digest this - cleveland clinic

{InsIde thIs Issue}

Maximizing Minimally Invasive Colorectal Surgery p.2

Why Colorectal Surgeon and Pathologist Collaboration is Essential p.4

Case Study: Retroperitoneal Sarcoma p.12

Digestive Disease institute | winter | 2012

Digestthis

Three Genes Linked to BE/EAC Discovered p.1

Digestive Diseases 2017What lies ahead for

our subspecialties? – p.6

dear Colleagues,

I am honored to recently have been named Chair of the Department of Gastroenterology

and Hepatology in Cleveland Clinic’s Digestive Disease Institute (DDI) and to introduce

the Winter 2012 issue of Digest This.

During my nearly 20 years as a gastroenterologist here at Cleveland Clinic, our field

has evolved dramatically – and the rapid pace shows no sign of slowing down any time

soon. In this issue, we usher in the new year with a cover story (p. 6) that examines

what each of our department chairs (myself and Drs. Feza H. Remzi, R. Matthew Walsh,

Steven Wexner, Roger Charles and Raul Rosenthal) believe are the hottest innovations

of today and what likely lies ahead for the subspecialties within our institute: colorectal

surgery, gastroenterology and hepatology, and general surgery, including bariatrics. In

another forward-thinking discussion (p. 2), Drs. Meagan Costedio, David Maron and

Dana Sands share how they are using various minimally invasive approaches in their

practice and the advances they see on the horizon.

We also provide updates on other DDI key specialties. On p. 1, we discuss ground-

breaking research by Dr. Charis Eng and colleagues that has identified genetic muta-

tions specific to patients with Barrett’s esophagus and esophageal adenocarcinoma,

which may one day aid risk assessment and increase patient survival. On p. 4, we

feature two case studies that demonstrate why collaboration between pathologist and

colorectal surgeon is essential. In addition, we showcase our bariatric services (p.11)

and a case study by Dr. Sricharan Chalikonda (p. 12) that shows why the multidisci-

plinary approach used within our Surgical Oncology Clinic is key to caring for patients

with retroperitoneal sarcomas.

I hope you enjoy this issue of Digest This and we look forward to collaborating with

you to provide the best possible care for your patients.

Sincerely,

John Vargo, MD, MPHChair, Department of Gastroenterology and Hepatology | Vice-Chair, Digestive Disease Institute | [email protected]

clevelandclinic.org/digestive 855.REFER.123 {1}

Digestive Disease Institute

three genes Linked to Be/eaC Discovered

Researchers at Cleveland Clinic’s Genomic Medicine Institute have identified

genetic mutations specific to patients with Barrett’s esophagus (BE) and esophageal

adenocarcinoma (EAC). And that’s inspired continued research by a team led by

Charis eng, MD, PhD, Chair and Founding Director of the genomic Medicine institute,

which could ultimately aid risk assessment and increase patient survival.

The study by Dr. Eng, published in the July 27,

2011 issue of the Journal of the American Medical

Association, identified three genes specifically linked

to BE/EAC. It’s been Dr. Eng’s goal to find that link

after a colleague’s mother died from EAC during Dr.

Eng’s medical oncology fellowship at Dana-Farber

Cancer Institute.

“My colleague, a professor, told me the whole family

had Barrett’s, and one or two developed into esopha-

geal cancer,” Dr. Eng says. “And ever since, I thought

about this gene.”

Related to gastroesophageal reflux disease, BE is

estimated to occur in up to 10 percent of the popula-

tion and diagnoses have tripled since 1970. BE is

believed to be a precursor to EAC. But EAC is typi-

cally not diagnosed until its advanced stages, when

chances of survival are poor.

To find genetic markers for BE/EAC, Dr. Eng led

researchers at 16 U.S. institutions to identify and

evaluate 298 participants with BE, EAC, or both be-

tween 2005 and 2010. The study used the latest in

genomics approaches and state-of-the art technology,

along with functional genomic validation, to identify

MSR1, ASCC1, and CTHRC1 as three genes mutated

in 11 percent of the BE/EAC patients studied, indica-

tive of a significant genetic predisposition. Mutations

in MSR1 were the most common, affecting seven per-

cent of the patients studied – and warranting further

study, Dr. Eng says.

Dr. Eng and her team have created and are now part

of the Familial Barrett Esophagus Consortium, working

with researchers at Johns Hopkins University School

of Medicine in Baltimore and Albert Einstein College of

Medicine of Yeshiva University in New York City. They

are seeking families with at least two relatives with

BE and/or EAC to search for susceptibility genes. They

also will accrue young onset BE (under age 60) or EAC

(under age 50).

Dr. Eng hopes to find study participants in a relatively

short period of time through study referrals – and

Cleveland Clinic patients seeking care for BE and EAC.

“We see these patients in clinic, and they fly in from

around the world,” Dr. Eng says. “But that’s what

happens at Cleveland Clinic – our ability to recognize

and our ability to treat unknowns attracts patients from

around the country and the world.”

The studies could lead to a tool to estimate a person’s

risk of having BE/EAC, similar to the Genomic Medicine

Institute’s online risk calculator for estimating risk for

a PTEN mutation, often associated with Cowden syn-

drome and Bannayan-Riley-Ruvalcaba syndrome.

Ultimately, the ability to identify genetic markers for BE

and EAC could help with risk assessment, early detec-

tion, improved disease management and, eventually,

increased survival.

Dr. Eng is Chair and Founding Director of the Genomic

Medicine Institute of the Lerner Research Institute at

Cleveland Clinic. She can be reached at [email protected]

or 216.444.3440. ■

Charis eng, Md, Phd

Recommended Reading: Familial Barrett Esophagous and Esophageal Adenocarcinoma. www.lerner.ccf.org/gmi/research/fbe/

10%BE is estimated to occur

in up to 10 percent of the

population and diagnoses

have tripled since 1970.

{2} digest this Winter | 2012

Cleveland Clinic

sPeCiaL Feature

Minimally Invasive Colorectal surgery

A new era in minimally invasive colorectal surgery has begun. MIS is now routinely used to treat an

increasing number of colon and rectal conditions. With experience and technological advancements,

more and more minimally invasive procedures can match the outcomes of conventional open surgery,

with shorter hospital stays and better cosmetic results for patients.

Here, we talk to colorectal surgeons Meagan Costedio, MD, from our main campus and David Maron,

MD, and Dana Sands, MD, from Cleveland Clinic Florida to get their views on how they are utilizing

laparoscopy, single-port surgery, natural orifice surgery (NOTES), robotics and transanal endoscopic

microsurgery (TEM) today and the advances they see on the horizon.

LAPAROSCOPY

“When laparoscopy was new in the 1990s,

many colorectal surgeons thought it was

a bad idea. It was never going to apply to

colon surgery,” recalls Dr. Costedio. “It was

good for gallbladder surgery, but for colon

surgery – not worth the time or the effort.”

As surgeons’ laparoscopic skills improved

over time, they realized they could tackle

more than a gallbladder or an appendix.

Incisions got smaller. OR times dropped,

instruments got better, and surgeons started

doing right and left colectomies until it

became commonplace.

“Now, the data shows that laparoscopy means

shorter hospital stays, better outcomes for

patients, and equivalent cancer surgery,” Dr.

Costedio says. “So now, it’s widely accepted

that laparoscopy is better and whether sur-

geons do it or not is their own preference.”

As technology gets better and the instru-

ments for laparoscopy get smaller and more

advanced, surgeons will be able to complete

more advanced, difficult surgeries laparo-

scopically, expanding this technology to

other fields, she says. “The instrumentation

is becoming so advanced that we may see a

day when surgeons are able to operate inside

the colon and rectum which would mean no

incisions for patients.”

SINGLE PORT

“One of the unique facets of colon surgery,

which is not true of every specialty, is that

the surgeon must remove the colon intact,”

Dr. Costedio says. “This means that we

always need a 2- to 3-cm incision to get the

colon out.” Three centimeters is plenty of

room to put two instruments and a camera

and remove a colon with no added incisions.

So, as the tables got better, and the instru-

ments got better and the cameras got better,

single-port colorectal surgery was made

feasible. Now, Dr. Costedio says she removes

one to two colons weekly with a single-port

technique that leaves a small incision in the

umbilicus that’s either not visible or a just

barely noticeable. She also uses patients’

ileostomy sites for the incision.

“Particularly for young people, I think

there’s a real benefit to not having incisions

all over your abdomen cosmetically,” she

says. “While we still need randomized stud-

ies, surgeons who are good at it are doing

so because they believe that the results are

equal to laparoscopy. I think it’s the future

of colon and rectal surgery as we keep

moving forward.”



ROBOTICS

Traditional laparoscopic surgery has some limi-

tations which can create obstacles in complex

and difficult operations. This is caused by the

peculiar drawbacks of laparoscopy, mainly

related to unstable video camera imaging,

which is dependent on the assistant’s skills

and is not under the surgeon’s control, the

limited motion of instruments, the related

loss of dexterity, and two dimensional imag-

ing. Robotic-assisted surgery theoretically

may overcome these pitfalls, Dr. Maron says,

because it includes three-dimensional imag-

ing under the surgeon’s direct control, and

provides instruments with seven degrees of

freedom that mimic the hand movements

and dexterity of the surgeon.

“Although data in the literature is limited,

while the use of the robot may prove to be

useful in colon surgery, its greatest benefits

are likely to be in minimally-invasive pro-

cedures involving the pelvis (rectal cancer,

rectal prolapse),” he says. Early studies have

demonstrated a decrease in the conversion

rate to open surgery in patients with rectal

cancer. DDI is now using robotics for these

deep pelvic surgery cases, but more long-

term studies are needed.

NOTES

Natural orifice transluminal endoscopic

surgery (NOTES) has encouraged industry

to catapult technology light years ahead.

However, Dr. Costedio says most general

surgeons and colorectal surgeons tend

to prefer to use the umbilicus – to avoid

disastrous holes in the stomach or colo-

vaginal fistulae.

“I think single port has been propelled from

the technology advancements from NOTES,”

she says. “And while there are people who

are good at it, NOTES is being held back

a bit because of the nervousness of these

potentially disastrous complications.”

TEM

Transanal endoscopic microsurgery (TEM) is

an older technology that served as colorectal

surgery’s gateway to NOTES. This technique

affords patients with benign and early-stage

rectal lesions an alternative to more radical

rectal resections, explains Dr. Sands.

“The technique is virtually pain free and

usually requires only an overnight hospital

stay,” Dr. Sands says. While the procedure

was first described in the early 1980s, it

did not generate significant interest due to

the complexity of the instrumentation and

surgeons difficulty learning the technique.

With the advent of laparoscopic surgery, and

the subsequent adoption of these procedures,

colorectal surgeons became for facile with

minimally invasive techniques, thereby spark-

ing a resurgence of interest in TEM in the

early part of 2000.

TEMS is an excellent alternative for a very se-

lect number of patients, including people with

large polyps in the rectum, very early rectal

cancers, and for debulking tumors in those

cancer patients who can’t withstand a big

operation. However, its application remains

limited, Dr. Costedio adds, because the TEM

instruments are straight unlike the robot’s,

which are wristed.

“As technology advances, if we’re able to get

wristed instruments thru the TEM machine,

we will be able to transect the rectum, and

take out the colon, through the anus. And

that will be the most pure form of NOTES

because we’re making a hole that needs

to be made anyway. But right now, the

instrumentation is not quite ready. There

are a few people trying it in cadavers,

but it’s quite difficult.

“Yet, TEM itself is very good. Unfortunately,

there’s a limited disease process that we can

fix with it. But it means no incisions – often

sparing somebody an abdominal operation,

going right back to work, minimal pain and

short, if any, hospital stay.”

To refer a patient for minimally invasive

colorectal surgery at DDI’s main campus,

call 1.855.REFER.123. Call 954.659.5278

for referrals to Cleveland Clinic Florida,

Weston. ■

Fascinated with forward-thinking discussions?Join us for any of the following upcoming

symposiums, which will tackle some of the

toughest issues in the diagnosis, treatment

and prevention of digestive diseases:

Feb. 14-19, 2012

23rd Annual International Colorectal

disease symposium

Combined

33rd Annual turnbull symposium

Feb. 17-18, 2012

Gastroenterology & hepatology symposium

Feb. 19-22, 2012

11th Annual surgery of the Foregut

To learn more or register for any of these

events, visit ClevelandClinicFloridaCME.org.


Cleveland Clinic

Behind the scenesWhy close collaboration between colorectal surgeon and pathologist is essential

At Cleveland Clinic, patients benefit from a unique partnership between colorectal surgeons

in its Digestive Disease Institute and pathologists in its Pathology and Laboratory Medicine

Institute. Very few institutions have the level of collaboration, cooperation and expertise

found between these two disciplines at both Cleveland Clinic’s main campus and Cleveland

Clinic Florida. Here we take a closer look at two cases that exemplify why the expertise of

our pathology colleagues is critical in allowing our colorectal surgeons to make key treatment

decisions to improve the care we provide to inflammatory disease and rectal cancer patients.

Case stuDy

CAse 1

Presentation: 51-year-old woman presents at an

outside institution with rectal bleeding. She had no

other significant clinical history.

diagnostics: A 1.7 cm pedunculated polypoid lesion,

7 cm from the anal verge, was colonoscopically com-

pletely removed at another hospital.

Pathological findings: A diagnosis of a “focus of well-

differentiated adenocarcinoma arising in a tubulovil-

lous adenoma” was rendered at the original institution

at which the polyp was removed. Based on the latter

diagnosis, the patient was referred to our colorectal

surgery department for radical surgery: a low anterior

resection. Our review of the outside slides revealed a

small focus of superficially invasive, well-differentiated

adenocarcinoma arising in a tubulovillous adenoma. The

invasive carcinoma involved only the head of the polyp

(Haggit level 1) without any vascular invasion or tumor

“budding.” The deepest level of the invasive carcinoma

was 6 mm from the stalk margin of resection.

Clinical Course: Based upon these histopathological

findings, a transanal excision rather than a low anterior

resection was recommended. Since no residual tumor

was identified, no additional surgery was undertaken.

Subsequent to that transanal excision, repeated endo-

scopic and imaging assessment have shown her to be

free of any disease.

discussion: The treatment of the so called “malignant

polyp” is often challenging and reaching a balance be-

tween the risks and benefits of radical resection vs. local

excision may be difficult to achieve. The pathologist

plays a critical role in the treatment decision process.

The accurate and consistent assessment of a group of

histological parameters that carry prognostic implica-

tions is essential to reach the best treatment decision

for each patient.

The level of tumor invasion within the wall of the

polyp, the presence of vascular invasion, the grade

of tumor differentiation and the distance of the

invasive carcinoma to the deep margin of resection

should routinely be assessed and documented in the

pathology report. Overall, malignant polyps could be

classified into those with “favorable histology” and

those with “unfavorable histology.” Well-differentiated

lesions with superficial invasion limited to the wall

of the polyp (head and neck of pedunculated polyps

and the superficial aspect of the submucosa in

sessile polyps), absence of vascular invasion and a

clear margin (2 mm or more) are features usually

associated with a low risk of lymph node metasta-

sis or residual carcinoma in the wall of the bowel.

Therefore, local excision seems to be a safe option

in these instances. Conversely, in cases in which one

or more unfavorable histological markers are identi-

fied, a radical surgical resection will likely be more

appropriate. In this particular case, the patient was

referred to us for a low anterior resection. However,

after critical re-evaluation of the histology slides and

based on the absence of poor prognostic markers, a

transanal excision was performed. No residual tumor

was identified. ■

Mariana Berho, Md Pathology Cleveland Clinic Florida

steven Wexner, Md Colorectal Surgery Cleveland Clinic Florida


Digestive Disease institute

P. Ravi Kiran, Md Colorectal Surgery Cleveland Clinic

Xiuli Liu, Md, Phd Pathology Cleveland Clinic

Case 1a: Low power of tubulovillous adenoma showing a focus of invasive carcinoma (arrows) (H&E x100)

Case 1b: Low power demonstrates clear margin of resection (arrows) (H&E x 100)

Case 2a: Continent Ileostomy – Appearance after completion of creation in the operating room

Case 2b: Final external appearance after procedure completion (continent ileostomy) – Continent ileostomy reservoir intubated with an indwelling catheter at the end of the procedure. After a few weeks, the patient will be able to intermittently intubate the pouch 3-4 times a day, without the need for an external appliance in between intubations.

CAse 2

Presentation: A 35-year-old male with a previous

diagnosis of Crohn’s colitis who previously underwent

a total proctocolectomy with end ileostomy five years

ago presents for the evaluation of a continent ileostomy.

He has been asymptomatic since surgery and is off

medications, but has had the need to empty the ostomy

every few hours with difficulty maintaining the ostomy

appliance. This has led to a poor quality of life with

inability to partake in running and swimming in public.

Since Crohn’s disease may involve the entire gastroin-

testinal tract from the mouth to the anus, the creation

of a reservoir using the small intestine raises concerns

for the development of Crohn’s disease in the segment

and consequently the risk of short gut over the long-

term due to repeated operations. However, the pattern

of disease raises the possibility of diagnosis revision to

ulcerative colitis on pathology review.

diagnostics: Ileoscopy to assess the state of small

bowel revealed a normal appearance of the terminal

ileum for an extent of 30 cm proximal to the ileostomy.

CT enterography also confirmed normal small bowel.

Pathological findings: Pathology of the proctocolecto-

my specimen confirmed Crohn’s disease. Biopsy of the

intestine did not show any evidence of active small

bowel Crohn’s disease.

Clinical Course: Based on the combination of clinical

history, endoscopic findings and especially the absence of

Crohn’s disease involving the small bowel on pathology, a

decision was made to proceed with a continent ileostomy

creation. The patient underwent the procedure, had an

uneventful postoperative period, and at follow-up had

good continence of the pouch with ease of intubation.

The avoidance of an external ostomy appliance resulted

in a dramatic improvement in quality of life.

discussion: The continent ileostomy is a viable option for

patients who need to or have had a proctocolectomy and

restoration of intestinal continuity is not feasible or advis-

able. Patients empty the continent ileostomy reservoir by

self-intubation a few times a day. The avoidance of an ex-

ternal stoma appliance allows for improved quality of life.

Since ulcerative colitis does not involve the small bowel,

inflammatory bowel disease patients with this diagnosis

are best suited for the procedure. A subset of carefully

selected Crohn’s disease patients with disease entirely

confined to the large bowel may, however, be candidates

for a small bowel reservoir. In the particular case of a

continent ileostomy, a judicious approach whereby pa-

tients continue to be free of small bowel disease several

years after a proctocolectomy may merit the consider-

ation of the procedure after due discussion of the pros

and cons in terms of the risk of disease recrudescence

vs. the potential benefits from improved quality of life.

Pathologic assessment of the small bowel that is being

used to create the reservoir is crucial in this decision-

making process. The diagnosis of Crohn’s disease – and

especially its differentiation from other conditions – can

nevertheless be difficult. Thus, pathologic expertise al-

lows the ability to reliably diagnose or refute small bowel

involvement by Crohn’s disease. Close collaboration

between the colorectal surgeon, gastroenterologist and

pathologist in circumstances such as this is crucial since

the management plan that best benefits patients in these

complex clinical situations can be selected. ■

1a 2a

1b 2b


Cleveland Clinic

COVER FEATuRE

Digestive Diseases

W H A T L I E S A H E A D F O R O u R S u B S P E C I A L T I E S ?

In our rapidly evolving subspecialties – colorectal surgery, gastroenterology and general

surgery – there are two ever-present questions: “What’s hot?” and “What’s next?”

So, Digestive Disease Institute Chairman John Fung, MD, posed these questions to his

department chairs, both at our main campus and at Cleveland Clinic Florida, Weston.

Here’s what they had to say about innovation, both today and tomorrow:



John Vargo, Md, MPhChair, Gastroenterology & Hepatology | Cleveland Clinic Main Campus

What’s hot in gastroenterology right now is the

detection and treatment of dysplastic and precan-

cerous lesions throughout the GI tract. Now, with

advances in endoscopy – including high-definition and zoom

endoscopy, with the use of supravital staining – we are much

more efficient at detecting abnormalities in various premalig-

nant conditions, such as Barrett’s esophagus, ulcerative colitis

and Crohn’s colitis. In particular, with Barrett’s esophagus, we

follow one of the largest groups of patients in the nation and

can now treat a subset of these lesions endoscopically that

were only treatable surgically 10 years ago.

Another area where we are seeing rapid advances is in extend-

ing the endoscope’s range. We’re now able to place them in the

biliary tree, which helps us treat conditions, such as stones, and

obtain tissue for diagnosis. With balloon enteroscopy, we’re able

to achieve examination of the small bowel endoscopically, which

aids in diagnosis and treatment.

There’s also been incredible development in the treatment of

refractory Hepatitis C with the release of protease inhibitors.

Another pharmacologic advance is immunomodulator agents for

IBD, which have been hugely successful for controlling disease

activity and limiting morbidities from other medications.

Here at DDI, one of the key characteristics that sets us apart is

taking the expertise of the gastroenterology and surgical special-

ties and combining them in multidisciplinary clinics, such as

our pancreas and hepatoma clinics. I think there’s an incredible

benefit because there’s a synergistic discussion, which helps us

provide efficient and timely patient care.

With developments in proteomics and genetic research, we’re

probably going to see screening tests based biologic samples,

that are obtained during endoscopy or through a simple blood

test. We will likely see more and more gene-centered medical

therapy for Crohn’s disease, liver disease and perhaps even

for Barrett’s esophagus. Another possibility is preemptive vac-

cines for patients with a predilection for the development of

Crohn’s disease, ulcerative colitis or Barrett’s esophagus.

On the technological front, we will probably see the develop-

ment of steerable endoscopy capsules, which may use biologic

triggers. For example, it may be able to sense blood or specific

morphology and turn itself on to document what it’s see-

ing. Or, alternatively, it may use the triggering mechanism to

render therapy or maybe even to do biopsies. I also anticipate

growth in a computer-rendered virtual examination. I believe

in the future that we are going to be able to perform endo-

scopic procedures from our desktops, and we may actually be

consulted from across the world to look at a particular image

and perhaps even render therapy.

Lastly, we are utilizing The Knowledge Program to record

demographic and clinical data in the electronic medical record.

We’ve only just begun to scratch the surface of the power of

the electronic medical record in terms of data mining. I really

believe that in the future through simple questions and tests,

we will be able to stratify patients’ risk for certain disease pro-

cesses and hopefully be able to intervene in a chemopreventive

manner before the disease process even starts. ■

What innovations in your field today are improving the care your staff at the

ddI provide to patients? What emerging advances do you believe will have the

biggest impact on your subspecialty over the next five to 10 years?Q:A:


Cleveland Clinic

Raul Rosenthal, MdChair, Bariatric and Metabolic Institute | Cleveland Clinic Florida

In bariatric and metabolic surgery, the introduction

and standardization of sleeve gastrectomy as a new

surgical treatment option for morbidly obese patients

will become the most prevalent procedure performed in bariatric

centers for this patient population.

It is a simple technique, which results in excellent weight loss

and resolution of co-morbid conditions, including remission of

metabolic syndrome and type 2 diabetes mellitus, when com-

pared to other well-established procedures.

In addition, there are no nutritional deficiencies that have been

described in long-term follow-up series. But, most importantly,

the sleeve gastrectomy has a significantly lower morbidity when

compared to all other surgical options for weight loss. ■

Feza h. Remzi, MdChair, Colorectal Surgery | Cleveland Clinic Main Campus

In colorectal surgery, there are three areas in which

we are currently making significant leaps in the field

and where there will be tremendous advances in the

next five to 10 years: surgical technology, collaborative innova-

tion and translational research.

In surgical technology, we’ve been the leader in single-port

surgery, which has really taken MIS to an entirely different

level – with potentially less pain, early recovery times and better

cosmesis. Robotic surgery also is complementing single port-

surgery, being performed here at DDI by Drs. Meghan Costedio,

Ihya Emre Gorgun and Brooke Gurland. In addition, the combina-

tion of endoscopy and laparoscopy techniques into one picture

is very important – such as in new mucosal resections initiated

by Dr. Gorgun for precancerous or early cancerous lesions. This

marriage of technologies means that we can now minimize the

trauma in procedures for certain tumors or lesions that previously

required major surgery. While much has been recently accom-

plished, I think there is potential capability to push the envelope

even further with even newer techniques in the near future.

Innovative collaborations also are helping us improve the care

we deliver to patients today. Not only does our Institute model

of medicine make multidisciplinary approaches possible, such

as disease-specific clinics where radiologists, pathologists,

surgeons, oncologists and radiation therapists discuss cases

and arrive at uniform decisions. But, we are hoping to use this

experience and work with other centers across the nation to

help establish national center for excellence guidelines for the

treatment of rectal cancer. This year, together with Cleveland

Clinic Florida, our department brought together an alliance to

begin these discussions and we are excited at the prospect of

being able to potentially improve the care offered patients with

this extremely complex pathology.

In translational research, Dr. Matthew Kalady has been making

remarkable headway in his work on the genetics of colorectal

cancer. I think in the future, work such as his will make it pos-

sible to optimize patients’ treatments with medications that will

impact their genes and eliminate their pathology. This move to

gene therapy will impact our subspecialty in the next five to 10

years. The other area that is going to impact us is stem cell re-

search, such as that currently being done at DDI by Dr. Massarat

Zutshi for fecal incontinence, which I think will revolutionize our

field in pelvic floor. ■

A:

A:



R. Matthew Walsh, MdChair, General Surgery | Cleveland Clinic Main Campus

Some of the most innovative procedures we are

performing today for transplant are composite tissue

transfer grafts, including abdominal wall replace-

ments. We have already performed one in our department and

look for that to be a component of future direction. This would

help meet and unmet need for patients who have had complex

prior abdominal surgery and have lost a significant portion of

their small intestine, or have had failed complex hernia repairs.

Islet cell transplants are another big area. In the future, there

is a real potential for allo-islet cell transplants for diabetes. There

are prospects for developing an islet program here as well as

performing isolated pancreatic transplants for diabetes. I also

see room for growth in our small bowel transplant program. In

addition, organ preservation is hopefully going to reach another

level. We are actively involved in research with oxygenating

organs to extend organ time and outcome.

In oncology, we are trying to build more integrated systems

between our main campus and community programs. We want

to move advanced procedures, such as robotics, out to the

community to increase accessibility. Probably the biggest ad-

vance in oncology in the future is with image-guided surgery, and

there is clearly industry interest in advancing the technology.

I think the interchange between laparoscopy, robotics and

image-guided technology is the future of surgery.

Cleveland Clinic is well-positioned to partner with industry to de-

velop these new technologies. We are currently working with a com-

pany to examine new, nonthermal ablation techniques that might be

applicable in breast cancer, giving patients a better cosmetic result.

In general surgery, there is ongoing development in the con-

cept of mesh for abdominal wall reconstructions and hernias.

New biologic-type products that will promote natural healing

are in their infancy, but will likely develop so we won’t have

to use synthetic plastics and can have a true ingrowth of

normal tissue.

Theoretically, I think minimally invasive approaches to almost

everything will continue to develop, especially in the world of

robotics, including its miniaturization. I think NOTES will con-

tinue to develop, but for very specific indications.

The future also is more integrated medicine. I think our Insti-

tute model allows us to have patients with complex diseases

evaluated by various subspecialties, have treatments specifically

designed for them, and makes neoadjuvant therapies possible,

when needed.

Also on the horizon is a better evidence-based approach to

outcomes using the electronic medical record and standardized

treatment plans. How we can use the EMR can be expanded,

including allowing for be better overall communication between

referring doctors, and facilitate web-based interactions.

In education, Cleveland Clinic has a new simulation lab and

center, which utilizes both individual and group training. The

concept is to get away from learning directly on the patient and

learn more in a simulation model. The whole world of education

is also going to be more online, independent learning. ■

A:

Abdominal wall transplants will help meet an unmet need for patients

who have had complex prior abdominal surgery and have lost a significant

portion of their small intestine, or have had failed complex hernia repairs.


Cleveland Clinic

steven Wexner, MdChair, Colorectal Surgery | Cleveland Clinic Florida

In colorectal surgery, what is currently having the

most impact on patient care are the continued advances

in minimally invasive surgery, including improved

platforms for transanal endoscopic surgery and laparoscopic surgery.

The ongoing refinements in both optics and instrumentation will

allow acceleration in adoption and penetration of these techniques.

The minimally invasive approaches confer significant short- and

long-term benefits, which will be appreciated by an increased num-

ber of patients as further maturation of the technology occurs.

Another significant advance has been our new methods of treat-

ing fecal incontinence. One of the most distressing conditions is

loss of bowel control. Until recently, therapeutic options in the

United States were limited to sphincter repair, nonstimulated

muscle transfer and a stoma. Within the last few months, the

U.S. FDA approved both sacral neuromodulation and injectable

therapy to treat fecal incontinence. During the next five to 10

years, more surgeons will become adept in and offer these

options and therefore, more patients will derive benefit. ■

A:

What is currently having the most impact on patient care in colorectal

surgery are the continued advances in minimally invasive surgery,

including improved platforms for transanal endoscopic surgery and

laparoscopic surgery.

Roger Charles, MdChair, Gastroenterology and Hepatology | Cleveland Clinic Florida

Advances in wireless technology have had a signifi-

cant impact on the care we deliver to GI patients.

Currently, our options include the endocapsule,

SmartPill and Bravo capsule. However, there are many techno-

logical developments on the horizon that are likely to have

a significant impact on patient care in the future.

Externally rechargeable batteries will prolong battery life, al-

lowing us to get more data – particularly in patients with slow

GI transit. Capsule endoscopies of the future will be able to

analyze GI tract secretions, biopsy abnormal tissue and deliver

drug therapy. We will gain the ability to maneuver capsule

endoscopes to have control over the rate of progress through

the GI tract and also closely inspect suspected abnormalities.

In addition, implantable wireless biosensors for the detection of

GI bleeding have been tested, which potentially can alert physi-

cians in real time of recurrent GI bleeding. These biosensors send

alerts to the physician’s cell phone so they can respond promptly,

thus improving patient outcomes.

Finally, other advances that I see in the pipeline are new gastric

pacing devices for the management of gastroparesis and using

peroral endoscopic myotomy (POEM) in patients with achalasia,

a less invasive treatment option that avoids surgery. ■

A:


Digestive Disease institute

DDI Spotlight: Bariatric Surgery

Cleveland Clinic surgeons perform a high percentage of full revisional operations on

patients in whom older bariatric procedures were not successful in the long term. And

a large majority of the entire scope of bariatric surgeries surgeons in our Bariatric and

Metabolic and Digestive Disease institutes perform – whether primary, revisional or

complex and high-risk – are done laparoscopically or robotically.

Laparoscopic Roux-en-Y gastric bypass continues to be

the most commonly performed bariatric procedure at

Cleveland Clinic. However, both Cleveland Clinic’s main

campus and Cleveland Clinic Florida offer the entire

gamut of bariatric procedures, giving patients a variety

of options and the ability to undergo a procedure tailored

to their individual weight-loss goals and comorbidities.

INNOVATIVE PROCEDURES ON THE HORIZON

Physicians and scientists at Cleveland Clinic and Cleve-

land Clinic Florida are investigating new techniques in

bariatric surgery, including the intragastric balloon, vagal

blocking and interventional therapies through the mouth.

“Endoluminal procedures are the next generation in

bariatric operations,” says DDI general surgeon Matthew

Kroh. “I think a lot of revisional procedures may be done

this way in the future as the tools get better.”

Cleveland Clinic also is investigating laparoscopic

gastric plication, a restrictive procedure in which the

greater curve of the stomach is folded in on itself.

“The procedure is less invasive involving no stapling,

cutting or removing stomach tissue and it is com-

pletely reversible with weight loss similar to sleeve

gastrectomy. (55 percent excess body weight loss),

says Philip Schauer, MD, Chairman of the Bariatric

and Metabolic Institute at Cleveland Clinic Ohio. The

procedure is in clinical trials to more clearly determine

the short- and long-term benefits.

BEYOND JUST WEIGHT LOSS

“Bariatric surgery as a tool to fight obesity and weight-re-

lated medical problems is really underutilized,” Dr. Kroh

says. The metabolic aspect of the operations, including

the ability of a gastric bypass procedure to put diabetes

into remission in about 80 percent of patients, is being

explored further at Cleveland Clinic. The laparoscopic

operations being done more often now do not have

the same complication rates of the open procedures,

making it possible to consider bariatric procedures in

patients with lower BMIs (30 to 35 kg/m2) in order to

treat conditions such as diabetes, hypertension, obstruc-

tive sleep apnea and abnormal cholesterol levels.

A TEAM OF ExPERIENCED ExPERTS

The surgical experience of Cleveland Clinic’s bariatric

center teams as well as the multidisciplinary approach

in supporting the patient before, during and after

surgery is what assists patients in having successful

outcomes, says Raul Rosenthal, MD, Chairman of the

Bariatric and Metabolic Institute at Cleveland Clinic

Florida. He credits the successful outcomes of Cleve-

land Clinic patients to the nurses, dietitians, program

coordinators and other allied health professionals who

work with them and handle their long-term follow-up.

Also important, he says, “We as surgeons choose who is a

candidate and which operation is best for our patients. We

customize our treatment. There is no ‘one size fits all.” ■

CENTERS OF ExCELLENCE

Both the Cleveland Clinic Bariatric and Metabolic Institute and its counterpart at Cleveland Clinic Florida

have been designated Bariatric Surgery Centers of Excellence by the American Society for Metabolic and

Bariatric Surgery. Both have been accredited as Level 1 facilities by the Bariatric Surgery Center Network

Accreditation Program of the American College of Surgeons Centers of Excellence Program.

To learn more about our programs, visit clevelandclinicweightloss.com and clevelandclinic.org/florida.

Matthew d. Kroh, Md

98%More than 98 percent of the

bariatric procedures performed

at Cleveland Clinic’s main

campus and Cleveland Clinic

Florida are minimally invasive.

8,000+Number of bariatric proce-

dures performed at Cleveland

Clinic Florida and Cleveland

Clinic main campus in the

past 11 years.


Cleveland Clinic

retroperitoneal sarcomaChallenging cases require multidisciplinary treatment

Case stuDy

sricharan Chalikonda, Md

MARCH 2009

A 60-year-old man presented to the Digestive Disease

Institute’s Dr. Chalikonda with symptoms of abdominal

fullness and pain. He had a CT scan performed at an

outside hospital that showed a large mass sitting in his

retroperitoneum on the right side. The mass appeared to

be involving his right kidney as well as his colon and liver

and was adjacent to his inferior vena cava. (Figure 1)

The size of the mass and location was consistent with

a soft tissue tumor known as a retroperitoneal sarcoma.

Given the size of the mass and high chance of local

recurrence if it was not completely resected, the deci-

sion was made to proceed with surgical resection and

perioperative radiation therapy.

He was then evaluated by our radiation oncologist and

it was determined that he would be a candidate for peri-

operative radiation, utilizing special catheters designed

to deliver radiation after the surgeon has packed the

bowel away from the field.

APRIL 2009

The patient underwent exploratory laparotomy and

resection of the tumor, which required a right hemi-

colectomy and right nephrectomy. He had his bowels

packed away and the catheters placed in the resection

bed. (Figure 2). He underwent radiation therapy over

the next 36 hours and was brought back to the operat-

ing room for removal of the catheters.

OCTOBER 2011

The patient’s most recent CT scan does not show any

evidence of recurrent disease and he is doing very well.

He is his back to a normal quality-of-life. (Figure 3)

DISCUSSION

Soft tissue sarcomas are very challenging to treat and

usually require multidisciplinary treatment. This case is

an excellent example of the collaboration between surgi-

cal oncology radiation therapy, and medical oncology in

our Surgical Oncology Clinic. Here at Cleveland Clinic,

we have performed nearly 30 similar procedures with

perioperative radiation over the past two years.

This type of treatment allows the radiation therapist

to administer higher doses of radiation than might

be possible with conventional external beam therapy.

In addition, the entire radiation therapy is completed

during one hospitalization without the need for subse-

quent visits.

Dr. Chalikonda is Director of Robotic Surgery in the

DDI’s Department of General Surgery. He special-

izes in surgical oncology and hepato-pancreato-biliary

surgery. He can be contacted at [email protected] or

216.445.0056. ■

Figure 1: Preop CT scan Figure 2: CT scan of catheters in resection bed Figure 3: CT scan postop

DIGESTIVE DISEASE INSTITUTE CHAIR John Fung, MD, PhD

MANAGING EDITOR Ann Bakuniene-Milanowski

ART DIRECTOR Mike Viars

SENIOR MARKETING MANAGER Matthew Chaney

MARKETING MANAGER Priya Barra

CONTRIBUTING PHOTOGRAPHERS Russell Lee

Cleveland Clinic Center for Medical Art and Photography

At the Digestive Disease Institute, one of 26 institutes at Cleveland Clinic, our colorectal surgeons and gastrointestinal specialists serve more than 66,000 patients annually. At Cleveland Clinic Florida, our gastroenterologists provide care in more than 6,200 patient visits each year. Innovative procedures and decades of experience enable our physicians to achieve success in preventing and treating the full specturm of digestive diseases. Cleveland Clinic is a nonprofit, multispecialty academic medical center consistenly ranked among the top hospitals in America by U.S.News & World Report. Founded in 1921, it is dedicated to providing qualityspecialized care and includes an outpatient clinic, a hospital with more than 1,300 staffed beds, and education institute and a research institute.

Dr. Fanning Receives Healthnetwork Foundation Service Award Alicia Fanning, MD, was awarded a Healthnetwork Foundation Service

Award for 2011. Dr. Fanning, a breast surgeon in our Department of

General Surgery, was one of 10 recipients of this annual award given

to physicians who have demonstrated an extremely high level of integ-

rity and compassionate care to Healthnetwork members. Healthnet-

work helps to fund the ground-breaking research being conducted by

these innovative national leaders in medicine. Dr. Fanning’s specialty

interests include breast cancer and breast disease, breast diagnostics,

breast diseases, breast surgical oncology, oncoplastic surgery.

Standardizing, Metric-based Protocols for rectal CancerDDI recently organized a Consortium on Rectal Cancer, which

featured surgeons and pathologists from 16 major national centers

that perform a high volume of rectal cancer surgery.

Using experience and data from their respective medical centers,

members of the consortium hope to develop a standardized, metric-

based protocol for the way rectal cancer is managed in North America

based on the current best-available evidence. They also hope to define

specific outcome measures that accurately reflect quality care for the

50,000 patients diagnosed annually with rectal cancer in the U.S.

The August 2011 event was led by colorectal surgeons from Cleve-

land Clinic and Cleveland Clinic Florida: Feza H. Remzi, MD, Steven

Wexner, MD, James Merlino, MD, and David Dietz, MD.

Dr. Vargo to Lead Gastroenterology & HepatologyFollowing a national search, John Vargo, MD, MPH, has been named

Chair of the Department of Gastroenterology and Hepatology of the

Digestive Disease Institute of Cleveland Clinic.

Dr. Vargo is Associate Professor of Medicine at the Cleveland Clinic

Lerner College of Medicine of Case Western Reserve University. He also

serves as Vice-Chair of the Digestive Disease Institute.

Dr. Vargo earned his medical degree from the University of Rochester

School of Medicine and Dentistry, completed his residency at Montefio-

re Hospital University Health Center, Pittsburgh, and his Gastroenterol-

ogy fellowship at Cleveland Clinic. Dr. Vargo was also Cleveland Clinic’s

first hepatology fellow. He holds a master of public health from Case

Western Reserve University, Cleveland, and is an honorary fellow of the

Gastroenterology Society of Ecuador. He is a councilor of the American

Society of Gastrointestinal Endoscopy and is recognized for his research

in procedural sedation, deep enteroscopy and endoscopic training.

He has earned several awards, including the American Society for

Gastrointestinal Endoscopy Career Development Award and numerous

Cleveland Clinic Innovator Awards. Dr. Vargo is currently an associate

editor for the journal Gastrointestinal Endoscopy.

A member of the Department of Gastroenterology since 1994, Dr.

Vargo’s research interests include sedation, physiologic monitoring,

outcomes and training. His endoscopic practice includes ERCP, EUS,

advanced imaging techniques, stenting, endoscopic mucosal resection

and deep enteroscopy. He holds two patents in endoscopy and

is widely published.

inBrief}

Digestive Disease InstituteThe Cleveland Clinic Foundation9500 Euclid Avenue/AC311Cleveland, OH 44195

Medical Concierge Complimentary assistance for out-of-state patients

and families 800.223.2273, ext. 55580, or email

[email protected]

Global Patient ServicesComplimentary assistance for national and international

patients and families 001.216.444.8184 or visit

clevelandclinic.org/gps

DDi referrals clevelandclinic.org/digestive

Colorectal Surgery | Gastroenterology & Hepatology

General Surgery | Human Nutrition

Ohio: 855.REFER.123

Florida: 954.659.5278

Clinical trialsVisit clevelandclinic.org/ddiresearch

for a complete listing of all active clinical trials.

Critical Care Transport WorldwideCleveland Clinic’s critical care transport teams and fleet of mobile ICU vehicles, helicopters and fixed-wing aircraft serves critically ill and highly complex patients across the globe. Call 216.448.7000 or 866.547.1467 or visit clevelandclinic.org/criticalcaretransport.

Track Your Patient’s Care OnlineDrConnect is a secure online service providing our physician colleagues with real-time information about the treatment their patients receive at Cleveland Clinic. To receive your next patient report electronically, establish a DrConnect account at clevelandclinic.org/drconnect.

Digestive Disease institute access guide

Same-day Visits AvailableSame-day appointments often are available for urgent cases. All same-day visits will be coordinated through the DDI patient navigator, a registered nurse who will triage all requests for same-day visits to ensure patients receive immediate attention. To arrange a same-day visit, call 216.444.7000.

SERVICES FOR PHYSICIANS

SERVICES FOR PATIENTS

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