Colon Watch

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February 2008

Colorectal Cancer Screening
Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the U.S.  The 5-year survival for early stage cancers is 90%, while only 10% of patients with advanced cancers survive 5 years.  As most cancers arise in polyps, and it takes an average of 10 years for a small polyp to progress to a cancer, screening should lead to a decrease in CRC related deaths.

Screening Patients at Average Risk:

Screening for patients at average risk for CRC should begin at age 50.  The simplest option is fecal occult blood testing (FOBT).  Patients should collect three separate stool samples at home on a yearly basis.  Since samples from digital rectal exam have a high false positive rate, they should not be used.  All positive tests mandate total colonoscopy (TC).  FOBT testing should occur on a yearly basis in conjunction with other screening tests. In prospective randomized trials, this approach has decreased CRC mortality by 15-33%.

Another option, flexible sigmoidoscopy, should be performed every 5 years.  Sigmoidoscopy is most effective when combined with yearly FOBT and with intermittent barium enemas to evaluate the right colon.  As with FOBT, all positive tests mandate TC. Double contrast barium enema (DCBE) every 5-10 years is another option.  DCBE does offer evaluation of the entire colon, but has only 83% sensitivity.  Furthermore, no studies demonstrate that DCBE lowers CRC related mortality. 

TC every 10 years may be the best method for CRC screening.  TC offers the advantages of complete colonic visualization with therapeutic potential.  Although no direct studies evaluate whether screening TC reduced CRC related mortality, the National Polyp Study estimated that 76-90% of colon cancers could be prevented through routine colonoscopic screening. 

Furthermore, TC is an improvement upon sigmoidoscopy, and there is direct evidence that sigmoidoscopy reduces CRC mortality.  TC has a sensitivity of 93% for detecting CRC.

Several recent reports have generated interest in CT colography (virtual colonoscopy) as a non-invasive method to evaluate the colon.   At this time there is no solid evidence demonstrating equivalent effectiveness at finding early cancers compared with currently recommended screening tests. More studies are needed before recommending it as a screening test for the general public.  At this time, CT colonoscopy represents a promising, but experimental, approach.

Screening High Risk Patients:

Individuals with a family history of CRC or adenomas in first-degree relatives should undergo TC every 3-5 years beginning at an age 10 years younger than the youngest effected relative.  Hereditary non-polyposis colorectal cancers should be suspected in any patient with several relatives with CRC, especially if any of the relatives was diagnosed before age 50.  Colonoscopic evaluations should be performed in these patients every 2 years starting at age 25, or 5 years younger than the earliest diagnosis of CRC, whichever is younger.  After age 40, TC should be done annually. 

Personal history of CRC requires TC before surgery or within 12 months of resection. If negative, subsequent procedures can be deferred for 3 years.  Frequency of endoscopy in patients with a personal history of adenomatous polyps depends on the number and type of polyps initially treated.  Although therapy for these patients should be individualized, TC is the preferred method of follow-up.

We believe colonoscopic screening most effectively reduces mortality from colon cancer; it is the most sensitive test and allows concurrent therapy.  Unfortunately, only 1/3 of patients actually undergo adequate screening.  In order to improve this community’s screening rate, we have a program in place to allow easy, prompt scheduling of this vital exam. (Gastrointest Endosc. 2000 Jun;51(6):777-82.  Other sources available on request) Summarized by Arun Gowdamarajan, MD.

Would a STARR help my patient with Constipation?
Approximately 80% of all individuals suffer from constipation at one point or another. 33% of patients suffer from these problems more than occasionally.  These symptoms may include excessive straining, hard stools, digitation, incomplete evacuation, a sense of anorectal blockage and less than three bowel movements per week. Fiber and numerous medications such as Miralax, Amitiza and, previously, Zelnorm have been used to promote bowel motility. However, some patients have pelvic floor dysfunction that prevents them from “emptying” their rectum. Most commonly in females, they complain of “incomplete evacuation”, “it’s down there and it won’t come out”, and then will often vaginally splint. These patients are often classified as having “Obstructive Defecation Syndrome” (ODS).

The work up for this problem often involves numerous tests. This includes anal manometry, surface electromyography, a defecating proctogram, colonic transit study and a colonoscopy.  The proctogram offers probably the most information. The test involves instillation of “barium paste” into the rectum and vagina (females). The design is to determine if the rectum is telescoping on itself (intussusception or internal rectal prolapse) or if there is development of a rectocele. Traditional surgical therapy (still applicable in many cases) for rectoceles has been either a transanal or transvaginal approach. The overall success rates have varied from 55-80%. However, with both approaches, concerns with fecal incontinence, dyspareunia, and stenosis have been described. Though mostly from urogynecologic data, mesh placement has also been used, but with varying success and with concerns about mesh erosions.

The STARR procedure (stapled transanal rectal resection) is a minimally invasive surgical approach to correct the anatomic disorder of ODS and allows patients to improve rectal emptying. The surgery involves using a circular stapling device to cut the “telescoping or prolapsing rectum” out via the anus in two half circles. Care must be taken to have the full thickness of the rectum, yet not incorporate the vagina. Most patients are kept in the hospital for 1-2 days. The original studies came from Boccasanta et al in 1994. They reported a 75% improvement in symptoms. Most notable were incomplete evacuation (98% to 19%), digitation (88% to 4%), laxative use (52% to 10%) and pain (63% to 10%). Their most frequent complications were fecal urgency (18%) and flatus incontinence (9%). The US pilot study began in 1995. For the initial 50 patients, the inclusion criteria were females (ages 21-80), and ODS symptoms for greater than 12 months. Excluded patients were those with anal incontinence, a resting enterocele, history of colorectal cancer or radiation, and those patients with previous colonic surgery of the sigmoid or rectum.  43 patients were able to be followed for up to 6 months after surgery.

The initial data was quite interesting. At 1 month, 71% of patients state they were greater than 50% better; at 3 months it was 62% and at 6 months it was 65%. The most notable improvements matched that of the European study, which were incomplete evacuation, digitations and laxative use. The most common adverse side effects were pain, bleeding and urinary retention. There were no rectovaginal fistulas or prolonged incontinence episodes. Overall, 59% of patients were completely satisfied with the procedure, and 88% were “above average” satisfied.

At Colon and Rectal Care, we are proud to be the first group in the state of Indiana to have been performing this procedure. We are near twenty patients over the past year (including four men). Our initial data suggests an overall satisfaction rate of 85%. Several patients have stated, “you have given me my life back”. We have had no episodes of rectovaginal fistula, prolonged incontinence or persistent pain. We certainly feel this procedure has a place in the algorithm for the management of constipation. All patients should have a careful work up as described above, but if they meet clinical indications, they can often have their quality of life improved significantly. (Corman et al. Colorectal Disease 2005. Boccasanta et al. DCR. 2005. Boccasanta et al. Int J. Colorectal Dis. 2004). Summarized by Shekar Narayanan, MD.

August 2007

What’s new in Colon and Rectal Surgery - Highlights from the 2007 Annual Meeting Laparoscopic Colon Surgery- Who is Benefiting?
Several years ago, the COST study showed laparoscopic surgery for colon cancer with equivalent results with no increase in morbidity, mortality or recurrence over traditional open surgery. We are now asking if ALL patients benefit from laparoscopic surgery for colon cancer. Plus, what are the financial ramifications of laparoscopic surgery? Four podium presentations helped to address this issue. Moolo, et al reviewed 387 consecutive laparoscopic colectomies done between 1991-2005. Theses included those cases that were “excluded” in the COST trial (metastatic disease, BMA > 30, transverse  colon lesions, and nonadenocarcinoma pathology).

Two groups were created (IG- originally included in the COST trial; EG- excluded). In analyzing data in regard to length of stay, intra-operative and postoperative complications and operative time, they found no difference. They did note that patients with transverse colon lesions and BMI’s >30 did have a high post-operative complication rate. However, most importantly they noted NO difference in 5-Year survival based on TNM staging. The authors concluded that ALL patients might benefit from laparoscopic surgery for colon cancer. Braga et al, decided to study the effects of laparoscopy (LPS) and age, in regards to the appropriateness of offering LPS to those patients over 70 years of age. Among the elderly patients 89 were assigned to the LPS and 112 to the open group. What was most interesting was in the OPEN group, where there was a significantly higher incidence of length of stay, wound infections, cardiac complications and infectious complications. This was NOT seen in the LPS.

The authors actually found a statistically significant difference in morbidity in elderly patients when comparing LSP to open surgery, but this was not realized in the non-elderly patients. Delaney, et al studied the outcomes of patients discharged within the first three days of surgery, as compared to those who stayed longer. 70% of patients met criteria for early discharge. There was no statistical difference in readmission rate, morbidity or mortality. By extrapolation, there is a significant economic advantage both within the hospital setting and for patients’ return to the activities of daily living.

Finally, Dobson et al studied the effects of laparoscopic surgery (LS) on surgical site infections (SSI) with the associated cost analysis. 603 patients, between 2003- 3006, were case matched to 2,246 consecutive open patients. Overall, SSI was noted in 5.8% of the LS group and 4.8% of the open group. However, only ONE of the LS patients required hospital readmission and NONE required surgery. But, in the open group, 52% required readmission and 12% underwent reoperation. In addition, there was a significantly higher incidence of needing home care ($162./dressing change) and placement of a wound vacuum device ($176.86/day). From a patient’s perspective, 92% of patients in LS with wound infections were able to manage their wound independently, compared to only 37% of the open patients. This study clearly shows the effects on wound, and with recently SSI cost analysis by CMS, this becomes a very warranted study. We, at Colon and Rectal Care, have been performing laparoscopic colon surgery for over 15 years. We concur with these studies that laparoscopic colon surgery patients suffer fewer wound complications, a shorter length of stay, and are to return to work/activities of daily living much faster, and no difference in oncologic recurrence for those patients operated on for a neoplasm. Our goal is to continue to reduce our incidence of SSI and sustain our high level of success with laparoscopic colon surgery. Moloo et al. Podium Presentation. ASCRS meeting. 2007. Braga et al. Podium Presentation. ASCRS meeting. 2007. Delaney et al. Podium Presentation. ASCRS meeting. 2007. Dobson t al. Podium Presentation. ASCRS meeting. 2007. St. Louis, MO. Summarized by Shekar Narayanan, MD.

For Patients Requiring Colorectal Evaluation to Assess for Possible Cancer, What is the Current Role for CT Colonography Versus Standard Optical Colonoscopy?
The recommendation for colorectal cancer screening has been well established. Cost effectiveness and cancer related death prevention are just two recognized benefits to the colon cancer screening and endoscopic polypectomy in those who meet criteria. Currently, amongst other indications, the general consensus suggests that anyone 50 years of age or older be considered for this evaluation.

CT colonography is a relatively new modality and ongoing research is looking into the ideal imaging protocols and the appropriate clinical circumstances in which sensitivity and specificity for screening is optimized with this technique and able to approach the current gold standard of colonoscopy.

The prep used for the CT colonography is typically the sodium phosphate type, which limits the amount of remnant fluid within the bowel lumen after the bowel prep. This feature enables a wider contrast necessary to detect lesions with comparable accuracy to colonoscopy. However, more recent data has become available concerning the safety of this preparation in patients with renal insufficiency and even many patients with no lab detected or previously diagnosed renal insufficiency. Currently at Colon and Rectal Care, Inc., none of the surgeons use this sodium phosphate preparation for any patient undergoing colonoscopy as a result of the concern regarding its safety in the general population.

To achieve good results with CT colonography, both supine and prone patient positioning appears to be necessary which can be difficult for some patients. Radiation exposure and the theoretical risk of cancer induction as a result, seem to be of limited concern with this modality. The Health Physics Society suggests that epidemiologic studies do not support any adverse health effects when patients are exposed to less than 50 mSv per year or 100 mSv in their lifetime beyond baseline natural exposure. The dosage for a CT colonography is quite low and on the order of 8-12 mSv since a substantially lower radiation dose than that used in standard CT scan imaging still enables adequate visualization of the bowel lumen. The downside is that the overall sensitivity for detecting extracolonic abnormalities is substantially lower than regular CT. This means that a patient who recently had a CT colonography with no other abnormal findings does not mean that they recently had a “negative CT” in terms of evaluating for other indications such as abdominal pain, etcetera. In addition, statistically, 7-11% of these studies show some other abnormality necessitating a workup that leads to a relevant finding in only 2-3%.

Same day referrals for patients having an incomplete colonoscopy is possible and enables the patient to avoid another bowel prep, however barium is typically given as part of the prep for the planned CT colonography which would not be present in that situation and therefore the specificity may be a bit compromised.

Benefits to the CT study compared to colonoscopy include the evaluation of the rare submucosal lesion,which is probably better seen with this modality than optical colonoscopy. The precise anatomic localization inherent to the CT scan can be quite difficult to achieve with colonoscopy in the very tortuous colon.

However, with lesion tattooing at the time of endoscopy, predictably accurate localization in preparation for surgery is much less of an issue. Evaluation of the colon proximal to a nearly or completely obstructing colon lesion in preparation for surgery is a real advantage to the CT. CO2 is used instead of oxygen and easily passes by the lesion enabling the proximal evaluation. Also for the patient needing colonic evaluation for synchronous lesions in the immediate postoperative setting after surgery for an  obstructed or perforated colon cancer, this is an ideal modality.

At Colon and Rectal Care, we believe that colonoscopy is still the gold standard for colorectal cancer screening and the therapeutic interventions that have led to the reduced rates of death from this cancer since the advent of screening. Nonetheless, we recognize the growing role for CT colonography under certain clinical circumstances and await further data on this most interesting subject. 1) Curr Probl Diagn Radiol July/August 1991; 123- 51. 2) Gastroenterology 2003;125:311- 319. 3) Semin Colon Rectal Surg 2007; 18(2):88-95. 4) Radiology 2006; 231:417-425. Summarized by Joseph C. Muller, MD.

May 2007

Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the U.S.  The 5-year survival for early stage cancers is 90%, while only 10% of patients with advanced cancers survive 5 years.  As most cancers arise in polyps, and it takes an average of 10 years for a small polyp to progress to a cancer, screening should lead to a decrease in CRC related deaths.

Screening Patients at Average Risk:

Screening for patients at average risk for CRC should begin at age 50.  The simplest option is fecal occult blood testing (FOBT).  Patients should collect three separate stool samples at home on a yearly basis.  Since samples from digital rectal exam have a high false positive rate, they should not be used.  All positive tests mandate total colonoscopy (TC).  FOBT testing should occur on a yearly basis in conjunction with other screening tests. In prospective randomized trials, this approach has decreased CRC mortality by 15-33%.

Another option, flexible sigmoidoscopy, should be performed every 5 years.  Sigmoidoscopy is most effective when combined with yearly FOBT and with intermittent barium enemas to evaluate the right colon.  As with FOBT, all positive tests mandate TC. Double contrast barium enema (DCBE) every 5-10 years is another option.  DCBE does offer evaluation of the entire colon, but has only 83% sensitivity.  Furthermore, no studies demonstrate that DCBE lowers CRC related mortality. 

TC every 10 years may be the best method for CRC screening.  TC offers the advantages of complete colonic visualization with therapeutic potential.  Although no direct studies evaluate whether screening TC reduced CRC related mortality, the National Polyp Study estimated that 76-90% of colon cancers could be prevented through routine colonoscopic screening. 

Furthermore, TC is an improvement upon sigmoidoscopy, and there is direct evidence that sigmoidoscopy reduces CRC mortality.  TC has a sensitivity of 93% for detecting CRC.

Several recent reports have generated interest in CT colography (virtual colonoscopy) as a non-invasive method to evaluate the colon.   At this time there is no solid evidence demonstrating equivalent effectiveness at finding early cancers compared with currently recommended screening tests. More studies are needed before recommending it as a screening test for the general public.  At this time, CT colonoscopy represents a promising, but experimental, approach.

Screening High Risk Patients:

Individuals with a family history of CRC or adenomas in first-degree relatives should undergo TC every 3-5 years beginning at an age 10 years younger than the youngest effected relative.  Hereditary non-polyposis colorectal cancers should be suspected in any patient with several relatives with CRC, especially if any of the relatives was diagnosed before age 50.  Colonoscopic evaluations should be performed in these patients every 2 years starting at age 25, or 5 years younger than the earliest diagnosis of CRC, whichever is younger.  After age 40, TC should be done annually. 

Personal history of CRC requires TC before surgery or within 12 months of resection; if negative, subsequent procedures can be deferred for 3 years.  Frequency of endoscopy in patients with a personal history of adenomatous polyps depends on the number and type of polyps initially treated.  Although therapy for these patients should be individualized, TC is the preferred method of follow-up.

We believe colonoscopic screening most effectively reduces mortality from colon cancer; it is the most sensitive test and allows concurrent therapy.  Unfortunately, only 1/3 of patients actually undergo adequate screening.  In order to improve this community’s screening rate, we have a program in place to allow easy, prompt scheduling of this vital exam. (Gastrointest Endosc. 2000 Jun;51(6):777-82.  Other sources available on request) Summarized by Arun Gowdamarajan, MD.

Clostridium Difficile is a Problem, but what are the Real Facts?

For any physician or healthcare worker involved in the care of hospital inpatients in 2007, clostridium difficile is a likely problem they will encounter.  Essentially, this is a spore forming anaerobic and contagious bacteria.  It is known to secrete toxins that lead to a potentially profound systemic inflammatory response syndrome (SIRS) and extensive cytotoxicity mediated by the toxins.  The phenomena results from selective elimination of bowel flora through the patient’s treatment with an antibiotic that exposes a suitable environment for clostridial bacterial proliferation.  Ultimately, in those that do not respond to medical therapy for this microorganism and require surgery, a 25-70% mortality rate is reported.  This is particularly true in the immunocompromised patient who is also at greater risk of developing the disease in the first place.

“C. diff” as it is routinely called, produces a toxin A which is a cytotoxin in and of itself that creates a bowel wall inflammatory reaction that increases bowel mural permeability to the even more cytotoxic toxin B.  A collagenase is also secreted that increases bacterial translocation leading to the release of inflammatory mediators that result in the SIRS response.  Since 2001, new strains have been found as well that secrete yet another “binary toxin” which further potentiates the toxicity to the patient and increases morbidity and mortality.

Clostridium difficile is also known as pseudomembranous colitis (PMC) and is most often and effectively detected through an ELISA testing for the toxin B that yields a 70-95% sensitivity and a 99% specificity.  A stool culture can be done as well, but this takes longer and has some degree of inaccuracy associated with it, as there are about 3% of asymptomatic carriers in the population that are completely healthy.  Endoscopy can be done to identify the pseudomembranes, but only about 50% of the patients with an ELISA positive test for the toxin B (indicating presence of toxic C. diff.) will have pseudomembranes present and be seen endoscopically.

Also, a flexible sigmoidoscopy will miss up to 70% of patients with PMC unless performed beyond the rectum and will still miss 10% even if performed to the most proximal extent of the scope.  Therefore, colonoscopy is really the gold standard for endoscopic diagnosis.

Treatment includes discontinuing the original antibiotic that enabled the process to start.  This may be the only treatment necessary in some cases.  First line treatment after this would be Metronidazole that may be taken orally (500 mg PO tid for 10-14 days) or intravenously, but the oral route is most effective for the disease.  For patients who have not responded to the Metronidazole, Vancomycin may be used (125 mg PO qid for 7 days).  However, the IV version of this is not at all effective for C. diff. and it is much more expensive.  Further preventing Vancomycin’s first line use is the very real concern with the proliferation of Vancomycin resistant enterococcus.  Bacitracin (20,000-25,000 units qid for 7-14 days) is another option.  Non-antibacterial options include anion exchange resins which can be used when antibiotics fail, but cannot be used with Vancomycin, as they will bind the drug as well as the toxin.  Data on the use of probiotics is conflicting at this time.  When all else fails, surgery is necessary and should be nothing less extensive than a total abdominal colectomy with an end ileostomy, which may be converted to an ileorectal anastomosis at a much later date, if the patient recovers satisfactorily.

Antidiarrheal medications are absolutely contraindicated in a patient with PMC, as this may exacerbate the disease and lead to fulminant colitis or toxic megacolon.  CT scan findings are non-specific. 

Don’t be fooled by a “normal CT” in a patient with diarrhea and abdominal pain.

The surgeons at Colon and Rectal Care remain cognizant of the seriousness of this disease and the importance of a timely intervention when necessary.  We continue to evaluate new data as it becomes available on this issue. Dis Colon Rectum 2000;43:551-554.   Am J Gastroenterol 2006;101:812-822.  Lancet 2005;366:1079-1084 + comment 1053-4.   Infect Control Hosp Epidemiol 1995;16:459-477.  Clinics in Colon and Rectal Surgery 2007;20:13-17.  Summarized by Joseph C. Muller, MD.

March 2007

Diverticulitis in Younger Patients: Surgery vs. Expectant Management

Diverticulitis continues to be a major medical issue that appears to be affecting younger and younger patients. The previous algorithm for such patients was to offer surgery after an initial attack to “prevent” future problems. Several papers have addressed this issue in hopes of understanding whether this is a different subtype and the appropriate therapy. Guzzo et al, in 2004, performed a retrospective review of 762 patients admitted between 1990 to 2001. 34% were less than age 50. They found no difference in the risk of requiring surgery between groups younger and older than age 50. They did find a statistical difference in overall surgical requirement due to an increase in colonic resections (40% vs. 26%), respectively. The authors concluded that after a single attack of uncomplicated diverticulitis, routine surgical intervention is not warranted in those patients less than 50 years of age. West et al, retrospectively, studied 64 patients during a six-year period of time. They again found no statistical difference in surgical intervention in those patients less than age 50.

As time has gone on, we have come to realize that it is possible that “young diverticulitis” may be a different type of pathologic problem. Controversy does exist as to the “aggressiveness” of the disease process. Two studies have attempted to address this issue. Lahat et al, studied 207 patients between January of 2000 to February of 2005. 12% were younger that age 45. In this subset they found these patients to have a  male predominance, a higher recurrence and complication rate (32% vs13%), and thus surgical intervention was performed in 38% vs. 13% of patients. Zaidi et al studied the CT scan and clinical features of diverticulitis in young patients. Of 104 patients they found that the 25% were younger than age 40. They also found that the subset of patient between the ages of 20-50 had greater abdominal obesity. However, they DID NOT find a difference in hospital admission,

surgery and/or percutaneous drainage of abscesses between the groups. Nelson et al, analyzed 5500 patients with diverticulitis over a 13-year period of time. 962 were younger than age 50. Comparing rates of emergency surgery, colostomies and recurrence rates, they found no statistical difference between the two groups. The authors concluded that “young patients with diverticulitis should be treated according to the same criteria used for older patients”.  With all this said, is 50 the correct age to set as “young”? Pautrat et al, have challenged that notion with some interesting data. They studied 284 patients between 2000 and 2004. They found 52 patients to be younger than age 50 and sub-categorized into two groups based on a cutoff of age 40.  94% had CT confirmation of diverticulitis. They found that the rate of complicated diverticulitis (abscess/perforation), immediate surgical intervention and major operations were all higher in the age group less than 40 years of age (p<.05). This is the first study in recent times that has changed the “age” criteria for young diverticulitis. A retrospective review from a multi-center trial would be valuable in ascertaining whether the age of 40 should be a criterion for surgical intervention.

We, at Colon and Rectal Care, continue to aggressively treat and manage simple and complicated diverticulitis. We, too, have found a trend in our data for surgical intervention in patients younger than age 40. However, we still maintain that each patient and their treatment algorithm should be done on a case-by-case basis.

Many patients younger than age 40 can still be treated conservatively with diet and/or prophylaxis with medications such as Xifaxan. However, certainly those patients with perforation, abscess or fistula should be referred for surgical intervention. Guzzo. DCR. 2004. Jul;4797):1187-90, West. Am J Surg. 2003 Dec;186(6):743-6, Lahat. World J Gastroenterol. 2006 May 14;12(18):2932-5, Zaidi. AJR. 2006 Sep;187(3):689-94, Neson. DCR. 2006 sep;4999):1341-5, Pautrat. DCR 2006. Dec. 13.  Summarized by Shekar Narayanan, MD.

When Surgery is done for Rectal Cancer, What Factors Influence the Likelihood that it will Recur?

The principles guiding the current management of rectal cancer involve surgical resection, coupled with adjuvant therapy, usually consisting of chemotherapy and radiation.  Cancer staging is important for many reasons as it dictates appropriateness for adjuvant therapy, stratifies patients in terms of their potential for cure versus palliation, and provides a framework from which to estimate statistics such as likelihood of recurrence, disease free survival, and overall survival.  Therefore, the first step to answer this question involves staging.  Staging is currently done through biopsies, endorectal ultrasound versus MRI, and radiographic imaging to assess for metastases such as a chest x-ray and CT scan of the abdomen and pelvis.  With this information, an estimate of the prognosis may be obtained.  From this baseline, the individual’s actual prognosis does vary somewhat based upon the specific tumor biology and details of surgical and adjuvant treatment management.

From a surgical standpoint, a number of details exist that markedly affect the local recurrence rate and quite possibly overall survival.  In addition, the goal of optimizing survival and minimizing local recurrence always has to be weighed against the potential morbidity and mortality of a proposed intervention. 

Surgical resection that does not result in the resection of absolutely all of the viable tumor cells is likely to result in recurrence either locally or distant.  Thus, surgical therapy is aimed at removing all tissue likely to harbor these cells based on imaging and staging if a cure is felt to be possible.  Some limits are placed on the general morbidity.  For example, there is probably a very small subset of patients that undergo major abdominal surgery for rectal cancer who will recur not as a result of inadequate proximal, distal, or circumferential margins on the resected tumor, but due to a para-aortic lymph node that is positive and is not removed with the surgery.  However, the likelihood of tumor existing in one of these nodes alone with no subclinical involvement of the liver, is very low.  Plus, the increased intraoperative and postoperative complication rate and decrease in patient quality of life associated with a para-aortic lymph node dissection is not felt to be justified by most authorities.

Total mesorectal excision was proposed by Heald¹ in 1979, based on the hypothesis that the 30-40% accepted local recurrence rate at the time after rectal cancer surgery was mostly due to inadequate excision of the mesorectum.  Although few surgeons have duplicated his extremely low reported local recurrence rate with this technique, total mesorectal excision has been shown in many studies to result in a statistically significant reduction in local recurrence and has now become the essential standard of care.  Reported local recurrence rates in many busy centers have now dropped into the 10-15% range since incorporating this practice. 

To optimize postoperative quality of life and function, great care is taken to offer autonomic nerve preservation (ANP).  Achieving a resection with adequate margins but without unnecessarily sacrificing nerves that may lead to impotence, urinary dysfunction, retrograde ejaculation and potential incontinence is where the skill and experience of the surgeon is most important.  Of all factors that affect a patient’s likelihood of developing a recurrence, the surgeon’s skill set is probably the most important consideration.

At Colon and Rectal Care, all four of the surgeons appreciate the very important role they play in providing the individual patient the greatest chance of a cure from this very troublesome disease.  They have undergone specialized training to enable strict adherence to the principles shown in the literature to result in the lowest possible recurrence rates and post-operative morbidity such as total mesorectal excision, autonomic nerve preservation, and restorative proctectomy whenever possible.  ¹Br J Hosp Med 1979;22:277-81.   ²Dis Colon Rectum 2007;50: 29-36.   ³Dis Colon Rectum 2007;50:168-175. Summarized by Joseph C. Muller, MD.

January 2007

What is the Role of HPV Vaccination for Perianal Condyloma?

Genital and perianal warts (condylomata acuminata) constitute a significant health problem in the United States.  This disease, which is caused by infection with the human papilloma virus (HPV), is the most common viral sexually transmitted disease with a rapidly growing incidence.  It has also been linked to the development of cervical and anal cancer.  High-risk serotypes (16,18,31,33,35,39,45,51, and 52) in particular seem to lead to dysplastic, pre-cancerous and malignant changes.

Until recently, therapy was limited to treating lesions after they were discovered with surgery or office based chemical treatments.  Recently, a vaccine has been released for prevention of the most common serotypes of HPV (6,11,16 and 18).  This vaccine is nearly 100% effective in preventing infection.        

Although studies have reported a prevalence of HPV infection in up to 75% of sexually active males, the currently released vaccine is only indicated for use in female patients aged 11-26 for prevention of HPV infection.   This is despite the fact that there is no difference in the immunologic response to the vaccine between males and females. 

There is currently no data to suggest that the current vaccine is effective in treating established HPV infection.  However, another vaccine currently in clinical trials shows great promise in treating patients already infected with HPV.  This vaccine has been shown to induce a profound immunologic response to the virus and has even been demonstrated to cause marked regression in high-grade cervical intraepithelial neoplasia (CIN). 

Almost all of the studies involving these vaccines have been in women and have dealt with prevention of cervical cancer.  This implies a benefit in the prevention of squamous cell carcinoma of the anus, as this disease paradigm is believed to be similar to

cervical cancer.  It has been suggested that anal cancer may arise from anal intraepithelial neoplasia (AIN) lesions in a fashion similar to the evolution of cervical cancer from CIN.  As HPV DNA is found in more than one-half of patients with squamous cell carcinoma of the anus, the current HPV vaccine will likely decrease the incidence of anal cancer markedly, and the investigational vaccine may have a role in treating high grade AIN.

At Colon and Rectal Care, we believe that the best approach to the problem of HPV related diseases would be widespread immunization.  As this is not currently feasible, vaccination in patients at high- risk of HPV infection may benefit from this exciting new therapy. Pediatrics.  2006 Nov; 118(5): 2135-45.  Cancer Gene Ther.  2006 Jun; 12(6):  592-7.  Lancet 2004 Nov; 364(9447): 1757-65).  Summarized by Arun Gowdamarajan, MD.

Do Spicy Foods Affect Hemorrhoidal Symptoms?

A wide proportion of the world population enjoys spicy foods.  These foods, however, have long been blamed for causing hemorrhoids or exacerbating hemorrhoidal symptoms.  However, until recently, there was no scientific evidence to support this claim.  A recent study gave patients with symptomatic hemorrhoids a capsule containing red chili powder.  The patients were assessed using a scoring system.  The results of this study showed no change in hemorrhoidal symptoms before and after administration of the red chili powder when compared to placebo.  These results clearly demonstrate that use of chili peppers, as a seasoning during a meal has no effect at all on hemorrhoidal symptoms.  So, when patients are unhappy because they believe they need to eliminate spicy foods from their diets because of hemorrhoidal symptoms, let them know that there is no need for them to eliminate these foods.    Dis Colon Rectum.  2006.  49(7):  1018-23.  Summarized by Arun Gowdamarajan, MD.

Inflammatory Bowel Disease and Osteoporosis

Inflammatory bowel disease (IBD) is known to be associated with an increased risk of osteoporosis and related problems such as fragility fractures and osteonecrosis.  Causal factors for this phenomenon include vitamin D and calcium malabsorption, treatment with glucocorticoids, high concentration of inflammatory cytokines associated with IBD, and hypogonadism induced by the bowel disease.  Measurement of bone mineral content by absorptiometry at the time of the initial diagnosis of IBD as well as laboratory evaluation of serum calcium and phosphate will help to plan the anti-osteoporosis regimen for these patients at high risk for osteoporosis.  Calcium and vitamin D supplementation and use of bisphosphonates and calcitonin may need careful consideration.  Bone density measurement is the well-accepted marker for osteoporosis.  Treatment options from management of postmenopausal and glucocorticoid-induced osteoporosis will be helpful in managing patients with IBD. 

When patients with IBD need steroid therapy on a continued and recurrent basis, osteoporosis prophylaxis is often prescribed.   Since there are no controlled trial data available re the efficient osteoporosis prophylaxis in patients with IBD, we are forced to extrapolate data from prevention and management of postmenopausal osteoporosis.  

We prescribe calcium supplementation of 1500 mg/day as well as 1000 units/day of vitamin D for our patients with IBD needing short-term glucocorticoidal therapy.  Patients needing high-dose steroid therapy may have to take bisphosphonates or activated form of vitamin D to achieve adequate prevention of osteoporosis.   Curr Opin Gastroenterol. 18:428, 2002. Inflamm Bowel Dis. 12:797, 2006. Summarized by Rama M. Jager, MD, Ph.D.

Medical Management of Anal Fissures

Anal fissure is considered an ischemic ulcer of the anoderm.  Abnormally high internal anal sphincter tone decreases the anodermal blood flow by compressing the arterioles traversing through the sphincter. High internal anal sphincter tone can lead to anorectal pain, anal fissures and often associated with thrombosed external hemorrhoids.  The resting tone of the internal anal sphincter is mostly myogenic and may depend on

neurohormonal substances such as Angiotensin II.  The sphincter relaxation is neurogenic through activation of non-adrenergic and non-cholinergic pathway that functions through release of Nitric Oxide and Vasoactive Intestinal Polypeptide. 

Pharmacologic means of decreasing the anal sphincter including the use of anticholinergics, calcium channel blockers, arginine and Botulinum toxin as well as surgical means such as internal anal sphincterotomy and CO2 laser photodestruction of superficial fibers of internal anal sphincter all are intending to counter the pathologically high internal anal sphincter tone. There are many advantages of  "chemical sphincterotomy” using medications such as Bethanechol, Nifedipine, Arginine and Botulinum Toxin A in contrast to surgical internal anal sphincterotomy since the surgical sphincterotomy can lead to clinical anal incontinence that is irreversible and not easily correctable. 

Our treatment of anal fissures always includes an initial trial with "chemical sphincterotomy" with a topical spasmolytic agent containing Bethanechol, Arginine and Nifedipine followed by intrasphincteric injection of Botulinum toxin A. Some of us also use photothermal destruction superficial fibers of the internal anal sphincter with a CO2 laser, which also decreases internal anal sphincteric tone aiding healing of the fissure. Surgical internal sphincterotomy is only considered if medical options fail. 

We are currently considering the topical use of the macrolide antibiotic Azithromycin to treat anal fissures.  Macrolides have a direct relaxant effect on the internal anal sphincter and also have bacteriostatic and anti-inflammatory effects, which will be helpful in promoting healing the anal fissure.  Azithromycin has a "concentration-dependent, epithelium-independent, direct relaxant effect" on smooth muscle through a mechanism independent of calcium channels.  It also inhibits IL17-induced IL8 production reducing the inflammatory response. Topical Azithromycin has been used for dermatologic and ophthalmic lesions and thus its topical use has been evaluated previously.  Its topical use may also be helpful in promoting healing of anal fissures.   Eur J Pharmacol.  553:280, 2006     Gastroenterology.  ;129:1954, 2005  Neurogastroenterol Motil.  17 Suppl 1:50, 2005. Summarized by Rama M. Jager, MD, Ph.D.

November 2006

Should we Screen Men who have Sex with Men for Anal Intraepithelial Neoplasia (AIN) Just as we Screen Women for Cervical Intraepithelial Neoplasia (CIN)?

In women, an association between high-risk HPV has been linked to the development of cervical cancer.  These high-risk types of human papilloma virus (16, 18, 31, 33, 35, 39, 45, 51, and 52) seem to predispose the development of what is known as a high-grade squamous intraepithelial lesion (HSIL).  It has been shown that statistically, about 36% of cervical HSIL’s progress on to an invasive cervical cancer over a 20 year period.¹    Since screening for cervical cancer with ablative therapy has been done for high-grade HSIL, there has been a 78% reduction in the incidence of cervical cancer.²  There is a striking similarity between anal intraepithelial neoplasia (AIN) as a precursor to squamous cell cancer of the anus and cervical intraepithelial neoplasia (CIN) as a precursor to invasive cervical cancer.  Unlike cervical cancer, AIN has not been proven to be a precursor lesion to squamous cell cancer of the anus.  However, HPV DNA has been identified in 35 to 61 percent of squamous neoplasms of the anus¹, suggesting a similar association and there is evidence that perianal Bowen’s disease is similar to anal HSIL and it is well established that Bowen’s disease is premalignant¹.

Should Anything be Done About AIN if it is Identified?

One approach to this problem favoring surveillance over intervention would point out that we currently have no acceptable way to cure dysplasia, so secondary prevention is impossible with current tools.³   The current data would suggest an exceptionally high recurrence rate of dysplasia approaching 100% by 50 months in the HIV population (which have 10 times the incidence of anal canal cancer over the general

population), regardless of any currently described modality of surgical therapy.³   In addition, even in the HIV negative population, after undergoing complete excision for Bowen’s disease (carcinoma in-situ), suffering complications such as stricture, ectropion, fecal incontinence, and often requiring extensive reconstruction, the recurrence rate has still traditionally been 25 to 50 percent.⁴   One would have to believe that the other less aggressive surgical modalities would have at least that high of a recurrence rate.   One group recommends an algorithm of q 6 month surveillance with biopsies taken for suspicious lesions positive for even high-grade AIN-III with excision or chemoradiation only when actual invasive squamous carcinoma is identified.⁴  This considers the statistics once a patient gets invasive cancer from several phase II and III trials involving chemoradiation protocols for invasive anal canal cancer yielding colostomy-free survival rates in the range of 66 to 87 percent and overall survival rates ranging from 61 to 84 percent.⁵

Other proposed algorithms favoring intervention over surveillance have favored infrared photocoagulation of anal squamous intraepithelial lesions⁶, Pap smears of the anus with high resolution anoscopy with biopsy and cauterization of aberrant lesions¹, and application of topical agents such as 5 Fluorouracil or Imiquimod.⁷   These proposals have noted that Bowen’s disease may progress to an invasive cancer 2-5% of the time⁷ and so some intervention should be considered, but they share the concern over the morbidity and high recurrence rate of the complete excision option.  One paper suggests a 16-week regimen of topical 5-FU therapy after initial anal mapping biopsies for near circumferential AIN-3 with breaks in between for poor tolerance and follow up biopsies with mapping within one year.  Out of 11 patients treated, all but one were completely free of any dysplasia at one year and also later at a mean follow up of 39 months.  The one patient was HIV positive, placing him at a much higher risk for recurrent dysplasia regardless of any

intervention.  Imiquimod was suggested for lower grade AIN-1 or 2 lesions.

Ongoing study will be needed to determine the appropriateness of these proposed interventions and the surgeons at Colon and Rectal Care maintain an interest in the data available to help our patients with these problems choose the right path for them.  For now, there does not seem to be a right answer, per se.  However, one thing is clear, patients with high-grade dysplasia will, at the very least, require close supervision and a low threshold for biopsy of any abnormal lesions. ¹Dis Colon Rectum 2002;45:453-458.   ²Dis Colon Rectum 2000;43:346-352.  ³Dis Colon Rectum 2006;49:36-40.  ⁴Br J Surg 1999;86:1063-6.  ⁵Dis Colon Rectum 2005;48(9):1742-51.  ⁶Dis Colon Rectum 2005;48(5):1042-1054.  ⁷Dis Colon Rectum 2005;48(3):444-450.  Summarized by Joseph C. Muller, MD

Robotically Assisted Colonic Surgery: Has the Time Come?

Robotically assisted surgical procedures are becoming more commonplace. The technology has essentially become the standard for prostatectomies, and has increasing usage for gynecology, urogynecology, thoracic and cardiovascular surgery. Recent data does suggest that its usage in colorectal surgery is feasible, but with inherent advantages and disadvantages.

Delaney et al, performed six robotically assisted colorectal cases between 2001 and 2002. Overall, there were no morbidities. There was, however, an increase in both cost and overall surgical time. They did note increased 3-dimensional visualization and dexterity. Braumann et al, studied its applicability in five patients with colorectal pathology. There were no morbidities, but there was difficulty with a lack of a large operative field and the need to dissect the flexures. They did note a great benefit with rectal dissection and pelvic visualization. Woeste et al, studied DaVinci (Robotic System) assisted colonic surgery in six patients (4 for Diverticulitis and 2 for Rectal Prolapse). They found NO difference in outcomes, morbidity or length of stay. There was, however, a significantly longer operative time.

Finally, Rawling et al, studied 30 consecutive colectomies performed with Robotic assistance between 2002-2005. There were 13 right colectomies and 17 sigmoid colectomies. The pathologies varied from cancer to unresectable polyps to diverticulitis.

They noted six complications in the study. These varied from a hip paresthesia, an anastomotic leak and a patient slipping off the operating room table. Overall, the length of operative time was longer but the length of stay was similar to standard laparoscopic surgery. The authors concluded that the procedure can be safely done with the assistance of the robotic system and recommended a large-scale trial to determine both feasibility and efficacy.

We at Colon and Rectal Care have been able to use the DaVinci Robotic system in selective patients with colorectal pathology. A total of three patients have been operated on to this point (One for a cecal polyp and two for rectal prolapse). Two out of the three had their operation completed with the Davinci system. We agree with the authors that the length of the operative time is certainly longer. However, the 3-dimensional viewing and dexterity is of great value. We especially find the system useful in the pelvic dissection in male patients and more importantly, being able to identify and preserve the hypogastric nerves that relate to sexual function.

Overall, these studies show that Robotic assisted colon surgery can be done safely and with good results. Issues related to operative time and cost certainly will play a large role in the eventual implementation of this technique. By no means do we feel standard laparoscopic surgery should be or will be replaced with this technique.

Our own experience has been positive and we continue to counsel and educate our patients on the various options for colonic surgery. Delaney. Dis Colon Rectum. 2003 Dec:46(12):1633-9, Braumann. Dis Colon Rectum. 2005 Sep; 48(9):182-7, Rawlings. Surg Endosc. 2006 Aug 28, Woeste. Int J Colorectal Dis. 2005 May; 20(3): 253-7.  Summarized by Shekar Narayanan, MD.

September 2006

TEM Now Available in Indy: Avoids Abdominal Surgery and Colostomy

Currently, the transanal endoscopic microsurgery procedure (TEM) is indicated for rectal polyps (even very large ones) and T1 invasive cancers that are well or moderately differentiated as a technique for cure. 

On Friday, June 2, 2006, the first TEM was performed in the state of Indiana by Dr. Muller of Colon and Rectal Care, Inc.  For the treatment of mid and upper rectal polyps and earlier rectal cancers and for the appropriately chosen patient, the technique often enables an outpatient procedure with minimal postoperative discomfort when the only alternative may often require major abdominal surgery that sometimes may even involve a permanent colostomy. 

Most importantly, the data from at least two series demonstrates that this improvement in outcome can be achieved without increasing the likelihood of a tumor recurrence and without decreasing the 5-year survival rate for the patient. 

The key lies in appropriate patient selection, familiarity with the technique, and meticulous attention to detail to verify clear margins of the specimen.  The procedure involves using specialized equipment that includes an operating tube proctoscope that is inserted into the rectum through which instruments similar to those used in laparoscopic surgery can be used.  In this manner, lesions up to 25 cm above the anus may be excised, enabling pathologic confirmation of clear margins, determination of risk for local and distant spread, and estimating cure rates.  For older or debilitated patients who are not good candidates for extensive surgery for cure, this technique also offers another alternative for good local control for palliation.

Candidates are chosen based on endorectal or endoscopic ultrasound staging and lesion biopsy results as well as other clinical factors.   Despite the necessity of a proctoscope throughout most of the case, postoperative fecal continence is rarely affected. 

Studies have repeatedly demonstrated shorter operating times, less blood loss, shorter hospitalizations, and lower analgesic requirements after this surgery. Perhaps the most difficult step in providing this improved method of treatment for patients lies in letting patients and physicians know that this is now available. In our opinion, a patient with any type of growth in the rectum or lower colon that has not yet been definitively diagnosed as an invasive cancer, and who is considering undergoing a major abdominal surgery for treatment, should be evaluated to see if they are a candidate for the TEM technique. Patients that have an early stage cancer with favorable pathology characteristics on biopsy should also be evaluated.                                                                 

Another very important role for this technique is completion excision of invasive carcinoma that first underwent piecemeal polypectomy using a colonoscope where cancer was then identified after the procedure.  Clean peripheral and deep margins after that situation is paramount for adequate staging and treatment planning to optimize outcome for the patient.

At Colon and Rectal Care we are excited to now offer this new technique to our patients as well as residents of Indiana and the surrounding areas.  We look forward to staying on the cutting edge to give patients with colorectal cancers the highest chance for survival and the best chance of successful treatment without the need for a colostomy.  We view any new technology that aims to advance either of these goals as a priority in our practice.  In addition, we carefully evaluate the efficacy and safety prior to offering any of these techniques to our patients.

If you believe you may have a patient or know of a patient that may qualify for this technique, you are encouraged to contact Colon and Rectal Care, Inc to discuss the case with one of the physicians to help determine candidacy. Dis Colon Rectum 2006; 49(2): 164-168.  Surg Endosc 2003; 17:1461-1463.   World J Surg 2001; 25: 870-875.  Dis Colon Rectum 2002; 45(5): 601-604.  Cancer Supplement 1992; 70(5): 1355-1363.   Dis Colon Rectum 2001; 44(9): 1345-1361

What new options are available to treat Crohn’s disease?

 Crohn’s disease is a chronic disorder that causes inflammation of the digestive tract.  It can involve any area of the GI tract from the mouth to the anus.  It most commonly affects the small intestine or colon.  The disease is characterized by persistent diarrhea, crampy abdominal pain, fever, and at times, rectal bleeding.  Patients will go through periods in which the disease flares up, and times in which the disease decreases. 

Complications of the disease include intra-abdominal complications and anorectal complications.  Abdominal complications include abscesses, enterocutaneous fistulas, entero-enteric fistulas, and strictures leading to obstructions.   Anorectal complications include abscesses, fistulas, and fissures. 

Because there is no cure for Crohn’s disease, the goal of treatment is to suppress the inflammatory response.  Several different groups of drugs are used.  Aminosalicylates are used mainly for mild disease.  They do not have a role in maintenance therapy.  

Corticosteroids are often used to treat moderate to severely active disease.  Unfortunately, they have significant long-term side effects, and should not be used as a maintenance medication.  Immune modifiers, such as Azathioprine, are used to help decrease steroid usage and can help maintain remission. 

Biological therapies, such as Infliximab, are a newer class of drugs.  They are often utilized in patients who are not responding to other therapies.  Infliximab is also effective in treating fistulous disease.  Unfortunately, as Infliximab is manufactured from mouse proteins, patients can develop antibodies against the medication.  Over time, the medication also can lose effectiveness.

A new biologic agent, Adalimumab, is now available. This medication has recently completed evaluation for

treating Crohn’s disease.  This agent is manufactured from human antibodies, so only 1% of patients treated developed antibodies against this medication.  In the difficult to manage patients who have been refractory to standard therapy, Adalimumab effectively induced remission in 39% of patients.  This is comparable to the historical rates achieved by Infliximab. 

At Colon & Rectal Care, we are excited about this cutting edge therapy directed towards Crohn’s disease.  We expect that the role of this drug will be in patients who are no longer deriving benefit, or are unable to take Infliximab due to intolerance.    Gastroenterology.  2006; 130(2) 323-33.   

Antegrade continent enemas for adults

Slow transit constipation in adults can be difficult to treat and often causes great discomfort.  Total colectomy is often offered but is associated with persistent constipation up to 20% of the time.  Recent long-term data is now available regarding the minimally invasive antegrade continent enema (ACE) in adults.

  The ACE procedure is performed laparoscopically.  Through these small incisions, the native appendix is brought through the abdominal wall and tunneled subcutaneously.  The tip is then opened.  This opening allows introduction of a small catheter, which is used to irrigate the colon on a regular basis. This lavage facilitates complete emptying of the colon, preventing the symptoms of severe slow transit constipation.  

At 5 year follow up, 60% of patients maintained function of the ACE.  These patients demonstrated satisfactory improvement in bowel function and showed significant improvement in quality of life scores. 

At Colon & Rectal Care, this technique has been utilized successfully for years in patients with severe constipation.  We also utilize the predictive nature of this technique to manage selected patients with fecal incontinence.  Poster presentation ASCRS Conference 2006.

July 2006

Highlights from the 2006 American Society of Colon and Rectal Surgeons meeting

The annual American Society of Colon and Rectal Surgeons meeting was recently held in Seattle. Below are highlights of some of the extremely important directions colon and rectal surgery is moving toward and how we at Colon and Rectal Care are spearheading these movements for the Indianapolis community.

Rectal cancer

Several studies focused on the recurrence rates for transanal excision of early rectal cancer. What was most disturbing was the increasing rate of reported local recurrence (18-24%). Schochet et al reviewed their 10-year follow up of Transanal Excision (TAE) for T1 and T2 cancers. In addition, they analyzed those patients who received adjuvant radiation and/or chemotherapy. Their data once again showed an unacceptably high recurrence rate. Their local recurrence rate was 18/33% respectively for T1/T2 lesions. It was also alarming that those patients treated with adjuvant therapy had a recurrence rate of 30%. This has prompted many to challenge current surgical technique.

Transanal Endoscopic Microsurgery (TEM) was the most talked about modality change at this years meeting. Dixon et al. reviewed the data regarding a comparison between traditional transanal excision (TAE) and TEM. Over a 6-year period of time they had 102 patients with either a T1 or T2 rectal cancer that underwent either a TAE or TEM. The follow up rate was around 4 years for both groups. They found a recurrence rate of 20% for the TAE group and a 0% recurrence rate for the TEM group. These two studies show that TEM is the most promising new development for early rectal cancer. We at Colon and Rectal Care are proud to be the first group to offer this surgery in Indianapolis. We now consider this to be standard of care for patients with early stage rectal cancer (T1 only) and who do not have negative tumor characteristics. Dixon et al. Podium Presentation. ASCRS annual meeting. 2006, Schocet. Et al. Poster Presentation. ASCRS annual meeting. 2006. Buess. Expert Pane. ASCRS annual meeting 2006 Summarized by S. Narayanan MD
 

Anastomotic Leaks

Anastomotic leaks are the most feared complication for colon and rectal surgeons. Incident rates range from 3-10%. Low rectal cancers treated with pre-operative chemotherapy and radiation often require a temporary ileostomy. Several studies used different augmentation materials to try and determine if these would decrease these leak rates and potentially eliminate the need for temporary diversion. Madbouly et al randomized 108 patients to receive oxidized cellulose anastamotic reinforcement in low rectal cancer and they found statistically different leak rates between the reinforced group vs. the non-reinforced group (7 vs. 12%). They hypothesized these were related to a decreased incidence of a local hematoma. Hagerman et al, used bovine pericardium in a canine model to buttress colorectal anastamosis and determine burst/tensile strength. They found the unbuttressed anastamosis was likely to burst at the anastamosis (63%), whereas the buttressed anastamosis was more likely to burst the adjacent tissue (75%). Hunt et al, used alloderm to reinforce 20 colorectal anastamosis in a porcine model. Compared to controls, they found statistically significant differences in burst pressures, and leak rates. They did note a statistically significant difference in luminal size secondary to the fibrosis of the alloderm but NO evidence of structuring. We at Colon and Rectal Care are pleased to have an anastamotic leak rate much lower than the reported average. However, we continue to monitor the data and clinical trials in hopes of eliminating this complication. Madboull. Podium Presentation. ASCRS annual meeting. 2006, Hagerman. Poster Presentation.. ASCRS annual meeting 2006, Hunt. Poster Presentation. ASCRS annual meeting 2006 Summarized by S. Narayanan, MD

Striving to Improve Quality of Care

Several other papers and posters showed the societies desire to improve the quality of care for those patients afflicted with colorectal disorders. New treatment strategies were presented in treating anal fistulas, diverticulitis, large colon polyps and improvement in our Laparoscopic colon operations. We at colon and rectal care share the societies vision and desire to improve quality of care for those patients with colorectal disorders. Summarized by S. Narayanan, MD

Colorectal Lymphoma: Rare, but increasing in incidence

Although uncommon, colorectal lymphoma is an important clinical entity to consider. Lymphoma is the sixth most common cause of cancer death in the United States with the gastrointestinal tract being the most common site outside of the lymph nodes. 15-20% of gastrointestinal lymphomas are found in the colon or rectum. Statistically, 1.4% of all non-Hodgkin’s lymphomas are colorectal lymphoma. Overall, they comprise less than 1% of all colorectal cancers.

Diagnostic criteria for this entity involves lymphoma in the absence of systemic disease occurring in the colon or rectum that meets the following criteria: 1) the absence of clinically enlarged lymph nodes on physical examination, 2) the absence of enlarged mediastinal lymph nodes on chest x-ray or CT scan, 3) normal hematologic laboratory values and bone marrow biopsy, 4) normal-appearing liver and spleen, 5) no CT evidence of retroperitoneal lymphadenopathy.

Since definitive therapy is usually chemotherapy, the faster growing and more aggressive tumors often have the better prognosis because they respond better to chemotherapy. The most common type is diffuse large B-cell lymphoma that is usually quite aggressive. Other varieties include MALT-associated low grade B-cell lymphoma, Mantle cell lymphoma, Burkitt’s lymphoma, and follicular lymphoma. T-cell, and Hodgkin’s type are very rare.

More than 70% of colorectal lymphomas are found proximal to the hepatic flexure. The most common presenting symptoms are abdominal pain and weight loss, although up to half may present with an abdominal mass, leading observers to believe the patients may remain asymptomatic for quite some time. Clinically or pharmacologically immunosuppressed patients are at particular risk for developing this entity. Radiographic, endoscopic, and pathologic findings can vary markedly and are usually non-specific, although lymphoma is most often large and polypoid. In addition, radiographic findings of colorectal lymphoma can mimic Crohn’s disease or ulcerative colitis. This emphasizes the importance of colonoscopic evaluation with biopsies that are often diagnostic or can rule out lymphoma.

As with most cancers, treatment involves surgery, chemotherapy, and or radiation. However, in this disease, combination chemotherapy plays a primary role with surgery being necessary to improve outcomes through local control to reduce recurrence rates. Similarly, external beam radiation is helpful for adjuvant local control, but is not preferred in lymphomas of the small or large bowel due to the potential for major complications in this area.
Prognosis varies depending on tumor type and whether or not disease has spread to any of the lymph nodes. One report indicated that 14-24% of patients in their series had no tumor involvement outside the primary organ and that this was associated with an 83% 10 year survival. They also noted a 74% local or disseminated relapse rate in the portion of this sub-group of patients receiving surgery alone, strongly emphasizing the importance of chemotherapy in the treatment protocol. Nonetheless, considering all patients with colorectal lymphoma, despite the option of salvage chemotherapy for recurrence, 33-75% of patients will have a relapse and most of them will die of this disease. Our experience at Colon and Rectal Care reflects what is seen in the literature in terms of the relative infrequency of this disease process and the typical presentation. The importance of early identification through colonoscopic surveillance as illustrated by the above statistics cannot be overemphasized (screening flexible sigmoidoscopy will miss over 70% of these). Also, the necessity of a careful multimodality approach established through close interaction with our medical oncology colleagues is instrumental to optimize outcomes with this disease. Dis Colon Rectum 2000;43:1277-82. Clinics in Colon & Rectal Surgery 2006;19:49-53. J Clin Gastroenterol 1994;18:291-297. J Surg Oncol 2002;80:111-115. Summarized by Joseph Muller, MD

May 2006

What new options are available to treat ulcerative colitis?
Ulcerative colitis is characterized by remissions and exacerbations of colitis associated with abdominal cramps, rectal bleeding, and diarrhea.  The disease usually affects patients in their youth or early middle age and can have devastating short and long-term effects.  There is no specific medical cure, although medical therapy may control exacerbations. 

Traditionally, medical therapy starts with mesalamine products for maintenance therapy as well as for treating acute attacks.  Should this fail oral corticosteroids are often added.  Failure of oral steroids to control the acute attack often leads to inpatient admission with the administration of intravenous steroids and gut rest.  Often, failure of these medications to adequately control the disease flare leads to surgical resection. 

Infliximab, a monoclonal antibody directed against tumor necrosis factor alfa was released several years ago.  It became an established treatment for Crohn’s disease.  In fact, it often effectively induced and maintained remission for prolonged periods of time in many patients with refractory Crohn’s disease.  These successes led to limited trials of Infliximab to treat refractory ulcerative colitis.  These initial studies produced equivocal results.  However, all of these studies were limited by extremely small sample size. 

Recently, two large prospective, randomized, blind studies evaluated use of Infliximab in moderate or severe, active ulcerative colitis.  Both studies demonstrated a significant clinical response in patients with severe, refractory ulcerative colitis. At eight weeks, 65% of patients demonstrated clinical significant clinical improvement (versus 29% in the placebo group).  One-year follow up demonstrated that this improvement was maintained in 45% of patients (versus 20% in the placebo group).  Further study to evaluate the long-term maintenance of remission is still needed.  At Colon and Rectal Care we have been using Infliximab in patients with refractory ulcerative colitis for several years based on the preliminary, smaller studies with comparable results to the most recent studies. Rugeerts P.  N Engl J Med.  2005.  353(23):  2462-76.  Summarized by A. Gowdamarajan, MD