Deborah S. Keller M.D.

Lee, L., J. Kelly, G. J. Nassif, D. Keller, T. C. Debeche-Adams, P. A. Mancuso, J. R. Monson, M. R. Albert and S. B. Atallah (2017). “Establishing the learning curve of transanal minimally invasive surgery for local excision of rectal neoplasms.” Surg Endosc: 2017 Aug [Epub ahead of print].

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INTRODUCTION: Transanal minimally invasive surgery (TAMIS) is an endoscopic operating platform for local excision of rectal neoplasms. However, it may be technically demanding, and its learning curve has yet to be adequately defined. The objective of this study was to determine the number of TAMIS procedures for the local excision of rectal neoplasm required to reach proficiency. METHODS AND PROCEDURES: All TAMIS cases performed from 07/2009 to 12/2016 at a single high-volume tertiary care institution for local excision of benign and malignant rectal neoplasia were identified from a prospective database. A cumulative summation (CUSUM) analysis was performed to determine the number of cases required to reach proficiency. The main proficiency outcome was rate of margin positivity (R1 resection). The acceptable and unacceptable R1 rates were defined as the R1 rate of transanal endoscopic microsurgery (TEM-10%) and traditional transanal excision (TAE-26%), which was obtained from previously published meta-analyses. Comparisons of patient, tumor, and operative characteristics before and after TAMIS proficiency were performed. RESULTS: A total of 254 TAMIS procedures were included in this study. The overall R1 resection rate was 7%. The indication for TAMIS was malignancy in 57%. CUSUM analysis reported that TAMIS reached an acceptable R1 rate between 14 and 24 cases. Moving average plots also showed that the mean operative times stabilized by proficiency gain. The mean lesion size was larger after proficiency gain (3.0 cm (SD 1.5) vs. 2.3 cm (SD 1.3), p = 0.008). All other patient, tumor, and operative characteristics were similar before and after proficiency gain. CONCLUSIONS: TAMIS for local excision of rectal neoplasms is a complex procedure that requires a minimum of 14-24 cases to reach an acceptable R1 resection rate and lower operative duration.

Keller, D. S., H. M. Joshi, M. Rodriguez-Justo, D. Walsh, J. C. Coffey and M. Chand (2017). “Using fluorescence lymphangiography to define the ileocolic mesentery: Proof of concept for the watershed area using real-time imaging.” Tech Coloproctol: 2017 Aug [Epub ahead of print].

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Recent advances in mesenteric science have demonstrated that the mesentery is a continuous structure with a ‘watershed’ area at the mesenteric apex between the right colon and terminal ileum, where lymphatic flow can proceed either proximally or distally. With this new understanding of the anatomy, functional features are emerging, which can have an impact on surgical management. Fluorescence lymphangiography or lymphoscintigraphy with indocyanine green allows real-time visualization of lymphatic channels, which highlights sentinel lymph nodes and may facilitate identification of the ideal margins for mesenteric lymphadenectomy during bowel resection for colon cancer. By using this novel technology, it is possible to demonstrate a watershed area in the ileocolic region and may facilitate more precise mesenteric dissection. In the present study, we provide proof of concept for the ileocolic watershed area using fluorescence lymphangiography.

Carmichael, J. C., D. S. Keller, G. Baldini, L. Bordeianou, E. Weiss, L. Lee, M. Boutros, J. McClane, S. R. Steele and L. S. Feldman (2017). “Clinical practice guideline for enhanced recovery after colon and rectal surgery from the american society of colon and rectal surgeons (ascrs) and society of american gastrointestinal and endoscopic surgeons (sages).” Surg Endosc: 2017 Aug [Epub ahead of print].

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This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The Clinical Practice Guidelines Committee of the ASCRS is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. In a collaborative effort, the ASCRS Clinical Practice Guidelines Committee and members of the SAGES SMART (Surgical Multimodal Accelerated Recovery Trajectory) Enhanced Recovery Task Force and Guidelines Committee have joined together to produce this guideline written and approved by both societies. The combined ASCRS/SAGES panel worked together to develop the statements in this guideline and approved these final recommendations. Through this effort, the ASCRS and SAGES continue their dedication to ensuring high quality perioperative patient care.

Carmichael, J. C., D. S. Keller, G. Baldini, L. Bordeianou, E. Weiss, L. Lee, M. Boutros, J. McClane, L. S. Feldman and S. R. Steele (2017). “Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the american society of colon and rectal surgeons and society of american gastrointestinal and endoscopic surgeons.” Dis Colon Rectum 60(8): 761-784.

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This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). The Clinical Practice Guidelines Committee of the ASCRS is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. In a collaborative effort, the ASCRS Clinical Practice Guidelines Committee and members of the SAGES SMART (Surgical Multimodal Accelerated Recovery Trajectory) Enhanced Recovery Task Force and Guidelines Committee have joined together to produce this guideline written and approved by both societies. The combined ASCRS/SAGES panel worked together to develop the statements in this guideline and approved these final recommendations. Through this effort, the ASCRS and SAGES continue their dedication to ensuring high quality perioperative patient care.

Keller, D. S., A. J. Senagore, K. Fitch, A. Bochner and E. M. Haas (2017). “A new perspective on the value of minimally invasive colorectal surgery-payer, provider, and patient benefits.” Surg Endosc 31(7): 2846-2853.

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BACKGROUND: The clinical benefits of minimally invasive surgery (MIS) are proven, but overall financial benefits are not fully explored. Our goal was to evaluate the financial benefits of MIS from the payer’s perspective to demonstrate the value of minimally invasive colorectal surgery. METHODS: A Truven MarketScan(R) claim-based analysis identified all 2013 elective, inpatient colectomies. Cases were stratified into open or MIS approaches based on ICD-9 procedure codes; then costs were assessed using a similar distribution across diagnosis related groups (DRGs). Care episodes were compared for average allowed costs, complication, and readmission rates after adjusting costs for demographics, comorbidities, and geographic region. RESULTS: A total of 4615 colectomies were included-2054 (44.5 %) open and 2561 (55.5 %) MIS. Total allowed episode costs were significantly lower MIS than open ($37,540 vs. $45,284, p < 0.001). During the inpatient stay, open cases had significantly greater ICU utilization (3.9 % open vs. 2.0 % MIS, p < 0.001), higher overall complications (52.8 % open vs. 32.3 % MIS, p < 0.001), higher colorectal-specific complications (32.5 % open vs. 17.9 % MIS, p < 0.001), longer LOS (6.39 open vs. 4.44 days MIS, p < 0.001), and higher index admission costs ($39,585 open vs. $33,183 MIS, p < 0.001). Post-discharge, open cases had significantly higher readmission rates/100 cases (11.54 vs. 8.28; p = 0.0013), higher average readmission costs ($3055 vs. $2,514; p = 0.1858), and greater 30-day healthcare costs than MIS ($5699 vs. $4357; p = 0.0033). The net episode cost of care was $7744/patient greater for an open colectomy, even with similar DRG distribution. CONCLUSIONS: In a commercially insured population, the risk-adjusted allowed costs for MIS colectomy episodes were significantly lower than open. The overall cost difference between MIS and open was almost $8000 per patient. This highlights an opportunity for health plans and employers to realize financial benefits by shifting from open to MIS for colectomy. With increasing bundled payment arrangements and accountable care sharing programs, the cost impact of shifting from open to MIS introduces an opportunity for cost savings.