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COLONIC SURGERY IN THE NEW MILLENIUM
Vinayak N Shrikhande
Professor; Bombay Hospital Institute of Medical Sciences and Post Graduate Studies and Shrikhande Clinic, Mumbai, India.
INTRODUCTIONSurgery for diseases of the colon, rectum and anus has been practised for more than 100 years. It has been, till recently, an integral part of general surgery and has evolved with proved understanding. The last 20 years has witnessed emergence of colo-rectal surgery as a speciality. The increasing attendance of colorectal surgeons at conferences speaks for the importance of this speciality. As we stand on the threshold of the new millenium, we make an attempt to highlight only some of the advances in colonic surgery and the possible future directions it is likely to take.
Benign Ano-Rectal Diseases
Ano-rectal diseases have been common since origin of man, a small price to pay for adopting an upright posture. In an Indian setting, many patients continue to treat haemorrhoids on their own because they feel shy to consult a physician. For many, any discomfort in the anal area is piles! Inspite of progress in sclerotherapy and band ligation and lasers, surgical excision has stood the test of time. However, patients often opt for non-surgical treatment of piles. The principles of preserving an adequate muco-cutaneous junction have remained unchanged. Unfortunately, surgery of haemorrhoids, fissure and fistula is taught by senior residents to junior residents. Improperly performed, these operations cause severe pain and an excellent procedure becomes unpopular in the patient's mind. However, since with a other non-surgical procedures there appears to be a gap between patient expectations and experiences, surgical treatment would continue to hold fort in the management of haemorrhoids. An expensive but promising technological advance in surgery is the recent development of staplers in the surgical treatment of haemorrhoids.While abscesses and low-fistulae are easy to treat, do not require prolonged hospital stay and give immediate cure, and the problem of high and recurrent fistulae continue to pose great difficulties. The anatomy of the ano-rectal ring maintaining continence was described in 1934. Thus, a good fistulogram to delineate relation of the internal opening with the ano-rectal ring is invaluable. Since the most important aspect of surgical treatment is to prevent damage to the ano-rectal ring, these complex problems are usually managed in stages. .
Diverticular disease
As a result of enhanced life expectancy and dietary changes, diverticular diseases are likely to be encountered more frequently in the future. The well accepted operative principles appear set to continue giving excellent results.
Ulcerative colitis
While developments in the medical management of the disease have slowed down in the past few years, surgery for ulcerative colitis has become increasingly safer and more acceptable. Total proctocolectomy with ileal pouch is now the accepted "Gold Standard". However surgical training needs to be well-planned and intensive, or else the results in experienced hands could be disastrous. On the other hand, with a 5-15% rate of pouch related complications, permanent ileostomy can and should still be considered as a logical alternative. Experience has shown that patient compliance with a permanent ileostomy can be excellent and a minimal follow-up is necessary. Furthermore, patient expenditure is almost zero after this procedure. Thus all these factors would have to be considered before offering the choice of surgery to patients of ulcerative colitis.
Irritable bowel syndrome
The incidences is ever increasing and is expected to increase even more in a developing country like India. A large number of tests from the supermarket of investigations are being unnecessarily asked for at all levels ranging from the general practitioner to the consultant. Proper education may prove helpful in reducing the cost and inconvenience caused to the patient in this era of defensive medicine. In the coming years, holistic medicine would gain prominence in the management of this troublesome disorder.
Constipation
There are some syndromes where the diagnosis of constipation is difficult with the available investigations and the cost is unknown.
1.IBS
2.Slow transit constipation
3.Pelvic flow dysfunction
4.Psychogenic and psychiatric factors
Slow transit constipation in a small group of carefully selected patients can be cured with surgery when the exact site is localised.Colon cancers
Detection of colonic cancer is easy amongst GI cancers. Also, the tumour biology appears to be better. Surgeons therefore have a greater chance of curing them. On the other hand, recurrences are common. It is now possible to detect recurrences at an early stage, but it is unlikely that it would influence the ultimate survival.
Aggressive surgery including liver resection for hepatic metastases shall give excellent palliation and long term survival. While the stool test for occult blood was proposed as early as 1901, tremendous technological advances in endoscopy have occurred in the last two decades. Early diagnosis of stomach cancers has given excellent results in Japan. One can therefore assume that similar results should follow colonic cancers. Apart from early detection, endoscopic removal of pre-malignant polyps gives endoscopy a therapeutic value and an advantage of avoiding surgery. Most of the operations for colon cancers are on a clean colon and good techniques behave well. Wound infection is a common complication of colon surgery. Good bowel preparation and avoidance of contamination is very important. No antibiotic will prevent infection in a heavily contaminated bowel. The risk of sepsis is dependent on two factors-
-adequacy of mechanical preparation of colon
-surgical technique.
In as much as infections are caused by patients own flora, nosocomial infections appear to be causing increasing problems. In a country of India's size with a large rural area, simple techniques that do not involve expensive devices will prove useful for decades to come. Halstead still lives amongst us. The technical principles in anastomosis, advocated 100 years ago, are still relevant. Some fundamentals need to be repeated. All anastomosis demand -
1. The cut edges have a good blood supply
2. A complete absence of tension
3. Water tight anastomosis
4. Pertfect haemostasis
5. Adequate lumen
6. No distal obstruction
7. Gap in the mesentery should be closed to prevent internal herniations
Staplers have come in a big way. Stapler anastomosis are common but while working in a teaching hospital the author decided to work and teach anastomosis with hands. We all must bear in mind that anastomotic leaks are as common today as shown many decades ago. Only in low anastomosis of the rectum are staplers safe and stapler anastomosis should be considered as first choice.
Patients will continue to present with obstructive colorectal cancers. They carry a poor prognosis since the disease is advanced. All that can be done is to reduce the post operative morbidity.
The three available options are -
1. A three stage procedure consisting of decompressive colostomy, resection of the tumour and colostomy closure.2. A two stage proceudre comprising tumour resection and decompression and later colostomy closure.
3. One stage operation of intraoperative colonic irrigation and primary anastomosis.
Centres with a large volume of work would able to provide good results with even one stage procedures and in an era of cost effectiveness such procedure would gain popularity. However, the other procedures would be safer in average hands and in centres without much experience in colon surgery.
A word on role of blood transfusions in colon surgery. There would be an increased risk of HIV and Hepatitis B. The policy to avoid blood and plasma transfusions would continue. Preoperative blood transfusions to correct anaemia are discouraged because the immuno-suppressive effects set in around the time of surgery. Whenever possible, autotransfusions should be utilised.
Laparoscopic surgery
Laparoscopic surgery has invaded all surgical specialities with a tremendous impact in the last decade. While laparoscopic cholecystectomy has rightly established itself, surgery on the colon is proving to be far more difficult. The problems are two fold-technical and the associated pathology. Not only are these procedures technically demanding but they are also time consuming. A conventional right hemicolectomy is a simple operation which even residents can learn. However a laparoscopic procedure is a difficult problem altogether. The learning is far more prolonged and as it happens in any other field, only a few centres with a large volume of work would be capable of handling this work satisfactorily. While laparoscopic surgery may have a future in benign disorders, it is unlikely to play any role in malignant diseases of the colon and rectum. An important question will persist - what is the role of minimally invasive surgery requiring a sophisticated infrastructure in our country where patients need treatment near their homes? The socioeconomic and geographical reality should never be bypassed. More than 70 million people in India do not have any access to even water! The necessity, safety and superiority of laparoscopic colorectal surgery will have to undergo a critical assessment.
Molecular biology
Some patients of cancer colon have a family history of hereditary susceptibility. Thus there is a great interest in scientific exploration for genetic susceptibility. Modern molecular biology is expected to play a dominant role in the management of Crohn's disease, ulcerative colitis and colon cancer in the near future. It would become an invaluable asset to the clinician and would become an integral part of all surgical training programmes.
Future
What should be our aim?
1. Compulsory continuing education to train surgeons in the management of common colo rectal problems.
2. Surgeons in an Indian setting should be trained and encouraged to avoid sophisticated techniques. Let us not forget and lose the old skills of hand anastomosis in our pursuit of modern "gold standards"!
3. The commonest diseases seen in any surgical outdoor - piles, fissures, uncomplicated fistulae should be well looked after even in small hospitals, clinics and nursing homes all over the country.
4. Major colonic surgery should be available at district hospitals.
5. Some patients who have difficult problems like ulcerative colitis, recurrent cancers, and very sick patients should be referred to a few selected centres for better management. What I have written is an ideal. Every system needs improvement. It is an attempt to move on from where we are to where we ought to go. This is a journey of excellence that should be the only motto for the new millenium.
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