Colorectal Symposium

MPG Surgical Specialists

Albert Chung, MD

April 25, 2016

Agenda

• What is a colorectal surgeon?

• Overview of colorectal cancer staging

• Colorectal at MidMichigan Hospital, Midland

– Oncology initiatives

– Minimally invasive surgery

– Enhanced recovery after surgery (ERAS)

Colon and Rectal Surgeon

• ACGME1 accredited fellowship with review by the RRC2

• 1 year fellowship training – After completing general surgery (5 years)

• Training – Specialized operative procedures – Colonoscopy – Curriculum

• Board certification by American Board of Colon and Rectal Surgeons (ABCRS)

1Accreditation council for graduate medical education 2Residency review committee

Curriculum • Conditions:

– Benign • Anal/rectal abscess and anal

fistula • Rectal prolapse • Fecal incontinence • Hemorrhoids, anal fissure • Diverticulitis • Intestinal stomas • Colonic inertia

– Inflammatory bowel disease • Crohn’s disease • Ulcerative colitis

– J-pouch creation

– Malignant • Colon cancer • Rectal cancer • Anal cancer

• Procedures:

– Colonoscopy

– Anal manometry

– Rectal/anal ultrasound

– Open surgery

– Minimally invasive

• Laparoscopic

• Robotic

Colon and Rectal Cancer Staging

Adapted from NCCN guidelines Colon and Rectal cancer (3.2015).

Colon and Rectal Cancer Staging

Staging the Easy Way…

• Stage 1

– T1 or T2, without N

• Stage 2

– T3 or T4, without N

• Stage 3

– Any N disease

• Stage 4

– Any M disease

Adapted from NCCN guidelines Colon and Rectal cancer (3.2015).

Clinical Staging

• Colon and rectal cancer – Complete colonoscopy with biopsy

– CT chest/abdomen/pelvis with oral and IV contrast

– Carcinoembryonic antigen (CEA), metabolic panel, CBC

• Additional: Rectal cancer – Proctoscopy

– Rectal ultrasound

– MRI of rectum

Treatment plan

Pathologic Staging

• Based on pathologic examination of surgical specimen

• Evaluation of primary tumor

• Evaluation of lymph nodes

– Minimum of 12 lymph nodes

Treatment plan

Colorectal in Midland • Hospital wide initiatives

– Clinic, OR, anesthesia, floor nursing, wound/ostomy care, physical/occupation therapy, nutrition, oncology…

• Center of Excellence of Colorectal Cancer – (Optimizing Surgical Treatment of Rectal Cancer) OSTRiCh

consortium – High volume centers

• Better survival, lower mortality, anal sphincter preserving procedure

– Oncology data reporting

• Tumor board – Every other week

– Attended by MidMichigan staff: • Medical and radiation oncologists, radiology, pathology, genetics

Colorectal in Midland

• Robotic surgery

– Better 3 dimensional visualization

– More precise instrument movement

– Elimination of human hand tremor

– Advantage: confined spaces such as pelvis

– 7 degrees of movement

– Superior ergonomics

– Shorter learning curve

– daVinci Xi arrival in 2016…

• Transanal minimally invasive surgery (TAMIS)

– Developed by: Attalah, Albert, Larach (2009)

• Florida Hospital

– Anus used as access port for laparoscopic surgery

– Surgical excision of rectal pathology without abdominal incision

Colorectal in Midland • Enhanced recovery pathway (ERAS)

– Initially developed by Kehlet, Fearon, Ljungqvist, et al. (2001)

– Standardization with evidence-based practices • Preoperative, intraop, periop, postop

– Goals of pathway: • Reduce stress, maintain physiology, enhance mobilization

Results: • Earlier return of bowel function

• Decreased LOS up to 2.5 days for open and laparoscopic cases

• Cost savings

• Considered safe: no sig. differences in readmission or mortality, lower total complications

Midland Colorectal ERAS Protocol • Clinic

– Education, nutrition, PT/OT, ostomy marking/education

• Preop – Mechanical and antibiotic bowel prep – Carbohydrate drink 2 hours before surgery – Ofirmev, gabapentin, robaxin – Transversus abdominal plane (TAP) block with exparel or bupivicaine – Intrathecal with morphine – Entereg

• Intraop – Minimal to none narcotics – Goal directed, fluid restriction

• Postop – Early mobilization – Early feeding – PCA, oral narcotics (eg percocet 7.5mg)

Current Results With ERAS • 42 total patients (25 robotic, 13 laparoscopic, 4 open)

– Admitted from outpatient, variety of pathology • Majority: IBD, colorectal carcinoma, diverticulitis

– Average age: 58.5 years (range: 26 to 81 years) – Average length of stay: 3.3 days (range: 2 to 9 days) – Number readmissions: 3

• inguinal hernia, fluid overload, ileus secondary to imodium

– Complications: • 1 urinary tract infection • 2 ileus • 1 alcohol withdrawal • 1 hyponatremia, postoperative bleeding • 1 reoperation for bowel obstruction from port site hernia

– Mortality: 0 – Conversion rate to open: 0

Length of Stay

• Right colectomy/ileocolic resection

– 8 cases, LOS: 2.5 days

• Left colectomy/Hartmann reversal/total colectomy (1)

– 12 cases, LOS: 2.9 days

• Proctectomy

– 14 cases, LOS: 4.4 days

Thank You

• Colorectal at MidMichigan Hospital, Midland

– Oncology initiatives

– Enhanced recovery after surgery (ERAS)

– Minimally invasive surgery

• Thank you to MidMichigan Midland Staff