Anal Fistula can be a real problem and very painful for the patients-Prof. Michael Thompson

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 Surgical Course for Coloresctal Diseases at JPMC-III

Anal Fistula can be a real problem and very painful
for the patients - Prof. Michael Thompson

Majority of Fistulas do not need investigations
as clinical examination is good enough

KARACHI: Anal Fistula can be a real problem and very painful for the patient.  Majority of the Fistula do not need any investigations as in 61% of the cases clinical examination is considered good enough. This was stated by Prof. Michael Thompson from UK who was the Clinical Coordinator for the Surgical Week for Colorectal Diseases held at JPMC from October 9-12th while speaking on Complex Fistula on the last day of the course.

Anal sepsis, he stated, is present as acute abscess or as a chronic fistulae. He then talked about the classification of anal fistula. It is inappropriate drainage of chronic abscess which then results in anal fistulae. He laid emphasis on clinical assessment of the patient and history of associated intestinal pathology.  Treatment of anal fistulae is treatment of infections without causing incontinence. Fistulotomy is most common but be careful in women patients, he cautioned. One should also be careful about associate diseases and anterior position fistulae. Recurrence is reported to be 21% which is very high and not at all acceptable. He then discussed the Seton technique and long term drainage to prevent acute sepsis condition.  An Indian doctors, he pointed out has come up with a good technique for Fistulotomy and repair of sphincter. Trans Anal Advancement Flap is a novel treatment of anal fistulae, he added.

Prof. Holm from Sweden then had live demonstration of surgical skills and also talked about mistakes and complications. The only way not to make mistakes and avoid complications, he remarked, was not to operate at al. He further stated that there are some unavoidable errors. One should try to understand how to avoid the complications.  Responding to a question Prof.Holm remarked that we always remove cancer which is removable and there are no inoperable cancers with us. He further advised that do not radiate those patients who do not need it. They do it for fear of litigations in Stage 4a tumours, he added. Replying to a question Prof.Holm remarked that he had thoroughly enjoyed his visit to Pakistan and he is going to promote this meeting to his colleagues urging them to visit Pakistan. Responding to yet another question Prof.Holm remarked that they do MRI before and after radiotherapy in Sweden to see whether the tumour has reduced or not. With washout, there are 50% less chances of recurrences in rectal cancer.

Prof. Michael Thompson spoke about Stoma care. He discussed in detail construction of an ileostomy. Site is marked before operation. He also referred to end ileostomy, loop ileostomy. Stoma care needs good nursing support to see patients with stoma. In some countries there are patient organizations, Online Support Colostomy Association is doing a commendable job in UK. Ileostomy Association of UK has a programme for counselling of patients. Talking about complications he mentioned retraction, re-do through stoma site if mobilization is possible otherwise select another site on the other side of the abdomen. Stenosis is rare but usually it is due to recurrent Crohn’s. Para stomal hernia is common but rarely causes strangulation. He also highlighted the importance of counselling of patient pre ileostomy.  Make site for stoma and ask the patient to wear a pouch pre operatively. Make sure that overweight patients are able to see the site.

Speaking about the complications of stoma, he mentioned leakage and soreness, stenosis, prolapse, para stomal hernia. Quality of life of the patients, he said, is almost normal or close to normal. His next presentation was on recto vaginal fistulae. Prof. Shamim Qureshi remarked that complex fistula is a complex disorder. First operation is the best management in these cases, hence one should refer these patients to someone who is doing it routinely.

Prof. Henrik, Prof. Michael Thompson sated was father of Enhanced Recovery After Surgery. It does not mean early discharge or fast track surgery but enhanced recovery after surgery. In Sweden on Sunday every adult after primary anastomosis, starts drinking and is mobilized on Monday, on Tuesday he starts eating and next day morning they go home. Enhanced recovery is better for the patient and better for healthcare delivery. We have a standard approach of using oral Paracetamol for post-operative pain relief.  We start early mobilization, early feeding. It also involves optimizing patient condition preoperatively besides reducing starvation by using carbohydrate drinks. After good surgery, there is no need for nasogastric tube. Early mobilization, early feeding also ensures good control of pain. It is also in line with the patient’s expectations as they are at home in three days after surgery and back to work after two weeks. We do not use any opiates but one should opt for slow implementation of Early Recovery After Surgery (ERAS). Talking about Pilonidal sinuses disease, it was stated that enlarged hair follicles develop in young adults.

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