E143 Masterclass with Antonio Caycedo-Marulanda on Transanal Excision of Rectal Lesions
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Chad Ball 00:06
Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball.
Ameer Farooq 00:26
This week we're absolutely delighted to have Dr. Antonio Caycedo-Marulanda join us in the podcast. Dr. Caycedo is a colorectal surgeon and another contender for the title of the most interesting man in the world. We talked to him about his fascinating life journey, as well as had a masterclass with him on the most common dinnertime conversation topic: transanal surgery. Stay tuned until the end of the video, where Dr. Caycedo shows us some clips of his own operations and shares his tips and tricks. If you liked the podcast, give us a review on iTunes and subscribe to us on our YouTube channel @coldsteelsurgery. Thank you so much for joining us in the Cold Steel podcast. It's an absolute pleasure to have you on the show as a true innovator and as someone who's just had an absolutely fascinating life journey. Tell us a little bit about where you grew up, and where you did your training.
Antonio Caycedo-Marulanda 01:19
Okay, well, first of all, thank you for having me and for inviting me to do this. I'm originally from Colombia, and I did my med school — I'm from a very small town here in Colombia. I went to Bogotá, did my high school there, then I went to do my med school. In Colombia, you go straight from high school to university, so I finished medicine at age 23. Subsequently, I did a compulsory social service, which is for 1 year, then went to do a residency for 4 years. I was able to work for about 18–20 months here. At that point, my wife and I had decided to immigrate to Canada. I wasn't really sure if that was feasible or not. Fortunately, things worked out well, and in 2004, I went to Canada. I landed in Montreal and started doing all the exams, the MCC and all that and after two-and-a-half years, I started residency again in Ottawa. Instead of doing the 5 years that typically residents, as an IMG and having had previous training, I started as a second-year resident, but I at the end was promoted. So I did 3 years before I did my protocol, and half my certification. After that, I went to London and Thailand to do a clinical fellowship. And that was only 1 year in London.
Chad Ball 03:02
That's a fascinating voyage. Now, you ended up in Sudbury next, and I'm curious — you know, we're going to talk a little bit about a real masterclass here that we're so thrilled to have you walk us through — but before we do that, you know, 1 of the things you're going to talk about, obviously, is the complexity and the volume and the density of the content and the technical requirement in the surgery that you were doing. How did you start that in Sudbury as a smaller centre? How was your support? How did your colleagues look at that? What were some of the challenges? Can you walk us through that genesis and that experience?
Antonio Caycedo-Marulanda 03:42
Yeah. So this is a, you know, a bunch of different steps that happen. So I'll go back a little bit. As an IMG, you have to do return of service. That's 5 years. The expectation of the government is you're going to remain in a place forever, because statistically, after 5 years in a place, you don't leave. And usually those are under-serviced areas in which there are some limitations in terms of resources in terms of the things that you can do. I started looking at where to go. Every other place was significantly small, but Sudbury was large enough, with regional hospitals and tertiary hospitals that have a large area of influence, but it was pretty much just general surgery, pure general surgery. So I started looking at that, and I remember at that time, people in London saying — what other people are saying to me — "Why are you going to go to Sudbury? There is nothing." And the interesting thing is every person that I asked, "Have you ever been to Sudbury?," none of them had been to Sudbury. So they had a preconceived idea about this place. I went there, the hospital was great. It was pretty large. The catchment area was over 600 000 patients. And there was no colorectal service at all. Nothing. When I did my residency in Ottawa, I had significant challenges, because I came to this country and I didn't know how to speak any English at all. So it was kind of like learning on the street when I did the exams. I didn't know how to read any English, I didn't know actually anything, so I had to pretty much use a textbook and a dictionary. So I was reading about 4 pages a day, and I'm talking about 12 hours a day, doing this with a dictionary and the textbook, reading like this, and it was just taking, you know, a lot of time when I did my first exam, and it worked. So I was ecstatic that, you know, things worked out that well. So I kind of, like, applied the same strategy for the second exam, and it worked. When I did the third one, the [inaudible] part 2, that was oral. The first attempt, I failed, but I knew exactly what happened; I understood. So I quickly registered for the second time, and it went well. Then I did the exam for the IMG. That was cool at that point — IMG Ontario — and IMG Ontario had about 500 applicants for 5 spots. At the end, they granted 3; 1 in Ottawa, 2 internal. So that was incredibly challenging to accomplish. I was not, I was not afraid of difficulties. I was very familiar with adversity. So, going to Sudbury and finding a place in which, the chief of surgery at that point joined us out here, and he was very generous to say, you can develop these in any way we want. And the 1 thing that I said very clearly is, I don't want to do hernias, I don't want to do breasts, I don't want — like, listen, if I'm here, I'm just going to do colorectal surgery. He said, "Yeah. Definitely. Do it." Most surgeons are opposed to that patient. And most senior surgeons that were there — you know, we've been doing this thing forever. So you come in here, you have an accent, you're not Canadian. Why — and you're younger than us — Why are you going to tell us what to do? So it was a constant, I wouldn't say fight, but there was always resistance. And people were, like, opposing you. In Sudbury, there was never a colorectal service. So patients, if they wanted or they needed something really specialized, they had to go to Toronto or Ottawa, depending on where they wanted to go. By pretty much is going to meet these surgeons, meet people, to travel to their communities, to start talking and start looking for new opportunities, bringing MIS, laparoscopic things, saying, you know what, like, let's decrease the rate of permanent colostomy that was close to 40%, 50%; being able to bring it down to under 10%. And people started noticing that and even the surgeons, and slowly they started to turn around and they said, okay, well, maybe we should, you know, give the rectal cancer patients to you and I started having those conversations with them. There was significant, significant challenge and resistance from many different sectors. But when people started seeing, kind of, like, good results, and the support was definitely having a chief of surgery that was very open-minded to allow these things to happen.
Ameer Farooq 08:54
I mean, it's worth saying that you were doing, you know, not just laparoscopic colorectal surgery, but you were really doing taTME, which I think it's very defensible to say it's one of the most complex operations that anyone could do in colorectal surgery; just the approach, the anatomy. How did you work that as a person, you know, without — and you know, I don't, correct me if I'm wrong, but I don't think you had another person with you in Sudbury who was doing taTME, so you really didn't have support per se or someone else that you could say, hey, what do you think is going on here? Because they wouldn't really know. So how did you approach that? Sort of, being a single surgeon approaching a complex case like that, how did you institute something like that and how did you approach those kinds of cases?
Antonio Caycedo-Marulanda 09:52
So in 2012 — I got surgery in 2011, and early, I wanted to do [inaudible]. I was familiar with [inaudible], but the cost of the machine was $100 000 capital. So as much as the hospital was very supportive, and John Schneider was very supportive, I knew they were not going to buy this machine for me. So I started doing some research, and I found that there was a [inaudible] from [inaudible], but there was no [inaudible] in Canada, so I located the vendor to [inaudible] Medical, and it was a company, different company here in Canada. So I approach this person and I said, you know what, we have this platform, but nobody that we have approached wants to use it. Like, we went to X number of different colorectal surgeons, but people don't want to use it. You know what? I want to use it, and I said I want to do it shortly. Okay, so they organized for me to go to Seattle. I met [Elizabeth] McLemore, and I did a course with her. At that point, I remember, they have particularly angulated instruments for the course. And they said no, I don't want to use angulated instrument, because where I am, they will not have those instruments. So I wanted to work with straight instruments. So in 2012, I came back to surgery, and our first patient is there. I remember doing that case; it took about 3 hours to do. I used a harmonic — the only time that I had used a harmonic for [inaudible], but I started doing it, and kind of, like, introduced [inaudible] for the first time ever in Canada. So we started doing it, I accumulated significant experience, and then the obvious next step was to move into taTME. So I went to Barcelona with Antonio Lacy and I did their course. They were very — at that point, there was a big high on taTME — probably the beginning of that high was taTME. So I went for the course, and I was very excited to do it. I was very familiar already with the platform. But this was probably May, June, when I went to Barcelona. So come back, came back, waiting for the correct case to do it. [I] didn't dare to do any cases, and then I remember this person had a T2 tumour, straight to surgery, no chemo [inaudible], no anything. So they measure this tumour at about 14 centimeters and repeated the scope. And yeah, this is an opera tour. Let's do it. So I did this laparoscopically. Everything went really good. The patient stayed a couple of days at the hospital. And a few days after, not even a week, I was walking by the hole and the pathologist told me, hey, Antonio, by the way, that case, just wanted to let you know, had complete response. There is nothing in this person. And I keep walking, "Thank you" and "Oh, that's great." And immediately I realized, well, this patient never had chemo [inaudible]. The tumour is still there. So, you know, it's — you get into like a panic mode at that point. What do I do? I call the patient, I said, listen, I need you to come back. It was an [inaudible] rectal cancer, 14 centimeters. So I was entirely convinced that I had resected this. The patient came back on a Friday, I [was] scoping and, indeed, the tumour was still there. So what do I do? I admitted a patient and I said we're going to do a taTME tomorrow — that was a Saturday — the patient came in, you set up [inaudible] for — all the upper resection had been already done, because I did that on Monday. I put my platform, with my suture, boom, boom, boom, disconnect the [inaudible]. First taTME that I did. Reconnected, the guy did great; he was very understanding of the situation. You know, it was something that I was forced to do this first taTME. And at that point, I became kind of, like, confident — okay, now we can start doing it. That was the first case. It took about a month to do analysis, starting to pick up lots of volume. You know, at some point I was doing probably about 80 rectal cancers a year, [inaudible] dedicated to rectal cancer surgeries. So I started [inaudible] days and what I did is I had a nurse that was very motivated. So I involved her in [inaudible]. She went with me to the conference. I took her always to like, you know, the training places, to everything. And she was there, I would say, in 95% of the cases. She was at the top and then she was at the bottom with me; like, she was always doing the camera with me. And there was a retired surgeon, Raymond Gay, who was almost always my assistant. So the 3 of us were almost always in the room, and we created a system in which, you know, at the end, I think we did over 250 taTME cases in Sudbury with this, still.
Chad Ball 15:11
That's an amazing story. And, you know, of course that volume is incredible just to consider given the complexity and the underlying epidemiology of that disease. I'm curious, you're in Sudbury, you know, this is going, it sounds like, very well, you've created this program, and then you were recruited to Queens and ended up there and then subsequently to Orlando. So I guess first of all, congratulations. How is your experience? Yeah, it's wonderful. How is your experience in the US been so far for you? What's your vision for that program, and where do you want to go with it?
Antonio Caycedo-Marulanda 15:48
Well, definitely it is different than in Canada, you know. And I can tell you, the Canadian health care system, despite what many people say and criticize is wonderful. It's wonderful, the fact that, you know, anyone can have access to these, and in the US there is always the challenge of the insurance company and what's going. I think very importantly about what the organization I am at is offering me, and it's pretty much to build a program from, I wouldn't say from scratch, but [inaudible] didn't really have its own colorectal service. The [inaudible] of being in Kingston, to me, was fantastic. It was a great experience, and all the colleagues that I had there, [inaudible] Patel and [inaudible]. And then, I think I was very lucky because they came with this taTME experience, but then I landed in Kingston, where, [as] you know, Ameer, the volume of robotic surgery is higher than anywhere else in the country. So I was able to then accumulate taTME, robotic surgery, laparoscopic surgery, which all together will be a pretty unique set of skills. So the plan now is to bring that, kind of, like, expertise, and also bring the expertise of having developed the colorectal surgeries in Sudbury from scratch, and take this one forward. What is my goal? Well, I'll tell you I never planned that I will be here; I didn't even — like, this is not even in the wildest of my dreams, I would have thought that I was going to be recruited to Orlando, I'd say not even in the wildest of my dreams I thought I was going go to Queen's, at any point. You know, at some point I wanted to do more than what I was doing in Sudbury, but surgery was great for me. I'm very grateful to everything that happened there, the opportunity that was given, that planned opportunity to say, you know, do whatever you want. So now my ambition with this program is, if I told you I want to get [inaudible], make this top world-class program, I will be — like, that's what I'm looking to do. And then, you know, bring things from a different perspective. There is a lot of things that are done, for instance, in the US that are based on seniority. I don't think that's the right way to do it. I think this should be based on people that are capable and people that are willing to do things — not because of seniority. So the same way that, you know, I found opportunities for me without having that seniority or without having that Canadian experience, and they were granted to me somehow, I want to be able to create something, because I think that's a very successful method; to find talent, to find, you know, great people and then, definitely, I want this run by people that I think are better than me so they can, you know, help me elevate this thing.
Ameer Farooq 18:49
I want to dive a little bit deep with you and do a little masterclass, here, on transanal surgery, for obvious reasons. We're going to confine our discussion, if that's okay for you, Dr. Caycedo, to talking about just TAMIS or TEM — so, excision of rectal polyps or early rectal cancers, from a transanal approach. And just, again, to define some of these terms, so, TAMIS is Transanal Minimally Invasive Surgery, and as Dr. Caycedo has said, that's a flexible platform that you can put in the anus and then put some trocars through, and you use traditional laparoscopic instruments to actually do the operation; whereas, a TEM is a Transanal Endoscopic Microsurgery — that's a more traditional platform where they use a rigid platform that we stick in the anus, and then use the angled instruments that you were talking about before to do this procedure. I think most places, now, in the world, probably, are actually — have moved towards using a TAMIS platform because, as you said, it's much cheaper and more flexible than a TEM platform. But I think many places across Canada, still, at least where I've trained, they're still using TEM because that was what people, kind of, started off with. So, let's say, Dr. Caycedo, you get a patient who is sent to you with a large rectal polyp or a rectal lesion. What are the things that you look at when you're assessing that lesion that make you think about whether this would be amenable or even appropriate to consider a transanal incision?
Antonio Caycedo-Marulanda 20:34
Sure. Well, definitely that will be that I believe, based on the evidence, that this is an early lesion. That is not an ulcerated, clearly fungating cancer that will be within the reach of the platform. That doesn't appear to be fixed [inaudible]. If, you know, you think it's a polyp or it's an early lesion, then obviously, you have to do the staging. Sometimes, you know, we will do the MRI — I think all the times we will do the MRI if we think there's a malignancy. If it has the appearance of being a polyp, probably the MRI will not be necessary, but I always do [inaudible], and I learned how to do [inaudible] myself, because it's very subjective, the endorectal [inaudible]. And one of the challenges with MRI, you probably know that already, is defined in between T1 and T2. The MRI has difficulties doing that. So the TAMIS — sorry, the indirect [inaudible] gives you that opportunity. Then, when I assess the patient, I always want to know what is the location inside the rectum; you know, if it is posterior, if it is lateral, if it is anterior. And the reason why I want to do this is, one, I want to move the [inaudible]. And second, I want to know what are the chances of me getting into the peritoneal cavity when I do engage? With the TAMIS platform that you train on there in Vancouver — and we actually did a study in which we pretty much compared the two with Canadian [inaudible] data. The two are definitely — there is no major differences. We're using either or. It all depends on what the resources and the ability of your hospital to have. And anyways, I want to know these type of things. One, it is clear to me where it is located, that it has these features. I decide, you know, I think it's amenable to TAMIS. In some centres, you know, they could have endoscopies that is a skillful, and I would say, you know, let's do an [inaudible] ESC endoscopy submucosal dissection, endoscopic [inaudible] resection, but in my hands, lesions like these, we'll go for TAMIS. Now, if you look at the textbook, they will say the definition is 3 centimeters, less than 30% of the circumference, that are below the peritoneal [inaudible], as you go, and I tell you, you can bend those rules. And you know, depending on how much expertise you accumulate, you could do more complex cases, which is the natural trend for any operation. So I've done things that are full circumference, that are definitely above the critical [inaudible] reflection that you get into the peritoneal cavity. So it all depends on what the indications you get to develop in your centre and what access you have. In Kingston, for instance, you have Rob Bashara, who is incredibly skilled with endoscopy; he's like a magician. And with him, we had established some sort of [inaudible] or informal tumour board for that. And we will get together and say, "What do you think?," and decide, let's do it for [inaudible] where this patient should go to you and do [inaudible].
Ameer Farooq 23:58
I think that's a really important point. I think it is worth reiterating what you said, that if you are at all concerned that this is a rectal cancer, or even an early rectal cancer, it's important that that whole lesion comes out in 1 piece and that it's full thickness, because that might actually be, like, their definitive surgery, right? And that might actually save them a radical resection but, you know, if it's piecemeal, or you're not sure about the margins, that's where, you know, the real problems can be. So I think that, like you talked about, having that really good relationship with your GI, colleagues can be so helpful, and having had these kinds of discussions beforehand so that, you know, there's an agreement or an understanding that, you know, if there's a big rectal lesion that would be perhaps better resected surgically through a transanal approach, that they kind of know about that and will, you know, not inadvertently, kind of, hoop the patient into ultimately needing a radical resection.
Antonio Caycedo-Marulanda 25:03
If I can add 1 thing to that. I I think that's a very, very important point. One is I always tell patients [inaudible] local resection, this is the ultimate biopsy. So you know, we're going to remove this, and this could be your definitive resection, or this could indicate [to] us that we are going to need to do more. So they need to understand that. And when we say full thickness, it's full thickness of the muscularis propria, but not full thickness of the mesorectal fat, and the reason is, if this person needs more surgery, you don't want to violate that plane. I think that should be really understood for people that do these.
Ameer Farooq 25:47
Talk to me a little bit about the height again, you know, because I think that's a really difficult thing for people to figure out, right? And, you know, talking specifically about the TAMIS, you know, the gel foam kind of platform, how high can you get with that? And are there any, kind of, tips and tricks if it's a, sort of, a higher rectal cancer? Is it — do you use a, sort of, a measurement, like, "Oh, above 12 centimeters; I won't do this"? Or is it more of a subjective thing as to, you know, how straight is the rectum, where is it with respect to the rectal [inaudible] body habitus? How do you make that decision?
Antonio Caycedo-Marulanda 26:23
Well, to me, it's very, very subjective thing; that I always want to scope the spaces myself and I want to know where they are, like, I want to know exactly, you know, if they are anterior, posterior. I don't ever, ever do a TAMIS without [inaudible]. If you have a TAMIS platform that is about 15 centimeters' length that you can, you know, get all the way here, it doesn't really matter. But the TAMIS platform is 4 centimeters in diameter and 4.5 centimeters in length, so the reach that you can get is very limited. The maximum that I got in to do something was 20 centimeters, but it was the right patient in which direction was kind of, like, straight and he was not really a candidate for anything else because of his other comorbidities. No, but I will say, you know, pretty much, 12 centimeters will be the ideal, because there is always going to be the [inaudible] and the curves and things like that will limit it. And I remember what I wanted to say: In my opinion, conventional transanal surgery [inaudible] should be of historical value. And there are people that are correct, you're different, but there is a lot less fragmentation, there is better exposure, you're serving that patient better. When you're doing this conventional transanal surgery, you are fighting with the light in a hole and you're struggling, and no matter how good you are, you are operating in a tiny hole in which you can only, you are the only person who can really see and say, oh, yeah, it was a good resection. [inaudible] become fragmented and with more likelihood of positive margins. Now, 1 thing that is important is to know, going to your original question, if it isn't [inaudible], and you think that you are going to violate into the peritoneal cavity, I always place these patients prone. If not, I lay them in [inaudible]. It doesn't really matter what it is. [inaudible] with the TAMIS platform, I initially was always putting my lesion at 6 o'clock. So I will [inaudible] the patient [inaudible] on the [inaudible], depending on that, then as I gain experience, I realized you don't really need to change. You could do it in either position. But if the lesion isn't [inaudible], and I think that I'm going to violate that, I get the patient prone, and the reason for that is when I'm going to close that [inaudible], I don't have the small bowel coming into view.
Ameer Farooq 29:00
Yeah. I think that's so critical because you only have to see it once, where you're in the peritoneal cavity and everything's flopping on into your face. To [inaudible] I would agree. So, let's move a little bit into the, sort of, some of the more technical details. We've sort of already touched on this a little bit, but you know, you, let's say you have the person that you think, either this is a early rectal cancer or this is just an advanced polyp. And you know, you've done your indirect ultrasound, you don't think that this is a T2 cancer, you're bringing this patient to the operating room. Do you do a bowel prep? Is that something that you do, just an enema?
Antonio Caycedo-Marulanda 29:42
No. For all TAMIS, all localizations — both. TaTME or TAMIS, I will do a full prep. I was [inaudible] before it was, you know, you were doing the cameras and it was [inaudible] and then all of a sudden you get a gush of stool, and then, you know, it messes up everything with the TAMIS. It's very challenging, because if it comes into the insufflation and suction device, it damages it. So I always give them a full bowel prep — always.
Ameer Farooq 30:11
And you talked a little bit about position, but, you know, I think as you got more experienced, it was reasonable for you to just, kind of, put the patient or the lesion in any position. But for people starting out early, do you still recommend that people have the legion, kind of, sitting at 6 o'clock, and put the patient in positioning for that? Or do you think it doesn't really matter?
Antonio Caycedo-Marulanda 30:35
I would say it depends on how you learn to do these and how you train. Like, you know, if you're a fellow and you are in a program in which they're teaching you [that] you could do these at any position, and you learn to do it that way, why wouldn't you do it that way when you get into your practice? So I think it all depends what you learned, and how did you learn to do this. Now, if you are already in practice in a place, and you want to do this just because you say, well, it's kind of, like, nice and sexy, I would not recommend it, because this requires volume, like everything else. You know, there has always been this discussion about rectal cancer, and I don't think local lesions are different than that. They need to go to a place where there is volume, where there is expertise. And going back to my original story about how I started this journey, I was lucky enough to be in a place in which volume was almost a guarantee; it was just a matter of concentrating that volume and preventing the leak of those patients. But you know, doing this, I think definitely requires volume and consistency.
Ameer Farooq 31:44
So, you have a patient in position. How do you actually set up your TAMIS platform? Are you putting in a [inaudible] star? What are some tricks that you can actually get things if faced enough that you can get the whole platform in, it doesn't move and you kind of have the maximum reach?
Antonio Caycedo-Marulanda 32:03
Yeah, actually, the TAMIS platform, as I said is 4.5 centimeters in length, so it has some [inaudible] for you to put it. If you're doing this for a female patient that had a very short anal canal, it's pretty easy to [inaudible]. And what I do before I put them on the start is I always, always put the stitches at the 4 corners to try to face the anal canal. So I put a [inaudible] with a [inaudible] with a big needle. Taking the anal verge and anal margin, and then perineal skin. [inaudible] to accordion the skin. That, in most cases, is enough for you to bend your [inaudible] and introduce it into the anal canal. Then, if you are — because you could imagine how this will be on an obese male with very big cheeks; it will be very challenging to put that. So I put those stitches, and if I still see, or I know in advance, I know in advance because I know about [inaudible] of the patient, and I will put the [inaudible]. Otherwise you'll be struggling, it will be pretty much impossible to set up that platform in there.
Ameer Farooq 33:10
You've talked to me before a little bit about how you actually introduced the TAMIS platform itself, in terms of bending it or — remind me again about how you actually would put the platform in.
Antonio Caycedo-Marulanda 33:25
Yeah, so you know, you take the circumference and you bend it. You create, kind of, like a [inaudible] without [inaudible]. You grasp that. So you decrease the [inaudible] that, then you insert, and you've got to make sure the rim, the upper rim, is above the [inaudible]. It gets stick there, and that's how you know for sure. Sometimes you put it in there and it has to have a perfect circle, and when it doesn't, sometimes it's when do you use that [inaudible]? That's the time when I use that [inaudible]. If you're going to try to put this platform straight with this [inaudible], you're going to pretty much like hurt these patients, rip tissues, damage the anal canal.
Ameer Farooq 34:11
Yeah. On our YouTube video, I'll put a picture of the platform so people can kind of know what we're talking about with respect to the [inaudible], etc.
Antonio Caycedo-Marulanda 34:19
I can also send you maybe a couple of pictures of those [inaudible] that I'm talking about in the quadrants and see how it made sense to face the anal canal with those, because it opens up the anal canal.
Ameer Farooq 34:30
Absolutely. And is there anything special about — so, for people who haven't seen this, this is, you know, there's sort of a gel [inaudible] port on one side of this TAMIS platform that you actually put the instruments into this gel [inaudible] port. It's kind of like, people have also seen the hand assist ports. It's a similar kind of setup where you can, where you can actually put the instruments in the ports right through that gel [inaudible] kind of membrane. Is there anything special in terms of the way that you actually put those ports in? Or is it just a standard kind of triangular formation?
Antonio Caycedo-Marulanda 35:12
Well, I, I have my standard, which is, you know, to try to put the 3 ports as far from one another. I put 2 at the top and 1 at the bottom. I put my left hand at the bottom, my right hand on the upper corner, and then the camera comes in the left top [inaudible]. The insufflation device that I use is the air seal, or something that is barbless that prevents the quivering of the rectum. Or you could have, now with this platform, there is a reservoir that creates that. So every person I think, will create his own method. For me to say, oh, no, you always have to do it this way, I think it will be wrong. It's just whatever really works for you. For me, what works is, I used to have this triangular configuration.
Ameer Farooq 36:09
You mentioned that, for instance, in terms of your instruments, you tend not to use an energy device like the harmonic [inaudible]. What's the reason for that? And what kind of instruments do you typically use?
Antonio Caycedo-Marulanda 36:22
Yeah, I didn't use any energy device, because I don't think you need it at all. It's not necessary. As I said, you know, the first time I did these, 3 hours and I used an energy device. You could use it just with regular [inaudible] or [inaudible]. And when you see a vessel, sometimes you will encountery, like, vessels that are enlarged, you could use a hot [inaudible] to do that. And the first thing is to demarcate your lesion. Before you do anything, you see where it is, and you demarcate it, you know, you put little burning spots to make sure you go there. If you don't do that, you're going to get lost. It doesn't matter how small the lesion is, you definitely are going to get lost.
Ameer Farooq 37:05
Right. And then when you go about resecting these, what's your approach? Do you typically — you know, marking out your margins, you typically go, sort of, proximal on the lesion and kind of work your way back. Do you start distally, try to raise it, or work on the sides and then come underneath it, or does it really depend? What's your, sort of, typical approach for most lesions?
Antonio Caycedo-Marulanda 37:29
So it's pretty much a combination of everything you said — you've got to be frugal. I would like to, if I can, come from [inaudible], but it's not always possible; formulations are too bulky or they're behind a [inaudible] or something like that. That's what I think is very important to demarcate a lesion in advance. So you do what, you know, what is feasible, what is possible. There are even situations in which I will say use a hybrid approach. If the lesion is very, very distant, you kind of, like, have to start open like it's a conventional transanal. You start, you know, opening your plane very distal, you lift that part of the lesion [inaudible] the wall, and after, you introduce your pattern and you continue that way. So it's almost, like, whatever works. Sometimes you start proximal, sometimes you start distal, sometimes you start open.
Ameer Farooq 38:30
Right. And what are you aiming for in terms of thickness? I think you alluded to this before. Do you always try to go full thickness for these? Or do you ever go submucosal? Do you ever inject submucosally to try to raise that?
Antonio Caycedo-Marulanda 38:47
You know, that's a great question. I do not typically will raise, I will try to go full thickness. You kind of, like, have an idea that this is not malignant, that this is just a polyp. But many times you don't know. So full thickness of the [inaudible]. Could you do kind of like an ESD just [inaudible]? Sure you can. But my preference is to go full thickness.
Ameer Farooq 39:23
And then, the perennial question about the defect. So, once you have this lesion out, you've removed it, what do you do with the defects? Are you closing these defects? Are you selectively closing them? Talk to me a little bit about that.
Antonio Caycedo-Marulanda 39:38
So, your teacher and your teachers in Vancouver — and you probably were part of that publication, Carl Brown and their group — they clearly demonstrated to us that there is really no difference. In my experience, the difference is, the ones that you don't close have a little bit of a greater tendency to bleed. I try to close all of them, and the reason is they heal faster, but also it's good practice for those lesions that are into the peritoneal cavity. Because when you see that in 2 different peritoneal cavities, you get the chills, but you need to be prepared to close that defect no matter what. So having this experience, when you don't have instruments that are angulated — when you don't have an angle, you are pretty much working in a parallel fashion. So you need to be able to close this — time is very [inaudible]. So I use some sort of a barbed suture that prevents you from having to tie. In the past, I used to play some clips [inaudible] made of Vicryl, but [inaudible] is very challenging. Installation is very, is something that, you know, closing it will narrow the lumen, then those defects I will leave open when they're too extensive to do. And I always recommend that, you know, always close in a horizontal fashion, never in a vertical fashion because that will narrow the lumen, and that's definitely something you don't want to happen.
Ameer Farooq 41:22
So let's talk for a brief second about that scary situation, when you clearly can see, oh boy, I'm in the peritoneal cavity and your sphincter is tight. Looking at the small bowel flopping into view, are there any tips and tricks for trying to close that type of defect when you're clearly into the peritoneal cavity and you know that you have to have that closed?
Antonio Caycedo-Marulanda 41:48
So in most instances, it shouldn't come as a surprise. You should know in advance that you're likely to get into a peritoneal cavity based on location. And that's why those patients, you most likely will have in a prone position, knowing that this will happen. Then, depending on the extent, you know, you will say, I will divide this differently. So I typically try to start with the most difficult corner. I try to define which one is most difficult to get on, and see if I can put it there. If I cannot put it — because if I am going to start with the most difficult corner, let's say the right upper, then I can put traction, and then bring it into view. By assigning to the easiest corner, sometimes seeing that one when the defect is closed, in my experience, is more challenging. Or sometimes what I've learned in the past is also, try to find the middle of the defect and start there, and put my first stitch there, close it and divide and then do the left side on the right side of that defect. It's viable. Sometimes it's not as massive, but it's always going to be larger than you think. You have these lesions and you say, oh, it's 2 centimeters, and then when you see the difference, it's always a lot [inaudible].
Ameer Farooq 43:06
That's fantastic. On a side note or, you know, I think 1 thing that we don't often think about is how we send those specimens, and for the pathologist. Do you do anything special in terms of pinning out the lesion, just to make sure that those margins that you've so carefully established at the beginning of the case aren't defaced or they don't, kind of, shrivel up when they are put in formalin? Do you pin those out or mark those out? What do you do with the specimen?
Antonio Caycedo-Marulanda 43:39
I always hit it on a piece of cork and different methods depending on [inaudible] you are. Before I used to use that little foam — you know, when the nurses discard needles. And I sutured to that there in Kingston, I was only using the pins on the piece of cork. But you want to do that otherwise, your margins, when it is in formalin, are going to shrink, and your pathologist is going to have a very hard time defining the margins.
Ameer Farooq 44:14
Dr. Caycedo, when you have this lesion back from the pathologist, and they say, "That was wonderful job, Antonio. The margins are all negative. But in fact there is a [inaudible] of an invasive cancer in this specimen." How do you approach that classic malignant polyp in the rectum? What are the things that are — the factors that you're looking at that would make you think, hmm, maybe this patient needs something more in terms of [inaudible] surgery?
Antonio Caycedo-Marulanda 44:46
Sure. Well, if it is a T1 lesion, you know, you're more likely or happy and convinced that you did sufficient treatment for the patient. As I said before, I always tell patients, you know, this is the ultimate biopsy. If it is more than a T1 lesion and a T2 or, like, any concerning features, I bring up the patient and say, you know, we got to do more for you. There are occasions in which, you know, you go knowing that this is a more advanced lesion, a T2 and T3 lesion, but the patient is not a candidate for anything. And so you want to do some sort of local debunking. But you know, anything that is more than a T1 lesion, you want to offer something more radical. Initially, studies suggested that a T1 lesion will have a risk of about 10% of having positive lymph nodes. We know now, more, that that risk is significantly less than that. But I always talk to patients, you know, they are people that are 40 years old, you find that the polyp was a malignancy, and it all depends on the level of comfort they have. You know, there's a small chance that you might have positive disease, and the patient might tell you, you know, I cannot bear the thought of having a single cancer cell in my body, let's go for something radical. And you tell them, it's very possible that [inaudible] will be fine. But [inaudible], as long as you understand the functional changes, you're going to have to ensure you go for that. I think if it's a 70-year-old guy or person that has this very early lesion, you most likely encounter patients that are very comfortable and say, I don't want to give them a second [inaudible]; leave me alone. They don't want to go for it.
Ameer Farooq 46:37
What are the high-risk features that you look for on the pathology report that you care about for T1 cancers? Are there any high-risk features that you care about?
Antonio Caycedo-Marulanda 46:46
Yeah. You know, I will say microvascular invasion, the MBI is 1 of those things that I think are critical for differentiation; it's a bad thing. You could also argue, depending on what your pathologist is going to tell you and how deep this is into the submucosa. And you know, it can get a little bit more complex into defining the depth of the significance as S1, S2 and S3, combined with 2 different aggressive features of [inaudible] differentiation. The MBI linked vascular invasion, in which you could say, you know, the biology of the lesion is more aggressive, so probably having something a little bit more radical will be necessary. Now, you can recall the CO.28 [trial] that came from Vancouver and a bunch of hospitals, we participated into that. And it was very promising to study, you know, having from T1 to T3 and see all lesions that received preoperative chemotherapy. And if they have an adequate response, to go for a local excision with the goal of organ preservation. That's a whole different thing, because it was a little bit more experimental. But you know, many of those patients possibly could have had these features there. So there's a lot of things that we need to learn more about, the biology — because what we do is purely mechanical.
Ameer Farooq 48:19
Yeah. So that was the NEO trial that Carl Brown, Hagen Kennecke — I think it's now published from ASCO. How do you follow these patients that you've just done a local excision on? How often are you doing endoscopy? Are you doing any kind of imaging to follow these patients?
Antonio Caycedo-Marulanda 48:38
So, let's say we have a T1 lesion that was excised and we are happy and the patient is happy to go that route, I will bring the [inaudible] to do [inaudible] every 3 months. I will do imaging — preferentially, the thing I would like to do [is] an MRI, just to see if there's any new lymph nodes. And taking this very, with a grain of salt information that you're going to get some [inaudible]. Like, you know, you do it very early, you're going to find inflammatory changes that could be confusing. So I will do a [inaudible] every 3 months. I probably will repeat the image in about 6 months to a year. And I typically will not do CA levels or things like that for T1, which are not really recommended; it will be more like an endoscopy than radiologic follow up. If this is something more advanced, then I will do a more aggressive type of follow up.
Ameer Farooq 49:32
That's fantastic. I'm actually going to — if it's okay with you — bring up some of your videos that you posted on Twitter. Here's a video that you talk about — where you talk about your approach or how you score, you use regular monopolar caudery, you do a full-thickness division. So talk us through what you're doing in this particular clip.
Antonio Caycedo-Marulanda 49:55
Yeah, so you see the lesion has been completely demarcated distally, proximally, and now I'm just defining getting into that bright yellow bile is the mesorectum. I want to be as close as I want to the wall, and the reason is, I don't want to violate the mesorectum. So here we're going from the distal aspect. Now we're taking more [inaudible], the last bit of installation. I'm not sure if this was a T1 or [if] it was just a polyp. Possibly it was a malignant polyp. Very careful with the traction that I create to that, because I don't want fragmentation. So I grab very firm, but in a very delicate fashion. So now I'm going in there into the fat, possibly here there was a vessel I think at the bottom. Then you can see it. Then you can easily control in most cases with the [inaudible]. Now you can see the [inaudible] is much larger than you thought. I always watch it and review hemostasis. These patients, almost always, I send home the same day. I keep the patient that got into the peritoneal cavity. And if you see, I started at a corner there. This is finished; 2 sutures went on, [inaudible] was closed completely. Review hemostasis. The other thing that I will say is, what I've seen is, if these patients take any type of NSAIDs after, those are the ones that leave. I don't have any hard data to support that to say, but I tell the patients not to take any [inaudible] and, you know, for about 2 weeks or so.
Ameer Farooq 51:42
And you're making this look pretty easy, but this is very hard, because you really don't have, you know, triangulation at all when you're doing these. Where is your assistant usually standing — usually kind of standing to your left side? Because you put the camera in the left upper quadrant, is that right?
Antonio Caycedo-Marulanda 52:00
Yeah. So, you know, there are, as I said before, you have no angulation of your instrument; they are parallel to you. Typically, the person will be on the left side. If you have something like a flexible camera, that makes it very easy, but in most places, it's rigid camera. So I will say having a 30-degree bent will be very useful, and the person holding the camera will be to my left.
Ameer Farooq 52:30
Here's, I think, the full video of you closing this defect. You're using a barbed suture? I think that's — I think that one is a V-loc.
Antonio Caycedo-Marulanda 52:40
Correct. And the thing is, you know, you can put your stitches. any way they come. You can put them from inside, outside of the defect; it doesn't really matter. So yeah, here's me closing that — going in any direction. You just want to make sure that this is being closed in a continuous fashion. So that is stitched, you saw there, the stitch went through the [inaudible] right there.
Ameer Farooq 53:08
Yeah, that's where it's nice, where it's easy. You can just take it in one, kind of thing, rather than having to try it out.
Antonio Caycedo-Marulanda 53:15
And if you take a look at the left hand, the left hand is pulling the suture, and that is used to present the tissue to myself. Rather than grabbing the tissue, I'm pulling on the suture.
Ameer Farooq 53:28
And you actually use 2 sutures there because it just — what was the thinking behind that in terms of using 2 sutures, as opposed to just running that 1 [suture] all the way over to the right — or all the way over to the left, rather.
Antonio Caycedo-Marulanda 53:45
One suture will not be sufficient. So I started in one corner, when I got to the middle, I say, this is not going to be enough. So I start at the other corner and try climbing to the centre. The alternative would have been to start in the centre, divide it in 2, and then go with 1 suture to one side, going to the other suture to the other side. The challenge, though, is that the corners are the most difficult parts to see, so it's better to try to start at the corners rather than leaving it to the end.
Ameer Farooq 54:25
It's always amazing to me that these patients don't really have more issues with stricture or narrowing, but I think it's very rare, especially when you're closing transversally like that, for patients to really have any issues with stricturing or narrowing. I don't know if you've had any problems with that or issues with that.
Antonio Caycedo-Marulanda 54:49
I don't think that I had a stricture with narrow so far. With that being said, I've had cases in which I started doing it and I realized this is going to be narrow. So I stop, I cut the suture and leave the defect open. But I haven't had any patients postoperatively that had a stricture and then they run into problems.
Ameer Farooq 55:15
Well, this has been an absolutely fantastic discussion with you today, Dr. Caycedo. We really appreciate your time. And I'll just mention for the listeners that you're actually in Colombia right now, helping people, you know, other surgeons out learning taTME and other techniques. You just keep, just keep rolling and keep grinding and pushing. So that's just amazing and inspiring for all of us who are, you know, early on in our career, so, so thank you again.
Antonio Caycedo-Marulanda 55:41
Thank you.
Ameer Farooq 55:43
If you could go back in time, knowing what you know now, what advice would you give yourself as an early attending or perhaps as a chief resident? Any piece of advice that you'd give yourself?
Antonio Caycedo-Marulanda 55:55
Sure. I'll tell you one thing. [inaudible], who was the chief of surgery in Ottawa. He was a master laparoscopic surgeon. He's no longer [inaudible], but he said to me once, we were doing surgery, I think I was a third-year resident in Ottawa, and he said, just have this in mind. No one, no one is indispensable. No one is absolutely necessary. But just make sure that you become almost indispensable, whatever [inaudible]. So I think that's the greatest piece of advice that I have ever received. I always mentioned that, because that is a way just to say: You always stay hungry. Because, you know, you do things that are going to differentiate what you do from what other people do — not just to say that you've got to be exclusive or anything, but just try to always push the envelope to see what else you could do. Just keep your motivation, I would say.
Ameer Farooq 57:14
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Posted March 20, 2023