Colorectal surgeons work with gastroenterologists to provide comprehensive care to patients with inflammatory bowel disease – ulcerative colitis, Crohn’s disease and diverticulitis. These surgeons were the first in the region to open a center providing diagnosis and treatment of benign anorectal and pelvic floor disorders, located at Barnes-Jewish West County Hospital. Faculty apply basic science research to the clinical realm and offer several colorectal cancer clinical trials. In addition to general surgery resident rotations, the section offers a one-year colorectal fellowship.
Section of Colon and Rectal Surgery | 2020 Annual Report
Colon and Rectal Surgery Section Chief Matthew Mutch, MD, and surgeon Steven Hunt, MD, have introduced a new standard of care for the treatment of locally advanced rectal cancer (LARC). This new regimen utilizes total neoadjuvant therapy to reduce the length of care, improve disease-free survival and increase the chance of complete pathologic response in rectal cancer patients.
This new treatment administers five days of short course radiotherapy, delivering the same biologic dose of radiation as the current standard of treatment in the United States in a shorter time. Systemic chemotherapy is then administered pre- operatively. For patients with complete pathologic response to these therapies, nonoperative management can replace surgery if there is no residual tumor. Close surveillance ensures that, if the tumor grows back, it will be identified and treated with surgery.
The regimen is the result of an international multicenter clinical trial to study the impact of neoadjuvant therapies on disease-free survival of patients with LARC. Researchers at Washington University School of Medicine in St. Louis and Siteman Cancer Center were the only participants from North America involved in this Phase III clinical trial.
The Rectal Cancer And Pre-operative Induction Therapy Followed by Dedicated Operation (RAPIDO) Trial compared conventional treatment of rectal cancer with an experimental treatment involving more pre-operative therapy and shorter Department of Surgery overall treatment time. The results of the RAPIDO Trial were published in the Journal of Clinical Oncology in May 2020.
The RAPIDO trial is the first trial to demonstrate an improvement in a lower rate of distant metastases in high-risk LARC patients, meaning the new treatment regimen reduced the rate of disease- related treatment failure and longer survival. Colorectal surgeons at Washington University have found that systemic chemotherapy is better tolerated before surgery than after, patients receive more systemic chemotherapy when given before than after surgery, and more total patients receive systemic chemotherapy—and their rectal cancers are more likely to shrink—with total neoadjuvant therapy.
Surgeons in the section continue to participate in further clinical trials researching the impact of total neoadjuvant therapy on rectal cancer treatment.
At the School of Medicine, surgeons, radiologists and oncologists take a truly multidisciplinary approach to managing rectal cancer, ensuring the most effective diagnosis, staging and treatment.
“Patients with rectal cancer will receive multidisciplinary care every step of the way, including diagnosis, staging and treatment,” Mutch says. “We work closely with our colleagues in radiation oncology and medical oncology to ensure that patients see all of the physicians they need in a timely fashion and receive the best possible care.”
2020 Highlights
CLINICAL
Colon and rectal surgeons from the School of Medicine are addressing disparities in health care by expanding access to screening and treatment throughout the St. Louis area. The section has secured grants to provide funding for patients who cannot pay for routine colorectal cancer screening. Surgeons from the section see patients at a growing number of clinical locations. Kerri Ohman, MD, joined the section, extending care to Christian Hospital and Siteman North County. Ohman completed a Colorectal Surgery fellowship and General Surgery residency at Washington University School of Medicine. Her specialty areas include colon and rectal cancer, anal cancer, inflammatory bowel disease, ulcerative colitis and Crohn’s Disease.
RESEARCH
Colorectal cancer is the third most common cancer and cause of cancer death globally, according to the American Cancer Society. Surgical resident William Chapman Jr., MD, MPHS, is collaborating with a team of biomedical engineers, pathologists, radiation oncologists and radiologists at the School of Medicine to improve diagnostic and surveillance imaging
for colorectal cancer patients. The results of a pilot study using a real-time co-registered photoacoustic and ultrasound tomography system to image ex vivo samples indicate the potential of using this system for future cancer screening and post-treatment surveillance of the colon and rectum. Chapman continues this research in the section with in vivo imaging, and continues to obtain funding for the project.
EDUCATION
Residents are making critical contributions to research in colon and rectal surgery under the mentorship of Matthew Silviera, MD, MS. Lab resident Ebun Otegbeye, MD, is researching ways to identify patients at increased risk of postoperative complications. Using the NIH-validated PROMIS (Patient-Reported Outcomes Measurement Information System) tool, Otegeye studied patient-reported outcomes related to overall function, physical ability and gastrointestinal symptoms. These PROMIS scores provide an opportunity for physicians to intervene in the preoperative period to reduce a patient’s risk of complications by engaging the patient in physical therapy, addressing medical issues or providing other forms of prehabilitation prior to surgery.
Surgeons and researchers at Washington University School of Medicine in St. Louis are working to reduce opioid prescriptions and use following surgical procedures. Practices of opioid prescribing vary widely across general surgery providers in the United States. The Section of Colon and Rectal Surgery is participating in a number of studies to assess opioid use
and prescription practices after surgery.
A recent study led by general surgery resident Bradley Kushner, MD, in partnership with surgical oncologists, minimally invasive surgeons and colon and rectal surgeons, used a text-based platform called Epharmix to assess patients’ postdischarge opioid utilization. The study, published in Surgery, sent text messages to enrolled patients after discharge, inquiring about the number of opioid pills taken since discharge as well as pain medication refills. The study, which was funded by the Barnes-Jewish Hospital Foundation, found that all patients consumed 25% or less of their total prescribed pills.
In response to these findings, colon and rectal surgeons have decreased the number of pills they prescribe after abdominal and anorectal surgery. Reducing the prescription has not been found to have an impact on patient utilization. Surgeons did not see any significant increase in requests for refills.
Surgeons have also developed an updated patient journey guide and preoperative opioid practice education. The patient journey guide is meant to educate patients, families, staff nurses and home care nurses on proper care of a colorectal surgery patient, while the opioid practice education informs patients about safe use of prescription medication following surgery.
“We then asked how we can decrease narcotic use in the postoperative period, while the patient is still in the hospital,” Colon and Rectal Surgery Section Chief Matthew Mutch, MD, says.
Surgeons in the section collaborated with colleagues in anesthesia to utilize the pain service for ileostomy closures and laparoscopic right colectomies. By providing preoperative adjunct pain control—such as a TAP block—and not administering patient-controlled analgesia in the postoperative period, the team has minimized narcotic use for these patients while still providing pain control. The section has since expanded this practice to all laparoscopic cases.
The Section of Colon and Rectal Surgery has long been committed to patient safety initiatives, with the goal of providing up-to-the-minute care in all aspects of colon and rectal surgery.