SRS TRAVELLING FELLOWSHIP 2000 – A REPORT

MR.G.NAGESH.RAO

I consider it a great honour to have been awarded this opportunity to visit the Pelvic floor laboratory and the Department of Colon and Rectal surgery at the University of Minnesota. My aim was to study –

a)       The functioning of a multi-disciplinary Pelvic floor laboratory and to see how they translate the vast amounts of information on each patient into clinical management plans.

b)       The standard of care provided for various colorectal problems and to compare the standard with what I learnt in my training in UK.

c)       Colorectal training, Audit and Journal club.

d)       Clinical and Diagnostic care pathways and patient feedback.

First five days were spent on 3 courses – Ultrasound workshop, Pelvic floor workshop and ‘Principles and Practice of Colon and rectal surgery’ course. The remainder of my stay was spent in the Pelvic Floor laboratory and a relatively small part was spent in the weekly clinical meeting, audit, Journal club and attendance in the Operating Rooms for the relevant cases.

PELVIC FLOOR CENTRE

Introduction:

Pelvic floor disorders very often involve more than one compartment with considerable overlap. Symptoms originating from one compartment do not imply absent pathology in another. Only a carefully elicited history and examination is likely to uncover this. Sometimes correction of problems in one compartment uncovers previously latent symptoms from another compartment.

For example, a perineal rectocoele repair without a preoperative double contrast defaecogram with/without peritoneography may cure the patient’s rectocoele but by missing an enterocoele her symptoms of obstructed defaecation might persist.

Repair of a large rectocele may correct obstructed defecation and a need to digitate for bowel movements but also uncover urethral instability and render the patient incontinent.

In both these cases, while the procedures have been a technical success, to the patient they have been a complete failure. 

It is only by fast tracking the diagnostic process and adopting a multidisciplinary approach can the underlying problem become clear and a management decision made. In the Pelvic floor laboratory, none of the investigations are performed by radiologists. The surgeons, specialist nurses and radiographers perform these. All the cine-defaecograms and ultrasound scans are interpreted by the Colorectal surgeon (with an interest in functional disorders) and a Urogynaecologist in a multidisciplinary meeting. Not all patients are discussed in the multidisciplinary meeting.  For instance it would be illogical to subject someone with a perfectly normal micturition to urodynamics and cine-cystourethrography.

Manpower :

1)    One Specialist nurse – who performs Anorectal physiology and looks after the instruments. May also be involved in Biofeedback.

2)        Two technicians – one of who also doubles up as a secretary.

3)        One secretary.

4)       One Research nurse who performs Biofeedback.

5)       One or two Colorectal Residents, who perform Anorectal Physiology, Endoanal/rectal Ultrasound scan under supervision.

6)       Three specialists – Two Colorectal surgeons (Dr.Congilosi who is overall in charge and has a strong Pelvic floor interest and Dr.Aguilara whose primary interest is Endorectal scans for malignancies and fistulae)

                                      One Urogynaecologist (Dr.Warshaw) who is part of the multidisciplinary team.

[There is also a session for a Urologist who scans patients with suspected prostatic problems. He is not involved in the multidisciplinary set up].

Scope:

The Pelvic floor centre is capable of assessing all functional/benign pelvic floor disorders, staging and follow-up of rectal cancers and assess fistulae. To manage the high volume of patients seen at the Pelvic Floor Center and provide a complete assessment recommended studies are performed for each diagnostic classification.

Working of the centre:

Patients referred to the centre, fill in a detailed symptom questionnaire and then enter a diagnostic care pathway. The history is checked and modified by the doctor prior to the patient signing an informed consent and the examination – physical and laboratory. The choice of investigation is based on the referral letter. Following the assessment – multidisciplinary or otherwise – recommendations for further treatment or investigation are made to the appropriate referring physician.  Most of the patients do not spend more than a day. For instance, someone with multiple compartment problems may have her Anorectal physiology, Endoanal scan and Urodynamics with cine-cystourethrogram in the morning and have her double contrast defaecogram with/without peritoneal contrast in the afternoon. An assessment of all the results are then made and a consultation with the specialist ensues. Consultation can be anywhere between half-hour to one hour. Finally patients fill in the feedback form.

Case illustrations: These are some of the cases I saw on one of the days.

Case 1: 45 year old lady with severe faecal incontinence following multiple anal procedures in the past. Endoanal scan demonstrated extensive scarring with practically non-existent sphincter musculature. Anorectal physiology demonstrated normal rectal sensations, extremely weak Resting and Squeeze pressure and a normal Pudendal nerve terminal motor latency and Puborectalis EMG. Options offered to this patient were continued medical management, sacral stimulation or artificial bowel sphincter.

Case 2: 35 year old lady with Obstructed defaecation. There was definite evidence of Paradoxical Puborectalis contraction on the EMG and on Cine-defaecography (double contrast). She was referred for Biofeedback treatment.

Case 3: 24 year old lady with normal Barium enema, Upper GI series and transit studies complained of Constipation and intermittent abdominal pain. Anorectal physiology was normal, as was a physical examination apart from a rectocoele (absent history of digitation). Cine-defaecography was entirely normal apart from a rectocoele, which emptied well on its own. Valsalva effort was minimal. EMG results indicated nonrelaxation of Puborectalis. Dietary advice and biofeedback was recommended.

Case 4: 34 year old lady with a two-year history of severe constipation. Transit studies showed 18 markers in the right colon on day 5. She had normal oesophageal and gastric motility, colonoscopy and Anorectal physiology studies. Cine-defaecography showed moderate widening of the rectovaginal septum with a rectocoele and enterocoele. Total colectomy with Ileo-rectal anastomosis was recommended with an enterocele repair.  

Case 5: 65 year old lady who had a difficult prolonged Forceps delivery 20 years ago. She had obstructed defecation, perineal fullness, and large symptomatic rectocoele and stress urinary incontinence. Upper and Lower GI series were normal. Cine-cystourethrogram with urodynamics demonstrated bladder neck hypermotility and a normal urethral pressure profile. EMG of peri-urethral musculature was normal. Anorectal physiology was normal apart from the presence of Paradoxical Puborectalis contraction on EMG. Cine-defaecography confirmed the paradoxical puborectalis contraction and demonstrated vaginal vault prolapse, wide recto-vaginal septum with a moderate septal peritoneocoele with rectal component and a large rectocoele. Recommendation was for an initial period of Biofeedback followed by Colposacropexy (with obliteration of rectovaginal space) and an anterior bladder neck suspension procedure.

Techniques:

There are no major differences in technique. A Water perfused 4 channel catheter is used for routine physiology. Recently the lab has acquired a solid-state transducer catheter for ambulatory manometry testing and research studies. Pudendal nerve terminal motor latency is measured with the disposable St.Mark’s pudendal nerve electrode mounted on the index finger. Puborectalis EMG is assessed using sponge mounted surface electrodes. EMG tracings are obtained in the sequence Rest-Squeeze-Rest-Strain. The obvious shortcoming of each of these techniques is well recognised here and taken into consideration in the final decision making process.

Quality assurance:

 All deviations from the diagnostic care pathway and patient feedback is assessed every month. Figure 1 shows the procedures performed in the lab over the last one year. Figure 2 shows the total number of procedures and patients managed in the ARP lab over the last one year. In the past there is more than 99% patient satisfaction and minimal deviation from the care pathway which is not surprising considering the time spent with the patients.

Endoanal and rectal Ultrasound:

This is used for

a)       Staging and follow-up of rectal cancers.

b)      Defining sphincter injury and fistulae.

The quality of images is very superior. My initial scepticism on the value of Endorectal scan in the management of rectal cancers was very quickly replaced by a belief that if the procedure is done by a surgeon using the ‘tricks’ that are employed here, a very high accuracy in staging and diagnosing recurrences can be achieved. This would place Endorectal scan as a very cost-effective method of assessment. It is my belief that the high quality of images is due to –

1)       Use of 10 MhZ scanner probe.

2)      Procedure being performed by a Surgeon (who is already at the peak of the learning curve), who can better visualise the lesion on the initial proctoscopy (10 cm proctoscope) and feel it on digital rectal examination. The scanner is then passed through the proctoscope. 

3)      Thorough suction of all the liquid stools after the initial Fleet enema, which is administered to patients before the procedure. I have seen a few scans being postponed by a few hours because of inadequate preparation. Faeces can produce the most amazing tumours!

4)      A digital rectal examination after the procedure. It is amazing how previously impalpable pararectal nodes become palpable.

5)      Use of Transrectal biopsy of nodes under ERUS control. This is possible in only suspected recurrence, as otherwise the needle has to traverse tumour tissue if it is performed for primary tumours. Large nodes greater than 1 cm is considered malignant.

6)      Variation of the technique as required. For Villous lesions the balloon around the scanner head will not approximate well with the rectal wall. In these cases, the rectum is filled with degassed water and scans are performed using the cone.

While there will always be the difficult one where one cannot be absolutely sure whether it is T2 or T3 (what is termed here as a ‘hard call’), in the majority, the distinction can be made. I understand that at the inception of ERUS, Radiologists used to perform the procedure and were somewhat reluctant to perform the initial rectoscopy. Image quality was consequently very poor.

Rectal Cancer Management:

The high quality of images along with the excellent interpretation has apparently brought about a change in management of rectal cancer. T1N0 and T2N0 lesions are treated by Local resection (not TEMS). T3 and T4s are pre-treated by Preoperative Radiotherapy and radical surgery. Professor Goldberg and all the others have shown that their local recurrence after local resection of T1 is 19% and for T2 it is 47% (DCR August issue). Those who have local recurrence undergo radical resection. There was no compromise in the 5-year survival when compared with the group who underwent radical resection. So the patients have lost nothing and in 80% of T1s and 50% of T2s, local resection this is successful treatment. For such a policy to work, the follow-up is very thorough and frequent. It is done using ERUS [four monthly for three years and six monthly thereafter]. The first ERUS at 4 months serves as the baseline. Any suspicious node is biopsied transrectally using a Core biopsy needle. While this has an undisputed place in T1s, some here wonder whether it can be justified as a cost-effective alternative to radical resection for T2s. I saw a Local recurrence of an adequately excised T2 lesion on the first follow up scan (at 4 months).

[I remember the rather uncomfortable anxious moment that I experienced in my Intercollegiate exam after mentioning Local resection for T1 and possibly for T2. The examiner clearly thought Local resection had no place in treatment of rectal cancer. Fortunately I did not argue and was not penalised!].

I saw several sphincter injuries and fistulae including all the three types of Horseshoe fistulae and a fistula arising from a Post-anal dermoid. The latter was subsequently excised using the York-Mason procedure and the track dissected out to the anal mucosa, much like a Sistrunk operation. Professor Goldberg had a patient with a high transsphincteric fistula with an intersphincteric extension into a Supralevator horseshoe abscess. Using Hydrogen Peroxide defined the anatomy on the EAUSS.

There are obvious limitations of USS in the diagnosis of high fistulae. This is well recognised. In complex and high ones, MRI is used as the second line of investigation before embarking upon surgery.

Fibrin Glue:

Fibrin glue is used here as the primary management of selected fistulae. Low ‘clean’ fistulae are routinely treated with this glue with or without closure of the internal opening. Recurrence rate is high approaching 90% or more in one year. Nevertheless it is a relatively minor procedure and nothing is lost, if at a later date the patient has to undergo a formal fistula surgery. That appears to be the rationale for its use. Pouch-Vaginal fistula has been treated with Fibrin glue with excellent results [Fibrin glue is expensive, takes time to prepare and with its high recurrence rate I doubt if it will ever take off in the NHS]. 

CLINICAL MEETINGS:

Weekly clinical meetings and Journal clubs are very well organised and there is active interest shown by everyone (trainers and trainees) in the discussion of articles. I found these meetings very interesting particularly as it concentrated on colorectal topics. These usually start at 7 AM with plentiful supply of good coffee (possibly Brazilian) and an assortment of different types of donuts and Danish pastries. In one of the meetings, there were two cases of post-polypectomy ‘problems’. One had a Post-polypectomy syndrome and the other with free intraperitoneal gas. Both were managed conservatively with success. Two cases of Pseudomyxoma Peritonei were presented. There was one case of massive lower GI bleed following a toothpick perforation of Sigmoid colon and Iliac artery. These are just a handful of interesting mix of cases.

There was one case of T1N0 rectal cancer at 6 cms who presented to St.Elsewhere. The Board eligible/certified general surgeon performed a Low Anterior resection and went through the tumour. So he performed a second laparotomy and resected a further 7 mm of rectum and found incomplete donuts after firing the gun. Patient had a leak for which the surgeon did a third laparotomy and raised a defunctioning loop ileostomy and referred him to the Colon and Rectal surgeons in Minneapolis-St.Paul. I understand the patient had a moderate size collection around his dehisced anastomosis. There was some discussion about whether this constituted malpractice, particularly as the lesion was not staged and a radical resection was performed for an early rectal cancer, which could have been resected locally.

I attended one of the combined medical and surgical gastroenterology meetings, where an outside speaker spoke at length about Infliximab and its uses.

COLORECTAL TRAINING

The one year structured colorectal training programme here impressed me. It is very competitive. Of the 1000 chief residents in US, every year, 85 apply to the Univ of Minnesota and only about 16 or 17 are shortlisted for 4 posts and it is my impression that excellent research credentials makes a lot of difference. Once in the program, training includes a period spent on specific aspects of cadaveric pelvic floor dissection. One day is spent in a cadaver lap and another morning spent presenting their assigned topics in pelvic anatomy. For instance one resident may be asked to present the different aspects of the Autonomic nervous system, another might be asked to present the anatomy of Denonvilier’s fascia and so on. Laparoscopic colorectal workshops, Management and Academic training are all integral parts of the one-year residency.

Colorectal fellows do operate a lot, mostly under supervision, similar to our system.

OPERATIVE SURGERY

Advantanges of having a choice of free coffee, donuts and sandwiches and a relaxed atmosphere (where time stands still and there is no waiting list and staff pressures) are obvious. There are a few interesting methodological differences such as positioning of patient and scrubbing the skin (in contrast to our painting or preparing the skin) performed by one of the OR personnel. The latter procedure is very thorough and includes the umbilicus. I was not familiar with some of the instruments such as the Bookwalter retractor (self-retaining retractor), the ‘Sweetheart’ retractor for Low Anterior resection and the Lone-Star retractor for perineal procedures. St.Mark’s retractor along with the Wylie renal vein retractor is still the favourite for pelvic dissection and is preferred to the ‘Sweetheart’ retractor.

Communication with patients’ relatives is top priority. As soon as the patient is opened up and the procedure is underway, message is sent to the relatives that the operation is proceeding well. This is in addition to the detailed appraisal after the procedure.

Prone-Jack-knife position is used commonly. It makes proctological procedures very easy including local resections of early rectal cancers. Prof.Goldberg considers this to be one of the important prerequisites for successful proctological surgery. Having used this position before, in one of my SpR jobs, he did not have to work too hard to convince me of its value both for the surgeon and for the assistant.

The procedures I saw were –

a)       One stage Restorative Proctocolectomy for FAP using an Ileal J pouch,

b)       Recto-vaginal fistula,

c)       Haemorrhoidectomy (in prone-jack-knife),

d)       Artificial anal sphincter.

e)       Perineal repair of rectocoele using Porcine alloderm (costs 1500$ for a small strip). 

SUMMARY:

My sabbatical at the Pelvic floor centre and the Colon and Rectal surgery foundation can be described as one of the intellectually stimulating periods of my career. Minnesota is a beautiful part of USA. The region is abundant in natural beauty and there are lots of lakes. People are friendly and the food is delicious [I now aim to burn of the excess calories on a diet of NHS sandwiches and exercise]. Clinical care pathways, clinical governance, re-validation are all integral part of the system here and has gained complete acceptance. Attempts are being made to concentrate rectal cancer treatment into Multi-disciplinary teams, but the day General surgeons give up rectal cancer surgery is far away. I have learnt a lot about setting up (including the teething problems and the problems of integrating into a team with members of other disciplines) and the running of a Pelvic floor laboratory. I hope to be able to use this knowledge effectively in the future. Pelvic Floor surgery is rapidly becoming a speciality in the US and there are proposals towards making it a 3 year residency in the US. Finally there are 16 Colon and rectal surgeons here, who deal with Colon and rectal surgery exclusively, for a population of about 400000 (1 for 25000). They also get referrals from outside. This is probably equivalent of the Colorectal workload of 4 NHS Colorectal surgeons. The latter have also got to deal with herniae, gall stones and many more general surgical cases unlike their American counterparts.

Figure 1 – Proportion of procedures performed in the ARP lab over the last one year.

 
Figure 2 – Total number of procedures and patients managed in the ARP lab over last one year.