A gastroenterologist and a colorectal surgeon seeing patients together eliminates long waits, and results in better and timely treatments.
(June 2010) Gastroenterologist Ioannis Oikonomou, MD, and colorectal surgeon Vikram Reddy, MD, PhD, work in offices side by side in the Yale Digestive Diseases suite in the Temple Medical Building in New Haven, where they call upon each other frequently. Both treat patients with inflammatory bowel disease (IBD), who suffer from recurring, debilitating symptoms such as severe pain and chronic diarrhea throughout their lives.
Gastroenterologists and colorectal surgeons usually work in separate practices, but Yale Medical Group doctors are finding that working closely has its benefits. When Oikonomou believes a patient needs surgery, Reddy is nearby for an on-the-spot consultation.
“Dr. Oikonomou can call me and say he has a patient in room six,” says Reddy. “He’s tried medications for this patient and everything has failed. I can talk to the patient and discuss the options for surgery or we can talk about clinical trials that are available. The patient will have access to all the options, both medical and surgical, and will be able to evaluate them based on the benefits and risks of these options.”
Oikonomou examines a patient while Reddy observes.
For patients, a visit with the team can eliminate days or weeks of waiting when one specialist refers them to another. For Oikonomou and Reddy, such teamwork can tip the balance between surgery that is too soon, because medical treatments might still help the patient, or too late, because busy schedules could delay surgery. As a result of these joint visits some patients receive medical treatments that allow them to avoid surgery altogether.
“Basically, it’s the gastroenterologist speaking to the surgeon in the same room as the patient, and there is better communication with the patient,” says Judy Cho, MD, director of the Inflammatory Bowel Disease Program at Yale.
Reddy and Oikonomou compare notes on cases in the Digestive Diseases suite with Anish Sheth, MD.
Walter Longo, MD, a colorectal surgeon, and Deborah Proctor, MD, a gastroenterologist, embraced the idea of GI/surgical collaboration within Yale Medical Group in 2004, when they were treating patients in the same location at the same time and saw how beneficial it was. Now a gastroenterologist and a surgeon are available most of the time in the Digestive Diseases suite during appointment hours. Oikonomou and Reddy are the team’s newest doctors, having joined the practice last summer. In addition, the rotation includes doctors Longo, Proctor and Cho.
While the doctors treat a variety of conditions, the majority of their patients have ulcerative colitis or Crohn’s disease, which are characterized by chronic inflammation of the intestinal tract and that together afflict more than a million people in the U.S.
Ulcerative colitis and Crohn’s disease are often managed successfully with medications, but many patients will require surgery. Crohn’s is a chronic unremitting disease that can be managed with medications, but such complications as abscesses, fistulas (permanent abnormal passageways), strictures (narrowing of sections of the passageway of the bowel), perforation or obstruction eventually require surgery.
Reddy and Oikonomou study test results together.
“In the vast majority of cases, the goal is to avoid surgery,” says Oikonomou. “Our approach is to offer a personalized treatment to patients with IBD.”
Avoiding surgery is an option for more patients as doctors become precise in their use of medications that have become available in the last ten years. These medications suppress the immune system, controlling inflammation of the bowel. A gastroenterologist with the expertise and the experience in treating patients with IBD is crucial for the management of patients with complicated disease presentations, says Oikonomou.
A frustrating downside of IBD care, especially for young people with Crohn’s, is the need for regular monitoring, which can mean multiple CT scans and significant radiation exposure. Yale radiologists recently have been using an alternative called MR enterography. This type of magnetic resonance avoids the radiation effects of the traditional X-rays and CT scans, and provides, in some cases, a better delineation of the intestinal tract.
But new treatments will only improve care if doctors are able to use them efficiently, say Oikonomou and Reddy. “We want to take care of these patients in a timely manner, when we have the best opportunity to make them better,” Reddy says.
Story by Kathy Katella
Photographs by Terry Dagradi
The young man was only in his teens, but ulcerative colitis had forced him to leave school. So Vikram Reddy, MD, PhD, planned surgery. It would be a complex procedure with considerable risk: Using minimally invasive techniques, he would remove the entire colon and rectum, all the way down to the anus, and reconstruct a rectum using the patient’s small intestine. His largest incision would be less than an inch.
The surgery was successful, and the patient went home in a few days. Within a few months, he texted Reddy to say he had taken up a sport and could he skip his next follow-up?
Since joining Yale Medical Group last year, Reddy has performed several highly advanced surgeries, prompting inquiries from outside surgeons who want to watch them. Most notably he used Natural Orifice Translumenal Endoscopic Surgery (NOTES) to remove an abdominal mass. Working through the anus, he used laparoscopic instruments and made no incisions, and left no scars or pain.
“NOTES surgery is still limited. We are limited by the instruments we have, by the advanced learning curve, and by realizing that we can apply this to only select patients after careful counseling,” says Reddy. He is currently working with companies to create better instruments to help make the surgery more routine and readily available.
In addition to NOTES, Reddy offers Transanal Endoscopic Micro Surgery (TEMS) to remove polyps and select cancers through the anus without an abdominal incision, sparing many patients from major abdominal surgery. Using TEMS, Reddy has removed cancers and polyps in debilitated patients who would otherwise not be candidates for surgery, and to repair complex fistulas that were out of reach of traditional methods.
For patients with ulcerative colitis, minimally invasive surgeries are not only curing the disease, but also helping with key quality of life issues. “Most of these patients are in their 20s and 30s. They may have a boyfriend or a girlfriend and body image is huge,” Reddy says. He is happy to send them home with little more than a Bandaid.
Yale Digestive Diseases
Temple Medical Center
40 Temple Street
New Haven, CT 06510
The building is handicapped accessible.