1. Colorectal diseases 2005 Mr Abhay Chopda MS ,FRCS,FRCSI
Consultant Colorectal and Laparoscopic Surgeon
The Clementine Churchill Hospital
The Cromwell Hospital- 0207
Ealing Hospital NHS Trust
Mobile

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%
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 Alternatively Current data Annual FOBT and
flexible sigmoidoscopy every 5 years
Alternatively
Colonoscopy every 10yrs / DCBE 5-10yrs
Current data
Nottingham study- FOB /biennial/ 45-74yrs/ 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 Test Sensitivity Specificity FOBT
69%
73%
Present
Flexible Sigmoidoscopy
78%-small
95%-large
Near 100%
Results awaited
Barium Enema
65% -small
80% large
83%
Colonoscopy
95%-small
Probably best

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
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 Rule out
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 Topical nitrates other than GTN
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 – Hyperbaric oxygen-
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 %
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 Anorectal advancement flap
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 Sacral nerve stimulation 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