Most colorectal diseases were discussed in detail during the four day course

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 Surgical course for colorectal diseases at JPMC

Most colorectal diseases were discussed
in detail during the four day course

KARACHI: Many interesting topics in colorectal diseases were discussed during the four day surgical course on colorectal diseases organized by Dept. of Surgery, Jinnah Postgraduate Medical Centre, Karachi from October 5-8th 2015.  The organizers kept up its past traditions of providing this education and training facility to a vast majority of surgeons particularly the young surgeons without any registration. This time,  the format was a bit changed as Prof. Francis Frizelle form New Zealand demonstrated his surgical skills and techniques while Prof. John Nicholls from St. Mark’s Hospital whowas on his second visit to Pakistan made presentations on various topics followed by lively discussion.

Some of the topics which were covered by the guest speakers during theirpresentations included  an overview of restorative proctocolectomy,Tips andTrick of Pouch Surgery and End anal Anastomosis through Video session,  how to manage and prevent pouch complications, Anorectal examination and operative options in Hemorrhoids, Total Mesorectal Excision,  Recurrent rectal and colonic cancer prevention and treatment, Management of Anastomotic leakage following rectal cancer surgery, operative intervention for fissure in ano, an overview of recent advances in surgery for rectal prolapse, Management of solitary rectal ulcer syndrome and rectocele.

Prof. Frizelle showed live demonstration of Milligan Morgan Hemorrhoidectomy, APR/Anterior Resection, and Fissure in ano-lateral sphincterotomy, abdominal rectopexy and Pilonidal sinus.

On October 7th, Prof. Riaz Dab from Faisalabad was moderator of the session.  In response to a question Prof. Frizelle said that use of diathermy is very easy. Some people are afraid to useit. What is adequate mobilization and the landmark to see the nerve, size of the stich in the rectum, biological mesh and its recurrences were also discussed. 

Prof. John Nicholls speaking about Rectocele and solitary ulcer syndrome said that it is anevacuations disorder obstructive defecation syndrome. It is very common with us and it is often missed.  It is the tip of iceberg of pathological diseases of which we are ignorant. In functional bowl disorders surgery, one has to be cautious, know the patient, and have full discussion with the patient. It is probably not the answer but in a few selected cases.Complicationsinclude delayedcolonic transit and obstructive defecationand one third of the patients have both.  Rectocele is mechanical obstructed defecation, incomplete emptying, trapping of stool, straining and digitation. Fecal incontinence leads to post defaecatory. Treatment options include conservative regulate bowl functions and biofeedback explanation.  Surgery consists of posterior colporrhaphy, Trans anal repair, internal Delorme’s procedureand, ventral rectopexy. Plication of rectovaginal is done both by gynecologists and proctologists in United States. Trans anal report, Prof.John Nicholls said gives good results in 80% of cases. Trans anal repair results by various surgeons shows a success in 50-75% of cases.  He also talked about StapledTrans anal RectalResection procedure. Stapler procedure is an expensive treatment for hemorrhoids. He quoted a study of 85patients whohad 58% improvement in symptoms, 11% had urgency and post-operative bleeding was seen in 12% of patients.

On October 8th the last day of the course, Prof. Frizelle gave a talk on Rectovaginal fistulae, Pilonidal sinus and enhanced recovery programme. Prof. Nicholls discussed fistulae plug, re-routing, LIFT- ligation of inter sphincteric fistulae track.  He pointed out that there have been marvelous new developments since 2007. It was first done by Rajanaskue and had a success rate of 70%.  Fistulae in Ano lay open is effective with good function most often.  Closure of internal opening is effective in 50% of cases.

In his next presentation he talked about STOMA indications, how to construct stoma and manage its complications. You want to do it when there is perforation, trauma, and obstruction, incontinent or distal pathology. It should be done by a competent surgeon or comprehensive trainee. Stoma therapist will mark the site, try out the appliance, pre-operative play, look at the location and see if the patient really needs it. One should avoid midline scar, bony prominence and skin creases particularly in obese patients. Do not remove subcutaneous fat and follow surgical principles of tension free. He then talked about ileostomy technical points. It was Brooke who is credited for creation of spout in 1952. He also talked about appropriate length of stoma, dusky stoma, vascular compromise and stromal relapse.  About 7% of all stomas have late recurrences. Skin complications, Prof. John Nicholls remarked are quite a problem like contact with faeces which is the most common. Contact allergy like dermatitis. Para stromal hernia prevalence is now known. Re-siting of stoma, water and electrolytesmanagement was also discussed in detail.

Prof. Mumtaz Maher winding up the discussion remarked that all major colorectal diseases were covered during this course. Most of the common topics were covered in detail. Prof. John Nicholls said that we have tried to keep the course clinical as far as possible.  It had been a pleasure to visit Pakistan again and meet with so many friendly people. Dr.Sughra Parveen remarked that Prof. John Nicholls has rightly emphasized the importance of history and clinical examination which is far superior to technology. Prof. Qamar Baloch and Prof. Razzak Shaikh from LUMHSHyderabad also spoke on the occasion and thanked the guest speakers for sharing their knowledge and experience with colleagues in Pakistan.