1. Colorectal and General Surgical Topics Relevant to GPs GP update meeting Addington Practice Tuesday 26th March 2014
Mr Steve Warren

2. Laparoscopic General &
Colorectal Surgeon
Colorectal and general surgical topics relevant to GPs: What do patients ask?

3. “I’ve got a groin hernia – what’s best: keyhole or open surgery?”
Recurrence rates same
Postop pain and recovery rates
Infection risks
Bilateral and recurrent herniae
General versus LA/sedation

4. “I’ve got sudden anal pain”
Rarely haemorrhoids
Usually fissure
Typical pain
GTN vs Diltiazem, stool softening
Lateral internal anal sphincterotomy vs Botox injections

5. “I’ve got sudden anal pain”
Rarely haemorrhoids
Usually fissure
Typical pain
GTN vs Diltiazem, stool softening
Lateral internal anal sphincterotomy vs Botox injections
Sometimes perianal haematoma
Referral for LA I&D

7. “I’ve got sudden anal pain”
Rarely haemorrhoids
Usually fissure
Typical pain
GTN vs Diltiazem, stool softening
Lateral internal anal sphincterotomy vs Botox injections
Sometimes perianal haematoma
Referral for LA I&D
Beware anal cancer
Difficult to examine
elderly

8. “I’ve had piles for years and I just want to get rid of them”
Internal haemorrhoids: bleeding, prolapse and irritation
Outpatient treatment
Injection/ Banding, stool softening
Course of treatment esp prolapse, irritation
Surgery
Problem of circumferential piles and anal stenosis
Standard operation painful
PPH circular stapling
HALO suturing
Recurrence

9. “My brother has just been diagnosed with bowel cancer - should I be checked?”

10. “My brother has just been diagnosed with bowel cancer - should I be checked?”
Few data/guidelines for polyps/CRCa, international differences
Depends upon age of relative(s) and patient, full FHx of polyps/CRCa/other related Ca
Preponderance of right colonic Ca in FHx therefore flex sig inadequate
Approx 10% 1st degree, 30% 2nd d, 0.2% < 45yr
For high risk families (FAP,Lynch synd, 2 or more younger relatives) also consider referral to clinical genetics unit

11. Family history of CRCa
2 relatives with CRCa, or younger first degree relative
colonoscopy at 45 years or 5 years prior to youngest diagnosed (5 yearly)
in reality – worried patients with first degree family history
consider FOBs for the worried well
aspirin/NSAIDs and CRCa risk reduction

12. “I’ve had IBS in the past but this is different”
Usually irritable bowel syndrome
Beware elderly or new diagnosis
Sometimes colitis
Occasionally cancer
Left sided, pink mucus, esp assoc blood
Don’t rely on age alone to differentiate
Tenesmus, pelvic pain
Anaemia and mass must be urgently referred
Constipation rarely cancer, but obstructive symptoms
FOBs and Hb

13. New Target Referral Guidelines
REASON FOR REFERRAL (Please indicate as appropriate)
Rectal bleeding with change of bowel habit of > 3 weeks (age 40 yrs and over)
Rectal bleeding without change in bowel habit with no obvious cause > 3 weeks duration (age 50 yrs and over)
Change of bowel habit persisting for 3 weeks or more without bleeding (age 50 yrs and over)
Abdominal mass thought to be large bowel cancer (any age)
Palpable rectal mass (any age)
Anaemia: Males any age Hb < 11 g/dl, ferritin < 30
Non-menstruating females Hb < 10 g/dl, ferritin < 30

14. New Target Referral Guidelines
Guidelines to increase emphasis upon anaemia
Change in bowel habit reduced and bleeding from 6 to 3 weeks
Ages reduced from 60 to 50 years
Emphasis on combination CBH and bleed reduced to 40 years
Also includes family history CRCa and ages of onset

15. Laparoscopic Surgery Advances
Colorectal cancer
95% CRCa lap resections at BCF & PPs (70%)
Enhanced recovery and lap resections
Laparoscopy in emergencies
Appendicectomies
Small bowel obst, perforations, adhesions
Single port laparoscopic surgery (SILS)

16. Laparoscopic Surgery Advances
Colorectal cancer
95% CRCa lap resections at BCF & PPs (70%)
Enhanced recovery and lap resections
Laparoscopy in emergencies
Appendicectomies
Small bowel obst, perforations, adhesions
Single port laparoscopic surgery (SILS)
Robotic laparoscopic surgery
NOTES (natural orifice trans-endoluminal surgery)

17. Thankyou
Referrals - Kate: