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Colorectal diseases 2005. Mr Abhay Chopda MS ,FRCS,FRCSI Consultant Colorectal and Laparoscopic Surgeon The Clementine Churchill Hospital- 02088723939 The Cromwell Hospital- 0207 Ealing Hospital NHS Trust -02089675875 Mobile 07960838353. Colorectal cancer. Screening

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colorectal diseases 2005

Colorectal diseases 2005

Mr Abhay Chopda MS ,FRCS,FRCSI

Consultant Colorectal and Laparoscopic Surgeon

The Clementine Churchill Hospital- 02088723939

The Cromwell Hospital- 0207

Ealing Hospital NHS Trust -02089675875

Mobile 07960838353

colorectal cancer
Colorectal cancer
  • Screening
    • Currently only about 37% of CRC diagnosed at early stage.
    • VA study- Trend towards more right sided cancers
    • Early CRC –Relative 5 year survival is 90%
    • Screening
      • All men and women 50 or older
      • People with increased risk
when to suspect
When to suspect
  • Patients aged over 45 years presenting with new large bowel symptoms
  • Alarm Symptoms
    • Rectal bleeding
    • Change in bowel habit
    • Faecal incontinence
    • Tenesmus
    • Anorexia and weight loss
    • Passing mucus per rectum
  • Must include a digital rectal examination=/- rigid sigmoidoscopy
screening
Screening
  • How to screen
      • Annual FOBT and

flexible sigmoidoscopy every 5 years

    • Alternatively
      • Colonoscopy every 10yrs / DCBE 5-10yrs

Current data

Nottingham study- FOB /biennial/ 45-74yrs/ 152850 pts

13% reduction in CRC mortality at 11 yrs

UK Flexible sigmoidoscopy trial-

170432/single flexible sigmoidoscopy at 60/ 62% of cancers diagnosed were Dukes A

Funen Study- relative risk reduced to 0.7 –(70000/biennial FOBP

what commonly happens in cases of delayed diagnosis
What commonly happens in cases of delayed diagnosis
  • Assumption that symptoms are due to
    • haemorrhoids or
    • Irritable Bowel Syndrome
  • Inadequate investigation of iron deficiency anaemia
  • Inadequate rectal or abdominal examination
asymptomatic patients
Asymptomatic patients
  • ASYMPTOMATIC PATIENTS
  • ALL AT 55
  • New patients registering at practise- family history
    • FAP
    • 3 or more colon or related cancer with one <45
      • HNPCC- Screening at 25
    • Relatives of patient diagnosed with colon cancer esp if at young age(<50)
    • Long history(>7 years) of inflamatory bowel disease
cancer surgery
Cancer Surgery
  • Laparoscopic Surgery
    • Early data with 2-3 yr follow up data –encouraging results for laparoscopic arm.
    • Comparable or marginally better survival. Lesser in hospital stay ,early ambulation and postoperative feeding.
    • CLASSIC /COLOR results encouraging.Results of open and laproscopic surgery similar with slight survival advantage in the laproscopic arm.
advantages of minimally invasive surgery for colon cancer
Advantages of Minimally Invasive Surgery for Colon Cancer
  • Smaller incisions -- two inches or less, compared with several inches for traditional surgery
  • Shorter hospital stay -- four to five days versus five to eight days
  • Less post-operative pain
  • Quicker overall recovery -- one month versus six to eight weeks
erectile dysfunction
Erectile dysfunction
  • Sidenafil can either completely reverse or satisfactorily improve postproctectomy erectile dysfunction in upto 79% of patients
    • Randomised controlled trial
    • n=32 . Mild side effects
    • Mortensen et al – Dis Col Rectum
colorectal cancer with liver metastases
Colorectal cancer with liver metastases
  • Evolving role of radiofrequency ablation for in-situ destruction
  • Chemotherapy with oxaliplatin and irenotecan.
  • Role of stenting
anal cancer
Anal cancer
  • Chemoradiation remains the mainstay.
  • APR for salvage when failure of chemoradiation.
  • For malignant melanoma anal canal – wide local excision a better choice compared to APR.
haemorrhoids
Haemorrhoids
  • Controversy with regards to role of the Longo procedure (PPH) persists.
  • Sutherland et al-metaanalysis
    • PPH –less bleeding at 2 weeks and shorter hospital stay, lesser pain
    • Finnish study – Compared PPH with conventional n=60. Similar results but PPH group reported fecal urgency , anal pain , bleeding.
hemorrhoids
Hemorrhoids
  • Use of bipolar scissors and ligasure technique have produced results comparable to diathermy haemorrhoidectomy.
  • Still a significant proportion of rectal bleeds due to cancer mistaken for haemorhoidal bleed.
    • MPS case report May 2004
hemorrhoidal artery ligation h a l procedure
Hemorrhoidal artery ligation-H.A.L procedure
  • New techinque
  • Doppler guided ligation of hemorrhoidal artery
  • Painless and quick
  • Outpatient treatment
  • Good results- approx 90%
fissure in ano
Fissure in ano
  • Potential pitfalls
    • Fissure in atypical position-ie off midline
    • Multiple fissures/large irregular fissures
  • Rule out
      • Crohn’s
      • TB
      • Neoplasm
      • anal herpes, syphilis, chlamydia, gonorrhoea, AIDS
conservative treatment gtn
Conservative treatment -GTN
  • A Cochrane systematic review concluded that glyceryl trinitrate (GTN) is far less effective than surgery, and marginally better than placebo, in curing chronic anal fissure[Nelson, 2003a].

Seven RCTs (694 people)

The healing rate in the placebo group was 38% (95% CI 24 to 53), in the 0.1% GTN group was 47% (95% CI 33 to 63), in the 0.2% GTN group was 40% (95% CI 26 to 56), and in the 0.4% GTN group was 54% (95% CI 37 to 71).

  • Recurrence rates of anal fissure after treatment with topical GTN of up to 40%
other therapy
Other therapy
  • Calcium channel blockers
      • Diltiazem
        • Topical 2%
        • Oral 60mg bd
      • Topical nifedipine
        • 0.2% gel
      • Oral lacidipine
  • Topical nitrates other than GTN
      • Topical preparations of isosorbide mononitrate and isosorbide dinitrate
  • Muscarinic agonists
      • Topical bethanechol 0.1% gel
  • Alpha-adrenoreceptor blockers
      • Oral indoramin 20 mg twice-daily
anal fissure
Anal fissure
  • Botulinum toxin –
    • 0.3 U /kg type A toxin
    • 74% healed with single injection , 87% with 2 injection.
    • Recurrence –At 42 months 40% recurrence.
  • Hyperbaric oxygen-
    • Refractory fissures only.
surgery
Surgery-
  • Lateral Internal Sphincterotomy
  • LIS is the standard surgical treatment for chronic anal fissure.
    • Most anal fissures heal after LIS. Healing rates of 93-100%
    • Recurrence rates are generally low. Studies report rates between 0% and 25%
    • Overall, the risk of incontinence is about 10% -usually flatus -transitory
    • LIS is far more effective than available medical treatments at healing chronic anal fissure
fistula in ano
Fistula in ano
  • Role of fibrin glue
    • In complex fistulas following seton drainage – 60% healed with one injection. 69% with second injection.
    • 6% risk of late recurrence
  • Anorectal advancement flap
    • Poor outcome if Crohn’s , RV fistula and predisolone use.
fecal incontinence
Fecal incontinence
  • Artificial sphincter
    • N=112
    • 85% functional success rate if sphincter retained. 37% required explantation
    • Infection significant risk 46%
  • Sacral nerve stimulation
    • N=15 , Kenefick et al
    • 73% fully continent after 2 years follow up. No complications
ct colonoscopy
CT Colonoscopy
  • Good for polyps > 5mm
  • Limited by false negative for small polyps
  • No therapeutic intervention possible
mri colonoscopy
MRI Colonoscopy
  • Hartmann et al,n=55 ,28 patients with 69 polyps
  • Polyps > 10mm -93 % detection
  • Polyps 6-9mm- 80% detection
  • 2 false positives
crohn s disease
Crohn’s disease
  • Trial of Helminth Ova
    • Summers et al, n=29
    • Active Crohn’s disease refractory to standard treatment given 2500 T.Suis ova every 3 weeks.
    • No side effects.
    • At 12 weeks 75.9% responded with 62.1% in full remission.
    • So has deworming of the population led to increased CD????
just a thought
Just a thought
  • A short history of medicine:
    • I have an earache
    • 200BC- Here eat this root.
    • 1000AD-That root is heathen,say this prayer
    • 1850AD-That prayer is superstition,drink this potion.
    • 1940 AD- That potion is snake oil,swallow this pill
    • 1985 AD- That pill is ineffective,take this antibiotic.
    • 2000AD-That antibiotic is artificial ,Here EAT THIS ROOT.
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