Pouch operations are now increasingly being done laparoscopically in specialized centers-Robin Phillips


 Surgical Week for Colorectal Diseases at JPMC-II

Pouch operations are now increasingly being
done laparoscopically in specialized
centers-Robin Phillips

While doing Pouch surgery two senior surgeons should work
together and learn from each other- Prof. Neil Mortensen

By our staff correspondent

KARACHI: On Second Day of the Surgical Week for Colorectal Diseases at JPMC on September 20th, Prof. Robin KS Phillips the visiting Master Trainer from UK made a presentation on Surgical Management of Ulcerative Colitis. He pointed out that those patients who fail to respond to medical therapy or have cancer are referred for surgery. In case of emergency surgery for ulcerative colitis, the surgeon should operate the patient along with Gastroenterologist. Exclude infections by doing stool cultures, start with steroids and antibiotics. TPN is a myth and it is not true. Plain abdomen X-ray was also suggested in these cases.

Continuing Prof. Robin said that colitis makes the patient preparation necessary.  He also talked about instant barium enema and colonoscopy in fragile colon in acute cases. He advised that keep on monitoring the patient and have good clinical examination. Fulminant colitis is an indication for surgery. Ever since the use of cyclosporine, there has been an increase in mortality. He also talked about colectomy or ileostomy in closed rectal stump. Acute illness, malnutrition will determine the choice. Failed medical therapy is an indication for laparoscopic management but in worst cases one should opt for open surgery.

Prof. Robin Phillips and Prof. Neil Mortensen the two eminent colorectal surgeons from UK who were the
Master Trainer and Clinical Coordinator at the just concluded Surgical Week for Colorectal Diseases
at JPMC photographed with Prof. Tariq Mahmood and others during the inaugural session.

Talking as to how one should go for the operative procedure Prof. Robin Phillips said that do it with midline laparotomy, mobilize the right sigmoid colon and in difficult cases divide blood vessels first. He also discussed the rectal stump operation. For sub-total colectomy one needs too much more length than one thinks. Rectal stump may be a reason for post-operative fever due to delayed rectoscopic drainage.  Failed medical therapy and risk of cancer is also an indication for elective surgery in these cases. While managing these cases we always involve the gastroenterologists to ensure that all medical therapies have actually failed. Cancer of the colon needs surgery.

Gastroenterologists Prof. Robin Phillips said can remove lesions endoscopically and then these patients can be referred to the surgeons. Common sense says that pouch is better as compared to ileostomy but the quality of life measured is the same. Similarly in hospital morbidity, stay, mortality is also the same.  Pouch patients might have to go to the toilet six times a day, one can wait for half an hour as the control is good. Almost 15% of Pouch are removed because of complications. In ileostomy there is a 28% chance of revision surgery but 85% cases of Pouch will be OK and will have no complications. Now Pouch is increasingly being done laparoscopically at specialized centers, he remarked.

Responding to questions during the discussion Prof. Robin Phillips said that if you make Pouch laparoscopically, there is a risk of affecting their sexual life. In 5-10% of cases of ulcerative colitis, diagnosis may change. People with ulcerative colitis are prone to Crohn’s disease. In ulcerative colitis one can get fistula, fissures and anal fistula. Pouchitis is a clinical condition. These patients may have fever, suffer from diarrhoea. If the pouch is too high, they can also have infection which is not Pouchitis. In some cases one might see chronic abscess behind the pouch.  There is a 75% chance of inflammation. It is important to exclude all other conditions before making diagnosis of Pouchitis. Ulcerative Colitis and Crohn’s disease are two different things and one should not confuse it, he added.

This was followed by a presentation by Prof.  Neil Mortensen another distinguished colorectal surgeon from Oxford UK who was the Clinical Coordinator for the course. He discussed in detail the Tips and Tricks in laparoscopic Pouch surgery. He pointed out that they started doing laparoscopic pouch surgery in 2005 and now hundred percent pouch surgery is done laparoscopically. The patients are put on steroids and antibiotics. It offers the advantage of a small wound in the abdomen which helps in early post-operative recovery. He however hastened to add that laparoscopic Pouch surgery mean different thing to different people. Most people man laparoscopic colectomy and then open proctectomy and pouch formation via a pfannensteil. He then showed an interesting informative video depicting colectomy technique and specimen extraction. He discussed in detail the sub-total and total colectomy. His advice was that two senior surgeons should operate, work together and learn from each other. One can use from 0-30 degree telescope and use the one with which you are comfortable. I use 30 degree camera, start from left to right umbilical and with four ports, and punch a hole through the Meso sigmoid. We use a combination of energy device, powered scissors and graspers and then take the mesentery comfortably. When the patient is very thin or in case of dysplasia, tie the vessels high.

While doing colectomy, proceed to the splenic flexure, remove and preserve omentum if normal. Then divide middle colic’s carefully, mobilize right colon and divide ileocolic. For specimen extraction, divide recto sigmoid with endoGIA, remove specimen through RIF’s trephine, and divide ileum just proximal to ileocaecal valve extracorporeally.  He also discussed rectal dissection wherein he talked about closing the rectal plane or Mesorectal plane, go to the pelvic floor and cross staple in the right place.  There are a few studies which show that time to diet and return of bowel function is superior in laparoscopic colectomy. Hospital stay after laparoscopic colectomy is shorter and there is no difference in early complications rate .However, late complications have not been reported in these studies.

He then briefly talked about latest developments in laparoscopic Pouch Surgery and mentioned about single port colectomy and bottom up style hybrid. If you go to the YouTube and select Colorectal Disease Journal, you will find lot of new techniques, he remarked.

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