The Sherman Prize: Phillip Fleshner, MD, on Perianal/Fistulizing Crohn Disease

Dr Fleshner discusses his work in colorectal surgery and in advancing and improving surgical research that resulted in his recognition with the Sherman Prize. The prize will be presented at the Advances in Inflammatory Bowel Disease annual meeting in December.

Phillip Fleshner, MD, holds the Shierley Jesslyne and Emmeline Widjaja Chair in Colorectal Surgery and is director of Colorectal Surgery Research at Cedars-Sinai and is a clinical professor of surgery at the David Geffen UCLA School of Medicine in Los Angeles, California.

TRANSCRIPT:

Phillip Fleshner:  Hi, my name is Phil Fleshner. I'm a colorectal surgeon at Cedars-Sinai in Los Angeles. I'm the program director in the colorectal surgical residency. Quite frankly, I'm honored to be one of the 2021 Sherman Prize winners.

It was a great honor to have this awarded on me. I think a number of levels, that it was a good honor. Quite frankly, $100,000 is a nice thing to have but it was way more than that.

One of the things that the Sherman Prize has shown, I hope, or at least being a surgeon winning the Sherman Prize, is the importance of surgery in this disease. Almost all of these patients, when they get their disease, they're initially treated by gastroenterologists. Not all gastroenterologists—thankfully, the minority—some gastroenterologists specifically try to keep their patients away from surgeons. In fact, even in our parlance, we call the patients who eventually are referred to surgery as a failure. That has a lot of negative connotation.

I hope that somehow, now that the recognition of the value of surgery in this disease has led, in some way, hopefully, to my winning this award, it has also, in many ways, vindicated what the approach has been in my life. That is to take various people around you and intertwine all of those together to answer questions that we're dealing with.

It's not just a surgeon that's doing this. It's not just a gastroenterologist. We have an inordinately friendly and collaborative group at Cedars-Sinai. We question each other in a nice way. We're colleagues. We're friends. That really fosters an environment of inquiry, doing things together.

A lot of the stuff that I've done has been taken from the bench—literally, translational research. Some of the stuff that a lot of the bench people have done is taken from things that I've provided to them. That gives a vindication, as I mentioned before, even another level of vindication, of why this award is so special.

That's where I am. In terms of the mantra in my life has been to change the paradigm of what we do in IBD surgery. To question what we're doing. One of the ways that we question what we do is by doing good quality research.

The problem that we've had as surgeons, particularly in the IBD world, is that a lot of the surgical research we do is poor. I remember, for example, when I started my internship a long, long time ago, my first year as a doctor, I did a randomized trial as an intern—looking at specific types of tubes that are used to decompress the gastrointestinal tract. It was a really nice study. It took me about 4 years to finish. Now, I finally published the data. It got accepted to The American Journal of Surgery. You look back at the data, and in fact, the conclusions were wrong. They were wrong because the study was underpowered.

It showed to me—this is the beginning—how surgeons are not very good researchers. That was also corroborated by a very scathing review in 1996 by a gentleman by the name of Richard Horton, who was the editor of Lancet. At that time, he came out with an article looking at surgical research. He basically—not basically, he lambasted us—to do better research. In fact, the name of the article was basically, "Surgical Research, A Comic Opera." Implying that we were not doing research very well. I actually agreed with him.

A lot of us in the surgical community had a wake-up call. I said to myself, when I read that article, that we're going to use the resources we have, both on the translational side and the IBD side, as well as us as surgeons, ourselves, that we're going to start doing high-quality research.

We embarked, at that point, on prospective research, randomized controlled trials. Level 1 evidence to try to answer specific questions that we were dealing with in the IBD realm. Obviously, in my particular realm, the surgical side of IBD.

Some of the studies that we did using that background is we showed the lack of efficacy of intravenous high-dose steroids in the perioperative period. There was absolutely no role to do that. We did prospective studies showing that biologics had no significant influence on surgical outcomes. Not based so much on clinical data, but based on serum levels of the drug, which was, if you think about it, a more accurate way to assess the biologic significance of the drug that you're using. We did it in a lot of different realms. That's pretty much my background, in terms of this Sherman Prize.