Excessive use of fiber does not prevent Rectal cancer- Prof. Francis Seow-Choen


 Proceedings of 13th surgical week for Colorectal Diseases at JPMC

Excessive use of fiber does not prevent 
Rectal cancer- Prof. Francis Seow-Choen

Hemorrhoids do not become cancer but the symptoms
become severe,
Non-operative methods are the first choice

From our correspondent

KARACHI: Many interesting topics in colorectal surgery were discussed by the guest speakers Prof.  Francis Seow-Choen from Singapore and Prof. Roger Motson from UK during the four day surgical week for colorectal diseases held at JPMC Karachi from October 8-11, 2018.

In his first presentation on First day of the course Prof. Francis Seow-Cohen presented lot of data to support that excessive use of fiber does not prevent rectal cancer. Fiber also does not have any effect on adenoma recurrences despite using high fiber diet which was shown through a study conducted among nine hundred nurses. However, he hastened to add that it is difficult to dispel myths. Another study had also shown that prevalence of cancer was much higher in the vegetarians as compared to meat eaters. The effect of excessive use of fruits and vegetables is also weak. There is no conclusive evidence about the benefits of high fiber diet as regards prevention of cancer. He was of the view that we must debunk the Myth and Truth must be installed.

Some of the faculty members of JPMC and members of the organizing committee of
Surgical Week for Colorectal Diseases held at JPMC photographed with Prof. Francis
Seow-Choen Master Trainer, Prof. Roger Motson Clinical Coordinator, Prof. Mumtaz
Mahar, Dr.Seemin Jamali
and Prof. Shamim Qureshi during the course.

His next presentation was on   Haemorrhoidectomy: Technical tips and complications. With the help of slides he showed the normal anatomical structure of the anal canal and pointed out that these are all normal structures which should not be confused as piles. What is considered as first degree hemorrhoids is normal hemorrhoids. Treatment must be tailored to relieve symptoms. He made it clear that not all piles need treatment. Prolapse is not the sole criteria used for treatment.  Patient’s description of discomfort is not accurate. Speaking about prolapse rectum, he pointed out that do not treat the patient, first carefully examine the patient. Prolonged staining creates problems. Once prolapse occurs, further engorgement leads to pain and inflammation and hemorrhoids becomes bigger with time. The patients Prof. Seow stated must be advised not to squat it will make piles worse. These patients should also be advised not to use paper but use water for washing. Use of paper for washing will lead to bleeding. Be careful, hemorrhoids do not become cancer but the symptoms become severe.  Non-operative methods are the first choice.

Continuing Prof. Francis Seow said that these patients should also be advised not to spend too much time in the toilet. Do not use too much fiber. For examining these patients use plastic proctoscopy. Daflon is effective in pain relief and swelling. Speaking about the principles of treatment of haemorrhoidectomy he mentioned ligate the feeding vessels with injection sclerotherapy. These days’ lasers are also used for treatment of hemorrhoids. It helps to shrink the polyps and they become smaller.

Prof. Francis Seow-Choen, Prof. Roger Motson, Prof. Mumtaz Mahar, Dr.Seemin Jamali and
Prof. Shamim Qureshi speaking at the inaugural session of the 13th Surgical Week
for Colorectal Diseases held at JPMC from October 8-11th 2018. Photo
Courtesy Shamsudidn Qureshi.

He also talked about staple haemorrhoidectomy. He was of the view that one must restore the hemorrhoids to their original place instead of cutting them. The main problem is with better understanding of the patient. It is important to ensure better realization of what the patient suffers from and what the patient wants. Piles should always be treated according to the symptoms, he remarked.

Surgical options in Pilonidal Sinus

Prof. Roger Moston’s presentation was on surgical options in pilonidal sinus. He termed it a congenital skin sinus.  It remains asymptomatic until the hair enters the sinus. Incision is made under general anesthesia. It will relieve acute symptoms. The wound is slow to heal. Post-operative care of acute pilonidal abscess needs expert supervision. Wound shape is also critical in healing. The wound should be twice as long as its width.

Sinus is destroyed by abscess. He also referred to fistula drain with no packing but separate dressing. Many treatments for the treatment of pilonidal sinus have been tried and abandoned. In case of extensive excision, wound is very slow to heal. He then discussed the Minimally Invasive Surgery approaches, the EPSiT technique which he opined was a promising technique for difficult problems. The results are encouraging. He then showed a video from Meiner’s and added that there has been no randomized trial of different surgical techniques.

Rectal Cancer

On second day of the course, Prof. Francis Seow Cohen’s first presentation covered Tips and Tricks in complete mesocolic excision. Challenges and advances in surgical treatment of Rectal Cancer. He discussed in detail the sharp dissection with some blunt tearing which also results in more bleeding. He pointed out that while in operation theatre the life of the patient is important but one should not forget the fact that the life of the surgeon in OT is also important. He then talked about sharp interior resection, indications for open TME surgery, laparoscopic surgery, post-operative recovery and cosmoses which mattes a lot for the patient. As regards good indications for laparoscopic surgery he mentioned small rectal cancer. He also talked about robotic rectal resection, Robotic vs. Laparoscopic surgery. We always try to reduce the cost of treatment but in case of robotic surgery, it increases the cost. He mentioned the indications for robotic surgery in detail and pointed out that sexual function was very important for patients. In obese patients, robotics is the best way to go.

He then discussed reverse TME and reasons for this. It is needed when the rectal cancer is very low down and in a difficult position. Minimally Invasive Surgery techniques are safe and effective but all this is technology driven and use of modern technology needs more funding. We must think, are we doing something better for the patient? Every surgeon, he opined, should not be doing all these procedures. Stick with few operative procedures which you do best and refer all other cases to other colleagues who are doing more cases which will be helpful for the patient. Patients managed at centers where workload of a particular surgical procedure is good, gives better results. Work should be based on the funding available.

Complete Mesocolic Excision

Prof. Roger Moston talked about complete mesocolic excision. He also talked about prevention and management of anastomotic leak following anterior resection. He made it clear that every surgeon will during his surgical career come across  anastomotic leaks, those who say No, they are either not operating or they are lying. He emphasized the importance of low tension, good blood supply. Almost 50% of patients, he said, die due to anastomotic leak. There are post-operative risks. Tumour, gender, age, distal tumor, stage and its size are some of the non-adjustable factors but there are other risks which can be adjusted. These include smoking cessation, obesity, alcohol, medication. Improvement in nutrition of the patient will pay dividends.

He then referred to Neoadjuvant chemo, radiotherapy. Intra operative risk factors include fluid replacement balance, epidural analgesia. Anterior resection is not possible with blood transfusion. Be careful about blood loss. He also talked about stapler, suture techniques, emergency injury, putting drains. Laparoscopy he emphasized was not a risk for surgery. Everybody in the operation theatre, he stated, must feel relaxed.  During operating, one can challenge the decision making in the operation theatre. He then discussed the anastomotic techniques in detail. Drains, he said, are never selected. There is always large variations.

Continuing Prof. Roger said that after surgery the surgeon takes rest for a cup of tea and the post-operative management team takes up the case. For this a new team is needed to look after the patient. Make sure that they are not seen as an extended part of the surgical team but they must feel that they are important members of the surgical team. It is important to improve infrastructure and the staff position. He also talked about clinical processes, data audit, simulators and felt that nobody does something wrong intentionally. It just happens hence in such a situation one should support each other through and through. We do CRP every day as it depends on the condition of the patient.  We do more than hundred cases every day. Sometime there are no discharges and at times there are some discharges after CPR.

Speaking about the discharge policy after resection, Prof. Roger laid emphasis on adopting a holistic approach to the patient. He then talked about global risk assessment, discussion in the multidisciplinary team and discussion with patient suffering from cancer. It is important to have in depth discussion with the patient, tell them the risks and rewards. Look can the patient survive a leak? Leak will prevent further treatment. There will be consequences for the patient of stoma. He discussed in detail the vital parts of the consent process. Tell the patient the treatment options available, what alternatives are available, what is the risks of no treatment are and what are the risks with treatment. Talk about the likely complications. If the patient and attendants are taken into confidence and they are taken along while deciding the treatment options, they are more forgiving if something goes wrong. It is always important to involve the patient in decision making to reduce the risks. He also highlighted the importance of meticulous minimal stapler fire and avoid drains as far as possible.

Continuing Prof. Roger Moston said do not panic if something goes wrong. Think, do not rush to the operation theatre immediately. Confirm leak, control source of leak. Resuscitate the patient. Treat sepsis. Team in the operation theatre should be ready to respond to any call. Immediately start antibiotics. While Prof. Roger was discussing this, Prof. Francis Seow was operating live on Ano vaginal Fistulae repair.

In the next part of his presentation Prof. Rogers discussed how to manage anastomotic leaks. CT scan can be used to investigate the leak. Antibiotic therapy can be initiated immediately. Focus on septic control and avoid any secondary damage. Experience of the surgeon and surgical team matters a lot.  One can use old Trocar site to have blunt access. Use extensive irrigation. He then demonstrated through the use of a video clip laparoscopic dissection,   laparoscopic washout drain. Leaks, he said, do happen we can prevent them while being careful. Patient selection is also important. It is important that one should promote anastomotic health to prevent leaks.

Trans Anal Total Mesorectal Excision

Prof. Roger Moston’s next lecture was on Trans Anal Total Mesorectal Excision. He pointed out that it can be difficult.  In some men with obesity, TME reduce local recurrences to have better functional results. Speaking about laparoscopic stapling, he said, that the number of stapler firing was associated with anastomotic leak. Better visualization of lower pelvis reduces the conversion rates. It also results in more reliable anastomosis. Natural orifice specimen extraction are some of the benefits, he added.

Trans anal surgery, Prof. Roger Moston said was started in 1970s by Sir Alan Park. Discussing how to get stated Prof. Roger suggested that one should team up with the consultant colleagues. Seek support in departmental training. Go for qualifications and sub-specialization. Clinical Governance, equipment and time are all important. We have trained   more than hundred surgeons in doing TME using cadavers. It is good before you start operating on the patients. We did our cadaveric work. Patient selection, expertize of the team is important for patient safety. For TaTME picking the right patient is important. We discuss all the rectal cases in the team how to manage them. First assessment of the tumour is important. Then dissect as far as comfortable and leave a swab which is easily found. Responding to a question he said that everyone has his/her own learning curve. It depends on the competence, initial training of the surgeon, he added.