Download kids and sleep apnoea - Sydney Adventist Hospital

KIDS AND SLEEP APNOEA
Dr Gillian Dunlop
DR GILLIAN DUNLOP
FRACS, MBBS(HONS), BSC(MED)
Dr Gillian Dunlop is an Ear Nose and Throat surgeon focusing
on rhinoplasty, otoplasty and general paediatric ENT. Her dual
career as a portrait artist gives her a unique ability to perform
these procedures.
P: 9487 7877 W: www.artofrhinoplasty.com.au
Most people think of tonsillectomy as treatment
for recurrent tonsillitis. However I now do
tonsillectomies 5 times more frequently for sleep
apnoea than recurrent tonsillitis.
It is important to raise awareness about sleep
apnoea in children because leaving sleep apnoea
untreated can have a profoundly negative impact
on their future intellectual, dental and facial
development.
WHAT IS OBSTRUCTIVE SLEEP APNOEA (OSA)?
OSA is a loss of adequate airflow and oxygen
supply to the brain. In children this is most
commonly due to adenotonsillar hypertrophy. The
tonsils and adenoids are enlarged, not because
of recurrent tonsillitis, but because of a genetic
predisposition and possibly because of frequent
coughs and colds.
As the tonsils naturally enlarge at about the
age of 2 years, many children with OSA start
snoring more loudly around this time. A smaller
percentage of children develop symptoms around
age 7-9. In these children allergy and obesity
may play a role.
The following may be seen in young children with
sleep apnoea:
• During sleep, they tilt their head and neck back
to stretch open the airway. This sign has the
highest correlation with a positive sleep study.
• They may snore, although up to a third do not.
Some parents just describe heavy breathing.
•
Parents may note occasional pauses in the
breathing, gasps and choking noises. Children
are more sensitive to apnoea than adults.
Even 1 – 3 seconds of apnoea is significant.
• They tend to be restless and can pivot around
the bed. Parents who co-sleep often note
kicking. Waking one or more times at night is
common.
• They may be sweaty at night.
• Bedwetting is sometimes seen.
• Some are skinny because they are burning up
calories at night, working hard to breathe.
•
They prefer a mushy diet such as yoghurt,
cheese and pasta. It is easier to swallow soft
food if the tonsils are bulky.
• Bulky food like meat tends to make them gag
or spit.
WINTER 2015
WHY DO WE NEED TO TREAT PAEDIATRIC
OSA?
If sleep apnoea is untreated, it will have an impact
on the developing brain. While adults with sleep
apnoea become tired and forgetful, children
become hyperactive, although they can also
be tired and cranky especially at the beginning
and end of the day. Their bad behaviour may be
mistaken for ADHD.
In 2010 a research study performed by the
University of Chicago found that children with
untreated sleep apnoea had an impaired uptake
of picture based memory tasks for immediate
and overnight recall. This study concluded that
as acquisition and retention of new material is
impaired in children with sleep apnoea, they
need more time and more learning opportunities
to keep pace with healthy children.
An even more impressive study was done by
researchers in Boston. This study demonstrated
that children with sleep apnoea who were
evaluated at the age of 4 and then re-evaluated
at the age of 8, with no treatment for their sleep
apnoea, had impaired literacy and numeracy
skills equivalent to a 10 point drop in their IQ.
After learning to walk, speech is the next
educational challenge for a young child to
conquer. Sleep apnoea in children results in poor
daytime concentration and may contribute to
speech delay.
HOW TO ASSESS AND TREAT PAEDIATRIC
OSA?
Ask the parents to bring in a smart phone video
of the child sleeping. Twelve percent of children
snore but only 3% have sleep apnoea. However,
even children who just snore or those who wake
frequently are at risk of behavioural problems
later.
Examine the child for enlarged tonsils and
signs of nasal obstruction which may be due to
enlarged adenoids. If the child does not breathe
through the nose, the mouth remains open and
lips become dry. Some children dribble. Others
get dark rings under their eyes. The palate can
shrink upwards so it is important to look for a
high arched palate. Having a high narrow palate
crowds the teeth so look for a cross bite, where
the teeth are angled inwards. (See figure 1 on
page 7) A small jaw or syndromes involving
facial abnormalities with features such as an
enlarged tongue also make OSA more likely.
continued on page 7
The views and opinions expressed in the articles in this publication are those of the authors and are not necessarily shared by the editors or Adventist
HealthCare Limited. The editors and Adventist HealthCare Limited do not accept responsibility for any errors or omissions in any article in this publication.
ABLATION OF
SYMPTOMATIC
ATRIAL FIBRILLATION
Dr Maros Elsik &
Dr Bill Petrellis
DR MAROS ELSIK B.SC (MED), MBBS, PHD, FRACP, FCSANZ
Dr Maros Elsik is a Consultant Cardiologist and Interventional Electrophysiologist. P: 9887 8888
DR BILL PETRELLIS
SAN DOCTOR WINTER 2015
MBBS, FRACP, FCSANZ
Dr Bill Petrellis is a Consultant Cardiologist and Interventional Electrophysiologist. P: 9422 6040
2
Atrial fibrillation (AF) is the most common
arrhythmia encountered in general practice.
The prevalence of AF in the general population
is approximately 1% and increases with age1.
Symptoms of AF include palpitations, an
irregular pulse, chest discomfort, dyspnoea,
reduced exercise capacity and fatigue. Some
individuals are asymptomatic, while others
present with thromboembolic complications,
most commonly stroke.
The classification of AF is based on the
duration of each episode. Paroxysmal AF
episodes last <7 days; persistent AF lasts >7
days and AF is considered permanent when
it is deemed that AF will not resolve despite
antiarrhythmic medications or cardioversion2 .
Paroxysmal AF is predominantly a disease of
the pulmonary veins (PV). “Sleeves” of left
atrial muscle extend into the proximal portions
of these veins. In 95% of cases, a focus of
rapidly firing myocardial cells within the veins
“trigger” and initiate AF. As recurrences occur
more frequently over time, 25% of patients
with paroxysmal AF will develop persistent or
permanent AF within 5 years3.
Persistent or permanent AF is a chronic and
complex disorder due to abnormalities of the
atrial tissue or “substrate” (atrial enlargement,
ischaemia,
neurohormonal
activation,
electrical remodelling) which promotes AF reinitiation and maintenance. In chronic AF, PV
“triggers” are less important4.
AF management is focused on managing
symptoms (rhythm control) and preventing
thromboembolic
complications
with
anticoagulation.
For
younger
(<75)
symptomatic patients with non-permanent AF,
a strategy of restoring and maintaining sinus
rhythm should be considered. The first line
approach involves antiarrhythmic medication,
such as sotalol, flecainide or amiodarone.
The efficacy of these medications is variable
and adverse reactions are common, limiting
therapy. Patients that remain symptomatic
despite medication should be considered for
ablation.
CATHETER ABLATION OF ATRIAL
FIBRILLATION
Catheter ablation is regarded a Class I
indication for the treatment of symptomatic
AF, in appropriately selected patients, that
remain symptomatic despite at least one
class I or class III anti-arrhythmic medication.
The procedure aims to restore and maintain
sinus rhythm in order to improve the patient’s
quality of life. Catheter ablation, does not
eliminate the need for anticoagulation which
Figure 1: 3D map of the left atrium showing the
pulmonary veins (posterior view). The ablation
lesions (red circles) surround the left superior and
left inferior pulmonary veins, as well as the right
superior and the right inferior pulmonary veins
respectively, to create pulmonary vein isolation.
Figure 2: A pre procedure CT scan of the left
atrium showing pulmonary veins of the same
patient. This image demonstrates the close correlation between the real time 3D map and the
CT scan. Corresponding ablation lesions (red
circles) are also shown.
is determined by the CHA2DS2-VASc score.
The primary endpoint of catheter ablation
is “pulmonary vein isolation” (PVI). It is
performed under sedation or anaesthesia
in the cardiac catheter laboratory.
Transoesophageal echocardiography is first
performed to exclude intra-cardiac thrombus.
A CT reconstruction of the left atrium and
veins is obtained to guide ablation. During the
procedure, catheters are passed into the left
atrium (LA). Sophisticated mapping equipment
is used to construct a real time 3D model of
the LA and PVs, which allows navigation of
the catheters to the target ablation sites (Figure
1). An ablation catheter allows focal delivery
of radiofrequency energy (RF) which heats the
tissue and creates localised scar. Sequential
focal RF lesions delivered around the PVs
in turn create linear scars which ultimately
causes electrical isolation of the pulmonary
veins from the atrium. Cryotherapy is ablation
causing tissue destruction by freezing, rather
than heating, delivered by a balloon catheter
placed at the opening of each pulmonary vein
and is an alternative method for achieving
PVI. Once the pulmonary veins are isolated,
electrical “triggers” are unable to enter the left
atrium, thus preventing AF initiation.
Additional ablation is required for persistent
AF. Linear and focal lesions are performed,
targeting abnormal atrial substrate which
is thought to be responsible for maintaining
and re-initiating AF. Ablation of persistent AF
is performed in a stepwise fashion, typically
requiring repeat procedures.
months) is often due to inflammation and
does not predict lack of long-term success. In
paroxysmal AF, a meta-analysis comparing
ablation with anti-arrhythmic or rate control
drugs alone indicated the overall success of
catheter ablation at 77.8% compared with
23.3%.5 5-year follow-up data demonstrates
that sinus rhythm was achieved in 80-92%
of patients with paroxysmal AF after repeat
procedures.6 Up to 85% of patients are able
to stop anti-arrhythmic medication following
successful ablation. For persistent AF, the
single procedure success rate is ~50-60%.
Repeat procedures targeting abnormal atrial
substrate improves the success rate to 65%7.
Ablation success is highest in younger
patients (< 65-70 yo) without structural heart
disease. Predictors of reduced success include
persistent AF, older age, severe left atrial
enlargement, obesity, sleep apnoea and
structural heart disease.
The overall complication rate for PVI is
comparable to other invasive cardiac
procedures. The most common complications
relate to groin access. Less common but serious
complications include cardiac tamponade
(~1%), stroke and TIA (0.5-1%), pulmonary
vein stenosis (<1%) and death ~0.1%8.
Post-procedural pericarditis is common but
manageable with analgesics. Atrial flutter
is also seen after ablation and may require
repeat ablation.
Due to the increased complexity of ablation
needed to treat persistent AF, PVI should
be considered earlier rather than later in
symptomatic patients, preferably when AF is
paroxysmal.
OUTCOMES OF CATHETER ABLATION
The goal of ablation is to reduce AF related
symptoms. Early AF recurrence (within 3
References available on request.
SURGERY FOR OBESITY –
CURRENT PRACTICE
Dr Philip Le Page
DR PHILIP LE PAGE
MBBS, FRACS
Dr Philip Le Page is an Upper Gastro-Intestinal and General Surgeon with formal training and special interest in obesity surgery,
reflux/hiatus hernia, upper GIT malignancy, endoscopy, laparoscopic hernia and gallstone surgery. After obtaining his Fellowship
with the Royal Australasian College of Surgeons, he undertook formal subspecialist training with the Australian and New Zealand
Gastro-Oesophageal Surgical Association (ANZGOSA) in Sydney and in Edinburgh.
P: 8197 9595 W: www.oclinic.com.au
Life-expectancy
In 2005 the “Swedish Obesity Study” was
published. It was a prospective controlled
study comparing surgery to lifestyle
modification and found less all-cause mortality
following surgery (8% versus 12%) after 16
years (particularly cardiac deaths), similar to
findings of other contemporary studies.
Co-morbidity and quality of life
improvement
Diabetes, hypertension, sleep apnoea,
reflux and other illness remission rates can
be achieved in over 80% in the Australian
population. General Practitioners are at
the forefront in monitoring and adjusting
medication and lifestyle changes accordingly.
Quality of life factors have objectively been
demonstrated to improve in numerous studies.
Economic benefits
Recent Western cost analysis studies have
indicated overall cost savings following
obesity surgery, by reduction in medication
and complications from obesity. The UK and
many European countries therefore have
extensively publically funded programs.
WHAT ARE THE RISKS OF SURGERY IN
THE MODERN ERA?
Laparoscopic surgery and aneasthesia
advances have led to dramatic reductions
in surgical risks – mortality is exceedingly
rare and major morbidity as low as 1.6%
in the recently published Australia-wide
official obesity society database. Nutritional
Figure 1. Mobilised stomach prior to resection
by sleeve gastrectomy.
deficiencies are possible (very rarely clinically
manifest) so multivitamins and annual blood
tests are recommended. Weight regain
can happen years after surgery but can be
attenuated by ongoing medical and dietetic
input. The low risk profile compared to
ongoing health risks of untreated chronic
obesity forms the basis for considering surgery
in obese individuals inadequately managed
conservatively.
WHAT SURGICAL OPTIONS ARE
AVAILABLE NOW AND WHAT DO THEY
INVOLVE?
Surgery should be viewed as a strong tool
to assist patients as part of an ongoing
multidisciplinary approach involving GP’s,
dieticians and psychologists. The most
common procedures are:
1. Laparoscopic Sleeve Gastrectomy
The most commonly performed bariatric
operation in Australia, 80% of the
distensible stomach is removed from a
carefully calibrated, stapled stomach tube
(“sleeve”). The procedure takes 60-90
minutes and patients are discharged day
2. Eating quality remains relatively normal,
with hunger and portion-sizes significantly
reduced.
2. Laparoscopic Gastric Banding –
A soft silicone ring is placed around the
upper stomach, attached by tubing to
a port on the abdominal wall. Patients
are discharged the next day and have
adjustments to band size by simple needle
puncture of the port in the clinic. Patients
need to make conscious changes to their
dietary habits to ensure tolerance and
effectiveness.
3. Laparoscopic Gastric Bypass – This
remains highly efficacious, especially for
those with poorly controlled diabetes.
New single-anastomosis techniques may
prove superior. Again, keyhole surgery
is performed and patients are usually
discharged on day 2.
WHO SHOULD BE CONSIDERED FOR
SURGERY?
Traditional guidelines have recommended
surgery for patients failing conservative
interventions and BMI >35 with obesity
related co-morbidities or BMI >40 alone.
Recently, international authorities recommend
accounting for individual circumstances, such
as BMI <35 with poorly controlled diabetes or
those with poor quality of life, such as major
joint problems impeding mobility.
Figure 2. Sleeve Gastrectomy - appearance
following stapled resection, carefully
calibrated to produce early satiety without
regurgitation or reflux.
References available on request.
SAN DOCTOR WINTER 2015
WHY DOES OBESITY OCCUR?
Excessive
adiposity
occurs
due
to
disproportionate intake of calories for the
amount metabolised. From the days of huntergathering when significant energy was
expended to obtain low energy unrefined
foods, dietary evolution has seen introduction
of readily accessible farmed food to that of
today’s society of constant availability and
marketing of highly processed and instinctively
appealing calorie dense foods, with less
necessity for an active lifestyle. Contemporary
evidence for individual variations of genetic,
metabolic, demographic and psychological
factors also exists. Over 25% of Australians
now classify as obese (BMI>30).
HOW HAS BARIATRIC SURGERY
DEVELOPED?
Original operations involved extensive
small bowel bypass to achieve significant
malabsorption
of
calories.
However,
major nutritional deficiencies necessitated
development of lesser degrees of intestinal
bypass and introduction of meal size
restriction/gastric volume reduction (gastric
bypass).
Purely
restrictive
operations
developed (Vertical Banded Gastroplasty)
to remove risks of intestinal bypass. A rising
incidence of obesity, combined with the
advent of laparoscopy, saw development
of safer and more accessible options, such
as the (potentially reversible) laparoscopic
adjustable gastric band (LAGB). Bypass
procedures are still undertaken given their
effectiveness and durability. More recently their
consequent beneficial metabolic alterations
have been better appreciated (randomised
trials reporting remission rates up to 90%). The
highly effective sleeve gastrectomy operation
was developed after observing substantial
weight loss and excellent outcome in high
risk patients, without needing to proceed to
their planned 2nd operation (biliopancreatic
bypass).
Endoscopic
treatments
(eg.
intragastric balloon) are feasible but only
temporary, hence less effective/durable.
WHAT ARE THE BENEFITS OF SURGERY?
Dietary and lifestyle interventions are
recommended and can be effective in the short
term but unfortunately weight loss is usually not
durable. Large controlled studies have shown
that surgery results in more extensive weight
loss (with metabolic benefits) and better longterm prognosis. Our unit recently published
the finding of an average 76% excess weight
loss after sleeve gastrectomy at 12 months.
3
MINIMALLY INVASIVE AORTIC
VALVE REPLACEMENT –
SUTURELESS TECHNOLOGY
Professor Tristan D. Yan
PROF TRISTAN D. YAN
BSC(MED), MBBS, MS MD, PHD, FRACS
Professor Tristan Yan is a consultant cardiovascular and thoracic surgeon and Director of Minimally Invasive Cardiothoracic
Surgery at the Sydney Adventist Hospital. He completed advanced fellowships in aortic surgery (England), minimally invasive
thoracic surgery (Scotland) and minimally invasive cardiac surgery (Germany). Professor Yan applies the latest pioneering
techniques to reduce surgical trauma, thus achieves a more rapid and comfortable recovery for his patients and is the
Editor-in-Chief of Annals of Cardiothoracic Surgery. P: 9550 1933 E:[email protected] W: www.tristanyan.com
SAN DOCTOR WINTER 2015
‘SUTURELESS’ AORTIC VALVE
REPLACEMENT TECHNIQUE
Aortic valve stenosis is the most frequent
cardiac valve pathology in the western
world, with a prevalence of 3% for
individuals over the age of 75 years1.
The incidence of aortic valve stenosis is
growing, a reflection of the rapid ageing
of the population2. As a result, there are an
increasing number of elderly patients eligible
for a prosthetic aortic valve replacement
(AVR) who present with greater morbidities
and underlying risk factor profiles. Based
on extraordinary short and long-term
outcomes, conventional AVR (C-AVR) is the
gold standard approach for the treatment
of symptomatic severe aortic stenosis3.
However, the greater morbidities and
risk profiles on the contemporary patient
population have driven the development
of minimally invasive interventions such
as percutaneous transcatheter aortic valve
implantation (TAVI), as well as minimally
invasive approaches and sutureless aortic
valve replacement (SU-AVR)4-7. Recent
technological developments have led to
an alternative minimally invasive option,
which avoids the placement and tying of
sutures, known as “sutureless” or rapid
deployment aortic valves. Sutureless valves
have been redeveloped in the last few years
based on modern experience with TAVI.
The current evidence demonstrates SU-AVR
as a promising option for aortic stenosis,
which facilitates minimally invasive surgery
while minimizing cardiopulmonary bypass
and cross clamp durations.
4
INTERNATIONAL SUTURELESS PROJECTS
The International Valvular Surgery Study
Group (IVSSG), initiated by Professor Yan
is the largest international collaborative
group to investigate this technology. The
IVSSG Sutureless Projects comprises over
36 surgeons from 27 centers worldwide,
and it is envisaged that this global
collaborative effort will shape clinical
guidelines, optimize patient outcomes, and
set future directions of research for SU-AVR8.
The primary objectives of the Sutureless
Projects will be to generate an international
multi-center retrospective and prospective
registry database for SU-AVR, which will
serve as a robust platform to perform
powered
analyses,
propensity-score
matching and risk-stratified analyses. Other
objectives of this project will be to: assess
short-term and long-term hemodynamic
profiles and safety outcomes.
CURRENT SUTURELESS AORTIC VALVE
PROSTHESES
Sutureless and rapid deployment aortic
valves
are
biological,
pericardial
prostheses that anchor within the
aortic annulus with no more than three
sutures. There are three commercially
available prostheses, including 3F Enable
(Medtronic, Minneapolis, USA), Perceval
S (Sorin, Saluggia, Italy), and Intuity Elite
(Edward Lifesciences, Irvine, USA).
SUTURELESS VS. CONVENTIONAL VS.
TRANS-CATHETER VALVE PROSTHESES
Sutureless technology will require a median
sternotomy or more preferably a minimally
invasive incision (5 cm incision) such as
mini-sternotomy and mini-thoracotomy.
The diseased valve is completely
excised, so that the sutureless prosthesis
is deployed and positioned snuggly in
the aortic annulus to minimize the risk of
paravalvular leak. Sutureless valves do not
require tying of sutures, which may cause
trauma to a fragile aortic root. Subsequent
to diseased valve excision, the sutureless
valve prostheses are sized and deployed
in the aortic annulus. This may translate
into reduced operation duration, especially
when a minimally invasive access is used 9-12.
Whilst a SU-AVR is in principle based on
a similar technology to TAVI prosthesis,
the former does not require crimping
of the leaflets. The sutureless surgical
approach provides direct visualization of
the implantation and target orifice location.
Furthermore, calcium removal in SU-AVR
may be effective in reducing stroke or
embolic events.
WHY SU-AVR? – RAPID DEPLOYMENT
The main advantage offered by SU-AVR
is a reduction in cross-clamp and bypass
durations. From a recent meta-analysis by
the IVSSG9, 12 observational reports were
identified for quantitative analyses. The
pooled cross-clamp and bypass durations
for isolated AVR using a sutureless
prosthesis was 57 minutes and 33 minutes,
respectively, half of that compared to
values reported by the Society of Thoracic
Surgeons (STS) National Database for
C-AVR. Thus, the reduction of cross-clamp
and bypass time with SU-AVR may improve
results in all patients, but may particularly
be beneficial in patients with significant
underlying comorbidities and high surgical
risk profiles.
WHY SU-AVR? - MINIMALLY INVASIVE
APPROACH
Minimally invasive aortic valve replacement
(MI-AVR) has shown to produce similar
efficacious outcomes as C-AVR, but with
decreased hospitalisation, reduction in
sternal wound complications, reduced
surgical trauma and improved cosmesis13.
The use of SU-AVR has the potential to
simplify the MI-AVR procedure. It is likely
that MI-AVR, with a reduction in operative
times using sutureless prostheses, may
further improve results, particularly patients
with highest operative risks.
WHY SU-AVR? – EXCELLENT
HEMODYNAMIC PERFORMANCE
Paravalvular leak is an important
complication when assessing the outcomes
of TAVI and C-AVR. Different from TAVI,
the nature of the SU-AVR approach is that
it involves excision of the calcified valve
and prosthesis placement under direct
visualisation, which reduces the risk of
paravalvular leak and improves the overall
hemodynamic performance9.
Figure 1. Mini-sternotomy Incision (5 cm)
CONCLUSIONS
Current results suggest that SU-AVR is
associated with reduced operation duration,
excellent hemodynamic outcomes, very low
transvalvular gradients and reduced risk
of patient-prosthesis mismatch. High-risk
patients are more likely to benefit from SUAVR, a promising alternative that facilitates
minimally invasive surgery.
References available on request.
OESOPHAGUS: EARLY CANCER
AND DYSPLASIA BY ENDOSCOPY
Associate Professor Gregory Falk
A/PROF GREGORY FALK
MBBS, FRACS, FACS
Associate Professor Gregory Falk is Professor of Surgery at The University of Sydney and Macquarie University. His expertise is
in gastro-oesophageal and minimally invasive surgery and he runs an oesophageal physiology laboratory. His research interests
include reflux, reflux cough, Barrett’s oesophagus and oesophageal carcinoma.
P: 9745 1099 E: [email protected] W: www.sydneyheartburn.com.au
radiofrequency ablation of the dysplastic
Barrett’s epithelium to surgical resection for
more advanced carcinomas. Combined
neoadjuvant therapy and surgery can be
offered for better cancer survival (13-15%
improvement) of advanced cancer.
Indications for endoscopic ablative
therapy include true low-grade dysplasia
(not inflammatory dysplasia), high-grade
dysplasia, and early intramucosal carcinoma
completely resected by EMR.
One of the problems addressed by the
endoscopist is that heterogeneity of
the Barrett’s epithelium and difficulty of
identifying areas of invasive carcinoma
within areas of dysplasia. This is not readily
apparent to endoscopic view. An older
study of resection specimens for high-grade
dysplasia found and diagnosed invasive
carcinoma in up to 40% of cases1. However
severe dysplasia can almost always be
treated by endoscopy with good results now
reported beyond five years, and excellent
control of the Barrett’s mucosa. The longer
the Barrett’s epithelium the more difficult it is
to obtain complete remission2.
PRACTICAL MANAGEMENT OF THE
PATIENT WITH EARLY CARCINOMA OR
DYSPLASIA
Dysplasia conveys significant risk for
progression to carcinoma over the next
several years. The patient is often male and
endoscopy has demonstrated high-grade
dysplasia on repeated biopsy in multifocal
multicentric fashion. The default position for
treatment of this situation is oesophagectomy
however patients may be offered endoscopic
ablation as an alternative.
The patients abnormal epithelium is closely
Figure 1: EMR: early Ca oesophagus removed
examined using light endoscopy and
narrowband endoscopy. Nodularity, stiffness,
depression or raised areas or apparent
depigmentation are treated by endoscopic
mucosal resection to gain a large specimen
into submucosa to determine if there is any
invasion. Once it is established that the
likelihood of invasive carcinoma or lymph
node metastasis is remote the patient may
be offered ablation. It has been the author’s
preference to use radiofrequency ablation
as there appears to be less oesophageal
stricture formation. Depending upon the
length of the Barrett’s oesophagus it will
require several treatments. Some patients
may be treated in this way if pathology of an
early carcinoma shows that it is confined to
the mucosa or only just enters the upper part
of the submucosa (pT1A, SM1). The rate of
node metastasis in this group is extremely
low.
Discomfort from this procedure is small, very
infrequently bleeding occurs, perforation
has been described in less than one in 300
cases, and the patient is managed on a
day only basis. Treatment with morning and
night proton pump inhibitor is required, oral
Gaviscon may help in the first several days
following procedure but considering the
amount of mucosa treated the discomfort
seems remarkably little.
Because of the recency of this technique the
patients continue on a surveillance program
even after the Barrett’s oesophagus is fully
removed and reflux management continued.
Patients too high risk for surgical resection
may still have early carcinoma managed by
endoscopy and so it is most applicable in the
older age group, otherwise not fit for surgery.
References available on request.
SAN DOCTOR WINTER 2015
PATIENT SELECTION
Patients with early carcinoma are identified
by expeditious investigation of changes in
dyspepsia of a minimal degree especially
in males over the age of 40. Males are at
special risk having a tenfold increased rate
of oesophageal carcinoma by comparison
with the female. It is also the author’s view,
somewhat contrary to current guidelines,
that most males requiring treatment for reflux
symptoms should have an index endoscopy
before the age of 40 to ascertain carcinoma
risk. Identification of Barrett’s oesophagus
in this group would lead to surveillance
and potentially improve outcomes. While
oesophageal carcinoma remains a rare
cancer overall risk-benefit analysis of
surveillance maybe; however the individual
diagnosed with early cancer or dysplasia
benefits are massive. Patients would wish
this discussed rather than paternal guideline
application. Patients who have already been
identified with Barrett’s oesophagus are
mostly on surveillance and although there is
some dispute in the literature of its value.
Carcinoma developing while on surveillance
is routinely at least two stages earlier
from that found sporadically, resulting
in enormous differences in survival after
treatment. Reflux symptoms seem to occur
in families and it has certainly been the
author’s frequent experience to have hiatus
hernia and reflux in three generations of
a single family. Thus there may indeed be
Barrett’s risk families and the association
with colonic polyps is recognised. History of
development of oesophageal carcinoma in
a member of the family or identification of
Barrett’s oesophagus could possibly be a soft
indication for endoscopy in other members of
the family. Obesity is one of the greater risk
factors in the development of oesophageal
carcinoma and may explain the rapid (10%)
increase in Australia and other comparable
western countries. It would therefore seem
appropriate to perform endoscopy in obese
gentlemen over the age of 40 with reflux
symptoms as a potentially higher risk group,
especially if smoking.
SELECTION OF EARLY OESOPHAGEAL
TUMOURS
AND
DYSPLASIA
FOR
ENDOSCOPIC THERAPY
The depth of invasion of tumour determines
the chance of nodal metastasis and so
determines therapy which may be offered to
an individual. This varies from endoscopic
mucosal resection of the tumour and
Figure 2: NBI gastroscopy oesophagus: white
lesion squamous HGD
5
NEW PARADIGMS IN
MANAGING MENIERE’S
DISEASE
Dr Payal Mukherjee
DR PAYAL MUKHERJEE
MBBS, FRACS (ORLHNS), MS (USYD)
Dr Payal Mukherjee is an Adult and Paediatric ENT Surgeon with a special interest in hearing and balance disorders. She has
subspecialty fellowship training in Otology, Cochlear Implantation and Lateral Skull base Surgery. She is an executive member on the
NSW committee of RACS, the ENT lead for research at the RPA institute of Academic Surgery and a board member on the Meniere’s
research fund. Dr Mukherjee is a Senior Clinical Lecturer at The University of Sydney. P: 97473199. W: www.entcaresydney.com.au
case reports of delayed implantation have
been reported6, a relatively new proposal
is to consider simultaneous implantation at
the same time as labyrinthectomy.
COCHLEAR IMPLANT CANDIDACY
CHANGES
A large proportion of patients seldom
fulfilled CI candidacy criteria under
previous guidelines which required
bilateral profound hearing loss (Figure 1).
With improved technology, less traumatic
electrodes, soft surgical techniques and
better understanding of different hearing
loss patterns, candidacy for CI has now
been extended to include single sided
hearing loss7 (Figure 2). CI in single sided
hearing loss has shown significant benefit
in tinnitus suppression8,9. It has also shown
a tremendous improvement in the ability to
localize sound and speech understanding
when there is background noise7,10.
CI is now considered the superior
alternative to other hearing solutions for
single sided hearing as it the only solution
that restores the ability of the patient to hear
in their deaf ear and acquire directionality
of sound.
CI CANDIDACY IMPACT ON MENIERE’S
MANAGEMENT
This revolutionary change in Cochlear
Implant candidacy has had a great impact
for many Meniere’s sufferers as a large
proportion of them have unilateral hearing
loss either due to the disease process or
due to ablative treatments. It means that
now their hearing rehabilitation can be
carried out independent of the hearing
status in their other ear. Therefore, patients
who are candidates for labyrinthectomy
can be considered for CI at the same
time. This circumvents the risk of cochlear
ossification and failure to implant which
is a risk patients would previously be
exposed to as they would have to wait to
lose hearing in their contralateral ear to
fulfil candidacy for implantation.
A current multicenter study being conducted
in Sydney by the author assessing outcome
of CI in Meniere’s disease, shows excellent
hearing outcome in these patients.
CI hearing outcome in patients with
labyrinthectomy are similar to outcome of
patients without a labyrinthectomy. Thus a
labyrinthectomy should not be considered
a contraindication for CI.
If the natural course of Meniere’s disease
has destroyed the patient’s natural hearing
in one or both ears or their vertigo control
meant that they needed ablative treatment
which destroys the hearing, patients can
attain good hearing restoration with CI,
provided of course that the patient is
motivated and had good postoperative
audiological rehabilitation which is crucial
for the success for any CI.
References avaliable on request.
SAN DOCTOR WINTER 2015
Meniere’s
disease
is
a
disorder
characterised by disabling attacks of
recurrent vertigo, fluctuating hearing loss,
tinnitus and aural fullness. Despite having
an estimated prevalence of 46-200 per
thousand patients1, the etiology remains
poorly understood. The disease classically
has a disabling and destructive effect on the
underlying hearing and balance function.
If patients experience “drop attacks”
or tumarkin crisis (marked by a sudden
sense of falling), or frequent unremitting
disabling vertigo uncontrollable by other
means, ablative treatment of balance such
as intratympanic gentamicin or surgical
labyrinthectomy may be considered2.
Though this brings permanent cure from
vertigo, it also ablates hearing in that ear.
In this setting the application of Cochlear
Implant technology has created a lot of
interest as it gives new hope for these
patients to regain their ability to hear.
Cochlear implantation (CI) has been used
for rehabilitation of profound hearing
loss for over two decades and its role
continues to expand. However, in the
setting of labyrinthectomy, many consider
CI a contraindication and especially
so if there is a significant time delay in
implantation following labyrinthectomy3.
This is because there is concern that
following labyrinthectomy the cochlea
may develop scarring, ossification and
obliteration
precluding
subsequent
cochlear implantation4,5. Though successful
6
Figure 1: Audiogram showing previous CI candidacy criteria
Figure 2: New CI criteria includes single sided hearing loss:
normal hearing in one ear and no hearing in the other ear
(continued from page 1)
It is also worthwhile asking about sleep
apnoea in relatives as sleep apnoea can
be hereditary.
If there are positive findings, refer the child
for a sleep study with a paediatric sleep
physician or review by an ENT Surgeon.
The definitive treatment for sleep apnoea
is adenotonsillectomy as the child needs
a bigger airway. Due to their increased
growth rate, the tonsils and the adenoids
are occupying too much space within a
small oropharynx.
Removal of the tonsils and adenoids
does not impair immunity. The tonsils and
adenoids are just 3 of approximately
120 lymph glands in the head and neck.
After adenotonsillectomy parents often
comment that coughs and colds are of
shorter duration. This may be due to better
drainage because of the larger nasal
airway.
Tonsillectomy involves an overnight stay in
hospital, although a third of children who
are 3 years and older can go home on the
day of surgery if they are eating well. This
occurs when their pain is under control.
Most children will need regular Panadol
for 5-7 days supplemented with prn
Oxynorm, especially at night. Codeine
is no longer used postoperatively. Ultrarapid metabolism is seen in up to 10% of
Caucasians and 10-29% of North African
and Middle Eastern people and can lead
to morphine toxicity even at low doses,
predisposing to respiratory arrest. The risk
is greater in children who have undergone
airway surgery, especially with a history
of sleep apnoea.
The risk of bleeding is reduced by avoiding
Nurofen, Fish Oil and Vitamin E in the 2
weeks before surgery. Nurofen is given
postoperatively if there is no alternative
analgesia. It is normal to have a cough,
temperature and referred pain to the ears
after the operation and children may
snore softly for 4-5 days due to swelling
of the uvula.
After 2 weeks parents often comment that
the child is more rested and settled in the
daytime. Parents are being woken less at
night too! By 3 months the parents often
comment that the child is eating more and
has grown possibly due to the growth
hormone which is now being produced
more efficiently in the deep sleep cycle.
Adenotonsillectomy restores normality for
children with OSA.
The 3 key messages are to look
for sleep apnoea if the child’s
sleep is disturbed, the speech is
delayed or the behaviour is poor.
This article is an abridged version of
Dr Dunlop’s video which can be seen on:
www.kidssleepapnoea.com.au
Figure 1: Crossbite – irregular angulation
of teeth
NEWLY ACCREDITED SAH SPECIALISTS
Dr Arpit Srivastava
BSc MBBS (Hons) FANZCA PGCert CU DDU
(Critical Care)
B.Sc (MED) MBBS (HONS) FANZCA PG Dip
Clin Ultrasound
Anaesthetist
Anaesthetist
Dr Chaminda Perera is senior Specialist
Anaesthetist with a scope of practice in the
following: neurosurgery, gynaeoncology,
general surgery, head & neck surgery, hand surgery, general
plastics and obstetrics. He has a special interest in critical care
echocardiography.
Dr Arpit Srivastava is an Anaesthetist
focusing his practice on cardiothoracic, orthopaedic, major
general and endocrine surgery. He has a special interest
in echocardiography, coagulopathy and peri-operative
medicine.
P: 0410 660 771 E: [email protected]
P: 8221 9694 E: [email protected]
Dr Senarath Edirimanne
Dr Simmerjyot Gill
General Surgeon
Obstetrician Gynaecologist
BMBS(HONS)Flinders FRACS
MBBS FRANZCOG
Dr Senarath Edirimanne is a specialist
Breast, Endocrine and General Surgeon and
specialises in management of benign breast
conditions, breast cancer including oncoplastic
breast surgery and immediate breast reconstruction, thyroid,
parathyroid, adrenal and elective/emergency general surgical
conditions including gall bladder surgery.
Dr Simmerjyot Gill is an Obstetrician
Gynaecologist at Sydney Adentist Hospital.
She has a special interest in high risk
pregnancy, including those complicated
with medical problems and VBAC births. She also has a
interest in menstrual disorders, abnormal pap smears and postmenopausal health issues.
P: 4736 6339 E: [email protected]
W: www.drsenarathedirimanne.com.au
P: 9869 2602 E: [email protected]
Dr Muzib Abdul-Razak
MBBS DNB (General Surgery) FRCSE FRACS
M Ch (Surgical Oncology)
Surgical Oncologist & Head and Neck
Surgeon
Dr Abdul Razak is a General Surgeon with
subspecialty training in surgical oncology and
head & neck surgery. His expertise includes treatment of advanced
skin cancer, melanoma, soft tissue tumors including sarcomas,
thyroid & parathyroid problems and head & neck cancers. He has
special interest in sentinel node biopsy for oral cancer.
P: 8850 8100 E: [email protected]
Dr Jayeshkumar (Jay) Parikh
MBBS MD FRACP
Neurologist
Dr Jay Parikh is a Neurologist. His interests
are neurophysiology and movement
disorders including beep brain stimulation
programming and botulinum toxin therapy.
P: 9488 0257 E:[email protected]
To find a San Specialist visit
www.sah.org.au
SAN DOCTOR WINTER 2015
Dr Ranjan Chaminda Perera
7
NEWS FROM SYDNEY ADVENTIST HOSPITAL
• Dalcross Adventist Hospital is transferring the major surgical
areas of Bariatric, Vascular, Neuro, Spinal and Orthopedic surgery to Sydney Adventist Hospital in August. Dalcross remains
as a specialist Ophthalmic, Plastic and Dental Surgical Hospital
and provides a new dedicated Rehabilitation facility.
• San Radiology recorded a world-first in CT imaging delivering
the lowest dose of radiation ever for a Cardiac CT, according
to the supplier Siemens, and still produced high quality images.
In another world-first, patients are expected to soon access
information that helps them track their lifetime cumulative
radiation dose from CT scans performed at San Radiology.
San Radiology recently installed 2 new NEW GE High-Resolution (3T), wide bore MRI scanners (100+% increase in capacity)
and 2 NEW Ultra-Low Dose CT scanners (384-slice Siemens
Force & 128-slce Siemens AS+).
• P urchase an Entertainment™ Book or Entertainment™ Digital
Membership and 20% of the purchase price is donated to
SAH’s humanitarian aid organisation, Open Heart International
(OHI). Go to http://bit.ly/ohientertainmentbook.
• P articipants are invited to join OHI’s fundraiser ‘Ride For Hearts
2015’ and cycle from Vietnam to Cambodia in October in
2015. Participants discover Southeast Asia while fundraising
to give children in Cambodia dying of heart disease a second
chance at life. Places are limited. Register at www.ohi.org.au
New dedicated Rehabilitation facility at Dalcross Adventist Hospital
2015 DIARY DATES
• A new Intensive Care Unit is opening in the L.W. Clark Tower
in August. Expanding on the existing comprehensive 13 bed
ICU facility, which treats more than 1,200 patients per year, the
new unit will feature 14 dedicated Neurovascular pods and 16
Cardiac/General pods. The $200 million 12-storey L.W. Clark
tower opened at the San in September last year. It features a
Maternity, Women’s Health and Children’s Unit, an Integrated
Cancer Centre and a Healing Garden and up to 24 new operating theatres, and with existing facilities provides total capacity
for over 550 inpatient beds, another 300+ day beds. For more
information visit sah.org.au/devt
• SAH Urologist Associate Professor Henry Woo attended The
Urological Society of Australia and New Zealand meeting in
April presenting research attributed to the Sydney Adventist
Hospital Clinical School of The University of Sydney. He also
attended the American Urological Association meeting in May
where he received ‘2014 Reviewer of the Year Award’ from the
prestigious Journal of Urology and he was also invited to talk in
the BAUS/BJUI/USANZ session.
SAN DOCTOR WINTER 2015
• Orthopaedic Surgeon Dr Michelle Atkinson has won one of the
five annual ‘Spine Society of Australia’ prizes for research and
presentation on the use of a bone graft substitute during surgery
to perform bone fusion on patients at SAH.
8
• To celebrate International Midwives Day and Mother’s Day in
May hundreds of San Babies and mums gathered on the Hospital Village Green for the San Teddy Bears’ Picnic. The day was
an opportunity to celebrate midwives, nursing staff and
doctors, and to thank the mums who chose to have their babies
at the San.
• SAH specialists and staff feature on Sydney radio discussing
a range of topical health and medical issues. ‘Health Matters’
airs on Radio 2GB (873) with Steve Price on Monday nights
after 9.30pm and ‘Health Checks’ airs on Radio 2UE (954)
with Tim Webster on Saturday afternoon at 4:15pm. Podcasts
at www.sah.org.au.
• Chief Scientist at SAH’s Australian Research Institute, Dr Ross
Grant shares health facts about the human body, medical
treatment and technology, health and wellbeing on 2GB Radio
every Monday, Wednesday and Friday morning. Podcasts at
www.sah.org.au/healthfacts
•C
ongratulations Mr John Sanburg and Mrs Marje Batchelor
for receiving a Medal of the Order of Australia, announced by
Governor-General Sir Peter Cosgrove on the Queen’s Birthday
for their humanitarian aid work with OHI.
John and Marje were inaugural members of the ‘Cleft Lip and
Palate’ project in 1994. Marje led the theatre team until the
projects conclusion in 2004. John went on to established the
‘Burns Surgery’ project which he led until 2014.
SAH GRAND ROUNDS (all GPs invited)
21 July
Professor Simon Finfer - ‘Saving lives & money - how
Australian (and NZ) critical care research changed
the world’.
20 August
Dr Christos Apostolou - ‘Pancreatic Neuroendocrine
Tumours: Current Diagnosis and Management’.
Grand Rounds are held in the Tulloch Building in the
Level 2 Conference Room from12.30 – 13.30pm.
(Light refreshments available from 12.00pm. Please register
on arrival.)
GP CONFERENCES (CPD points available with proof
of attendance)
21 July
GIT
19 August
Neurosciences / Spine
16 September
Respiratory
21 October
Ophthalmology
FREE PUBLIC FORUM (everyone welcome)
September 2
Men’s Health
Dates and topics are subject to change. Contact 9487 9871
to register for conferences or forums or visit www.sah.org.au
for further details.
EVENTS
15 November
San Run for Life
13 December
Free Carols by Candlelight
See www.sah.org.au/event-calendar for further details.