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Head of Canada's national lab opts for 'natural orifice' surgery for cancer

10/15/2012 10:58 EDT | Updated 12/15/2012 05:12 EST
TORONTO - Earlier this year, Dr. Frank Plummer found out he had cancer.

Plummer is the scientific director of Canada's National Microbiology Laboratory. His is a busy job which has him shuttling several times a month between Winnipeg, where the lab is located, and Ottawa, home of the Public Health Agency of Canada. As he puts it, his suitcase is rarely unpacked.

After experiencing some gastro-intestinal symptoms for about six months, Plummer went in for a diagnostic colonoscopy in March.

It was the first colonoscopy Plummer, 59, had ever undergone and it revealed he had a villous adenoma — a large polyp — in his rectum. During the procedure, the polyp was removed and sent to a pathology laboratory that looks for cancer in growths and tissues cut from the body. The results of that testing showed Plummer's polyp contained cancerous cells.

Though the growth had been removed, Plummer was told the chances were good that the area around the base of the polyp might also harbour cancer cells.

"They couldn't really tell from the pathology whether there'd actually been any invasion of the muscle and the colon itself," he said in a recent interview.

Plummer's medical team had several case conferences to map out how to proceed. He wasn't keen to undergo the procedure that traditionally would have been done to explore whether the cancer had spread. It would have involved accessing the rectum via a major incision across the abdomen. That is major surgery and would have meant weeks of recovery time.

He didn't like the idea of the down time, but Plummer had even more concern about another possible outcome of the surgery. It might have required his surgeon to resection the bowel — cut out a piece of the tube-like organ. As a result, he might have needed a colostomy, an opening in the abdominal wall through which stool drains into a bag.

Not so long ago, Plummer's other option would have been to elect to wait — have doctors monitor him for signs of spread and only deal with the situation if the need arose. That's the way he was leaning.

"I think if they had said, 'Well, you need to have it out and we're going to cut you open and you may end up with a colostomy,' I might not have done it. I would have just had them monitor it carefully," he admits.

But then another option was put on the table. Plummer was informed he could elect to have a surgical procedure that uses an existing opening in the body — the anus — as the entry point.

"I was astounded when I heard about it," Plummer admits.

And so on Aug. 28, Plummer had the procedure performed at Victoria General Hospital in Winnipeg. His surgeon, Dr. David Hochman, used a endoscope equipped with a camera to locate the polyp scar on the rectal wall, then punched out a seven-centimetre piece of tissue from the area.

Plummer was released from hospital the next day and two weeks later, he was back at work. The pathology report showed the tissue was clean — no signs of cancerous cells.

He doesn't need follow-up chemotherapy or radiation, though he will be closely monitored for the next few years.

Hochman, his surgeon, spoke about Plummer's case with the scientist's permission. He says that while this surgical approach isn't right for everyone, it was a good option for Plummer.

"We prevented a big operation for him," says Hochman, who is one of a small but growing number of surgeons in Canada using this approach, called transanal endoscopic micro-surgery, which goes by the acronyms TEM or TEMS.

"This is really one of those rare situations in surgery where we really have a better mousetrap than what we had before."

The procedure Plummer avoided by opting for the transanal surgery would have required a seven-to-10 day hospital stay and a month off work. It also would have involved a lot of pain.

"We've done a strategic strike in a sense," Hochman says.

"We've taken that scar where we know the polyp was, we took a margin around that entire scar, we cut deep into the rectum and the fat around the rectum, making sure if there are already roots we get underneath them, and what we were able to give the pathologist is this beautiful disk of tissue which included the rectal wall, the rectal muscle and the peri-rectal fat and they can look at any way they wanted to."

The camera in the endoscope projects images of the field of surgery onto high definition TV screens in Hochman's Victoria General operating room. Hochman, who has done more than 100 such surgeries, says the learning curve is steep. Operating in such a confined area requires good laproscopic surgery skills.

The procedure is far less invasive for a patient, he says. While the rectum does register the sensation of stretch, it doesn't have pain sensors, he notes.

"What that means is by going through the rectum and operating within the rectum . . . the body really doesn't even know you were there," Hochman says.

"They wake up. They have real lunch or real dinner and they can go home."

Less time in hospital lowers the cost of the care, and the risk the patient will pick up a hospital-acquired infection. In fact, the risk of infection overall with this approach is lower than when rectal surgery is performed via the abdomen.

"Remarkably, in spite of the fact that when we think about the rectum we think about stool, we think about tons and billions of bacteria, this part of the body is designed to handle that," Hochman says.

While Plummer is thrilled by the outcome of his surgery and his surgeon is enthused about the possibilities of this approach, it is important to note this surgery is not for everyone.

Plummer's cancer was at an early stage — the T1 stage. If it had been more advanced and the risk of spread to the lymph nodes had been greater, this would not have been the right approach, experts say.

"For early-stage cancers, if you can get negative margins and pull the whole polyp out, it's a reasonable procedure to do, but it's not applicable to every polyp that has cancer in it," says Dr. Barry Feig, chief of the sarcoma surgery section in the department of surgical oncology at the University of Texas's M.D. Anderson Cancer Center in Houston.

"There are other pathological features that need to be looked at in that polyp to determine whether it's appropriate to do a minimally invasive procedure or not."

The limitations don't simply relate to the stage of a patient's cancer. The scope used is large in diameter and cannot be accommodated by all patients.

"There's no delicate way to put it, but that's the fact. It's big," Feig says. "One size does not fit all."

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