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

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

“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

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

“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

“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

“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

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

“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

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

“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

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

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

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)

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)

Thankyou Referrals - Kate: 020 8882 4794 www.StephenWarren.com