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   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

   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

 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/ UK Flexible sigmoidoscopy trial were Dukes A 152850 pts 13% reduction in CRC mortality at 11 yrs 170432/single flexible sigmoidoscopy at 60/ 62% of cancers diagnosed Funen Study- relative risk reduced to 0.7 –(70000/biennial FOBP

Which screening test

Which test to choose

Test Sensitivity Specificity FOBT 69% 73% Flexible Sigmoidoscopy Barium Enema Colonoscopy 78%-small 95%-large 65% -small 80% large 78%-small 95%-small Near 100% 83% Near 100% Present Results awaited Probably best

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 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

 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     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

 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

 Evolving role of radiofrequency ablation for in-situ destruction  Chemotherapy with oxaliplatin and irenotecan.

 Role of stenting

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

  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

  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

 New techinque     Doppler guided ligation of hemorrhoidal artery Painless and quick Outpatient treatment Good results- approx 90%

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

  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

    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

  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-

 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

  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

  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

Virtual Colonoscopy

 CT col

CT Colonoscopy

 Good for polyps > 5mm  Limited by false negative for small polyps  No therapeutic intervention possible

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

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

 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.

The Future