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Removal of Large SSA at Ileocecal Valve April 29, 2015

April 11, 2016

During a routine colonoscopy, I was diagnosed in February 2015 with a very large (5cm / 2.5in) SSA (sessile serrated adenoma, also referred to as sessile serrated polyp, SSP) at the ileocecal valve. It was biopsied, but due to its size and location, removal was not attempted. The biopsy confirmed SSA, but no dysplasia or malignancy. However, due to the malignant potential for this type of colorectal polyp, the standard recommendation was for surgical removal of sections of both the large intestine and small intestine (this would include the ileocecal valve). I was offered a surgical consult for a “minimally invasive,” laparoscopic surgery, but never investigated its full implications as I wanted to avoid surgery if possible. From what I have since found, this would have involved hospitalization, extended recovery and some loss of function. I started immediately searching Google for my diagnosis and quickly found this comprehensive description of someone in my same position who wanted to preserve his colon if possible (see http://www.sease.com/polyp/emr.html). I owe a debt of gratitude to Mr. Sease because he comprehensively covered his experience from diagnosis, to recovery with a compelling story of dealing with insurance company gatekeepers, persistence at seeking an alternative to laparoscopic surgery, finding an alternative, and his recovery now several years out after receiving EMR removal. His listing of doctors and clinics that emphasize EMR was quite helpful and ultimately helped me identify a doctor from links provided in his write up. I also used Google Scholar to find recent studies of either EMR or SSA progression to cancer (note, many of these cost money to view, but for a layperson, just going through abstracts which are generally free eventually gives one a flavor (http://scholar.google.com/scholar?start=20&q=sessile+serrated+polyp&hl=en&as_sdt=0,5 ). The current treatment protocol is for the complete removal of the SSA (see the wiki article http://en.wikipedia.org/wiki/Sessile_serrated_adenoma). Not knowing if my polyp would be amenable to EMR treatment, I decided to look at some of the centers and doctors in the Eastern US to see if I could get a rough opinion on what could be done without having to travel for an opinion. I was willing to accept the fact that surgery was the only viable alternative, but did not just want to elect surgery without other opinions. My attempts with major clinics providing interventional endoscopy / EMR failed to provide any kind of direct contact – I was just looking for an opinion as to whether EMR would even be a consideration. This led me to look wider and I followed a link in Mr. Sease’s article to the underwater technique of Dr. Binmoeller at https://vimeo.com/channels/uwe. This link provides several videos of single-piece, en bloc removal of a variety of polyps. This seemed like a very attractive alternative, so I Googled Dr. Binmoeller and found him at California Pacific Medical Center. I phoned and within a few minutes was offered the opportunity to provide a copy of my colonoscopy images and pathology which I did via email. Within a couple of days, I received a call back that the Dr. Binmoeller had viewed the images and was optimistic that an EMR procedure would be feasible. At that point I felt like I would commit to traveling to San Francisco for the procedure. I did some more Googling and found an NIH clinical study of Dr. Binmoeller’s which gave me further confidence to try this treatment. (https://clinicaltrials.gov/ct2/show/study/NCT01712048). If my polyp proved too dangerous to remove with EMR, I could always have surgery later. (I should have mentioned given the size of this polyp I probably had it for several years, so surgery immediately did not seem necessary). I scheduled the procedure for late April. As with any colonoscopy the prep (for me) is worse than the procedure. There are strict guidelines starting about a week out with a final 2 days of liquid diet, then the Suprep the night before and day of the procedure. After an ECG/EKG and blood labs, I met Dr. Binmoeller for the first time in person. We talked about the procedure for around 20 minutes and went over the risks and factors that would not be known until the polyp was examined with endoscopic ultrasound (partly to rule out cancerous penetration into the intestinal wall) and its precise margins and location were mapped. My polyp was considered difficult for EMR due to 1) its location at the ileocecal valve, and folding into the small intestine, 2) its size 5cm which covered a substantial surface area of the colon, and 3) the fact that it was sessile (or flat, thus difficult to remove). Dr. Binmoeller was guardedly optimistic going in to the procedure with the caveat that you never really know before the ultrasound is performed. I was anesthetized under the “MAC” protocol (which seems to be common these days), my best guess is the procedure as in the 45+ minute range. The resection was complete, taken in 2 pieces due its extension over the ileocecal valve. From a prep and recovery perspective this was no different to me than a standard colonoscopy. On the night of the procedure, I had some slight discomfort if I rolled onto my right side. I would rate this “1” on a 1-10 scale, 1 being lowest. It was barely detectable and caused no concern to me whatsoever. Just over a week later I received the biopsy results which were confirmed negative for dysplasia or malignancy. At my six month follow-up with Dr. Binmoeller (October 2015), the scar was healing nicely and there were no further signs of the SSA. I am next scheduled for a repeat colonoscopy in 3 years. I was lucky to have an SSA that had not evolved to something more serious and invasive. Malignancy could well have ruled out the EMR procedure, but I turned out to be lucky. Even if EMR would not have been appropriate for me, I felt the risk and inconvenience made this the first preferred option, since even if there was only a small chance of success, it was worth the attempt. I did not get a local consultation on EMR, but there are doctors in the DC area that do EMR techniques. My choice was to go with a true expert and innovator in EMR techniques. I knew ahead of time that my case was difficult and required experience, skill and sophisticated equipment, so this was definitely the correct choice for me. If you are in a similar position and considering EMR versus surgery, I hope this helps the decision process. ---------------------- Dr. Binmoeller wrote a nice note to go along with my results. I’ll quote directly, and this is something to mention when going in for a colonoscopy since you can’t predict what will be found beforehand: “By the way, here are key messages for fellow patients: 1. One chance to cure by endoscopic resection! A failed attempt at complete resection of a polyp will leave scarring that will make it more difficult and sometimes impossible to complete the resection a second time around. Tell your gastrointestinal endoscopist to not attempt any resection unless he/she is sure it can be completely removed at the first attempt. If a large or very flat polyp is found, the best is to referred to a specialist who does "EMR" (endoscopic mucosal resection). 2. If a tattoo is placed, it should be far away from the growth on the opposite wall since the permanent ink causes scarring that will make removal more difficult. 3. Always seek a second opinion before going to surgery. An attempt at endoscopic resection does not burn the bridge to surgery – you have nothing to lose! As a rule, surgery should always be the last resort for the treatment of any condition.”

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