Download - Colorectal Update Ipswich 2012 James Pitt MSc FRCS Consultant Surgeon Ipswich Hospital NHS Trust
Colorectal Update
Ipswich 2012James Pitt MSc FRCSConsultant Surgeon
Ipswich Hospital NHS Trust
Introduction Who’s Who at Colorectal Department at Ipswich
Hospital Colorectal cancer
Workload and outcomes Investigation and community endoscopy Case reports colorectal cancer Treatment
Surgery Enhanced recovery after surgery
Update in Proctology Haemorrhoids Fissures Fistulas
Ipswich Colorectal DepartmentConsultants
James Pitt Abdel Omer Michael Crabtree Matthew Tytherleigh
Ian Scott
Rubin Soomal Oncologist
Ipswich Colorectal Department
Nurse Specialists
Claire Swann Jenny Pratt
Colorectal Cancer Workload and outcomes Year
2010-11 2WW
referrals 68-129 per month 1105 per year 1022 (92.5%) seen within 2 weeks
MDT discussed 1255 patients (1047) Screening colonoscopies 256 – 32 cancers 244 colorectal cancer patients treated 175 colorectal cancers resected
30% laparoscopic
Colorectal CancerReferrals
All Ages • A definite palpable right-sided abdominal
mass. • A definite palpable rectal (not pelvic)
mass • Rectal bleeding WITH a change in bowel
habit to looser stools and/or increased frequency of
defecation persistent for 6 weeks. Over 60 years† • Rectal bleeding persistently WITHOUT
anal symptoms • Change of bowel habit to looser stools
and/or increased frequency of defecation,
WITHOUT rectal bleeding and persistent for six weeks. Any Age • Iron deficiency anaemia WITHOUT an
obvious cause
Symptoms of Colorectal Cancer
Thompson MR et al., Portsmouth BJS 2007
12 year review of 8529 patients 5.5% had cancer (all referrals) Age +
Change bowel habit Rectal bleed Perianal symptoms
Symptom combinations
Risk of Rectal Bleeding
Non bleeding risk of CRC
Rectal bleeding in General Practice
Review of 319 patients presenting with rectal bleeding >34y
Prevalence 15/1000 >34y 3.4% had cancer 9.2% had cancer if change bowel
habit also 11.1% had cancer if change bowel
habit & no perianal symptomsEllis & Thompson, Br J Gen Pract Dec
2005
Iron deficiency anaemia
2-5% prevalence Study of 204 referrals for IDA in 1 year 9.4% had Colorectal Cancer Only 10.8% referrals conformed to BSG
guidelines Only 21% had coeliac serology Excluding this, 62% conformed
78% Hb too high 26% non iron deficient
Shaw et al. (Derby) Colorectal Dis Mar 2008
2WW Referrals
Practice data
Investigation All patients with possible cancer should
be investigated with colonoscopy Barium enema CT pneumocolon CT Long oral prep (ezcat) Iron deficiency anaemia
Iron profiles Serum iron Transferrin Saturated transferrin Ferritin
Community Endoscopy
PCT put out to tender Won by Prime Diagnostics
Braintree Peterborough Dorset Saffron Waldon Bristol Thetford 15 Feb 2012
Community Endoscopy 2
Starting mid May 2012 Ravenswood practice, Ipswich 3 full days per week one room
10-12 colonoscopies per day 20 OGD or flexi sigmoidoscopies
Histology Ipswich (unconfirmed) Feed direct into Ipswich MDTs as
2WW referrals
Staging
Whole body CT MR for rectal cancers
Good T3 bad T3 N0 N1
Endorectal ultrasound T0 –T1 –T2
MR for uncertain liver lesions PET CT for metastatic
Holistic care
All core members of MDT have been on advanced communication training
Nurse specialist to be present when bad news given and operation explained
Fax to GPs when significant news given
Fax GPs MDT proformas Friday afternoons
Permanent record of consultations Patient information booklets
including spiritual support, sexual needs etc
Case presentations
Randomly selected from ward and office
Just typical cases, nothing unusual Lots of anaemia
Case 1 JF 51F Ipswich IP3
2005, 2008, 2010 intermenstrual bleeding
March 2011 Hb 6.8 MCV 64 MCH 17 Ferritin <5
May 2011 hysteroscopy and 3cm polypectomy
Sept 2011 dark rectal bleeding 5 months looser stools but once daily Referred non 2ww
Oct 2011 seen in nurse clinic Referred OGD/colonoscopy
Case 1 JF 51
Feb 12 Jan 12 Sept 11 Mar 11
Hb 10.7 8.1 10.7 6.8
MCV 71 70 85 64
MCH 24 21 28 17
Ferritin <5
Case 1 JF 51F
Dec 2011 OGD duodenal biopsies normalColonoscopy adenocarcinoma 20cm
CT no mets tumour not seen Jan 2012
MR distal sigmoid Feb 2012
Laparoscopic anterior resection
Case 2MR 78F Kesgrave
2005 TAH BSO endometrial ca 2010 Discharged Nov 2011 referred 2WW
Anaemia BOR No blood
Case 2
Feb 12 Oct 11 Sep 11 Mar 11 Mar 10
Hb 8.3 7.8 9.7 10.1 13
MCV 81 79 89 82 91
MCH 27 24 28 26 32
Iron low
Case 2Iron profile
Serum iron 3.7 (14-28) Transferrin 3.5 (2-4) Sat Transferrin 5 (15-50) Ferritin 9 (22-30)
Case 2
Dec 2011 OGD normal duodenal biopsies Colonoscopy splenic flexure carcinoma
Jan 2012 CT no mets
Feb 2012 Surgery
Case 3BB 74M Ipswich
Nov 2011 OPA 3 months loose stool 2-3/am Wt loss Anorexia No abdo pain No blood
Case 3
Dec 2011 Colonoscopy Carcinoma 18cm
Jan 2012 MR and CT 15cm no mets Laparoscopic anterior resection Dukes C1
Case 4JS 79F 2007 Ipswich
Oct 2006 74y 6 weeks loose stools at night No blood but pos FOB Referred not 2ww
Nov 2006 nurse specialist clinic 6 months loose stool Fresh blood on paper Referred barium enema
Case 4 JS 74
BE 3.5cm malignant appearing polyp rectosigmoid junction
CT no metastases Jan 2007 anterior resection
Dukes A
Case 5PR 65M Felixstowe 2007
May 2007 60y 3 months explosive diarrhoea in
morning Partially resolved with movicol Ache left iliac fossa Referred Gastroenterology
Referred direct for flexible sigmoidoscopy
Case 5PR 65M Felixstowe 2007
June 2007 Flexible sigmoidoscopy 2 sigmoid cancers
July 2007 CT no mets August 2007 Sigmoid colectomy
Dukes C1
Case 684F Ipswich 2009
Jan 2010 Referred 2WW proforma ‘bleeding without change in bowel habit’ box ticked.
Jan 2010 seen in nurse clinic 2 months fresh blood mixed in dark
stools Movicol helped Anaemia Referred CT colon
Case 684F Ipswich 2009
Mar 2010 Dec 2010 Dec 2008
Hb 11.8 9.3 13.2
MCV 93 88 94
MCH 32 29 33
Case 684F Ipswich 2009
Feb 2010 CT colon Ascending colon tumour
Staging CT no mets Apr 2010 Right hemicolectomy
Dukes C1
Case 7PO 49M Felixstowe 2006
Dec 2006 43M Intermittent bleeding 6 months Abdo pain and bloating Pos FOB
Jan 2006 Nurse specialist 2 months fresh blood mixed with stool No change bowel habit 2 weeks lower abdo pain better with
mebeverine Referred ba enema
Case 7PO 49M Felixstowe 2006
Ba enema proximal sigmoid cancer CT no mets March 2006 Sigmoid colectomy
Dukes C1
Case 8JP 89F Chelmondiston
Oct 2009 referred non 2ww Anaemia since July 2009 More diarrhoea than usual
Nov 09 seen clinic OGD Colonoscopy
Case 8JP 89F Chelmondiston
Jan 10 Dec 09
Hb 11.6 10.6
MCV 86 86
MCH 29 30
iron Low ironLow sats
Case 8JP 89F Chelmondiston
Dec 09 OGD normal Colonoscopy limited transverse colon
Jan 10 CT colon Carcinoma ascending colon
Feb 10 Staging CT Apr 10 Right hemicolectomy Dukes
B
Preassessment By Specialist nurses
Vicki Reid Colorectal ward nurse specialist
Sharon Stopher Stoma nurse
Sally Power Stoma nurse
Stoma information Enhanced recovery MRSA swabbing Anaesthetic assessment Bowel preparation
Enhanced recovery
Patient information preoperatively/expectations
No bowel prep Come in day of surgery Preload Strict perioperative fluid balance Minimal access surgery/transverse
incisions Early diet and mobilization Lines out day 1
Laparoscopic Colorectal Surgery
Laparoscopic surgery BMI <30 T3 tumour at worst No previous surgery Tumour right sided or sigmoid
Lapco programme Colchester At most will be 50% of cases
Proctology Update
Haemorrhoids
Haemorrhoids
Injection/banding Diathermy haemorrhoidectomy Stapled haemorrhoidopexy HALO/HAL-RAR
Stapled haemorrhoidopexy
HALO
Doppler ultrasound
Haemorrhoidal artery ligation
Rectoanal repair
Anal Fissure
Anal Fissure
0.2-0.4%% GTN ointment 2% Diltiazem cream Botox injections Anal advancement flaps Sphincterotomy
GTN ointment
Botox
Botox Review
Methods The following methods are compared
(carried out under general anaesthesia in the lithotomy position):
M1: 40U BT and anal advancement flap, M2: 100U BT, M3: 40U BT, M4: 30U BT and a fissurectomy. Case notes of 76 patients who had BT for
CAF from 2004 to May 2011 were reviewed
Anal advancement flap
Lateral anal sphincterotomy
Sphincterotomy complications
Fistula in ano
Fistula-in-ano
Lay open Loose seton Tight seton Glue Collagen Fistula plug Rectal advancement flaps
Fistula plug
Fistula Plug
Fistula plug
Thank you