Fecal incontinence is under reported as patients are reluctant to discuss it-Prof. Francis Seow-Choen


 Surgical Week for Colorectal Diseases at JPMC-II

Fecal incontinence is under
reported as patients are reluctant to
discuss it-Prof. Francis Seow-Choen

Perineal Delrome’s surgery is operation
of choice in Rectal Prolapse

KARACHI: On Third Day of the 13th Annual Surgical Week for Colorectal Diseases organized by JPMC Karachi from October 8-11th 2018 Prof. Francis Seow-Choen started the day’s proceedings with a presentation on Strategies in Fecal incontinence. He pointed out that people are reluctant to discuss this and it remains under reported. Its prevalence is reported to be 8.3-20% among US women and only one third of these US women seek care. Age, watery stools, congenital malformations are some of the reasons. He laid emphasis on complete physiological and anatomical assessment, looking at neurological defects and also suggested annual pelvic ultrasound examination.

Prof. Francis Seow-Choen

Continuing Prof. Seow said that incontinence could be of solid, liquid stools, incontinence of gas, severity of incontinence is variable while patient’s anatomy and life styles are also variable. He also talked about dietary modifications and said that use of fiber results in more bulky stools and also more incontinence. Low fat diet decreases diarrhea. These patients should avoid taking food with lot of chilies and pepper.

Speaking about drug therapy he said Loperamide, Atropine are helpful and easy stool. Pelvic floor exercises, digital feedback is also helpful. Nurses are trained in it. Nerve stimulation also results in 50% improvement. The side effects include 3% infection and 12% dislocation of the device. Posterior nerve stimulation is also helpful, patients maintain continence. Artificial bowl sphincter is yet another useful device. Pump is also used, the patients are asked to pass the stool and then inflate the pump. He also referred to the Magnetic ring series of beaded titanium, muscle transposition and reconstruction of anus which helps 75% patients achieve continence. Fecal diversion colostomy is cost effective but patients have to be educated in stoma management. He then talked about collagen silicone injectable which are useful for those who have failed with medical treatment or suffer from mild incontinence. Almost 50% of patients will find it effective. Other treatment modalities which he discussed included plug anal insertion device which is reported to be effective in 62% of the patients who pass stool and after that one can remove the plug. Vaginal bowl control device was also discussed. He concluded his presentation by stating that there was a wide range of devices which can be used. One must select the simple, tailor to the needs of the patient and start with dietary control.

His next presentation was on Rectal Prolapse surgery. Rectal prolapse, he said, is defined as full thickness protrusion. Almost 90% of women over fifty years of age suffer from this disorder. Male patients are younger due to congenital deformity. These patients are either in nursing homes or are elderly. He then discussed in detail narrowing of the anal orifice, restoration of pelvic floor, perineal approaches. As regards mucosa length of rectal prolapse, when we cannot pull it out, it is sutured. Most of these patients are managed on Day Care basis. Abdominal approaches have 33% morbidity which include obstruction and erosion. He then spoke about Laparoscopic Ventral Mesh Rectopexy (LVMR). Different approaches are followed in United States and Europe. He was of the view that we need to select the simple operation in our part of the word which has low morbidity and low recurrence. Perineal Delrome’s surgery is operation of choice, he added.

Laparoscopic Rectopexy

Prof. Roger Motson made a presentation on Laparoscopic Rectopexy. He pointed out that there are different options but many do not work. We sill to not understand rectal prolapse and the operation of choice though abdominal Rectopexy was the current favourite. Abdominal Rectopexy is most effective, has more morbidity while perineal operation is also safe but there are chances of incontinence and recurrence. We need to opt for a procedure which is cheap, cost effective, has less complications.

Prof. Roger Motson 

Wound hernias occur in 4% of patients with abdominal procedure whereas perineal procedure has 18% recurrence. Laparoscopic procedures are preferred as compared to open if the patient is fit for general anesthesia. First I used to use Mesh but no more. I gave up using Mesh twenty five years ago. He then discussed his surgical technique which was supplemented with a video presentation.

Continuing Prof. Motson said that both Lap Anterior Rectopexy and Abdominal Rectopexy have advantages as well as disadvantages. LAR is used for internal rectal prolapse. He laid emphasis on good patient assessment, trial of initial conservative management, use of stool hardening medications. Clinical examination he opined was very important. Inadequate resection is part of recurrence. One should be good at dissection and suturing before start doing rectal surgery. The learning curve depends on the individual’s competence and ability. Responding to a question Prof. Motson remarked that Gluing and then pulling is not a good combination. However, Prof. Shamim Qureshi opined that some surgeons do use glue and then use two stiches. Prof. Motson further stated that Mesh should not be too tight, but it should be relaxed otherwise there will be recurrence. He then jokingly remarked that rectum as well as surgeon should also be relaxed. Conclusions from his presentation were that evolution in rectal prolapse surgery have been going on but still we do not know which one is the best. LAR can also be used in carefully selected cases for internal rectal prolapse. Simple Lap sutured Rectopexy is mostly used these days. There could be troubles ahead with Mesh. He then disclosed that one of the surgeons was suspended from operating who had used Mesh in vaginal prolapse. In Ventral Mesh Rectopexy the future is uncertain, he added.

On fourth day of the course Prof. Roger Motson discussed Lap Restorative Proctolectomy. For this procedure, he opined, one should choose the right patient who is not too fat and not too thin. The patient should not have any previous surgery before restorative proctolectomy. One should prepare the surgeon, nursing staff and anesthetist team for the case. No one should be under pressure. Embark upon an operation which you have done most often. He then discussed at length anterior resection, left hemi colectomy, right hemi colectomy. Have your best assessment, ask the nursing staff to scrub and then mark site for stoma pre-operatively. The one with his head down is a happy anesthetist. There should be multiple moveable monitors in the OT. Patient’s legs should remain down until pouch and anal anastomosis. He then talked about placement of port. In left hemi colectomy lean towards meso rectum. In anterior resection, most resection is from right side. Transect with 30mm stapler. AP is often best. He also referred to perineal push and felt that one should leave some rectum in pelvis. In right hemi colectomy one should stand on left side but in transverse colectomy come back to the right side. Retract colon, transect middle colic vessels, it is easy to get host hence check direction of travel frequently. In the next stage which relates to specimen delivery, pulling hard may damage the terminal ideal mesentery turning into a disaster. Make a small enterotomy in the colon and suck out the contents. Make a pouch and then close the stoma site. His advice to his surgical colleagues was that never lose concentration at the end, find edge of small bowel mesentery over the duodenum. Follow it to the pouch with all the small bowel. Next stage is pouch anal anastomosis and then put a tube drain in the pelvis. Level the patient and ensure small bowel is lying in orderly pattern. After this re-open the stoma site and deliver the ideal loop.

Replying to a question during the discussion Prof. Motson said that do not open as transverse colon will take more time as it is more difficult. Prof. Francis Seow showed liver surgery operating on a twenty years old female patient who was suffering from ulcerative colitis and was on steroids. Prof. Motson also referred to selection of stoma site and pointed out that small stoma will end up with obstruction. Prof. Seow in response to a question said that he personally do not like music in the operation theatre. Instead I would like to talk to my trainees. Music is distracting and one cannot concentrate on surgery which will make the life more miserable. In the end music becomes distraction and I do not like distraction while I am operating, he added.