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Strategies for Blood Conservation in Complex Colorectal Surgery

Strategies for Blood Conservation in Complex Colorectal Surgery. Andreas M Kaiser, MD FACS FASCRS Professor of Clinical Surgery. Division of Colorectal Surgery Keck School of Medicine of USC. Disclosures. Consultant for Ethicon Endosurgery Consultant for American Medical Systems

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Strategies for Blood Conservation in Complex Colorectal Surgery

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  1. Strategies for Blood Conservation in Complex Colorectal Surgery Andreas M Kaiser, MD FACS FASCRS Professor of Clinical Surgery Division of Colorectal Surgery Keck School of Medicine of USC

  2. Disclosures Consultant for Ethicon Endosurgery Consultant for American Medical Systems Salix, Inc (Solesta) Advisory Board McGraw-Hill Uptodate AM Kaiser McGraw-Hill Manual Colorectal Surgery 2009

  3. Background - Traditional surgical thinking Operation = loss of blood Inability to transfuse = high risk of death Cancer is the only justification to operate on a Jehovah’s witness patient, because the cancer would cause death if left untreated

  4. Background - Traditional surgical thinking Fear factors: Surgeons Anesthesiologist Hospitals … and the patients?

  5. Background - Traditional surgical thinking … leads to a nihilistic approach, i.e. patients do not get the appropriate care they would need for their symptoms/problems.

  6. Educated surgical thinking Goal: to provide the highest quality care to all patients who wish to avoid the use of blood transfusions

  7. Educated surgical thinking Strategy I: Optimize blood levels prior to surgery Strategy II: minimize loss of blood during operation (P.S. … not just for JWs!) Strategy III: Select less invasive alternative procedures Strategy IV: Operation as tool to minimize loss of blood

  8. Irony in surgical evolution: Parallels • HIV epidemic/HIV patients • Bloodless surgery • Historical fear to take care of these patients • Both groups of patients triggered a change in surgical technique and strategy: • Avoid bleeding • Increase transfusion threshold • Reduce need for transfusions

  9. Spectrum of colorectal diseases Abdominal and pelvic: cancer / tumors of the colon / rectum: established cancer precancerous conditions: polyps/polyposis syndromes diverticulitis inflammatory bowel disease (IBD) pelvic organ prolapse constipation radiation damage post-surgical problems

  10. Spectrum of colorectal diseases Anal: hemorrhoids, lumps and bumps incontinence abscesses / fistulae/fissures anal tumors anorectal malformations Endoscopic polyps tumors screening

  11. Last 13 years at USC 61 colorectal surgeries in 51 patients: Abdominal: 38 - cancer / tumors of the colon / rectum - diverticulitis - inflammatory bowel disease (IBD) - prolapse - constipation Pelvic: 12 cancer RV fistula Anorectal: 6 Endoscopies: 5 (not reliably counted) 50 major cases: Mortality = 0

  12. Anatomy Segments: Ascending colon Transverse colon Descending colon Sigmoid colon Rectum Each segment has: Bowel Blood vessels Lymph nodes

  13. Anatomy of Hemorrhoidal Disease External hemorrhoids Pure internal hemorrhoids Hemorrhoidal plexus/cushions are part of the normal anatomy and may contribute to the continence mechanisms! Mixed hemorrhoids

  14. Spectrum of colorectal techniques Abdominal: segmental or total colectomy sphincter-saving ultralow resection/coloanal anastomosis total mesorectal excision (TME) multiorgan resections (e.g. pelvic exenteration) pouch procedures, continent ileostomy (T-pouch) laparoscopic surgery (LAC), hand-assisted laparoscopic surgery (HALS), robotic surgery stoma creation Anal: transanal local excision – excisional and stapled hemorrhoidectomy (PPH) transanal endoscopic microsurgery (TEMS) artificial bowel sphincter (ABS, Acticon Neosphincter) office procedures: banding, I/D, etc Endoscopic: colonoscopy / flex sigmoidoscopy virtual colonoscopy

  15. Bleeding risk Abdominal/pelvic, major Abdominal, minor Anorectal Endoscopic

  16. However: … … … anticipate! • E.g. • Colonoscopy: • Perforation, bleeding at polyp stalk, etc • Rectal prolapse: • perineal approach: better tolerated, but if ischemia  lots of bleeding • Fancy MIS procedure: • disorientation  injury to ??? • Determine whether complication of a “simple” procedure could require severe, risky procedure!!

  17. Evolution of surgical management • Better knowledge of anatomical planes • Minimally invasive techniques: • initially only for the smallest/safest interventions • evolution of MIS to be applied to MAJOR surgery • Changed transfusion strategies: • Negative impact on immune system • Reduced transfusions even in non-JW patients • T/S, but no routine T/C before CRS operations

  18. Minimize bleeding during surgery Three major driving forces: Transfusion-borne infections / reactions HIV Hepatitis CJD Development of laparoscopic surgery Increasing experience Increasing complexity of cases Increasing competition Jehovah’s witnesses  benefit and improved quality of surgical care for all, because it is good medical practice

  19. Patient categories Category One: Patients will decline blood and blood products IN ALL SITUATIONS. Category Two: Patients will consider the use of blood and blood products in serious/life-threatening situations.

  20. Educated surgical thinking Strategy I: Optimize blood levels prior to surgery Strategy II: minimize loss of blood during operation (P.S. … not just for JWs!) Strategy III: Select less invasive alternative procedures Strategy IV: Operation as tool to minimize loss of blood

  21. Strategy I: Optimizing the patient For pre- or post-operative anemia, medications can be given to boost the bone marrow to make more red blood cells Recombinant erythropoietin: biosynthetic form of natural human hormone responsible for stimulation of red blood cell production. It is manufactured using recombinant DNA technology Improve nutritional status Treat the disease conservatively Timing!!!

  22. Educated surgical thinking Strategy I: Optimize blood levels prior to surgery Strategy II: minimize loss of blood during operation (P.S. … not just for JWs!) Strategy III: Select less invasive alternative procedures Strategy IV: Operation as tool to minimize loss of blood

  23. Strategy II: Minimize bleeding during surgery Meticulous surgical technique and extra caution Exact knowledge of the anatomy and anatomical planes allows smoother advancement Modern techniques for prevention/stopping of blood loss: clamping or cauterizing of bleeding vessels use of non-traditional cutting scalpels staplers argon beam coagulators / surgical lasers energy blood vessel sealing devices Fibrin glue etc? Cell saver?

  24. Tools for prevention / stopping of bleeding Stapling instruments A B

  25. Energy devices for bloodless dissection Ultrasonic scalpel Electric vessel sealing devices C A B

  26. Tools for prevention / stopping of bleeding and blood loss hemostatic agents A B C D

  27. Tools for prevention / stopping of bleeding and blood loss Fibrin glue Thrombokinase + Ca2+ Prothrombin II Thrombin Fibrin Fibrininogen I Factor XIII

  28. Anatomy Segments: Ascending colon Transverse colon Descending colon Sigmoid colon Rectum Each segment has: Bowel Blood vessels Lymph nodes X X X X

  29. Prevention / stopping of bleeding Surgical technique!!! • Example: rectal cancer • Evolvutiont of best surgical • technique: • Less bleeding • Better chance to perserve the anus • Better survival • Less tumor recurrence

  30. Surgical techniqueSpecimen-oriented resection under visual control Kaiser AM - McGraw-Hill Manual in CRS, 2008 • Dissection in the avascular areolar plane • Intact mesorectal compartment containing LN • Smooth external appearance • No specimen waiste

  31. Educated surgical thinking Strategy I: Optimize blood levels prior to surgery Strategy II: minimize loss of blood during operation (P.S. … not just for JWs!) Strategy III: Select less invasive alternative procedures Strategy IV: Operation as tool to minimize loss of blood

  32. E.g.: CR Emergencies – Treatment Options Once problem identified decide on approach • leave it in • take it out • drain it • scope • stent • divert • …

  33. Large bowel obstruction – Txoptions • Discontinuous resection with stoma (Hartmann) • Segmental resection with primary anastomosis (w/woontable lavage, w/wo proximal diversion) • Extended resection with ileo-colonic/-rectal anastomosis or stoma • Proximal stoma only • Stenting • definitive • as bridge to surgery • Asgeirsson T & Kaiser AM - Hospital Physician General Surgery Board Review Manual. 2010;9:2-12.

  34. Large bowel obstruction – extended resection • 65 y/o JW, kept for 3 months @OSH for TPN to bring up H&H  Transfer with complete LBO

  35. Stategy III: Less invasive treatment optionsE.g. obstructing colon cancer • Placement of metallic wall stent • Stretch open a narrow segment • avoid emergency operation/ avoid ostomy

  36. LBO - Stenting • … followed by (semi-) elective resection

  37. Are there limits despite best technique? Yes: occasionally a disease / condition / tumor has such an unfavorable appearance/location that the theoretically optimal treatment cannot be performed: E.g. if: a cancer has grown into major vessels, a removal could only be performed with available transfusions a tumor sits so deep in an inaccessible area that part of the operation would have to be done just with tactile sensation but without view

  38. Bloodless surgery - Decision-making process Disease severity Clinical exam DDx DECISION FOR SURG? Age/ Comorbidity etc Complication Surgeon + 1°TEAM Multiorgan failure Response to cons mx

  39. Educated surgical thinking Strategy I: Optimize blood levels prior to surgery Strategy II: minimize loss of blood during operation (P.S. … not just for JWs!) Strategy III: Select less invasive alternative procedures Strategy IV: Operation as tool to minimize loss of blood

  40. Strategy IV: Operation to minimize loss of blood? ?

  41. Case discussion 55 y/o patient Jehovah’s witness 1 year history of ulcerative colitis, i.e. inflammation of the large intestine Seen in the office to discuss role of surgery  just started on more aggressive medications: no response yet. Major surgery would be needed and would involve removal of the whole large intestine and reconstruction ?

  42. Case discussion (cont’d) 4 weeks later: acute admission for massive thrombosis to lower extremities, involving whole vena cava for that condition, he needs to be on anticoagulation anticoagulation causes the colon to bleed, hematocrit dropping to 21. SURGERY? ?

  43. Case discussion Normal blood level Critical blood level TIME

  44. What should we do? Perform surgery? Wait with surgery? • Contra: Risk of further bleeding, dropping of blood level below critical level • Pro: removing the diseased organ, reducing the hypercoagulable state • Contra: continued bleeding from diseased organ • Pro: Avoid bleeding during operation

  45. Case discussion: window of opportunity? Normal blood level Critical blood level TIME

  46. Surgery was performed Removal of the diseased organ During the surgery: no blood loss postop Hct from 21  22.

  47. Case discussion Normal blood level Critical blood level OPERATION TIME

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