Published by : PROFESSIONAL MEDICAL PUBLICATIONS
continuing medical education
|October - December 2007 (Part-I)||
Proceedings of workshop on
Shaukat Ali Jawaid*
Pak J Med Sci October - December 2007 (Part-I) Vol. 23 No. 5 818-822
Shaukat Ali Jawaid,
Pakistan Journal of Medical Sciences,
KARACHI: Keeping up its past traditions Colorectal Surgery Division of Dept. of Surgery at JPMC headed by Prof. Mumtaz Mahar organized yet another academic feast here from October 22-25th 2007. Prof. Ralph John Nicholls an eminent colorectal surgeon who is Professor of Surgery at St. Mark’s Hospital London was the master trainer during the workshop. It was attended by over hundred postgraduates, junior and senior surgeons from the city hospitals while some participants also came from interior of Sindh and Lahore. Registration was free and it provided a rare opportunity to the participants to witness the eminent British colorectal surgeon operating on many complex and complicated cases.
Arrangements had been made for showing live surgery from the operation theatre in the surgical hall with facilities for interactive discussion. Audiovisual arrangements were excellent and the participants were able to see the live surgery being performed witnessing even minute details. These days when holding conferences and workshops at Five Star Hotels has become a fashion with the doctors community, all paid for by the pharma industry, it is indeed commendable that we still have some conscious people among the healthcare professionals whose preference is advancing academics, providing learning opportunities to juniors in a most cost effective way. Tea and lunch boxes were provided to the participants all free and help and assistance from the Pharma industry was sought to arrange for suturing material, staples and sponsoring the guest speaker. One hopes and pray that this infection spreads among other conference organizes as well.
Speaking in the inaugural session held on October 22nd, Prof. Mumtaz Maher said that Prof. John Nicholls has a great name in the field of colorectal surgery and any book or article on the subject will have his references. He has made his impact in the field of colorectal surgery. The workshop participants, he said, will have the benefit of witnessing excellent surgical skills and surgery for ulcerative colitis without using staples. We have two objectives of this workshop firstly though we the seniors can travel any where but juniors do not have enough resources to go abroad and see such type of surgery. So we invite these experts here so that the juniors have an opportunity to see them operating. It will help the junior surgeons also to learn the skills. Seniors will also pick up some tricks of the trade.
Continuing Prof. Mumtaz Mahar said that due to lack of leadership among the general surgeons, we have failed to grab the opportunities with the result that some of our work has now been taken up by radiologists and gastroenterologists while laparoscopic surgeons were also grabbing the opportunities. During the four to five years training period for postgraduates that we have, it is difficult to accomplish all that. Hence after doing FCPS, the junior surgeons should go to learn to those places where complex surgical procedures are being performed. The second objective of this workshop is that we should have specialized centers in different institutions where people can take up different aspects of surgery. Laparoscopic surgery can be projected on the screen. Earlier we had organized a surgical workshop on ano-rectal benign diseases and this time we will try to do open methods. He requested Prof. John Nicholls to explain even the basics during the surgery. Watching something and doing live is a bit different. We should try to develop different skills in specialization rather than doing the routine things at the tertiary care centers. Volume of work load has increased manifold at these centers hence one surgeon cannot do everything. As such if different surgeons take up different aspects of surgery and concentrate on that, their results will be better as they will be handling large number of patients in that particular area, Prof. Mumtaz Mahar remarked.
Prof. Tasnim Ahsan who was the chief guest at the occasion in her address said that it is not possible to become super specialist without good grasp on basics. Hence need for refreshing the basics will always be there. She emphasized the importance of learning basic surgical skills. Addressing the participants she said that with the organization of this workshop, an opportunity has come to their doorstep and they should avail it to their best. Time has come that we must develop among ourselves at the highest level of specialization a critical mass of people, she added.
Dr. Baddar Siddiqui another noted surgeon commended the efforts of Prof. Mumtaz Mahar and his team for organizing this series of workshops on colorectal surgery which are meaningful. He opined that we must have a structured training programme. Doors for training overseas have almost closed and we are already very much behind in various surgical areas. Once we have an indigenous structured programme in every institution in Pakistan, things will start improving. He called upon the organizers to keep it up since it is an urgent need and a significant step. Learning never ends, he added.
Addressing the participants Prof. John Nicholls said that during the workshop we will learn from each other. He called upon the participants not to hesitate asking questions as it was important to have a meaningful dialogue
Tracing the history of colorectal surgery Prof. John Nicholls first talked about proctolectomy with straight ileo anal anastamosis which was described by Ravitch and Sabiston in 1947. Pouch surgery, he said was introduced in mid 1940s. Till then it was not classified as a disease. Diarrhoeal diseases were considered infections. From 1870 to 1900, Ulcerative Colitis began to be identified as a disease. In 1900 non-infective proctolectomy had been identified. In 1915 these patients had been identified and treated. Loop ileostomy was described by a US surgeon and mortality for a diversion process was about 50%, hence most of the surgeons were afraid to do that. With the advances and developments in surgical techniques, surgeons in Canada reported reduction in mortality to 5%. Devine and Webb from Australia reported removing inflamed mucosa of rectum in 1952. Valiente and Bacon in 1955 described straight ileo-anal procedures which could improve poor function but the results were not good. In 1969 Kock demonstrated intra abdominal reservoir in a patient with permanent ileostomy. Endo anal anastamosis was practiced in 1978. He then talked about choice of operation including pouch operation, indications and complications in detail. Since 1976 RPC is increasing every year, he added.
Prof. Iftikhar Rathore pointed out that while general surgery was doing well but there were very few people in chest surgery. He called upon the young surgeons that more and more people should come forward in neurosurgery, chest surgery and other sub-specialties.
Earlier Dr. Shamim Qureshi organizing secretary of the workshop in his introductory remarks said that the objective of starting a colorectal clinic at JPMC was to provide specialized services to the patients. Colo Rectal Division was established at JPMC about five years ago and we are providing opportunities to people to polish their skills.
Demonstration of Live Surgery
The first case which Prof. John Nicholls demonstrated was of restorative proctocolectmy. He also described the contraindications of doing a pouch procedure. In such cases I do staple anastamosis in 2-3% of cases. In this case I did manage anastamosis as far as possible. He further remarked that traction injuries on spleen are very uncommon while he does this procedure. Big incision will not make a big difference but a beginner may find himself more comfortable with a bigger incision. Crohn’s disease should not be treated with this operation. Failure rate with Pouch operation in such cases is between 30-40% if cancer is low down in rectum. Weak sphincter is a contraindication for this operation, he added. During the procedure he also remarked that it is said that colorectal surgeon works in an area where sun does not shine. Inside view by the laparoscopic camera was excellent enabling the participants to note each and every surgical move by Prof. John Nicholson.
The second day of the course started with an open discussion on training of postgraduates and it was suggested that the PGs should be sent on rotation to different institutions within the city and to other cities as well. This will enable them to have a look and benefit from the experience of different surgeons.
The first case which Prof. John Nichollson operated was a fifty five years old lady. It was a case of adeno cancer of anal canal. He discussed the new staple devices. Prof. Mumtaz Maher emphasized the importance of concentrating on practical surgical aspects of these procedures and try to take home some message whereas theoretical aspects can be discussed later. Prof. John Nicholls also talked about nerve sparing surgery He was of the view that it is useful to divide the colon first while doing this procedure. I usually take out the vagina in all malignant cases to avoid making hole in the anus. About 2mm margin is left. It is dependent on pathology and local spread of the tumors, he added. One of the participants pointed out that 40% of such cases may result in incisional hernia.
The second case which he did was of abdomino perineal resection, rectus abdominis putting a flap doing some plastic surgery as well. It was a bit complicated case and much difficult than the earlier one.
The next day started with a presentation by Prof. John Nicholls on developments in colorectal surgery and decision making in Haemorrhoids. In category one, he said, there is no need of any treatment. Just reassure the patient as there is no serious colorectal lesion. In 10% of cases bleeding predominates and injection sclerotherapy is quite effective. Ideal haemorrhoidectomy is simple to perform and is efficacious. He also talked about staple vs. non-staple haemorrhoidectomy. PPH is feared in all categories except recurrent prolapse as skin tags recurs. Comparative studies of MMH vs. PPH show that more patients of PPH are satisfied. He also talked about PPH vs. classic haemorrhoidectomy. However, Prof. John Nicholls made it clear that there are very little long term results of PPH vs. MMH. In some studies MMH gives better results. Even NICE in UK has not been able to understand it either. PPH complications include late pain, rectal perforation, and rectal vagina fistula. These do not happen with classical haemorrhoidectomy. He also discussed open vs. closed haemorrhoidectomy. Meta analysis of RCTs has shown that metronidazole does reduce pain after classic haemorrhoidectomy. Even otherwise patients expectations are better with metronidazole. Diltiazem cream 2% is also used in open haemorrhoidectomy but it is expensive. In UK National Health Service covers it. Botulinum is toxic during MMH but some patients do benefit. Prof. John Nicholls was of the view that the patients should be told before hand that it will be painful and give them metronidazole. GTN cream and Diltiazem are expensive. NSAIDs can be given. Comparison of LigaSure vs. conventional haemorrhoidectomy shows that as regards duration, pain, wound healing LigaSure is better but there is no difference between the two as regards complications and recurrence. Responding to a question he said that he had no complication with diathermy haemorrhoidectomy.
The next case was of strategies for rectal prolapse. This, he said, can be managed with abdominal and perineal approach. Talking about comparison of recurrences after abdominal vs. perineal procedures in rectal prolapse he mentioned about rectopexy, 50% of patients complain of constipation. Rectal sensation is a real problem; hence I decided to leave it. Advantages of perineal procedures for rectal prolapse are that it is well tolerated, has low constipation rate but has similar morbidity and low sexual dysfunction.
During the discussion Dr. Turab who was moderating the session remarked that in massive prolapse haemorrhoids in advanced cases, since the tissue is large, one gets an incomplete donut. In grade one, Prof. John Nicholls opined that dietary advice is helpful but in grade two band is helpful. Dr. Shazia remarked that PPH is good for stage three patients. Prof. Mumtaz Mahar stated that PPH is one way of sorting out a problem. It is not for every organ around this area. Patient will not have as much pain as in open procedure. Patients usually do not have haemorrhoidectomy for years though they have fistulas which are painful.
The next patient was a sixty years old female a known case of ulcerative colitis. Dr. Turab pointed out that pyoderma is very rare in Pakistan and it is a very mysterious condition. In case of inflamed bowel, stapling, Prof. John Nicholls said, is out since it takes too long. Hence he did hand suturing in this patient and made an ileostomy. He emphasized that try to do it right first time but in case you encounter some problem, it is better to redo it again rather than leaving it for the Nature to manage it. The cases which he did on third day included surgery for ulcerative colitis. Since this patient had surgery earlier, it was a bit complicated case. Pouch anal anastamosis was done with hand suturing rather than using staples. Delorme’s procedure for rectal prolapse and haemorrhoidectomy were the other cases demonstrated live.
The cases which he did on October 25th the last day of the workshop included complex fistula in Ano, Rectovaginal fistula and anal sphincter repair. During surgery he emphasized the importance of good physical examination particularly finger examination, digital examination and assessment. Finger examination, he felt, was most important in fissure in Ano.
Participating in the discussion Prof. Naheed Sultan remarked that we have learnt some new surgical procedures. She thanked Prof. Mumtaz Maher for arranging the workshop. Prof. Majeed Chaudhry Principal Fatima Jinnah Medical College from Lahore said that we can jointly have a similar workshop at Lahore in the coming months. Colo rectal is a poorly understood areas in Pakistan. It is important to find a Guru and learn from him. Due to our neglect, this area has been encroached upon by Hakeems, Homeopaths and Quacks but when they themselves have some perianal problem, they come to us for surgery. We have seen some mega disasters in this region. Patients die sitting on the WCs. Burning of anal canal is also resorted to by quacks, he added.
Prof. Rasheed Jooma Director JPMC was the chief guest in the concluding session. He commended the efforts of Prof. Mumtaz Maher and his team for successfully organizing the workshop despite law and order situation in the city while some other institutions had to cancel their programmes. It is gratifying to see how much progress has been made in this field over the past three decades since he was a house surgeon. It is an exciting and interesting field. It is always gratifying to have a Master come and perform, demonstrate all these procedures. He urged Prof. Mumtaz Maher and his team to continue such academic activities for which the administration will extend all possible help and support. He also presented a traditional Sindhi Cap and Ajrak to Prof. John Nicholls who was also presented some other gifts and souvenirs on behalf of the organizers.
Prof. John Nicholls speaking at the occasion said that he enjoyed his time in Pakistan and thanked Prof. Mumtaz Mahar and Dr. Shamim Qureshi for inviting him here. I am overwhelmed with the generous hospitality. I enjoyed working with the surgical team, the help and assistance of support staff in the operation theatre was just excellent, he added.
Earlier Prof. Mumtaz Maher in his address thanked Prof. John Nicholls for coming all the way to Pakistan to demonstrate some innovative and latest surgical procedures. It is our good fortune that the cases that we selected, though looked simple, but turned out to be very complex and complicated. It provided us an opportunity to see what we would have done and how an expert had handled and managed them. He used all his experience to sort out some of these problems.
He thanked the audiovisual team headed by Mr. Shams which did a wonderful job. Laparoscopic imaging was excellent and we did not encounter any problem throughout the four day workshop. Attendance by participants was good and every body had some message to take home. He thanked Dr. Shamim Qureshi for making it possible and Prof. Rasheed Jooma for his institutional support. We are happy to note that participants came not only from other institutions of Karachi but also from Hyderabad, Sukkur, Nawabshah and Lahore. M/s Ethicon, Johnson and Johnson as usual were extremely helpful in providing suturing material and staplers, Roche supported this effort in a big way while Searle also contributed in this academic activity. Prof. Mumtaz Maher particularly thanked the team in the operation theatre i.e. the surgical assistants, nurses and OT technicians Dr. Aisha, Dr. Ishaq Soomro, Dr. Talal, Tariq and Tabinda. Dr. Umar, Imdad Solangi and Mr.Nadeem.
Unlike the previous workshop on benign anal diseases, this time not many senior surgeons were seen participating. Apart from Prof. Mumtaz Mahar those who actively participated and acted as moderator during the workshop included Dr. Shamim Qureshi, Prof. Naheed Sultan, Prof. Shafiqur Rehman, Dr. Turab, Dr. Sadaf, Dr. Shazia and Prof. Majeed Chaudhry both from Lahore and others.
HOME | SEARCH | CURRENT ISSUE | PAST ISSUES
Room No. 522, 5th Floor, Panorama Centre
Building No. 2, P.O. Box 8766, Saddar, Karachi - Pakistan.
Phones : 5688791, 5689285 Fax : 5689860