Prof. Adam Dziki highlights different surgical procedures for treatment of ulcerative colitis

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Prof. Adam Dziki highlights different surgical
procedures for treatment of ulcerative colitis

Vaginal delivery is safe after restorative proctocolectomy
but it is advisable to suggest for C-section to these patients

Most of our teaching hospital lack behind, We all must look into
ourselves as to why we are not moving forward in the field
of laparoscopic surgery - Prof. Mumtaz Maher

KARACHI: On first day of the colorectal surgery course held at JPMC, Prof.Adam Dziki made a presentation on surgical treatment of Ulcerative Colitis. Among the operative findings, he mentioned Subtotal colectomy (STC) and end ileostomy, total abdominal colectomy (TAC) and ileal-rectal anastamosis, Total proctocolectomy (TPC) and end ileostomy, Total proctocolectomy and continent ileostomy besides Total proctocolecotmy and ileal pouch-anal anastamosis.

Prof. Adam Dziki photographed along with organizers and some participants of colorectal
surgery course at dinner reception hosted in his honor at a local hotel.

Talking about indications for STCD and End ileostomy he mentioned significant co-morbidity, obesity, some patients who are on immune-modulating drugs, some are on high doses of corticosteroids, severe hypo albuminemia and sever anaemia. In Sub-total colectomy and ileostomy avoid peritonitis. TAC and IRA are indicated in obesity, stage IV colon cancer, concern for fertility and marginal sphincter strength. Total proctocolecotmy and end ileostomy is indicted in patients with significant co-morbidity, obesity, marginal or poor sphincter strength, stage II-IV upper or middle rectal cancer, stage I-IV low rectal cancer and failed IPAA. As regards TPC and Continent Ileostomy its indications include marginal or poor sphincter strength, aversion to end ileostomy, stage I-III low rectal cancer and failed IPAA. He laid emphasis that sharp dissection should be performed in all procedures so that there is no bleeding. He also briefly discussed how to perform S. Pouch and how to do anastamosis.
Continuing Prof. Adam Dziki said that there are some controversial topics in TPC and IPAA which includes its appropriateness for elderly patients, its appropriateness for toxic colitis, appropriateness for Stage I-III colorectal cancer, avoidance of mucosectomy, pouch configuration, avoidance of ileostomy, its appropriateness in Cohn’s disease and infertility. In elderly there is comparable morbidity. In toxic colitis there is increased re-operation rate and increased pouch failure. He also talked about anastomotic complications, dysplasia and cancer risk. In TPC and IPAA avoid ileostomy; it should be performed as an elective procedure by experienced surgeons. There is a three fold increase in infertility after IPAA. Vaginal delivery is safe after restorative proctocolectomy but it is advisable to suggest for C-section to these patients. Vaginal delivery is associated with significantly increased sphincter injury and decreased squeeze pressure. Quality of life and functional outcome is comparable between vaginal delivery and C-section and C-section may be better in pelvic pouch patients. Leak of anastamosis and late operative complications can be seen. Laparoscopy and IPPA is feasible but it is a longer procedure, is safe, ensures quick short term recovery, conversion rate is acceptable and it is associated with less pain. However, I do not have much experience of this, he remarked.

Giving results of a study using infliximab in Ulcerative Colitis, he said, eighty five patients were treated of which forty six had two stage procedures. Infliximab was administered within a median of sixteen weeks preoperatively. Median use of infusions was 3.2. Six patients suffered from side effects which could be attributed to the drug and one patient developed lymphoma in the pouch. Infliximab use in ulcerative colitis, Prof. Adam Dziki said increased the risk of early and late postoperative complications and there is a greater need for unplanned 3-stage RP. He was of the view that the risk of both use of infliximab and surgery should be presented to the patient who fail to respond on conventional medical therapy. Results from over four thousand patients showed that 97% of the patients said that they would prefer to go for surgery again and 97.4% stated that they would be willing to recommend surgery to other patients.
Prof. Mumtaz Maher was the next speaker who pointed out that we had thought that we will have such a course in rotation at different centers in Karachi but it did not work out. We wish to promote laparoscopic surgery. We wanted to promote laparoscopic colorectal surgery and it has also not materialized for various reasons. Our objective was to disseminate surgical skills. We all must look into ourselves as to why we are not moving forward in the field of laparoscopic surgery. Most of our teaching hospitals lack behind in laparoscopic surgery. Good laparoscopic surgery is superior to good open operation; it is minimally invasive, offers superior imaging with superior haemostatic and anatomic dissection techniques. Bad laparoscopic surgery is detrimental to patients. Open surgery offers a lot of advantages. One should try to achieve good laparoscopic results. Malignancy poses its own challenges. Advanced cases of cancer even Stage-III is not good for laparoscopic surgery. Very small number of colon cancer can be suitable for laparoscopic surgery. Once I made a stoma in a cancer case and the scar was large enough.

Visiting Polish Colorectal Surgeon Prof.Adam Dziki photographed
with the surgical team in the Operation Theater at JPMC.

Speaking about how to start laparoscopic colorectal surgery Prof. Mumtaz Maher said one should ask oneself a few questions i.e. why are you doing it? Who should be doing it? One must have enough experience with open colonic surgery, a good number of patients, proper equipment, and team and back up support. If you do not have enough number of patients, do not go for laparoscopic surgery, he remarked. Remember learning curve is long and surgery is demanding. One must have good experience in open colonic surgery. Cancer cases have to be dealt with differently following principles of cancer surgery. To become a specialist in laparoscopic surgery one must attend workshops and do a fellowship for couple of months. It is important that one understands the principles of open colorectal surgery; one must have enough basic training in laparoscopy doing appendix and gallbladder and understand application of these principles to laparoscopic colorectal surgery. To ensure success, it is important to institutionalize this specialty, pool the cases, and learn to work as a group. Record and review each and every case and know your results. I have got both thirty degree and forty five degree telescopes. It is also important how you use your instruments. You should learn how to introduce Trocars; you should know how to assist to become a good surgeon. In a group you learn together. Do not go on making mistakes. It is important for the seniors to allow young generation of surgeons to grow together and learn together. Get the basics right i.e. positioning of the equipment, patient, tilt the table, have an intelligent person on the camera, how to insert Trocars, use two hands technique, learn hand eye coordination. If there is some problem, you should know how to get things right otherwise you will be frustrated. Prof. Mumtaz Maher further stated that one should learn to use both hands, learn advanced techniques, how to manipulate tissues pushing, pulling, how to use energy source, use of staples, suturing and how to retrieve specimen. It is high time that we look for reasons why we are not progressing in laparoscopic surgery in Pakistan, he remarked.


Live Demonstration

This was followed by a live demonstration of EUA and lateral sphincterotomy for fissure in ano. Prof. Adam Dziki cautioned the audience that one has to be careful while operating in this area not to damage the external sphincter. Do not use diathermy too much. The patient he was operating upon had a deep chronic fissure. He advised that one can put Gauze and some other agents to stop bleeding.
Participating in the discussion Surgeon Naveed Shah said that laparoscopic surgery is not easy and one requires a reasonable amount of volume. If you do not have enough patients, do not do it. It is also important that one should know what he/she is doing and do not do if you do not know, he remarked. Prof. Muzzafar from Peshawar remarked that there is lot pelvic floor abnormality in patients that we see there. Patients suffer from incontinence and urgency. We need to train some female pelvic floor specialists and we also need to train some female urologists. Dr. Bushra Shirazi remarked that it is a reality. We all have been trained, some are better than others. Some do ontological surgery which they should not be doing. The problems we are facing are lack of equipment, lack of volume. Those in public healthcare facilities do not know it. If one person has eight trainees, they all won’t get hands on training. Not being in an ideal situation, how we can move forward, she asked? Prof. Mumtaz Maher remarked that if people agree and decided to sit together, things will work out. But our problem is that we do not sit together. We need to identify a few juniors who are interested and then train them. Decision has to be taken early as laparoscopic surgery takes time and we should not discourage juniors which will not be good. Dr. Jamil from Peshawar said that there are no structured programmes and no workshops. We need to have a two to three weeks course. CPSP may be approached to start a Fellowship in Colorectal Surgery. We need to have dietetician and psychologist as members of the team and those at the helm of affairs have to start the process.
Prof. Majeed Baloch former Director of JPMC said that we are not moving forward but going backward as a Nation in every sphere of life and it is true in surgery as well. Laparoscopic surgery has advanced and we in UK hardly see any patient coming with a scar. Most surgical procedures including thyroid surgery is being done by minimally invasive surgery, laparoscopic surgery. It has become our national character, we only talk and do not do. We suffer from lack of resources, people lack trust in each other and all this needs to be corrected. It is good that at last we have started talking about it; some one will have to come forward and do it. Prof. Leghari from LUMHS Hyderabad opined that in most units, juniors are not allowed to do laparoscopic surgery; they should be given a chance. Prof. Muzzafar said that we have started colorectal OPD. In the days to come we can form the Colorectal Society of Pakistan to promote this specialty.

Prof. Mumtaz Maher said that one cannot practice during an emergency. Some of the laparoscopic colonic procedures which can be performed include appendicectomy, bowel diversion, colonic mobilization and restoration of bowel continuity. There is a long learning curve. The number of cases one should have done to become efficient in the technique vary but it must include some complicated procedures as well. It is important that one plans the operation, have proper access and good vision, know the maneuvers, different stages. One should be aware of the likely complications, how to avoid it, deal it and how not to get into trouble. If problem arises, then one must know how to get out of it and make sure that patient does not suffer. Those interested should go and watch experts operating. There are many training options available which include going through the literature, video and looking at the internet, computer simulation, case observation, attending laparoscopic courses, having a surgeon as a Mentor and going for Surgical Fellowship. The limiting factors for surgery include operating time, blood loss and transfusion rates, complication rates, pathological margins and lymph node yields. Conversion rate of less than20% is acceptable, he added.