Transcript Colorectal Update - Ipswich and East Suffolk CCG > Home

Colorectal Update
Ipswich 2012
James Pitt MSc FRCS
Consultant Surgeon
Ipswich Hospital NHS Trust
Introduction
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Who’s Who at Colorectal Department at Ipswich Hospital
Colorectal cancer
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Workload and outcomes
Investigation and community endoscopy
Case reports colorectal cancer
Treatment
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Surgery
Enhanced recovery after surgery
Update in Proctology
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Haemorrhoids
Fissures
Fistulas
Ipswich Colorectal Department
Consultants
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James Pitt
Abdel Omer
Michael Crabtree
Matthew Tytherleigh
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Ian Scott
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Rubin Soomal Oncologist
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Ipswich Colorectal Department
Nurse Specialists
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Claire Swann
Jenny Pratt
Colorectal Cancer
Workload and outcomes Year 2010-11
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2WW
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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
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30% laparoscopic
Colorectal Cancer
Referrals
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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
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12 year review of 8529 patients
5.5% had cancer (all referrals)
Age +
Change bowel habit
 Rectal bleed
 Perianal symptoms
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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 symptoms
Ellis & Thompson, Br J Gen Pract Dec 2005
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Iron deficiency anaemia
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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
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Only 21% had coeliac serology
Excluding this, 62% conformed
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78% Hb too high
26% non iron deficient
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Shaw et al. (Derby) Colorectal Dis Mar 2008
2WW Referrals
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Practice data
Investigation
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All patients with possible cancer should be investigated
with colonoscopy
Barium enema
CT pneumocolon
CT Long oral prep (ezcat)
Iron deficiency anaemia
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Iron profiles
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Serum iron
Transferrin
Saturated transferrin
Ferritin
Community Endoscopy
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PCT put out to tender
Won by Prime Diagnostics
Braintree
 Peterborough
 Dorset
 Saffron Waldon
 Bristol
 Thetford 15 Feb 2012
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Community Endoscopy 2
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Starting mid May 2012
Ravenswood practice, Ipswich
3 full days per week one room
10-12 colonoscopies per day
 20 OGD or flexi sigmoidoscopies
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Histology Ipswich (unconfirmed)
Feed direct into Ipswich MDTs as 2WW
referrals
Staging
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Whole body CT
MR for rectal cancers
Good T3 bad T3
 N0 N1
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Endorectal ultrasound
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T0 –T1 –T2
MR for uncertain liver lesions
PET CT for metastatic
Holistic care
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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
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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
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MCV 64 MCH 17 Ferritin <5
May 2011 hysteroscopy and 3cm polypectomy
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dark rectal bleeding 5 months
 looser stools but once daily
 Referred non 2ww
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Oct 2011 seen in nurse clinic
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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
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2011
 OGD duodenal biopsies normal
 Colonoscopy adenocarcinoma 20cm
 CT no mets tumour not seen
 Jan 2012
 MR
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distal sigmoid
2012
 Laparoscopic
anterior resection
Case 2
MR 78F Kesgrave
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2005 TAH BSO endometrial ca
2010 Discharged
Nov 2011 referred 2WW
Anaemia
 BOR
 No blood
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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 2
Iron profile
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Serum iron 3.7 (14-28)
Transferrin 3.5 (2-4)
Sat Transferrin 5 (15-50)
Ferritin 9 (22-30)
Case 2
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Dec 2011
OGD normal duodenal biopsies
 Colonoscopy splenic flexure carcinoma
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Jan 2012
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CT no mets
Feb 2012
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Surgery
Case 3
BB 74M Ipswich
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Nov 2011 OPA
3 months loose stool 2-3/am
 Wt loss
 Anorexia
 No abdo pain
 No blood
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Case 3
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Dec 2011 Colonoscopy
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Carcinoma 18cm
Jan 2012
MR and CT 15cm no mets
 Laparoscopic anterior resection
 Dukes C1
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Case 4
JS 79F 2007 Ipswich
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Oct 2006
74y
 6 weeks loose stools at night
 No blood but pos FOB
 Referred not 2ww
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Nov 2006 nurse specialist clinic
6 months loose stool
 Fresh blood on paper
 Referred barium enema
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Case 4
JS 74
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BE 3.5cm malignant appearing polyp
rectosigmoid junction
CT no metastases
Jan 2007 anterior resection
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Dukes A
Case 5
PR 65M Felixstowe 2007
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May 2007
60y
 3 months explosive diarrhoea in morning
 Partially resolved with movicol
 Ache left iliac fossa
 Referred Gastroenterology
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Referred direct for flexible sigmoidoscopy
Case 5
PR 65M Felixstowe 2007
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June 2007 Flexible sigmoidoscopy
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2 sigmoid cancers
July 2007 CT no mets
August 2007 Sigmoid colectomy
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Dukes C1
Case 6
84F Ipswich 2009
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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
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Case 6
84F Ipswich 2009
Mar 2010
Dec 2010
Dec 2008
Hb
11.8
9.3
13.2
MCV
93
88
94
MCH
32
29
33
Case 6
84F Ipswich 2009
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Feb 2010 CT colon
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Ascending colon tumour
Staging CT no mets
Apr 2010 Right hemicolectomy
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Dukes C1
Case 7
PO 49M Felixstowe 2006
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Dec 2006
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43M
Intermittent bleeding 6 months
Abdo pain and bloating
Pos FOB
Jan 2006 Nurse specialist
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2 months fresh blood mixed with stool
No change bowel habit
2 weeks lower abdo pain better with mebeverine
Referred ba enema
Case 7
PO 49M Felixstowe 2006
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Ba enema proximal sigmoid cancer
CT no mets
March 2006 Sigmoid colectomy
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Dukes C1
Case 8
JP 89F Chelmondiston
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Oct 2009 referred non 2ww
Anaemia since July 2009
 More diarrhoea than usual
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Nov 09 seen clinic
OGD
 Colonoscopy
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Case 8
JP 89F Chelmondiston
Jan 10
Dec 09
Hb
11.6
10.6
MCV
86
86
MCH
29
30
iron
Low iron
Low sats
Case 8
JP 89F Chelmondiston
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Dec 09
OGD normal
 Colonoscopy limited transverse colon
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Jan 10
CT colon
 Carcinoma ascending colon
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Feb 10 Staging CT
Apr 10 Right hemicolectomy Dukes B
Preassessment
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By Specialist nurses
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Vicki Reid
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Sharon Stopher
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Stoma nurse
Sally Power
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Colorectal ward nurse specialist
Stoma nurse
Stoma information
Enhanced recovery
MRSA swabbing
Anaesthetic assessment
Bowel preparation
Enhanced recovery
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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
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Laparoscopic surgery
BMI <30
 T3 tumour at worst
 No previous surgery
 Tumour right sided or sigmoid
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Lapco programme Colchester
At most will be 50% of cases
Proctology Update
Haemorrhoids
Haemorrhoids
Injection/banding
 Diathermy haemorrhoidectomy
 Stapled haemorrhoidopexy
 HALO/HAL-RAR
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Stapled haemorrhoidopexy
HALO
Doppler ultrasound
Haemorrhoidal artery ligation
Rectoanal repair
Anal Fissure
Anal Fissure
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0.2-0.4%% GTN ointment
2% Diltiazem cream
Botox injections
Anal advancement flaps
Sphincterotomy
GTN ointment
Botox
Botox Review
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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
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Lay open
Loose seton
Tight seton
Glue
Collagen Fistula plug
Rectal advancement flaps
Fistula plug
Fistula Plug
Fistula plug
Thank you