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eDigest, Spring 2012

Outpatient Endoscopic Needle Knife Treatment Can Cure Surgical Anastomotic Leaks

Cleveland Clinic Digest Disease Institute physicians are the only group in the world routinely using the endoscopic needle knife to treat presacral sinus occurring at the ileal pouch-anal anastomosis or ileorectal anastomosis. Anastomotic sinuses are a serious complication following bowel resection, with the risk for the development of pelvic abscess of even osteomyelitis of the sacrum.

“We developed the technique in 2008 and use it to treat several patients every week. In a select patient population, the endoscopic needle knife may help avoid the need for surgery and cure or “shrink” the leak,” says Cleveland Clinic gastroenterologist Bo Shen, MD.

Chronic anastomotic leak or sinus typically requires a major surgical intervention with staged procedures. Although the surgery is effective, it is more invasive and post-surgical recurrent anastomotic leak can occur. We developed a novel endoscopic technique using doppler-ultrasound needle knife to perform “sinusotomy”. The concept is that needle knife sinusotomy helps to drain the sinus cavity into the lumen of the gut. The procedure is easy to perform and the whole procedure takes approximately 20 – 30 minutes, according to Dr. Shen.

“It is not as invasive as surgery and is easier on the patient,” he says.

In an outpatient procedure using mild sedation, Dr. Shen performs an endoscopy to identify the anastomotic leak with a guidewire, followed by performance of Doppler ultrasound (to avoid blood vessels underneath the cutting area), and treatment with a triple-lumen needle knife in a setting of ERCP Endocut.

“We have used this method on more than 50 patients, so far, and 50 percent have avoided surgery,” says Dr. Shen.

Our group has also developed Doppler ultrasound-guided endoscopic needle knife therapy for bowel strictures related to Crohn’s disease and bowel surgery. We found that the technique is more effective in treating refractory, fibrotic strictures than conventional through-the-scope balloon dilatation.

Surgeon Pioneers "Natural Orifice" Approach to Endoscopic Submucosal Dissection (ESD)

Interluminal lesions can be successfully removed “en bloc” through the anus using endoscopic submucosal dissection (ESD). Once the surgeon is comfortable with the procedure, it can be performed on an outpatient basis with general anesthesia, says colorectal surgeon Emre Gorgun, MD, the first U.S. colorectal surgeon to take this approach in the lower gastrointestinal tract..

“The anal approach to ESD is technically challenging, but provides a less-traumatic method for removing colon and rectal lesions. The procedure is particularly useful for patients, who might have difficulty recovering from a major surgical procedure, or even a laparoscopic procedure, due to age or presence of comorbidities, ” he says.

To date, he has performed the procedure successfully on several patients, including an 88-year-old candidate for bowel resection.

“I felt he would be an ideal candidate for ESD, so I removed his tumor through the anus, and he went home the next day,” says Dr. Gorgun.

In search of new, less-invasive colorectal surgery techniques, Dr. Gorgun appropriated the “natural orifice” approach pioneered for esophageal lesions. Using high-definition colonoscopes and miniaturized tools, he began performing ESD in the colon through the anus.

Carbon dioxide is used to enlarge the bowel for better visualization and instrument accommodation. Saline mixed with special dye is injected to elevate and separate the lesion from underlying muscle tissue in the bowel wall. The submucosa surrounding the lesion is then cut away with an EndoKnife and EndoHook, enabling the lesion to be removed in a single piece.

According to Dr. Gorgun, tumors as large as 4-5 centimeters, or obstructing up to 50 percent of the bowel lumen, can be resected in this fashion. “Removing the lesion in a single piece enables pathology to determine whether the margins are positive or not,” he explains.

The primary risk of ESD is intestinal perforation. For this reason, Dr. Gorgun suggests the procedure be performed in an operating room by a surgeons. “Whether it's a full-thickness injury or a cut, we are able to repair it immediately using laparoscopic techniques,” he says.

Interested surgeons can learn more about the technique from Dr. Gorgun's presentation on June 4 at the 2012 Annual Meeting of the American Society of Colon and Rectal Surgeons in San Antonio, Texas.

“I think this will be a very important technique for surgical treatment and management of these lesions in the future,” he says.

Caesarian Section Recommended for Pregnant Pelvic Pouch Patients

Cleveland Clinic studies suggest that Cesarean section may be the safer delivery option for pregnant pelvic pouch patients.

“Vaginal delivery increases the risk of harm to the anal sphincter muscles, creating injuries that may impair pouch function and quality of life later in life. Although Cesarean section is associated with a longer recovery time and carries the potential risks associated with any abdominal surgery, it does not appear to substantially influence pouch function and quality of life in the short- or long-term,” says Cleveland Clinic colorectal surgeon Emre Gorgun, MD.

Postoperative scar tissue within the abdominal cavity is common following pelvic surgery. These adhesions may deform the normal relationship between the fallopian tubes and ovaries, contributing to infertility. Pelvic pouch patients have infertility rates of 30-50 percent, as compared with 15 percent in the general U.S. population. However, many patients are able to conceive and carry the pregnancy through to live birth.

In one Cleveland Clinic study on the effects of pregnancy on the pouch, a trend toward increased urgency and fecal incontinence were noted in the second and third trimesters, with 30 percent of the women reporting worsening urgency in the third trimester.

“This study suggests that pregnancy does not affect pelvic pouch function to a great extent, but its effects on the pouch may be slightly more pronounced during the third trimester,” says Dr. Gorgun.

To determine the optimal method of delivery, the surgeons examined the rates of anal sphincter injuries in women who had undergone vaginal delivery and Cesarean section. Fifty percent of the women who delivered vaginally suffered a tear in the internal or external sphincter, as compared with 13 percent of women who underwent Cesarean section.

A smaller percentage of those who underwent Cesarean section developed a surgically related problem, such as wound infection or hernia, which was resolved using conservative management.

“Based on the results of our studies on this topic, we can conclude that Cesarean section remains the safer alternative for women with a pelvic pouch, unless contraindicated,” says Dr. Gorgun.

Pioneering Robotic Single-Port Laparoscopic Cholecystectomy

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