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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

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Colorectal diseases 2005 l.jpg

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 l.jpg

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


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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


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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


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Which screening test


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Which test to choose


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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


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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


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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.


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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


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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


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Colorectal cancer with liver metastases

  • Evolving role of radiofrequency ablation for in-situ destruction

  • Chemotherapy with oxaliplatin and irenotecan.

  • Role of stenting


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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.


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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.


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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


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Hemorrhoidal artery ligation-H.A.L procedure

  • New techinque

  • Doppler guided ligation of hemorrhoidal artery

  • Painless and quick

  • Outpatient treatment

  • Good results- approx 90%


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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


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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%


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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 l.jpg

    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.


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    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


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    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 l.jpg

    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


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    Virtual Colonoscopy

    • CT col


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    CT Colonoscopy

    • Good for polyps > 5mm

    • Limited by false negative for small polyps

    • No therapeutic intervention possible


    Mri colonoscopy l.jpg

    MRI Colonoscopy

    • Hartmann et al,n=55 ,28 patients with 69 polyps

    • Polyps > 10mm -93 % detection

    • Polyps 6-9mm- 80% detection

    • 2 false positives


    Capsule endoscopy l.jpg

    Capsule Endoscopy


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    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????


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    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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    The Future


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    Thank You


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