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Dr. Calder Lavery discusses surgical management of ulcerative colitis, recent advances in surgery for rectal prolapse, complex anal pathology, complex fistulas.

Byline: Shaukat Ali Jawaid

KARACHI -- Keeping up its past traditions, Colorectal Surgery Division at Jinnah Postgraduate Medical Center Karachi organized a surgical week for colorectal diseases. Dr. Ian Calder Lavery consultant colorectal surgeon at Digestive Disease Center Cleveland Clinic Ohio USA was the master trainer. Apart from making brief presentations on Ulcerative Colitis, Total Mesorectal Excision, Recent advances in surgery for rectal prolapse and complex anal pathology, he also operated upon over a dozen cases which included Ulcerative Colitis-Pouch technique, Rectal Cancer- the APR technique, Rectal prolapse doing abdominal rectopexy using stapler and complex fistulas, which were shown live to the participants from the operation theatre. The meeting was well attended by senior surgeons besides postgraduates many of whom had come from interior of Sindh, Lahore and Peshawar.

Seminar room was connected with the Operation Theater with audiovisual facilities enabling interactive discussion between the surgical team and the participants.

Prof. Tasnim Ahsan Director JPMC in her speech on the occasion thanked the brave American Dr. Ian Calder Lavery who had come all the way from United States despite disturbing law and order situation in the city to teach surgical skills to Pakistani surgeons. This, she said, will be extremely helpful particularly for those who do not have the resources to go abroad. It is an opportunity for the participants to learn, start colorectal surgery and sustain it. She also commended Dr. Shamim Qureshi for his efforts to organize this programme on time despite the fact that JPMC was passing through difficult times in its history. It will improve patient care and training not only for the surgeons working at JPMC but from all other institutons from the country who are participating.

Prof. Mumtaz Maher a noted colorectal surgeon who had in fact initiated this training course many years ago and who is also patron of this academic activity in his speech said that Surgeons Society of Pakistan does not organize such courses. Live demonstration of the cases being operated will be helpful for the younger generation of surgeons in particular to pick up important things during these procedures. Prof. Ghulam Asghar Channa HOD of Surgery introduced the guest speaker. Earlier Dr. Shamim Qurehsi in his welcome address said that to improve is to change and to be perfect, it is said, one should change often. This course, he felt, will help improve the standard of colorectal surgery in Pakistan. We started this academic activity about six years ago and since then many eminent colorectal surgeons from UK and India have come here and demonstrated live various surgical procedures. Participation is absolutely free as there is no registration fee.

He also commended Prof. Tariq Mahmood Head of the Dept.of Radiology with whose efforts they were able to renovate and furnish this seminar room. He hoped that Prof. Tariq will continue to help and support us in future as well.

Ulcerative Colitis- the Pelvic Pouch Technique

Formal inauguration was followed by a presentation on Ulcerative Colitis- the Pelvic Pouch technique by Dr. Lavery. Dr.Abu Bakar from Lahore and Dr. Saif from Karachi were the moderators in this session. Dr. Lavery pointed out that for him it was a wonderful opportunity to give some idea about the type of practice they have in United States. He then discussed some of the steps in construction of Pouch and said that J-Pouch is by far the simplest operation to do as other surgical procedures do have some problems. He also referred to the W Pouch technique using stapling device. This can be done by hand as well. Use three to four staples to make 100mm pouch, then do anastamosis in the anal canal .Make sure that there are no problems with the anastamosis. He further stated that foreign trainees who come to him for training, first I ask them to do a few cases by hand before using stapler because if some thing happens and the stapler does not work, one should be able to do anastamosis by hand.

He showed different types of pouch i.e. S pouch, W pouch and J pouch. Anastamosis at the end of the anal canal is easier. One should also be careful to check the suture level before closing. Satisfaction with IPAA is good but less than ideal. Some of the concerns which he talked about were like leakage of stool, mucus, mucosal symptoms, dysplasia and cancer.

Continuing Dr. Lavery pointed out that in ulcerative colitis mucosectomy is essential. Leakage is less after stapled IPAA than after mucosectomy by hand. He then gave details of a study in which fifty four patients had no anal manipulation and ninety nine patients had anal manipulation. In the anal manipulation group twenty two patients had Tran's anal pursesting while seventy seven had mucosectomy. There was no difference as regards number of stools and leakage. The number of pads used by the patients was also the same. No manipulation group had minimum leakage at night and also used less number of pads. He then discussed results of long term functional outcome in another study conducted between 1986-1997, which included 1156 patients of which 535 were male and 442 female, 80% of the cases had MUC, 123 were in determinants, 3-5% had cirrhotic disease. Talking about the risk of dysplasia after pelvic pouch surgery he said, seven out of two hundred ten patients developed dysplasia.

Prior cancer had significant association. Gender, duration of disease, age of patient, diagnosis or surgery had no association. These patients had 4-51 months post operative follow up with mean follow up of eleven months. He also discussed the benefits of stapled IPAA. Presence of dysplasia in rectum, colorectal cancer, and severe anal mucosal involvement is some of the contra indications, he added.

This was followed by a live demonstration of a case which was forty years old male on steroids for the last three years. Digital rectal examination was normal. He pointed out that before pouch surgery as a part of pre operative preparation, the patient should be kept on liquids. Do nutritional evaluation of the patient. See what operation you are going to do and in case the patient is malnourished, put him on parenteral nutrition for a couple of days. Steroids, he said, are not only bad but also affect healing but when you stop steroids, it will make the patient more sick. I do not like to operate on a patient who is on steroids, he remarked. His advice to the participants was that one should operate upon the patient when they are well. This particular patient, he said, has been on a large dose of steroids hence I will feel the tissue first to see how it looks like and then operate. He then made a midline incision to operate upon this patient.

Total Mesorectal Excision

On second day first a few cases were discussed in the consultant corner which was followed by live demonstration of a few surgical procedures. Dr. Calder Lavery pointed out that there is no harm in undertaking more radical procedure in young patients. New chemotherapeutic agents are much more effective as therapy. In the patient under discussion there were no anal symptoms on anal examination and no tumors were seen on radiology. Sigmoidoscopy was not done as it was not available. The patient had liver involvement and secondaries but pulmonary involvement was doubtful. It was planned to remove the liver metastasis. Dr. Lavery was of the view that it should always be evaluated as to how safe one is in liver segmental resection. Pet Scan CT shows if the disease is there.

He also talked about the usefulness of CT guided liver biopsy. MRI shows resectable tumours but when the surgeon went in, it could not be resected. In such cases the patient will have miserable life, symptoms will persist and the patient will have lot of pain before eventual death.

Successful Treatment of Rectal Cancer

Dr. Ian Calder Lavery then made a presentation on successful treatment of rectal cancer wherein he discussed investigations and management and highlighted certain points which he said were relevant to the case which they will be operating later. Screening, he opined, is cost effective. Colonoscopy is inconclusive, the patients are not compliant and they do not come for examination again and again. In United States, we have one lac fifty five thousand new cases of rectal cancer every year. It is always essential to do digital examination before starting adjuvant therapy. Investigations include proctosigmoidoscopy, biopsy, ultrasound but MRI is much more accurate and reliable than intra operative ultrasound. He then highlighted the importance of appropriate treatment in such cases and also mentioned about adjuvant treatment, local excision, major excision, APR and sphincter saving which were all discussed in detail. He also referred to good and bad surgery and good as well as bad biology.

In case of good surgery with good biology, the patient will be cured. Good biology with bad surgery will lead to local recurrences. Bad biology and bad surgery will result in distal, local recurrences. He laid emphasis on good surgery and pointed out that till August 2011 he had operated upon 719 such cases. Among these 55% had lower third end rectum involved, in 31% of cases middle third of rectum was involved, 77% had surgical operation and 11.4% had contact radiotherapy. Among the surgical cases, 88.7% had curative surgery, 10.8% had palliative surgery and in 20% of the palliative surgery cases had APR. Again 8.9% of the patients from this palliative group had local treatment.

Giving details of the surgical procedures in the curative cases Dr. Ian Calder Lavery said that 37.6% had CRA, 52% had APR and 21% had morbidity in all procedures. As regards complications 3.9% had anastomotic leak, 8.5% had perineal infection, 2.8% had local recurrences and 11.6% had distal recurrences which was related to biology of tumour. Local recurrences mostly occur within two years. The patients have poor quality of life. He then discussed the principles of treatment in detail. He was of the view that adequacy of blood supply after appropriate ligation should be ensured. Block resection was done in 43% of patients. Dr. Lavery further stated that always try to do a good operation whether it is TME or any other procedure. Total Mesoresection Excision is not necessary in cancer of upper rectum. Outcome of treatment of cancer of upper rectum is same as sigmoid colon cancer. Speaking about reconstruction he mentioned about abdomino perineal resection which is the latest and current standard.

Sphincter saving should be attempted if feasible. In a series of one thousand one cases, 261 had complete resection. Tumour size was between 5-7 cm and median follow up was 59 months. Five years survival in 5-7 cm tumour is identical whether you do SSP or APR. His conclusions were that chances of cure are not compromised following sphincter saving procedures. Cost of sphincter saving includes uncontrolled passage of flatus to fecal incontinence, urgency and frequency. Screening, prevention, pre operative staging and adequate surgery are all important. Solution lies in reducing the severity of symptoms. Urgency and use of Pads is same as in J Pouch. Narrow pelvis, bulky colonic pouch, fat mesocolon are some of the technical issues involved in this surgery.

He also discussed his experience with coloplasty CCF and said that it was safe as other techniques and it gives better functional results and it is comparable or marginally better than J pouch. Some studies suggest benefits with adjuvant therapy He also discussed the biological rational for peri operative treatment.

Surgery for Rectal Prolapse

Recent advances in surgery for rectal prolapse were discussed on the third day of the course. Dr. Muzzafar from Peshawar and Dr. Turab Pishoroi from Karachi moderated this session. Dr. Shamim Qureshi in his introductory remarks said that there are many operations to treat this condition which shows that none of the therapy is good enough. Dr. Ian Calder Lavery in his presentation pointed out that in some parts of the world young people have prolapse and leakage but this does not and should not happen to every body. Some patients have impaired sphincter due to prolonged labour, obstetric injury, duodenal damage, and trauma, Post surgical or congenital. In diabetics secondary nerve involvement can result in poor function. CNS damage can lead to scleroderma. In such patients one must have good detailed stool history of fecal incontinence, urgency, frequency, stool consistency, pain, frequency of evacuation, blood in mucous, use of pads diapers which show severity.

Use of laxatives can give a feeling of false stool, leakage, urinary incontinence. In women take obstetric history, number of children, their weight, size, did she had episiotomy, infection, tears, proper repair, long delivery and use of forceps which can damage the pelvic floor. In physical examination look at impaction, straining, do anal exam, rest and squeeze, proctoscopy. Solitary rectal ulcer can be misdiagnosed as cancer though it may be benign on pathology. To confirm incontinence, put hundred cc (100cc) water in the anus and ask the patient to hold, if the patient cannot, it confirms that there is some problem. Nerve studies and endo sonography can be done as some of the diagnostic tests.

Non operative measures include diet; change the route of medications, kegel exercise after delivery which will make the muscle much bigger and strong. The patients should be taught how to make their muscles work. Surgical treatment consists of sphincteroplasty which is very useful. However, the patients may start leak after some years. Posterior levatroplasty is another surgical procedure. Encirclement is the other procedure known as Thiersch operation. Artificial sphincter is not so successful as foreign body usually gets infected. Muscle Transposition is a bigger operation. Technically this procedure works best and it works satisfactorily. High percentage of artificial sphincter gets infected. Ileostomy or colostomy is the operation of lost resort if it interferes with patient's quality of life. As regards impaired rectal reservoir, infections are quite common. Then there are classic pelvic floor problems, hence endoscopy should be performed.

If the surgeon does correct anastamosis there won't be impaired continence after surgery which will correct anatomic abnormality but it will not improve constipation. The patients will get rid of hanging rectum all the time. We do not know what causes it and what the best operation is. During the discussions it was pointed out that there are some congenital causes and in some of these cases we can do nothing. However, one must ensure that the child has diet which helps in normal bowl habits.

Problems of Fistulas

On last day of the course October 6th2011, the problems of fistula and their recurrence were discussed. Management of anal fistulas, flap repair of fistulas all came under discussion. Dr. Ian Calder Lavery first talked about the anatomy of anal canal, internal opening. The surgeon, he opined, must know anatomy of anal canal for successful surgery. Anal fistulas can present as acute abscess following external drainage or occult internal drainage. Patient can complain of pain, fever, drainage with resolution and recurrence. Usually in recurrence use the same drain and treat. He then depicted some slides of anorectal ring, anal orifice. Low level fistulas Dr. Lavery opined can be treated very simply by opening anal canal. In iatrogenic fistulas it is the tension in the tissues which hurts. Put in local anesthetics and ensure that tissues are loose which will prevent pain.

He then presented details of a Scandinavian study of 199 sphincter pressures and fistulotomy. In this 34% of the patients had substantial reduction in anal pressures. In case of long fistulas, pull them down, leave them there for few days and then amputate it which will give good results. CCF is more commonly used for Crohn's disease. He also discussed Trans abdominal mobilization and rectal vaginal fistulas complexities. He was of the view that some time it is difficult to find out where the internal opening is . He also discussed management of recurrent ano rectal sepsis. Sub mucosal abscess, Dr. Laverey stated, is very common. Complex fistulas are difficult to define. One should drain abscess, re examine the patient after few days and keep the drain there and probe gently to avoid injuries. He then depicted multiple cutaneous opening slides. Mushroom devices, he said, come in various sizes. These devices are soft enough to be tolerated by the patients very well.

For identification of internal opening, one has to do digital exam, assess sphincter, external orifice location, probe direction residual sepsis and do anoscopy. Fistulography was uncomfortable, inaccurate in 84% of cases in one study. There were many false positive results in excessive operation. He also referred to the role of manometry besides discussing the role of multipara women and previous anal surgery.

During the discussion which followed, it was stated that drainage dries out but fistula remains. MRI can be helpful in many cases of complex fistulas. Responding to a question from Prof. Amjad Siraj, Dr. Lavery said that he does imaging with the radiologist and if you rely on radiologist alone you will always be in a mess. Sit baths after surgery is useful and it works well in some cases. Responding to yet another question he said he does not have any experience of ligating internal opening. Flexible fistuloscopes can be used to staple internal opening. It was emphasized that this is not the operation for junior surgeons and only seniors should be doing such procedures.

Later on the first case which Dr. Ian Calder lavery operated was eighteen years old male of complex fistula. He also had second degree haemorrhoids and two fissures. He had haemorrhoids for quite some time. Bad bowl function was the cause of all problems. Lot of pain after anal surgery Dr. Ian Calder Lavery opined is due to use of diathermy. The surgeon should only remove skin and save the underlying tissue and ensure that there is no damage to sphincter. He then showed how he was pushing the muscle back and then removed the external haemorrhoids. He pointed out that there are different ways of decreasing pain in haemorrhoids surgery. This patient had big bulky haemorrhoids.

Replying to a question he said this haemorrhoid was bulky for banding. Post operative pain is bad. There is always some discomfort in some patients; they have a sensation of incomplete evacuation for some days. Oral analgesics can be quite useful and these patients are usually out of the hospital in 24-48 hours. In case of insurance company involvement, some of these patients in USA go home the same day as they wish to curtail the hospitalization charges. Answering another question he said it is a painful operation and there is always little bit of infection in such cases. Bad bowl habits are responsible for all the problems in these patients. Answering yet another question Dr. Lavery said that there is no chance of anal stenosis in this case which he had just operated. One should always leave some skin between two wounds to avoid stress taking place. As regards chances of anal strictures, anal stress in such cases. IM injections will release the muscles, he added.

Concluding Session

Speaking in the concluding session Prof. Mumtaz Maher said that ever since the start of this course couple of years ago different surgeons have been coming here and demonstrating different surgical techniques and procedures. At times there is a feeling among some that there should be more didactic lectures which will be helpful for the postgraduates. We should be selecting simple straight forward cases for live demonstration instead of testing the skills of the trainers. They should be asked to discuss basic anatomy and pathology and then demonstrate a few cases. Dr. Shamim Qureshi suggested that the participants should come early so that the programme could be started in time. It was also emphasized that efforts should be made to bring in interesting cases for live demonstration and if you find any such interesting case, if possible keep it for the next course.

Another suggestion made was that if possible after consultation with the CPSP if these lectures and live demonstration could be shown at other centers of CPSP through Video conferencing facility which is available at CPSP, it would be much more useful. Prof. Mumtaz Maher opined that consultants have no time to do simple haemorrhoids; they do give hernias to juniors. The basic objective of this course was to train juniors who do not have the facilities and resources to go abroad so that they can benefit and learn from distinguished colorectal surgeons coming here.

Prof. Channa commended the vision of Prof. Mumtaz Maher who initiated this activity couple of years ago and Dr. Shamim Qureshi has taken it forward. Colorectal and anus are the difficult areas to operate. It is also difficult to get any new specialty recognized. We heard it from Dr. Ian Calder Lavery how difficult it was to establish this even in United States during his presentation at CPSP. Prof. Mumtaz Maher opined that there must be some take home messages. He commended the master trainer who demonstrated lot of surgical procedures. Dr. Ian Calder Lavery said that he was delighted to be a part of this special programme at JPMC. The thought and philosophy behind this academic activity is commendable which is better insight into different aspects of colorectal diseases. He hoped that the participants will carry few things from this course which will help improve and change their practice.

Later the master trainer Dr.Ian Calder Lavery was presented mementoes by Prof. Mumtaz Maher, Dr. Shamim Qureshi and Prof. Channa who also presented a shield from CPSP for delivering a lecture at the CPSP which was also shown live at all the regional centers of CPSP. Prof. Tariq Mahmood, members of the OT team, surgical team and all others who worked hard to make the course successful were also recognized.
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Publication:Pulse International
Geographic Code:9PAKI
Date:Nov 14, 2011
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