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Digestive Diseases
13.00 REGISTRATION AND LUNCH
13.30 Mr John Grabham: Rectal bleeding and colorectal cancer
14.00 Mr Neil Smith: Enhancing recovery in GI surgery
14.30 BREAK
14.45 Dr Gary Mackenzie: Upper GI disease
15.15 Dr Azhar Ansari: Inflammatory bowel disease
15.45COFFEE BREAK
16.00 Dr Jonathan Stenner: Hepatology
16.30 Mr Paras Jethwa: Management of gallbladder disease
17.00CLOSE
Digestive Diseases Department
Gastroenterology
Colorectal Surgery
Upper GI Surgery
Jonathan Stenner
Gary Mackenzie
Azhar Ansari
John Grabham
Neil Smith
Mohammed Aslam
Tim Campbell-Smith
Paras Jethwa
Alan James
Website and
extranet
Surrey & Sussex
Healthcare NHS Trust
http://www.sash.nhs.uk/ourservices/digestive-diseases/
Message 1.
The Digestive Diseases
Department
- A coherent team of sub-specialists
- Provide a multi-disciplinary service
- Clear internal and external audit and
clinical governance pathways
Guidelines for TWR referral
Bleeding and diarrhoea >40 (>6/52)
Bleeding w/o anal symptoms >60 (>6/52)
Diarrhoea >60 (>6/52)
Abdominal or rectal mass
Iron-deficiency anaemia
NOT FOBs
Colorectal TWRs: Surrey & Sussex Healthcare NHS Trust
April 2005 - March 2010
Data Source: Open Exeter Quarterly Reports
1200
1042
Patients Seen
1000
800
1123
1071
892
754
600
400
200
0
2005/6
2006/7
2007/8
2008/9
2009/10
Colorectal TWR Conversion Rates in SASH and SWSH Cancer
Network April 2005 - March 2010
SASH
SWSH CN
12
Percentage %
10
8
8.6
7.4
9.9
8.7
9.3
9.1
7.6
7.5
7.3
6.1
6
4
2
0
2005/6
2006/7
2007/8
2008/9
2009/10
Route of Referral
Follow Up
10%
Routine
7%
Soon
1%
Urgent
39%
Urgent
2WR
Soon
Routine
Follow Up
2WR
43%
62 day & 31 day targets
Urgent GP referral
Received
by hospital
1st OPA
@hospital
MDT meeting
Diagnostic
investigations
?? Further
investigations
Clinical Diagnosis
1st definitive
treatment
Decision to
treat
Emergency
Admission
31 Days
62 Days
Time
Work-up of patients with suspected
colorectal cancer
Colonoscopy & Biopsy
CT scan
CEA
MRI pelvis
EUS
MRI liver
PET scan
CT assessment of colonic 1*
Anterior rectal cancer invading uterus
Solitary liver metastasis
6/12 post-right hepatectomy
62 day & 31 day targets
Urgent GP referral
Received
by hospital
1st OPA
@hospital
MDT meeting
Diagnostic
investigations
?? Further
investigations
Clinical Diagnosis
1st definitive
treatment
Decision to
treat
Emergency
Admission
31 Days
62 Days
Time
62 day TWR referral to treatment
B reaches
Co mpliant
12.0
10.0
8.0
6.0
4.0
2.0
Se
p
O
ct
N
ov
D
ec
Ja
n
Ju
l
Au
g
Ja
n
Fe
b
M
ar
Ap
r
M
ay
Ju
n
0.0
31 days decision to treatment
Breaches
16
14
12
10
8
6
4
2
0
Ju
l
Au
g
Se
p
O
ct
N
ov
D
ec
Ja
n
Ja
n
Fe
b
M
ar
Ap
r
M
ay
Ju
n
Compliant
Clinical Results
Resection rate
Peri-operative mortality
Major complications
Clear resection margins
Local recurrence
Comparisons with ACPGBI database
Resection rate = 93% (cf 89.5%)
Mortality rate = 7.2% (cf 7.5%)
Anastomotic leakage = 4.8% (cf 4.9%)
Positive CRMs = <1% (10%)
Local recurrence for T1-3 = <1% (10%)
Message 2.
Summary of Colorectal Cancer
Service
Rapid, efficient service
Excellent clinical outcomes
Please continue to refer your patients
Rectal Bleeding Pathway
Causes of Rectal Bleeding
Haemorrhoids
Fissure-in-ano
Other benign ano-rectal pathology
Polyps
Cancer
Diverticular disease
Colitis
Haemorrhoids
Common >15%
Usually associated with perianal symptoms
Often associated with straining
High fibre
Bulking agents
Topical agents
Exclude serious pathology
Banding / injection – maximum twice
Rubber band ligation
Thrombosed external haemorrhoid
Stapled haemorrhoidectomy
Stapled haemorrhoidectomy
Fissure-in-ano
Common esp young adults
Anal spasm
Rectal bleeding and pain
Often assoc with straining
Difficult to examine
Fissure-in-ano
Sentinel Tag
Fissure-in-ano management
6/52 GTN or Diltiazem ointment
? Lignocaine, ?anxiolytic, ?stool softener
Clinical review – 1/20 underlying pathology
Need to visualise rectum
Anal Warts
Anal Cancer
Carcinoma sigmoid colon
Rationale for early flexible
sigmoidoscopy in rectal bleeding
Haemorrhoids – common and may coexist with other pathology; treatment
unreliable
Fissure – difficult to examine; sometimes
associated with serious pathology
Reassurance of “nothing serious”
Colonic disease – allows a reliable, safe,
preliminary assessment
Message 3.
Revised clinical algorithm
Rectal bleeding
Flexible sigmoidoscopy
GPH ECN Booking Process
Book patient into “Rectal Bleeding Clinic”
Fax form to secretary
Referral validated
Information, instructions and enema sent
to patient
Procedure carried out promptly
Summary
Please refer to members of the Digestive
Diseases Team
Excellent clinical outcomes
Please refer all rectal bleeding for flexible
sigmoidoscopy