Colorectal diseases 2005

1. 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

2. 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

6. 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

7. 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/ 152850 pts 13% reduction in CRC mortality at 11 yrs UK 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

8. Which screening test

9. Which test to choose

10. 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

11. 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

12. 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.

13. 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

14. 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

15. Colorectal cancer with liver metastases • Evolving role of radiofrequency ablation for in-situ destruction • Chemotherapy with oxaliplatin and irenotecan. • Role of stenting

16. 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.

17. 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.

18. 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

19. Hemorrhoidal artery ligation-H.A.L procedure • New techinque • Doppler guided ligation of hemorrhoidal artery • Painless and quick • Outpatient treatment • Good results- approx 90%

20. 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

21. 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%

22. 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

23. 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.

24. 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

25. 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.

26. 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

27. Virtual Colonoscopy • CT col

28. CT Colonoscopy • Good for polyps > 5mm • Limited by false negative for small polyps • No therapeutic intervention possible

29. MRI Colonoscopy • Hartmann et al,n=55 ,28 patients with 69 polyps • Polyps > 10mm -93 % detection • Polyps 6-9mm- 80% detection • 2 false positives

30. Capsule Endoscopy

31. 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????

32. 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.

33. The Future

34. Thank You