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