Colonoscopy can reduce the colorectal cancer rate- Dr. Saad Khalid Niaz

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COLOCON 2015 Conference Proceedings

Colonoscopy can reduce the colorectal
cancer rate - Dr. Saad Khalid Niaz

IBDs require multidisciplinary approach, IPPA is
demanding but procedure of choice - Tabish Umar Chawla

KARACHI: Colorectal surgery as a sub-specialty is gradually being recognized and finding a place in Pakistan. It was Prof. Mumtaz Maher who took an initiative and developed a Division of Colorectal Surgery and started a training programme which continues for the last many years. Now Prof. Amjad Siraj Memon at Dow University of Health Sciences/Civil Hospital Karachi has developed a dedicated unit for colorectal surgery with state of the art diagnostic and treatment facilities. They organized the COLOCON 2015 from May 22-23rd 2015 which was followed by pre-conference workshops.

On first day of the conference apart from the inauguration, there were three scientific sessions. Dr. Bushra Shirazi from Ziauddin Medical Univrsity discussed issues in proctology in females and highlighted the fact that women are reluctant to consult doctors and when they do, it is too late with the disease having advanced too much. Dr. Iqbal Memon discussed ligasure hemorhoidectomy while Dr. Zafar Sajjad from Aga Khan Univesity discussed the role of MRI in Cancer. Other topics discussed included changing paradigms in managmeentof rectal cancer by Najim S/. Khan and role of neo-ajuvant chemoradiaiton in rectal cancer by Dr. Najeeb Naimatullah. Dr. Shamim Qureshi talked about management of rectal prolapse while Dr. Javed Ahmed presented rectal prolapse experience at Civil Hospital Karachi.

On second day of the conference on May 23, 2015, the programme started with a video presentation highlighting the facilities and services available at the colorectal unit at CHK. It was pointed out that morbidity and mortality meeting is held in the unit regularly. There are facilities for stoma care in the unit besides lower as well as upper GI endoscopy services. Other facilities include VAF treatment, Haemorrhnoids Clinic, Banding facilities. The unit has been furnished at cost of Rs. 75 million. A patient support group for colorectal cance has also been established which will help in reducing morbidity and mortality from this disease.

Dr. Saad Khalid Niaz was the first speaker in this session and topic of his presentation was role of colonoscopy in the management of polyps and colorectal cancers. He pointed out that it is most common in patients between 40-50 years of age. Bleeding per rectum, he further stated, should not be ignored. One should not lable everything as haemorrhoids unless sigmoidoscopy is performed. Endoscopy has a diagnostic as well as therapeutic role. Speaking about screening and surivillance Dr. Saad Khalid Niaz said that we are looking for those patients who have blood in stool, weight loss or changes in stool habits. He then talked about polyps detection, polypus retrieval, withdrawal time. Complete examination is essential whether it is complete or partial obstruction. Sometimes people are unable to negotiate. Colonscopy, Dr. Saad Khalid Niaz opined can reduce the colorectal cancer rate. These patients should be advised to have flexible sigmoidoscopy every five years and double contrast enema every five years. Family history is also important. For screening polyps, follow up of these patients should be carried out every three to five years.

Dr.Saad Khalid Niaz then talked about obstructive malignant pathology and therapeutic colonscopy. There are different kinds of polyps. He then referred to direct polypectomy technique and cautioned that one should be careful about perforation with diathermy. Chronic polypectomy should take out the polyp and then burn the remaining tissues with diathermy. He then talked about EMR indications for endomucosal resedction. While doing endoscopic mucosal resection, EMR should not be used for ulcerated lesions and submucosal resection. Japanese, Dr. Sadd Khalid Niaz stated, are expert in ESD efficacy and safety. He then quotd a study which had 608 patients and it had 99.2% enblock resection. This study had a complication rate of just 4.1% i.e. perforation with bleeding. Two patients needed emergency surgery but this, he hastened to add, was Japanese experience.

Continuing Dr. Saad Khalid Niaz talked about colonic dilatation, colonic SEMS ASGE guidelines. Giving details of a study regaring colonic stenting which had 791 patients, he said, it had 10.5% post operative complications. He also showed the colonic stent placement. Stent placement success rate, he said, is very high and I have been doing it. Success also depends on the patient but they usually come late. Endoscopic ultrasound, Dr. Saad Khalid Niaz said, has a role in diagnosis. Success is also operative dependent. He then showed a case of 58 years old male with rectal cancer. CT Scan was suspicious and second colonscopy gave the same results but later EUS confirmed rectal cancer. He concluded his presentation by stating that EUS has a definite role in staging and diagnosis and early diagnosis is the best way and with better techniques, the results are encouraging.

Dr. Tabish Umar Chawla from Aga Khan University Hospital was the next speaker who discussed surgical management and outcome of inflammatory bowel disease. He pointed out that the incidence of ulcerative colitis has been increasing but still its incidence is less in Pakistan. Crohn’s disease patients 70-75 years of age may require surgery at some time. These patients may present with abdominal pain, bloody diarrhea, severe diarrhea and fever. He also talked about pouch design and said that 50% of patients may develop significant complications with pouch like small bowel obstruction and pouchnitis. However, their quality of life is much better. Speaking about indications for urgent surgery for ulcerative colitis he mentioned uncontrolled colonic bleeding, fulminant attacks. He also referred to elective surgical options. About 7-9% of patients, he said, may suffer from anastomotic leak.

Giving details of their local study of inflammatory bowel disease, he stated that during the last twenty four years they looked at forty seven files and there were thirty six cases in middle age. Most of the ulcerative colitis patients wee suffering from hypertension and diabetes mellitus and 7% of them had cancer. Almost 25% of these patients had emergency surgery and the remaining 75% had elective surgery. There was higher rate of wound infection while nine patients had IPPA. Inflammatory bowel diseaserequire multidisciplinary approach. IPPA is the procedure of choice in most cases but it is demanding procedure.

Responding to various questions during the discussion Dr. Saad Khalid Niaz said that there have been lot of improvements in medical management of ulcerative colitis. In Pakistan now we do not see the same disease which was seen some years ago. UC patients can be very well and effectively managed. However, it is important that we should pick patients at right time and do not delay surgery.

Dr. Jehangir Farman Ali also from AKUH presented details of an institutional audit regarding APR for low rectal cancer, its management and prognostic predicdtors. His presentation was based on sixty two patients which included 22(34.5% ) female and 40 (64.5%) male. Most of the patients were operated afte 2001 and 8% of them were obese. Majority of these patients presented with bleeding per rectum and weight loss, 66% had adequate lymphnodes. Only 5% had MRI and dissection had good prognosis.

Dr. Batool Urooj discussed five years experience of colonscopy at Civil Hospital Karachi. Her presentation was based on 1902 patients between the age of 19-40 years, mean age 37 years. Almost 47% had bleeding per rectum and also complained of diarrhea. Normal endoscpy accounted for 45% while success rate was 87-97%. No pathology was found in 50% of patients and there was no mortality. She emphasized the importance of better supervision and training.

Participating in the discussion Dr. Saad Khalid Niaz opined that only those who have a colonscopyu success rate of above 98% are allowed to do cancer screening in UK. In addition, patient satisfaction, time take for withdrawal are all important and this requires expertise. In UK those who have a colonscopy success rate of less than 90% are sent back for training to learn colonscopy under supervision. He further stated that do not send patients to that centre where the operator does not go up to the cecum and in fact these are the people who do not know how to do colonscopy, he remarked.

Prof. Shafiqur Rehman along with Dr. Sheharyar Ghazanfor chaired the second session. Dr. Shahid Khattack from Shaukat Khanum Memorial Cancer Hospital Lahore discussed SKMT experience of managing lower rectal cancer. He pointed out that it was the sixth most common cancer and in male it is second after Head and Neck cancer. Two third are in reach of flexible sigmoidoscopy. If these patients are missed and treated as hemorrhoids, we will miss this cancer. He laid emphasis on direct rectal examination, history, colonscopy and biopsy. He was of the view that we should stage the disease before starting treatment. As regards investigations CT Chest, MRI pelvis, EUS and CEA are useful. Most of these patients, he said, are in stage III and IV. We at the SKMT have multidisciplinary discussion before starting treatment. T1 and T2 cases, he said, can be treted by surgery. Radiotherapy usually makes surgery difficult. One can plan surgery much better. EUS and MRI are better staging tools. He also talked about the classification of low rectal cancers. Talking about the factors which affecdt sphincter preservation he mentioned surgical training, surgical volume, new adjuvant chemoradiation. He then referred to direct involvement of sphincter muscles and pointed out that your results will depend on patient selection. Young patients, he said, are difficult to convince for permanent stoma. Talking about the role of a pathologist, Dr. Shahid Khattak said, he will let you know how good surgeon you are.

Continuing Dr. Shahid Khattak said that from 2008 to 2013 they managed 316 patients at SKMT with median age of 44 years. Follow up was 4-60 months. Complete colonscopy was done before surgery or within six months after treatment. Patients with nodal involvement had Ct and most were in stage-III. APR was the commonest procedure performed. Again most of the procedures were done laparoscopically though previously open procedures were more. Now with the passage of time we are doing more and more cases endoscopically. The highest numbers of these patients were in Stage-III. Thirty one patients which 22% had APR. Most cases that we see are young male with T3 and T4. One of the patients had liver and lung metastic disease. Mean duration of surgery was 357 minutes, one patient had conversion, 10% had readmission and re-exploration i.e. two cases each. Hospital stay was 6.6 days. Perineal wound problem is there. Radiologist, Dr. Shahid Khattak stated has an important role in these cases. One has to go for specimen oriented approach, sphincter should be preserved is possible and we also need standardization of APR procedure, he concluded.

Dr. Samina Patima from AKUH talked about pathological aspecdts of TME. She discussed in detail circjumferential resection, assessment of mesorection, inking of specimen and lymphnode dissection. Her conclusions were that evaluation of TME plays an important role in assessment an prognosis of these patients.

Dr. Khursheed Saqmo from DUHS presented their experience of colorectal cancer at Civil Hospital Karachi. During the last five years, he said, they have seen 260 patients of colorectal cancer. It included 150 male and 110 female. Most of their patients were between the age of 31-40 years. The youngest patient they saw was elevenyears of age. Almost 77.6% of the patients had left sided tumour. He emphasized the importance of organized approach in diagnosis, early treatment. There is a role for screening which should be more frequent and endoscopic evaluation of high risk symptomatic patients. Colorectal cancer, it was further stated is increasing. Most of the patients are in advanced stage and aggressive in nature at the time of diagnosis, hence they have poor outcome. During the discussion standardization of treatment of rectal cancer was highlighted. It was also suggested that we must create more awareness among GPs, Family Physicians and the population at large. Prof. Abul Fazal opined that screening should be done only in high risk patients.

Dr. Attaur Rehamn from CHK discussed stoma care. He pointed out that it is a life saving procedure and its incidence is increasing due to trauma. He then gave details of anxiety and depression in the stoma patients which they had studied.