Changing – and Saving – the Lives of Patients with Colorectal Disorders
Historically, many patients with colorectal disorders have gotten little help from doctors – even if their symptoms were painful or embarrassing enough to make their lives miserable. That’s what happens as people age, they heard, or that’s an inevitable consequence of pregnancy. Patients who did find treatment often faced only highly invasive options.
Those limited options are not acceptable to the colorectal specialists with Bon Secours Surgical Specialists, a practice dedicated to comprehensive, coordinated care of conditions of the bowel, rectum and anus.
The team of three physicians is exceptionally experienced; they are experts in colorectal surgery and offer a full range of diagnostic and therapeutic services, including advanced non-surgical treatments, endoscopy and minimally invasive procedures.
Each team member is committed to treating the full spectrum of bowel disorders in a comfortable and supportive environment, from common complaints such as hemorrhoids and anal fissures and fistulas to life-threatening cancers and complex or rare conditions.
All patients have access to prominent specialists and cutting-edge technologies such as robotic surgical options, the region’s most advanced physiology laboratory and defecography X-ray equipment – which can fluoroscopically evaluate the anatomic condition of the pelvic floor and anorectal structures.
Prompt evaluation, early diagnosis and customized care, along with fully electronic medical records, can significantly improve patient outcomes.
“We are excited about introducing a new era in unmatched, patient-centered colorectal medicine and surgery right here in Hampton Roads,” says Philip D. Kondylis, MD, FACS, FASCRS. “Sometimes a small procedure can fundamentally change a patient’s quality of life. Every day we see somebody who has tried to get treatment for years; some are despondent. It’s extremely satisfying to be able to help them.”
The center’s physicians are all fellowship trained colorectal surgeons and have extensive clinical experience treating patients in both academic and community-based medical settings. They also work in collaboration with a variety of dedicated nurses specializing in clinical care, endoscopy, enterostomal therapy, biofeedback therapy and physiology lab techniques– as well as a caring nurse navigator available to address questions and concerns 24 hours a day.
In addition to colonoscopy, the precise diagnostic tests offered include: anorectal ultrasound, to study muscle structure and function; transit time studies, to follow how well food moves through the digestive tract; high-resolution anal/rectal manometry, to measure pressure and sensation using a digital monitor; needle-free electromyography (EMG), to assess the health of both muscles and the nerves that control them; pudendal nerve testing, to identify anal sphincter nerve damage and responsiveness; and MRI fistula evaluation, to provide a highly detailed view of perianal anatomy.
With detailed information on a patient’s condition, physicians can move as quickly as possible to address:
• Anal pain and itch
• Rectal bleeding
• Colorectal polyps and cancer
• Crohn’s disease and other inflammatory bowel disorders
• Ulcerative colitis, damage to the lining of the colon and rectum
• Diverticular disease, bulging tissue pouches in the colon and/or inflammation of those pouches
• Constipation and/or diarrhea
• Bowel leakage
• Rectocele, a prolapse of the wall between the rectum and the vagina
• Rectal prolapse
• Anorectal infection
“We have established and are now growing our center of excellence, where we can radically change how we approach many of these conditions,” says Chong S. Lee, MD, FACS, FASCRS. “We have upgraded all aspects of the delivery of colorectal surgical care to go above and beyond what has traditionally been provided in our community.”
Treatment options include second opinions, medical therapies, biofeedback therapy, office-based hemorrhoid procedures and advanced endoscopic therapies for hemorrhoids, fissures and fistulas such as Botox injections, fibrin glue, collagen plug fistula ablation and several minor surgical procedures. Those include the Ligation of Inter-sphincteric Fistula Tract (LIFT) procedure, Procedure for Prolapse and Hemorrhoids (PPH) and Transanal Hemorrhoidal Dearterialization (THD).
The list of minimally-invasive colorectal surgeries covers fully laparoscopic surgery, single incision laparoscopic surgery and transanal endoscopic microsurgery. Bon Secours physicians also are highly experienced with anal sphincter-preserving rectal cancer surgery, sacral nerve stimulator surgery, artificial bowel sphincter surgery and pelvic floor operations.
Furthermore, the team is eager to educate residents on early symptoms of colorectal cancer and the importance of screening tests, particularly colonoscopies that generally should begin at age 50. The disease has a fairly high incidence in the Hampton Roads region.
“Colonoscopy is one of the few medical screening tests that has been proven to reduce cancer rates,” says Emily B. Rivet, MD, MBA, FACS. “If we can find a tumor at an early stage, it can mean the difference between a one-day outpatient procedure and about a year of multi-modality treatments: chemotherapy, radiation and multiple surgeries.”
The center’s surgeons currently are based at Bon Secours Maryview Medical Center in Portsmouth and Bon Secours DePaul Medical Center in Norfolk, with the physiology lab at Bon Secours Health Center at Harbour View in Suffolk.
The practice is dedicated not only to bringing relief to patients but to helping them feel empowered –never frustrated or embarrassed – throughout their treatment. As Patient Care Coordinator for the colorectal program, Robin Boothe, RN, provides her cell phone number to patients and encourages them to call her anytime with questions about symptoms, treatments and special preparation plans they should follow in the days leading up to certain tests.
Boothe, a registered nurse for 37 years, is also happy to simply listen to their fears and concerns. She has worked with the Bon Secours colorectal program for eight years.
“I try to put myself in their place, and think about how I would want myself or one of my relatives to be treated,” she says. “It’s often an uncertain time for them, and they don’t want to talk about these issues with just anybody. I love being there to educate them and to hold their hands. We’re committed to being a high-tech but also a ‘high-touch’ practice.”
Pelvic floor disorders and disorders of the rectum
Many colorectal practices focus on performing colonoscopies and treating classic conditions such as hemorrhoids, fissures and fistulas, all high-volume and high-profit endeavors. The Bon Secours Colorectal Center is eager to help those patients with basic but life-changing procedures such as hemorrhoid ablation or drainage of a perirectal abscess.
The center can also handle less common and more complex conditions, including defecatory disorders that can be difficult to diagnose. That level of expertise is not typically found in most community-based centers.
Doctors’ understanding of anal-rectal physiology and continence has advanced greatly over the past 10 to 20 years. “It’s an exciting time for the field,” Dr. Kondylis says. “Twenty years ago, for example, patients with incontinence had so few options beyond colostomy. Now, colostomies are almost unheard of because treatments have changed so fundamentally.”
Dr. Kondylis has more than 20 years of experience in his specialty. He came to Bon Secours last year from Erie, Pa., where he served for 12 years as a core faculty member and most recently director of the colorectal surgery program at Saint Vincent Health Center. He earned a medical degree from the University of Massachusetts Medical School, where he also completed a National Heart, Lung and Blood Institute student research fellowship.
After medical school, Dr. Kondylis did a general surgery residency at the Yale University-affiliated Hospital of Saint Raphael in New Haven, Conn., and a colorectal surgery fellowship at Saint Vincent. A registered investigator for the National Cancer Institute, he has given 34 major research presentations and written 14 peer-reviewed publications.
A good number of patients who come to see Dr. Kondylis have been misdiagnosed or suffered in silence, sometimes for months or even years. “If you have something like anal leakage, you’re likely going to wait for a long time before reporting it to a doctor,” he says. “If you’re then brushed off, you may never ask anyone else.”
Just one example of a frequent misdiagnosis: women with a rectocele, a bulging of the front wall of the rectum into the back wall of the vagina that can require surgical repair, often are told they have constipation and instructed to eat more fiber, drink more water and use a stool softener. “None of that works because there’s nothing wrong with the consistency of their stool,” Dr. Kondylis says.
The center also treats many women who begin experiencing progressive bowel habit disturbances – straining, pelvic pressure and never feeling empty – one or two decades after having children. Almost a third of women who give birth vaginally suffer some sort of injury to their anal sphincter, even if they don’t tear externally during delivery. That scar tissue can weaken with time and contribute to significant bowel leakage or incontinence.
Women who have Caesarean sections aren’t immune either, as supporting the weight of a baby strains the pelvic floor. More than half of pregnant women also experience minor damage to a nerve that stretches to the anal sphincter.
“In many cases, treatment can be very simple,” Dr. Kondylis reports. “Dedicated biofeedback therapy to strengthen a damaged sphincter might be all a woman needs.” That therapy uses computerized feedback to retrain muscles to relax during evacuation and contract at appropriate times, as well as teaching patients to build strength and endurance with sphincter contraction.
Men who have undergone treatment for prostate cancer, particularly radiation therapy, are another vulnerable group. Radiation can damage the same nerve to the anal sphincter, as well as nearby blood vessels. Many patients respond well to medication or Argon beam therapy to destroy abnormal vessels.
The key to tailoring the best treatment is to have a detailed diagnosis. At the physiology lab at Bon Secours Harbour View in Suffolk, experts can fully evaluate the anal sphincter muscle and nerves that nourish it, as well as precisely measure pressures generated by the contraction of the sphincter.
The procedures, usually no more involved than a rectal exam, utilize a finger-sized ultrasound probe – that offers a 360-degree image inside the anal canal – or a soft plastic tube about the size of a drinking straw that can digitally calculate contractions. Patients don’t need an intravenous line or sedation. Testing also can uncover a failure in colon function in patients with profound constipation, another population that tends to be overlooked and mistreated with laxatives.
“In regards to colorectal surgery, we are virtually a one-stop shop,” Dr. Kondylis says. “We want people to stay locally rather than have to travel for treatment.”
Catching cancer early
Physicians in the colorectal surgery division are passionate about educating local residents on the importance of regular screening for colon cancer. The five-year mortality rate for colon and rectal cancers is consistently higher in Bon Secours’ primary service area than nationwide, according to data from the National Cancer Institute.
From 2006 to 2010, the age-adjusted death rate for the cities of Chesapeake, Newport News, Norfolk and Portsmouth was 18.3 deaths per 100,000 of population, about 11 percent higher than the national rate of 16.4 per 100,000. Within that primary service area, Portsmouth topped the list at 20.4.
Colon cancer is the third most commonly diagnosed cancer and the second leading cause of cancer death in men and women combined in the United States, according to the Colon Cancer Alliance. The American Cancer Society estimates that 143,000 people are diagnosed each year; about 51,000 die. Data shows that 72 percent of cases originate in the colon and 28 percent in the rectum.
Five-year survival rates increase dramatically if colon cancer is caught early. More than 90 percent of patients diagnosed when cancer is found at a local stage – confined to the colon or rectum – live more than five years, alliance statistics show. If the cancer is regional and has spread to surrounding tissue, that rate drops to 69 percent; once it has spread to distant sites, it plummets to just 12 percent.
However, the majority of colon cancers are not discovered early: 39 percent are found while the cancer is at a local stage, 37 percent at a regional stage and 20 percent after the disease has spread to distant organs. By the time colon cancer causes symptoms such as pain, bleeding or obstructed bowel movements, the disease usually has spread beyond the local stage.
A traditional colonoscopy is the gold standard for screening, although physicians also can gain valuable information from sigmoidoscopy, fecal occult blood testing and virtual colonoscopy. Most people should schedule an initial colonoscopy at age 50 because while the disease can strike at any age, about 90 percent of new cases occur in people ages 50 and older. Those at higher risk due to family history should consult their doctor about starting earlier. Schedules for follow-up screens vary based on individual results and medical history.
Colonoscopies can not only find small tumors but polyps that might one day become problematic. “In many cases, we can remove polyps before they ever have a chance to become cancerous,” Dr. Rivet says. “The procedure itself is very quick and has a low rate of complications. I can’t tell you how many people have said to me, ‘Wow, that was so much easier than I thought it would be.’”
To catch rectal cancer early, Dr. Rivet also urges people to seek help if they see bright red blood, experience rectal pain or itching, or feel as if they have abnormal tissue protruding from their anus.
“Often within 15 minutes, I can reassure someone that there is not something significant going on, or make a plan to perform further evaluation,” she says. “If needed, our team can provide comprehensive guidance through the treatment process.”
Small rectal tumors can sometimes be removed through the anus in a quick outpatient procedure, sparing patients far more grueling cancer treatments. “My feeling is that people in our community are very stoic and might delay approaching a doctor until it’s too late for that level of care,” Dr. Rivet says. “That’s one reason we are dedicated to raising awareness.”
Lifestyle choices also may help prevent colon cancer. While no study to date has found a direct correlation between one behavior and increased risk of disease, healthy habits – eating plenty of fruits, vegetables and fiber, limiting processed foods and smoked meats, exercising regularly and not smoking – are always wise.
Like her two colleagues, Dr. Rivet has experience treating a wide variety of colon and rectal diseases in men and women. In fact, she chose to specialize in colorectal care for the interesting mix of cases, along with a personal reason: her grandmother died of colorectal cancer.
Dr. Rivet came to Hampton Roads in 2008 after her husband, a neurosurgeon, began practicing at Portsmouth Regional Naval Medical Center. She has a medical degree from the Washington University School of Medicine in St. Louis, Missouri, and completed her surgical training, including a general surgery residency and a colon and rectal surgery fellowship, at Barnes-Jewish Hospital in St. Louis. She also holds a master’s in business administration from Washington University, with a focus on professional ethics and health care systems.
Dr. Rivet has won numerous awards for academic achievements and surgical expertise and, following an interest in promoting patient safety in a hospital setting, has published articles on peri-operative patient care and the critical care of surgical patients.
The colorectal surgeons with Bon Secours Surgical Specialists “all have slightly different passions but work together seamlessly,” she says. “Put bluntly, we all understand why there’s the expression ‘pain in the butt.’ There’s almost nothing that’s more miserable for patients, and when we can help people feel better, they are exceedingly grateful. We consider it our privilege.”
Minimally invasive options and patient support
Fortunately for patients who need surgery, Bon Secours Surgical Specialists physicians can perform about 80 percent of colorectal operations with a minimally invasive approach, thanks to specialized surgical techniques, interventional radiology and state-of-the-art equipment.
“The result is better outcomes, higher patient satisfaction, shorter hospital stays and faster recovery time,” says Dr. Lee, who has more than 19 years of experience managing complex colon and rectal surgical diseases. He joined Bon Secours last summer.
Laparoscopic surgery now is standard practice for common conditions such as inflammatory bowel disease, diverticulitis and Crohn’s disease. Most Crohn’s patients – often young, in their 20s or 30s – no longer have to lose much of their small bowel. “It’s much less disfiguring, which can make an enormous difference in terms of patient satisfaction,” Dr. Lee says.
For patients with chronic or complicated ulcerative colitis, there are sphincter-saving surgeries designed to preserve fecal continence, avoid a permanent abdominal ileostomy and improve quality of life. Patients with rectal prolapse, which frequently causes incontinence, can benefit from the Altemeier procedure, a perineal approach done under regional anesthesia that also allows for repair of pelvic floor muscles if necessary. Without making an abdominal incision, surgeons can remove the prolapsed rectum through an incision in the protruding rectum.
Colorectal Center physicians also have experience in treating complex cases that otherwise would require a trip to a major academic medical center. One of Dr. Lee’s specialties is removing presacral tumors or masses – very rare growths in the space between the rectum and lower spine, most common in young women – using a discreet, approximately inch-long incision in the tailbone area. That compares to a major, highly visible incision and removal of the tailbone in traditional surgery.
Among Dr. Lee’s goals is to expand robotic surgical options, the most advanced form of minimally invasive surgery available today, for colorectal patients. He led a similar effort in his previous post as Service Chief of Surgery at Henry Ford West Bloomfield Hospital in West Bloomfield Township, Mich.
Surgeons are now beginning to use the da Vinci Surgical System – previously adapted for urological and gynecological cases – for bowel cases, both colon cancer and non-cancerous colon diseases.
“The task now is to fine-tune the system for more colorectal cases,” Dr. Lee says. “More innovative equipment is likely to come out in the near future, and we are committed to taking advantage of that. I really see robotic surgery as replacing laparoscopy in many cases.”
Robotic surgery offers many benefits to patients compared to open surgery, including shorter hospitalization time, reduced pain, faster recovery and return to normal activities, reduced blood loss and smaller incisions, resulting in minimal scarring and a reduced risk of infection. For surgeons, assistance from a self-powered, computer-controlled robot and 3-D camera allows for enhanced dexterity, flexibility, visualization and precision.
Dr. Lee, like Drs. Kondylis and Rivet, specializes in colorectal surgery but also has a background in general surgery. He holds a medical degree from the University of Illinois College of Medicine in Urbana, Ill., and completed his internship and residency in general surgery, as well as colon and rectal surgery fellowship, at the University of Minnesota Hospitals in Minneapolis, Minnesota. He joined the Henry Ford Health System in 1994 and was heavily involved in General Surgery Residency education and Colon & Rectal Surgery education from the onset, until he left to join the Bon Secours DePaul Medical Center in August, 2013. He contributed in 10 peer reviewed publications and presented in seven national and international surgical meetings. Dr. Lee has been recognized in Best Doctors in America® and as Hour Detroit magazines Top Docs. Dr. Lee also holds a Master’s Degree in Electrical and Computer Engineering from the University of Illinois, Urbana-Champaign.
Regardless of what kind of treatment a patient needs, the entire Bon Secours team is there to offer support to individuals and their families. Boothe, the Patient Care Coordinator, starts by helping patients adhere to pre-operative and pre-testing guidelines. People who need a barium enema, for example, have to follow a special diet two days beforehand.
“I don’t want them to make a three-day commitment before they understand exactly what they need to do to get the results we need to best help them,” she says. “I am there to translate any language that’s confusing into very simple terms.”
As for cancer patients, many still come in for colonoscopies and post-operative care long after their initial treatments and even after five-year checkup appointments. “Those people are mine for life,” Boothe says. “Sometimes I end up taking care of their relatives, too, if a disease has a genetic component. We become a family.”
Sharon Winchell, RN, Clinical Program Coordinator for the oncology department at DePaul, feels the same. Winchell works closely with Dr. Lee to help cancer patients and their families navigate multiple appointments, tests and treatments. The team also is careful to clearly explain all treatments so each patient is more likely to stay in compliance and follow appointment schedules, thereby enjoying the best possible long-term prognosis.
“We give them everything that they need to make the most informed decisions for their care,” says Winchell, who is oncology-certified and has worked with colon cancer patients for more than 16 years. “Our patients deserve, and get, a powerful combination of expertise and compassion. We know the word ‘cancer’ is scary, and we don’t want them to feel rushed or overwhelmed.”
The Bon Secours team plans for a future of growth, by adding more talented colorectal surgeons to the staff and hopefully initiating a fellowship training program. “We want to bring in young surgeons to mentor them,” Dr. Lee says. “By offering state-of-the-art, innovative care, we have an exciting potential for recruitment.”
Physicians encourage any person who suspects a bowel disorder – due to pain, constipation, incontinence or other troubling symptoms – to get to a specialist sooner rather than later. At Bon Secours, nobody will tell them they’re just getting old.
“We’re in a position now where we can help a lot of people,” Dr. Kondylis says. “We can improve their daily lives in a significant way.”
For more information about Bon Secours Surgical Specialists’ Colorectal Division, please contact us at
483-3030 or 889-6830
or visit us online at bshr.com/bsss.