Surgical Sub-specialization: Colorectal Specialist Peter W. Marcello, M.D. Vice Chairman, Department of Colon & Rectal Surgery Lahey Clinic Burlington, Massachusetts Disclosures I am a paid consultant for: Applied Medical Covidien Olympus Well recognized specialty field Disease oriented specialty makes sense Technical advances training case volume Colorectal surgeons 1,500 General surgeons 18,000 311 million to 340 million by 2020 ~320,000 colorectal procedures 50-100,000 anorectal procedures We can t do it alone!! Where specialization matters How to train general surgeons? How to plan for the future in your system? A Poll? How many do > 20 colectomies? How many do lap colectomy? How many see > 4 rectal cancers a year? 1 1
Colectomy by General Surgeons Review of ABS database 2434 general surgeons at recertification Percentile Procedure Mean 70% 90% Colectomy 11.2 14 23 Total colectomy 1.0 1 3 APR 0.8 1 2 Hyman, J Am Coll Surg 2002, 194:37 Treatment for Rectal Cancer?? Proctectomy for Rectal Cancer: Technique Matters Surgeon to Surgeon Variability Survival Local Recurrence M Ardle et al. BMJ 1991 Hermanek et al. Eur Surg Oncol.. 1996 Holm et al. Br J Surg. 1997 Porter et al. Ann Surg 1998 Dahlberg et al. Br J Surg. 1998 Read et al. Dis Colon Rectum. 2002 Rogers, Ann Surg 2006 Rectal Cancer Surgery Can be difficult Pelvis is a narrow bony box Lots of choices Neoadjuvant therapy Radiation: short course, long course Chemotherapy: drugs, delivery method, dosing Proctectomy or transanal excision Reconstruction: colonic J pouch, coloplasty Rectal Cancer: What makes a center of excellence? Hospital Volume Surgeon Volume Surgeon training/specialization Colorectal Cancer: Hospital & Surgeon Volume California Cancer Registry, 1996-1999 28,644 stage I-III colorectal cancer High volume hospitals and surgeons better 5 yr survival, mortality, sphincter salvage, use of XRT 5 yr survival HV surgeon >40/4 yrs 59% vs. 53% Rogers, Ann Surg 2006;244:1003 2 2
Rectal Cancer: What makes a center of excellence? Hospital Volume: Indirect effects Surgeon volume Radiation Oncology Medical Oncology Radiology Nursing: OR, Ward, ETRN, Coordinators It ain t the bricks and mortar! Rectal Cancer: What makes a center of excellence? Surgeon volume SEER Surgeon volume more important than hospital volume» Schrag D, Panageas KS, Riedel E, et al. Ann Surg 2002; 236:583. Maryland Surgeon volume more important than hospital volume, but hospital volume still had an independent effect on outcome» Harmon et al. Ann Surg 1999; 230:404. Surgeon Variability Read TE, DCR 2002;45:904 384 pts with Rectal Cancer All had preop XRT Surgery by CRS or GS Same stage and distance from anus CRS GS Sphincter salvage 52% 30% Read TE, DCR 2002;45:904 Surgeon Variability CRS GS 5yr Survival 77% 68% 5yr Local Recur. 7% 16% Rectal Cancer: Using National Databases Rocco Ricciardi, MD MPH Lahey Clinic Variability in reconstructive procedures following rectal cancer surgery in the United States. nonrestorative procedures 49%, some counties >60% DCR June 2010 Presence of specialty surgeons reduces the likelihood of colostomy after proctectomy for rectal cancer. OR 0.7 DCR Feb 2011 Who performs proctectomy for rectal cancer in the United States? 40% only perform nonrestorative procedure Surgeon who do anorectal procedures or IPAA, higher restorative procedures DCR Oct 2011 Rectal Cancer: Common Sense A surgeon who: Is specially trained Has an interest in the disease Takes care of lots of patients suffering from the disease Has built a team of people to assist in the care of patients with the disease should do better than the casual proctectomist 3 3
Where specialization matters How to train general surgeons? How to plan for the future in your system? 320,000 Colon Resections/Year - 2010 25-30% MIS 16,000 HAND Options in the USA 5% Exclude surgeons 20% 75% HAND LAP OPEN Training in Laparoscopic Colorectal Surgery Should exclude surgeons who do less than 25 colectomies/year? Await the growth of our young residents Find an easier way to teach and learn? The role of the hand Laparoscopic Colectomy: Learning Curve Steep (20-50 cases) Depth perception Multiple quadrants Reverse angles Coordination of team Operative times Conversion rates Cadaver Course Have organized and participated in more than 120 course 2010 10 courses I see surgeons in their learning curve all the time. How to get More Surgeons Involved? Options in the USA Exclude surgeons Should exclude surgeons who do less than 25 colectomies/year The growth of our young residents Find an easier way to teach and learn? The role of the hand 4 4
2500 2000 1500 1000 500 Colon Resection for Cancer 5.6% 0 1994 1996 1998 2000 2002 2004 Schoetz, JACS, September 2006 41.1% Laparoscopic Open 50 45 40 35 30 25 20 15 10 5 0 % Laparoscopic Resections 1994 199519961997 19981999 200020012002 20032004 2005 Diverticulitis Colon Cancer LAR IC Crohn's IPAA How to get More Surgeons Involved? Options in the USA Exclude surgeons Should exclude surgeons who do less than 25 colectomies/year Await the growth of our young residents Find an easier way to teach and learn? The role of the hand Schoetz, JACS, September 2006 Learning Laparoscopic Colorectal Surgery: Do Weekend Courses Work? Parswa Ansari MD Peter Marcello MD Lawrence Rusin MD Department of Colon and Rectal Surgery Lahey Clinic Ansari, Marcello, NESS 2006 Outline Lecture & Videos Positioning Right Colectomy Complications Energy in the OR Discuss colon cancer trials Left colectomy and pelvic dissection Evaluation by Instructor Cadaver Course Ansari, Marcello, NESS 2006 Cadaver Course Do Weekend Courses Work? 32 surgeons surveyed 79% <25 colon resections/year 87% limited experience with lap. colectomy Mean f/u 12 months (4-48 mo) Adoption 78% overall 81% of inexperienced surgeons Most began within one month 22% nonadopters await the perfect case Marcello, 2006, NESS 5 5
Laparoscopic Colectomy: Cost Clinical Practice Cleveland Clinic, 19% conversion ASA III/IV Elective resection, case control study LAP OPEN p value n=231 n=231 Direct costs ($) 7,533 8,333 0.05 -Quality group, quality work, quality outcome Surg Endosc 2010, 24:1280 Laparoscopic Colectomy: Cost Clinical Practice University Healthsystems - Large Database Sigmoid resection benign and malignant Elective resection 10,603 patients, 10.3% LAP LAP OPEN p value n=1,092 n=9,511 Direct costs ($) 13,814 15,626 < 0.05 - Lower LOS (2 days) and complications ( 6%) in LAP Group - Reduced overall costs Surg Endosc 2010, 24:1280 Laparoscopic Colectomy: Conversion Clinical Practice Nationwide Inpatients Sample 20% of all procedures 2002 2007 261,238 patients % LAP % Conversion 2002 3.3 35.7 2007 9.3 38.0 - Conversion associated with: infectious complications IR 1.64 anastomotic complications IR 1.28 Am J Surg 2011, 201:630 Where specialization matters How to train general surgeons? How to plan for the future in your system? Ethical Dilemmas in Training? How do we develop successful training models? Who develops them? Who validates them? Who enforces them? Ethical Dilemmas in Training? Success Stories SAGES FLS Fundamentals of Laparoscopic Surgery FES Fundamentals of Endoscopic Surgery FUSE Fundamentals in Usage of Surgical Energy FHS Fundamentals of Hernia Surgery ASCRS OR Competency Committee Develop validated testing of colorectal techniques GAGES Global Assessment of Gastrointestinal Endoscopic Skills Surg Endosc Aug 2010 6 6
Ethical Dilemmas in Training? NOTES Courses Your chairman asks you to develop a weekend course to teach NOTES: Design a weekend course to introduce NOTES Design a weekend course with testing and credentialing component Work with NOTES leaders to design a validated standard curriculum for credentialing Decline chairman s offer Kodner, Surgery 2012, 151:484 Ethical Dilemmas in Training? NOTES Courses Your chairman asks you to develop a weekend course to teach NOTES: Design a weekend course to introduce NOTES Design a weekend course with testing and credentialing component Work with NOTES leaders to design a validated standard curriculum for credentialing Decline chairman s offer Kodner, Surgery 2012, 151:484 Where specialization matters How to train general surgeons? How to plan for the future in your system? Planning for Your Future Prospective data collection on what you do You decide the important measures You collect your data Your analyze your data Make improvements Hold steadfast against insurance, government, lawyers Planning for Your Future: Lahey Clinic Prospective data collection on all surgical procedures Prospectively collect 30 day outcome measures Morbidity Review our data Implement improvement processes Foley catheters Anastomotic air leaks WHAT IS THE EVIDENCE FOR ANASTOMOTIC LEAK TESTING IN COLORECTAL ANASTOMOSES? R Ricciardi, PL Roberts, PW Marcello, LC Rusin, JJ Murray, JA Coller, DJ Schoetz Department of Colon and Rectal Surgery Lahey Clinic Burlington, MA Arch Surg. 2009;144(5):407-411 7 7
RESULTS RESULTS CLINICAL LEAK: ANASTOMOTIC METHOD Cohort 2,627 procedures 998 (38%) left-sided 899 (90.1%) stapled Circular stapler (811) Linear stapler (88) 99 (9.9%) hand-sewn Arch Surg. 2009;144(5):407-411 n Leak Test Intraoperative Leak Hand-Sewn 99 21 2 (9.5%) Stapled 899 804 63 (7.8%) TOTAL 998 825 65 (7.9%) Arch Surg. 2009;144(5):407-411 Clinical Leak 15.00% 12.00% 9.00% 6.00% 3.00% 0.00% p=0.13 4.4% Stapled 8.1% Hand-sewn Arch Surg. 2009;144(5):407-411 Clinical Leak CLINICAL LEAK: AIRLEAK TEST RESULT 30.00% 20.00% 10.00% 0.00% CIRCULAR STAPLED ANASTOMOSES 3.6% 4.8% 21.4% Airtight Airleak Untested p=0.04 Arch Surg. 2009;144(5):407-411 REPAIR OF INTRAOPERATIVE AIRLEAKS Redo, 14 Divert, 10 65 total intraoperative air leaks Sutured, 41 Clinical Leak 30.00% 20.00% 10.00% 0.00% REPAIR OF INTRAOPERATIVE AIRLEAKS 0% 0% 12.2% Redo Divert Sutured p=0.41 Arch Surg. 2009;144(5):407-411 8 8
Suture Repair PERCEPTION: Suture repair alone should have same leak rate as a no air leak group 12.2% leak vs. No air leak 3.7% p<0.04 Surprising Clinically relevant Where specialization matters How to train general surgeons? How to plan for the future in your system? Give up mid and low rectal cancer Foster collaboration to develop validated training Track your results Re-evaluate with your results 9 9