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Colorectal Update Ipswich 2012

Colorectal Update Ipswich 2012. James Pitt MSc FRCS Consultant 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

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Colorectal Update Ipswich 2012

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  1. Colorectal UpdateIpswich 2012 James Pitt MSc FRCS Consultant Surgeon Ipswich Hospital NHS Trust

  2. 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

  3. Ipswich Colorectal DepartmentConsultants • James Pitt • Abdel Omer • Michael Crabtree • Matthew Tytherleigh • Ian Scott • Rubin Soomal Oncologist

  4. Ipswich Colorectal DepartmentNurse Specialists • Claire Swann • Jenny Pratt

  5. 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

  6. Colorectal CancerReferrals

  7. 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

  8. 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

  9. Symptom combinations

  10. Risk of Rectal Bleeding

  11. Non bleeding risk of CRC

  12. 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

  13. 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

  14. 2WW Referrals • Practice data

  15. 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

  16. Community Endoscopy • PCT put out to tender • Won by Prime Diagnostics • Braintree • Peterborough • Dorset • Saffron Waldon • Bristol • Thetford 15 Feb 2012

  17. 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

  18. 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

  19. 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

  20. Case presentations • Randomly selected from ward and office • Just typical cases, nothing unusual • Lots of anaemia

  21. 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

  22. Case 1 JF 51

  23. Case 1 JF 51F • Dec 2011 • OGD duodenal biopsies normal • Colonoscopy adenocarcinoma 20cm • CT no mets tumour not seen • Jan 2012 • MR distal sigmoid • Feb 2012 • Laparoscopic anterior resection

  24. Case 2MR 78F Kesgrave • 2005 TAH BSO endometrial ca • 2010 Discharged • Nov 2011 referred 2WW • Anaemia • BOR • No blood

  25. Case 2

  26. Case 2Iron profile • Serum iron 3.7 (14-28) • Transferrin 3.5 (2-4) • Sat Transferrin 5 (15-50) • Ferritin 9 (22-30)

  27. Case 2 • Dec 2011 • OGD normal duodenal biopsies • Colonoscopy splenic flexure carcinoma • Jan 2012 • CT no mets • Feb 2012 • Surgery

  28. Case 3BB 74M Ipswich • Nov 2011 OPA • 3 months loose stool 2-3/am • Wt loss • Anorexia • No abdo pain • No blood

  29. Case 3 • Dec 2011 Colonoscopy • Carcinoma 18cm • Jan 2012 • MR and CT 15cm no mets • Laparoscopic anterior resection • Dukes C1

  30. 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

  31. Case 4 JS 74 • BE 3.5cm malignant appearing polyp rectosigmoid junction • CT no metastases • Jan 2007 anterior resection • Dukes A

  32. 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

  33. Case 5PR 65M Felixstowe 2007 • June 2007 Flexible sigmoidoscopy • 2 sigmoid cancers • July 2007 CT no mets • August 2007 Sigmoid colectomy • Dukes C1

  34. 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

  35. Case 684F Ipswich 2009

  36. Case 684F Ipswich 2009 • Feb 2010 CT colon • Ascending colon tumour • Staging CT no mets • Apr 2010 Right hemicolectomy • Dukes C1

  37. 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

  38. Case 7PO 49M Felixstowe 2006 • Ba enema proximal sigmoid cancer • CT no mets • March 2006 Sigmoid colectomy • Dukes C1

  39. Case 8JP 89F Chelmondiston • Oct 2009 referred non 2ww • Anaemia since July 2009 • More diarrhoea than usual • Nov 09 seen clinic • OGD • Colonoscopy

  40. Case 8JP 89F Chelmondiston

  41. 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

  42. 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

  43. 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

  44. 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

  45. Proctology Update

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