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Minimally Invasive Surgery In The Treatment Of Colon And Rectal Disease

For some time now, there has been significant interest in understanding and defining the role of minimally invasive surgery in colorectal cancer. Laparoscopic surgery has been shown to have similar or better outcomes compared with open surgery.

Patients who choose UAB Medicine for their gastrointestinal cancer care will benefit from a pacesetting team of specialists, state-of-the-art technology, and many treatments not available at other centers. Our outstanding physicians and surgeons work with members of the departments of Radiation Oncology and Radiology and the divisions of Hematology/Oncology, Gastroenterology, and Endoscopy to provide you with the latest diagnostic and therapeutic options.

Listen in as Gregory Kennedy, MD explains the advantages of using minimally invasive surgery in the treatment of colon and rectal disease.
Minimally Invasive Surgery In The Treatment Of Colon And Rectal Disease
Featured Speaker:
Gregory Dean Kennedy, MD
Gregory Dean Kennedy, MD is a general surgeon with The Kirklin Clinic of UAB Hospital.

Learn more about Gregory Dean Kennedy, MD 

Dr. Kennedy has no financial relationships related to the content of this activity to disclose. Also, no other speakers, planners or content reviewers have any relevant financial relationships to disclose.

There is no commercial support for this activity.
Transcription:

Melanie Cole (Host): For some time now, there's been significant interest in understanding and defining the role of minimally invasive surgery in colorectal cancer. Laparoscopic surgery has been shown to have similar or better outcomes compared with open surgery. My guest today is Dr. Greg Kennedy. He's the John H. Blue Endowed Chair in General Surgery and the Director in the Division of GI Surgery at UAB Medicine. Welcome to the show, Dr. Kennedy. Tell us a little bit about the history of minimally invasive surgery for colon and rectal diseases and the conditions it's been typically used to treat.

Dr. Greg Kennedy (Guest): Thank you, Melanie. So, the history of minimally invasive surgery for colorectal surgery is a little bit mixed. It dates back to the early 90's when the surgeons were just starting to use laparoscopy for things like gallbladder surgery; a little more straightforward. A smaller group, people like Steve Wexner, Tony Senagore, and others started experimenting with laparoscopy for colon and rectal disease. What they found in those early 90's is that, actually, at least for colon cancer, local recurrence was a bit of a problem. Because of that, the American Society of Colorectal Surgery actually put a moratorium on laparoscopy for malignant disease and it wasn't until Heidi Nelson and her group published the landmark paper in the New England Journal showing that laparoscopy was, in fact, safe for treating colon cancer that really laparoscopy took off at that point. So, this was in about 2001, or so, that data was released. After that, laparoscopy has been somewhat slowly adopted, honestly. In the mid-2000's, 2005, 2006, what we saw was about 30% of all colon and rectal disease being treated laparoscopically. Maybe a little bit higher in benign disease, but certainly not as high in malignant. Now, we're up to just around 50%-60% of all colon and rectal surgery being done in some sort of minimally-invasive fashion.

Melanie: So, why are you doing laparoscopic versus open? Is there a reason?

Dr. Kennedy: Well, I think what the randomized controlled trials have not shown is a benefit to the patients for laparoscopy and what I mean, specifically, Melanie, is that they've shown that it can be done safely. Laparoscopic or minimally invasive surgery can be done safely, but they really haven't shown that the patient's benefit. We've published several papers, our groups have published several papers, looking at specifically patients who have had laparoscopic surgery comparing to the patients who have had open surgery. What we've pretty clearly shown is that patients do better with minimally invasive approaches. Their infection rates are lower, their length of stays are lower; their readmission rates are lower. Just almost every metric you look at, the patients do better. Because of that, we've pretty much adopted minimally invasive approaches in just about everything we do. So probably about 90% of our practice here is a minimally invasive operation for colon and rectal disease, whether it's colon cancer, diverticulitis, ulcerative colitis, Crohn's disease--whatever the indication, we're trying to approach the patient in a minimally invasive fashion.

Melanie: Dr. Kennedy, if we're looking at rectal cancers, are there technological challenges performing laparoscopic resection of these cancers, or an uncertainty of the oncologic quality of the surgical resection?

Dr. Kennedy: Yes. That's a great question and it's really come under close scrutiny here with Jim Fleischmann's recent paper in JAMA, showing that perhaps there's a little bit worse cologic outcome in patients who have a minimally invasive approach for rectal cancer. There are lots of reasons, lots of problems with the study, in my opinion. I think the technical problems are is that the pelvis is a fairly narrow space. Now, perhaps, robotic approaches might improve those approaches. So, the robotic surgery may improve the minimally invasive approach to rectal cancer simply because it's perhaps a better platform for the pelvic work. But, honestly, I think what you really need is an experienced, highly-qualified surgeon who's going to be doing the operation. I think that what we know from lots of other work, from overseas, from Connor Delaney's group, Steve Wexner's group, what we know is that, in fact, minimally invasive operations for rectal cancer are very safe, oncologically sound, can be done. The difference might be that these guys are really and truly expert surgeons. We've shown the same thing in our own smaller series that, in fact, the oncologic operation is just fine for rectal cancer. You just need a highly experienced surgeon.

Melanie: Are you seeing a preference for robotic rectal surgery as an attractive alternative to the laparoscopic surgery because you were talking about the narrow pelvic field, more precision dissection? Do you have a preference?

Dr. Kennedy: Well, you know, honestly, my preference is whatever it takes. I'll use the robot or the laparoscope, but I've done you know, several hundred. That being said, I think most surgeons today are really moving towards the robotic platform just because it is a little bit technically easier. I've certainly adopted the robotic platform, as well, but I sort of go back and forth between robotics and laparoscopy. Where I really find the added value in my own practice for robotics is in the morbidly obese patient; for the patient with a BMI over 40 who technically, is very complicated, very difficult to get done laparoscopically simply because of some physical problems. The robot doesn't necessarily have the same physical limitations of the laparoscope. So, I think those are the patients who really have added value.

Melanie: And how often might you have to convert from laparoscopy to open surgery?

Dr. Kennedy: That's a great question. So, when you look at historic data, the conversion rates are around 20%. So, if we look back at those seminal trials published by Heidi Nelson and others, conversion rates are 20% and that's sort of the accepted number. When we look at more recent data from groups that are really expert, what you see are conversion rates plummeting below 10%, even below 5%. Our own personal conversion rate is closer to the 5, or 4-5%, and I think those are reasonable numbers that you should be looking at for the expert laparoscopic colorectal surgeon.

Melanie: And, so, what are some other options laparoscopic or robotic, for the uses that you can see?

Dr. Kennedy: Well, certainly for disease, if we're talking about diseases, I would say everything. I mean, we use the laparoscope or robotic approaches for virtually every disease process. So, if it's Crohn's disease, ulcerative colitis, and cancer; we're using laparoscopy or minimally invasive approaches. If we're talking about the patient who has had multiple operations, multiple prior operations, so the Crohn's patient, for example, who's had multiple, prior laparotomies, I think, again, laparoscopy is a viable option, in the right hands. So, we've done, hundreds of re-operative cases all laparoscopically. So, it can be done. It's just a matter of persistence and expertise. Other options, though, when we start talking about these minimally invasive platforms, we start thinking about single-incision laparoscopy. So, for the patients who have a particular concern about cosmesis, single-incision laparoscopy, suggests using a port through the umbilicus or elsewhere in a more cosmetically-approved site. These are all options that we can think about.

Melanie: Have you seen a use for a hybrid approach to robotic assisted rectal surgery with laparoscopic colon mobilization or is this not done anymore?

Dr. Kennedy: That's a great question. Actually, that's how I do them, to be honest with you. So, when I'm doing a robotic rectal cancer operation, I typically will mobilize the colon laparoscopically. There are a couple of reasons for that. One, I am a faculty member at a University. I teach residents. It's easier for me to have the residents doing the laparoscopic part of the operation with me there at the table, carefully assessing them. The second reason, I guess, that I like to use a laparoscope, is I don't find the robotic approach quite as nimble as we swing from the pelvis up to that left upper quadrant, mobilizing the splenic flexure. The robot just isn't quite perfect, in my opinion, for making that swing. So, oftentimes, you have to dock it in a less than ideal position for either the pelvis or for the left upper quadrant. It's hard to have it be perfectly docked to do both things. So, you're either going to have to dock it twice, do one part and re-dock it for the second part; or you're going to have less than ideal docking to do the whole thing. So, just to counter that, I just do the laparoscopic mobilization, and then dock the robot for the pelvis.

Melanie: What a great point. And in the last few minutes, Dr. Kennedy, how can a community physician refer a patient to UAB Medicine?

Dr. Kennedy: Well, it's a fairly straightforward process. We've got the MIST operators readily available ready to take phone calls, they can get anybody on the phone immediately. That number is 1-800-UAB-MIST. Once you talk to the MIST operators, they can connect you to any surgeon that you want to talk to and patients can easily get in to see us in a timely fashion.

Melanie: tell us about your team. Why is UAB so great to work with?

Dr. Kennedy: Oh, the team here at UAB is phenomenal for lots of reasons. So, we've got four colon and rectal surgeons--all of us are board-certified, all of us are well-trained pretty much all doing the same thing. So, if you refer a patient, if a patient is referred in to UAB, what the referring doctor can be certain of is that they're going to get the top-shelf surgeon, no matter who they end up seeing. That's number one. Number two, I think all four of us certainly can say for my three partners, they're three of the nicest people I've ever met. These are just very humble, very technically gifted people, so I just can't say enough about them as people. The third reason, and this is maybe beyond what the referring doc will see, is we've got a great staff here at UAB. I can't tell you how many patients I've had come to the clinic after surgery and say, “This was the best experience I've ever had at a hospital from the cleaning people in the room to the nurses, to the lab techs, to the discharge process, and the people pushing me out. This was just a phenomenal experience.” And I'll tell you, I think there's a lot of truth to that. The people I've seen really care about their job, really care about people, so it's just a great place to work and it seems to be a great place to be a patient.

Melanie: Thank you so much for being with us today, Dr. Kennedy. You're listening to UAB MedCast. For more information for resources available at UAB Medicine, you can go to www.uabmedicine.org/physician. That's www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.