Prof. Evaghelos Xynos discusses Total Mesorectal Excision, Surgical treatment of rectal prolapse, surgery for UC and faecal incontinence


Surgical Week for Colorectal Diseases at JPMC

Prof. Evaghelos Xynos discusses Total Mesorectal
Excision, Surgical treatment of rectal prolapse,
surgery for UC and faecal incontinence

KARACHI: On the first day of Surgical Week for Colorectal Diseases held at JPMC from October 1-4th, Prof. Evaghelos Xynos the visiting colorectal surgeon from Athens, Greece gave an overview of restorative proctocolectomy which was followed by a live demonstration of this surgical procedure. The patient was a thirty five years old female . Prof. Xynos opined that ileostomy should have been done in this case in acute phase of the disease. Two bleeds of stomach were repaired. His advice was that be careful not to contaminate the abdomen. Speaking about the mobilization of colon, Prof.Xynos said that he preferred to use diathermy for mobilization. Meso colon is one of the most important organ of abdomen which he called as the “policeman”.

Prof. Evaghelos Xynos the visiting colorectal surgeon from Athens, Greece presenting mementoes
to Prof.Mumtaz Maher, Dr.Shamim Qureshi and Prof. Tariq Mahmood during the concluding
session of Surgical week for colorectal diseases at JPMC Karachi on October 4th 2012.

Responding to a question from the audience, Prof. Xynos said that he does not do bowel preparation in such cases of ulcerative colitis. Usually no blood is used as the patient is taken to the operation theatre with good haemoglobin. However, some pints of blood are always in store but it is seldom used. He further sated that so far he had done thirty cases of laparoscopic mobilization in colitis and never had any splenic injury. Splenectomy, he opined, was a very good operation by laparoscope unless the spleen is very big. If there is dysplasia, one needs to do resection. Be careful and do not damage the nerves. If I make a hole in the vagina, I will repair it. I usually cover such patients with antibiotics, he remarked.
Discussing surgical treatment of ulcerative colitis Prof. Xynos described in detail the indications for surgery including elective surgery, selection of patients for proctocolectomy plus IPPA, dissection of rectum. He also discussed laparoscopic surgery for ulcerative colitis. This, he said, is feasible and safer; it has longer duration and increased technical difficulties. There is a steep learning curve and patient’s selection criteria are still to be defined. However, it offers faster recovery with lower morbidity and offers superior cosmoses.

Prof. Evaghelos Xynos presenting mementoes to members of the surgical team
which helped in organizing the surgical week for colorectal diseases
at JPMC during the concluding session.

Total Mesorectal Excision

On Day two, Prof. Xynos gave a presentation on Total Mesorectal Excision and also discussed the audit of this technique. He pointed out that the removal of entire mesorectum leads to lower recurrence which is less than 10%. It also improves survival which is almost 80% in stage one to stage three. He then discussed the technical considerations for rectal cancer, removal of the entire sigmoid colon, complete TME and construction of new rectal pouch. Appropriate training and audit of the outcome, he felt was necessary. There is 5-15% increased risk of anastomosis leakage. In case of cancer of low rectal third, distal margin of one cm is enough. He also talked about laparoscopic approach in rectal cancer which leads to faster recovery and reduced post operative morbidity but there is a risk of increased risk of anastomosis leak. He also talked about main predictive factors for laparoscopic TME for rectal cancer. Gender and type of anastomosis fashion are independent risk factors. He then referred to guidelines for the objective of audit which are quality assurance and good quality of surgery. It has local recurrence less than 10% with over 75% survival. Colorectal surgery is a team work and pathologists are extremely helpful in staging of the disease. No individual should ever be allowed to take a decision.

Some of the participants to the course on colorectal diseases
photographed along with the guestspeaker and master trainer
Prof. Xynos, 
Prof. Mumtaz Maher, Prof. Irshad Waheed and Dr. Shamim Qureshi.

Prof. Xynos then talked about training of surgeons for rectal surgery, MRI assessment and importance of pelvic radiology sessions. He also laid emphasis on microscopic assessment of fixed specimens, assessment of specimen’s quality, data collection for national audit, multidisciplinary approach, treatment categorization and national audit registries. The multidisciplinary team should consist of colorectal surgical team, pathologist, radiologist and medial oncologist,
Speaking about neo-adjuvant treatment of rectal cancer, Prof. Xynos said that overall recurrence rate is 2-8%. There is decrease in overall five years mortality by 19%, decrease in cancer related mortality by 29% while overall survival rate in stage two and three diseases is more than 80%. Distant margin of one cm is enough after neo adjuvant treatment. One needs to organize workshops for training the surgeons so that they are oriented to colorectal surgery, qualified and trained colorectal surgeons should be appointed at referral centers and an individual surgeon has to attend quite a few workshops. The training should consist of evidence presentation, anatomy of pelvic session with surgeon’s radiologists view, techniques should be presented through video demonstrations and live surgery sessions, laboratory sessions on cadaver anatomy and it should also have histopathological sessions. These training programmes should be accredited. Sufficient experience in open TME is a pre-requisite for laparoscopic approach. The preliminaries include basic workshops, knowledge of laparoscopic instrumentation, training on fresh cadavers and training with experienced performer. One has to be careful while selecting patients with rectal cancer and should be assisted by an experienced laparoscopic surgeon. This presentation was supplemented with a large number of informative slides of anatomy of mesorectum lateral view, fasciae-spaces of mesorectum, innervations for the pelvis, posterior plane of dissection with laparoscopic TME, lateral plane of dissection and completed dissection, colorectal anastomosis, macroscopic quality assessment of specimen and distal transaction anastomosis.
This was followed by a live demonstration of an open haemorrhoidectomy. Prof. Xynos pointed out that he decides about the type of operation after examining the patient on the table because at times the patient does not push adequately. He then showed and discussed the anatomy of anal canal. Replying to a question he said that he does not dilate the anal particularly in female patients. More than fifty years old patients, he said, should have colonoscopy. His advice was that never succumb to the temptation of taking out lot of mucosa. I have not tried local anesthetics for such cases. Speaking about pre operative preparations for haemorrhoids, he said, I advice the patients to have an enema. To close the wound, he felt, was a futile exercise. One should try to reduce the post operative local pain with the use of local anaesthetics. Take every precaution and educate the patient. ‘There is a 50% recurrence rate. It seems to be simple operation but it is not so even for seniors. If the patient complains of more pain, give them pain killers and ask for anesthetist’s advice. It is mostly a Day Care surgery and we keep such patients for about six hours in the hospital unless there is some complication. I myself, Prof. Xynos said prefer this technique for type two and type three cases and do PPH for stage three and four, he added.

Surgical treatment of Rectal Prolapse

On third day of the course, Prof. Xynos discussed surgical treatment of rectal prolapse. He pointed out that every one does rectal prolapse through different procedures in which the results are best but there is no uniformity of views on a particular approach. Surgical treatment can be divided into three group’s i.e. transabdominal operations, trans anal procedures and transanal perineal procedures. Perineal transsacral procedures do not have good results. There is increased recurrence rate and it should be reserved for very poor risk patients. In transabdominal procedure, one can do open or laparoscopic approach. Correction of rectal prolapse is achieved in more than 90% of patients and correction of fecal incontinence is seen in 65% of cases. Post operative morbidity is less than 30% while post operative mortality is less than 2%. In laparoscopic repair there is less blood loss. Laparoscopic ventral colporectopexy fixes the rectum and vagina. Surgery is of short duration with short hospital stay. Recurrence of prolapse is seen in 4%. Improvement of obstructed constipation as well as continence is seen in over 80% of the patients. There is limited data on constipation. Hew then showed a video clip of resection rectopexy in rectum mobilization. This was followed by surgical clips of various techniques, video of dissection of Douglas pouch and fixation of prosthesis. He also referred to the selection of patients for different procedures. In the later part of his presentation he showed ventral colporectopexy technique for rectal prolapse and discussed in detail the position of the patient besides dissection at the promontory.
Responding to various questions from the participants Prof. Xynos said that urine incontinence is a major problem in ladies. First they go to the gynecologists who remove the uterus during hysterectomy which of course is a bad operation for several reasons. Posterior rectopexy with mesh is a good operation. Rectal prolapse and piles is seen only in about 3% of males. I have seen some young medial students in Middle East with rectal prolapse. In case of total prolapse, one should correct it first and then do haemorrhoids surgery. However, it also depends on person’s choice.

Faecal Incontinence

On the last day of the course Prof. Xynos spoke about faecal incontinence. Its projected prevalence, he said is between 2.2 to 20.7% but in geriatric population it could be as high as 50%. It can be congenital or acquired. Speaking about evaluation of these patients, he referred to physical examination including inspection of the perineum, digital examination, and protosigmoidoscopy besides laboratory assessment of anorectal physiology. As regards conservative treatment, patients should be advised on behavioural modifications and anti-diarrhoeals can also be quite effective.
The patients should be advised pelvic floor muscle strengthening exercises while application of local agents is also quite effective. He then discussed in detail the sphincteroplasty –anal sphincter repair. In acute trauma end to end repair is advised. In delayed repair, overlapping suturing is suggested. Its success rate is between 50-85%.
Speaking about Fistula-in-ano, Prof.Xynos said that one has to take the decision on case to case basis. He discussed at length fistulotomy, fistulectomy besides endorectal advancement flap. In my practice, I have 70% Crohn’s fistula and each patient has its own problems since all patients are not the same. It is not easy to find the internal opening. In pre operative evaluation he mentioned about medical history, physical examination, anal ultrasound, and anal manometry. MRI identifies level of fistula with respect to sphincters. . MRI, he opined, is a very useful diagnostic tool.
The organizers have also announced the guest speaker, master trainer for the 8th annual course on colorectal diseases which will be held from September 30th to October 3rd 2013. Adam J. Dziki FRCS, PhD from Poland will be the guest speaker and master trainer.