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Colorectal diseases 2005
Mr Abhay Chopda MS ,FRCS,FRCSIConsultant Colorectal and Laparoscopic SurgeonThe Clementine Churchill Hospital- 02088723939The Cromwell Hospital- 0207Ealing Hospital NHS Trust -02089675875Mobile 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 dataNottingham study- FOB /biennial/ 45-74yrs/ 152850 pts
13% reduction in CRC mortality at 11 yrsUK 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
Which screening test
Which test to chooseTest Sensitivity Specificity
FOBT 69% 73% Present
Flexible Sigmoidoscopy
78%-small95%-large
Near 100% Results awaited
Barium Enema 65% -small80% large
83%
Colonoscopy 78%-small95%-small
Near 100% 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
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