Hartman's procedures in particular if the patient's not particularly unwell. If you look at the data you can see that a lot of Hartman's procedures don't get reversed. So I will try and do an anastomosis in every patient if I can and if the bowel is dilated and looking a bit tatty and you want to wash it out before you join it up, then I was taught a technique which I think is quite neat and odourless, which is even better.
so i've got some anesthetic tubing sterilized for just this purpose in my hospitals and what i do is either take the appendix as a conduit for inserting a catheter or the site of my potential ileostomy if I'm going to use one. And I put a Foley catheter in through either of those two orifices into the cecum and then I run some warm saline usually.
the bags that they would use in neurology the two litre bags into the bowel now before i start running that what i do is take the end of the bowel that i'm looking at anastomosing and going a little bit more distally and i'll open that bowel and put the sterile anesthetic tubing into an area where i purse string the bowel around that anesthetic tubing the other end goes off into a double yellow bag
and we put a nylon tape around both ends that I tie down to the bag and to the bow. The cuff on the anaesthetic tubing is a really good place to snug down your knots in the nylon tape. And then when you start running the irrigation into the bowel, it'll siphon off and into the bag that you've got on the floor. Now, as it siphons off, it'll suction part of the bowel. So it can be difficult to maintain the irrigation. So you do need...
that mobility of the bowel to milk the faecal material through but then when you're finished you can cut off the bit of bowel that has the purse string and the anesthetic tubing in it and drop it into the second bag that you've got around the original irrigation bag tied up and no one's smelt or seen a thing and the bowels all clean. We might have to do a video recording of that because I think it is a really great approach to what can be quite a messy procedure at times.
Thank you so much for finally letting me pin you down to do this podcast episode. I'm sure everyone's learned so much about management and surgical management of IBD. I'm really grateful for your time. Any last minute words of advice or wisdom for trainees who are... Sitting their fellowship exam? It's always simple surgery is the answer in the exam. Nothing too sexy is what one of my mentors told me.
And that's it for this guest episode on inflammatory bowel disease surgery. Thank you so much for joining us and I'm sure you'll all join me in thanking Michael Johnston for coming on the program and sharing all of his wisdom about inflammatory bowel disease surgery.
I'm so grateful to him for giving up his time to talk to us today, but also really proud to have him on the program because he's been such an amazing mentor to me over my entire career. And it makes me really happy to be able to have him on the podcast to share. A little bit of what he's taught me over the years with all of you as well. It's time to close up. Thanks for listening to First Incision. If you have any comments or feedback...
send us a message at firstincisionpodcast at gmail.com or follow us on Instagram at firstincision. Happy studying!