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1:03

Hello! Behind the Knife Westerners, we

1:05

are very excited to be back

1:07

with you for another journal club

1:09

and Cohen and Ragdoll Surgery. Today

1:12

we're gonna die in to to

1:14

paper it's on he nods dysplasia

1:16

and anal square missile he answer.

1:19

With. The Way He Colorectal Surgery Chain.

1:22

Reminder. Of there is yes,

1:24

another awesome colorectal group. Coming.

1:27

To us at of Louisville the recorded

1:29

two episodes so far an Aston Years

1:31

and Parenting Once flaps. And.

1:33

We do have another very special guests who

1:35

is joining us today. I nominate

1:37

introduce them shortly. So welcome

1:40

again Team that Peter West

1:42

Marcello doctor test. Hannah. A

1:44

Let has a go against. All.

1:46

It's awesome! It's great to be back together.

1:49

We're. Getting into the holiday season so.

1:51

We. Just had Thanksgiving those lot to

1:53

be thankful for. We did tremendous in

1:55

our match for our residency and we're

1:58

very excited about that! Last.

2:00

Time! We just had our holiday party.

2:02

So is a time together Via together

2:04

and and enjoy. And. As we

2:06

get to to Christmas coming Santa was

2:08

very nice to was. And. I

2:10

take a very proud of other never presentations

2:12

we have at a. Podium:

2:15

Is posters and video for the National Mid

2:17

South a lot to be type of. While

2:19

I want to wish all be higher than

2:21

a Listers. A happy healthy holiday

2:24

season. Test.

2:27

Man. I can't really follow that that was

2:29

I agree after as up the heat and

2:31

at. Least. Since it wasn't say

2:33

they're get yeah. And.

2:36

Say. I mean I

2:38

guess I'm pregnant unexpectedly give me the

2:41

yeah so unblock the be back for

2:43

more dig. Didn't my best to stay

2:45

hydrated and eating fiber to avoid the

2:48

hemorrhoids and scissor. Sisters Decay of all

2:50

will it will tear my to thank you

2:52

for them anyway and ads. On

2:54

this is number two is number to protest the

2:56

at the same side as well as yet. He.

2:58

Ain't. Or a

3:01

let's introduce our very, very special

3:03

guests who is joining us. I'm

3:05

honored to take a first crack

3:07

at introducing Doctor V. Submarine. So.

3:10

Doctor Brain Complete or Medical School at

3:12

Brown University? Ah! She then

3:14

went on and did her eyes john

3:16

surgery training at Beth Israel Deaconess. Ah,

3:19

And then she can put your

3:21

Colon Michael Surgery fellowship at obviously

3:23

none other than any hospital medical

3:25

center but was wasn't called Les

3:27

Aspin Medical Center. Than. It. Was

3:30

a lazy nice of the was a lady has cock

3:32

were in. The guys i think I was the one

3:34

lady has got. Year: velveeta of money

3:36

involved laziness. Or

3:39

Gracie then took a job at Brigham

3:41

and Women's Or Medical Center where she

3:43

spent twenty years and and we were

3:45

lucky enough to have to rejoin the

3:47

team at Lady. And she actually

3:49

served as are fellowship program director and

3:51

starting. And twenty seven kids were thrilled

3:53

out for. Joining. Us today and

3:56

share expertise on the topic. Think

3:58

it's coming? right?

4:01

But thanks for inviting me. I was saying earlier.

4:03

I think it might roll. Here is the history.

4:06

Of Eden or and I were talking earlier before the

4:09

recording started about this is his brain different disease

4:11

that? but we were fellows. When. I'm

4:13

looking forward to hearing all any stuff. When.

4:16

I just wanna give a shoutout to

4:18

Lisa because she really broke route as

4:21

the is my first quarter surgeons to

4:23

be at Brigham and Women's. Did.

4:25

A tremendous job there and and also her.

4:27

Role in Education. I mean, she was a

4:29

year behind me. But. I go to

4:31

law firm this a brain is as a better

4:33

education. She was a charge of the Harvard torture

4:36

for the medical students and then we were lucky

4:38

to have a year and take over our lives.

4:40

The program. And. We're We're

4:42

really excited to have her with us and

4:44

to be with us tonight. Grudge. On.

4:47

My. right? Let's dive into the

4:50

heart of this discussion of anal dysplasia

4:52

and this is. A bear

4:54

very confusing topic for all and

4:56

admittedly sometimes even for us call

4:58

sergeants. Any. A part of

5:00

that is because the terminology and least

5:02

in regards to pathology, is actually quite

5:04

variable. And. In a letter sure

5:06

is a bit limited and so there is

5:08

extraordinary durability. In fact, is that so. Hopefully.

5:11

We by the ended today will be

5:14

able to break down some of the

5:16

barriers to understanding. so we have two

5:18

great articles to review. Successive.

5:20

Get us started! Saw with an

5:22

article from Disease and Call Rectum

5:24

Know their seek me Out Spain

5:26

policy Twenty twenty two. And

5:28

then I'm going to share the results

5:31

of the much anticipated Anchor trial that

5:33

was published in the New England Journal

5:35

Madison. I tried to itself just

5:37

launched. Take it away and will go go to

5:39

next slide again. Reminder: for those of us you

5:41

are Jozy are watching. On you to be

5:43

couple one with us. A

5:46

son. So this study. Aimed

5:49

to determine the incidence. Of

5:52

anal sway missile cancer and the

5:54

efficacy of a screening program. It

5:56

took place in in Hiv Clinic

5:58

in Spain, France, from 2004

6:02

to 2017, and their primary

6:04

outcome was the incidence of anal

6:07

squamous cell cancer, ultimately

6:09

finding that participation in a screening

6:12

program reduced the incidence of anal

6:14

squamous cell cancer. Before

6:17

I dive in too deep, I just wanted to

6:19

clear up some of the terminology that you alluded

6:22

to, which I think reviewing

6:24

the literature can be very confusing

6:27

because the terminology can be so variable,

6:30

and why discussing this topic can be

6:32

challenging. If you're following

6:34

again on YouTube, check out this

6:36

slide. I think this schematic is

6:39

helpful in terms of understanding dysplasia

6:41

and progression to anal cancer.

6:44

Additionally, anal cancer is mainly

6:46

caused by the HPV virus,

6:48

type 16 and 18. This

6:51

virus changes the cells and

6:54

again can cause both L-cell

6:56

and H-cell. This

6:58

terminology has been confusing because previously it

7:00

was termed AIN 1, 2, and 3,

7:05

and so there can be a lot of variability when

7:07

you're looking at studies or

7:09

reviewing pathology or outside providers' notes

7:11

in terms of the pathology. Now

7:15

we are recommending that everything

7:17

get lumped into two categories,

7:20

low grade or high grade, this L-cell

7:22

or H-cell. We're going to try to

7:24

be consistent tonight in using those terms.

7:27

So HIV- I'll just

7:30

jump in. Sorry, I'll just jump in one second to

7:32

estimate. Sometimes I remember

7:35

a professor or a surgeon who taught

7:37

us in residency would be very, very,

7:40

very, very particular about the words we

7:42

used. And I,

7:44

I think as a trainee, sometimes found that

7:46

maybe a little annoying. But

7:49

I do think when you're talking to talk,

7:51

it is important actually to really

7:53

be able to speak the correct lingo. So it

7:55

might seem like a, maybe a silly thing out

7:57

there, but it actually is quite important. Sorry, I

7:59

just wanted to- emphasize that. Absolutely,

8:03

completely great. HIV,

8:06

as many of us know, is associated

8:08

with increased risk of anal squamous cell

8:10

cancer. The study that

8:13

they performed in Spain was

8:15

conducted in an infectious disease

8:17

clinic in Spain where patients

8:19

living with HIV were routinely

8:21

followed. This is an

8:23

existing population. Data was prospectively entered

8:25

beginning in 2004 and patients were

8:30

basically included if they had at least

8:32

one follow-up visit. Beginning in

8:34

2010, they instituted

8:36

a specialized screening program

8:39

treating anal neoplasia that

8:41

was abbreviated SCAN. This

8:44

program was specifically for men

8:47

who have sex with men within the clinic. This

8:50

program included various efforts

8:52

including anal cytology, high-resolution

8:54

manoscopy, as well as

8:56

some treatment, mainly thermocoragulation

8:58

of high-grade or H

9:00

cell lesions. I think

9:04

this is a very important point in all of these

9:06

studies on anal condyloma

9:08

or anal cancer. What

9:11

is the intervention? Again, they did

9:13

screening with cytology and high-resolution

9:16

manoscopy and then performed

9:18

again some thermocoragulation for

9:20

the high-grade lesions. The

9:23

study was divided into two periods. So the first

9:25

period was in 2004 to 2010 before they instituted

9:27

this SCAN program and then

9:33

afterwards from 2011 to 2017. They

9:36

had a very fairly robust

9:38

population with a total of 3,800

9:42

patients participating in the study. 41% of

9:45

these were men who

9:47

had sex with men and 17% were

9:49

women. So a majority of these were

9:51

male patients. In

9:54

total, 897 participated in

9:56

the SCAN program when

9:58

It began in 2013. Are

10:01

they also monitored c Four counts as

10:04

well as a new and restoration in

10:06

terms of Hiv status. During.

10:09

The study period a total of

10:11

twenty eight all swim us all

10:13

cancers were diagnosed. With

10:15

worked. Out to about one point five

10:18

cases per year. Fifty. Five

10:20

percent of these been diagnosed with

10:22

in the Msm population. And

10:25

four of twenty were diagnosed in

10:27

the ski and group who are

10:29

being actively screened and potentially treat

10:31

it. All. Of these. He.

10:34

Answers for added twenty were: early stage

10:36

cancer is t one or two to.

10:39

Two. Of these were asymptomatic and were.

10:41

Detected. at routine visit we other

10:44

to. Had. Actually not attended.

10:46

They recommended are scheduled visits and

10:48

were diagnosed judith symptoms later on.

10:51

Whereas. In a non screening group, the

10:53

non scanned group only twenty five percent

10:56

of these. Cancers.

10:58

Were. Diagnosed that early stage, so more likely

11:01

to be a later stage of the

11:03

time of diagnosis. Which.

11:05

I think is an important point the

11:07

overall incidents and rate of in all

11:09

squamous cell cancer with sixty eight per

11:12

one hundred thousand person years in this

11:14

cohort of Hiv patients. And.

11:16

Looking at the various time period they

11:18

did note in increase in incidence. Throughout.

11:21

The study with the later time period

11:23

having an increased incidence of an old

11:25

squamous cell came from you know, squamous

11:28

cell cancer. The. right?

11:30

Word. Dramatically higher in Amazon

11:33

population Bomb. They. Did

11:35

look at immune reconstitution and that

11:37

was noted to be a protective factors

11:39

so as your hiv with under better

11:41

control. Highlighting. The importance of

11:44

art therapy and in each of

11:46

the suppression in developing a lot

11:48

squamous cell cancer. And the

11:50

strongest impact that they found was. The.

11:52

Lack of or a new restoration

11:54

and terms of your rate of

11:56

developing this. If. You're

11:59

less than thirty fiber over fifty

12:01

you had high education or injection

12:03

use as turret transmission of each

12:05

I need. This was protective

12:07

first when us up a key a

12:09

concert a again in their population. So.

12:12

When comparing the anal screen, us

12:14

all from twenty ten to twenty

12:16

seventeen. In. A scam group Compared

12:18

to the followed their significantly decreased rates

12:21

of else when a cell in the

12:23

scan through the screen and group. Based.

12:25

Unless they concluded that participation

12:28

in this screening program. Significantly.

12:31

Reduce the incidence of anal swim a

12:33

cell cancer in the Msm population. Setting.

12:36

This overall said he had limited data

12:38

in terms of adherents in compliance to

12:41

the program. While. Their initial

12:43

numbers are really good. thirty eight

12:45

hundred, a smaller number that was

12:47

actually enrolled in or screening program.

12:49

And again, this apply to a

12:51

limited population. This other Hiv Amazon

12:54

population that was in the screening

12:56

program said thinking about how this

12:58

job is generalizable to the broader

13:00

population. That we may be seen. So.

13:03

It also the other thing we didn't

13:05

get that specific details on maybe the

13:07

treatment that they have received about. The

13:09

patience. Thanks.

13:14

To us so bored go through newspapers I'm really

13:16

trying hit on worse and that the key points

13:18

I guess. I'm. Instead Third, purely

13:21

so your thoughts about the paper.

13:23

I guess billion to a little

13:25

bit of the store. Go contacts

13:27

about training early part of your

13:29

career. What? Was the were the

13:32

summer thought process about always been the space

13:34

or some the treatment option So. I.

13:36

Would you think. So.

13:39

What I used for thought that as well presented

13:41

test. Thank you for going through that. And

13:44

I do think the value. Particular. Talking

13:46

about whoever hires people. That

13:49

really need to be watching out for screening. But

13:51

I think Peter and I were talking earlier like

13:53

what we were fellows, right? This wasn't a disease

13:55

rate because no one had Hpv. Really? that that

13:57

are they did. They didn't have it long enough

13:59

to. The shrine have a problem. And

14:02

when someone had eight of game a cell

14:04

with a big deal when someone had able

14:06

to slays it was really unusual on so

14:08

we would take the zebra, the Lr duties

14:10

mapping biopsies about ten centimeters out from the

14:12

rain us and a lot as a microscopic.

14:14

The combat positive isn't even though we might

14:16

have seen this little area of demarcation on

14:18

the perry else can have some fry like

14:20

leaving within the anal canal that came back

14:23

a cell. And we would remove and that

14:25

we don't really stuck with. What? Are

14:27

we going to do about all this microscopic stuff? By.

14:30

So than they would have Two schools of thought

14:32

was cool. Thought was we have to find

14:34

a better way to identify each sale besides just

14:36

looking at it. And. Then there was kind of

14:38

the school of thought that said, well. It

14:40

It's gonna have to go through a phase where

14:42

you going to see something to the naked eye

14:45

before it goes into a base of cancer and

14:47

of we just survey people frequently enough that we

14:49

catch anything. That nice. Be

14:51

treated, will treat it. And so I think

14:53

for people my generation has always been the

14:55

trouble. It hasn't been should we surveyed these

14:57

people. It's then how can

15:00

we survey them frequently enough or effectively

15:02

enough that we catch these lesions so

15:04

we don't really know the timeline? And.

15:06

We don't really know the best tools and so

15:08

this says if you watch people. That.

15:10

See something you want to treat it? Play that idea.

15:14

But. I don't think you can see much more because they

15:16

didn't say what. You know the

15:18

routine, what the policy was, the for what it

15:20

was after in terms of intervals. Comply and. Cetera,

15:23

Et cetera were all these. Lesions only see

15:25

night or a were some unseen

15:27

visibly. Does

15:31

city. You're.

15:34

A I'll add to that is to say

15:36

that I think it's matter of also them

15:38

figure out your risk population right and so

15:40

we're talking about the pieces were of highest

15:43

risk new. Motto. Is I

15:45

who men Hiv positive population in our

15:47

rights as and to your general population

15:49

and has either makes you more confusing

15:51

but I think import message there needs

15:54

to be some screening done to help

15:56

patients. Whether. There are hardly worthy

15:58

or during the highest as or. They are numerous

16:00

a lower risk. Especially. If they

16:02

have a sober says also and so all

16:04

I will say is if you're also the

16:06

begin with, you're probably not gonna flip as

16:08

often to a cell. Least. In

16:11

our understanding of thus. The. So history

16:13

can repeat itself. So. I. Worry

16:15

less about somebody who doesn't have worrisome

16:17

lesions. Whoa. Where's this? Doctors?

16:22

Although it is really interesting is that there are a lot

16:24

of. Patience. At that I've

16:26

seen in the transplant population. I. Said

16:28

there any out of rise as a transplant

16:30

and they had Cervical a volver dysplasia that

16:33

was carrying all the know into the El

16:35

Canal and so kind of. Spreading.

16:37

that way so I feel on was like

16:39

when someone I do think the high risk

16:41

population that david undecided test test as taper.

16:44

Are super important pay attention to. but I

16:46

think if anybody shows up. With. A

16:48

cell. I. Can't seem to stop wanting

16:51

to surveyed them. Yogi.

16:54

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GLOW. All right,

18:28

let's launch into the ANKER trial.

18:31

This is also known as the

18:33

treatment of anal high-grade squamous intrapathial

18:35

lesions to prevent anal cancer. And

18:38

so we actually had the benefit and

18:40

luxury and full disclosure to do a

18:42

journal club within our lay heat program

18:44

last week. And so we actually reviewed

18:46

this article as well as the other

18:49

article. And so, you know, one

18:51

of the interesting points I'll just bring up is like all

18:53

along, there's always been this question of like,

18:56

what do we do with HPV and H-CIL?

18:59

And the thought process was, well, let's just wait for

19:01

ANKER. Let's just wait for ANKER. And then we'll know

19:03

all the answers. So let's talk about

19:05

the article and see if we have all the answers.

19:08

So the background or the impetus for

19:10

the study. So we believe

19:12

that anal cancer is preceded by H-CIL.

19:15

But they was really lacking

19:17

from prospective studies about the treatment

19:20

of H-CIL and

19:22

whether or not that can actually prevent

19:24

anal cancer. So this was a phase

19:26

three multi-institutional randomized study that

19:29

investigated whether treatment for H-CIL

19:32

is effective and safe in reducing the

19:34

risk of progression to anal

19:36

cancer among persons living with HIV

19:39

compared with active

19:41

monitoring of H-CIL without treatment.

19:44

The study was conducted at 25 US sites. One

19:47

of the things I learned is that one of our

19:49

partners, Dr. Kunin, was that the EMC, when they were

19:51

enrolling, it was actually a part of helping enroll and

19:54

take care of some of these patients. So

19:56

patients with HIV who were 35 years

19:58

or older with... biopsy proven

20:00

H cell were randomly assigned

20:03

to either active monitoring or treatment

20:05

of the H cell. Okay

20:08

and so treatment at least the way

20:10

that they defined in this study is

20:12

that it could be office-based, ablative procedures,

20:14

ablation or excision under anesthesia or the

20:17

use of topical for your cell or

20:19

amickelma. So again what

20:21

any of these studies is important to be clear what's

20:23

the intervention. So intervention in this

20:25

study was ablation or excision of or

20:28

topical for your cell or amickelma of

20:30

H cell. So the primary

20:32

outcome was progression to anal

20:34

cancer and all participants underwent

20:37

HRA every six months. So

20:39

they had about 4400 patients who

20:41

underwent randomization. The median

20:43

follow-up was about 25 months. There

20:47

were 9 cases of anal cancer

20:49

in the treatment group and

20:51

21 in the active

20:53

surveillance group and the rate

20:55

of progression to anal cancer was lower in the

20:57

treatment group by about So

21:00

Kapp and Meyer did demonstrate a decreased

21:03

rate of progression to anal cancer in

21:05

the treatment group. And

21:07

so while the trial didn't necessarily

21:09

look at the efficacy of different

21:11

methods for treating H cell, most

21:14

in fact were office-based electrocautery. So

21:17

overall the study demonstrates that the

21:19

treatment for anal H cell does

21:21

significantly reduce the progression to anal cancer among

21:23

persons living with HIV 35 years or older.

21:28

And there was a low incidence of serious

21:30

adverse events. And so I think

21:32

I'll just say I think the well-conducted randomized

21:34

controlled trial with good study design there's certainly

21:37

limitations of the study but I think

21:39

I'm interested to hear what again start

21:41

with Lisa. So what are

21:43

your thoughts about anchor trial and what

21:45

this means for us going forward? I

21:49

mean I agree with you that it's

21:51

good to finally have something that's you

21:53

know this rigorous in terms of a

21:55

trial out there to sort of give some guidance and

21:58

like we were saying earlier. If you

22:01

know someone has H-Cyl, you should definitely

22:03

treat it. The

22:05

question is where is it and

22:07

how do you know what the borders of it are,

22:09

right? Because this was great that

22:11

it was biopsy proven H-Cyl but it wasn't like

22:15

is it demarcated? Is it a field defect

22:17

of the whole anal canal or the whole

22:19

perianal skin? And because they

22:21

would treat it a lot of times with

22:24

things that didn't like non-excision treatment,

22:26

right? You shouldn't know whether your margins are

22:28

negative when you treated it, right? So

22:30

it's great that the patients are being

22:33

surveyed, maybe being surveyed by something that

22:35

maybe is going to be more important

22:37

at reducing the transmission. I mean the

22:39

development of invasive square cell than just

22:41

looking via anoscopy, hard to say but

22:43

this is certainly one making you wonder

22:45

about that. And then I think that

22:47

the thing that historically has always been tough is that we

22:49

would excise all this stuff. And there

22:52

was a lot of morbidity with that. And so this has shown you

22:54

that you can probably do other forms of

22:56

treatment, which I think we're going to talk a

22:58

little bit more about

23:00

that could be very effective

23:02

and don't really harm the patients in

23:04

terms of their continents or

23:06

a lot of problems with pain and other

23:09

things like that. So I think

23:11

it's all very positive and moving people towards paying attention

23:13

to these patients and trying to figure out who's

23:15

got H-Cyl and where is

23:17

it? Is it a visible lesion

23:20

or is it a field defect? And

23:22

then what are your treatment options? Yeah,

23:24

and for me I'll just carry forward just

23:27

the historical perspective. When

23:29

Elise and I were on our trainings in the

23:31

early years, all we had was excisional

23:34

treatments. You know, we didn't think

23:36

that distal plating, thermal ablation would be adequate for

23:38

these lesions. So the problem is the morbidity.

23:41

Like if you would excise and then we

23:43

get a stricture and now you're dilating the

23:45

anus, so again also with vulvar lesions in

23:48

a similar fashion that our only

23:50

thought was well we better remove the

23:52

tissue rather than try to treat the

23:54

tissue. So I

23:56

think sometimes less is more and that

23:59

I think our movement

24:01

now is away from less major excisions

24:03

and more about other options. And so

24:06

I think less is more. It can

24:08

be helpful. Yeah. I

24:11

think this INCR trial gives

24:13

us really good data to

24:15

say that treating H-cell decreases

24:17

the rate of anal cancer,

24:19

specifically also in these high-risk populations. It seems

24:22

like we're all on the same page about that.

24:24

If you have H-cell, we have to treat it,

24:26

right? And this supports that. And

24:28

it is a good study, prospectively

24:30

well-designed, big study that helps to

24:32

kind of solidify that thinking. I

24:35

guess, Lisa, you kind of alluded to this,

24:38

but what did they use? What treatment options?

24:40

I think the question that

24:42

I have is, you know, how

24:44

are these people being surveyed? Do

24:46

we have to do high-resolution anoscopy

24:50

for everybody? Or is

24:52

office-based anoscopy digital exam

24:55

okay? And

24:57

so I kind of opened

24:59

that up to the group to say, what

25:01

are you guys doing now and what should

25:03

we be doing as a society? Because I

25:06

know that there's still a lot of debate

25:08

about how these people should be surveyed. So

25:13

I think that's a great question, Tess. I mean, I

25:15

think, again, we used to call this the East Coast-West

25:17

Coast debate. So everybody in the West Coast

25:19

wanted to do HRA, and everyone in the East

25:22

Coast wanted to do anoscopy. And

25:24

so I'm still not sure that these studies are

25:26

granular enough to sort of say whether

25:29

HRA is necessary to

25:31

find the HCL or not. It certainly doesn't

25:33

seem like it hurts, particularly if you're kind

25:35

of not really sure where the margins of

25:37

your HCL are. The

25:39

treatments aren't all that

25:42

morbid. So

25:45

it's okay to maybe over-treat some areas or maybe

25:47

under-treat and then catch some of the next go-around,

25:49

you know, kind of thing. But

25:51

I don't think a digital exam is probably adequate

25:53

because most of this stuff is soft. And

25:56

by the time it's firm, it's probably already progressed.

25:59

But I do think... you know, at the

26:01

very least a good anoscopy and

26:05

probably a lot of people are going to

26:07

be comfortable with HRA once people get past what I think

26:09

is a pretty tough learning curve

26:12

for that. Yeah, I think part of

26:14

it is the patient is at risk. If

26:16

you've got a discrete lesion, one discrete

26:18

lesion you've removed and you haven't seen anything

26:20

else, I'm not sure of that person

26:22

then maybe they get HRA for a little bit and

26:24

then they fall back out if nothing else is showing.

26:27

Like again, history repeats itself. If you've

26:30

got somebody with multiple H-cell then

26:32

that person and you keep finding

26:34

it, then that person is

26:36

going to keep getting high resins and aoscopy. So

26:38

part of matching a bit of what

26:41

you're going to do to what you're concerned about

26:43

for the patient. Yeah,

26:45

not to cross pollinate too much or be a

26:47

self-promoter too much but I'll just throw a plug

26:50

in there that our recent

26:52

Gut Check Podcast which is

26:54

our official podcast for ASCRS,

26:57

we talked about this and we talked about all

26:59

the different variations in practice and HRA and how

27:02

you do screening and we sort of went around

27:04

and talked about what our

27:07

offices are set up and who does it and

27:09

there's just huge variability out there. And I think yes,

27:11

there was a concept, I think that like, oh, we'll

27:13

just wait for anchor and that will tell us everything

27:15

but anchor wasn't there to tell

27:17

us, hi, are you going to do HRA the

27:20

best? So

27:22

I think that's where it's like really focusing on what is

27:24

the goal of the study and what's the takeaway. Yeah,

27:30

and I do think that there's definitely room

27:33

in the literature to kind of tackle

27:35

that as a next step in

27:37

terms of hammering down how are

27:39

we implementing doing HRA and what are

27:42

the like bigger prospective studies in terms

27:44

of using that technique and then specifically

27:48

how often compliance adherence

27:50

and some of the treatment

27:52

that is being used, you know, with

27:56

HRA. Any

28:01

other, in terms of, I know when I

28:03

was at Wakey, Dr. Breen,

28:05

I believe that you were starting

28:08

to do more in collaboration with,

28:10

I think, maybe dermatology or ID in

28:13

regards to some of the anti-viral therapies.

28:15

Are you still using any of these,

28:17

or what's been your experience with some

28:19

of the topical treatments? So,

28:22

I think that's a

28:24

great question. So I think, again, how

28:26

I approach visible lesions, something that's demarcated

28:29

or raised, or I feel like

28:31

I know where the borders are, and how I

28:33

treat something that is just visibly,

28:35

completely normal, and maybe some little

28:37

pinch biopsies have shown H-sil here

28:39

and there, but I'm not really

28:41

sure on the HRA how discrete

28:43

these lesions are. Those are kind

28:45

of the field defect lesions. So

28:48

if it's small and definable,

28:50

I'll usually excise it for PAS, and I'd like

28:53

to know that there's negative margin. If

28:55

it's a field defect, then I think

28:57

coterie works well inside the

28:59

anal canal. I think coterie of the perianal

29:02

skin is rough. I think

29:04

topical treatments of the perianal skin are

29:06

a great choice, but it's hard to

29:09

get patients to put the topical treatments inside the

29:11

anus all the way up to the dentate line.

29:14

And it's kind of one of these things where,

29:16

like, you try a little coterie, then you try

29:18

a little effidex, and then we started getting interested,

29:20

like you said, based on collaboration

29:22

with dermatology with an agent called Cetovivir, which

29:25

is another one of these broad-spectrum

29:28

DNA, against DNA

29:30

viruses. And it's, I

29:32

think it may end up being more helpful

29:34

for L-sil and condyloma, because that's where a

29:37

lot of the work has been done. And

29:40

again, topical lesions. And so I had

29:42

a few patients that I've shared with

29:44

dermatology who have had just confluent condyloma

29:47

of the whole perineum, and the

29:49

topical Cetovivir cream has been great.

29:52

But you have to fail, Dara, a couple

29:54

times, and then you have to really go

29:56

out negotiating with the insurance companies with all

29:58

the letters, et cetera, et cetera. follow-up.

30:01

I think when you were a fellow,

30:03

we experimented for a little while with

30:05

thinking about intralesional, it was called, sedofavir.

30:07

And the idea here was, again,

30:10

HCL keeps showing up inside the anal canal.

30:12

The patient can't put the topical cream up

30:14

there. We've full graded

30:16

it a few times. It's too

30:19

diffuse to think about excision without

30:21

causing stricture. So we were

30:23

like, well, maybe we can just start

30:25

injecting the IL interlesional sedofavir, which is

30:27

something that has been done for like

30:29

laryngeal condyloma. But I

30:32

think with people

30:34

being more free with electrocottery and with

30:36

the interlesional being, I'm just not

30:41

sure we've been feeling like there's a big need for it.

30:45

And it doesn't seem as sort

30:47

of diffusely applicable because you have to get

30:49

under the mucosa and inject so it's not

30:51

like the cottery where you can kind

30:54

of buzz all around. Yeah,

30:57

I'd say for me for treatment, it's hard

30:59

for me to get patients to comply with

31:01

topicals and therefore I'm more likely to be

31:04

doing some intervention, whether it's excision or a

31:06

thermal treatment. I've not had

31:08

good experience in my population of

31:10

the topicals long term. Of

31:13

the perianal skin as well or just the...

31:15

Perianal skin, that sounds like when you have

31:17

it on the outside. I just sometimes I guess

31:20

I'm more, I will treat you

31:22

and then we'll follow you whether then you're

31:24

there, they're taking control of their disease. I

31:26

find it hard. Don?

31:31

Well, yeah, I guess

31:33

I would say like, and not to be too

31:36

like off putting about it,

31:38

but it's a little like you come to the barber

31:40

once like and so I'm like, I'm more inclined to

31:42

say let's cut some out. And so I guess I

31:44

would say I'm not always like that

31:46

for all disease processes, but I feel like I'd

31:48

be much more inclined to trust like going to the

31:50

OR and trying to cut something out or a blade

31:52

as opposed to saying try this topical cream. So

31:55

that's I think my bias. I

31:58

you know, so far early on. I

32:00

don't have as much experience, but, you

32:02

know, many patients where I'm a little

32:04

hesitant to go to the OR or

32:06

will try topical treatments where maybe they

32:08

have some more comorbidities or frail, I

32:11

found even trying the topicals, they then

32:13

often maybe will have trouble applying it

32:15

and doing it like we've talked about.

32:17

So, ultimately, I still ended up having

32:20

to go to the OR to ablate or

32:22

excise. And so, I agree

32:24

with what everybody said. There's definitely

32:26

a lot of, I think, limitations to

32:28

the topical treatments. Well,

32:33

I'll just say, I think this

32:35

is a great discussion. I think

32:37

our listeners will agree. Would you guys agree? Absolutely.

32:41

Yeah. Well, thanks for

32:43

joining us, Dr. Breen. So, let's get to some

32:45

of our takeaways. Tess, why don't you kick us

32:47

off? Yes. So,

32:50

know your high-risk populations and make sure

32:53

when you're seeing patients that you're asking

32:56

all the questions in order to identify

32:58

and properly acknowledge

33:00

what patients you should be following more

33:02

closely. And then,

33:05

depending on each

33:07

patient, you're going to need to have an informed discussion

33:10

about all the different options and

33:12

kind of come to an agreement on what

33:15

is going to be appropriate for that patient,

33:17

whether you want them in a formal HRA

33:19

program, whether you're going to do anoscopy in

33:21

the office, making sure you're

33:23

following those patients and have a treatment plan,

33:25

I think is key. All

33:28

right. I'll

33:30

go to you, but the Marcellus must-know. Well,

33:32

first, treat H cell. Okay. I think

33:34

we're all in agreement about that. But history

33:37

tends to repeat itself. If you've got

33:39

somebody who's not growing a lot of

33:41

lesions much, don't be as aggressive. And

33:43

sometimes, I think, less is more. I

33:45

am doing more, probably, thermal treatments and

33:47

less aggressive resections to avoid the complications.

33:50

Treatment can be worse than the disease. Brain

33:56

is besties. It's awful. All

33:58

right. And I think I'm saying the same thing,

34:00

everyone. is saying here, which is treat any reliably

34:03

identifiable H-CIL that you know of in any

34:05

patient. And it can still be

34:07

a little tricky what is reliably identifiable

34:09

H-CIL. You know, like just saying plain

34:11

inoscopy, high resolution inoscopy, are we really

34:13

going to find this stuff? And

34:16

then there are much less morbid treatment options

34:19

available nowadays than just pure excision and so I

34:21

think that gives us a little latitude to be

34:23

a little more aggressive in treatment. So,

34:28

I think it's, Jory's

34:30

still out a little bit about how

34:32

we, what's the exact best way to

34:34

do surveillance and treat and so I

34:37

would just say like don't throw up your hands and not do

34:39

anything. I would just say pick something that you feel comfortable with

34:41

and follow your patient and watch closely. I

34:44

think even that hopefully if there is going to

34:46

be a cancer you'll find it early. Alright,

34:49

so with that we're going to wrap up

34:51

our eighth episode and again if you like

34:54

diving into the weeds you consider joining us

34:56

Sunday evenings for a co-work surgery virtual education

34:58

series. You can also check out some of our

35:00

show notes for some details and so

35:02

we do hope we continue to have the privilege

35:05

of creating awesome content for you in the future.

35:08

In May we're going to present

35:10

an interesting case about parasomal hernias,

35:12

talk about a couple interesting approaches

35:14

and I will say if you enjoyed the session do take

35:16

a minute or two out of your day to leave us a

35:18

review. And so as Behind

35:20

the Knife says, team until the next time,

35:22

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35:25

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35:29

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35:32

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35:34

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35:54

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