Well informed motivated, fit rectal cancer patient can be successfully managed with multidisciplinary approach-Prof. Holm


 Surgical course for Colorectal Diseases at JPMC-IV

Well informed motivated, fit rectal cancer
patient can be successfully managed with
multidisciplinary approach - Prof. Holm

The cause of anterior resection syndrome is considered 
to be multifactorial - Prof. Michael Thompson

KARACHI: On second day of the Surgical Course for Colorectal Diseases held at JPMC from October 9-12, 2017, Prof.  Torbjorn Holm from Sweden discussed Challenges and Advances in surgical treatment of Rectal Cancer. He discussed in detail the various surgical options in low rectal cancer besides LAR with stapled anastomosis. He was of the view that TaTME is a feasible safe operation which was a new technology. It offers shorter operation time and high complete TME rate was one of its advantages. However, all patients cannot have TME- a restorative procedure. One should do MRI to see how tumour is growing. He also talked about problems associated with conventional API.

Prof.  Torbjorn Holm

Speaking about changing concept of APE Prof. Holm opined that each procedure should be standardized. He also highlighted the indications for APE in rectal cancer. He then mentioned the patients who are not suitable for bowl reconstruction. Inter sphincter APE is better than low Hartman’s procedure as it has reduced rate of pelvic sepsis. He then showed a Video of indications for extra levator API in rectal cancer. He also talked about locally advanced primary rectal cancer the tumour infiltrating other organs (T4b), rectal cancer adhesions to other organs. Surgery, he stated, was a multidisciplinary approach in which urologist, plastic, vascular surgeon and orthopedic surgeons all have to be involved. He advised that one should assess MRI and plan the procedure in detail. Patient will have pain, hence the patient must be informed about it. These patients can be cured if they are treated properly though here may be some morbidity. He concluded his presentation by stating that well informed motivated and fit patient can be successfully managed with multidisciplinary approach. Pre-operation radio, chemo is necessary and these patients need extensive surgery.

During the discussion it was pointed out that we need to improve, identify patients at high risk metastases. Better radiological prediction in stage-III and very intensive follow up is needed for good oncological outcome. About 10-20% of patients will have complete response after CRT in locally advanced rectal cancer while 65-70% will need surgery. Care Cancer is good management of rectal cancer. Prof. Holm remarked that a fool with Tool is still a Fool. In surgical techniques, any tool should be used properly and judiciously.

Post-operative complication
of low rectal cancer

In the next session Prof. Michael R Thompson from UK Clinical Coordinator of the course talked about post-operative complications in low Rectal Cancer. He pointed out that while working at a district hospital one does not have control over radiologists and pathologists. You have to see what is possible to do in such circumstances. Talking about anastomotic leak he suggested washout- open operation if you are not sure of a thorough removal of all solid fecal debris. Stoma was suggested in ileostomy or end-colostomy after disconnecting the anastomosis if there is a concern that a significant leak might continue from the anastomosis. As regards pelvic abscess, he suggested rectal examination by operating surgeon to drain an established abscess through hole in the anastomosis, insert a drain into the cavity and then flush daily.

Prof. Michael R Thompson

Speaking about bowel dysfunction in anterior resection syndrome Prof. Thompson said that 90% of the patients having a low anterior resection will end up with some form of bowl dysfunction. At present there is no precise definition or casual mechanisms which have been established. It can have a substantial negative effect on quality of life. Symptoms vary widely from daily episodes of incontinence to obstructed defecation and constipation. The cause of anterior resection syndrome is considered to be multifactorial. There is reduced neo rectal reservoir volume, colonic pouches, internal sphincter is damaged by instrumentation. Flexible sigmoidoscopy shows poor emptying of descending colon above anastomosis.

Continuing Prof. Thompson said that diet, stimulant laxatives, loperamide and enemas are important in the management of empirical and symptom based treatment for ARS. With time symptoms do improve or the patients learn to manage them and it is rare to do a stoma. He felt that it was all due to loss of the normal mass evacuation due to the disruption of some reflex interaction between rectum and colon. In case of bladder dysfunction and the catheter for more than four days, and if removal fails, leave the catheter in and readmit the patient under urologists for trail without catheter. Sexual dysfunction is poorly studied in women but Viagra works in about 60% of cases.

Prof. Torbjorn Holm Master Trainer and Prof. Michael Thompson the Clinical Coordinator of the Surgical
Week for Colorectal Diseases held at JPMC photographed along with Dr. Shamim Qureshi
the organizing
secretary of the course and some other participants.

There was a brief break to show live surgery on a 35 years old patient having colostomy for low rectal cancer. Prof. Holm who was operating remarked that it is nice to have an impotent man rather than let him die. There was lot of bleeding in this case. Prof. Arshad Cheema remarked that all patients with advanced cancer will have some deficit. It depends on at what deficit the patient will be happy to accept? But remember this is the price one has to pay for living, he remarked. Prof. Shamim Qureshi talked about honourable retreat of a surgeon from operation if one fails to do a proper job and it may harm the patient? Responding to this Prof. Holm remarked that cancer was a different case. Without surgery he is going to die. Since it is a young patient, we will try to do our best but in case of an eighty years old patient, we won’t do this procedure, he added. PET scan is done in all advanced cases. If the patient has lot of metastases, do not operate these patients. Surgery beyond TME has its own repercussions. Some of these patients live longer with miserable symptoms, they do not die early hence one should do whatever one can to cure the patient of cancer, he remarked.

Continuing his presentation on postoperative management of low rectal cancer Prof. Thompson suggested PET scan imaging to determine extent of local disease. Cochrane data on colorectal liver metastases published in 2008 shows that 50% of patients develop colorectal metastases mostly in the liver. Of this 25% are amendable to curative surgery while 12% of all patients will have bowl cancer. Their five years survival is between 30-50%. Treatment options include surgical removal of section of the liver, cryosurgery, radiofrequency thermal ablation. Author of this Cochrane review had concluded that there was very limited evidence to support the effectiveness of one intervention over the other. Local ablative therapies might be useful for the management of liver metastases but further research is required to evaluate the effects of these treatments and their potential role in increasing the disease-free survival and in decreasing recurrence rate.


Prof. Torbjorn Holm Master Trainer operating upon a patient which was shown live during the
Surgical Week for Colorectal Diseases held at
JPMC recently.

Prof. Thompson concluded his presentation by stating that colorectal cancer metastases grow very slowly in some patients. Some of these patient may live with untreated diseases for long periods of time. Hence it is difficult to determine how much treatment of liver/lung metastases prolong life rather than cures patients. The benefit is in a small number of patients is outweighed by high morbidity and high cost of treatment. However, he hastened to add that surgical removal of lung and liver metastases probably cures some patients and extend lives of others. Surgical treatment should be offered to younger patients and fit elderly patients if it can be done with low morbidity and mortality without which any potential benefit will be lost.

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