State of the Union: Colorectal Surgery in 2021
An interview with P. Ravi Kiran, MD, Chief and Program Director, Division of Colorectal Surgery.
- K-pouch and J-pouch
- Crohn’s Disease and IBD
- Anal Fistula
- Colorectal Cancer and Colonoscopy
- Surgical Recovery
- Pelvic Floor Disorders
- Advancement and Collaboration
Under the realm of colorectal surgery, what conditions are you treating most frequently?
At the moment, it's IBD [inflammatory bowel disease], Crohn's disease, ulcerative colitis, cancer, and a lot of anorectal conditions, diverticulitis, pelvic floor problems. You know, the gamut of everything.
We also see a lot of the continent ileostomy; that’s where we create a pouch inside the body called the K-pouch. We do a lot of K-pouches because there are very few surgeons who do them in the world. There are very few centers that do them.
We see probably the biggest number of K-pouches in the world at our center.
Explain the K pouch. What are they, and who needs them?
So, different from an ostomy or a bag on the outside and the J-pouch, which is basically an internal reservoir just above the sphincter, the K-pouch is also a reservoir, but you don't go to the bathroom the usual way. You go out of your abdomen, and you don't have to collect the waste into a bag. There's a tiny hole low down in your beltline, which does not leak any gas or stool. It's got a one-way valve that we create out of the bowel. When a patient gets a sense of fullness, they put a tube in three times a day to empty their stool.
We do K-pouches when the colon is diseased or doesn't function and their muscles don't work well. You need to have good sphincter muscles if we’re going to take out the colon and rectum and then still be able to go to the bathroom the normal way with a J-pouch.
Some patients have suffered with the disease so severely, going to the bathroom 30, 40 times a day for years. And they say, "Look, I would rather not ever have to go again because I'd rather have the freedom to control my life.”
Everybody prefers to go to the bathroom the usual way, but if they don't have that option or their quality of life is so poor, the K-pouch can be great because you’re not carrying a bag on the outside or dealing with the potential problems with that. It gives patients more freedom, like going swimming and having little children and pets jumping on them. You know, ostomy bags would potentially fall off, but this is secured.
Why do so few surgeons do K-pouch surgery?
The surgery is complicated; it takes hours and hours of working hard at it, and it's not predictable. There is a bit of an art form to noticing the signs; it's not like you do the same procedure every time, and you get the same results. You have to have your thinking hat on when you do the surgery, and you have to be quick at the operation. Somebody who does straightforward operations and takes a long time with operations cannot do this because it's like four steps more difficult than a regular colectomy procedure.
Most of our K-pouch patients have had operations before. It's re-operative surgery, you're doing a lengthy operation, and you've got to do it with minimal complications.
What are the potential complications?
If you cause any inadvertent injuries when you’re straightening out the bowel, you're going to cause problems for the patient. If you wait too long on the operating room table, the bowel becomes like blotting papers, and you can't create a pouch out of it. Even if you've finished the procedure, but you've taken too long, the patient might get swelling of the abdomen, so then you can't close the abdomen.
Wow. It sounds like there are a lot of sensitive calculations at play.
Definitely. The other part is that we use almost 60 centimeters of the small bowel to create the pouch. You need to be confident that you're going to succeed, and you have to be persistent. Because if you start doing the pouch and the pouch doesn't work, that’s a huge problem. For example, we create a little valve over the small bowel, and if for any reason the valve mechanism doesn't work, you're almost going to be forced to remove that 60 centimeters of small bowel.
You're taking a risk on the table, and you're assuming that it'll work when you create it. Losing 60 centimeters is a big deal for these patients because the colon is all gone. They only have small intestines. And you need to have a critical length of small intestine for them to be able to survive and eat food by mouth. If you don't have enough bowel left, then you're stuck to IV nutrition for the rest of your life.
Those are very high stakes, indeed. How long does a K-pouch procedure take?
It's variable. We don't usually do it on patients who have never had previous surgery because the colon and rectum are still inside. But if you're going to take the colon and rectum out, then do the K pouch, probably about four hours. And again, that’s for somebody who's done a lot of them and who can also do the operation efficiently and fairly swiftly.
Given all the factors you’ve described, how do you identify when a K pouch is right for someone?
It requires a motivated patient. Somebody who understands the risks and benefits. Somebody who knows what they want and understands that this procedure is not for everybody. As I said, there are some potential complications with the procedure—the valve could slip, they may need a reoperation.
Let’s talk J-pouch. You mentioned that if you have an intact sphincter, the J-pouch is a good option. Would the J-pouch be done before considering a K-pouch procedure?
Exactly, you're spot on. Typically, that's what people want, right? To go to the bathroom the normal way. But then the occasional patient will say, "Look, Doc, I'm fed up with this. What if the J-pouch doesn't work and I have the same problem again? Just give me a bag." That's when the K-pouch discussion comes in. "Sure, we’ll do a bag, but do you want one on the outside?"
There are some people who don’t want the risk of reoperation with K-pouch and say “I would rather just have a bag on the outside." And of course, we respect and support their choices. The other thing about the J-pouch is that you can convert a J-pouch into a K-pouch.
We usually use 40 centimeters of the bowel for the J-pouch. So, the good thing about going from J to K is that if we need to, we could go down into the pelvis and use the same reservoir. Just connect the J-pouch from the sphincter but take a little bit of bowel above it to create a valve, and then we call it a pouch rotation. So that's the advantage of going from a J to a K; you’re conserving bowel.
How well-known are these pouch procedures? Do you have a lot of folks who come in assuming an ostomy bag is the only option?
Oh yeah, absolutely. It’s very common because so few surgeons do them now. No one is going to give them the option of a K-pouch. And no one wants an ostomy. We do everything we can to avoid the ostomy.
With the things that I do, it's essential to listen to patients because I, like Dr. James Church, do some operations which adhere to the quality of life, not necessarily disease. So it's not, "I've got a cancer, take it out." It's also, "What's best for you?" or "I have an ostomy, and I don't want it." Then it’s, "Okay, are you a candidate for the various procedures? What's best for you? What risks and benefits make sense for you?"
The other extreme is you might have a patient who says they don't want an ostomy, but in their case, an ostomy is probably the best thing for them. Quite often, you can tell fairly quickly, the moment you start talking. And you cannot give the same option to one patient that you would give to someone else.
Historically, people would get the ileostomy, the external bag. But the K-pouch was first done in the late 60s. And J-pouch was described in the 1980s. Then surgeons stopped doing the K since the J-pouch is easier to create, and it's obviously more natural than having a K-pouch. Then people forgot how to do it, and few surgeons want to start on these complicated procedures for all the reasons I mentioned. So many patients all over the world haven’t been given the option.
What else is new in surgical care that we should know about?
I’ll start with more about the J-pouch. Because when a J-pouch fails or it doesn't work, there are lots of options available at a center like ours. Like I’ve said, no place has as much expertise as we do.
If you're coming to Columbia, Dr. Shen can do a lot of endoscopic treatments for the pouch, and he’s probably the only one in the world. He’s the one who has described all the endoscopy procedures to fix pouches, written the books on them. If it fails, the pouch can be revised or redone, and then of course, the K-pouch is still an option.
Do you see a lot of folks who come in with ostomies that can be converted to one of the pouches?
Oh yes. If someone's got an ostomy, we can convert it to a K-pouch. I’ve had some patients with an ostomy who were told they couldn’t get a J-pouch, but I was able to do it.
I was trained at the Cleveland Clinic with Dr. Victor Fazio and Dr. Church amongst partners, so I do some rare procedures where you can reconnect pouches using some special techniques that otherwise nobody else would offer those patients.
What about treatment for Crohn’s Disease and IBD?
Along with the same concept of preserving bowel and preserving quality of life—fixing the disease—Crohn's disease and IBD also follow the same thinking. Dr. Shen can do an interventional IBD procedure for a patient with stricture and endoscopically open up those strictures, so patients are not obstructive.
I do bowel-conserving Crohn's surgery, which includes both the small intestine and a bag on the outside in many cases. Then Dr. Church has expertise in fistulas and, again, conserving bowel in other patients with polyposis, which is a heredity condition that causes different polyps to develop. So, all of this expertise melds together.
What’s new in non-surgical treatment, endoscopic techniques?
Well, more polyps can now be removed with the new endoscopic techniques. There's something called ESD/EMR; basically they are techniques where you can try and remove the polyps endoscopically, and it requires more advanced skill, which we have.
Not a whole lot is new otherwise. There are some more precise radiation techniques. Chemotherapy is evolving for cancers. There are always new medications for IBD and some trials on them.
How do those medications for IBD work?
There are different kinds of biologics, which is what they are called on the market, that actually reduces the need for surgery. However, when patients do come in for surgery, they are a lot sicker, because you treated them so extensively with medication. So, when they have surgery, the recovery is a bit longer. It really requires expertise and an individualized approach.
Let’s jump to anal fistulas and fissures because I recently learned from Dr. Church that many younger people assume they have hemorrhoids when in fact that have an untreated fistula.
Yeah, it’s very, very common. A fistula is basically a tunnel that’s been made between the anus and the skin because of an infection in the anal gland; it starts with something like a pimple on the anus. And this is in both men and women, any age group, young and old. Treating them properly takes skill because they are very difficult to heal due to the location and they don’t go away on their own. At best, the books say 80 percent success with these operations, and Dr. Church has like a 95-97 percent success.
Often, any problem down below people think is a hemorrhoid. Then really when you examine them, it's not a hemorrhoid. It’s a multitude of things. Frankly, it could be cancer.
That seems very important to highlight, “Never assume it’s just a hemorrhoid.”
Basically, any problem that persists, that lingers, that's different, go see a doctor. You cannot assume anything. Nowadays, cancer is occurring in more and more younger people as well. So absolutely, awareness is important.
When it comes to colorectal cancer, is there anything new in genetic profiling and markers?
The relatively recent change is that everyone now gets tumors profiled. It helps us understand the prognosis and understand specific chemotherapeutic agents that can be used. And with patients who carry those genetic markers, you know, they have a much, much greater chance of getting cancer. So routine screenings, management, and awareness are critical. And that’s also Dr. Church’s expertise. If colorectal cancer is caught early it’s curable with surgery.
Last year, the colonoscopy guidelines changed from age 50 to 45 due to the rise in colorectal cancer in younger people. What should patients know about getting colonoscopies? Does it matter where you go to get one?
I think most of the people trained in colonoscopy are well-trained nowadays. There are some very good benchmarks that everybody collects. I think the professional societies have done a great job of making everybody aware that you have to meet some guidelines.
The things like withdrawal time—there's data to show that if you pull out the scope too soon after you get to the start, then you miss things. Individual proceduralists’ are usually getting feedback on their data or outcomes. So, if you're falling below a certain number, you're probably doing a bad job of picking it up. The whole point of doing a screening colonoscopy is to pick up polyps, to destroy them so they don't turn into cancer. In general, I think the honest answer would be that most places would do a good job.
Although someone like Dr. Church is such an expert that he does sedationless colonoscopies, people are completely awake. He’s so good that he can insert the scope, remove polyps, and you don’t feel a thing, completely painless. He’s a master endoscopist beyond just technique. He takes out huge polyps and things nobody can usually take out in endoscopy.
That’s incredible. Have there been any changes in surgical approaches to colorectal cancer? Do you use robotic surgery or minimally-invasive techniques?
We're using the robot routinely in our division, but we are careful about using it for the right indications because you don't really need it for everything. Basically the robot helps the surgeon. And most procedures we do, I think 70-80 percent, are all minimally invasive. Only 20 percent is through old-fashioned operative surgery. But sometimes you have to do it that way for the reoperative procedures.
Is that common in colorectal surgery as a whole, the majority of procedures being done laparoscopically?
I think so. Most places will offer a laparoscopic surgery for all these. But we do a fair amount of complicated surgery through laparoscopy. And in this day and age, considering the patient benefits, I think that's what you should offer patients.
Let’s talk surgical recovery for a moment. Will you explain ERAS, the Enhanced Recovery Pathway?
Basically, these are opiate sparing pathways, using opioid-sparing medications, procedures and protocols. They are ways to make patients feel better quickly and recover faster because traditionally after any colon surgery or abdominal surgery, the bowel goes on strike—it's called ileus. By avoiding opiates and taking care of pain, patients can recover faster. They don't get ileus so they can leave the hospital faster. So, we routinely use that with all of our colectomy patients.
What about nutrition and immune-nutrition diets for surgical patients? When are they used?
Basically, the traditional way of treating patients who had any bowel or abdominal surgery on the intestine or stomach was to place a nasal gastric tube, which they would stay for days on end because doctors were worried to feed them, thinking that the area that was sewn up together or stapled together had to heal. But we know more and more now that doing that is actually not good and counterproductive.
I feed my patients the same day after surgery any soft food, which actually promotes recovery. The bowel heals, and they get out of the hospital faster. It reduces the risk of ileus as well.
Then in terms of diet, some immuno diets are supposed to promote recovery. Many institutions have incorporated these diets as part of their recovery pathways. We haven't at Columbia as yet. Only because the data on that is not entirely suggesting that we have to go there.
Interesting, what is the immuno diet?
It's basically a higher protein diet that you can do up to the time of surgery, so not the typical overnight fast after midnight. It is a diet that doesn't end up resting in your stomach. So, not a lot of fat, which might cause an aspiration risk during anesthesia. Patients will basically have a functioning gut up until close to the time of surgery. Quite often you can put them on shakes to improve their ability to recover after surgery. And you can do that ahead of time too. That's the general principle.
Let’s move to pelvic floor disorders. How are they treated?
Also very common. Both men and women have it, though more women than men, especially after childbirth. Obviously young and old, but more common in the older and middle-aged. And it’s usually problems related to the large intestine or rectum, colon, as well as the urinary tract, and of course the combination there of. And this is another area of management in which Dr. Church is excellent; a lot of providers don’t understand it.
Patients typically will have two problems, either loss of control or they'll have difficulty in the evacuation. Typically, we think it’s due to the muscles down there—the sphincter muscles as well as the pelvic floor muscles, and how the evacuation mechanisms work. Quite often, people have problems with control of urine or difficulty passing urine. And specific to colorectal surgery, evacuating bowel or controlling bowel movements. Going to a center that specializes in these disorders is important because quite often none of these problems can be pinpointed.
Meaning it takes a high level of thoughtfulness and awareness to treat?
Absolutely. There's a little bit of an art form to it again. It's not a colon cancer where you see the cancer, and you take it out and expect the patient to get better. Here, it's more the patient has symptoms, and you have to do a series of tests and line up the problems. Because a lot of the findings you can see in testing would also show up in the average population, but they may not have these symptoms.
Very often, these disorders can be fixed with a combination of biofeedback, which is non-surgical treatment, or medical treatment, or surgical therapy. There are a lot of surgical treatments now available for the management of these conditions.
How does biofeedback work?
It's basically pelvic floor retraining or rehabilitation. It helps strengthen the muscles or helps them coordinate. Some people lose that reflex to relax when they have to go to the bathroom. This is a way to retrain them either with positive range reinforcement, showing them pressure measurements, or showing them electromyography tracings. Sometimes help with the stimulation of the muscles to help them learn how to actually go to the bathroom, strengthen the muscles, or both.
And our nurse practitioners are phenomenal. They're the ones who do the biofeedback, which is unique to our program. In many places, physical therapists do it. But the nice thing about NPs doing them is they understand the medical part of the problem. They understand a lot more of the pelvic floor than most surgeons do, because they're doing it day in and day out. They offer feedback to our surgeons too, when doing procedures for this. And that makes our results for patients very, very good.
On average, how much time do people spend in biofeedback treatment before seeing results?
We typically do six sessions, and just for convenience, we try to space it out once a week. And we see about 80 percent success with most patients feeling better. Now, are the symptoms completely gone? Not necessarily. But again, quality of life is a very personal thing. If a patient said, "Look, I had a lot of problems before, and now I have a little bit of a problem, but I can live with it.” Then why push them to do anything else? If or when that fails, quite often surgical options are available.
Would you say that your philosophy in colorectal surgery is to do as much non-surgically as you can before bringing a patient to the OR?
Absolutely. But it's two ends of the spectrum, right? For benign conditions, that's what you do.
On the other hand, you have a patient with a cancer, or a bad disease; you’ve got to be aggressive and take it out. Otherwise, they’ll have lingering problems. Then somewhere in between, you have re-operative surgery—The other thing we specialize in is surgical complications.
Patients who have had surgery elsewhere, getting complications like fistulas of the abdominal wall. They need the big, big surgeries to get all that fixed and reconstruct their abdominal wall. That, too, is something that I think we at Columbia are known for.
So, it’s that thoughtfulness you mentioned—that intervening group where you have to combine both concepts of being aggressive and being conservative at the same time. It has to be the right mix and balance. Taking all the diseased parts but making sure you have enough of the healthy part and not doing too much.
Any new or ongoing research you’re excited about?
For anal fistula, especially in Crohn's disease, there is a trial with stem cells. And I think it will help patients with fistulas in Crohn’s disease because they have much worse outcomes than other patients with fistulas. So we are part of that multi-institutional trial. Although, as I mentioned, Dr. Church has excellent outcomes regardless.
There is a fair amount of outcomes research currently at Columbia. A lot of pouch-related research, and Dr. Shen heads the global IBD outcomes group. We're putting out a series of consensus guidelines on how to do interventional IBD and how to manage pouch disorders because of the experiences that we have, expertise, we would like to spread out everywhere.
But it's not a one-sided thing where Dr. Shen is saying what to do, or I'm saying what to do. We’ll be getting input from everybody with expertise so that we have guidelines for everyone. We've done a series of three of them so far, published in Advanced Gastroenterology. We're currently working on the fourth of those guidelines.
It seems like there is such a need for more specialists, more expertise throughout the country and world. Why is there still such a void in these areas of colorectal surgery?
A lot of this emanated from people interested in pushing the limits: Dr. Fazio, Dr. Shen, and Dr. Church. Decades ago, they built the center at Cleveland Clinic that kept pushing the boundaries on what we can do better next.
You know, it would be much easier for me to tell a patient, "Okay, leave with the ostomy bag." It's much more difficult for me to spend the time to think about various options, to spend that time in the operating room, to try to get them better. Sometimes I may fail. If I fail, I have to spend that extra time with that patient, trying to convince them again to go back to square one.
But I think they pushed the limits all over the place and just kept knocking things that were not popular, and they got more and more experienced at that. And I'm trained by Dr. Fazio and Dr. Church. And Dr. Shen is the best gastroenterologist there is.
So all of this advancement came from this group of physicians at Cleveland Clinic?
Yes, pretty much. Dr. Fazio realized that there's a whole bunch of patients with surgically-created pouches that will get problems. We needed somebody who would be a gastroenterology caretaker. That's how Dr. Shen got his expertise. Of course, Dr. Church, all along, was doing all of this in relation to all the other things he does: fistulas, cancer, genetic disorders, polyposis.
So having it all here at Columbia is the magic formula, right? It’s rare to find people who do these procedures. And we’ve brought them all to one place to change that. We want to grow what we do and educate everybody and share this knowledge and expertise.
It’s a trifecta of expertise. What are your short and long-term goals with all this experience in one place?
It really is amazing. We have the opportunity of being the absolute best division that could ever be in colorectal surgery. Our patients have all the expertise under one roof.
And from there, it’s really about building on our great breadth of coverage and expertise. We’d like to stack that up over the next five years and recruit more doctors with similar expertise and those who can do the more straightforward operations. Then we want to train the subsequent generations of surgeons to do these complex procedures. And from that group, identify the people who can go to the next level—that’s the ten-year goal, 15 and 20-year goals.
How do you work together now as a division? Do you all collaborate?
We all work very well together, and we all help each other. We're always helping each other in the operating room or with endoscopy. Dr. Shen and I often work on the same patient together in the operating room for the surgical part and vice versa. The main strength of our program is the people, an excellent faculty that are very motivated, all enthusiastic, highly interested.;
That’s so great to hear. Any closing thoughts?
Every bit of expertise a patient needs is available at Columbia. Our staff—the office staff, the nurses, the ostomy nurses, nutritionist, the doctors are all very invested in their care. Our ostomy nurses are probably some of the best in the world. They deal with K-pouches; they are there for our patients through everything. In the office and on the phone whenever needed.
Everyone is always willing to put the patients first. We collaborate, and we won't ever give up, ever. We do what we as patients would want.