E101 Masterclass with Helen Macrae on Approach to Acute Colitis, Total Colectomy and Pouches
Listen to this podcast on SoundCloud
Chad Ball 00:04
Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity and fulfillment of the surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:37
This week we had a masterclass on the surgical management of inflammatory bowel disease by Dr. Helen Macrae. Dr. Macrae is a colorectal surgeon at Mount Sinai Hospital in Toronto and has an extensive background and amazing practice taking care of patients with inflammatory bowel disease. On this episode, we focused on the acute clinic, and how to manage that patient in hospital, as well as her technical tips and tricks for both total or subtotal colectomies, as well as J-pouch reconstruction. So, sit back and enjoy our discussion and conversation with Dr. Helen Macrae.
Chad Ball 01:15
I was wondering if you could tell us where you grew up and what your training pathway looked like?
Helen Macrae 01:20
Okay, so I'm a Westerner originally. I grew up in Edmonton. I was born in Edmonton, raised there and went from high school to the University of Alberta. At that time, you could do two years of premed. So, I did two years of premed and then I went into medical school directly after that as well at U of A. And then after that, I was looking initially, I was interested in doing a trauma and ICU fellowship. And I actually had a fellowship in ICU setup in Vancouver where my husband was in practice. But one of my last rotations in general surgery was with colorectal surgeon, Ernie Wiens. And he sort of said to me, trauma and ICU, that's going to keep you up at night and out of the ER. And I sort of thought, yeah, you're right. And I really loved his practice. And so that's when I decided I wanted to do colorectal surgery. After I finished med school, that was in the 80s, mid 80s. At that time, most people in Western Canada were still doing a rotating internship. And so, I went to St. Paul's Hospital in Vancouver for rotating internship. So, during medical school, I really loved general surgery. But at the time in Edmonton, there were no female general surgeons, no female role models in general surgery. And I just wasn't sure if that was something I wanted to commit to long term. So that was another reason why I decided on the rotating internship. So, I moved to Vancouver for a year and left it there. Left St Paul's from west in Vancouver. It was a very interesting year because it was in the height of AIDS, and I could tell you St Paul's hospital was really the height of aid in the 80s. My first central line, I remember was a patient in ICU with PCP pneumonia, and I gave them not just pneumothorax but a tension pneumothorax. I've never been able to put in an IJ line since then, without having my heart rate go up to about 150. Anyway, after I finished my rotating internship, I actually did a year of general practice locums in the interior. But by that time, I pretty much decided that I wanted to do general surgery. So, I applied to two programs: UBC and U of A. And at the time I decided to go back to Edmonton. So, I did my general surgery at the University of Alberta at a time that I think general surgery residency was pretty tough. I was on call the last two years of my residency but really felt like you could deal with anything when you finished. I'm a lot more of a wuss now than I think I was at the end of general surgery training.
Chad Ball 04:40
Well, that's fascinating. I didn't ever know that you were from Edmonton. So, I'm going to make the assumption, the hopeful assumption with full disclosure that you're still an Oilers fan as opposed to a Leaf's fan.
Helen Macrae 04:50
You know what, I'm a Raptors fan. It's so funny because I grew up, my dad had tickets to the Oilers from when they were in the WHL? The World Hockey League?
Chad Ball 05:05
WHA, yeah for sure.
Helen Macrae 05:07
So, he had seasons tickets like through all the Gretzky years and everything and I was dragged to a lot of hockey games. And was there during the Stanley Cup run and everything so I was a big Oilers fan then. But since moving to Toronto, I have to say, I'm more of a Raptors fan. Although it's not looking good.
Chad Ball 05:28
Yeah, it's been a tough year. That's really funny. Well, I'm sure we were in the building at the same time because my parents growing up had those tickets, and they used to drop my brother and I off, and often we'd wander into the game, some of the playoff games even. And they would go for dinner. And to this day, I can't figure out why they did that. But boy, we were lucky beneficiaries of it. You know, one of the things that Toronto is, amongst many things, clearly so well known for is the powerhouse nature of many high-volume fellowships. And obviously, I'm biased on the HPB transplant side of things. But your colorectal group for decades has been recognized as one of the very preeminent colorectal fellowships in the world. How did that come about? And how have you guys achieved such a strong legacy and perpetual, both academic and of course, clinical footprint?
Helen Macrae 06:21
So, I think that Robin McLeod and Zane Cohen really were instrumental in developing the program. And, you know, they were really started at a time when colorectal was really gaining ground, you know, at around the time that pelvic pouches were starting to be done and TME for rectal cancer was starting to be recognized. And so, they, I think that Robin and Zane really complemented each other. Zayn is a fantastic administrator and was really good at pulling together a team of people. So, he brought GI radiology pathology, stoma, therapy, genetics and nursing all together, really allowing for the comprehensive treatment of colorectal cancer and colorectal patients. And I think at that time, you know, now we sort of talk about the team-based approach, and everything. But I think if you're thinking about the 80s, medicine was probably still a lot more siloed than it is right now. And I think Zane has always been very good at bringing people together for a common goal. And then Robin had clinical epidemiology training. She's got a motor and an engine like nobody you've seen. Marcus Bernstein always says, she's the best three people I know. It's true. I mean, Robin Hood's great, really can get an incredible amount accomplished. And so, I think she really ran with developing databases and getting research off the ground and looking at quality of life measures. Again, really getting in on the forefront of that type of thing when people were just starting to look at quality of life as an important outcome for surgery. So, I think the two of them really worked synergistically and the rest of us have just been riding on their coattails. They were also both fantastic surgeons and teachers. So that combination really developed a really good program. And then they put together the fellowship bringing other colorectal surgeons from their around the city, Marcus Bernstein, Richard Resnick, Zane Cohen, Robin McLeod, were all part of the fellowship and I think that really got things started and off the ground.
Chad Ball 08:48
Well, I think you're too humble, you know. All of you guys, as you as you insinuate, have contributed so much to that fellowship and your legions of trainees will certainly, and do often, comment on that. You know, one of the things I think we know you nationally for is your, essentially, as a master surgical educator, your work in surgical education. You were for sure the director of the surgical skill center in Toronto and amongst many, many other things. It's a paper that you and Richard Resnick wrote I think almost 15 years ago, give or take in the New England Journal. We quote that paper a lot on some of the trauma simulation stuff and some of the Spaceflight stuff that Andy Kirkpatrick and the group of us do here as well. In terms of how you talked about virtual reality and simulation, in the field of surgical education really, really early compared to really almost everyone else in the world. How did that sort of evolve and I'm curious how that paper came to be and where do you see the big challenges in that arena going forward for surgery and surgical training in particular?
Helen Macrae 10:03
Well, I have to say that there, I was riding on Richard's coattails, because I think Richard was really, you know, he was one of the first people that had master's in education. And looked at surgical education as a career pathway. You know, putting surgery and education together, like other people maybe put clinical epidemiology and surgery or basic science and surgery together. And so, Richard, very early, was interested in the idea of ex vivo training for surgical skills. And one of the first labs in North America for surgical skills training really was here at Mount Sinai. That started in the early 90s, early to mid-90s. And at that time, you know, we also developed a curriculum for our PGY ones, and twos, in technical skills training in the lab. So, I think that based on the research that we had done here, in terms of teaching technical skills and how that can transfer to the operating room, that's where that paper came from. At the time, we were pretty early in virtual reality. And I think in some ways, we're still not that far along in the use of virtual reality and surgical training. But I think that overall, people have embraced ex vivo training of surgical skills and moving some of the technical training outside of the operating room.
Ameer Farooq 12:14
I think that's well said. And like I said, before we started the podcast, we could talk to you about the surgical education stuff at length as well, but we wanted to leverage your other, you know, area of expertise, and you become a guru in Canada and in North America for inflammatory bowel disease patients. And right off the hop, the one thing I wanted to ask you to start off with is why did you get interested in IBD? You know, I think, rightly or wrongly, a lot of surgeons actually kind of are worried about IBD patients in that patient population, because sometimes it can be a challenging patient population to treat. So, what drew you to IBD initially?
Helen Macrae 12:56
So, why I like IBD. First of all, having done my fellowship at Mount Sinai, we've really did a lot of IBD during fellowship, but I really like the IBD patients. And the IBD surgery. I love IBD surgery at this stage of my career, it's pretty much all I'm doing. I do the occasional, either benign or malignant colorectal case. But I would say 95% of what I do now is IBD surgery. So people say that the IBD patients are challenging, but when you think about these poor patients, I think you just have to be a little empathic about them, you know, here are these poor 20 year olds that are trying to get through their education, meet somebody, get on with their life, you know, it's a time of life that's very exciting, and lots of things going on. And on top of all of the normal things that people struggle with, you know, what am I going to do in my career? Who am I going to marry? These poor patients have also have to deal with chronic illness. That's not an easy illness, necessarily to talk about. And so, I think it can really have a devastating effect. I find that a lot of these patients who've had a lot of encounters with the healthcare system for them, you know, the lack of control over their life can be an issue and so I just try to think about where they are in their life. And I don't find the vast majority of them are difficult once you get to know them and know what their fears are. I don't really find that they're difficult patients. There are the occasional ones, but there are the occasional difficult patients in any field. I mean, trauma. The patients aren't exactly known as being fantastic. Also, the IBD surgery I mean, I think that there's a nice mix of, you know, fairly straightforward cases like subtotal colectomies, and then some of the more challenging Crohn's patients or redo pouches. So, it's, it's kind of a nice mix of operations I find as well.
Ameer Farooq 15:20
I think that's really well said. And I think you're right, that the stereotype isn't really true. And it's so important to have that understanding of how hard that must be, to just be in so many different health care situations and have to meet so many different providers and tell your story again and again, and then deal with all the symptoms that they have to deal with. So, I think that's totally right. So why don't we segue into a scenario that I was hoping to leverage your expertise on? So, I think a pretty common scenario is, you know, you're the general surgeon on call. And you get a 35-year-old female with newly diagnosed ulcerative colitis. And she's sort of in that state where she's presenting acutely with 15 to 20 bloody bowel movements per day, abdominal pain, she's tachycardic. How do you approach that patient who's sort of presenting in, you know, sort of a full colitis type picture?
Helen Macrae 16:15
Well, I think that some of the key elements that you want to think about on history and physical examination is, first of all, I want to know, you know, when I get called from our gastroenterologists, about an acute catalytic, how worried do I have to be? Is this somebody that I'm worried is going to preferorate in the near future? Like, how sick do they look? Do they have fever, tech, cardia? Anything? Do things have to be done urgently? Or do we have a bit of time? So, that's sort of my first overall approach is how sick are they? I have to say that most of the time, like unless there's something that you urgently have to operate on, you have time to sort of get to know the patient a little bit, give medical therapy a chance to work. So, I usually will go in, I'll introduce myself, take a little bit of a history of their disease, look at how sick they are, if they look like someone who still has the option for some medical management of their colitis, then I kind of back off a little bit and let the gastroenterologist deal with them initially. We do talk a little bit about surgery. But I like to initially just kind of introduce the idea of surgery without overwhelming someone with too much information. If we have time to do that.
Ameer Farooq 17:39
I'm curious Dr. Macrae, at Mount Sinai do the gastroenterologists sort of consult you on almost any ulcerative colitis patient that they admit to hospital? You know, I know in Calgary where I did residency, the group at the Foothills actually had a very good relationship with Dr. McLean and Dr. Buoy. And so, they sort of had this agreement that they would ask the surgeon to kind of be involved with anyone that they thought potentially might need surgery, even if they were fairly certain that medical management would be an option in that patient, just to sort of have them be involved from the get go. So there's not sort of a, you know, an emergency situation where you're coming in, meeting the patient the first time. Is that sort of the relationship you have at Mount Sinai? Or how does that relationship play out?
Helen Macrae 18:26
Yes, it really is the type of relationship that we have. Pretty much anyone that they're thinking of putting on steroids for, you know, is sick enough to be admitted to hospital. And I have to say, the vast majority of them, we probably don't operate on, on that admission. But you know, a lot of times I think that patients need to know what the alternatives are, because otherwise they're making decisions based on a fear of something. And so, I think it's important for patients to see a surgeon and to have a discussion about what surgery involves, what the reconstructive options are, and everything so that they're not making decisions based on a fear of surgery. The other problem sometimes is that gastroenterologists and patients get into almost like a cycle where surgery is a failure, as opposed to surgery is another treatment option. You know, and for patients that have failed a couple of biologics, I think that it's important. I always tell our gastroenterologist once they're switching biologics, just to have the conversation about surgery. I think it's important for patients just so that they really know what their decision, what their options are, as opposed to just making a decision based on fear of surgery.
Ameer Farooq 20:07
Yeah. And I want to come back to that in a second. Because I think that's so critical in terms of how you have that discussion and frame that whole decision. Because, as you say, there's this perception for patients that if they have to have surgery that that they failed, you know, that word "failed" medical management really does play heavily into patient's minds. So, I want to come back to that here in a second. But before we do that, I just want to ask for completeness sake. Is there any workup that you routinely make sure happens for these patients? You know, let's say, who gets admitted. They have formative colitis. They're being treated medically. But yet they still seem like they're heading towards surgery. Is there any workup or imaging that you sort of routinely want to see before you'll consider them for surgery?
Helen Macrae 20:58
Well, generally, they will have sort of the whole workup including, you know, looking for C Diff looking for CMV, making sure you know that there's nothing other than colitis that's treatable. If they're quite sick, we'll usually get a CT scan just to make sure that there's no small bowel inflammation, not that that's really going to change anything in a really sick colitic. And then, often a Flex Sig, just to make sure, again, that there aren't any surprises. But other than that, I don't think that there's anything I really would feel strongly I needed. In your 35-year-old, I'd want to make sure that her sphincter was okay. Even preoperatively, because, you know, somebody that's had vaginal deliveries, if they had any sort of instrumental delivery, there's almost always a sphincter injury. And it's not that it's going to change the first operation, but it does potentially change their options for the long term. So, I always assess the sphincter muscle.
Ameer Farooq 22:15
I know usually, the gastroenterologists are sort of involved, in charge of the medical management piece of this, but how do you sort of think about the triggers for surgery and in the context of medical management? You know, obviously, I think the mainstay for these patients is getting put on IV steroids. But, you know, what are the things in your mind that will tell you, look, this person needs to have surgery? Is there a time frame that goes through your head or sort of a treatment pathway that these patients go down to that really tells you that, you know what, this patient just needs to have surgery?
Helen Macrae 22:51
I think that sometimes they're a little bit slower than we would be. If somebody hasn't responded at all within 72 hours of IV steroids, I think you've got to be thinking either something else or surgery. If there's obviously anything that makes you worry, like they've got peritonitis, if they've got fever, then those things make me very concerned. The other thing that I like to look at a little bit is the albumin and when it's starting to get really low. I think that that's a bad sign. So, I keep an eye on the albumin and nutritional status as well.
Ameer Farooq 22:51
I think the hard part, Dr. Macrae sometimes is that there will be a patient who perhaps gets a little bit better on steroids and they're already on a biologic and gastrologists are talking about, you know, switching them to another biologic, as you talked about. How do you sort of navigate that situation where, you know, they're not sick? And well, you know, they're not getting sicker, I should say, but they're not clearly ready to go home or they're not better yet. They haven't clearly responded. Especially in that scenario, you might have to switch biologics, how do you sort of navigate that particular scenario?
Helen Macrae 24:13
So that particular scenario, I mean, with the non-urgent colitic, I have to say that I never tried to push them into surgery. Because patients have to feel ready for surgery and obviously, unless it's a life-threatening situation. But in patients that are just sort of grumbling, I start to talk a little bit about the inevitability of surgery that, you know. You failed the biologic, the likelihood that suddenly the next biologic is going to make a huge difference is starting, it's probably reasonably small. That if you want to try it as long as you're otherwise relatively stable you can. But I start sort of pointing out that they're feeling very unwell. But likely, with surgery, they're going to feel better a lot sooner. I quote quality of life studies suggesting that patients with colitis that end up needing surgery, 96 to 97% feel that their quality of life is better after surgery. So those are the types of things I would talk to them about. But again, you know, unless it's really life threatening, the patient has to feel ready for surgery. But I find that as you sort of start to come and talk to them a little bit and have developed a bit of a rapport with the patient so that they trust you a little bit more. Most of the time, they end up getting the surgery.
Ameer Farooq 25:56
Can you walk me through how you approach that discussion? Because I've seen a lot of people do this, that discussion, particularly in hospital, and what always strikes me is that it's very hard to do that discussion, because there's so many different aspects and things that you have to think about, you know, particularly in young patients, you know, there's the aspect of sexual dysfunction and fertility. There's the medication side of it, there's the symptom side of it. You know, all those different factors kind of play into it. The previous information that they have received about surgery, all of those kinds of factors play into that discussion and their perception of surgery. So, can you walk me through how you actually approach that discussion?
Helen Macrae 26:41
I talk a lot about how they feel overall, because I think that, you know, you have the acute situation. But most of the patients, especially the ones that have failed the biologic, have had sort of chronic disease for quite a while. And so, what I ask them to reflect upon, is how they are compared to other people they know their age, what their energy level is, like, you know, can they go to the park with their kids? Can they reliably do what they want to do? Or are they allowing the disease to take over their life? And most patients with sort of chronic ulcerative colitis, they'd have sort of this grumbling, pan-colitis. When they really reflect on their quality of life overall, not just right now in hospital, but how the disease has affected their life overall. They recognize that they're chronically fatigued, that they aren't doing everything that they want to do. That they are missing hockey games, etc., because of their disease. And so, I really try to frame surgery as a quality-of-life intervention so that they look sort of more broadly rather than just right now trying to deal with the acute phase. Sort of looking at getting better for the long term.
Ameer Farooq 28:14
So let's go back to our scenario, you know, this patient that got admitted needs a colectomy. They haven't responded after 72 hours, and it's clear that they need surgery. Can you talk us through briefly how you approach the laparoscopic total abdominal colectomy in this situation, you know, everything from sort of positioning to ports, how do you sort of approach that operation?
Helen Macrae 28:43
Okay, so always have them marked for stoma preoperatively. Always. To the point that in our hospital, we have stoma therapists, but we also have nurses on the surgical wards that are trained to do proper stoma marking because quality of life with a stoma is completely dependent on how good a stoma you get. And one of the important factors is where's that stoma sighted. And so, you can't cite a stoma properly with a patient lying on the table asleep in the operating room. You have to have it cited ahead of time. So, in terms of the surgery, I'm lazy so I do it supine. I don't put them in stirrups. If you're going to do it supine, you do have to be able to work a little bit backwards at the splenic fracture. But I find that that's fine. So, I have both arms tucked, patient supine. At the start of the procedure, I always put in a rectal tube. So, I use a 30 Foley, just blow up the balloon with 10 CC's. And the reason I put it in at the start of the procedure is first of all, then I don't forget, at the end of the procedure, sometimes the patient's waking up at the end of the procedure, and so it's more of a pain to get it in. Also, as you manipulate the rectum during the case, sometimes you'll get stool coming out, so it keeps the area cleaner. So, I always start with the rectal tube in, catheter in. I put my 12-millimeter camera port just above the umbilicus. And then I do two five-millimeter ports on either side. I always start with the medial to lateral approach, and I start on the right colon. So, I do a high ligation of the ileocolic. So, if you do a high ligation of the ileocolic, you're not tethering the TI as much. And so, you actually get a better stoma. But also, in the long term for a pouch procedure, you actually have more length. There's always sort of a 15-centimeter segment of TI that has a vessel but it's kind of a continuation off of the SMA. And so, if you do a distal ligation of the ileocolic, that vessel...the TI is less mobile than if you do a high ligation. So always a high ligation. So, I do medial to lateral approach. I start coming underneath the ileocolic vessel, mobilize all the way up, bring down the duodenum, and I go underneath that transverse column then I'll go laterally to the lateral attachments and then inferiorly as much as I can. I take the ileocolic vessel with the ligature. And then, after I've completely mobilized from medial to lateral, I go inferior medial and make sure that the terminal ileum is really well mobilized off the retro peritoneum. And then you should just have the lateral attachments. I just go through those quickly with the hook. So, the patient has been pretty much in Trendelenburg, right side up for this part of the procedure. And then I move them into head up and I take that hepatic flexure. So, to do that, I use the two left sided ports. I try to grab tissue as little as possible when I'm doing anything laparoscopically. So, I do a lot of mobilizing just by holding things up with my graspers but I don't actually grab anything with the grasper. So to mobilize the hepatic flexure, I use the left lower quadrant port. And I bring my grasper, sort of alongside the transverse colon, pulling it down and lifting it up. And then you can just use the ligature and come through taking that hepatic flexure down. Is that clear?
Ameer Farooq 33:28
Yeah, that's great. You answered a bunch of the questions that I had up front, you know, about the rectal tube and about ports. You know, I think that that makes a lot of sense. And I'm glad that you brought up the point about the high ligation, because I think, you know, intuitively think, well, this is a benign disease, why wouldn't I just stay high up on the bowel wall? And you know, not have to deal with the vessel that way. But that's such a great point that I hadn't thought of.
Helen Macrae 33:57
And pouch length, if it's a first-time pouch, and people are having trouble with length, it's usually because they've done a distal ligation.
Ameer Farooq 34:07
Okay, so you've done that hepatic flexure, I assume carry that along the transverse colon and then do you kind of attack the splenic flexure next?
Helen Macrae 34:18
So, I always take the omentum with the colon, I do not leave the omentum behind. Anybody that does a lot of redosurgery hates the omentum. So, the omentum goes. So, the next thing I do is I get into the lesser sack. So usually, I'm helping somebody through this. So, what I do is I'll grab the omentum just beneath the gastric polyp and sort of open things up when we get into the lessor sack and then take the omentum towards the splenic flexure and then finish it off towards the hepatic flexure as well so that the omentum is now divided. The colic is divided, and the splenic flexure is still there. I find that the most nerve-wracking part of a colectomy for me is the transverse mesocolon. And if you've mobilized both the hepatic and the splenic fracture, and that's all really floppy, and it's harder, I think to take the transverse mesocolon. So, I like to leave the splenic flexure and then I go back and get the transverse mesocolon. And how I take the transverse mesocolon, so this is benign disease. If you go back to the cut edge, where you've taken your ileocolic, you can now from the right side, put a grasper there and you drape the transverse colon over top of your grasper, what you're doing then is you're displaying the whole transverse mesocolon, it's right there. So, beneath you is the SMA and the small bowel mesentery. The colon is draped over top of your grasper. So, then you can just take the ligature, and just come right across the transverse mesocolon and you know you're safe, right? In a really skinny patient, you actually can get way too close to the SMA. Whereas if you're draping it over, you've got some extra length there. And so, you're know you're safe as you're coming across the transverse mesocolon. So, at this stage, I have all of the mesentery up to probably getting close to the splenic flexure. Done. And so, then I will come on the left side. I think that one mistake people make when mobilizing left colon, if they go a little too far laterally. As you sort of lift up the colon, you can almost see a little bit of a groove fairly close to the colon. So, I try to get into that groove. And then I'll sort of bluntly mobilize the colon off Gerotas and get around the flexure that way. So, if you just follow the white line, you end up at the spleen, that's not where you want to be. You want to be more medial. And I think that people, you really have to make a conscious effort to stay medial on that mesocolon on the left. So, I mobilize the left side in the flexure from the left side mostly, and then I'll lift the colon up and start taking the left column mesentery.
Ameer Farooq 37:36
Okay, so the other kind of, I think, couple of important questions that I wanted to get to, was like how much distal sigmoid...like, do you go to the top of the rectum? Do you take superior hemorrhoidal artery, you know, and there seems to be some difference in the way that people approach that particular thing? And, you know, some of the colorectal surgeons always talk about leaving superior hemorrhoid so when they do the pouch, you can follow that plane to the rectum. What's your take on that?
Helen Macrae 38:05
So, you should leave the IMA alone, you're much more likely to injure pelvic nerves if you have to go back and somebody has already been in that plane. So, my approach is that you want to leave enough rectus sigmoid, in that if you're coming across the colon, if it falls apart, you can bring it out as a lateral mucus fistula. So, if it's a fat patient, you have to leave in more than if it's a skinny patient. And so, I want to leave...so I never go down to the top of the rectum. I leave a little bit of distal sigmoid in. But just enough that I can bring it out as a mucus fistula if I have to. So, the thing that bothers me if somebody else have... you know, sometimes when people are doing a lot of subtotals for ulcerative colitis, they feel that they have to get as much out as possible in a way and you know, they'll go down even to the peritoneal reflection. And that makes the redo surgery much more difficult because now you're suddenly in redo planes around all the nerves that you don't want to injure. So, you really want to stay out of the pelvis. And you want to leave enough length that if you have a rectal stump blow out, you can exteriorize it if you have to.
Ameer Farooq 39:31
That was going to be my next question. So, let's say postoperatively, the patient develops what looks like a rectal stump, a blowout clinically and radiologically. How do you sort of approach that particular scenario?
Helen Macrae 39:43
So, most of the time, they get pretty sick because the patients that have a rectal stump blow out, they usually had pretty bad colitis and it's not usually just a tiny blowout. It's usually the whole thing. I mean, obviously if it was just a small, contained leak, I wouldn't operate. But most of the time you do have to operate. So, hopefully, enough rectal link has been left that you can bring out a mucus fistula, I do bring out a mucus fistula. I do it in the left lower quadrant, almost like a Burmese incision lateral to the rectus muscle. So, you don't have to bring it through the rectus because it's not going to be a stoma. And so, it's just easier. You know, the abdominal wall is thinner if you go lateral to the rectus. And so that's, I think it's important not to bring a mucous fistula up through an incision, because if you bring it up through an incision, your whole incision is going to be infected, and you're going to have a hernia. And so mucus fistulous should be away from the incision. And that's another reason why though to leave the rectal stump long to begin with, is that sometimes, you know, you come across it with a stapler, and it just falls apart in front of your eyes. And if you've gone down low, and that's the case, you're sort of screwed, you know, you don't really, if you don't have to length to bring it out. So, I always assume it's gonna fall apart and always leave enough in that I can bring it out if I have to.
Ameer Farooq 41:16
How long do you leave the rectal tube in generally?
Helen Macrae 41:19
I always joke that we'll step on it as you're walking at the hospital. But you know, I'll try to leave it in until they're pretty much ready to go. So, three or four days if I can. Sometimes if they're pretty miserable, and it's not draining much, I'll take it out it two or three days.
Ameer Farooq 41:41
So, let's say now you have that patient that you've done the subtotal on, they've done well, they have recovered. They're back in your office, and you're thinking about doing a J-pouch on them. Are there any big considerations that you think about preoperatively when you're thinking about taking someone for a J-pouch?
Helen Macrae 41:59
So, someone where I've reviewed the pathology, it's ulcerative colitis, there aren't any concerns about underlying Crohn's disease. A female, we've talked about fertility issues etc. They don't want to have their babies now and have the poach done afterwards. If it's a woman, I think the fertility issues are important. But also, if they've had previous vaginal deliveries really assessing the sphincter well, as I spoke about before. And anything else in particular you were thinking about or wanting me to cover?
Ameer Farooq 42:34
No, those were the kinds of things that I had in my mind. And I think that you raised the point that was so important about reviewing the pathology, because you don't necessarily know what you might find, incidentally, in that specimen. So, I think that's such an important point.
Helen Macrae 42:51
Yeah, and if they've had their subtotal colectomy done elsewhere, I usually will have our GI pathologists review the pathology. I also have to say that I think that probably Crohn's is over called a little bit by non GI pathologists, because when you have a really fulminant colitis, you can get transmural inflammation. And so, it's not that common to get a really fulminant colitis with Crohn's disease, so if somebody is referred to me for completion proctectomy because of Crohn's, I'll usually get that pathology reviewed as well and often the diagnosis will be changed to ulcerative colitis.
Ameer Farooq 43:34
You're such a high-volume pouch surgeon. Can you walk us through how you approach that operation, sort of at a 30,000 foot level?
Helen Macrae 43:42
So, I do most of them as a laparoscopic assisted approach. If the subtotal was done laparoscopically. If the subtotal was done open, I just do the pouch open because really the evidence for lap poaches in terms of benefits, there isn't really great evidence so it's mostly long term. You know, the incision and adhesions. So, if they already have a midline incision, I just go with the midline incision. I think first you want to assess the small bowel. I take down any adhesions. Make sure that it looks like there's lots of length. If they've had a subtotal and they've had an ileostomy for a while, it's pretty rare that they don't have length. If I was doing sort of a two-stage pouch, safer dysplasia or FAP, where you're doing the subtotal colectomy and rectal dissection at the same operation, the only patients that you might worry a little bit about length in is the really big male. And so, you know, I think before you start the rectal dissection, you just want to make sure that length isn't going to be an issue. Although first time pouch, if you do a high ligation of the ileocolic, length doesn't tend to be an issue. So, you want to assess the small bowel if they've had surgery elsewhere, especially, I just want to double check, make sure there's nothing that looks like Crohn's disease. I take down all of the adhesions, if they look at what the length is going to be like, and then I start with the rectal dissection with the rectal dissection, you have to remember this is benign disease, it's not malignant disease. So, I start a little bit higher with my incision along the peritoneum and sort of come down along the mesa rectum, so that I really make sure that I'm getting the nerves back, right on the mesa rectum all the way down. But then as I get down, sort of below the perineal reflection, I tend to hone in on the rectum a little bit more than you would do for cancer. Again, it's not cancer. And so, the thing that the patients are most worried about is pelvic nerve damage. So, I come in on the meso rectum a little bit. But it's important that you get low enough. And so, one of the tricks is once the rectum goes from sort of having that ampulla to starting to thin down a bit, that means that you're getting low enough. So, once you can kind of get your kind of get your thumb and index finger right around the rectum, that means that you're starting to get into the anal canal. And that's where I start to check on my length. Distally, I have to say that I always do my distal stapling open. So, I'm a bit of an old timer that way. I hate the endo GIA across the distal rectum. You know, when you see people could chunk across the distal rectum two or three times and you know, you only get one good shot at a pouch. I can get a nice TA 30 right across the rectum. One nice staple line. And I can usually do that through a four- or five-centimeter fan and still incision. I just think it's safer than going across multiple with multiple firings of the GIA. And I don't know, I haven't figured out a good way to get the GIA across the distal rectum.
Ameer Farooq 47:45
It always seems like there's it's just not...either the stapler is too big, or you have to take multiple bites of it with a smaller stapler. So, I hear what you're saying. There's no real nice way to do it.
Helen Macrae 47:57
Yeah, whereas when you're doing it open through the Fanny, you know, you've got one TA 30. That's it, and you've got a nice distal rectum. If you're within the anal canal, you know, you've got one nice staple line. And I'm not sure that avoiding that five-centimeter Pfannenstiel is worth making a suboptimal distal staple line.
Ameer Farooq 48:27
Then how do you construct the pouch, Dr. Macrae?
Helen Macrae 48:28
So, I've taken down the ileostomy, transected distally. So then, I would say 99% of the time I do a J-pouch. So, I like to do staple J with the mesentery anterior in the pouch posterior. If you think about how the mesentery comes, if you put the mesentery anterior, you've actually got the most length on the mesentery. If it's posterior, you're pulling the mesentery down along the sacrum and I think you have a little bit less length there. So, what I do is I pull the small bowel down to the pubis. And I hold sort of what will be the apex of the pouch and try to measure so that there's about 18 to 20 centimeters pouch length. And then I lift it up so that the bowel falls posterior to the mesentery and the mesentery is going to lie anteriorly and then that's where I make an enterotomy to do the apex of the pouch. I've started making my pouches with three firings of the endo GIA. I used to use the GIA-80, but we've had quite a few staple line bleeds. Because the endo GIA has the three staple lines, I just feel a little bit more comfortable with that now. And so, I've been doing three firings at the endo GIA to make the pouch. And then, use the EA 28. One other little technical thing. When I put in my anvil, I always make sure that my knot and my ends in the proline stitch for the anvil lies directly anteriorly on the pouch, because when you've got a small incision and you're doing a lab poach, it just helps you a little bit with orientation, if you know that that's the direct anterior part of the pouch. So, I leave those a little bit long, not so long that they're going to get caught in a staple line, but just so that I can see them. So, I always make sure that's how I put it in my purse string.
Ameer Farooq 48:42
What do you do Dr. Macrae, if you know you're struggling to actually get length on a poach? We've talked about this a little bit. But are there any strategies that you employ if you're struggling to get a poach down?
Helen Macrae 51:06
So, you really have to mobilize off of the duodenum. So, you know, you're more going to have problems with length on a hand sewn pouch on a redo pouch. But there you really want to get the SMA off duodenum, the mesentery off duodenum, as far up as possible. Again, going back to high ligation of the ileocolic, make sure that that's not holding you back. I'd say that for first time pouch, especially, those are the maneuvers that you really need. For redo pouch, you really need someone above and below to help get the pouch down because you have to sort of recall the poach down from above within the rectal cuff that you have left. But mobilizing off the duodenum, high ligation of the ileocolic. I don't find that, you know, if you look in textbooks, people talk about making little cuts in the mesentery. I've never had to do that. And it makes me nervous to do that. Because I think you're potentially going to get a hematoma in the mesentery and maybe affect the blood supply of the pouch.
Ameer Farooq 52:27
Yeah, I see the pictures in the textbook, and it makes you incredibly nervous thinking about that.
Helen Macrae 52:33
But if you look at those pictures, actually it was Marcus Burnstein's article when he was a fellow, that's the picture people are looking at. But if you look at those pictures, they have not done a high ligation of the ileocolic.
Ameer Farooq 52:47
You know, Dr. McCray, there's so much more that we could talk to you about, about all these different things. And we actually had a whole scenario. Another scenario about Crohn's. So, we'll have to bring you back on the show. But one thing I did want to just ask you, in closing, which is a question that we ask all of our guests, which is, you know, you've had this career doing so many amazing things with such a complex, but interesting practice, all the work that you've done in surgical education. So, having had the career that you've had thus far, if you could go back in time and give yourself advice as a trainee, what would that advice be?
Helen Macrae 53:25
I think, you know, and partly when I was going to do ICU and trauma that was partly training for a job, as opposed to training for what I really wanted to do. And so, I think you really have to follow what you like. Follow what your passions are and follow where your interests are. The other thing that's been extremely important to me and to my career is to have mentors and to seek out mentors that are really going to tell you the truth, have your back, give you good advice. And you know, for me, I had Robin and Zane on the surgical side of things and Richard Resnick on the education side of things and I have to say I think everything I've accomplished in my career is directly attributable to those people because they really set the groundwork and it's difficult to do things completely on your own. You know, mentors are really important, so seek them out.
Ameer Farooq 54:56
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. This podcast was edited and produced by Tyler Daniels. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So, feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.