if you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.
if you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.
if you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.
if you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.
if you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.
if you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.
quotecolonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority, but it's certainly the best thing we have↗
▶Ep 1 · 1:16
clinicalColonoscopy is still the best test for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 1 · 2:05
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps, particularly large ones in the right colon) have genetic predisposition, tie into family cancer syndromes, and carry very high cancer risk.↗
▶Ep 1 · 2:38
quotethese polyps have a really high risk of cancer. So it's very important to deal with them, but third is that it's very important to be able to tell the patient that they're at higher risk↗
▶Ep 1 · 2:42
guidelineFinding serrated adenomas requires family assessment for hereditary cancer syndromes and may necessitate changes in colonoscopy frequency and family member screening.↗
▶Ep 1 · 3:27
clinicalSerrated polyps can be flat and difficult to visualize; retroflexion in the cecum is increasingly used because they are often on the inferior or superior side of folds.↗
▶Ep 1 · 6:13
clinicalFor rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if necessary, and 1 cm for very low tumors as long as they are not poorly differentiated.↗
▶Ep 1 · 7:25
clinicalThe measurement '6 centimeters from the anal verge' varies significantly by patient body habitus and can represent different anatomical locations (anorectal ring vs. near dentate line).↗
▶Ep 1 · 8:01
quote6 centimeters doesn't mean 6 centimeters. It's not the same to everybody and it's not the same to every patient.↗
▶Ep 1 · 9:31
guidelineDistant staging for rectal cancer is best performed with CT abdomen (for liver metastases) and CT chest (replacing chest X-ray per current guidelines).↗
▶Ep 1 · 9:50
clinicalMRI has become the standard for local staging of rectal cancer, with high-resolution, high-Tesla magnets using standardized protocols developed by Bill Heald and Gina Brown at the Royal Marsden.↗
▶Ep 1 · 10:27
clinicalMRI is particularly good at distinguishing T3 and T4 tumors and assessing circumferential resection margins, though less accurate at distinguishing T1 from T2.↗
▶Ep 1 · 10:39
clinicalCircumferential resection margin is the most important margin (or many think more important than distal margin) for preventing local recurrence in rectal cancer.↗
▶Ep 1 · 10:51
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20–38%, with some series up to 50%.↗
▶Ep 1 · 10:51
quoteif you look back in the literature for rectal cancer. Local recurrence rates in series from good institutions were 20 to 38% and some up to 50%. Nowadays, really it should be under 10%, and if you look at our last 10 years, Jeff, it was about 3%.↗
▶Ep 1 · 11:04
epidemiologicalWith optimized surgery and imaging, local recurrence rates for rectal cancer should now be under 10%; Cleveland Clinic's rate over the last 10 years was about 3%.↗
▶Ep 1 · 11:57
quotewhen you do an operation, and we'll come back to the neoadjuvant treatment, but when you do the operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.↗
▶Ep 1 · 12:24
quoteyou can take out a whole rectum with about 5 mL of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 1 · 12:24
clinicalTotal mesorectal excision (TME) can be performed with about 5 mL of blood loss because it follows a bloodless embryological plane; bleeding indicates wrong plane unless deliberately outside TME plane.↗
▶Ep 1 · 12:54
guidelineNeoadjuvant therapy for rectal cancer is indicated for T3 tumors (outside the rectal wall) or node-positive disease.↗
▶Ep 1 · 13:18
guidelineStage 1 rectal cancer (node-negative, T1 or T2), particularly in the upper third of the rectum, does not require neoadjuvant therapy.↗
▶Ep 1 · 13:37
clinicalMRI is 90 to mid-90s percent accurate for T-staging and high 80s to 90% accurate for nodal staging of rectal cancer.↗
▶Ep 1 · 13:56
clinicalEndoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator-dependent than MRI.↗
▶Ep 1 · 14:35
guidelineTransanal resection for rectal cancer is generally limited to T1 tumors less than one-third circumference and ideally less than 2 cm.↗
▶Ep 1 · 14:51
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across multiple centers.↗
▶Ep 1 · 15:05
opinionTransanal endoscopic microsurgery (TEM) may produce better outcomes than traditional transanal excision, though it is unclear whether this is due to technology or improved surgical understanding.↗
▶Ep 1 · 15:27
guidelineFor young, curable patients, radical resection is generally favored over transanal resection; transanal resection is typically reserved for patients unfit for radical surgery or those who would require permanent stoma.↗
▶Ep 1 · 16:24
clinicalFor rectal cancer, full-thickness excision is required; ESD or EMR is never appropriate for proven cancer, only for benign polyps.↗
▶Ep 1 · 18:04
guidelineShort-course radiation (5×5 Gy over 5 days, surgery 1–2 weeks later) is commonly used in Europe; long-course chemoradiation (40–45 Gy over 6 weeks with 6–8 week wait) is standard in the US.↗
▶Ep 1 · 18:26
clinical25 Gy over a short period is radiotherapeutically equivalent to 40–45 Gy over a longer period, but long-course therapy may produce better tumor downstaging for bulky tumors.↗
▶Ep 1 · 19:51
guidelineFor colon cancer, at least 12 lymph nodes are required for adequate staging, though many surgeons aim for at least 16.↗
▶Ep 1 · 19:59
clinicalHigh ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is standard for sigmoid colectomy, with protection of autonomic nerves to preserve sexual function.↗
▶Ep 1 · 20:18
clinicalTotal mesocolic excision for colon cancer should be performed with about 5 mL of blood loss in the embryological plane between retroperitoneal peritoneum (Toldt's fascia) and mesocolic peritoneum.↗
▶Ep 1 · 20:48
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (high 20s%) before focus on complete mesocolic excision technique.↗
▶Ep 1 · 23:12
clinicalFor cecal or ileocecal valve tumors, 10 cm of small bowel should be resected; for mid-ascending colon tumors, 5 cm of small bowel is adequate.↗
▶Ep 1 · 24:00
epidemiologicalExtracorporeal stapled anastomosis for right hemicolectomy achieved a leak rate of 0.8% over 1000 cases at Cleveland Clinic.↗
▶Ep 1 · 24:56
guidelineGenetic assessment is indicated for colorectal cancer patients with Bethesda criteria risk factors, cancer under age 40, first-degree relatives with cancer, or multiple cancers in the family.↗
▶Ep 1 · 25:33
clinicalGenetic diagnosis affects both family screening recommendations and surgical approach; patients with hereditary syndromes may require subtotal colectomy or proctocolectomy rather than segmental resection.↗
Colorectal Cancer
▶Ep 2 · 1:15
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 2 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 2 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 2 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 2 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 2 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 2 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 2 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 2 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 2 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 2 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 2 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 2 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 2 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 2 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 2 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 2 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 2 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 2 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 2 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 2 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 2 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 2 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 2 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 2 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 2 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 2 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 2 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 2 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 2 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 2 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 2 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 2 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 2 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 2 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 2 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
▶Ep 2 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
Colorectal Cancer
▶Ep 3 · 1:15
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 3 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 3 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 3 · 1:15
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 3 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 3 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 3 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 3 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 3 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 3 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 3 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 3 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 3 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 3 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 3 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 3 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 3 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 3 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 3 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 3 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 3 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 3 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 3 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 3 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 3 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 3 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 3 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 3 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 3 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 3 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 3 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 3 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 3 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 3 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 3 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 3 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 3 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 3 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 3 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 3 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 3 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 3 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 3 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 3 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 3 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 3 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 3 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 3 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 3 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 3 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 3 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 3 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 3 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 3 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 3 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 3 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 3 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 3 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 3 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 3 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 3 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 3 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 3 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 3 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 3 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 3 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 3 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 3 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 3 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 3 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 3 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
▶Ep 3 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
▶Ep 3 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
▶Ep 3 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
Colorectal Cancer
▶Ep 4 · 1:15
clinicalColonoscopy is still the best test for colon cancer detection, with approximately 90-95% accuracy for finding cancers and polyps, though not perfect.↗
▶Ep 4 · 1:15
clinicalColonoscopy is still the best test for colon cancer detection, with approximately 90-95% accuracy for finding cancers and polyps, though not perfect.↗
▶Ep 4 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority.↗
▶Ep 4 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority.↗
▶Ep 4 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 4 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 4 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 4 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have a very high risk of cancer and are associated with genetic predisposition and family cancer syndromes.↗
▶Ep 4 · 2:03
guidelineSerrated adenomas require family assessment, may necessitate altered colonoscopy frequency, and family members may need colonoscopy or other testing.↗
▶Ep 4 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have a very high risk of cancer and are associated with genetic predisposition and family cancer syndromes.↗
▶Ep 4 · 2:03
guidelineSerrated adenomas require family assessment, may necessitate altered colonoscopy frequency, and family members may need colonoscopy or other testing.↗
▶Ep 4 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 4 · 3:26
clinicalSerrated polyps are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 4 · 3:26
clinicalSerrated polyps are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 4 · 4:59
quote6 centimeters in a 90-pound, 80-year-old female can be almost mid-rectum. 6 centimeters in a guy who's 6'6 and 300 pounds can be the top of the anal canal or even close to the dentate line.↗
▶Ep 4 · 4:59
quoteyour distal margin needs to be 5 centimeters if you can get it, 2 centimeters if you can get it, and for the very lowest tumors, perhaps 1 centimeter as long as they're not poorly differentiated.↗
▶Ep 4 · 4:59
guidelineFor rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if achievable, and for very low tumors 1 cm is acceptable as long as they are not poorly differentiated.↗
▶Ep 4 · 4:59
clinicalSix centimeters from the anal verge can mean different things depending on patient size: in a small elderly female it may be mid-rectum, while in a large male it can be near the dentate line.↗
▶Ep 4 · 4:59
clinicalSix centimeters from the anal verge can mean different things depending on patient size: in a small elderly female it may be mid-rectum, while in a large male it can be near the dentate line.↗
▶Ep 4 · 4:59
guidelineFor rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if achievable, and for very low tumors 1 cm is acceptable as long as they are not poorly differentiated.↗
▶Ep 4 · 4:59
quoteyour distal margin needs to be 5 centimeters if you can get it, 2 centimeters if you can get it, and for the very lowest tumors, perhaps 1 centimeter as long as they're not poorly differentiated.↗
▶Ep 4 · 4:59
quote6 centimeters in a 90-pound, 80-year-old female can be almost mid-rectum. 6 centimeters in a guy who's 6'6 and 300 pounds can be the top of the anal canal or even close to the dentate line.↗
▶Ep 4 · 6:51
clinicalUpper third rectal cancers likely do not need preoperative therapy or stoma, while middle and lower third cancers have a good chance of needing neoadjuvant therapy and temporary or rarely permanent stoma.↗
▶Ep 4 · 6:51
clinicalUpper third rectal cancers likely do not need preoperative therapy or stoma, while middle and lower third cancers have a good chance of needing neoadjuvant therapy and temporary or rarely permanent stoma.↗
▶Ep 4 · 9:03
guidelineDistant staging for rectal cancer is best done with CT abdomen for liver assessment and CT chest (now preferred over chest x-ray per most guidelines).↗
▶Ep 4 · 9:03
guidelineMRI with high-resolution, high Tesla magnet and standardized protocol (developed by Bill Heald and Gina Brown at Royal Marsden) is now the standard for local staging of rectal cancer.↗
▶Ep 4 · 9:03
guidelineDistant staging for rectal cancer is best done with CT abdomen for liver assessment and CT chest (now preferred over chest x-ray per most guidelines).↗
▶Ep 4 · 9:03
guidelineMRI with high-resolution, high Tesla magnet and standardized protocol (developed by Bill Heald and Gina Brown at Royal Marsden) is now the standard for local staging of rectal cancer.↗
▶Ep 4 · 10:43
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20-38%, with some up to 50%, but with optimized surgery and imaging should now be under 10%.↗
▶Ep 4 · 10:43
quoteif you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 4 · 10:43
epidemiologicalCleveland Clinic's local recurrence rate for rectal cancer over the last 10 years was approximately 3%.↗
▶Ep 4 · 10:43
clinicalCircumferential resection margin is the most important margin in rectal cancer surgery; a negative pathological margin results in low chance of local recurrence.↗
▶Ep 4 · 10:43
clinicalTotal mesorectal excision (TME) can be performed with about 5 mL of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or deliberately in the wrong plane.↗
▶Ep 4 · 10:43
clinicalMRI is approximately 90-95% accurate for T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 4 · 10:43
quotewhen you do an operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.↗
▶Ep 4 · 10:43
quoteif you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 4 · 10:43
quotewhen you do an operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.↗
▶Ep 4 · 10:43
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 4 · 10:43
epidemiologicalCleveland Clinic's local recurrence rate for rectal cancer over the last 10 years was approximately 3%.↗
▶Ep 4 · 10:43
clinicalCircumferential resection margin is the most important margin in rectal cancer surgery; a negative pathological margin results in low chance of local recurrence.↗
▶Ep 4 · 10:43
clinicalTotal mesorectal excision (TME) can be performed with about 5 mL of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or deliberately in the wrong plane.↗
▶Ep 4 · 10:43
clinicalMRI is approximately 90-95% accurate for T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 4 · 10:43
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 4 · 10:43
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20-38%, with some up to 50%, but with optimized surgery and imaging should now be under 10%.↗
▶Ep 4 · 13:11
quoteMRI is probably 90 to mid 90s accurate at T staging, and it's probably high 80s to 90% accurate for nodal staging.↗
▶Ep 4 · 13:11
clinicalEndoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator dependent than MRI.↗
▶Ep 4 · 13:11
guidelineStage I rectal cancer (node negative and T1 or T2), particularly if upper third, does not require preoperative radiation.↗
▶Ep 4 · 13:11
quoteUltrasound is much more operator dependent, and it's probably only 70% accurate for predicting nodal involvement.↗
▶Ep 4 · 13:11
quoteMRI is probably 90 to mid 90s accurate at T staging, and it's probably high 80s to 90% accurate for nodal staging.↗
▶Ep 4 · 13:11
quoteUltrasound is much more operator dependent, and it's probably only 70% accurate for predicting nodal involvement.↗
▶Ep 4 · 13:11
guidelineStage I rectal cancer (node negative and T1 or T2), particularly if upper third, does not require preoperative radiation.↗
▶Ep 4 · 13:11
guidelineNeoadjuvant therapy is indicated for rectal tumors that are T3 (outside the wall) or node positive.↗
▶Ep 4 · 13:11
guidelineNeoadjuvant therapy is indicated for rectal tumors that are T3 (outside the wall) or node positive.↗
▶Ep 4 · 13:11
clinicalEndoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator dependent than MRI.↗
▶Ep 4 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were approximately 18%, remarkably consistent across several major centers.↗
▶Ep 4 · 14:07
opinionFor young, curable patients, radical resection is generally favored over transanal resection; transanal approaches are reserved for patients unfit for rectal resection or those whose tumor location would require permanent stoma.↗
▶Ep 4 · 14:07
guidelineTransanal resection is appropriate for tumors less than one-third circumference, ideally less than 2 cm, that are T1.↗
▶Ep 4 · 14:07
guidelineTransanal resection is appropriate for tumors less than one-third circumference, ideally less than 2 cm, that are T1.↗
▶Ep 4 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 4 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were approximately 18%, remarkably consistent across several major centers.↗
▶Ep 4 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 4 · 14:07
opinionFor young, curable patients, radical resection is generally favored over transanal resection; transanal approaches are reserved for patients unfit for rectal resection or those whose tumor location would require permanent stoma.↗
▶Ep 4 · 15:58
guidelineRectal cancer requires full-thickness excision; endoscopic submucosal dissection (ESD) would never be used for proven or high-risk cancer, only for benign polyps.↗
▶Ep 4 · 15:58
guidelineRectal cancer requires full-thickness excision; endoscopic submucosal dissection (ESD) would never be used for proven or high-risk cancer, only for benign polyps.↗
▶Ep 4 · 16:23
quoteif it's a rectal cancer, it needs to be a full thickness excision. So you would never do an ESD type procedure.↗
▶Ep 4 · 16:23
quoteif it's a rectal cancer, it needs to be a full thickness excision. So you would never do an ESD type procedure.↗
▶Ep 4 · 17:25
clinical25 Gy over a short period is radiotherapeutically equivalent to 40-45 Gy over a longer period, but long-course therapy produces greater tumor downstaging and is preferred for bulky tumors.↗
▶Ep 4 · 17:25
quoteIn Europe, it's very much gone towards five times five gray, given over five days. And then you operate about a week to two weeks later. In Europe, sorry, in the U.S., for a variety of reasons, it's a six-week, 40 to 45 gray, given with chemotherapy, staged over six weeks, and then a six-week to eight-week waiting period.↗
▶Ep 4 · 17:25
quoteIn Europe, it's very much gone towards five times five gray, given over five days. And then you operate about a week to two weeks later. In Europe, sorry, in the U.S., for a variety of reasons, it's a six-week, 40 to 45 gray, given with chemotherapy, staged over six weeks, and then a six-week to eight-week waiting period.↗
▶Ep 4 · 17:25
guidelineShort-course radiation (5×5 Gy over 5 days, surgery 1-2 weeks later) is preferred in Europe, while long-course chemoradiation (40-45 Gy over 6 weeks with 6-8 week wait) is preferred in the U.S.↗
▶Ep 4 · 17:25
clinical25 Gy over a short period is radiotherapeutically equivalent to 40-45 Gy over a longer period, but long-course therapy produces greater tumor downstaging and is preferred for bulky tumors.↗
▶Ep 4 · 17:25
guidelineShort-course radiation (5×5 Gy over 5 days, surgery 1-2 weeks later) is preferred in Europe, while long-course chemoradiation (40-45 Gy over 6 weeks with 6-8 week wait) is preferred in the U.S.↗
▶Ep 4 · 19:22
clinicalHigh ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is performed in sigmoid colectomy, with protection of autonomic nerves to preserve sexual function.↗
▶Ep 4 · 19:22
guidelineFor colon cancer, surgeons should aim for at least 12 lymph nodes, though many hope for at least 16.↗
▶Ep 4 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were higher than for rectal cancer (despite rectal rates of high 20s) because adequate colon cancer surgery technique was not being performed.↗
▶Ep 4 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between Toltz fascia (retroperitoneal embryological peritoneum) and the mesocolon peritoneum, achieving complete mesocolic specimen with minimal blood loss.↗
▶Ep 4 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were higher than for rectal cancer (despite rectal rates of high 20s) because adequate colon cancer surgery technique was not being performed.↗
▶Ep 4 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between Toltz fascia (retroperitoneal embryological peritoneum) and the mesocolon peritoneum, achieving complete mesocolic specimen with minimal blood loss.↗
▶Ep 4 · 19:22
clinicalHigh ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is performed in sigmoid colectomy, with protection of autonomic nerves to preserve sexual function.↗
▶Ep 4 · 19:22
guidelineFor colon cancer, surgeons should aim for at least 12 lymph nodes, though many hope for at least 16.↗
▶Ep 4 · 21:23
clinicalFor mid-sigmoid cancer (35-40 cm), resection can extend from mid-descending colon to rectosigmoid junction without necessarily taking the splenic flexure, provided there is good vascularity with pulsatile flow.↗
▶Ep 4 · 21:23
clinicalFor mid-sigmoid cancer (35-40 cm), resection can extend from mid-descending colon to rectosigmoid junction without necessarily taking the splenic flexure, provided there is good vascularity with pulsatile flow.↗
▶Ep 4 · 22:44
guidelineFor cecal tumors, 10 cm of small bowel should be taken; for mid-ascending colon tumors, 5 cm of small bowel is adequate.↗
▶Ep 4 · 22:44
guidelineFor cecal tumors, 10 cm of small bowel should be taken; for mid-ascending colon tumors, 5 cm of small bowel is adequate.↗
▶Ep 4 · 23:55
epidemiologicalExtracorporeal stapled anastomosis through the extraction site for laparoscopic right colectomy has achieved leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 4 · 23:55
epidemiologicalExtracorporeal stapled anastomosis through the extraction site for laparoscopic right colectomy has achieved leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 4 · 24:32
clinicalGenetic diagnosis may change the surgical approach: patients with multiple polyps or significant family history may be better served with subtotal colectomy (ileosigmoid or ileorectal anastomosis) rather than segmental resection.↗
▶Ep 4 · 24:32
clinicalCleveland Clinic has a low threshold for genetic assessment, consulting coordinators when patients meet Bethesda criteria, have first-degree relatives with cancer, young family members with cancer, or multiple cancers in the family.↗
▶Ep 4 · 24:32
clinicalGenetic diagnosis may change the surgical approach: patients with multiple polyps or significant family history may be better served with subtotal colectomy (ileosigmoid or ileorectal anastomosis) rather than segmental resection.↗
▶Ep 4 · 24:32
clinicalCleveland Clinic has a low threshold for genetic assessment, consulting coordinators when patients meet Bethesda criteria, have first-degree relatives with cancer, young family members with cancer, or multiple cancers in the family.↗
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 208 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 208 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 208 · 1:15
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 208 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 208 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 208 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 208 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 208 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 208 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 208 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 208 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 208 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 208 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 208 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 208 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 208 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 208 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 208 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 208 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 208 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 208 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 208 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 208 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 208 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 208 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 208 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 208 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 208 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 208 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 208 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 208 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 208 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 208 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 208 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 208 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 208 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 208 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 208 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 208 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 208 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 208 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 208 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 208 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 208 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 208 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 208 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 208 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 208 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 208 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 208 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 208 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 208 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 208 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 208 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 208 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 208 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 208 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 208 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 208 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 208 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 208 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 208 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 208 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 208 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 208 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 208 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 208 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 208 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 208 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 208 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
▶Ep 208 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
▶Ep 208 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
▶Ep 208 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
Colorectal Cancer
▶Ep 209 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 209 · 1:15
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 209 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 209 · 1:15
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 209 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 209 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 209 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 209 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 209 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 209 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 209 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 209 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 209 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 209 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 209 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 209 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 209 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 209 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 209 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 209 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 209 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 209 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 209 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 209 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 209 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 209 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 209 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 209 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 209 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 209 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 209 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 209 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 209 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 209 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 209 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 209 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 209 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 209 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 209 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 209 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 209 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 209 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 209 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 209 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 209 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 209 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 209 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 209 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 209 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 209 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 209 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 209 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 209 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 209 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 209 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 209 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 209 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 209 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 209 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 209 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 209 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 209 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 209 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 209 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 209 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 209 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 209 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 209 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 209 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 209 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 209 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
▶Ep 209 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
▶Ep 209 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
▶Ep 209 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
Colorectal Cancer
▶Ep 210 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority.↗
▶Ep 210 · 1:15
clinicalColonoscopy is still the best test for colon cancer detection, with approximately 90-95% accuracy for finding cancers and polyps, though not perfect.↗
▶Ep 210 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority.↗
▶Ep 210 · 1:15
clinicalColonoscopy is still the best test for colon cancer detection, with approximately 90-95% accuracy for finding cancers and polyps, though not perfect.↗
▶Ep 210 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have a very high risk of cancer and are associated with genetic predisposition and family cancer syndromes.↗
▶Ep 210 · 2:03
guidelineSerrated adenomas require family assessment, may necessitate altered colonoscopy frequency, and family members may need colonoscopy or other testing.↗
▶Ep 210 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 210 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have a very high risk of cancer and are associated with genetic predisposition and family cancer syndromes.↗
▶Ep 210 · 2:03
guidelineSerrated adenomas require family assessment, may necessitate altered colonoscopy frequency, and family members may need colonoscopy or other testing.↗
▶Ep 210 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 210 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 210 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 210 · 3:26
clinicalSerrated polyps are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 210 · 3:26
clinicalSerrated polyps are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 210 · 4:59
clinicalSix centimeters from the anal verge can mean different things depending on patient size: in a small elderly female it may be mid-rectum, while in a large male it can be near the dentate line.↗
▶Ep 210 · 4:59
guidelineFor rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if achievable, and for very low tumors 1 cm is acceptable as long as they are not poorly differentiated.↗
▶Ep 210 · 4:59
quote6 centimeters in a 90-pound, 80-year-old female can be almost mid-rectum. 6 centimeters in a guy who's 6'6 and 300 pounds can be the top of the anal canal or even close to the dentate line.↗
▶Ep 210 · 4:59
quoteyour distal margin needs to be 5 centimeters if you can get it, 2 centimeters if you can get it, and for the very lowest tumors, perhaps 1 centimeter as long as they're not poorly differentiated.↗
▶Ep 210 · 4:59
quote6 centimeters in a 90-pound, 80-year-old female can be almost mid-rectum. 6 centimeters in a guy who's 6'6 and 300 pounds can be the top of the anal canal or even close to the dentate line.↗
▶Ep 210 · 4:59
quoteyour distal margin needs to be 5 centimeters if you can get it, 2 centimeters if you can get it, and for the very lowest tumors, perhaps 1 centimeter as long as they're not poorly differentiated.↗
▶Ep 210 · 4:59
clinicalSix centimeters from the anal verge can mean different things depending on patient size: in a small elderly female it may be mid-rectum, while in a large male it can be near the dentate line.↗
▶Ep 210 · 4:59
guidelineFor rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if achievable, and for very low tumors 1 cm is acceptable as long as they are not poorly differentiated.↗
▶Ep 210 · 6:51
clinicalUpper third rectal cancers likely do not need preoperative therapy or stoma, while middle and lower third cancers have a good chance of needing neoadjuvant therapy and temporary or rarely permanent stoma.↗
▶Ep 210 · 6:51
clinicalUpper third rectal cancers likely do not need preoperative therapy or stoma, while middle and lower third cancers have a good chance of needing neoadjuvant therapy and temporary or rarely permanent stoma.↗
▶Ep 210 · 9:03
guidelineDistant staging for rectal cancer is best done with CT abdomen for liver assessment and CT chest (now preferred over chest x-ray per most guidelines).↗
▶Ep 210 · 9:03
guidelineMRI with high-resolution, high Tesla magnet and standardized protocol (developed by Bill Heald and Gina Brown at Royal Marsden) is now the standard for local staging of rectal cancer.↗
▶Ep 210 · 9:03
guidelineDistant staging for rectal cancer is best done with CT abdomen for liver assessment and CT chest (now preferred over chest x-ray per most guidelines).↗
▶Ep 210 · 9:03
guidelineMRI with high-resolution, high Tesla magnet and standardized protocol (developed by Bill Heald and Gina Brown at Royal Marsden) is now the standard for local staging of rectal cancer.↗
▶Ep 210 · 10:43
clinicalTotal mesorectal excision (TME) can be performed with about 5 mL of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or deliberately in the wrong plane.↗
▶Ep 210 · 10:43
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 210 · 10:43
quotewhen you do an operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.↗
▶Ep 210 · 10:43
quoteif you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 210 · 10:43
quotewhen you do an operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.↗
▶Ep 210 · 10:43
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 210 · 10:43
clinicalCircumferential resection margin is the most important margin in rectal cancer surgery; a negative pathological margin results in low chance of local recurrence.↗
▶Ep 210 · 10:43
clinicalMRI is approximately 90-95% accurate for T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 210 · 10:43
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20-38%, with some up to 50%, but with optimized surgery and imaging should now be under 10%.↗
▶Ep 210 · 10:43
epidemiologicalCleveland Clinic's local recurrence rate for rectal cancer over the last 10 years was approximately 3%.↗
▶Ep 210 · 10:43
clinicalMRI is approximately 90-95% accurate for T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 210 · 10:43
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20-38%, with some up to 50%, but with optimized surgery and imaging should now be under 10%.↗
▶Ep 210 · 10:43
epidemiologicalCleveland Clinic's local recurrence rate for rectal cancer over the last 10 years was approximately 3%.↗
▶Ep 210 · 10:43
clinicalCircumferential resection margin is the most important margin in rectal cancer surgery; a negative pathological margin results in low chance of local recurrence.↗
▶Ep 210 · 10:43
clinicalTotal mesorectal excision (TME) can be performed with about 5 mL of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or deliberately in the wrong plane.↗
▶Ep 210 · 10:43
quoteif you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 210 · 13:11
guidelineNeoadjuvant therapy is indicated for rectal tumors that are T3 (outside the wall) or node positive.↗
▶Ep 210 · 13:11
clinicalEndoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator dependent than MRI.↗
▶Ep 210 · 13:11
guidelineStage I rectal cancer (node negative and T1 or T2), particularly if upper third, does not require preoperative radiation.↗
▶Ep 210 · 13:11
quoteMRI is probably 90 to mid 90s accurate at T staging, and it's probably high 80s to 90% accurate for nodal staging.↗
▶Ep 210 · 13:11
clinicalEndoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator dependent than MRI.↗
▶Ep 210 · 13:11
quoteUltrasound is much more operator dependent, and it's probably only 70% accurate for predicting nodal involvement.↗
▶Ep 210 · 13:11
guidelineNeoadjuvant therapy is indicated for rectal tumors that are T3 (outside the wall) or node positive.↗
▶Ep 210 · 13:11
quoteMRI is probably 90 to mid 90s accurate at T staging, and it's probably high 80s to 90% accurate for nodal staging.↗
▶Ep 210 · 13:11
quoteUltrasound is much more operator dependent, and it's probably only 70% accurate for predicting nodal involvement.↗
▶Ep 210 · 13:11
guidelineStage I rectal cancer (node negative and T1 or T2), particularly if upper third, does not require preoperative radiation.↗
▶Ep 210 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were approximately 18%, remarkably consistent across several major centers.↗
▶Ep 210 · 14:07
guidelineTransanal resection is appropriate for tumors less than one-third circumference, ideally less than 2 cm, that are T1.↗
▶Ep 210 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 210 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 210 · 14:07
opinionFor young, curable patients, radical resection is generally favored over transanal resection; transanal approaches are reserved for patients unfit for rectal resection or those whose tumor location would require permanent stoma.↗
▶Ep 210 · 14:07
opinionFor young, curable patients, radical resection is generally favored over transanal resection; transanal approaches are reserved for patients unfit for rectal resection or those whose tumor location would require permanent stoma.↗
▶Ep 210 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were approximately 18%, remarkably consistent across several major centers.↗
▶Ep 210 · 14:07
guidelineTransanal resection is appropriate for tumors less than one-third circumference, ideally less than 2 cm, that are T1.↗
▶Ep 210 · 15:58
guidelineRectal cancer requires full-thickness excision; endoscopic submucosal dissection (ESD) would never be used for proven or high-risk cancer, only for benign polyps.↗
▶Ep 210 · 15:58
guidelineRectal cancer requires full-thickness excision; endoscopic submucosal dissection (ESD) would never be used for proven or high-risk cancer, only for benign polyps.↗
▶Ep 210 · 16:23
quoteif it's a rectal cancer, it needs to be a full thickness excision. So you would never do an ESD type procedure.↗
▶Ep 210 · 16:23
quoteif it's a rectal cancer, it needs to be a full thickness excision. So you would never do an ESD type procedure.↗
▶Ep 210 · 17:25
clinical25 Gy over a short period is radiotherapeutically equivalent to 40-45 Gy over a longer period, but long-course therapy produces greater tumor downstaging and is preferred for bulky tumors.↗
▶Ep 210 · 17:25
quoteIn Europe, it's very much gone towards five times five gray, given over five days. And then you operate about a week to two weeks later. In Europe, sorry, in the U.S., for a variety of reasons, it's a six-week, 40 to 45 gray, given with chemotherapy, staged over six weeks, and then a six-week to eight-week waiting period.↗
▶Ep 210 · 17:25
quoteIn Europe, it's very much gone towards five times five gray, given over five days. And then you operate about a week to two weeks later. In Europe, sorry, in the U.S., for a variety of reasons, it's a six-week, 40 to 45 gray, given with chemotherapy, staged over six weeks, and then a six-week to eight-week waiting period.↗
▶Ep 210 · 17:25
guidelineShort-course radiation (5×5 Gy over 5 days, surgery 1-2 weeks later) is preferred in Europe, while long-course chemoradiation (40-45 Gy over 6 weeks with 6-8 week wait) is preferred in the U.S.↗
▶Ep 210 · 17:25
clinical25 Gy over a short period is radiotherapeutically equivalent to 40-45 Gy over a longer period, but long-course therapy produces greater tumor downstaging and is preferred for bulky tumors.↗
▶Ep 210 · 17:25
guidelineShort-course radiation (5×5 Gy over 5 days, surgery 1-2 weeks later) is preferred in Europe, while long-course chemoradiation (40-45 Gy over 6 weeks with 6-8 week wait) is preferred in the U.S.↗
▶Ep 210 · 19:22
guidelineFor colon cancer, surgeons should aim for at least 12 lymph nodes, though many hope for at least 16.↗
▶Ep 210 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were higher than for rectal cancer (despite rectal rates of high 20s) because adequate colon cancer surgery technique was not being performed.↗
▶Ep 210 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between Toltz fascia (retroperitoneal embryological peritoneum) and the mesocolon peritoneum, achieving complete mesocolic specimen with minimal blood loss.↗
▶Ep 210 · 19:22
clinicalHigh ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is performed in sigmoid colectomy, with protection of autonomic nerves to preserve sexual function.↗
▶Ep 210 · 19:22
guidelineFor colon cancer, surgeons should aim for at least 12 lymph nodes, though many hope for at least 16.↗
▶Ep 210 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were higher than for rectal cancer (despite rectal rates of high 20s) because adequate colon cancer surgery technique was not being performed.↗
▶Ep 210 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between Toltz fascia (retroperitoneal embryological peritoneum) and the mesocolon peritoneum, achieving complete mesocolic specimen with minimal blood loss.↗
▶Ep 210 · 19:22
clinicalHigh ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is performed in sigmoid colectomy, with protection of autonomic nerves to preserve sexual function.↗
▶Ep 210 · 21:23
clinicalFor mid-sigmoid cancer (35-40 cm), resection can extend from mid-descending colon to rectosigmoid junction without necessarily taking the splenic flexure, provided there is good vascularity with pulsatile flow.↗
▶Ep 210 · 21:23
clinicalFor mid-sigmoid cancer (35-40 cm), resection can extend from mid-descending colon to rectosigmoid junction without necessarily taking the splenic flexure, provided there is good vascularity with pulsatile flow.↗
▶Ep 210 · 22:44
guidelineFor cecal tumors, 10 cm of small bowel should be taken; for mid-ascending colon tumors, 5 cm of small bowel is adequate.↗
▶Ep 210 · 22:44
guidelineFor cecal tumors, 10 cm of small bowel should be taken; for mid-ascending colon tumors, 5 cm of small bowel is adequate.↗
▶Ep 210 · 23:55
epidemiologicalExtracorporeal stapled anastomosis through the extraction site for laparoscopic right colectomy has achieved leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 210 · 23:55
epidemiologicalExtracorporeal stapled anastomosis through the extraction site for laparoscopic right colectomy has achieved leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 210 · 24:32
clinicalGenetic diagnosis may change the surgical approach: patients with multiple polyps or significant family history may be better served with subtotal colectomy (ileosigmoid or ileorectal anastomosis) rather than segmental resection.↗
▶Ep 210 · 24:32
clinicalCleveland Clinic has a low threshold for genetic assessment, consulting coordinators when patients meet Bethesda criteria, have first-degree relatives with cancer, young family members with cancer, or multiple cancers in the family.↗
▶Ep 210 · 24:32
clinicalGenetic diagnosis may change the surgical approach: patients with multiple polyps or significant family history may be better served with subtotal colectomy (ileosigmoid or ileorectal anastomosis) rather than segmental resection.↗
▶Ep 210 · 24:32
clinicalCleveland Clinic has a low threshold for genetic assessment, consulting coordinators when patients meet Bethesda criteria, have first-degree relatives with cancer, young family members with cancer, or multiple cancers in the family.↗
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 2 · 1:15
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 2 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 2 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 2 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 2 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 2 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 2 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 2 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 2 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 2 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 2 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 2 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 2 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 2 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 2 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 2 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 2 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 2 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 2 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 2 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 2 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 2 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 2 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 2 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 2 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 2 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 2 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 2 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 2 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 2 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 2 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 2 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 2 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 2 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 2 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
▶Ep 2 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
Colorectal Cancer
▶Ep 3 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority. But it's certainly the best thing we have.↗
▶Ep 3 · 1:15
clinicalColonoscopy is still the best test available for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 3 · 2:03
clinicalSerrated polyps have a very high risk of cancer and require family assessment to determine if patients have a family cancer syndrome.↗
▶Ep 3 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 3 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 3 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have good evidence of genetic predisposition and tie into many family cancer syndromes.↗
▶Ep 3 · 3:26
clinicalSerrated adenomas are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 3 · 4:59
quotesix centimeters can be a very different thing in many surgeons' minds or gastroenterologists, and it can also be a very different thing depending on the patient.↗
▶Ep 3 · 4:59
guidelineDistal margin requirements for rectal resection: 5 centimeters if possible, 2 centimeters if possible, and for very lowest tumors perhaps 1 centimeter as long as they are not poorly differentiated.↗
▶Ep 3 · 4:59
clinicalSix centimeters from the anal verge can be mid-rectum in a small patient (90-pound, 80-year-old female) or close to the dentate line in a large patient (6'6", 300 pounds).↗
▶Ep 3 · 9:03
quoteIf you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 3 · 9:03
guidelineFor total mesorectal excision, the circumferential resection margin should be one to two millimeters; if threatened, this is an indication for neoadjuvant therapy or extended resection.↗
▶Ep 3 · 9:03
clinicalA total mesorectal excision can be performed with about 5 milliliters of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or in the wrong plane.↗
▶Ep 3 · 9:03
guidelineMost accepted guidelines for neoadjuvant therapy in rectal cancer are for tumors that are T3 (outside the wall of the rectum) or node positive.↗
▶Ep 3 · 9:03
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20 to 38 percent, with some up to 50 percent.↗
▶Ep 3 · 9:03
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 3 · 9:03
epidemiologicalWith optimized surgery, imaging, and patient selection, local recurrence rates for rectal cancer should be under 10 percent; Cleveland Clinic's rate over the last 10 years was about 3 percent.↗
▶Ep 3 · 13:11
guidelineFor node-negative T1 or T2 rectal tumors (stage one), particularly if upper third, neoadjuvant therapy can be omitted.↗
▶Ep 3 · 13:18
clinicalEndoscopic ultrasound is much more operator dependent and probably only 70% accurate for predicting nodal involvement in rectal cancer.↗
▶Ep 3 · 13:18
clinicalMRI is probably 90 to mid-90s percent accurate at T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 3 · 14:07
guidelineTransanal resection is generally appropriate for tumors less than a third of the circumference, ideally less than two centimeters, that are T1.↗
▶Ep 3 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 3 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across outcome data from several big centers.↗
▶Ep 3 · 14:07
opinionFor young, curable patients, most surgeons favor radical resection over transanal resection; transanal resection is generally kept for patients unfit for rectal resection or those whose tumor is so close to the dentate line that a permanent stoma would be required.↗
▶Ep 3 · 16:23
clinicalFor rectal cancer, full-thickness excision is required; ESD (endoscopic submucosal dissection) would never be done for a proven cancer, only for benign polyps.↗
▶Ep 3 · 17:25
guidelineIn Europe, short-course radiation is five times five gray given over five days, with surgery about one to two weeks later.↗
▶Ep 3 · 17:25
guidelineIn the U.S., long-course radiation is 40 to 45 gray given with chemotherapy over six weeks, followed by a six to eight week waiting period.↗
▶Ep 3 · 17:25
clinicalTwenty-five gray over a short period is radiotherapeutically equivalent to 40 to 45 gray over a longer period, but longer course can make a big difference for tumor response and physical downstaging.↗
▶Ep 3 · 17:25
quote25 gray over a short period is equivalent to 40 to 45 over a longer period. But it can make a big difference for tumor response.↗
▶Ep 3 · 19:22
quoteif you look at the Scandinavian data, I mentioned their local recurrence rates were 27%, high 20s, when they were doing some very good rectal cancer trials. They focused on rectal cancer surgical technique and got the local recurrence rate down to under 10%. While their local recurrence rate for colon cancer was even higher than their rectal cancer local recurrence rate, because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 3 · 19:22
guidelineFor colon cancer surgery, goals include at least a 5 centimeter proximal and distal margin (usually determined by blood supply) and at least 12 lymph nodes, with many surgeons hoping for at least 16.↗
▶Ep 3 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between the embryological peritoneum of the retroperitoneum (Toldt's fascia) and the embryological peritoneum on the mesocolon, keeping the mesocolon complete.↗
▶Ep 3 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (which was high 20s percent) because they realized they weren't doing adequate colon cancer surgery.↗
▶Ep 3 · 22:44
guidelineFor a cecal tumor or lesion near the ileocecal valve, 10 centimeters of small bowel should be taken; for mid-ascending colon, 5 centimeters should be taken.↗
▶Ep 3 · 23:59
epidemiologicalExtracorporeal stapled anastomosis for right colectomy has reported leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 3 · 24:32
guidelineGenetic workup should be considered for patients with cancer under age 40, first-degree relatives with cancer, multiple cancers in a family, or non-GI cancers in a family.↗
▶Ep 3 · 24:32
clinicalGenetic findings may change the surgical operation: a patient with a right colon cancer plus multiple polyps or significant family history may be better served with a subtotal colectomy rather than segmental resection.↗
Colorectal Cancer
▶Ep 4 · 1:15
quoteColonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority.↗
▶Ep 4 · 1:15
clinicalColonoscopy is still the best test for colon cancer detection, with approximately 90-95% accuracy for finding cancers and polyps, though not perfect.↗
▶Ep 4 · 2:03
quoteover the last five to ten years, particularly, as we've found out more, it's become clear that these weren't actually hyperplastic, and they were really polyps that are better described as serrated adenomas.↗
▶Ep 4 · 2:03
guidelineSerrated adenomas require family assessment, may necessitate altered colonoscopy frequency, and family members may need colonoscopy or other testing.↗
▶Ep 4 · 2:03
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps) have a very high risk of cancer and are associated with genetic predisposition and family cancer syndromes.↗
▶Ep 4 · 2:03
quotethese polyps have a really high risk of cancer, so it's very important to deal with them.↗
▶Ep 4 · 3:26
clinicalSerrated polyps are often flat and difficult to see; retroflexion in the cecum is useful because they are often on the inferior or superior side of the valve or on folds.↗
▶Ep 4 · 4:59
quote6 centimeters in a 90-pound, 80-year-old female can be almost mid-rectum. 6 centimeters in a guy who's 6'6 and 300 pounds can be the top of the anal canal or even close to the dentate line.↗
▶Ep 4 · 4:59
quoteyour distal margin needs to be 5 centimeters if you can get it, 2 centimeters if you can get it, and for the very lowest tumors, perhaps 1 centimeter as long as they're not poorly differentiated.↗
▶Ep 4 · 4:59
guidelineFor rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if achievable, and for very low tumors 1 cm is acceptable as long as they are not poorly differentiated.↗
▶Ep 4 · 4:59
clinicalSix centimeters from the anal verge can mean different things depending on patient size: in a small elderly female it may be mid-rectum, while in a large male it can be near the dentate line.↗
▶Ep 4 · 6:51
clinicalUpper third rectal cancers likely do not need preoperative therapy or stoma, while middle and lower third cancers have a good chance of needing neoadjuvant therapy and temporary or rarely permanent stoma.↗
▶Ep 4 · 9:03
guidelineMRI with high-resolution, high Tesla magnet and standardized protocol (developed by Bill Heald and Gina Brown at Royal Marsden) is now the standard for local staging of rectal cancer.↗
▶Ep 4 · 9:03
guidelineDistant staging for rectal cancer is best done with CT abdomen for liver assessment and CT chest (now preferred over chest x-ray per most guidelines).↗
▶Ep 4 · 10:43
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20-38%, with some up to 50%, but with optimized surgery and imaging should now be under 10%.↗
▶Ep 4 · 10:43
clinicalMRI is approximately 90-95% accurate for T staging and high 80s to 90% accurate for nodal staging in rectal cancer.↗
▶Ep 4 · 10:43
epidemiologicalCleveland Clinic's local recurrence rate for rectal cancer over the last 10 years was approximately 3%.↗
▶Ep 4 · 10:43
clinicalCircumferential resection margin is the most important margin in rectal cancer surgery; a negative pathological margin results in low chance of local recurrence.↗
▶Ep 4 · 10:43
clinicalTotal mesorectal excision (TME) can be performed with about 5 mL of blood loss because it is a bloodless plane; bleeding indicates being outside that plane or deliberately in the wrong plane.↗
▶Ep 4 · 10:43
quoteif you look back in the literature for rectal cancer, local recurrence rates in series from good institutions were 20 to 38 percent and some up to 50 percent. Nowadays, really, it should be under 10 percent. And if you look at our last 10 years, Jeff, it was about 3 percent.↗
▶Ep 4 · 10:43
quotewhen you do an operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.↗
▶Ep 4 · 10:43
quoteyou can take out a whole rectum with about 5 mils of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 4 · 13:11
guidelineNeoadjuvant therapy is indicated for rectal tumors that are T3 (outside the wall) or node positive.↗
▶Ep 4 · 13:11
quoteUltrasound is much more operator dependent, and it's probably only 70% accurate for predicting nodal involvement.↗
▶Ep 4 · 13:11
quoteMRI is probably 90 to mid 90s accurate at T staging, and it's probably high 80s to 90% accurate for nodal staging.↗
▶Ep 4 · 13:11
clinicalEndoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator dependent than MRI.↗
▶Ep 4 · 13:11
guidelineStage I rectal cancer (node negative and T1 or T2), particularly if upper third, does not require preoperative radiation.↗
▶Ep 4 · 14:07
quoteif you look at the historical local recurrence rates for these transanally excised rectal cancers, it was about 18%. And it was remarkably consistent across outcome data from several big centers, about 18%.↗
▶Ep 4 · 14:07
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were approximately 18%, remarkably consistent across several major centers.↗
▶Ep 4 · 14:07
guidelineTransanal resection is appropriate for tumors less than one-third circumference, ideally less than 2 cm, that are T1.↗
▶Ep 4 · 14:07
opinionFor young, curable patients, radical resection is generally favored over transanal resection; transanal approaches are reserved for patients unfit for rectal resection or those whose tumor location would require permanent stoma.↗
▶Ep 4 · 15:58
guidelineRectal cancer requires full-thickness excision; endoscopic submucosal dissection (ESD) would never be used for proven or high-risk cancer, only for benign polyps.↗
▶Ep 4 · 16:23
quoteif it's a rectal cancer, it needs to be a full thickness excision. So you would never do an ESD type procedure.↗
▶Ep 4 · 17:25
guidelineShort-course radiation (5×5 Gy over 5 days, surgery 1-2 weeks later) is preferred in Europe, while long-course chemoradiation (40-45 Gy over 6 weeks with 6-8 week wait) is preferred in the U.S.↗
▶Ep 4 · 17:25
quoteIn Europe, it's very much gone towards five times five gray, given over five days. And then you operate about a week to two weeks later. In Europe, sorry, in the U.S., for a variety of reasons, it's a six-week, 40 to 45 gray, given with chemotherapy, staged over six weeks, and then a six-week to eight-week waiting period.↗
▶Ep 4 · 17:25
clinical25 Gy over a short period is radiotherapeutically equivalent to 40-45 Gy over a longer period, but long-course therapy produces greater tumor downstaging and is preferred for bulky tumors.↗
▶Ep 4 · 19:22
guidelineFor colon cancer, surgeons should aim for at least 12 lymph nodes, though many hope for at least 16.↗
▶Ep 4 · 19:22
clinicalHigh ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is performed in sigmoid colectomy, with protection of autonomic nerves to preserve sexual function.↗
▶Ep 4 · 19:22
clinicalTotal mesocolic excision should be performed in the plane between Toltz fascia (retroperitoneal embryological peritoneum) and the mesocolon peritoneum, achieving complete mesocolic specimen with minimal blood loss.↗
▶Ep 4 · 19:22
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were higher than for rectal cancer (despite rectal rates of high 20s) because adequate colon cancer surgery technique was not being performed.↗
▶Ep 4 · 21:23
clinicalFor mid-sigmoid cancer (35-40 cm), resection can extend from mid-descending colon to rectosigmoid junction without necessarily taking the splenic flexure, provided there is good vascularity with pulsatile flow.↗
▶Ep 4 · 22:44
guidelineFor cecal tumors, 10 cm of small bowel should be taken; for mid-ascending colon tumors, 5 cm of small bowel is adequate.↗
▶Ep 4 · 23:55
epidemiologicalExtracorporeal stapled anastomosis through the extraction site for laparoscopic right colectomy has achieved leak rates of 0.8% over 1,000 cases at Cleveland Clinic.↗
▶Ep 4 · 24:32
clinicalCleveland Clinic has a low threshold for genetic assessment, consulting coordinators when patients meet Bethesda criteria, have first-degree relatives with cancer, young family members with cancer, or multiple cancers in the family.↗
▶Ep 4 · 24:32
clinicalGenetic diagnosis may change the surgical approach: patients with multiple polyps or significant family history may be better served with subtotal colectomy (ileosigmoid or ileorectal anastomosis) rather than segmental resection.↗
clinicalColonoscopy is still the best test for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 7 · 1:16
quotecolonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority, but it's certainly the best thing we have↗
▶Ep 7 · 1:16
clinicalColonoscopy is still the best test for colon cancer detection, finding the vast majority of cancers and polyps, though not perfect.↗
▶Ep 7 · 1:16
quotecolonoscopy is still very important. It's still the best test that we have. There is no perfect test, and we know that colonoscopy doesn't find every cancer, although it finds the vast majority, every polyp, although it finds the vast majority, but it's certainly the best thing we have↗
▶Ep 7 · 2:05
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps, particularly large ones in the right colon) have genetic predisposition, tie into family cancer syndromes, and carry very high cancer risk.↗
▶Ep 7 · 2:05
clinicalSerrated adenomas (previously misclassified as hyperplastic polyps, particularly large ones in the right colon) have genetic predisposition, tie into family cancer syndromes, and carry very high cancer risk.↗
▶Ep 7 · 2:38
quotethese polyps have a really high risk of cancer. So it's very important to deal with them, but third is that it's very important to be able to tell the patient that they're at higher risk↗
▶Ep 7 · 2:38
quotethese polyps have a really high risk of cancer. So it's very important to deal with them, but third is that it's very important to be able to tell the patient that they're at higher risk↗
▶Ep 7 · 2:42
guidelineFinding serrated adenomas requires family assessment for hereditary cancer syndromes and may necessitate changes in colonoscopy frequency and family member screening.↗
▶Ep 7 · 2:42
guidelineFinding serrated adenomas requires family assessment for hereditary cancer syndromes and may necessitate changes in colonoscopy frequency and family member screening.↗
▶Ep 7 · 3:27
clinicalSerrated polyps can be flat and difficult to visualize; retroflexion in the cecum is increasingly used because they are often on the inferior or superior side of folds.↗
▶Ep 7 · 3:27
clinicalSerrated polyps can be flat and difficult to visualize; retroflexion in the cecum is increasingly used because they are often on the inferior or superior side of folds.↗
▶Ep 7 · 6:13
clinicalFor rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if necessary, and 1 cm for very low tumors as long as they are not poorly differentiated.↗
▶Ep 7 · 6:13
clinicalFor rectal cancer, distal margin requirements are 5 cm if achievable, 2 cm if necessary, and 1 cm for very low tumors as long as they are not poorly differentiated.↗
▶Ep 7 · 7:25
clinicalThe measurement '6 centimeters from the anal verge' varies significantly by patient body habitus and can represent different anatomical locations (anorectal ring vs. near dentate line).↗
▶Ep 7 · 7:25
clinicalThe measurement '6 centimeters from the anal verge' varies significantly by patient body habitus and can represent different anatomical locations (anorectal ring vs. near dentate line).↗
▶Ep 7 · 8:01
quote6 centimeters doesn't mean 6 centimeters. It's not the same to everybody and it's not the same to every patient.↗
▶Ep 7 · 8:01
quote6 centimeters doesn't mean 6 centimeters. It's not the same to everybody and it's not the same to every patient.↗
▶Ep 7 · 9:31
guidelineDistant staging for rectal cancer is best performed with CT abdomen (for liver metastases) and CT chest (replacing chest X-ray per current guidelines).↗
▶Ep 7 · 9:31
guidelineDistant staging for rectal cancer is best performed with CT abdomen (for liver metastases) and CT chest (replacing chest X-ray per current guidelines).↗
▶Ep 7 · 9:50
clinicalMRI has become the standard for local staging of rectal cancer, with high-resolution, high-Tesla magnets using standardized protocols developed by Bill Heald and Gina Brown at the Royal Marsden.↗
▶Ep 7 · 9:50
clinicalMRI has become the standard for local staging of rectal cancer, with high-resolution, high-Tesla magnets using standardized protocols developed by Bill Heald and Gina Brown at the Royal Marsden.↗
▶Ep 7 · 10:27
clinicalMRI is particularly good at distinguishing T3 and T4 tumors and assessing circumferential resection margins, though less accurate at distinguishing T1 from T2.↗
▶Ep 7 · 10:27
clinicalMRI is particularly good at distinguishing T3 and T4 tumors and assessing circumferential resection margins, though less accurate at distinguishing T1 from T2.↗
▶Ep 7 · 10:39
clinicalCircumferential resection margin is the most important margin (or many think more important than distal margin) for preventing local recurrence in rectal cancer.↗
▶Ep 7 · 10:39
clinicalCircumferential resection margin is the most important margin (or many think more important than distal margin) for preventing local recurrence in rectal cancer.↗
▶Ep 7 · 10:51
quoteif you look back in the literature for rectal cancer. Local recurrence rates in series from good institutions were 20 to 38% and some up to 50%. Nowadays, really it should be under 10%, and if you look at our last 10 years, Jeff, it was about 3%.↗
▶Ep 7 · 10:51
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20–38%, with some series up to 50%.↗
▶Ep 7 · 10:51
epidemiologicalHistorical local recurrence rates for rectal cancer from good institutions were 20–38%, with some series up to 50%.↗
▶Ep 7 · 10:51
quoteif you look back in the literature for rectal cancer. Local recurrence rates in series from good institutions were 20 to 38% and some up to 50%. Nowadays, really it should be under 10%, and if you look at our last 10 years, Jeff, it was about 3%.↗
▶Ep 7 · 11:04
epidemiologicalWith optimized surgery and imaging, local recurrence rates for rectal cancer should now be under 10%; Cleveland Clinic's rate over the last 10 years was about 3%.↗
▶Ep 7 · 11:04
epidemiologicalWith optimized surgery and imaging, local recurrence rates for rectal cancer should now be under 10%; Cleveland Clinic's rate over the last 10 years was about 3%.↗
▶Ep 7 · 11:57
quotewhen you do an operation, and we'll come back to the neoadjuvant treatment, but when you do the operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.↗
▶Ep 7 · 11:57
quotewhen you do an operation, and we'll come back to the neoadjuvant treatment, but when you do the operation on these patients, you've got to do it in a way that they have a negative pathological margin. If you have a negative pathological margin, the chance of local recurrence is low.↗
▶Ep 7 · 12:24
quoteyou can take out a whole rectum with about 5 mL of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 7 · 12:24
clinicalTotal mesorectal excision (TME) can be performed with about 5 mL of blood loss because it follows a bloodless embryological plane; bleeding indicates wrong plane unless deliberately outside TME plane.↗
▶Ep 7 · 12:24
clinicalTotal mesorectal excision (TME) can be performed with about 5 mL of blood loss because it follows a bloodless embryological plane; bleeding indicates wrong plane unless deliberately outside TME plane.↗
▶Ep 7 · 12:24
quoteyou can take out a whole rectum with about 5 mL of blood loss because it's a bloodless plane. And if you've got bleeding, you hopefully are deliberately outside of that plane, but otherwise you're in the wrong plane.↗
▶Ep 7 · 12:54
guidelineNeoadjuvant therapy for rectal cancer is indicated for T3 tumors (outside the rectal wall) or node-positive disease.↗
▶Ep 7 · 12:54
guidelineNeoadjuvant therapy for rectal cancer is indicated for T3 tumors (outside the rectal wall) or node-positive disease.↗
▶Ep 7 · 13:18
guidelineStage 1 rectal cancer (node-negative, T1 or T2), particularly in the upper third of the rectum, does not require neoadjuvant therapy.↗
▶Ep 7 · 13:18
guidelineStage 1 rectal cancer (node-negative, T1 or T2), particularly in the upper third of the rectum, does not require neoadjuvant therapy.↗
▶Ep 7 · 13:37
clinicalMRI is 90 to mid-90s percent accurate for T-staging and high 80s to 90% accurate for nodal staging of rectal cancer.↗
▶Ep 7 · 13:37
clinicalMRI is 90 to mid-90s percent accurate for T-staging and high 80s to 90% accurate for nodal staging of rectal cancer.↗
▶Ep 7 · 13:56
clinicalEndoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator-dependent than MRI.↗
▶Ep 7 · 13:56
clinicalEndoscopic ultrasound is only about 70% accurate for predicting nodal involvement in rectal cancer and is much more operator-dependent than MRI.↗
▶Ep 7 · 14:35
guidelineTransanal resection for rectal cancer is generally limited to T1 tumors less than one-third circumference and ideally less than 2 cm.↗
▶Ep 7 · 14:35
guidelineTransanal resection for rectal cancer is generally limited to T1 tumors less than one-third circumference and ideally less than 2 cm.↗
▶Ep 7 · 14:51
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across multiple centers.↗
▶Ep 7 · 14:51
epidemiologicalHistorical local recurrence rates for transanally excised rectal cancers were about 18%, remarkably consistent across multiple centers.↗
▶Ep 7 · 15:05
opinionTransanal endoscopic microsurgery (TEM) may produce better outcomes than traditional transanal excision, though it is unclear whether this is due to technology or improved surgical understanding.↗
▶Ep 7 · 15:05
opinionTransanal endoscopic microsurgery (TEM) may produce better outcomes than traditional transanal excision, though it is unclear whether this is due to technology or improved surgical understanding.↗
▶Ep 7 · 15:27
guidelineFor young, curable patients, radical resection is generally favored over transanal resection; transanal resection is typically reserved for patients unfit for radical surgery or those who would require permanent stoma.↗
▶Ep 7 · 15:27
guidelineFor young, curable patients, radical resection is generally favored over transanal resection; transanal resection is typically reserved for patients unfit for radical surgery or those who would require permanent stoma.↗
▶Ep 7 · 16:24
clinicalFor rectal cancer, full-thickness excision is required; ESD or EMR is never appropriate for proven cancer, only for benign polyps.↗
▶Ep 7 · 16:24
clinicalFor rectal cancer, full-thickness excision is required; ESD or EMR is never appropriate for proven cancer, only for benign polyps.↗
▶Ep 7 · 18:04
guidelineShort-course radiation (5×5 Gy over 5 days, surgery 1–2 weeks later) is commonly used in Europe; long-course chemoradiation (40–45 Gy over 6 weeks with 6–8 week wait) is standard in the US.↗
▶Ep 7 · 18:04
guidelineShort-course radiation (5×5 Gy over 5 days, surgery 1–2 weeks later) is commonly used in Europe; long-course chemoradiation (40–45 Gy over 6 weeks with 6–8 week wait) is standard in the US.↗
▶Ep 7 · 18:26
clinical25 Gy over a short period is radiotherapeutically equivalent to 40–45 Gy over a longer period, but long-course therapy may produce better tumor downstaging for bulky tumors.↗
▶Ep 7 · 18:26
clinical25 Gy over a short period is radiotherapeutically equivalent to 40–45 Gy over a longer period, but long-course therapy may produce better tumor downstaging for bulky tumors.↗
▶Ep 7 · 19:51
guidelineFor colon cancer, at least 12 lymph nodes are required for adequate staging, though many surgeons aim for at least 16.↗
▶Ep 7 · 19:51
guidelineFor colon cancer, at least 12 lymph nodes are required for adequate staging, though many surgeons aim for at least 16.↗
▶Ep 7 · 19:59
clinicalHigh ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is standard for sigmoid colectomy, with protection of autonomic nerves to preserve sexual function.↗
▶Ep 7 · 19:59
clinicalHigh ligation of the inferior mesenteric artery (above the takeoff of the left colic artery) is standard for sigmoid colectomy, with protection of autonomic nerves to preserve sexual function.↗
▶Ep 7 · 20:18
clinicalTotal mesocolic excision for colon cancer should be performed with about 5 mL of blood loss in the embryological plane between retroperitoneal peritoneum (Toldt's fascia) and mesocolic peritoneum.↗
▶Ep 7 · 20:18
clinicalTotal mesocolic excision for colon cancer should be performed with about 5 mL of blood loss in the embryological plane between retroperitoneal peritoneum (Toldt's fascia) and mesocolic peritoneum.↗
▶Ep 7 · 20:48
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (high 20s%) before focus on complete mesocolic excision technique.↗
▶Ep 7 · 20:48
epidemiologicalScandinavian data showed local recurrence rates for colon cancer were even higher than for rectal cancer (high 20s%) before focus on complete mesocolic excision technique.↗
▶Ep 7 · 23:12
clinicalFor cecal or ileocecal valve tumors, 10 cm of small bowel should be resected; for mid-ascending colon tumors, 5 cm of small bowel is adequate.↗
▶Ep 7 · 23:12
clinicalFor cecal or ileocecal valve tumors, 10 cm of small bowel should be resected; for mid-ascending colon tumors, 5 cm of small bowel is adequate.↗
▶Ep 7 · 24:00
epidemiologicalExtracorporeal stapled anastomosis for right hemicolectomy achieved a leak rate of 0.8% over 1000 cases at Cleveland Clinic.↗
▶Ep 7 · 24:00
epidemiologicalExtracorporeal stapled anastomosis for right hemicolectomy achieved a leak rate of 0.8% over 1000 cases at Cleveland Clinic.↗
▶Ep 7 · 24:56
guidelineGenetic assessment is indicated for colorectal cancer patients with Bethesda criteria risk factors, cancer under age 40, first-degree relatives with cancer, or multiple cancers in the family.↗
▶Ep 7 · 24:56
guidelineGenetic assessment is indicated for colorectal cancer patients with Bethesda criteria risk factors, cancer under age 40, first-degree relatives with cancer, or multiple cancers in the family.↗
▶Ep 7 · 25:33
clinicalGenetic diagnosis affects both family screening recommendations and surgical approach; patients with hereditary syndromes may require subtotal colectomy or proctocolectomy rather than segmental resection.↗
▶Ep 7 · 25:33
clinicalGenetic diagnosis affects both family screening recommendations and surgical approach; patients with hereditary syndromes may require subtotal colectomy or proctocolectomy rather than segmental resection.↗
