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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.