E139 Neil Smart on Parastomal Hernias
Listen to this podcast on SoundCloud
Ameer Farooq 00:14
Welcome to Cold Steel, The Canadian Journal of Surgery podcast, with your hosts Ameer Farooq and Chad Ball.
Chad Ball 00:20
We recorded this episode live at the 2022 Canadian Surgery Forum in Toronto, Canada. We managed to catch up with the globe-trotting colorectal surgeon Dr. Neil Smart right after his in-depth session on peristomal hernias. Dr. Smart, as many of you know, is based out of England and is the current editor-in-chief of the Journal of Colorectal Disease. In this masterclass episode, we delve deep into the management of parastomal hernias, stoma formation itself and the management of this complex disease. Be sure to check out the study notes below. We hope you enjoy.
Ameer Farooq 01:16
Can you tell our audience where you grew up and where did you train?
Neil Smart 01:20
So I'm Neil smart. I'm a colorectal surgeon. I currently work in Exeter in the United Kingdom — although I'm not from Exeter originally — I went to medical school up in the northeast of England and Newcastle upon Tyne. I did my early surgical training up there, and then I moved to the southwest of England to do my surgical training in and around Bristol, Exeter, Plymouth, and then I did a fellowship over in Colchester, with Tim [inaudible] and Roger Watson doing laparoscopic colorectal surgery, before eventually taking a consultant job back in Exeter. So [I've] been, I guess, a consultant now for 9 years, something like that.
Ameer Farooq 02:01
Fantastic. And I guess the real question that we have to ask right off the hop is which football team do you support?
Neil Smart 02:07
Newcastle United.
Ameer Farooq 02:09
Newcastle United? They're going through a revolution.
Neil Smart 02:11
They are, indeed.
Ameer Farooq 02:12
They're awesome to watch. What's the name? He's such a [inaudible] player, the midfield? How can I forget his name? He wears a headband.
Neil Smart 02:23
Yeah, Saint-Maximin.
Ameer Farooq 02:26
Saint-Maximin. He's just a joy to watch.
Neil Smart 02:27
He's just an absolute joy. isn't he? Yeah.
Ameer Farooq 02:30
I love watching Newcastle play. From what I understand, you originally actually wanted to be a neurosurgeon. Is that right?
Neil Smart 02:36
Yeah. I mean, I had a slightly strange path through medical school because I did the first 2 years of med school, which is an undergraduate program in the UK, and took some time out to go and do a PhD in the middle, and I did it in developmental neurophysiology. And at the end of that, as a medical student, I thought, wow, wouldn't it be great to put my PhD to some use clinically? So I explored the idea of doing pediatric neurology, which wasn't really to my liking. [I] couldn't really cope with some of the non-accidental injury stuff and child abuse, found that a bit much. And then I ended up having some experience with neurosurgery, and I thought, this is quite good fun. And that's what really got me interested in surgery. But you know, as you go through postgraduate training, you meet some people, and I was really fortunate to meet a guy called Mark Mercer-Jones, who was colorectal surgeon up in the northeast of England who said to me, "Why don't you come here and be a colorectal surgeon?" And I thought, well, you seem to have a lot of fun when you do your job. So the rest, as they say, is history.
Ameer Farooq 03:45
I mean, to our benefit and neurosurgery's downfall, I guess. So thank you to Dr. Mercer. You are the editor-in-chief of Colorectal Disease [inaudible] on that. You've been there now for a couple of years.
Neil Smart 04:00
Yeah, I started in December 2019. I took over when the previous editor-in-chief Neil Mortensen demitted because he was standing for election as president of the Royal College of Surgeons of England, which he currently still is; he's in that position. So [it] wasn't small shoes to fill, so it's quite daunting. But you know, I had great mentorship from the island before that from John Nichols from St. Mark's as well. So it's been challenging times, particularly with the pandemic but immense fun, and really good fun.
Ameer Farooq 04:38
What kind of got you interested in, in being the editor in chief and being involved with the journal.
Neil Smart 04:43
So it started towards the end of my training as a surgeon — this is about 2011 — and Colorectal Disease decided to that it was going to have what, in essence, was an internship for a junior editor to get people exposed to the processes behind editorial decision-making and publishing journals. And I applied and was 1 of 2 candidates who were successfully appointed along with a guy called Martin Evans, who's a good friend of mine and a colorectal surgeon in Swansea. He's now one of the editors of British Journal of Surgery. And we had a 2-year period where we had — it has to be said — quite the most amazing mentorship from the editorial team; people like John Nichols and Najib Haboubi, who was another one of the presidents of the [European] Association of Coloproctology. And it was a crash course in how to do peer review, how to get others to do peer review, what to look for in quality of peer review, how to look at what to publish, how to publish it, how you might alter what you do as a journal to try and make yourself more relevant to readers to improve your citation metrics. And it was absolutely brilliant; it was unparalleled as an experience. I mean, the mentorship went deeper than just what you had in terms of, for the journal from an editorial perspective, it was really about the entirety of your career, how to build editorial roles with academia and with your clinical practice. So it was, it was superb. And then after that came to an end, we were invited to stay on as associate editors, and we had defined roles with certain aspects of the journal, like do things like supplements and how to do things that would appeal both financially to readers, advertisers and academics, or videos and different elements of publishing. So it was a real rounded period of time for me looking at how to do things better. And then when the opportunity came, for looking at the editor-in-chief role, it was about saying, "Well, you know, we've had some truly world-class, world-renowned surgeons, and I'm not even going to pretend that I'm in the same league as either of them." But what I thought was that there's a way forward for the journal, as we head to a new decade, about being online publications, rather than in print, and about being journals as they all seem to move towards open access with all the things that have come about through the transformative agreements, the Plan S processes for making everything open access, and the way in which funders were going with mandating that both in North America and in Europe. And I thought, there's some real exciting ways forward here, and that really appeals to me to be able to lead at that time and to see those changes through into fruition. So it was an opportunity that I thought, well, I can't ignore that. If I don't do it now, I won't necessarily have that opportunity again. So I applied and was fortunate enough to be appointed.
Ameer Farooq 08:25
You know, I'm curious to hear where you think the journal, in particular Colorectal Disease, is going to go in the future, and more general, but one thing I've definitely noticed is, the journal has done a lot of amazing things with the YouTube channel. Like, I think Colorectal Disease — I'm giving a talk later today, and I've used, you know, a clip from one of the videos in the journal and it's some really stunning content that's in the journal. Is that something that you think is going to be, like, kind of, the way forward? Or what, what other things do you think are in the works?
Neil Smart 08:55
Yes, and I think from the YouTube channel side of things, I mean, I'm fortunate to have 2 great editorial colleagues and [inaudible] and [inaudible], who run that side of things. And it has been a phenomenal success story. You know, we've now got over 60,000 subscribers, we've got something like nearly 50 million views of the content, and it's become one of great [inaudible] for continuing surgical education about techniques and their implementation. So that's really delighted to see because surgeons, by and large, are visual animals; they like to see what is actually done as well as reading descriptions. But I think where we've had a real niche in the market is the fact that everything is peer reviewed. It all goes through [an] external peer review process. And, you know, this stuff that we reject, this stuff that we accept, except it's not perfect, but it illustrates a nice point. Some of the videos, particularly the proctology ones are enormously popular, which have had 3–4 million views because it's been traditionally very difficult to get access to some of the training and those techniques, because some of them are done in community hospitals where the trainees might not be able to get to if they've got commitments for like, theatres, and you know, whether they're doing major resection of cases, they might not get to do some of the proctology stuff. And there's been a constant comment for trainee, certainly in the United Kingdom, and in some parts of Europe, that their proctologist education hasn't been as detailed as perhaps their cancer resection work has been in training. So there's been some great opportunities there. And do I think it's going to carry on? Yes. Do I think it's going to grow? I do. Do I think it's going to change direction slightly? I think it will, and I explained how. There are real moves afoot amongst the academic community about describing and implementing innovation better. There are certainly colleagues at the University of Bristol who are looking into how innovation is described and reported. And I think having repositories of new surgical techniques, which can be publicly displayed, evaluated, and then outcomes documented, and in a standardized fashion, are really going to come to the fore, because patients, perhaps quite rightly, want to move away from being a guinea pig. You know, they want to know that something is going to work or is at least going to be evaluated appropriately. I think governance structures around health care systems going to demand the same. We've seen issues globally, but particularly in some European countries, about outcomes related to transanal TME [total mesorectal excision]. And I think that side of things about how innovation is described and implemented is going to come to the fore, and videos are going to be at the heart of that. And it's going to be fundamental for future education. So I think it's one of the bits of the journal I'm really happy about and pleased about. But where else do I think things are going to go? I think, undoubtedly the open access revolution is here to stay. I don't think it's going to go. I think the way in which most of the major funders have gone — North America, Europe, Australasia, New Zealand — it's going to make all high-quality, public-funded research be open access in the public domain. And I think most journals will probably go to that model, across the board. When do I think, well, the original declarations were hoping that that would have happened by 2023/2024. The pandemic's kind of put pay to that. I think it's going to be delayed. I don't think everyone will have gone in that direction by the end of this decade, but I think certainly the majority will have done.
Ameer Farooq 13:11
I can talk to you about this all day. You know, I think there's so many neat things that are happening in research, and I'm particularly a huge fan of the video. And so I totally agree; I think if we don't put into place some ways that we're going to monitor innovation and video is going to be, I think, at the heart of that. I think someone else will do it for us. But I think I would do a disservice to our listeners to not ask you, if you have any of your real pearls of wisdom or tips and tricks in terms of things that you look for in high-quality research, things that you think, like, now, having been in the editor-in-chief role, there's some really important, I think, messages of communication that you want to put out to people in trying to publish good-quality research.
Neil Smart 13:55
So I think the landscape in surgery has changed dramatically over the past 10 to 15 years. Traditionally, surgeons were quite a competitive bunch, and it was not unusual to find a drive amongst surgical units to publish their data. And so we got a lot of single-institution, predominantly retrospective, case series. And the difficulty is it's not widely applicable. People don't have the same referral basis or the same practices or volumes. And it didn't really take things forward for either the patients or the surgeons. The world has changed and I think where we've moved to now is collaboration. And we've seen a big shift in terms of surgeons getting together, pooling their data across a variety of units within a country, between countries, and now pulling data from around the globe, so that they can talk about what happens more meaningfully for the average patient in the hands of the average surgeon in the hands of the average hospital. I, it's not just about taking your bell curve of surgical performance and stretching one of the tails out to the far right-hand side; it's now about shifting the entire bell curve to the right, so that patients across the board get better outcomes. And those collaborative studies, frequently covering thousands or tens of thousands of patients, and often hundreds of collaborators, are the things that are delivering research papers that are infinitely more impactful. So as an editor, when I'm looking for something, if someone comes to me and goes, "Here's our unit's data from the past 20 years about this rare condition, and we've got 20 patients. These are our outcomes," I might go, "So what? No, thank you." But if you come to me and say, "Here's this snapshot study of 500 hospitals from around the globe who've looked at this, and here's the data on 1000 patients and what happens to them," I go, "I'm interested." The world's moved, and I think surgeons have to get used to moving with the times. So, sad as it may seem, particularly to some units that were particularly intent, historically, on publishing their data. Increasingly, editors are not that fussed. We want data from across the board. Tell me what happens at a big level — across nations, across regions.
Ameer Farooq 16:53
That's, I think that's brilliant, and I couldn't agree with you more. I mean, I think, you know, what — the topic that I — the clinical topic that we wanted to review with you on this episode is about parastomal hernias. I think parastomal hernias is a great example of, you know, a clinical scenario where people will publish their results and say, "Oh, this is," you know, "This is not so great. This is, these are our outcomes," and people try to replicate that and really aren't able to. So, you know, I think parastomal hernias is a great paradigm example of that. So for our listeners, especially our medical student listeners and our resident listeners maybe listening to this, can you define for us what is a parastomal hernia?
Neil Smart 17:33
It's great question, and perhaps the answer to that is "No." I mean, there's an official definition from the European Hernia Society about it's a protrusion of the intra-abdominal contents through the [inaudible] in the abdominal wall that was made to allow the afferent stem or limb to pass. But I think there are many people who are perhaps uncomfortable with that definition because it explicitly excludes the problems that arise from what may be described as a syphon loop or subdermal prolapse of that afferent stoma limb into the subcutaneous fat. Our colleagues in Denmark have tended to emphasize that any bulge around a stoma is probably important to a patient and what drives them to seek health care, and it's probably a better definition. So a bulge adjacent to a stoma is probably the one that is more meaningful to patients, and the one that we should probably look towards.
Ameer Farooq 18:38
So, I mean, just to back up a little bit. You were telling me a little bit before we started the show about your, sort of, your practice, and what was it about parastomal hernias that sort of drove you to study this problem?
Neil Smart 18:50
So I do, predominantly from a colorectal perspective, I do rectal cancer surgery. And, you know, the national data from the United Kingdom is very clear from the National Bowel Cancer Audit for all the rectal cancers that we have, which is mid- and low rectal cancer is what it collects data on, your probability of having a stoma for that cancer at some point, 18 months down the line is 50%. So I create, we create as a community of colorectal surgeons in the UK, a lot of stomas. And despite the fact that there are all these fancy new techniques that have come along in the past decade and all the things that you can do to try and treat rectal cancer, our rates of stoma formation for rectal cancer have not fallen. They've not shifted one bit — not moved at all. So I know people might think that you can avoid doing stomas in certain circumstances, but on a population level, zero impact. We create lots of stomas. And I was creating lots of problems because all these patients were coming back 2, 3 years down the line; they have bulges, they have pain, they have discomfort, they had poorly fitting appliances, they had leaks. They were miserable. And I was curing their cancer, and that's great, but I was leaving them in a situation where I cured the cancer but I had left them with a terrible quality of life. And that wasn't a win. It's not just about winning that battle with cancer; it's about winning the piece and that postoperative recovery, and that's what I was trying to do better. And that's what really drove me to think, one, how can I make stomas better so that I don't end up giving them a hernia in the first instance; and two, once they got a hernia, what can I do to try and make them better, and certainly to try and avoid making them worse, which sometimes happens. So that's what really drove it; it was the clinical problem that I was seeing in front of my eyes that drove me towards thinking, well, I really need to look at this in more detail.
Ameer Farooq 20:54
And one of my — and I think we'll come back to this at some point, because, you know, you're running some really big studies, and I think one of the unique things of what you're doing is trying to look at the patient perspective, which is, I think, something that we fail to do a lot of the time. But I'm curious, when you're seeing a patient in the clinic or in the office with a peristomal hernia, what are the symptoms that you're looking for, or you're interested in? Is it, you know, are you — I got a sense here, not like, okay, here's a bulge, I have got to fix it, right? What are the things that really, in your mind, are important to try to suss out if someone is referred to you with a parastomal hernia or you notice a parastomal hernia?
Neil Smart 21:32
So the thing that I think I've got the ability to correct from an operative perspective, as opposed to a non-operative perspective, is pain. And patients often describe pain and dragging sensations. And they're the things that you stand a better chance of being able to improve. The cosmetic aspect, I don't think should be discounted, because it does impact a number of patients quite profoundly. And particularly those who are younger and of working age, they find it quite debilitating. It stops them living active, fulfilling lives. And so I think that is something that I do take heed of, although it probably isn't the primary thing that will make me want to operate. But I try and tease apart from what the patient tells me about how their quality of life is adversely impacted by the peristomal hernia. And what it is that they want to achieve from the management strategy that will agree together, particularly if it's surgery, and then what degree of risk are they prepared to accept in order to achieve that improvement? And that helps me figure out what might be the best strategy for that individual patient.
Ameer Farooq 22:59
So, like, what are the things that indicate to you that you need to just watch this person with a parastomal hernia, that quote unquote watchful waiting, which I think you've taken issue with? Or, which are the things that you're really going to pursue? And this is a difficult question to answer, but who are the patients that you're not going to operate on, is I guess what I'm asking?
Neil Smart 23:18
So, patients who perhaps have a very high degree of comorbidity and for whom surgery would be very high-risk and would have a substantial risk of mortality or further morbidity from surgery. I think you always have to be very cautious. Fools rush in where angels fear to tread. So that group, I think, you know, we've got very good now, I think, as a community of assessing these patients better, through shared decision-making processes, joint with an anesthetist, or anesthesiologist or whatever want to call them, perioperative care physicians. And we can do things to help elicit what degree of risk there is and quantify it by using things like cardiopulmonary exercise testing. You know, you can use risk predictors that exist. There are a number of different models that are out there. So I think we've got very good at that. And that's very often useful and quite sobering for patients when they sit down and I told, you know, your actuarial life survival is, I don't know, on average, you could reasonably expect to live for 3 years and your mortality from an operation is, say, 10% and your morbidity would be 80%. Your chances of being more dependent after an operation is 50%. So if you're at home, independent now, there's a 50/50 chance you'd end up in a nursing home dependent on care. Those types of figures, which we can now give to patients and we're pretty good at doing that, they're quite sobering, and they help people concentrate their minds about what level of risk is acceptable to them. So picking who not to, who not to operate on, I think has become a bit clearer. Saying who to operate on is quite difficult. I think people who really can't work, particularly when they're young and they've got families to support, you know, they've got all of those financial obligations, they've got children who they're trying to look after. They've got to service all of the things that life throws at them, mortgage and everything else. And you've got a really good indication for that group of patients who've got large hernias, who have got a lot of pain and discomfort and are struggling to leave the house and they're conservative measures, such as support garments, really haven't helped them. I think those patients, I think you've probably got a lot to offer. It won't be fixing the hernia in perpetuity, because we know that the recurrence rates are high. But your probability of giving them a better quality of life, and giving them a quality of life that works for them and their families, I think is quite good. So they're the ones where I think you've probably got the greatest win.
Ameer Farooq 26:19
Yeah, and, you know, I think there's a lot of questions I want to ask you about, that you're planning particularly about imaging, but I want us to, again, just to take another step back. And one of the things I found most interesting about your talk was actually talking about stoma formation. I think that's a piece that we often forget about when we're talking about parastomal hernias. And as you pointed out in your talk, you know, the way that we created — or the techniques that we use for creating stomas — hasn't really changed in a very long time. And you're doing a big study, the CIPHER study, looking at that — at stoma creation. Are there any pearls that you've been able to extract in terms of how to actually create a good stoma?
Neil Smart 27:02
So, I think the challenge is that most of the data we've had up until this point has all been retrospective, poor quality and isn't really reflective of contemporaneous practice. What should we do in the world where most of our colorectal resections are now minimally invasive, certainly in the developed world? I think it's difficult to say what's the right way to do something. The one thing I will say is that your best opportunity for giving someone a really good-quality stoma is the first time that you make it. And I think what struck me when I was starting out on this journey was how often the stoma creation is left to perhaps some of the most junior surgeons in the operating theatre at the end of the operation when surgeon — boss might say, "Well, I'm tired, because I've done all the difficult bit down in the pelvis. I'm going to leave the trainees to close the wounds and make the stoma," and often the level of supervision and training hasn't been there; and certainly, I think, in the past, that was the case. I think there's been a big culture shift over the past decade — probably for the better — but invariably there's probably more variation out there in practice than any of us would like to admit. I think many of the patients would, probably be quite distressed to hear that their stoma was created by the most junior surgeon who might have only seen it done once or twice before, and certainly that used to happen. It happened to me when I was in training. And I think many of them go, "Well, something that is so profoundly influencing on my long-term quality of life; how can it be left to someone?" And I think that has to probably change. So having seen your people around and supervising matters, I think in terms of creating the stoma itself, I spout even the colostomy just a little bit so that you get a better appliance fixation and seal — not as much as it would do in early ileostomy — but making it about 5 millimeters proud of the skin is probably best. I use a rapidly absorbable bit of braided suture material, but I try not to go through the mucosa so that you don't get those implantation islands around the mucocutaneous junction. I try and do all the sutures into the skin subdermal rather than through the skin to avoid that, as well. And I don't do any fixation of the [inaudible] of the bow to the anterior rectus sheath; I don't think it makes any difference. I don't route the stoma through an extraperitoneal approach because I think it's difficult to do, particularly laparoscopically. And when you've created your hole in the peritoneum, usually you've just left a space where the small bowel can herniate into, and they end up with bowel obstruction, and I've seen that on more than one occasion. So that was not something I've tended to favour, although I know that there are some people who will say very clearly that if they do extraperitoneal routinely, that you do get lower rates of parastomal hernia formation — I'm not convinced. Do I use prophylactic mesh? I do in patients who are having end colostomies formed for rectal cancer or anal cancer; I do put prophylactic mesh in, particularly if they've had neoadjuvant radiotherapy of any description because of the impact on wound healing. I want to try and avoid those problems of patients getting parastomal hernias because you've created a [inaudible] through a bit of tissue, which frequently has had low-dose radiotherapy to it. And the radiotherapy fields, even the modern ones, which are located and focused down on those low rectal cancers, the target in the abdominal wall gets irradiated to some degree, so they all have worse wound healing afterwards. So yeah, I do use prophylactic mesh.
Ameer Farooq 31:23
You know, like, they have these figures in the textbook where they show these, you know, hernia, the stoma triangles, try to locate it at the, you know, at the rectus muscle, above or below the umbilicus; are those things that play into your decision-making as well?
Neil Smart 31:40
So having the stoma created at the site where the stoma care nurse is marked preoperatively, I think is really important, because it's in the place which is the best place for the patient. And that takes into account all sorts of different things like their body habitus, how they like to wear their clothes, what type of clothes they like to wear. And having something that can be looked after easily, which the patient could see not have to be dependent on using mirrors to change appliances is really important for the patient quality of life, and I think we know that. In terms of those classic descriptions in the textbook about that stoma triangle, I mean, I think the days of seeing patients with body mass indices between 20 and 25, having low rectal cancer, is increasingly rare. Not saying it never happens, it's just that most of my patients have high body mass indices because the obesity epidemic is global across most high-income nations now. And so, it's not unusual to see people with at least a body mass index of 30 and frequently higher: 35, 40. Because we know obesity is a risk factor for rectal cancer. So realistically, are they still relevant? I don't think so very often. If you're going to create a stoma, it tends to be above the arcuate line of Douglas — better support for the stoma as it comes through. I've tended to make it through the body of the rectus muscle. I've tried to avoid going lateral to the rectus sheath. And I've not been convinced about some other techniques, where people argue about rooting the muscle around the lateral border of the rectus abdominus muscle. I think you get denervation injuries if you retract immediately because of the way in which we know the rectus muscle is innovated, so I haven't gone for that. I do place prophylactic mesh in the retrorectus plane for the majority of those patients.
Ameer Farooq 33:54
So you presented some pretty compelling data about the use of prophylactic mesh in the, sort of, elective setting. When you're using prophylactic mesh, where are you putting it? How are you putting it? And what kind of mesh do you use?
Neil Smart 34:07
So it tends to go in the retrorectus plane. I tend to use the cheap polypropylene midweight mesh that we tend to use for inguinal hernia surgery. It tends to come with a standard size, which is about 7.5 centimeters by 15 centimeters. The rectus sheath is usually about 7 centimeters in width, on average. So it's ideal; you can trim it lengthwise so that you've got unacceptable length, but you'll get an ideal width just the way it comes. I tend to have a circular trephine in the middle of the mesh for end colostomy. That trephine is usually 20–25 millimeters depending upon the size of the patient and the bow that you bring in through, and it's slightly larger than the trephine in the anterior posterior rectus sheath I would make. I tend to take a disc of skin, take a little bit of subcutaneous fat but not much, I make a circular incision, about 20 millimeters in the anterior rectus sheath, or separate the fibers of the rectus abdominus and then create the retrorectus plane by sweeping my finger in a circular fashion underneath it. And then I place the mesh, using a clip to make it lie flat, I make a circular hole in it and then make my incision in the posterior rectus sheath and then pull the stapled-off end of bowel through. So you know, the bowel's stapled off; there's no risk of bowel content, spillage or contamination. And you pull it through and then form your [inaudible] stoma.
Ameer Farooq 35:52
And you don't have to do any fixation because —
Neil Smart 35:54
There's no retroactive plane. Absolutely. So you don't need to the pressures on the abdominal wall from intra-abdominal pressure and from the muscles alone will hold in place.
Ameer Farooq 36:02
And you know, this is, again, getting very nitty-gritty. But a lot of the time we're doing this laparoscopically. So, are you creating the stoma aperture on the posterior sheath laparoscopically at all? Are you doing this all from the stoma opening?
Neil Smart 36:17
Yeah, I've tended to think that the stoma site is absolutely sacrosanct. And I try and avoid using the stoma site for anything else. I don't convert [inaudible] sites, I don't extract specimens through the stoma site; I do nothing. The stoma site is absolutely sacrosanct. You get the one opportunity to get it right the first time. And if you mess that up, it's gone. So for me, you — it's the one thing that the patient is going to have to live with for the rest of their life, in almost all cases. You know, you have to get it right, because if it goes wrong in any way, shape or form, the impact you have on their quality of life is profound.
Ameer Farooq 37:09
And are you changing the diameter of your trephine to match the caliber of the bow? Because you know, we've all seen some people who have slightly larger colons or slightly larger small bowel.
Neil Smart 37:22
Yeah, the fatty mesentery is really problematic. And we see that increasingly and yeah, you do have to make — sometimes you do have to make the trephines larger in order to accommodate, because the one thing you don't want to do is to have any narrowing or pinching, because then you get things like problems with erosions, strictures, and you want to avoid that, if at all possible.
Ameer Farooq 37:46
Right. So a little bit of playing plave to size things for the colon or the bowel is important.
Neil Smart 37:52
Yeah, I mean, a millimeter or 2 larger is normally all that you need. But you don't need to have things so big that it won't help reinforce the trephine that you've made. You need to make sure that, ultimately, that the mesh is going to do what you want it to do, which is to provide. As the body heals, it's got to have that degree of tissue ingrowth, scarring fibrosis that will help stabilize the trephine in the abdominal wall and stop it getting larger over time.
Ameer Farooq 38:20
So I think those are some pretty important pearls for anybody listening to this, whether you're a colorectal surgeon or a general surgeon that has to make these stomas. Just adhering to those principles, I think is just critical. So going back to that patient you're seeing in the clinic who you think needs an operation; are you doing any imaging on these patients?
Neil Smart 38:40
So when they've got a hernia, yeah. I mean, for me, CT is everything. There's a number of things that you're looking for. The first is I don't like surprises. I don't like them at all. I like to be forewarned, I want to know what's going on. So I want to know the size of the trephine. I want to know how big the sack is. I want to know what's in the sack. And I want to know what else is going on in the abdominal cavity. And a lot of the time, if you're going to do something for these patients and you're going to use mesh to help reinforce any repair that you do, it's going to make doing further laparotomies in future more difficult. So you want to make sure that you've found that [inaudible] second malignancy. You want to make sure that you've identified whether there are any metastatic deposits anywhere. You know, you kind of need to know all that upfront because there might be other things going on that are going to take precedence. Again, are there any issues with other diseases that might need treatment, particularly in the male population? If they've been hard smokers then there's a question as well of: Have they got an abdominal aortic aneurysm? Is anything going to need [inaudible]? If you do something are you going to take away the options that your vascular colleagues may want to have in a year or 2's time? You just need to make sure that you've got all the bits of information available to you. And if there is an issue about why did the patient have the indexed stoma in the first instance? Have you excluded any problems; for example, if it was inflammatory bowel disease, and they've got a paraileostomy hernia? Is there any signs of any problems due to Crohn's disease intra-abdominally? Are you certain it was ulcerative colitis? You need to know those kinds of things; if they had their stoma for FAP, are there any desmoid tumors, you know. Just take away all of the guesswork and no. And then when you've got your CT, you're looking for elements surrounding the parastomal hernia itself. And then any other hernias of the abdominal wall. Have they got an incisional hernia? Has a port site or an extraction site in the midline, whether they have a midline laparotomy for it. Have they got incisional hernias there? Because it can influence what you might do and how you might approach things.
Ameer Farooq 41:12
Totally. And you know, one of the things you talked about in your talk was about the risk factors for developing these — and I think most of us would know many of these — risk factors for poor wound healing. And I'm curious, you know, for the obese patient, diabetic patient, obviously, when you're — they have the rectal cancer, you can't really do much; you got to go ahead and do their operation. Typically, if you're considering a parastomal hernia repair, you have time, in an elective setting, to think about what operation you're going to do and optimizing factors. Are there things that you tell the patient that they need to optimize before you'll consider doing an operation, such as losing X amount of weight, stopping smoking, things like that?
Neil Smart 41:54
Yeah, absolutely. So I think for us, smoking cessation is absolutely non-negotiable. If you don't stop smoking, you don't get a hernia repair. I think most hernia centres in the United Kingdom are fairly clear about that now. Where uncertainty exists is about nicotine replacement therapies, and which ones are acceptable to different clinicians. I think, from my perspective, through all of the traditional nicotine replacement therapies that we saw — so, things like patches, gum, lozenges — I think, you know, we've got extensive evidence from multiple surgical specialties now that they do not adversely impact wound healing, so they're fine. So if your patient is using those to give up smoking — absolutely. Great. I'm very happy with that. The controversy exists around the use of electronic cigarettes and vaping, largely because there isn't a standardized form about what that is. The things that are in existence in Europe are different from the ones that exist in North America, for example. From a UK perspective, I've tended to say, I can live with people who vape if that's the nicotine replacement therapy that they need, to get off smoking. The things that cause the damage to wound healing are predominantly the tar — it's not the nicotine per se. So if the vape gets them off, I'll say it's good risk reduction. It's not a no risk option, but it's a substantial risk reduction; you know, 90, 95 percent plus. So I'll take that. And I'm a pragmatist. I think you have to be. You know, you can't be an absolutist on these things. So I'll accept vaping. Not everyone — well, I know there's intense debate about that. Weight reduction–wise, yes, we try and work with patients, with dietitians, and in cases where need be, with our colleagues who do bariatrics. Trying to get a patient to get the weight down to a body mass index of less than 35, if we can, will help. But it's not always feasible; it depends on the starting point. And in addition to that, prehabilitation, I think, is increasingly recognized as being important, not just from the wound-healing side of things, but also about cardiorespiratory complications across the board. So I think nowadays, dedicated graduated exercise programs have become increasingly the norm. You know, we're not asking patients to go out and run a marathon or, you know, win the Tour de France or anything like that, but we want them to do the lifestyle modifications. Now, what proportion of patients buy into the whole program? Fifty percent. There's a lot who don't, there's a lot who continue to eat very poor diets, who put on weight despite trying to lose it, they continue to smoke, they won't buy into the whole scheme. And in those patients, do I go ahead and operate? No I don't, not unless they present as a life-threatening emergency. Why not? Well, because the outcomes, we know are so poor, and many of the patients struggle, but to go, "Well, how can it be worse than this?" Well, it's the golden rule of surgery, and we all know it: You always have the capacity to make someone worse, not better. And, you know, sadly, I've learned those lessons the hard way, just as every other surgeon does. I've got my collections of skeletons in the closet of people where it's gone truly horrifically wrong, and I've lived with a bit of regret of intervention, and I wish I had sat on my hands. Lessons learned.
Ameer Farooq 45:58
We all have our little graveyards that we visit from time to time.
Neil Smart 46:02
We do indeed.
Ameer Farooq 46:03
So, what — now, you've made the decision. You optimize a patient as much as you can. What's the operation that you're going to do? And I know this is a huge topic. You've just spent the better part of an hour talking about this. Are there any — Tell us your thoughts about local revision of stomas. Are you a [inaudible] guy [inaudible] or open? What's, sort of, your preferred approach?
Neil Smart 46:25
Okay, so, first, the easy thing to talk about is the emergency situation. Someone who's in extremis, they've got incarcerated hernia with obstruction, or they've got dead gut and a strangulated parastomal hernia — they're quite easy situations. You're there to save the patient's life and relieve the obstruction. So in those situations, don't do anything clever. Do what you have to do. If it's dead gut, cut it out, or divide the adhesions, do a local repair, get out of a difficult situation, getting them out of hospital alive and well and come back another day for a definitive repair at another time. There is no such thing as an emergency transversus abdominus relief — just don't go there; don't try and do anything clever. And in fact, I'm even at the stage of saying, don't even think about using mesh in those circumstances because you've got to get the patient out of hospital alive. And don't go using expensive things like biologic meshes or the fancy bioabsorbables or anything like that. Keep it simple, stupid. Focus on your goal: get the patient out of hospital alive, well. Do I like relocating stomas? No, I avoid it if I can at all help it, because if you're not careful, they end up with parastomal hernia at the new site, an incisional hernia at the old stem site and an incisional hernia at the laparotomy that you made to move it. So I avoid that at all costs unless the patient can't see the stoma and look after it. What else do I do? Well, it depends, then, if you're doing a planned operation on what the index operation was and what it was for. Commonest thing that we tend to see are patients who've got apparent colostomy hernia having had a laparoscopic abdominal perineal excision for low rectal cancer. Now, for many of those patients, they will have a European Hernia Society Class 1 parastomal hernia. So usually, with bits of omentum, occasionally with bits of small bowel, come through the trephine, reducing the contents. There's an argument about whether or not you should do a hybrid approach and excise the sack through a hemi-circumferential mucocutaneous incision, closing off, tightening the trephine, and then doing something like a Sugarbaker approach. It's a good option. It has a role. And for many patients, particularly if they are older in years and have got 1 or 2 comorbidities, doing a minimally invasive approach has got a lot of advantages. It reduces their chest complications. Will it work? Well, permanently, I don't think anything really does. But it offers a lot for that group of patients, and I think in terms of bang for the buck or what you're trying to achieve, it's got a lot to offer. If you've got someone who had open surgery as their index procedure, say for example, they had fecal peritonitis, they had a laparotomy and a Hartman's procedure, and they've got medical problems that mean, for example, that you wouldn't want to necessarily consider re-anastomosing them and restoring their GI continuity. And the patient wants to keep their end colostomy. But they've got European Hernia Society Class 4 parastoma hernia. They've got a big incisional hernia, they've got a large peristomal hernia. They've got almost anterior abdominal wall failure. That group of patients, as long as you've dealt with the bioburden of all the previous contamination, open surgery, retrorectus mesh, tends to be permanent synthetic mesh, midweight aquaporous polypropylene — nothing particularly fancy — is what I would tend to use. Does it matter whether you use a circular trephine? Does it matter whether you use that extraperitoneal Sugarbaker or Pauli approach? I'm not certain that we've got enough data to say at the moment. I've done both. Risks and benefits to the different ones. It depends upon what it looks like at the time. I've got no hard-and-fast rules. If it looks right, it probably is right; it's probably the best thing to say. I do have some concerns about the role of the Sugarbaker technique and an extraperitoneal plane in the long term. I don't think we have the data yet to say that it is truly safe. And what the mesh against the bowel is like, particularly if there have been things like lots of adhesiolysis, as they've got those micro-abrasions across the [inaudible] does leave me a little bit uncomfortable. So in that group, haven't done anything different — well, occasionally I have used one of those small pieces of a bioabsorbable-type mesh to act as a barrier. So I have done that. Not particularly scientific. Does it work? I think time will tell. It's difficult. It's certainly a really tough problem, and maybe, hopefully, you know, more people like yourselves and future people will continue to work on this problem, because it's clearly not a problem that's going away, and we don't really have great solutions, you know, at least currently, in terms of long-term success. I think you've done some amazing work, and I think I'd be remiss not to mention and ask you about some of the work that you're doing. You talked about 2 of these huge studies that you're doing with the CIPHER and ProFHER studies with [inaudible]. Can you tell us a little bit about those studies and what you're working on with those studies in particular? So the CIPHER study was a UK government–funded study from the National Institutes of Health research, and it was to look at the rate of parastoma hernia formation in terms of definitions through a CT scan and through patient symptomatology. And a minimum of 2 years follow-up and I think the median follow-up will be well over 3 years because of the pandemic. And we would look at the patient factors and all the technical steps, index stoma formation, to see what predisposed patients to developing a parastomal hernia and how it impacted their symptoms and what happened to them. So we're in the follow-up phase of that at the moment. We've just collated the final patient questionnaires in terms of quality of life questionnaires, symptomatology questionnaires, and we've also just collated all of the CT scans. So we've got about 8000 CT scans sequentially across the 2500 patients. So we'll be able to describe more accurately the natural history, radiologically, of what happens to these hernias. Do they enlarge with time? Do they get bigger with time? So it gives us the opportunity to think about what might happen in an index operation and how it relates to the rate of change of size of the stoma trephine and how it relates to hernia development. What are the things that we can advocate not doing or to do when creating stoma, might be useful; might also allow us to figure out that if you make a stoma one way, it might not alter the rate of parastomal hernia, but it might either increase or decrease your risk of having worse symptoms and coming to need a repair. So all of those things I think will be really useful for surgeons when deciding what techniques to employ when they create stomas and will help get better outcomes for their patients. I'm trying to do something that's directly impactful for the patient and make life better for them. In terms of what to do, once you've got a parastomal hernia, I'm really struggling with the fact that I don't think any of us have got any great-quality data, and I don't think we really know what to do either, in terms of the surgical technique to use nor the type of mesh that we should use and where we should place that mesh. So, the ProFHER study is designed to look at management techniques for patients, whether they be conservative, then through expert stoma care nursing, whether it's altering the type of appliance that they have; is it altering some of the support garments that they need? Is it doing exercise and weight reduction techniques in a conservative manner? Does that help manage their hernias better? There's all of that versus all the operative interventions. And it's really just to try and catch patient-level, patient-reported outcome data in terms of the different management strategies, because if we're not measuring what matters to patients, how do we know whether what we're doing is actually making any sort of difference? You know, we might quite conceivably come along and operate on these patients and go, look at me. I'm the man with the golden hands; I fixed your hernia. And it's not come back when either I examined your abdomen or on the CT scan. But the patient turns around and goes, "That's true, doctor, but my life is a misery because I've had 15 admissions to hospital over the past 12 months with adhesions of my small bowel to the mesh that you've implanted in me and it's made my life a misery and I'm in chronic pain. I can't work. I can't leave the house." It's like, but you don't have recurrence. I've made a successful operation, haven't I? I think our definitions of success need to be revised. And I think the definition of success that we should look at is the one that the patient says is a success.
Ameer Farooq 56:46
That's fantastic. And I'll put the shownotes in the — or the links in the show notes so that people can find your studies. I know that you're still recruiting for the ProFHER study, and people around the world can contribute patients to that.
Neil Smart 56:59
Absolutely. The European Society of Coloproctology, who are running it, are really keen to have contributors from around the globe. I think what's really important to say about it is that I think it's the first time that we've seen a study that has been predominantly designed by a patient who, herself, has had 6 parastomal hernia repairs, and much of what we've decided to do has been borne out from her experiences and lived experiences of being a patient going through this process. So it's been brilliant to work with Sue Blackwell. I mean, she's been an absolute inspiration to many of us on the team involved. And it's been having the opportunity to take her expertise as a patient and marry it together with expertise of surgeons, clinical trials units, statisticians, trial managers. And to come up with something which is, we hope, relatively simple and straightforward for all health care professionals who are participating in the care of such patients to contribute to. So it's not just surgeons — it could be the stoma care nurse. Any health care professional can contribute. That's what we're really after.
Ameer Farooq 58:15
It's been an absolute delight — absolutely delightful conversation with you today. And one of the questions we always like to ask our guests at the end of the show is: If you could go back in time to your days as a senior trainee or maybe an early attending and give yourself advice, knowing what you know now, is there any advice that you'd give your former self?
Neil Smart 58:40
I think the only thing I would say is that it's meant to be fun. And if what you're doing isn't fun, and you're not enjoying it, you're doing it wrong. And I've been really fortunate. I mean, I've been an incredibly lucky man. I work with great teams in my hospital. I work with great teams editorially and around the globe doing some of the research that I do. I've been a very fortunate person. And it has been immensely rewarding, partly because it's been so much fun. And I think the people who make it fun more than anyone else, it's the patients. You know, and seeing the rewards from making their lives better is what really drives it forward. And so I'll just say to people: Enjoy what you do, because it's a great career.
Ameer Farooq 59:37
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you liked what you've heard, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback, so send us an email at [email protected] or tweet at us @CanJSurg. Thanks again.