Good knowledge of anatomy and good surgical technique are important for better outcome in rectal cancer surgery - Prof. Adam Dziki

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8th Annual Colorectal Surgery Course at JPMC-II

Good knowledge of anatomy and good surgical
technique are important for better outcome
in rectal cancer surgery - Prof. Adam Dziki
It is advisable to discuss all the related problems
with the patient before initiating any surgical procedure

KARACHI: While managing patients suffering from rectal cancer it is essential that one discusses all the problems with the patient before initiating any surgical procedure. Good knowledge of anatomy and good surgical technique are important in ensuring better outcome. This was stated by Prof.Adam Dziki Prof. of Surgery from Medical University, Lodz, Poland. He was making a presentation on rectal cancer surgery on the second day of the 8th Colorectal Surgical Course held at the JPMC from September 30th to October 3rd where he was the invited guest speaker and the master trainer.
Speaking on the goal in rectal cancer surgery Prof.Adam referred to preparation in the right planes and ensuring that there is no bleeding during and after the surgery. There should be no breakdown of mesorectum, no tension of the anastomosis and there must be adequate margins i.e. proximal, distal, and lateral and above all there should be no functional deficit. He then talked about factors in rectal cancer patients which could be patient related, tumour related or technical factors. The patient related factors include age of the patient and the gender. Doing rectal surgery in obese patients is a challenge for the entire surgical team and it may affect the surgical outcome. Bulky deep tumours, location and invasion of surrounding tissue all make it difficult. In obese patients, non-visibility of inside and outside, non-palpable structure, tissue consistency and not enough light to see well are some of the difficulties one faces in such patients.
Discussing steps in rectal cancer surgery Prof.Adam Dziki mentioned above the pelvic prim, below the aortic bifurcation, along the pelvic side walls, distal anterior dissection, posterior and distal dissection besides extreme distal dissection. As regards sigmoid mobilization, descending is better than sigmoid colon. Some oppose while some prefer J. Pouch. He then talked about mobilization of left colonic flexure and said that one should beware of splenic injury. Stay close to bowl wall while doing division of bowl, always do sharp dissection. In the beginning posterior dissection is easy. Markers have quality of life, preserve continence and ensure distal clearance margins. Stoma is a better choice for old ladies as they have lose sphincters since some of the ladies have too many deliveries. Ensure that the patient has reasonable bowl frequency. He then showed a number of slides depicting along the pelvic side walls lateral rectal dissection, distal anterior dissection Denovillier’s fascia, posterior and distal dissection in rectal dissection and perimesorectal dissection. He also laid emphasis on avoiding permanent sexual and urinary disturbances. For preservation of continence, ensure distal clearance margins. He was of the view that as long as margin itself is not involved risk of recurrence is not increased.
During the discussion it was stated that local recurrence can be reduced form 8-2%. Short course and long course of adjuvant therapy with radiotherapy lasting from five days to six weeks have been recommended. After radiotherapy you have less lymhnodes than without radiotherapy. Lower and lower means bigger risk of anastomic leak. Go for 5cm below mesorectum. Upper and lower mesorectum are difficult. In case of lower, go for total mesorectum but in case of upper, leave 4cm margins. Endorectal ultrasound is quite helpful but MRI is not available all the time.
Prof. Mumtaz Maher talked about acceptable surgical limiting factors and mentioned operating time, blood loss and transfusion rates, high ligation, complication rates, pathological margins, lymph node yields. He was of the view that we were not moving forward as regards laparascocopic colorectal surgery was concerned. We do not have enough volume which is not good. He again reiterated his suggestion that public healthcare facilities should select some juniors who are interested and send them for training to good centers; all the wards should pool their resources. Make sure that while one is operating, other two are assisting. It will reduce the learning curve. If one in five cases have to be opened up, look at the reasons why conversion had to be done and then correct those mistakes. In case of laparoscopic stoma, select benign case rather than a malignant one. As regards selection of patients, female is better and right side is easier while working in the pelvis area. One does not see central obesity much in the West. He then talked about the size of the pathology, BMI of patient, risk factors and pointed out that discuss doables as a team. If you are not making any progress, it is better to convert. Securing blood vessels, knowing anatomy of vessels is important to avoid bleeding. There should be no compromise on blood supply, ensure tension free anastomosis. He also laid emphasis on having right set up, proper equipment, ensure availability of retractors as you may need anything hence they should all be available in the operation theatre. Insufflations can be a problem and it can do harm. He also referred to the drop test and said that make sure to flush the needle and if there is some tissue inside, it will be removed. Then gently insert the needle. He then discussed the placement of trocars.

Live Demonstration

This was followed by a live demonstration of open haemorrhoidectomy which was the first case done by Prof. Adam Dziki. He pointed out that if need be, one can use the pain killers but after the procedure, these patients can be sent home next day and one should not wait for bowl movement in the hospital. Responding to a question Prof.Adam said that we do give pills for pain relief on demand and they are advised sit bath post operatively. We do not use antibiotics post operatively, Prof.Adam Dziki stated.
Continuing his presentation Prof. Mumtaz Maher said that in one patient one can have one trocars for telescope, two for surgeon and one for anesthetist; hence four to five trocars can be used in one patient. It all depends on the number of instruments you are going to use. However, he cautioned that be careful of trocars going into different vessels and causing injury. You can cause damage and correct it but better to avoid it. As regards single incision surgery, I do it only for gallbladder and not for everything as patient safety comes first, Prof.Mumtaz Maher remarked.
Continuing Prof. Mumtaz Maher said that while we started doing laparoscopic obesity surgery, we had to invest in table and lot of equipment which was very costly. It is one thing to look at the technique but in practice you require lot of support services as well. Having appropriate equipment is the first thing and then one should go and assist and not look at someone doing it. You can come across anesthetic problems, take it more seriously. We have got endotrainers in various hospitals but we are not using them. Suturing can be learnt on them very easily. Once an investment has been made use these endotrainers for skills proficiency. It is the practice which makes one perfect. The results, Prof. Mumtaz Maher said can be good and bad. Do the right thing only then it makes it perfect, he remarked.
Responding to questions during the discussion Prof. Mumtaz Maher said that one learns by assisting. One has to learn the various maneuvers, hands and eye movements, using both hands. One of the participants remarked that government hospitals are under pressure to do more work because of burden of diseases. hence specialization does not get any importance. Prof. Mumtaz Maher said that let the public healthcare facilities, tertiary care centers send some young people abroad for training. It requires a policy decision but we continue to do the same things in all the different units in the same hospital. We do recognize that something is going bad but the problem is that we cannot get together and set things right.
The next case which Prof. Adam Dziki operated and showed live was of cancer of rectum. It was a forty years old patient. He described the anatomy of pelvis and emphasized that one must take care of sexual and bladder function. This was followed by a brief presentation by Dr. Abul Fazal Khan from Lahore who described his technique of haemorrhoidectomy.
During the discussion in the consultant corner on management of low tumour rectal cancer, it was emphasized that one should not change the golden principles just because one of the team members is not in agreement. In Pakistan, Prof. Majeed Baloch said one stage surgical procedure is more acceptable than two stage procedure. When patients get fed up they run away with colostomy. It is important to counsel the patients. Two stage surgical procedure works in UK and USA because of their literate population. Prof. Adam suggested that if someone has obstruction, then one should go for stoma. During radiotherapy tumour does shrink. This patient, it was stated, again presented with acute intestinal obstruction ten days later, surgical stoma was made in local but it did not change the fate of the patient who then left against medical advice. The next case presented was of pseudo myxoma secondary to mucocele and the next case was of carcinoid tumour who also became LAMA and later had a right hemicolectomy in a private hospital.

Rectal Prolapse and Incontinence

On third day of the course Prof. Adam Dziki made a presentation on choosing the operation for rectal prolapse and incontinence. Speaking about the goals for surgery for rectal Prolapse, he said that it consists of preventing Prolapse, prevention of progression of incontinence besides improvement of associated incontinence and constipation. Nearly all these patients need surgery. There are over hundred different surgical procedures described for this condition but none of them is perfect, hence it is advisable to individualize the patient and adopt the procedure which is suitable for that particular patient. Non surgical management consists of Truss. The surgical procedure for rectal Prolapse, Prof, Adam Dziki said depends on age of the patient, co-morbid conditions, degree of Prolapse and associated pelvic disorders. He then referred to abdominal approach vs. perineal approach and said that in abdominal approach there is less recurrence. It can be done laparosocpically. There are negligible anastomotic leak, abdominal sepsis, stricture, adhesions and need general anaesthesia but perineal approach is less invasive, has less morbidity. It can be performed in frail elderly patients, it can be done with regional anaesthesia and there is negligible infection and wound breakdown. In abdominal approach, one should know how much to mobilize and resection can also lead to constipation.
Speaking about functional outcomes in abdominal approach for rectal Prolapse, Prof.Adam Dziki said that with anterior rectopexy, constipation becomes worse in 20% of cases, there is over 70% improvement in incontinence while with posterior rectopexy, incontinence improvement is seen in over 50% of the patients but constipation becomes worse in 20% however in resection rectopexy there is 77% improvement in incontinence. Laparoscopic surgery is very attractive, it is feasible, effective with good results in good hands, and recurrence is low. It has many advantages but high cost is an important issue. Long term recurrence is not significant. In open method, there is more morbidity; it is a difficult perineal approach. Loss of rectal reservoir is the disadvantage of rectal surgery. For females and elderly male patient’s Laparoscopic Rectopexy is good. For those elderly patients who are unfit for surgery, perineal approach is good. Speaking about treatment options for fecal incontinence he discussed the traditional treatment modalities like medications biofeedback, sphincteroplasty, colostomy while the new treatments include sacral nerve stimulation, injectable and implantable agents besides artificial anal sphincter. Sacral nerve stimulation can lead to 50% reduction in fecal incontinence but it is not good for every patient. Implant devices result in site pain in 28% of cases, paresthesia in 15%, and change in sensation of stimulation in 12% and implant site infection in 10% of patients. Sacral Nerve Stimulation offers high success rate which seems to be sustained in long term, it also works in patients with sphincter defects. As regards injectable biomaterials, the sub mucosal injection is easy and does not require any local anesthetic but intersphincteric injection need ultrasound direction and local anesthetic. There are easy procedures for Magnetic anal sphincters, they offer 50% improvement and there are no major adverse effects as well.
Talking about the treatment modalities at the horizon Prof.Adam Dziki mentioned percutaneous tibial nerve stimulation, magnetic anal sphincter, ventral rectopexy, rectal sling and implantable bulking agents. Treatment of choice in children is sub mucosal injection using mucosal Prolapse. Wait for sphincter to repair. Pelvic floor exercises, it was stated, are also quite helpful. Some surgeons and patients say they had good results with biofeedback but we did not have good results with it. Post anal repair is successful in some cases but implants are very expensive, he added.
The next live demonstration was sphincter repair which was done by Prof. Adam Dziki. He laid emphasis that first does no harm. Avoid tearing the muscle. After the surgical procedure, these patients should be kept on liquid diet for three to four weeks. These patients remain in hospital for five days and the success rate is between 50-55%. Wash the area and then close the wound with a hole. Always cover the perineum. Responding to a question from the audience as to what type of operation it was Prof Adam Dziki said that it is known as double breast procedure. Surgeon Moiz wondered about the long term effects of this operation in female patients. Prof. Majeed Baloch suggested pelvic floor exercises.
One of the cases presented in the consultant corner was of solitary rectal ulcer. Participating in the discussion Prof. Amjad Siraj said that in patients with normal bowl habits, one should treat the constipation first and then go for surgery. Dr. Shamim Qureshi said that some of these patients spend too much time in toilets and some of them are already taking antipsychotics and antidepressants. Another patient who presented with rectocele had ventral rectopexy.

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