We should always be striving for improved outcome and ensure best care to the patients-Dr. Farooq


COLOCON  2017 proceedings

We should always be striving for improved
outcome and ensure best care
to the patients - Dr. Farooq

Patient’s survival is better with robotics as compared
to laparoscopic surgery- Prof. Amjad Pervez Cheema

KARACHI: Colorectal Surgery Unit at Dow Medical University, Civil Hospital Karachi organized its 3rd annual meeting from December 22-23, 2017 which attracted many surgeons interested in this specialty from all over Pakistan. The speakers included surgeons doing colorectal surgery besides a few invited guest speakers from UK who also conducted a pre-conference workshop. The colorectal surgery unit at CHK/DUHS, it may be mentioned here was established by Prof.Amjad Siraj and is serving the patients for the last three years.

Prof. Amjad Siraj Chief Organizer of COLOCON 2017 presenting a memento to Prof. Saeed
Qureshi VC DUHS who was the chief guest at the inaugural session of the conference.

The first session on December 22nd 2017 was jointly chaired by Prof. Shafiq Ur Rehman, Dr. Nadeem Khurshid and Dr. Farzana Memon while Dr. Samreena Riaz moderated the session.  Prof.Shahryar Ghuzzanfar from DUHS was the first speaker who talked about local experience with Robotic Surgery.  He was of the view that robotic surgery is the future and it was the way forward. Commenting on the presentation one of the chairpersons remarked that people might say that in a country where children are dying of diarrhea, what is the justification for robotic surgery but we do need to establish a few centers where this facility should be available.

This was followed by an excellent presentation by Dr. Mohammad Farooq from UK who described his personal experience on Laparoscopic training and how to set up a laparoscopic service. He pointed out that his patients were doing him a favour. Addressing the participants he said that you are lucky as you are serving people of your country doing a wonderful job. We should always be striving for improved outcome and ensure best care to the patients. Training is a problem. To get Fellowship in laparoscopic surgery one needs to spend more than ten years. It includes five years basic medical education followed by three years of SHO job, then I served as Specialist Registrar for eight years which was followed by two years training for fellowship in laparoscopic surgery before I became a consultant. I have surrounded myself with competent laparoscopic surgeons. One learns a great deal watching a competent surgeon operating. There is nothing wrong to aspire to be the best. If you aim for the stars, you will land at the Moon. He then described in detail the national training programme in laparoscopic surgery in UK. Laparoscopic surgery was funded by a Cancer Action Team and the aim was to provide laparoscopic surgery training for consultants in UK. He also disclosed that almost 25% of laparoscopic surgeons in UK were trained at one center.

Continuing Dr. Farooq said that to save the patient was most important. Now it is an era of patient centered care. Exposure of the patient and gentle surgery is important. The structured breakdown of modular training programme was also discussed in detail. He then talked about evaluation of training and remarked that gone are the days of training through humiliation. The trainers are supposed to encourage the trainees, guide them, it is important how the trainers talk to their trainees and it matters a lot. One has to adopt a different approach.  Majority of the trainees are grateful to the trainers but then hastened to add that there are good and bad trainers. You do not know who is going to do your operation hence make sure to train everyone to ensure they are competent and train them well. There is a culture change taking place in UK for the right reasons. Dr. Farooq also highlighted the importance of reassuring the patient and said that by doing so you are worshipping all the time. By serving you patient, you are serving your God. We have many people who are doing a commendable job who came back to serve their own people and country. There are people by whom everybody would like to be trained. He then showed a Video of training which depicted an authoritative, humiliating trainer and his body language was also not at all helpful and assuring for the patient who was being examined. This type of training is no more accepted by any one and no one appreciate it. Continuing Dr. Farooq said that of course there are hurdles in training and one has to plan how to overcome those hurdles. He then demonstrated the safe access and port positions, safe dissection of pedicles.  Positive improvement in the next case should be one’s aim. We view the video of our cases again and again which consolidates the learning, he added.

Vice chancellor of DUHS Prof. Saeed Qureshi presenting mementoes to Dr. Farooq and 
Prof. Amjad Pervez 
Cheema the guest speakers at the COLOCON 2017.

Prof. Amjad Pervez Cheema from UK was the next speaker whose presentation was on “Robotic Rectal Surgery: What and How? He pointed out that he was interested in training. I am trained laparoscopic surgeon who later shifted to robotic surgery. Now it is quite popular in UK and the patients ask for it. If this facility is not available, they go to some other hospital. The patients wish to live longer. Remember we all are going to die one day but there should be better short term outcome. Continuing Prof. Amjad Pervez Cheema said that always respect embryology. Anatomy has not changed only new techniques have come in. We have many laparoscopic surgeons who do good surgery and they are not interested to change. They call robotic surgery as Dark Room surgery but things have changed. Laparoscopic surgery is now seen as a gold standard in UK. There have been advances in technology and now more data is becoming available.

He agreed that laparoscopic robotic surgery was not cheap, it is expensive. However now over 55% of colon rectal cancer in UK is being done through laparoscopic surgery. Everything should be for the benefit of the patient. Local recurrence is very painful and these patients die a miserable death. He then gave details of a rectal cancer unit which he had established wherein they use robots. One must look at the quality of surgery. Remember rectal perforation rate is at times very high and statistics never lie. Look at everything carefully and try to improve your technique to avoid chances of rectal perforation instead of stopping doing laparoscopic surgery. Robots, he further stated, are here to say but there is reluctance among some surgeons to change. With the passage of time the cost of system, services will come down. At present many centers in Europe have stopped doing robotics because people are not prepared to do it. He then talked about minimal tissue handling and said, let us make this surgery a common operation. We must learn to teach something which is good.  Patient’s survival is better with robotics as compared to laparoscopic surgery as shown by a study from Korea. The authors have reported that it improves long term survival. He also talked about robotic surgery in high risk patients. Robotic surgery ensures reduced blood loss, better conversion rates and offers good results, he added.

Exposure Prof. Amjad Pervez Cheema opined is very important in surgery.  If you can see it, you can do it. There are different stages of training starting from the beginners to advance followed by Competent surgeons and then one becomes proficient. Training consists of five modules. Every trainee has to submit two videos of his surgery and then the experts who evaluate them look at those videos carefully. At present one hundred twenty surgeons are being trained, twenty eight have graduated and thirty are under assessment. He concluded his presentation by stating that precision surgery is the concept and Robotic platform provides the best tool. Responding to various questions during the discussion, he suggested that one must listen twice and speak once only then you can appreciate and find out what the critics wish you to do.

Inaugural Session

Prof. Shafi Qureshi Vice Chancellor of Dow University of Health Sciences was the chief guest at the formal inauguration ceremony. Speaking at the occasion he said that colorectal diseases have become an epidemic in UK. We in Pakistan mostly do open procedures. Dr. Shamim Qureshi has been running a Surgical Course in Colorectal Diseases at  JPMC for the last many years. He commended Prof.Amjad Siraj and his team for organizing this conference for the third consecutive year and hoped that this academic activity will continue in future as well. We still have to do open procedures for resection which limits our approach. We have to convert in a large number of cases for various reasons if we attempt laparoscopic surgery.  Last year the organizers had concentrated on pelvic floor surgery and this year we have seen a different favour of laparoscopic robotic surgery, he remarked.

Prof. Fuad Moosa along with Prof. Adnan Aziz, Prof. Wajahat Wasti and Dr. Ali Haider 
chairing one of the scientific sessions during the COLOCON 2017 held at Karachi recently.

Prof.  Moizuddin Ahmad along with Dr. Javed Ahmed chaired the next session. Prof. Shamim Qureshi from JPMC was the first speaker who discussed cytoreductive surgery and the role of HIPEC. He pointed out that they have been doing colorectal surgery for the last sixteen years and mostly they do open procedures rather than using laparoscopic or robotics. The idea is to give safe surgery. Speaking about HIPEC in Pakistan, he said when he learnt that Dr. Inam Pal has done it in AKU, he thought we can also do it. Colorectal primaries are slow in progression as compared to secondary. Survival of the patient can be ensured by careful selection of the cases. In cytoreductive surgery we remove all amentomectomy. We started doing this procedure at NICVD as we did not have all the facilities but later on we purchased our own machine worth thirty five lacs. We started doing cytoreductive surgery at JPMC. This surgery CRS plus HIPEC takes about twelve hours. We planned to treat fifteen patients. All of them had CT scan while some also had PET scan and tumor markers. Out of fifteen patients selected, five were inoperable as they had come very late. One of the patient had the disease for the last twelve years. One patient was unfit, hence eventually only nine had CRS plus HIPEC. Seven cases had primary and two were secondary.  Since we wanted to play safe, we selected good primary cases. It included five cases of PMP, one colonic, four cases of appendix, and two cases of mesothelioma, one ovary and one colorectal cancer. Speaking about complications Prof. Shamim Qureshi mentioned thermal burns, diarrhea. One patient developed sepsis and multi organ failure who later died. Another developed persistent hypotension, developed ventilator associated pneumonia and died. Another patient developed acute renal failure and had sudden death. The one with ovarian malignancy had uneventful recovery. This surgery needs a multidisciplinary team including surgeon, anesthetist, oncologist, Perfusionist and paramedical staff. It is a team work. Currently we at JPMC Dr. Shamim Qureshi stated are striving for human resource development.

Dr. Tabish Chawla from AKUH was the next speaker who talked about Role of place of surgery on final outcome in colorectal cancer surgery.  He pointed out that currently colon and rectal cancer is No. 4 malignancy in USA and it also accounts for 8% of all newly diagnosed cancer cases there. Majority of them have localized disease when they present and later it spreads to resistant lymph nodes. Five years survival is reported to be 64.9% if we can get these cases early. Early diagnosis ensures better prognosis. Proper staging allow for proper treatment and proper resection which leads to better outcome. We studied whether the healthcare facility where these procedures are performed does make a difference? They looked at one hundred ten specimens received at AKU lab from all over the country which showed that rectal specimens accounted for 23%.  They included twenty eight cases which had fourteen from Karachi. He then briefly talked about tumour characteristics. We noted that samples received from small cities were inadequate while specimens coming from big centers were adequate for analysis. They also looked at the site of the tumour and hospital quality of care was measured. His conclusions were that oncological surgery should be performed in tertiary care facilities with high volume and better trained surgeons in public and private hospitals affiliated with medical colleges.

Prof. Abul Fazal and Prof. Arshad Cheema from Lahore sitting along with Prof. Dahri 
at the COLOCON 2017.

Dr. Naila Kiani also from AKU discussed AJC Guidelines on Colonic Cancer reporting. She pointed out that it was important to look at site, nature of specimen, polyp’s type, margins, tumour resection. She also mentioned about four tier system of histological grading, per neural invasion, tumour budding, extra perineural investigations, tumour deposits, what is lymph node. It is difficult for the pathologist to comment on what is the tumour depth. She then talked about Ryan Scoring System tumour response and use of new adjuvant therapy before surgery. She concluded by stating that surgical resection remains most effective therapy for colorectal cancer.

During discussion one of the participants pointed out that we should train people to do colorectal surgery, oncological surgery at District Hospitals as it is not feasible and practical to send patients to big public and private hospitals in bigger cities. Responding to this Dr. Chawla said that it was up to the surgical community to train people but he was highlighting the ground realities which are that best surgeons are working in bigger cities at big centers. Patient safety has to be considered that is why he felt that these patients should be operated at major public and private hospitals. Quality of resection at big public hospitals is good and they are doing an excellent job. Another participant referred to variation in reporting of pathology and said what kind of training for pathologists was required? Dr. Naila Kiani said that if the surgeon has done a good job, life of the pathologist becomes easy. You can only see what you know. Good quality pathology services are now available at many centers in the country. Reporting is done on prescribed template. Most information given is recorded. We all have a learning curve, we need to search for lymph nodes. Problems still remain with deposits but we are certainly better than what we were few years ago.

On Day-2 of the conference the first session was chaired by Prof. Faud Moosa along with Prof. Adnan Aziz and Prof. Wajahat Wasti. Prof. Abul Fazal from Lahore was the first speaker who shared his personal experience with HAL-RAR. His presentation was based on one hundred sixteen male and thirty four female patients. Mean operating time was forty five minutes. Mean Hall was seven ligations, three RAR per patient. Average hospital stay was nineteen hours though it was between fourteen hours to two days. The patient’s age was between 27-75 years. Eighteen patients, Prof. Abul Fazal said required narcotic analgesics post operatively, three patients complained of excessive pain and in two patient’s pain lasted for five days.  Responding to various questions he pointed out that Hemorrhoidal artery band ligation will have more complications, bleeding and recurrences. Rectal anal repair is old dented procedure and it works for a while but it has staining and prolapse. Recto anal repair is done where there is prolapse. Patients, he stated, should be educated not to strain while going to the toilet. Responding to yet another question regarding  encounter of primary or secondary bleeding, Prof. Abul Fazal remarked that theoretically there is a risk of bleeding but if it occurs, one suture it unless patient has bleeding tendencies. I did not need to connect it. Just release sutures, pain will go away. He also disclosed that it was Surgeon Baddar Siddiqui at Karachi who had started this HAL-RAR procedure. By now we have done over six hundred cases since 2008.  Bowel training of the patient is very important. External hemorrhoids is burnt, do not do anastomosis as it is the addition of internal hemorrhoids. On proctoscopy few areas of necrosis are seen, he added.

Prof. Arshad Cheema from Lahore was the next speaker who talked about J-pouch following total colectomy for familial polyposis and ulcerative colitis. He presented an analysis of fifteen cases. He pointed out that familial polyposis and intractable ulcerative colitis are the diseases which require total proctolectomy otherwise they will develop cancer. One has to operate to prevent cancer. He then talked about J-pouch ileoanal anastomosis and said that it was difficult to manage stoma in this country hence if you can make J-pouch it is better. He then described in detail how to make J-pouch and discussed this procedure in detail. One can use Stappler or make pouch without using Stappler as both works. We did manage twenty one patients at Mayo Hospital of which eleven were of ulcerative colitis, he remarked.

Continuing Prof. Arshad Cheema said that one patient developed pouchitis, two had intra-abdominal collection, one had pouch bladder fistula. There was zero thirty day mortality. One patient suffering from Crohn’s disease died. We had just one death out of these twenty one cases, he remarked. His patients included five siblings from a single family out of which five have been operated upon. If colectomy is delayed, the patient will develop cancer as was seen in one patient who developed cancer at the age of seventeen years. There was growth in transverse colon. By twenty years, they all develop cancer. Ulcerative colitis patient, he further stated are more miserable. We have seen patients with steroid toxicity. One ten year’s old patient came with sigmoid carcinoma, we do not know the reason, and he had no family history of cancer. He was of the view that J-pouch has clear advantage over stringent anastomosis.  We have helped to establish Paediatric GI unit at NICH Karachi, Faisalabad, Peshawar and Rawalpindi for which he commended the services of Prof. Huma Arshad Cheema. We established Surgical Oncological Society which has organized forty seven training courses all over Punjab. Tumour is the most common elective surgery. Replying to a question Prof. Arshad Cheema said that they could not do any genetic work up on these cases. Punjab University has some facilities for genetic testing. Tension free anastomosis, he opined, is important and do not make big Pouch.

Prof.Razzak Sheikh from Hyderabad discussed laparoscopic surgery for rectal cancer. At present various procedures including SILS, ROBOT, and NOTES are being performed. He discussed the open surgery cases. Lap colectomy, he said, has got acceptance gradually. He showed the TME classical specimen which has the advantage of less blood loss, reduced pain, fast recovery and decreased adhesions. However, it has a steep learning curve. He also discussed four different techniques of laparoscopic rectal surgery, optic image processing and robotic surgery were the latest, he remarked.

In all these patient CT abdomen MRI pelvis is done. The patients are counselled about colectomy and sexual function. He also discussed in detail the general principles of the technique, left colon preparation, and pelvic dissection. The patient is followed up for two weeks and then they are referred to oncologists for adjuvant therapy. His presentation was based on thirty one cases, twenty one male and ten female. One needed re-admission, one required re-operation, and local recurrence was seen in one patient. There was no mortality but two patient had wound infection. His conclusions were that Lap resection of rectal cancer is safe with zero mortality.

Prof. Aziz Abdullah from LNH Karachi spoke about Vesico Rectal Fistula. He discussed in detail assessment and identification of defects, history and general condition of the patient. Find out if the patient has history of obstructed labour. He suggested the repair of rectal fistula first to avoid contamination. In pre-operative care, correct anaemia and improve the hygiene. He further stated that most of the time we do not do colostomy which is not indicated.  Position of the patient and timing of the operation were also discussed, besides sutures of Ano rectal junction, perineal body reconstruction, post-operative care and the patient is fully mobilized in the next twenty four hours. So far Prof. Aziz Abdullah said we have done 234 cases from 2015-2017. It included 88 RVF, one hundred forty six had fourth degree tear.  Eighty five patients had obstetric trauma, seventeen were post hysterectomy, and thirteen were post radiation fistula. Inadequate episiotomy repair was seen in 119 cases. Two hundred one patients, he said, had compelte healing, twenty nine had partial breakdown, four had complete breakdown, and two hundred one cases had complete continence while four had fecal incontinence.  During the discussion Prof. Aziz Abdullah said that one Dutch surgeon has done over ten thousand cases of colostomy in Nigeria. One of the participants remarked that one should attempt two repairs before going for colostomy.

Dr. Saad Niaz Honorary Director of Endoscopic Surgery at Surgical Unit-4 at Civil Hospital Karachi talked about EUS and colorectal stents. He pointed out that since the prevalence has gone up, they were detecting more cases. We have no Registry.  Many patients continue to bleed and it is considered hemorrhoids but later on it is detected to be cancer. In case of acute malignant colonic obstruction, he suggested putting in metallic stent. It has 39% morbidity and 13% mortality which is considered a bit high. Colonic stenting he stated can be put in any part of the colon, in our practice we put it in left colon in 70% of the cases. CT prior to stenting is useful and enema is considered enough for colonic stent placement.  Average learning curve for endoscopy is twenty procedures. People who do ERCP do better. There is no difference in clinical picture between covered and uncovered stents. However, covered stents are more likely to migrate, small stents also have a tendency to migrate.  Stents, he said, should preferably cover two cm on both ends of the lesion. We had clinical success rate of 92% and technical success rate of 89-100%.About 5% of cases complained of severe pain, bleeding accounted for 5%, perforation 4% which depends on dilatation. Stent migration is a problem. Re-obstruction is seen in 10% of patients. Low post-operative mortality is the greatest advantage. One of the Meta Analysis has reported 100% technical success. It is better to put stent in high risk cases than operate on them. Stent also offer advantages over emergency surgery. Primary anastomosis is high in stent group. He concluded his presentation by stating that colonic stenting is safe and useful modality. It is not recommended as bridge to surgery and one must discuss co-morbidity with the patient.

Replying to questions during the discussion Dr. Saad Niaz said that obstruction and migration of stents can be easily managed. Malignant strictures should not be stented, they will perforate and the patient will die. Benign strictures can be dilated, we have not dilated and we had no perforation in our cases, he remarked.

Dr. Sadaf Khan from AKUH Karachi discussed organ preservation for rectal cancer. She discussed in detail disease control, long term survival wherein one should preserve the functions of sexual and sphincter besides stating modalities. Combination of chemo plus radiation should be preferred, chemo alone is not good, she stated. About 12-30% of patients have complete clinical response and they have no palpable abnormality. There is near complete response after local excision or TME.  She laid emphasis on early screening, public education, education of primary healthcare professionals, staging MRI. Pathologists and Radiologists should be trained to read the reports. She also called for enhancement of old and development of new skills, amount of excised specimens and acquiring new skills like TEM and TAMIS.

Participating in the discussion, Prof. Amjad Siraj said that be honest with the patient. It depends how you counsel your patient about new procedures, there may be an element of bias. We must see whether wait and see is worth. Now survival of these patients has come down from 79-56%. Dr. Sadaf remarked that one must balance outcome with quality of life. Dr.Saad Niaz opined that screening colonoscopy should be reviewed. For evaluation one should use fiber optic sigmoidoscope and go the cecum as well.

Dr. Roger Gill from AKUH discussed management of stomal prolapse.  He talked about conservative maneuvers for stomal prolapse. In the surgical options he mentioned removal, resection, revision and relocating them. Local approach should be practical. He emphasized the importance of low risk and high benefit solutions.  Prof.Amjad Siraj remarked that these procedures cannot be done in periphery because of staplers.

In the next session Prof. Sughra Parveen discussed the huge burden of benign Ano-rectal diseases. Her presentation was based on 1825 cases of which 1429 were benign. It included 35% fissures, 42% hemorrhoids. A vast majority of these patients usually do not consult the doctor. She also highlighted the menace of quackery in Ano-rectal diseases. Dr. Noor Mohammad Soomro described his experience of colorectal malignancies seen at the newly established oncology unit at DUHS. This 52-bed unit provides free treatment. Data collected from ten centers in the country showed that colorectal cancer was the third most common malignancy. Since 2004, they have seen 730 cases of colorectal diseases. Most of the patients were between the ages of 21-50 years. About 59% of the cases were of rectum and 85% were adenoma carcinoma. We must promote the use of vegetables which will reduce the prevalence of cancer, he added.

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