Serjay Kantsevoy, M.D., a gastroenterologist at Mercy Medical Center in Baltimore, Maryland, talks about a new cutting-edge way to fix tears in the colon.
Interview conducted by Ivanhoe Broadcast News in October 2016.
With an increased number of people having endoscopic colonoscopy have there been an increased number of perforations and can you tell me a little bit about that?
Dr. Kantsevoy: Colonoscopy is a very important technique. It saves lives because it detects precancerous lesions at a time that they can be removed without doing major surgery. It saves life and it saves the colon. Unfortunately, when we do screening colonoscopy there is a chance to cause perforation because we put a semi-ridged instrument inside the colon. We would expect one perforation per thousand colonoscopies. In the United States, about fifteen million colonoscopies are performed each year. Some of them are diagnostic, where the chance is one in a thousand; but, some of them are done for therapeutic indications, meaning the patient has a precancerous or early cancerous lesion in the colon. We can remove them endoscopically without sending patient for surgery. But, when we do endoscopic procedure to remove a tumor especially advanced endoscopic procedures, the chance of perforation is much higher, between five and ten percent. The number of patents with colonic perforations will get higher and higher because we will remove endoscopically more and more colon cancers and precancerous lesions.
What is the risk and what is the danger to a patient when there is that perforation, what’s the health risk?
Dr. Kantsevoy: Colonic perforation used to be the most dangerous complication because people cannot live with a hole in the colon. In the past, before we got the suturing device, when people got colonic perforation the patient would automatically go for surgery. That surgery would be done in conditions of contamination because it takes some time to arrange for surgery; it cannot be done right after the perforation is diagnosed. Patients need to go to the operating room, operating room needs to be prepared and during all this time the content of the colon is leaking into their abdomen. So it makes surgery difficult and more dangerous. Even in our experience we used to have patients who would go for surgery when they had colonic perforation.
Is it life threatening?
Dr. Kantsevoy: It is definitely a life threatening condition; it cannot be treated without surgery.
You said prior to having a new way of doing this, major surgery? Surgery is the only. What do you do now?
Dr. Kantsevoy: Since 2011 we have an endoscopic suturing device. First it was used for elective procedures; when a patient had some kind of suture needed inside the human body. But we started to use it for closure of colonic perforation and we actually are the first institution in United States, and in the world, that have started to do this endoscopic suturing for patients with colonic perforation. For the last three years nobody with colonic perforation needed surgery in our institution, they all were sutured endoscopically.
What is the benefit of being able to suture this way to close that perforation?
Dr. Kantsevoy: It’s completely changed everything. In the past the procedure would end and then patients would wake up. If there was a perforation, the patient would have tremendous amount of pain and would obviously be distressed as well. You would have to call surgeons, explain the procedure and at this point the level of patient’s and relatives’ anxiety would get even higher. And since it is a major surgery, the patient post operation has to be admitted to intensive care. Often up to a week or maybe even ten days in the hospital. Finally, after surgery, they’re sent home with significant restriction in their lifestyle, and significant restriction in their physical activity. Now, the situation is completely different. We discover a perforation during the procedure and we close it; we use the endoscopic suturing device. This way the patient wakes up from procedure with no pain and no complaints. We obviously explain everything to the patient and the family; if there was a complication or if there was a perforation. We explain we fixed it endoscopically and there is no need for surgery. We give people antibiotics to take and most of those patients don’t even require admission so they go home straight from the endoscopy. It saves a tremendous amount of money. Imagine how expensive spending ten days in the hospital would be. Instead, the patient goes home and they resume their regular physical activity the next day.
You’ve done a recent study, can you tell me a little bit about the findings of that study?
Dr. Kantsevoy: We first published a video presentation of a large colonic perforation which was repaired endoscopically. Endoscopic repair saved the patient from having major surgery. This presentation was published in GI Endoscopy which is a premier journal in the United States and around the world. Then we analyzed our data from 2008 to 2015 and there were approximately twenty one, twenty two colonic perforations. In the beginning of the study, some of them were closed with endoscopic clips, when the endoscopic suturing device was not available. All these patients ended up having surgery. Closure with clips was not adequate, and unfortunately it did not prevent surgery. After endoscopic suturing device became available we started to close those perforations with the suturing device. First, we managed several patients in the hospital with admission. Two people even required diagnostic laparoscopy because surgeons wanted to make sure that the closure was adequate. Surgeons looked into the abdomen and saw that the closure was good and reliable as a surgical closure. From that time forward we started to manage these patients purely endoscopically. None of the subsequent patients needed to go for surgery.
Is there any patient population or any patients who would not be good candidates for this kind of endoscopic closure if there were a perforation?
Dr. Kantsevoy: I think every patient with perforation needs to be closed endoscopically, and if the closure is reliable, then they will not need surgery. If for some reason the closure did not work, those patients will have the option to go for surgery. So far that hasn’t occurred.
Is there anything I didn’t ask you about closing endoscopically the perforation that you think people need to know?
Dr. Kantsevoy: I think that this is a cost effective measure because even without considering the cost of admission, the cost of surgery by itself is probably close to twenty five, thirty thousand dollars. We eliminate surgery by doing endoscopic closure. Just imagine how much money we save for the community, for this particular patient and for insurance companies; especially now when their cost of medical care is so expensive. These endoscopic suturing devices completely change everything.
How many have you done?
Dr. Kantsevoy: I do approximately seven hundred difficult polyps a year and with the rate of perforations probably less than three percent. So you can calculate how many of them end up with a perforation and none of them need to go for surgery.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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