Proceedings of the 9th Annual Surgical Week for Colorectal Diseases held at JPMC


Proceedings of the 9th Annual Surgical Week
for Colorectal Diseases held at JPMC

By Shaukat Ali Jawaid

KARACHI: Scientific programme of 9th annual Surgical Week for Colorectal Diseases held at JPMC recently consisted of early morning presentations on various important subjects by the Master Trainer Prof. Emmanuel Tiret a world renowned colorectal surgeon from Europe practicing in  Paris France. It was then followed by live demonstrations of various surgical techniques when he operated on a number of patients suffering from various colorectal diseases. The live demonstration was supplemented with interactive discussion between the Master Trainer and the audience in the auditorium and these proceedings were moderated by different Pakistani surgeons every day. Late in the afternoon, a few cases some of which posed some diagnostic problems were discussed in the consultant corner wherein the management of these cases was also discussed in detail.


Photographed in the inaugural session of the Surgical Week for Colorectal Diseases
held at JPMC from (L to R) are Prof. Tasnim Ahsan Director JPMC, Prof. Emmanuel Tiret
Master Trainer from Paris, Prof. Mumtaz Maher and Dr. Shamim Qureshi.

Restorative Proctocolectomy

On September 29th 2014, the first day of this course, Prof. Tiret made a presentation on Restorative proctolectomy. Ulcerative colitis, he said, is a benign disease but there is a chance of cancer as well. He discussed in detail the various operative techniques i.e. subtotal collectomy, proctectomy plus ileal-pouch-anal anastomosis and closure of ileostomy. In case of rectal cancer, one has to do oncological surgery. In severe acute colitis, the patient may complain of bloody diarrhoea for couple of days. Signs of systemic toxicity include tachycardia >90 bpm, hemoglobin <10.5 g/dl, ESR >30mm/h. Some of these patients may need admission to hospitals to rule out CMV and other infections. He also talked about postoperative use of anti-TNF, Recto sigmoid stump, Laparoscopic subtotal collectomy for ulcerative colitis in detail. Describing the technique for Restorative proctocolectomy for ulcerative colitis, he mentioned different techniques like collectomy, proctectomy, musosectomy and diversion. He also talked about the results of these different techniques with likely complications and functions.

Speaking about Collectomy, Prof. Tiret said that in ulcerative colitis patients with high grade dysplasia or colorectal cancer the colon and rectum should be removed with en-block oncological resection of lymhnodes in all colonic segments to the high risk of multiple locations and preoperative under staging. He then referred to close rectal resections and highlighted the importance of preservation of pelvic autonomic nerves. Find out the absence of cancer of dysplasia. In TME plane in the absence of dysplasia or cancer of the rectum a close rectal resection can be performed. Anterolateral resection posterior to Denonvillers fascia might preserve the autonomic nerve better thus minimizing the risk for urogenital complications. There is a risk of sexual dysfunction in 3% of patients hence sperm banking is recommended. He then talked about open approach, Hybird hand assisted laparoscopy i.e. laparoscopic collectomy and pfannenstiel incision for rectal dissection. Then he spoke about Hand assisted laparoscopic vs restorative proctectomy and pointed out that laparoscopic approach results in short hospital stay. If facilities and expertise is available, it should be the treatment of choice. It ensures better short term outcome. In the long term the benefits include reduction in adhesions.  However, this is technically demanding surgical procedure but feasible proctectomy approach. It gives good cosmetic results both for men and women. He then showed a number of surgical slides depicting Division of the superior mesenteric pedicle, peritoneal incision, mesenteric window and approach to mesenteric lengthening.

Group photograph taken during the Surgical Week for Colorectal Diseases held at JPMC recently shows
the Master Trainer Prof. Emmanuel Tiret along with some of the organizers and participants of the course.

Talking about ileal pouch, Prof. Tiret said that now most surgeons go for G Pouch because functionally it is now considered as the best. He then spoke about colon carcinogenesis in inflammatory bowl diseases, dysplasia in IBD endoscopically visible dysplastic raised lesions, peritoneal incision and mesenteric window, hand sewn vs stapled ileal pouch anastomosis. In case of cancer, hand sewn anastomosis is better. As regards dysplasia in IBD, you may not see it on colonoscopy and may do many biopsies. Studies have showed that endoscopically visible dysplasia has raised lesions.  In such cases one has to go for surgery but endoscopically all the lesions cannot be taken out. Recommendations for surgery and long term functional outcome were also discussed in detail. He also referred to expected results at one, five and ten years after these procedures. Most patients, he said, have no urgency for surgery. They have no incontinence; quality of life of these patients is good at one year and after ten years. However, there is decrease in fertility in female patients after surgery.

Talking about the postoperative complications of this surgery, he said, they are many which include hemorrhage, stenosis, dysplasia, fistula. Pouchitis is late complication of surgery and its incidence is about 30%. In some cases pouch has to be excised. There are multiple causes of failure and septic complications account for 50%. In Pouchitis the patient may complain of diarrhoea, bleeding, urgency, incontinence, fever, arthralgia but they respond to Metronidazole or Ciprofloxacin.  Other causes of failure include dysfunction, crohn’s disease and Pouchitis. Early complications account for 33.5%, late complications account for 29.1% while   Pouch survival at ten years is 95%, Prof. Tiret concluded.

Prof. Mumtaz Maher showed some video clips of laparoscopic anatomy and access and Right Colectomy which was followed by live demonstration of Restorative Panproctocolectomy by Prof.  Emmanuel Tiret.  In right hemicolectomy more pathology, he said, is on the right side. Hence proper placement of Trocas to get into the abdomen is important. These are advanced laparoscopic procedures.  Prof. Abul Fazal from Fatima Jinnah Medical College Lahore was the moderator in this session.  The patient was a thirty six years old female who complained of diarrhoea, fever, body aches and failed to medical therapy. It was a case of moderate ulcerative colitis. This patient was already on low dose steroids. Prof. Tiret opined that in such cases, they stop steroids before surgery.

Dr. Shahid Khattak

Dr. Shahid Khattak from Shaukat Khanum Memorial Cancer Hospital Lahore also showed some surgical procedures of Laparoscopic Transverse and Left collectomy which was followed by another live demonstration of Milligan Morgan Hemorrhoidectomy by Prof. Tiret. The day’s proceedings ended with the consultant corner in which some interesting cases were presented for discussion.

Total Mesorectal Excision

The Day Two programme started with a presentation by Prof. Emmanuel Tiret on Total Mesorectal Excision.  He discussed in detail the quality of the mesorectum, why it is important and why should one do TME.  Prof. Tiret opined that it offers two benefits i.e.  as regards local recurrence and survival besides sexual and urinary functions.  He then gave results of implementation of TME as a routine treatment in Norway and in Netherlands. In the later the patients were operated on with curative intent without preoperative radiotherapy. Quality of mesorectum, he said, has three grade-score. Plan of surgery he opined, is an independent prognostic factor for local recurrence. He then showed some interesting slides of autonomic innervations and also talked about risk of damage during surgery to hypogastric nerve, exigent nerve, cavernous nerve, lymphadenectomy and superior hypogastric plexus. He further stated that at the level of the promontory the hypogastric nerves are at risk of injury. Posterior dissection is performed outside and close to the fascia recti. The sacrorectal ligament must be divided by sharp dissection.  He then showed anterior dissection in front of Denovillier’s fascia, excessive traction he opined may induce injury to the pelvic plexus.

Referring to the COREAN trial with 340 patients with preoperative CT, BMI 24, he said estimated blood loss was 200ml and anastomotic leakage was seen in 1.2%. He also highlighted the post operative recovery and complications. Continuing Prof. Tiret said that excellent result are very difficult to reproduce. He also highlighted the advantages of laparoscopic approach. He then gave results of rectal cancer from Belgium and said it was a good study but from one center without any risk but this is the only center in the whole country which is very expensive. If you have an excellent center with rich expertise, you can go for laparoscopic approach which offers good results but be careful. He then discussed low stapled anastomosis, closure of rectal stump, incision of macularis besides opening of Pouch. He was of the view that in some cases it is not possible to save sphincter or anus. Go for limited perianal incision particularly in female patients and stay at good distance from the tumour. He also briefly talked about hand sewn anastomosis. The dissection is carried upto the inferior aspect of the levators, the pelvis is entered posteriorly in the precoccygeal space and then the levators are divided close to their lateral insertion. The specimen is delivered through the perineal wound, omentoplasty is sewn to the subcutaneous tissues and perineal skin is closed primarily. He then talked about APER in lithotomy, recurrence and survival. Prof. Tiret was of the view that one does not have to flip the patient for the abdominal and perianal approach.

During the discussion which followed his presentation he pointed out that it is easy to see hypogastric nerve and there is a risk of damage. Patient has to be informed and if the surgeon is obliged to sacrifice one nerve due to cancer, he has to report it in the surgical notes.

Dr. Shahid Khattak from SKMT Lahore  then showed some video clips of  laparoscopic surgery of TME, post positioning, entry  posterior TME Plane. He pointed out that the left side ureter is easy to identify than the right side.

Prof.  Emmanuel Tiret then showed live demonstration of Abdominoperineal Resection (APR), Anterior Resection. This fifty years old female had squamous cell carcinoma of anal canal. She had chemo radiation for growth of anal canal.  Prof. Jamil was the moderator in this session.  Responding to a question Prof. Tiret said that she will have poor wound healing because of radiotherapy. Dr. Shahid Khattak pointed out that all such patients should have colonoscopy and we should have picture with us but it is the finger which will give you all the information. The second case which he demonstrated live was of open haemorrhoidectomy. Replying to a question from the audience Prof. Tiret said that he does not do an open haemorrhoidectomy in France anymore and he does not remember when he did the last case.

Recent advances in surgery for Rectal Prolapse

On Day-III of the course, Prof. Emmanuel Tiret made a presentation on recent advances in surgery for rectal Prolapse.  Speaking about surgical treatment he discussed anal enrichment, rectopexy, ventral rectopexy open as well as laparoscopic, perineal resection and sigmoidectomy. With laparoscopic ventral rectopexy continence is improved post operatively.  In anterior rectopexy preoperative constipation is reported to be   30-67% while post operative it is 15-75%.  He also talked about rectal Prolapse and obstructive defecation, altemier procedure which has immediate post operative results. Morbidity is between 14-16% and mortality from zero to 1.6%. The average hospital stay is about 4.2 days. Delorme procedure Prof. Tiret said was another option in such cases. Recurrence is seen in 10-27% improvement in fecal incontinence is seen in 63-87% of patients. Prolapse length, he opined, is not related to outcome. This procedure can be safely applied in young health patients.

Transanal procedures Prof.Emmanuel Tiret said reduces rectal capacity, it has increased recurrence rate with unsatisfactory functional outcome.  Cochrane Review of twelve randomized trials of Resection Rectopexy showed reduced incidence of constipation, laparoscopic procedures require less hospital stay. He concluded his presentation by stating that laparoscopic ventralrectopxy has become the procedure of choice for most patients with full thickness rectal Prolapse. Resection Rectopexy has some limited residual indication in case of refractor constipation, delayed colonic transit or redundancy of sigmoid colon.  Delorme procedure and Altemeier’s procedure are indicated in elderly and high risk patients. Responding to a question Prof.Tiret said that hypogastric nerve can be damaged but the risk is very low if the procedure is done carefully.

Local experience with laparoscopic ventral rectopexy

Prof. Mumtaz Maher then talked about local experience with laparoscopic ventral rectopexy. He pointed out that he has done a few procedures. Speaking about the basic requirements for this operation he said if you are not comfortable with suturing, do not attempt it.  Join with gynecologists and do it first on vaginal wall. He then showed some video clips of the procedure and said; one should learn how to stitch. One cannot imagine a laparoscopic surgeon who does not know how to stitch. Some learn it on Endo Trainer. Do not learn on patients how to stitch. It is extremely important that one learns how to suture and become efficient, he remarked.

In the live demonstration Prof. Emmanuel Tiret showed abdominal rectopexy and Delorme’s procedure. He again emphasized that one should save the hypogastric nerve.

Complex Anal Pathologies

On Fourth Day October 2nd 2014, Prof. Emmanuel Tiret made a presentation on Complex Anal pathologies. Fibrin glue, he said, has a success rate of 30-70% in simple fistula. It is a very simple technique. He also talked about anal fistula plug vs fibrin glue. He further pointed out that many centers could not have the same success rate and it was less than 50% success in most centers.  He also discussed the Lift technique and closure of external sphincter defects. Use of fibrin glue and advent flaps is associated with low incontinence. During the discussion Prof.Abul Fazal from FJMC Lahore highlighted the efficacy of Endo Anal Ultrasound which is done by the surgeon and sinologist together.

Prof. Emmanuel Tiret then demonstrated live sphincter repair in a twenty seven years old female with fecal incontinence.