Some rectal prolapse do need abdominal Operation-Prof. Robin Phillips

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 Surgical Week for Colorectal Diseases at JPMC-III

Some rectal prolapse do need abdominal
Operation-Prof. Robin Phillips

In future TME will decline, Organ preservation strategies
will increase and treatment will become more tailored
and personalized-Neil Mortensen

KARACHI: On September 21st, the Third Day of the Surgical Week for Colorectal Diseases at JPMC Prof. Robin Phillips the noted colorectal surgeon from St. Mark’s Hospital UK talked about Rectal Prolapse and Incontinence. He pointed out that arterial tethering and sigmoid redundancy helps choose the procedure. He showed a full thickness rectal prolapse in an eighty five years old lady in whom Delorme’s procedure had failed. Rectal prolapse could be complete, mucosal, internal or solitary ulcer.

 

Prof. Robin Phillips along with Prof. Neil Mortensen responding to questions
from the audience during the discussion at Surgical Week for
Colorectal Diseases held at JPMC recently.

Talking about the historical background of rectal prolapse he mentioned about the various abdominal operations i.e.  Wells posterior Wrap, Rip stein anterior wrap while the perineal operations include Delorme’s and Altemeier. Some rectal prolapse, Prof. Robin Phillips opined do need abdominal operations. In UK, USA, China and Japan there are different procedures. In abdominal operations, use of Mesh is not necessary since sutured rectopexy is just as good.  It has low recurrence, low morbidity. One can do it in elderly patients but it is associated with unpredictable constipation.  We found that almost 50% of patients will develop continence and results of surgery for constipation are un-predictable. As regards perineal operations, Delorme’s procedure is conceptually easy but it is more difficult in practice while Altemeier is conceptually difficult but easier in practice. Complications include haemorrhage, dehiscence of suture line and stenosis. Other issues in rectal prolapse are recurrence, constipation, potency and incontinence.


Laparoscopic rectopexy is cosmetically better, has fewer adhesions but is potentially less effective.  Laparoscopic rectal dissection increase the risk of nerve damage in men. Laparoscope, he said, was just a tool and a fool with a tool is still a fool.  Laparoscopic ventral mesh rectopexy is inappropriately used over a wide range of disorders. In fact it is oversold and now its application was declining, he remarked. Results are not as good as published.  One has to be realistic and there are 20-30% recurrence. He further pointed out that enthusiasm follows fashion. Sphincter repair results depend on bowl regularity, quality of residual muscle and presence of IBS besides the extent of original injury.  Prof. Robin Phillips further opined that surgeons have never been able to do internal sphincter repair.  Nobody has shown it though many people say they have done it. Electively surgeons cannot repair the internal anal sphincter. It controls fine continence to gas, prevents slight mucus leakage and continuing damage leaves a keyhole deformity making the cleaning awkward. As such surgery should be avoided since anal sphincter repair is very difficult. Bowl control will not be perfect as internal sphincter cannot be repaired. Anal sphincter repair he further stated cannot be predicted to give a better results than the patient already has. Nerve damage makes it hopeless. In others repair can be tried but results are likely to be inferior. Patients with diarrhoea, on a high fiber diet with an underlying bowel pathology or with IBS are likely to do worse. Some patients will have fecal incontinence and evacuation disorders.  We do make some of these patients better with sphincter repair. He also briefly discussed post-operative management of sphincter repair. Both immediate and delayed repairs deteriorate with time and the menopause, he added.

Responding to a question as to which operation was better in which patients, Prof. Robin Phillips said that there is no single answer.  Decision will depend on individual patients and age of the patient. I will do perineal operation in elderly patient. There is no one thing called rectal prolapse.  These patients can be very difficult. Outcome for constipation is unpredictable. Young patients may be on psychotropic medication, hence it is difficult to give a perfect answer, he remarked.  It is very difficult to do second Delorme’s operation.

The next session was in memory of late Prof. Sami Ashraf wherein Dr. Vaqar Bari from Radiology Dept. of Aga Khan University spoke about defecating proctogram and surgery. He pointed out that some tests are available for rectal prolapse but proper indication is a must for ordering these tests.  Constipation and incomplete evacuation are some of the indications for defecography. Functions of sphincter are checked by prompting patients to hold, no stress and at evacuation. He also talked about the anterior and posterior rectocele besides limitations and contra indications for defecography. Noncompliance and suspected perforation are some of the contra indications for this test.

Prof. Neil Mortensen talked about modern surgery for rectal prolapse and pointed out that they do not do so many rectal prolapse surgery in their practice these days. He also referred to efficacy and safety in abdominal and perineal operations and pointed out that there is 4% recurrence in abdominal surgery as compared to 18% in perineal procedures hence one has to balance between effectiveness and safety. Prof. Robin Phillips demonstrated life surgery for rectal prolapse and also mentioned about rectal massage. He opined that one should put some adrenaline and give it some time to work. In some patients after Hemorrhoidectomy, sphincter injury can occur.

On last day September 22nd which was devoted to colorectal cancer, Prof. Robin Phillips talked about changing practice in rectal cancer surgery. He discussed at length the role of staging and pointed out that it is truly local disease.  The influence of pre operation radiation therapy in tumour down staging is misleading. In fact it is downsizing. He discussed staging rectal cancer and lymph node involvement. He was of the view that small nodes may be involved and big nodes may be reactive. He then discussed how to use local staging. MRI, Prof Robin Phillips said was essential for rectal surgery while ultrasound is worthless. One should not kill patient on the operation table. He also emphasized the importance of Intensive Therapy Unit, High Dependency Unit and proper anesthesia which reduces the local recurrence.  Pre-operative chemotherapy improves quality of life. Indications for colo anal anastomosis are TME, difficult pelvis. He also discussed the technical considerations and Delorme’s procedures.  No tension means more length.  As regards anastomotic options, there is no difference in stapled or sutured. Colonic pouch will be useful in elderly.

 

Prof. Neil Mortensen speaking at the Surgical Week for Colorectal Diseases
held at JPMC last month.

During the discussion he said that generally one should wait for four to six weeks to see the effects of chemo radiation therapy. We use long term chemo radiation if circumferential margins are involved. In big cases one needs multidisciplinary team to manage these patients and it should include an orthopaedic surgeon as well. One needs some sort of a system for second and third opinion in the management of these patients. He also highlighted the indications for radiation therapy in UK. When the pathologist is doubtful to confirm cancer, in such cases one needs a multidisciplinary team to discuss and take decisions.

New developments in treatment of rectal cancer

This was followed by an excellent presentation on recent advances in rectal cancer and new developments in its treatment by Prof. Neil Mortensen. He pointed out that at present you see many advanced cases but with education and more awareness, you too will not see these advanced cases in the days to come. He also referred to local excision in rectal surgery. Continuing Prof. Neil Mortensen said that a quiet revolution has been taking place with changes in surgery, changes in imaging, changes in neoadjuvant treatment and changes in organization.  He was of the view that surgical failure alone is seldom cause of RI failure as it is related to poor response to downsizing than Mesorectal defects. He also talked about abdomino perineal excision.  Patient with RI resections are significantly more likely to have bad ugly cancers and consequent downsizing chemo radiation than those with resections. Perfect surgery is needed and there is no place for neoadjuvant or adjuvant therapies. Only the total Mesorectal operation TME will do.

He then talked about MRI guided treatment Maastricht. MRI helps to determine CRM status T and N stage. In one of the studies disease free survival was reported to be 80% with local recurrence of 2.2%. He also discussed endoscopic mucosal resection and TEM for early rectal cancer. Case selection, he said, was important. It is also important to ensure better assessment of nodes. There is increasing evidence for CPR and downsizing.  There is better outcome in overall survival in those patients having good response to chemo radiation therapy as shown in one of the studies. Chemo Radiation will improve survival and reduce complications. T3 cases will be able to down size in next ten to fifteen years.  There will be advances in chemotherapy and radiation therapy besides digital rectal exam and endoscopy. He also referred to TAMIS trans anal minimal invasive surgery. This, he said, was a new commercially available device. Robots can use it but it is not widely used and applicable.  He also talked about TEM as a platform for NOTES, Hybrid NOTE TEM, and Tran’s anal Endoscopic TAEP technique and there are about nineteen hundred cases in this Global Registry so far. He also showed a video of Trans anal Total Meso Rectal Excision with a stapled side to end anastomosis and extraction of specimen from the anal canal. Steps in preparation for anastomosis were also showed in detail.


Speaking about the role of colorectal MDT, he said that it provides rapid diagnostic and assessment service. It can manage all patients with colorectal cancer. It will be responsible for provision of information, advice and support for all patients and carers. It will also ensure that the General Practitioners are informed. Collect data for network and audit.

It was suggested that one should wait for twelve weeks after neo adjuvant chemotherapy for surgery.  One of the participants said that in Pakistan we get 90% of patients who are stage T3 and T4. Watch and Wait is not relevant in our practice but may be one day it is possible. Responding to another question Prof. Neil Mortensen said that because of cost involved, we do tumour markers in selected cases and do not do it routinely. He further suggested that one should learn surgery first on cadavers and then do surgery under supervision. On should learn how to do surgery in cancer and not everybody should start doing it. At Oxford we do 20-30 cases of MDT every week and make sure that everybody is doing right thing.  One learns a lot while working as a member of a team. He then quoted a study from GUT 2008 article which stated that when there is unacceptable variation in abdomino perineal excision, it is time to intervene. There is a risk adjusted APE rate among surgeons. Governments and profession must work together to improve the outcome in this surgery.


He concluded his presentation by stating that in the days to come TME will decline. Organ preservation strategies will increase. Treatment will become more tailored and personalized. Every surgeon’s outcome will be published for which high volume and concentrated expertise will be essential. Now 90 days mortality of all surgeons is available on our website in UK as we have to put all our results in this Registry. Asked about the high volume surgeon, he said that some body may be doing thirty cases of colon and rectal cancer per year in UK but in USA, over forty cases per year is considered high volume. At present we are doing over three hundred cases with eight consultants at the center.