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