Seminars in Colon and Rectal Surgery最新文献

Physician burnout, characterized by exhaustion, depersonalization and reduced satisfaction, is an important and increasingly discussed issue. It has an impact across all specialties, with highest rates among surgery, neurology and other high-demand specialties. Risk factors for this epidemic are diverse and are seen as early as medical school. The impact of burnout is being noted in various studies in both physician personal lives and well-being, and quality of patient care. It is clear that this is an issue that needs to be addressed, and mitigation strategies are important at individual, institution and government level to optimize patient care, maintain the physician work force and protect physician well being.

As healthcare markets have become increasingly consolidated, the vertical integration of physician practices with hospital networks has drawn additional scrutiny. While vertical integration within healthcare was once predicted to improve efficiency and quality of healthcare delivery, empirical study has uncovered mixed results. In a review of existing literature, vertical integration has yielded inconsistent effects on health quality metrics, with modest improvements at best, but has consistently driven up prices. This article reviews economic theory and the real-world effects of vertical mergers within healthcare and discusses policies driving this trend. Given the impacts of vertical integration on healthcare outcomes, cost, patient choice and physician wellbeing, physicians should advocate for regulations that preserve sufficient competition in healthcare markets and diversity of practice settings.

Nowadays, endoscopy has achieved amazing results in the treatment of benign and malignant pathologies, but it has yet to establish itself fully in the sense of an operative endoscopy. It is commonly believed that traditional endoscopy has reached its limits due to the intrinsic characteristics of existing platforms. Numerous robotic endoluminal platforms have been developed to overcome limitations in recent years. Existing robotic endoluminal platforms can be divided into three categories: fully robotic flexible endoscopic, robotic add-on systems, and traditional surgery-based platforms. These platforms are incredible pieces of technology, but in reality, they can only be considered a bridge to a genuinely robotic surgical system. Nowadays, both gastroenterologists and surgeons perform endoscopic procedures all over the world. We believe these platforms, leading to increased manipulation possibilities, may require an increasingly excellent knowledge of surgical techniques to develop their potential fully. Surgeons' unique training and experience push surgeons to take the lead in endoscopic operations over gastroenterologists due to the potential advantages in surgical precision and patient outcomes. However, gastroenterologists deeply understand gastrointestinal disorders and a collaborative effort between them and surgeons can lead to an efficient approach to endoscopic surgery.

Patients with large colorectal polyps or mucosal neoplasms not amenable to standard polypectomy have traditionally undergone colon resection. However, minimally invasive surgical techniques have gained popularity over the past two decades. Transanal approaches such as transanal endoscopic microsurgery and transanal minimally invasive surgery have enabled surgeons to treat mucosal neoplasms located in the rectum. Later on, robotic surgery was incorporated into the transanal approach. Meanwhile, there was no such treatment option for more proximal colonic neoplasms then, and endoscopic mucosal resection and endoscopic submucosal dissection emerged in Japan to provide resection in treating such proximal lesions. Nowadays, all procedures performed in a hollow organ integrating standard surgical (dissection, resection, suturing, homeostasis) and oncological principles (en-bloc resection, clean surgical margins) are merged under endoluminal surgery. Within the scope of this review, we aimed to elaborate an overview of the role of endoluminal surgery in daily colorectal surgery practice while focusing on endoscopic procedures.

Endoscopic submucosal dissection (ESD) is an advanced therapeutic technique used to remove non-malignant polyps (NMP) and early cancers. Benefits include reducing unnecessary colectomies, cost, and morbidity of NMP treatment. Other roles for ESD and associated skills are likely to expand in the future, including in the non-operative management of rectal cancer. The learning curve is feasible with established training methods. Colorectal surgeons already perform routine endoscopy and manage endoscopic complications and endoscopically incurable lesions- endoluminal surgery (ELS) is a natural extension of this. Expanding technologies will only improve our ability to resect these lesions endoluminally moving forward. Collaboration with gastroenterologists and acquiring, rather than abandoning, this skillset is important and obtainable. Colorectal surgeons have the tools and professional duty to stay at the forefront of managing colorectal diseases endoscopically. Despite substantial barriers to mastering ELS, the value to our patients and profession means all colorectal surgeons should learn these techniques.

Endoscopic submucosal dissection is a challenging technique that allows en bloc removal of sessile colorectal polyps and constitutes definitive treatment for superficial T-1 cancers. To successfully complete ESD cases, the great majority of endoscopists need to acquire several new skill sets. Learning about, practicing, and becoming proficient with the advanced skills in the clinical setting is a huge challenge because of the fact that these are usually low volume cases and there may be weeks or months between cases.

Advanced endoscopic procedures require a complex skillset to remove larger, benign and early malignant lesions within the colon and rectum. These procedures require large amounts of resources and have costs associated with them. They also are associated with huge benefits to the patient and cost savings when compared to colon resection as an alternative. Maximizing reimbursement and ensuring sustainability of these techniques requires a thoughtful approach to implement into everyday practice. This manuscript explores these issues in greater depth.

Detection of colon polyps is common and is expected in 20–30 % of screening colonoscopies. As the number of colonoscopies performed increases, the detection of advanced and difficult to resect polyps will also rise. These polyps tend to be larger, greater than 2 cm, have flat morphology, and are in difficult anatomic locations behind haustral folds or at sharp flexures of the colon. Advanced endoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are useful to remove these polyps. However, many polyps remain unresectable with these techniques. Combined endoscopic laparoscopic surgery (CELS) has shown to be an effective technique to facilitate safe removal of complex polyps. CELS encompasses a variety of techniques including laparoscopic assisted ESD/EMR and laparo-endoscopic full thickness excisions (FLEX). Success rate of CELS ranges from 70 to 100 %, with less than 5 % conversion to colectomy. Perioperative outcomes boast shorter hospital length of stay, with low rates of serious post-op complications when compared to colectomy. Malignancy rate after CELS in appropriately selected patients is low, ranging from 1.6 %-10 % of cases. Polyp recurrence rate after CELS is also low, usually less than 10 %. Use of CELS for early-stage cancers remains controversial but maybe adequate in appropriately selected patients. Further evaluation and long-term studies are needed to study its efficacy in cases of known cancer. The purpose of this review is to provide recommendations for use of CELS techniques, appropriate indications, describe technical tips, and review potential future applications.

Endoscopic resection (ER) is the standard of care for the management of large (≥20 mm) non-pedunculated colorectal polyps (LNPCP). Certain lesion characteristics increase the risk for incomplete ER, recurrence, harbouring submucosal invasive cancer and post ER adverse events. These include lesion location, morphology, difficult endoscopic access and prior attempts at resection. Such LNPCP are termed ‘complex’. Recognition of complexity is a crucial component of technique selection and resource allocation. Until recently, resection of complex lesions was dominated by surgery. Surgical resection of benign lesions is associated with prolonged hospital stay and post-operative recovery, stoma creation, post-operative complications and even death. Advances in ER techniques have enabled huge strides in the management of these lesions and is proven to be safer and more cost-effective than surgery.

Endoluminal surgery in colorectal surgery involves the removal of polyps/lesions using advanced colonoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Prior to the adoption of these techniques in a new colorectal surgery practice, a colorectal surgeon should have some mastery of basic colonoscopy skills along with colonoscopic polypectomy. There are a variety of training options to learn endoluminal surgery including industry and institutional based courses, observation of a master endoscopist, or observational experience in Japan. Adoption of these techniques in a new practice is facilitated by knowledge of what equipment is required and the availability of trained staff. Endoluminal management of T1 colon cancers is an acceptable method of treatment and an alternative to surgical resection provided that the proper parameters are met.