CW the Journal Surgical

the Journal A premier service for private patients Fourth Edition, August 2016

How to prepare diabetic patients for day case surgery

Chelsea and Westminster Hospital

Innovative approaches to pain and botox therapy

Under the spotlight: Acute cancer, Safe in our hands: Primary care bowel cancer, complex gynae, management strategies for carpal prostate cancer and skin cancer tunnel, arthritis and burns

In short, our surgical teams change lives every day.

Welcome from Amanda Grantham General Manager, Private Care Welcome to our fourth edition of CW Journal which has a focus on surgery. Although surgery is traditionally a last resort for many patients, patient safety and the best possible surgical outcomes is the top priority for our surgical teams and it shows. We have had outstanding results in a recent colorectal surgery audit, the cancer team are nationally recognised for their acute oncology work and our hand unit is rated one of the best in the country. We are a designated bariatric service and a regional burns centre for both adults and paediatrics.

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The benefit to a patient choosing to access a Private Patient Unit co-located within a world-class NHS hospital is that they get access to the best of the NHS within the comfort and security of a luxury private ward environment, with all income being invested back into the NHS services provided to our local population.

Private Patient Services at Chelsea and Westminster Hospital have developed significantly over the past three years and this is due in no small part to the feedback from yourselves and your teams and our ambition to be the private hospital of choice within our local area, as well as be a first choice provider to those seeking innovative healthcare treatment within the UK. To support this work, there are a number of new additions to the private patient team, which you can find out more about on page 34. The team would love the opportunity to come and talk you through the private patient services on offer at Chelsea and Westminster Hospital and will happily accept questions on referrals. If you have any questions about our private services you can contact 0203 315 8411 or email private.enquiry@chelwest.nhs.uk

Contents

Adult emergency general surgery

4-5

What you need to know: Diabetes and day case surgery

6-7

Going into hospital? Don't leave home without your guide for patients, carers and families

7

Pain services

8

Turning that frown upside down: Botox therapy for targeted pain relief

9

The craniofacial team continue to turn heads

10

Laser treatment for burns care

11

The latest clinical innovations for burns patients

12–13

Treating the many challenges of cancer

14-15

The bottom line: Improving patient recovery following bowel cancer operations

16-17

Meet the colorectal consultants

18-19

Irregular bleeding? What to do

20-21

Mini-guide to prostate cancer

22-23

The cancer might be skin deep but the scars need not be

24-25

Safe in our hands: Managing carpal tunnel and cubital tunnel nerve compressions

26-27

Under the thumb: Slowing down the progression of hand arthritis

28-29

Management of shoulder pain in primary care

30-31

Who’s Who: Private care consultants

32-33

Who’s who: New members of the private care team

34 3

Adult emergency general surgery

Mr Nebil Behar Emergency Surgeon

The NHS supporting private surgeries that don’t go to plan is never far from the spotlight. Chelsea and Westminster Hospital are bucking this trend by offering a world-class private emergency adult surgical service alongside our elective surgical options. We interviewed Mr Nebil Behar, our specially designated emergency surgeon, to find more about our emergency surgical service for private patients — how it works and why private patients and private insurers should consider going privately for emergency surgery.

Historically, emergency surgery was not a priority for general surgery as it was an add-on to elective surgical work. Chelsea and Westminster Hospital has been at the forefront of recognising emergency surgery as a surgical specialty in its own right.

This shift began six years ago with the appointment of Mr Nebil Behar, Consultant Laparoscopic Emergency Surgeon.

Mr Behar operates daily on appendicitis, bowel perforations, bowel obstructions, strangulated hernias and any emergency surgical complications arising from elective surgeries.

The dedicated emergency general surgery service enables rapid consultant-led diagnosis and surgical interventions with innovative techniques such as laparoscopy 4

for abdominal emergencies becoming the standard of care; enabling early recovery and return to normal daily activities for majority of patients.

Conditions such as appendicitis, bowel perforations, bowel obstructions, strangulated hernias are all managed by a dedicated team of surgeons. All this, is replicated with a consultant delivered service in our private Chelsea Wing with full support from all the in-house specialities within the hospital for a quick consultation, should this be required. As the private wing is located within an NHS hospital, a consultant is always available on-site, so should there be any situations requiring early review, patients never have to wait.

Why was there a need to separate emergency surgery within general surgery?

For years emergency surgery has been a “Cinderella” speciality within general surgery. Everyone was focusing on cancer targets and the predictable work of elective surgery. As a society and a surgical community, it is true to say we have probably neglected emergencies.

While we wouldn’t accept high rates of complications in elective surgery, in emergencies, it was felt to be an inevitable part of a “dangerous” condition. Commonly, patients were admitted at unsociable hours and operated on by junior surgeons while the senior surgeons focused on elective work. National audit has shown dramatic variations in care demonstrating

a need for change. Most hospitals in UK now recognise this, and more and more of them provide dedicated emergency surgical Services. I believe this shift also raises the bar for private surgery.

Surgical emergencies are unplanned and as such require early consultation and diagnosis by a consultant who operates regularly on emergency patients.

Post-operatively, careful monitoring is essential as recovery needs to be closely supervised. Patients may have co-existing medical conditions that require optimising before surgery in an accelerated manner with restoration of physiological disturbances rapidly for safe surgery.

Can emergency operations wait until the morning?

At Chelsea and Westminster Hospital we perform 75% of emergency operations in daytime hours. Clearly some emergencies can’t and shouldn’t wait until the morning.

At the initial consultation the possibility of operating at night is discussed with the patient. We have 24/7 access to emergency operating theatre and radiological services on a need-based priority, so the timing of operation is often based on the patient’s individual circumstances rather than availability of resources.

What’s next for the emergency surgical service?

While Chelsea and Westminster Hospital was pioneering in establishing this service in the UK, the speciality is still in its infancy. Many hospitals are still catching up in appointing emergency surgeons to improve their service. Private medicine also needs to catch up in providing emergency with dedicated teams available daily and providing continuity of care.

To refer patients to Mr Behar please contact T: 0203 315 8484 or E: private.enquiry@chelwest.nhs.uk 5

What you need to know: Diabetes and day case surgery

Dr Kevin Shotliff Consultant Endocrinologist

People with diabetes mellitus are more likely to be admitted to hospital than those without this condition. This coupled with the increasing trend towards day case procedures and the fasting requirements daycase of surgery, means that more elements of the patient’s preparation and recovery from a surgical procedure are increasingly self-managed by the patient, and may need to be overseen by the primary care team.

In emergency and longer stay inpatient elective surgery situations, the hospital clinical team will oversee any medication adjustments required for diabetic patients undergoing surgery and stabilise their therapy post operatively prior to discharge.

We caught up with Dr Kevin Shotliff, Consultant Endocrinologist, for his thoughts on pre-operative diabetes management strategies and effective troubleshooting should any post-operative issues arise.

The fundamental goal is establishing good pre-operative glycaemic control.

If the operation is not urgent, it may be sensible for people with very poor glucose control to have their therapy reviewed and adjusted to optimise this prior to undertaking surgery, either by their General Practitioner, the community diabetes team, or the secondary care diabetes service.

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It is standard protocol at Chelsea and Westminster Hospital to prioritise any person with diabetes on a surgical list to minimise fasting time, and to allow adequate time post operatively to recover from the anaesthetic and the surgery prior to discharge the same day if possible.

Careful antiemetic therapy and making sure people can eat and drink prior to discharge helps settle things acutely and achieving good glycaemic control helps to minimise the risk of post-surgical infection. Our goal is to have prospective day case diabetic patients with a target blood glucose from 6-10 mmol/l (with an acceptable range of 4-12mmol/l). Following surgery, our diabetic specialist nurses encourage and support the day unit staff and the patient to resume diabetes self-management as soon as possible.

Medication adjustments: What to stop and what not to stop?

This will depend on the surgery: local anaesthetics with no potential to progress to a full anaesthetic may need very little adjustments apart from missing insulin secreting therapies or short acting insulin prior to the procedure and restarting with food post operatively.

Patients undergoing a general anaesthetic will need more careful alterations to their therapy pre and post operatively. Type 1 diabetics need care to avoid depriving them of insulin and precipitating a ketoacidotoic episode. Type 2 diabetics on oral agents need to avoid lactic acidosis associated with metformin and hypo glycaemia with secretagogues such as the sulphonylureas in particular.

PRIOR TO DAY-SURGERY

DAY OF SURGERY

POST-OPERATIVE

Metformin should be discontinued two days before surgery and restarted two days after the surgery if renal and liver function is normal.

Stop any bolus / short-acting insulin for the meals that are being with held.

Following surgery, diabetic patients may experience an increased demand for insulin due to the stresses surgery places on the body. Type 1 patients particularly can experience ketoacidosis if insulin is withheld, particularly an issue if their basal insulin is inappropriately stopped.

Other insulin sensitising agents and insulin secretagogues are missed on the day of the procedure, and restarted when the next meal is taken post operatively.

Reduce, but do not stop, any basal long / intermediate-acting insulin.

Long acting insulin and insulin analogues can be continued. Typically the dose is reduced 1-2 days prior to the procedure depending on the agent and restarted at the normal dose after surgery, with increased capillary blood glucose monitoring and short acting insulin adjustment to maintain good glucose levels.

Following day case surgery and discharge, we recommend increased frequency of capillary blood glucose testing and also vigilance for the following potential issues in any patient with diabetes: · Ketoacidosis · Hypo glycaemia · Infection

Going into Hospital? Don’t leave home without your guide for patients, carers and families From cradle to grave, hospitals are a constant presence in people’s lives, with even the healthiest of us likely to visit or be admitted at some point. Yet being admitted to hospital can be an overwhelming, confusing and highly stressful experience, both for the patient and their families or carers. The environment is strange, the daily routine unfamiliar and the language confusing. In many ways, the experience is similar to visiting a foreign country.

Recognising this, Mr Oliver Warren, Consultant Colorectal Surgeon, has joined forces with two of the UK’s leading Professors of Patient Safety, Professor Charles Vincent and Professor Bryony Dean Franklin, to write the world’s first ‘travel guide’ to the hospital, aimed squarely at patients, families and carers.

“Studies show that patients who are well informed and who understand concepts like choice, risk and benefit work better with their doctors and are safer in the

hospital environment. The problem is that for many patients, hospital is like a foreign country, full of strange language, customs and routines that leave people nervous, confused and overwhelmed.

These feelings are even harder to deal with when you, or someone close to you, are ill. Rarely a week goes by when I don’t help a friend or family member navigate and deal with an increasingly complex healthcare system in the hope of improving their quality of care. This book is an attempt to do this for all those going into hospital, as a patient, carer or family member.”

Mr Oliver Warren – co-author and Consultant Colorectal Surgeon Going into Hospital? is packed full of clear and practical advice about how hospitals work, the right questions to ask before going into hospital, and what a patient can expect and plan for during their stay, including: · Preparing to become an inpatient or outpatient · Acclimatising to the daily routine

· Knowing the roles of different members of staff · Understanding the ‘hows and whys’ of medical tests and treatments · Emergency or elective surgery · What to do when children or older people go into hospital 7

Pain services Dr Ben Thomas Consultant in Pain Medicine

Pain services have rapidly become essential sources of expert advice for multiple conditions including early non-operative spine diagnosis and management, neuropathic pain and radicular symptoms.

Just as cardiac patients who previously only had surgical options available have benefitted from the expansion of the cardiology discipline, so patients who previously only had orthopaedic options have gained from the holistic options that pain physicians provide and manage.

The holistic approach taken by our multidisciplinary pain physicians is underpinned by a mandatory qualification and dedicated training pathway with Royal College governance.

The pain medicine physicians at Chelsea and Westminster Hospital have established links with orthopaedic surgeons, neurologists, rheumatologists and physiotherapy colleagues for input as needed.

The pain management services available at Chelsea and Westminster Hospital covers a range of conditions from acute back pain to chronic issues such as neuropathic pain.

Managing musculoskeletal pain Musculoskeletal issues are the predominant group of conditions 8

that our specialists see with the majority of patients treated managing acute or chronic spinal pain including lower back pain, radicular or discogenic pain.

Osteoarthritic and degenerative complaints that may not be amenable to surgical intervention may be best managed with analgesic strategies. In fact the vast majority of spinal and back pain complaints will not require a surgical solution.

Our consultants are experts at examining and investigating lower back pain with traditional imaging such as plain X-rays and MRI scans as well as newer nuclear imaging CT scanning. The pain service offer a full range of spinal treatment options for targeted improvement to facilitate rehabilitation and increased function.

These include: 路 therapeutic spinal injections 路 diagnostic blocks 路 neuromodulation therapy 路 radiofrequency techniques

Managing neuropathic pain Pain and chronic dysaesthesia following surgery, trauma or burns occur more frequently than is always recognised, and an insidious onset of symptoms may result in a prolonged time until specialist referral. Pain and abnormal sensations within operation sites and scars make up a considerable percentage of the conditions we see.

Other neuropathic pains include post-herpetic neuralgia, where alongside updates in medication guidelines, steps forward in treatment in recent years include topical and plaster based medications.

Neuropathic diagnoses can be addressed with peripheral neuromodulation techniques with great success. These techniques can also be used to address radicular or discogenic pain alongside radio frequency techniques, steroid injections or other minimally invasive practices that avoid the need for surgery and enable recovery.

Where routine medication and interventional techniques have failed to help patients with chronic pain issues or have compounded patient anxiety as a result of inadequate pain relief, there is still hope for patients. For this patient cohort, the pain team will explore the biopsychosocial model and coordinate patient access to expert pain informed psychology and physiotherapy services.

To refer patients for a pain consultation or for more information, contact T: 0203 315 8484

Turning that frown upside down: Botox therapy for targeted pain relief

By Dr Benjamin Thomas, Consultant in Pain Medicine Mr Jonathan Collier, Consultant Craniofacial Surgeon Facial trauma and neck pain

Botulinum toxin is well known for its use in the cosmetic industry where its properties as a muscle relaxant have long been exploited.

It is less well recognised, however, that the use of this molecule also extends to non-cosmetic medical uses in nearly all parts of the body.

Botulinum toxin has long been used to reduce muscle hyperactivity, treat the pain associated with increased muscle tension, and it is now being intensively investigated since evidence emerged of its own intrinsic pain relieving potential.

Many patients present with undiagnosed pain involving the head, face, shoulders, and neck. Referral of pain, and the patterns resulting from various muscular aetiologies can make diagnosis and treatment challenging. The proper assessment and treatment of conditions causing pain across the scalp, face, temporomandibular joints, neck and cervicothoracic regions is essential. Pain can be caused by a range of conditions and patients will benefit from consideration of all the local structures. A holistic approach supported by examination and imaging of structures including the jaw and cervical spine will help to identify the most likely cause of symptoms. Pain of dental origin may also radiate to the face and a detailed oral examination is a frequent part of patient assessment.

Jaw joint pain Pain relating to jaw joint function can be broadly classified as pathologies leading to intra-articular changes (internal derangement) or those emanating from the complex myofascial structures relating to jaw movement, mastication and deglutition. The two categories are not mutually exclusive and patients often require multimodal treatment. The role of botulinum toxin in the treatment of pain in the masseteric and temporalis regions is now well established. Simple, percutaneous administration of the toxin to muscle trigger points can provide significant relief for up to 12 months in selected patients.

Side-effects are rarely reported and multiple treatment courses are not frequently required. Concomitant treatment with other treatment modalities, such as dental splintage, neuro-modulating medication and cognitive-based treatments are often required for long-term improvement. Consequently assessment and treatment in a truly multidisciplinary environment that we have here at Chelsea and Westminster Hospital favours improved patient outcomes.

The use of botulinum toxin in the facial trauma patient is increasing.

Post-traumatic neurogenic pain may well respond to localised botulinum toxin injection, most likely as the result of the antinociceptive pathways but this is still being investigated. Occipital neuralgia, cervicogenic headache and myofascial trigger pain are other examples of conditions that can present with pain across the head, scalp and neck.

Multiple pathologies can co-exist, and assessment of these patients by clinicians familiar with these conditions is always beneficial. Careful assessment of a patient’s condition may also be aided by appropriate imaging including MRI of the facial bones and cervical spine.

Small volume, local anaesthetic injections can provide short-term relief, as well as point to the likely diagnosis. The distinctive advantage to botulinum toxin in these situations is the ability to provide targeted therapy to specific painful areas or trigger points which can be repeated and can provide assistance for months.

Other examples of use of botox include: · camouflage of the effects of nerve palsies · chemo immobilisation of facial scars to minimise hypertrophic healing · reduction in autonomic disturbance following nerve regrowth and cross-innervation Generally botox has few side effects, although local inflammation and the risk of bruising is always present. The mechanism of action means that the onset of improvement is not immediate and can take up to three weeks. Pain associated with muscle hyperactivity can be improved for several months. This in itself may be sufficient but where further treatment such as dental treatment or physiotherapy is required, it can help provide a window for treatment.

In summary, pain in the head and neck regions can be complex to diagnose and treat. Often symptoms and pathologies can overlap and a multidisciplinary approach to assessment and treatment is required to maximise patient benefits. Botulinum toxin offers an increasingly effective role in head and neck pain management for selected patients, but does not sit in isolation as a treatment. Due to the complexity of the surrounding anatomical structures, its use and delivery should be carefully planned. The multidisciplinary approach taken by both the craniofacial services and pain management physicians at Chelsea and Westminster Hospital allows cross referral and consideration of joint clinical consultations to provide high quality, timely care for your patients.

To refer patients to Dr Benjamin Thomas, Consultant in Pain Medicine or Mr Jonathan Collier, Consultant Craniofacial Surgeon, please contact T: 0203 315 8484 or E: private.enquiry@chelwest.nhs.uk

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The craniofacial team continue to turn heads Mr Simon Eccles has played a leading role as consultant in the craniofacial unit at Chelsea and Westminster Hospital for 10 years.

During this time, he has spearheaded paediatric craniofacial services and in his role as head of paediatric services, has led the organisation through the establishment of the Chelsea Childrens’ Hospital within Chelsea and Westminster Hospital.

The craniofacial department has gone from strength to strength during this period and now performs more craniofacial procedures than any other unit in the country. To complement our craniofacial service we also offer a comprehensive maxillofacial service, headed up by Mr Jonathan Collier.

Simon and his craniofacial consultant colleague, Mr Chris Abela, have cared for many patients over the years and their specialist interests include: ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙ ∙

Facial plastic surgery Head and neck cancer Skin cancer Congenital craniofacial conditions Paediatric plastic surgery Surgery for neurofibromatosis Vascular malformations Craniofacial trauma Secondary craniofacial reconstruction following trauma/cancer surgery Computer aided design and modelling for craniofacial reconstruction Facial palsy Orthognathic surgery Cosmetic surgery and body contouring Non-surgical treatments

Simon and Chris present internationally on craniofacial clinical outcomes, with particular reference to reconstruction and the unit’s world-class experience in plexiform Neurofibromatosis Type I. With this in mind, the department is proud to announce the launch of the Country’s most up to date 3D camera, which will be used in a pilot study for babies with asymmetric heads (plagiocephaly) and to aid the planning and measurement of the outcomes of surgery. It will also help families decide whether helmet therapy or surgery for their babies is appropriate.

Profiles

Mr Chris Abela

Mr Simon Eccles

Simon and Chris have been working with Amanda Grantham (General Manager Private Care) to improve access to private patient care. This has involved the organisation of ‘care packages’ for selfpay patients across all the subspecialty areas of plastic surgery, including cosmetic surgery. This should make paying for private services more transparent and straight forward. If you would like further information about these packages you can contact the Private Enquiry office on 0203 315 8484.

To discuss any referrals with Simon you can contact him via E: simon.eccles@chelwest.nhs.uk To discuss any referrals with Chris you can contact him via E: christopher.abela@chelwest.nhs.uk 10

Mr Jonathan Collier

Chris has been a part of the plastic and craniofacial unit at Chelsea and Westminster since 2005 as specialist registrar and senior registrar, prior to his consultant appointment in January 2015. Chris undertook a fellowship at Great Ormond Street Hospital, specialising in craniofacial malformations in children and helped coordinate the separation of conjoint craniopagus twins, supported by the charity ‘Facing the World’.

Simon is the President of the Plastic Surgery Section of the Royal Society of Medicine. He is Secretary and Trustee of the charity Facing the World and Patron of the charity Elizabeth’s Legacy of Hope. Simon specialises in paediatric and adult craniofacial reconstruction, head and neck reconstruction and management of skin malignancy.

Jonathan is qualified in both medicine and dentistry. He is on the specialist register for OMFS and oral surgery.

Mr Collier has a specific interest in the correction of craniomaxillofacial deformity in both adults and children as part of the craniofacial team.

This includes surgery for congenital conditions, complex oral and dentoalveolar surgery, facial trauma and reconstruction following skin cancer.

Laser treatment for burns and scars

Mr Declan Collins Burns and Plastics Consultant

Despite considerable advances in burns care, scars can still be a devastating and visible consequence of burn injury. The disfigurement and symptoms such as pain, itch and restricted motion may significantly diminish quality of life. Ensuring that the wound is managed in a way that promotes healing will inuence the long term quality and appearance of the scar. Currently a considerable therapeutic void remains between traditional conservative measures of treating scars (such as pressure garments, silicon sheets) and surgical management. The recent refinement of laser technologies is offering an alternative and highly effective way of treating scars.

CO2 ablative fractional laser (AFL) therapy

V-beam pulsed dye laser

CO2 ablative fractional laser (AFL) therapies have proved to be an effective technology allowing selective manipulation of the burn scar through photothermolysis and fractional ablation of abnormal tissue. This allows the scar to remodel improving texture, itch and function.

This treatment is particularly of use in hypertrophic scars and can significantly improve the appearance.

The pulsed dye laser is considered the laser of choice for most vascular lesions and the dyschromia found in scars because of its superior clinical efficacy and low risk profile. The laser produces a beam of light that is absorbed by the redness of the blood vessel in the lesion but passes through healthy tissue, just beneath the surface of the skin, without damaging it. It has a large spot size (5 to 10mm) allowing large areas to be treated quickly. It can be used on erythematous scars as early as three months post injury or surgery.

The ultrapulse laser, available at Chelsea and Westminster Hospital, is the most powerful of all CO2 fractional lasers, whilst being able to deliver high energy treatments safely. The short pulse duration, in combination with minimal collateral tissue heating, reduces the chance of adverse side effects. Many of the laser procedures can be performed in the outpatient setting thus avoiding surgery, reducing the risks associated with a general anaesthetic. The CO2 laser can be used on hypertrophic scars, acne scars and atrophic scars. Typically laser treatments are every three months with a course of 3-4 sessions necessary in most cases.

Similarly laser treatment would be every three months with a course of 3-4 sessions necessary in most cases.

Laser consultations will be available from September 2016.

Any questions about laser therapy at Chelsea and Westminster Hospital can be directed to declan.collins@chelwest.nhs.uk For more CW+ supported innovations - see overleaf.

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The latest clinical innovations for burns patients CW+, the charity for Chelsea and Westminster Hospital, has funded burns research which is discovering new ways to accelerate healing and localise the body’s inflammatory response.

CW+ is also working closely with Vasia Dekou, Clinical Research Manager, and the burns team to identify clinical innovation opportunities to fund and develop. These innovations aim to improve burns patients' care and experience - both here at Chelsea and Westminster Hospital and in other hospitals throughout the UK. Exciting innovations which are currently being invested and developed include:

Fractional ablative CO2 laser CO2 laser therapy improves scar appearance by re-modelling collagen. Its main application is in hypertrophic and contracted scars. It can alter the scar by skin resurfacing improving the appearance in addition to reducing pain and itching. The CO2 laser capitalises on the growing demand on the burns services. It will offer cost savings by removing the need for numerous operative procedures. Progress from the operating room to the outpatient environment saves costs and reduces the risks of general anaesthesia. Increased treatment of patients in the out-patient setting will reduce the operative waiting list.

Selected patient impact / benefits include: · Reduction of infection · Minimises damage to adjacent tissues · Maximisation of recovery in terms of form, function and feeling · Can be performed in out-patient setting; avoiding surgery and general anesthesia Two fractional ablative CO2 lasers will be in place by the end of 2016.

Vivostat ®

V-beam pulsed dye laser The pulsed dye laser is considered the laser of choice for most vascular lesions and the dyschromia found in scars because of its superior clinical efficacy and low risk profile. The laser produces a beam of light that is absorbed by the redness of the blood vessel in the lesion but passes through healthy tissue, just beneath the surface of the skin, without damaging it. It has a large spot size (5 to 10mm) allowing large areas to be treated quickly. It can be used on erythematous scars as early as three months post injury or surgery.

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Vivostat® Vivostat® enables fast and simple processing of a small sample of a patient’s blood into a fibrin glue, to be used to secure skin grafts. Using Vivostat® versus staples may also result in significant cost savings by reducing operation time and the time for dressing changes. Most importantly we believe it will enhance the patient experience of dressing changes by minimising the pain involved with staple removal. The ability to add co-factors such as platelets will expand the use of Vivostat® in difficult to treat wounds such as diabetic or chronic wounds.

Patient impact / benefits include: · Fast application, reducing operative time · No need for staples and suturing · No need to return to theatre for the removal of staples · Reduced post-operative pain

Cellutome

Vivostat® has loaned the burns team equipment for the next two years, so it is available now.

ARTISS

Patient impact / benefits include: · No need for general anaesthesia · Quicker healing of wounds · Minimally invasive and painless technique · Scarless donor site · Can be used on chronic wounds and in patients not fit for general anaesthetic

ARTISS (fibrin sealant) is tissue glue used to adhere/ seal subcutaneous tissue in paediatric patients, as a replacement or an adjunct to sutures or staples.

We aim to increase the use of ARTISS (fibrin sealant) for skin graft adherence.

Adoption of Cellutome will result on cost savings: · It can be used on the ward/clinic, reducing costs by decreasing the number of patients needing theatre for their skin graft · Promotes healing thus reduces out-patient or outreach visits

ARTISS provides a cost-effective alternative to staples for securing split skin grafts in medium-sized burns.

Previous studies have shown ARTISS to lower rates of graft loss and offer earlier discharge.

Patient impact / benefits include: · Fast application, reducing operative time · No need for staples and suturing, or return to theatre for removal of staples · Reduced post-operative pain

The Cellutome™ Epidermal Harvesting System is a minimally invasive tool for harvesting an epidermal micrograft.

Cellutome will be available in the next few months.

For more information about hospital charity CW+’s innovation programme in partnership with Chelsea and Westminster Hospital, please visit their website cwplus.org.uk/ehp

ARTISS is available now.

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CANCER

Treating the many challenges of cancer Dr Tom Newsom-Davis introduces our Acute Oncology Service

Dr Tom Newson-Davis Lung Cancer Specialist

Where did your personal fascination with oncology come from?

As a junior doctor, a cancer diagnosis seemed to me then the most important diagnosis a patient could have; something that had implications on every part of the body, and that affected everyone within the patient’s family. Working with oncology patients is very rewarding and I wanted to be involved in their care. Oncology calls on all aspects of general medicine to manage a patient’s needs, whether this relates to their cancer diagnosis or treatment, and some oncologists describe it as akin to being a patient’s second GP. Latterly, as my interest in research developed, cancer medicine seemed even more attractive. The challenge of understanding the molecular biology of cancer, and using this to design treatments, seemed then – and remains – the most interesting thing anyone could do. Recent paradigm shifts in the treatment of lung cancer is an example of this.

The Chelsea and Westminster Acute Oncology Service was one of the first in the UK and has evolved into a beacon service, gaining national and international recognition. Dr Tom Newsom-Davis, Lung Cancer Specialist, leads the Acute Oncology Service and we caught up with him to find out more about acute oncology, lung cancer and the care they are delivering at a traumatic time in peoples’ lives.

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Can you explain more about these paradigm shifts?

It has long been recognised that the immune system can target cancer cells, but that cancer cells evade the immune response.

Stimulating the immune system enough to allow it to target cancer cells has been one of the great challenges of oncology.

Immunotherapy itself is not that new (I was developing these agents during my PhD in 2007), but it is only now that we have drugs capable of producing extremely impressive results.

Recently, immunotherapy has transformed the way in which we treat cancer, and this will only increase in the years to come. For example in lung cancer, the tumour type I specialise in, the immunotherapeutic agent Nivolumab, is now licensed but is currently only available privately, including through health insurance. Meanwhile in melanoma, another immunotherapy agent, Pembrolizumab, has been to shown to be very effective and is available both for NHS and private patients.

Acute oncology appears to be a newer cancer specialty – what exactly is it and how did it come about at Chelsea and Westminster?

Acute oncology essentially focuses on three complications: complications relating to a patient’s cancer diagnosis;

complication of cancer treatment; patients with an acute new cancer presentation. We know from national reports that this patient group is large, and needs specialist oncology input from the beginning and throughout their admission. Our unit has been running for more than five years now and has led the way in demonstrating the benefits of acute oncology. We have also pioneered various innovations including educational courses, apps to promote local clinical guidelines, and novel clinical services.

A quarter of all cancer patients are first diagnosed with their disease as part of an attendance to acute medical services such as A&E. This is not only associated with a poor patient experience but, crucially, is associated with worse survival than for patients diagnosed through their GP. Chelsea and Westminster Hospital offers a rapid access clinic for patients presenting acutely with suspected cancer. This Acute Diagnostic Oncology Clinic is aimed at primary care and allows patients to have their investigations done rapidly, with continuity of care from the same team, in a controlled manner.

The clinic has just completed its one year pilot, supported by Cancer Research UK, and has proved to be an effective, efficient way to diagnose this vulnerable patient group and user feedback from GPs and patients about this new service has been extremely positive, which is very important to us. I am delighted that we have been shortlisted for a national Macmillan award for this ward. We find out in November if we have won.

GPs with patients who have clinical or radiological suspicion of cancer, and who cannot wait two weeks for an urgent suspected cancer appointment, are always welcome to contact the ADOC team (0203 315 5000 option 6 or chelwest.acuteoncology@nhs.net) to discuss and refer patients.

What make our Acute Diagnostic Oncology Clinic stand out from other similar units?

The Acute Diagnostic Oncology Clinic is an oncology consultant and nurse led service, which sees all patients within 24 hours of referral. Patients can expect a fast, highly personalised service, whilst GPs can expect ease of access and communication with the team. Taking advantage of all the comprehensive range of medical and surgical specialities onsite, patients are diagnosed through our established MDT pathways to ensure they gain maximum access to this specialist input.

Patients requiring admission are usually cared for on the newly developed, single-bedded Ron Johnson Ward that consistently has outstanding patient reviews reflecting the high quality environment and nursing care.

What are the most common concerns for patients with acute cancer and what advice would you give to GPs in alleviating patients’ and families’ concerns?

I think that patients often have three main concerns: 1. Understanding treatment options and how they will feel during and after treatment 2. How to navigate the complications of cancer and treatment 3. Worries about prognosis and outcome

It is not possible to solve these concerns at one stroke, but with the first two there are many things oncologists can do to explain how treatments will make patients feels, and what to do in event of problems and complications.

To address some of these, we are working with a number of cancer partnership organisations to develop resources to help support primary care colleagues and patients. This includes developing a set of user-friendly acute oncology guidelines with RM Partners (formerly the London Cancer Alliance) for General Practitioners which should be available later this year.

I am also working with Macmillan to publish a quick guide to symptoms and what to do – the original version is aimed at community pharmacists but we also hope to create a spin-off edition for General Practitioners. Lastly we, with CW+, have created an acute oncology app (available to all) – designed primarily for secondary care and currently being rolled out across London, but following this success we hope to create a bespoke version for primary care, time permitting!

If you would like further information about ADOC or to discuss a patient case or to make a referral (NHS or Private), T: 0203 315 5000 option 6 or E: chelwest.acuteoncology@nhs.net

15

CANCER

The bottom line: Improving patient recovery following bowel cancer operations

Miss Sarah Mills General and Colorectal Surgeon

In recent months the colorectal team at Chelsea and Westminster Hospital has doubled in size and the team are already demonstrating that bigger is better according to research and the latest patient outcome data. The following findings are due to be presented at two national conferences this year but here is an exclusive preview.

At Chelsea and Westminster Hospital, the majority of colorectal resections are performed laparoscopically (unless the patient concerned has had multiple previous surgeries or the tumour is very extensive) and this approach is paying dividends: the latest surgical outcome data from the team’s cancer work demonstrates an above national average performance despite our local population being older and presenting with more advanced disease than the national average.

The facts: · Patients operated on by the team are older than the national average and are classified by the American Society of Anaesthesiologists’ Score (ASA) as very high risk (38% vs a national average of 21%) · 51% of cancers operated on by the team were locally very advanced (T4 stage) compared to the national average of 24% · 21% of patients had distant metastatic disease compared to a national average of 9% · 24% of bowel resection operations are performed as emergencies compared to a national average of 20% On initial investigation we think the reason our patient cohort differs so radically from the national average, particularly in the severity of their disease, is due to many of our patients graduating the bowel screening programme and its’ 70 years 16

of age cut off: many of our patient cohort are over 75 and we have introduced ‘straight to test’ protocols for GPs to refer patients directly into to ensure patients at risk receive care with minimum delay.

Despite these factors, total clearance of the cancer was achieved in 85% of resections and 30 day mortality rates in the unit are below those predicted by the mortality risk prediction model for this patient cohort.

C&W

National Average

High risk patients operated on

38%

21%

Advancement of cancers operated on

51%

24%

Patients with distant metastatic disease

21%

9%

Bowel resection operations as emergencies

24%

20%

Why are colorectal patient outcomes are so good at Chelsea and Westminster: These results are due to a number of factors, namely 1

High quality surgery - except in the most straightforward of cases, elective operations involving bowel resection are performed as two consultant operations guaranteeing the highest possible level of surgical expertise whilst offering peace of mind to patients and their families.

2

Exemplar post–operative care - at Chelsea and Westminster Hospital, 83% of patients receive their post-operative care in an Intensive Care or High Dependency setting, with one-to one nursing and intensive monitoring, compared to a national average of 32%. Surgical outcome data highlights failure to identify complications early enough as a big risk to patients and our protocols of 1:1 care following surgery enables us to identify any potential problems quickly.

3

Patients in the colorectal unit typically stay an average of seven days for planned bowel resections. Previously patients would have stayed 2-3 weeks. This length of stay reduction reflects the success of the Enhanced Recovery Programme (ERP) introduced in the unit in 2015. EPR ensures, less post-operative pain, reduced postoperative complications such as chest infections and blood clots, and a faster return to eating and mobilising.

Key elements of our Enhanced Recovery Pathway ∙ Laparoscopic (keyhole) as oppose to open surgery, which results in smaller, less painful and cosmetically better surgical wounds ∙ Reduced use of post-operative drains, nasogastric tubes and urinary catheters ∙ Specially designed protocols for managing peri-operative pain and nausea ∙ Use of chewing gum to speed up the return of gut motility ∙ Physiotherapist-led protocols for early mobilisation ∙ Use of pre-operative carbohydrate drinks to boost recovery ∙ Careful monitoring of IV fluid administration to prevent oedema (swelling) post-operatively

17

CANCER

Meet the Colorectal Consultants

Miss Sarah Mills and Mr Oliver Warren are both as anal fissures, fistulae and rectal prolapse. They offer London-trained General and Colorectal Surgeons who a variety of different surgical options for haemorrhoids, the commonest pathology seen in both their NHS specialise in laparoscopic (keyhole) surgery.

They work with a dedicated team of anaesthetists, and Private Practices. They both perform emergency allied specialists and specialist nurses to deliver a general and colorectal surgery for conditions such high quality service that places surgical excellence as appendicitis, abscesses, incarcerated herniae, and patient satisfaction at the heart of all that they do. diverticular complications, rectal bleeding and bowel obstruction. They are happy to accept emergency Both surgeons have an interest in complex and straight- cases at short notice and work with a dedicated forward pilonidal disease and benign proctology, such anesthetist.

Mr Oliver Warren qualified from Imperial College, London in 2001. He gained his Doctorate in 2009 from Imperial College, London. He was awarded Fellowship of the Royal College of Surgeons in 2012, for which he was awarded the ASGBI Gold Medal for outstanding performance.

Prior to becoming a consultant, he undertook colorectal surgery Fellowships at St Mark’s Hospital, London, The Royal Prince Alfred Hospital, Sydney and was the 2013 Association of Coloproctology’s visiting fellow at the Cleveland Clinic, Ohio, USA. Since starting at Chelsea and Westminster Hospital, Mr Warren has established a combined multidisciplinary team with the plastic surgery service to care for patients requiring input from both specialties. This includes abdominal wall reconstruction techniques, complex abdominal herniae and post-partum abdominal wall insufficiency (PPAWI). He is also a JAG accredited lower gastrointestinal endoscopist.

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Miss Sarah Mills graduated from Oxford University Medical School in 1998. In 2005, she was awarded an MD thesis for her work at St Mark’s Hospital, London, on the immunology of inflammatory bowel disease.

Sarah is the trust lead for day case surgery and enhanced recovery protocols and has developed the use of virtual clinics at Chelsea and Westminster Hospital to fast-track the investigation and treatment of suspected colorectal cancer patients. She plays an active role in developing strategies to improve standards in cancer services in London through her work at the London Cancer Alliance.

Miss Mills is a JAG accredited endoscopist and is developing a specialist practice in interventional endoscopy and cutting edge techniques for treating complex polyps and early rectal cancers, by minimally invasive and endoscopic methods. She also has a specialist interest in laparoscopic surgery for colorectal cancer, diverticular disease, and inflammatory bowel disease.

I would recommend Miss Mills unconditionally as a truly outstanding practitioner. Her competence and consideration for my worries were amazing, and the test (endoscopy) was trauma free. Nick Walker

Thanks to Miss Mills, I was operated upon with consummate skill. Miss Mills and her team were unfailingly kind and supportive to both me and my family. The relationship between patient and doctor was a real pleasure - it was really entirely like 'being among friends'. At all times Miss Mills could not have taken any more time and trouble in explaining all aspects of the treatment which she was giving me which was always very reassuring. After the operation last October I feel that I have been granted a new lease of life. David Clarke

My elderly father was diagnosed with bowel cancer in September 2015 and was told by another Hospital Consultant he would have major surgery and permanent stoma. Being 84 years old I had my doubts as my father also had multiple health issues, including heart disease.

I sought a second opinion, and thank God I did! We were referred to Dr Warren and within one month my father is living without cancer, stoma free!!!*

Following a consultation with Professor Allen-Mersh at the Bupa Cromwell, I was referred me to Miss Mills at Chelsea and Westminster Hospital. Thanks to Ms Mills and her surgical colleague my operation was successful and I was saved the added impediment of a temporary colostomy bag: fantastic news for me and a big aid to a speedy recovery. Since the operation Ms Mills has continued to provide the most diligent and professional post-operative care including personally dressing the wound on several occasions. Sarah Mills is an outstanding medical practitioner, putting in extraordinary working hours, and always greeting you with a lovely smile. A true professional.

It was a pleasure to have been her patient. Malcolm O’Neill

It is very difficult to see a loved one getting diagnosed with cancer but I was amazed that the news could be delivered in such a positive, optimistic (under the circumstances) way without being ippant.*

Dr Warren listened carefully and sensitively to me and made me very relaxed during my appointment. Very refreshing.

I would certainly recommend Dr Warren and feel lucky he is my doctor.*

*www.iwantgreatcare.org/doctors/mr-oliver-warren

19

CANCER

Irregular bleeding? What to do A challenge in primary practice to distinguish cancer from the benign

Mr Amer Raza is a Consultant Obstetrician and Gynaecologist with a special interest in laparoscopic surgery. He carries out most of his gynaecological operations laparoscopically including total laparoscopic hysterectomy, laparoscopic myomectomy, removal of severe endometriosis and ovarian cysts. He is part of Gynaecology Rapid Assessment Service (GRAS) and carries out a weekly outpatient hysteroscopy clinic.

Gynaecological cancers pose a significant challenge in primary care due to overlapping symptoms: irregular bleeding is a common problem from very early stages of menarche right thorough the fertility period and in the menopause stage.

The majority of women will suffer with abnormal patterns of bleeding secondary to common hormonal variations however there are cancerous causes which need to diagnosed and managed quickly. Upon referral, patients are seen by the specialist nurse for a thorough assessment including transvaginal ultrasound scan then an outpatient hysteroscopy appointment is scheduled, if clinically required.

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‘An average GP will come across two cases of skin cancers, one case of breast cancer, and two new cases of endometrial cancer in any given year.’ An average GP will come across two cases of skin cancers, one case of breast cancer, and two new cases of endometrial cancer in any given year. In contrast they will come across a significant number of patients with symptoms potentially indicative of cancer such as coughs, lumps, irregular bleeding etc. This brings a particular challenge to general practice not to overreact whilst not missing a cancerous lesion.

Common gynaecological presentation with irregular vaginal bleeding and recommended treatment approach Any patient with irregular vaginal bleeding may be suspected of endometrial cancer, vulval cancer and cervical cancer.

Endometrial cancer

Intrauterine fibroids

Endometrial cancer is most common in women aged 45 onwards. The risk factors include postmenopausal bleeding, irregular heavy periods after 45, obesity, HRT and tamoxifen treatment. Any patient presenting with above symptoms should have a detailed history and thorough examination to assess the risks. A transvaginal ultrasound scan is mandatory to check for intrauterine pathology such as uterine polyp, abnormal growth and measuring endometrial-lining thickness.

The second common cause of abnormal bleedings is intrauterine fibroids with a very small associated risk of uterine sarcoma. Its incidence varies from 1 in 200 to 1 in 500. All the symptoms will be same as in fibroids such as heavy periods, irregular bleeding and pressure symptoms however the growth of cancerous fibroids will be much quicker as compared to benign fibroids. A transvaginal ultrasound scan can be helpful in detecting the abnormal blood flow pattern and an MRI is helpful in distinguishing a sarcoma from a benign fibroid. A full detailed history will be key to detect quickly changing symptoms and need for urgent referral to hospital.

If any of the above is found then these patients must be referred for hysteroscopy as an urgent case.

One of the benefits of private services co-located within a world-class NHS environment at Chelsea and Westminster Hospital includes patient access to a dedicated state-of-the-art outpatient hysteroscopy service. The unit has one of the best equipment for out patient polypectomy. If endometrial cancer is diagnosed after investigative process then cases are referred to multidisciplinary discussion for immediate review of the best treatment options for the patient. There has been tremendous progress in surgical approach towards laparoscopic procedures including total laparoscopic hysterectomy where clinically indicated. The benefits of laparoscopic surgery are well documented with earlier discharge from hospital, less pain and quicker recovery for patients.

Cervical cancer The third common cause of abnormal bleeding is cervical cancer. There has been significant reduction in the incidence of cervical cancer since the introduction of cervical screening program. The current change for HPV screening will help further to reduce the overtreatment of early cervical abnormalities. Previous normal cervical smear does not exclude the possibility of cervical cancer. A good detailed history; thorough cervical examination and cervical smear would be mandatory to diagnose cervical cancer. A friable abnormal growth on the cervix that bleeds easily on touch should prompt a primary physician to refer patient for urgent colposcopy. A colposcopy and biopsy in the tertiary unit can help to make a definitive diagnosis either way.

Mr Amer Raza, Consultant Obstetrician & Gynaecologist

Mr Raza is a gynaecologist with advanced skills in minimal access surgery. He is leading the way for a change in gynaecological surgery to carry out complex gynaecological operations though keyhole approach as standard. The increasing demand for laparoscopic procedures including laparoscopic hysterectomies (removal of uterus) is directly correlated to shorter stays in hospital, less post-operative pain and a quicker return to work with better cosmetic results (small scars) for patients. Other laparoscopic operations available at Chelsea and Westminster Hospital include laparoscopic myomectomy (removal of fibroid), laparoscopic cystectomy, laparoscopic removal of endometriosis and removal of large fibroids laparoscopically with the added advantage of less adhesion, less pain and a similar earlier discharge for patients. There has been a steady increase in demand for laparoscopic approach over the last few years.

To discuss a referral with Mr Raza, you can contact him via E: amer.raza@chelwest.nhs.uk Private consultations are available by T: 0203 315 8484 E: private.enquiry@chelwest.nhs.uk 21

CANCER

Mini-guide to prostate cancer

Mr Bijan Khoubehi Consultant Urologist

The urology team at Chelsea and Westminster Hospital provide a comprehensive urological service to both NHS and private patients.

The clinical Lead is Mr Bijan Khoubehi, who subspecialises in uro-oncology. He provides laparoscopic and robotic surgery for renal and prostate cancer treatment.

Prostate cancer • Prostate cancer is the most common cancer diagnosed in men in the UK, with 40,000 new cases each year, accounting for 25% of all cancers in men. Over 40,000 men are diagnosed with prostate cancer every year and over 250,000 men are currently living with the disease.

• It is the second most common cause of cancer related death in men in the UK- that's more than 10,500 men every year.

• 1 in 8 men will get prostate cancer in their lifetime.

Risk factors: In the UK, about 1 in 8 men will get prostate cancer at some point in their lives. Older men, men with a family history of prostate cancer and black men are more at risk.

Age: strongest risk factor for prostate cancer. The disease mainly affects men over 50, and the risk increases with age.

Men under 50 can get it, but it isn’t common. The average age for men to be diagnosed with prostate cancer is between 70 and 74 years. After the age of 80, in excess of 70% of men will have prostate cancer, however, many tumours remain indolent, and do not affect longevity or quality of life.

Family history: an important risk factor but its overall influence is small. About 5–10% of prostate cancers are thought to have 22

a genetic link. This figure increases to 30–40% for early onset cancers (<55 years). Men with a first-degree relative diagnosed with prostate cancer have two and a half greater risk than the general population. This risk increases to fourfold if the relative is younger than 60 at the time of diagnosis or more than one relative is affected. Risk of prostate cancer increases if a first-degree has had breast cancer, particularly if they were diagnosed under the age of 60 and had BRCA1 or BRCA2.

Ethnicity: Black african and caribbean men have two to three times higher incidence and death rates from prostate cancer than white men (possibly related to a genetic cause). In the UK, about 1 in 4 black men will get prostate cancer at some point in their lives. Asian men have lower rates.

Body weight: being overweight or obese increases risk of aggressive prostate cancer.

Symptoms Most men with prostate cancer are asymptomatic; the majority of prostatic symptoms are due to benign disease.

Locally advanced disease may cause pain, urinary frequency, nocturia, haematuria, haematospermia or renal failure. Metastatic disease may cause pain in the back, hips and pelvis or even symptoms of spinal cord compression.

Diagnosis

Prostate biopsies

PSA testing PSA is a simple test, but a very poor diagnostic test as a high PSA does not equate to prostate cancer. It is also worth noting that a ‘normal’ PSA does not exclude the possibility of having a significant prostate cancer.

The biopsy can be trans-rectally or trans-perineally. The trans-perineal route, offers a higher accuracy, ability to target the lesions better, higher accuracy and much lower septicaemia rate.

At Chelsea and Westminster Hospital, patients are routinely offered trans-perineal biopsies – this is routinely offered in very few hospitals in the UK.

Men need to be aware of the limitations and the implications of having a PSA test. The PSA levels increase with age. Using a PSA level of 4ng/ml, the test has a sensitivity of approximately 80% and a specificity of 60%. However, the accuracy of test improves by using age related values: Age

PSA values (ng/mL) 0.0 to 2.5

40-49

0.0 to 3.5

50-59

0.0 to 4.5

60-69

0.0 to 6.5

70-79

Positive predictive value (PPV) of PSA varies depending on its level: PPV

PSA 0-1

2.8-5%

1-2.5

10.5-14%

2.5-4

22-30%

4-10

30-40%

>10

50-60%

>20

80-90%

Digital rectal examination (DRE) DRE is a subjective examination and is subject to under and over-staging. However, most prostate cancers are located in the peripheral zone and may be detected when their volume exceeds 0.2ml. A suspicious DRE is an absolute indication for prostate biopsy in men who will benefit from radical treatment.

A suspect DRE alone can detect disease in 18% of patients, irrespective of PSA level. DRE has a sensitivity of 53% and specificity of 83%, with a positive predictive value of 17.8%.

Performing a DRE will not significantly affect the PSA.

MRI The use of MRI has increased over the last few years in diagnosis of the prostate cancer. At Chelsea and Westminster Hospital prostatic MRI is performed on everyone pre-biopsy.

Multiparametric MRI (mpMRI) which combines standard sequences with diffusion weighted sequences (DWI) and dynamic contrast (DCE), has increased the sensitivity and specificity. The sensitivity is over 85% and specificity is over 90% with a high NPV of around 95%.

This technique not only allows more accurate diagnosis, but helps with targeting the biopsies to the correct part of prostate.

Furthermore, it reduces the number of negative/unnecessary biopsies.

Management of prostate cancer

The type of treatment that can be offered partly depend on the risk stratification of tumour, patient characteristics (age, general health) and patient preference. Localised disease prostate cancer is divided into low, intermediate and high risk: Clinical Stage

Level of risk

PSA (ng/ml)

Gleason Score

Low risk

<10

and

≤6

and

T1–T2a

Intermediate risk

10–20

or

7

or

T2b

High risk

>20

or

8–10

or

≥T2c

Low-risk disease can be managed with: 1. Active surveillance for men suitable for radical treatment should their disease progress or watchful waiting for patients who are elderly with a relatively short life expectancy.

2. Active radical treatment: Radical prostatectomy (at Chelsea and Westminster Hospital, this is offered robotically); radical external beam radiotherapy (with or without neoadjuvant hormonal treatment), brachytherapy. Treatment such as HIFU and cryotherapy only offered in the context of clinical trial, due to lack of long term data.

Intermediate risk cancer can be managed with: 1. Radical treatment: Radical prostatectomy (at Chelsea and Westminster Hospital, this is offered robotically); radical external beam radiotherapy (with neoadjuvant hormonal treatment), brachytherapy. Treatment such as HIFU and cryotherapy only offered in the context of clinical trial, due to lack of long term data.

2. Active surveillance or watchful waiting in certain circumstances High risk prostate cancer should be managed with: 1. Radical prostatectomy (at Chelsea and Westminster Hospital, this is offered robotically); radical external beam radiotherapy (with neoadjuvant hormonal treatment) Metastatic disease The majority of patients will respond well to treatment with androgen ablation. The median duration of response time is one to two years. When the disease becomes castrate resistant, there are now multiple treatments that have been shown to improve survival. These include chemotherapy with Docetaxel or Carbazitaxel, hormone therapy with Abiraterone or Enzalutamide and a radio-isotope called Alpharadan. Trials are ongoing to determine how best to sequence these new treatments.

23

CANCER

The cancer might be skin deep but the scars need not be

Mr Richard Young Consultant Plastic Surgeon

Mr Richard Young is a Consultant Plastic Surgeon and Service Lead for Plastic Surgery here at Chelsea and Westminster Hospital. In his role he oversees all burns, craniofacial, hand and general plastic surgery. On an individual level he carries out many of the skin cancer removals and reconstructions here at Chelsea and Westminster Hospital.

We met up with Mr Young to discuss how we are minimising the long-term aesthetic impacts for skin cancer patients.

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Where is the most common reconstruction procedure cancer patients undergo?

The majority of skin cancers are sited on the head and neck as this area gets more sun exposure than other areas of the body. Removing cancers from the around the eyes, nose and mouth can require complex reconstruction to maintain good function as well as acceptable appearance. This might involve a standard surgical excision or Mohs surgery, which is a very specialized way of excising skin cancer in functionally sensitive areas. In Mohs surgery we employ a two-team approach: a resecting team and a reconstruction team. We are very fortunate at Chelsea and Westminster Hospital to have an excellent Mohs resection team in Dr Shelley and Dr Navara from the Dermatology department. During Mohs surgery thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains. This means the resulting defect is as small as possible and the chance of recurrence as low as possible. The defects are then reconstructed by the Craniofacial Plastic Surgery team either with stiches, local ďŹ&#x201A;aps or skin grafts. Typically these surgeries are either back to back on the same day or on two consecutive days to minimise the disruption and recovery times for patients. Occasionally the reconstruction may require more than one operation over a number of weeks. Post reconstruction, our in-house dressings team are on hand to provide expert wound care in the weeks that follow and our skin cancer nurse specialist is available to help patients and answer many of their questions.

MOHS case study: Mr T

This 79 year old male has had multiple skin cancers removed from his face and body over several years. A number of Mohs resections have been done, in this case near his eye with the reconstruction performed using local ďŹ&#x201A;aps (pictured above).

Four months after his reconstruction with everything healed (pictured on right).

Is surgery the only option for patients?

There are other ways to treat skin cancers although the gold standard is usually surgery. Radiotherapy is sometimes an option or light therapy involving photodynamic therapy (PDT) but this is only applicable in some cases. A number of creams can be used in some cases and more recently drug treatments have become available for specific advanced skin cancer.

What advances are you seeing in plastic reconstruction techniques?

The main development has been the shift towards using self-expanding tissue expanders when we need to stretch skin and then move the skin in the form of a ďŹ&#x201A;ap to reconstruct an area. Traditional tissue expanders require topping up with air or water every week and involve multiple hospital visits which is not particularly convenient for patients. However, newer self-expanding tissue expanders absorb ďŹ&#x201A;uid from surrounding tissue over a period of 6 weeks which causes them to swell dramatically reducing the number of required hospital visits.

These self-expanding tissue expanders are proving increasingly popular with patients.

What advice would you give to GPs with patients with suspected skin cancer?

If surgery is the likely outcome for patients because the diagnosis has been made after a biopsy in the community or the diagnosis is obvious then I would recommend that GPs refer directly to Craniofacial Team at Chelsea and Westminster Hospital

(rather than Dermatology) as this ensures patients are seen and treated in the most timely way.

Why refer patients to the team at Chelsea and Westminster Hospital?

We offer excellent clinical skills as demonstrated by our low cancer recurrence rate and excellent functional and aesthetic outcomes. Additionally the team leads the specialist skin cancer meeting for this region (North West London) so we are experienced in determining the optimal treatment not just for patients in our direct care, but all those being treated in other centres as well. We are also fortunate to have a wonderful hospital environment and we are often the most convenient choice for many of our patients.

Any final thoughts?

It is worth stressing that no matter how good our patient outcomes are with many surgical scars invisible just weeks to months later (see case study above), ideally prevention is better than cure. It would be remiss of me not to emphasise the preventative benefits of daily sunscreen, wearing hats in the sun, avoiding sunburn and supplementing with vitamin D to prevent deficiency and keep you healthy.

To refer patients to Mr Young and colleagues, please contact T: 0203 315 8484 or E: private.enquiry@chelwest.nhs.uk

25

Safe in our hands: Managing carpal tunnel and cubital tunnel nerve compressions

Ms Effie Katsarma Consultant Plastic Surgeon

Ms Effie Katsarma, Consultant Plastic Reconstructive and Hand Surgeon leads the nerve compression clinic at Chelsea and Westminster Hospital, building on the success of the one-stop carpal tunnel clinic she developed at Chelsea and Westminster Hospital in 2006.

This clinic, and its predecessor, has been revolutionary in transforming patientâ&#x20AC;&#x2122;s experience and in reducing patient delays in getting a diagnosis and accessing appropriate treatment. The clinic can cater for the entire spectrum of nerve compression be that carpal tunnel or cubital tunnel syndrome.

Carpal Tunnel Syndrome - a compression of the median nerve at the level of the wrist.

The more common nerve compression, with more obvious symptoms involving altered sensation of the 3½ radial digits of the affected hand and weakness of the thumb Cubital Tunnel Syndrome - second compression of the ulnar nerve at the level of the elbow. Cubital tunnel patients experience numbness of the ulnar 1½ digits, tenderness over at the level of the elbow and some weakness in bringing the fingers apart or together.

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Carpal Tunnel Syndrome

Ulnar Nerve Impingement

The Nerve Compression Clinic On arrival at the nerve compression clinic at Chelsea and Westminster Hospital, patients are given a self-assessment questionnaire to complete as well as a video introduction to nerve compression to review via an ipad. This short video spans aetiology, progression and treatment of their condition and gives patients an opportunity to familiarise themselves with the science behind their condition.

During their clinic appointment, patients receive an initial consultation and examination, nerve conduction studies and a post-diagnostic consultation. During this latter consultation, the consultant will review the clinical and neurophysiological findings with the patient and discuss their treatment options with them.

The ability to assess, diagnose and decide on the treatment pathway in one visit is still fairly unique in healthcare and is a source of much delight to our patients.

(Previously a patient might attend three different appointments over a duration

of six months before a course of action could be agreed).

Treatment options are dependent on clinical and neurophysicological findings and can be either conservative in the form of a splint or steroid injections or a surgical procedure for more advanced cases.

Both cubital and carpal tunnel patients can be offered a steroid injection in the clinic or under ultrasound guidance. If it is determined that conservative treatment is not indicated, the patient will be booked for either surgical release of the carpal/ cubital tunnel in the main theatres. The team at Chelsea offer the latest in innovative surgical procedures including endoscopic carpal tunnel decompression (if clinically indicated) as well as more traditional open surgical release of the carpal tunnel.

At Chelsea and Westminster Hospital, we see over 500 patients suffering from nerve compression every year and we surgically treat over 100 patients a year with highly successful results. We are also happy to see patients that have complications following surgery performed in another centre.

Typical recovery period following surgical release is approximately 10 days for skin healing and a few weeks to a few months before a full return to normal activities.

In patients who have jobs with high physical demands e.g. manual workers, we can arrange a course of hand therapy to increase the strength of the involved limb.

patients suffering from tendonitis at the level of the elbow, (otherwise known as lateral epicondylitis or Tennis elbow) and also for tendonitis at the level of the wrist.

When to refer

Dupuytren's condition can be treated surgically at Chelsea and Westminster and we also offer non-surgical treatment using Xiapex injections or Collagenase injections for patients that fulfil appropriate criteria.

We like to see the patients sooner rather than later, ideally before the compression becomes severe and the nerve change is non-reversible. As an interim measure between referral and the consultation the clinic, carpal tunnel patients can be given a Futuroâ&#x201E;˘ night splint, which holds the hand in a neutral position whilst asleep. For cubital tunnel patients we recommend a splint with an aircushion that can be applied in the area of the elbow be worn during daily routine activities and at night.

Treating other hand conditions Outside the nerve compression clinic, Ms Katsarma is happy to see patients with a variety of conditions requiring hand surgery, be that elective and emergency. We are seeing an increasing number of patients with trigger finger and we currently have the biggest series in UK and internationally.

For trigger finger patients, we typically advise innography treatment to endoscopically release their A1 pulley.

Other innography treatments offered include PRP (platelet rich plasma) for

We also treat a significant number of patients that suffer from osteoarthritis of the base of the thumb and the digits either surgically or with steroid injections or more recently, with Hyaluronic acid injections under image intensifier.

To refer patients to Ms Katsarma, please contact T: 0203 315 8484 or E: private.enquiry@chelwest.nhs.uk Ms Katsarma was appointed a Consultant at Chelsea and Westminster Hospital in 2001 following her completion of training in plastic surgery and an 18 month fellowship at Christine Kleinert renowned Institute for Hand and Microsurgery in USA, Louisville, Kentucky where she participated in the hand transplants and became a member of the Hand Transplant Team.

27

Under the thumb: Slowing down Almost 100% of men and women develop some form of arthritis in their hands in later life and is often a debilitating and painful condition if left untreated. Hand arthritis is very common with almost 100% of men and women developing radiographic evidence of the disease with variable clinical symptoms particularly; at the base of the thumb.

Mr Maxim Horwitz Consultant Hand Surgeon

Arthritis can be primary (e.g. rheumatoid, osteoarthritis) or secondary osteoarthritis as a consequence of trauma or infection. Inflammatory arthritis and osteoarthritis present with different signs as well as histories. The inflammatory arthritides includes rheumatoid arthritis, gout, systemic lupus erythematosus (SLE), scleroderma, psoriatic arthritis and juvenile rheumatoid arthritis.

Quick guide to osteoarthritis and rheumatoid arthritis:

Rheumatoid arthritis

Epidemiology

Signs and symptoms NOTE: It is important to assess if the patient has any functional deficit in the activities of daily living.

These include simple things such as fastening buttons, holding a tea cup, opening and closing a tap, and maintenance of personal hygiene.

∙ This condition generally starts in the 4th and 5th decade with an insidious start

∙ Osteoarthritis may affect more than one joint but generally is localised to the joints only

∙ It is associated with systemic features such as morning stiffness of greater than an hour, arthritis in more than three joints, arthritis in the hand joint, symmetrical arthritis, rheumatoid nodules, a positive rheumatoid factor and radiological changes

∙ It may also be secondary to trauma

∙ Patients often present with the previously mentioned symptoms of morning stiffness and an aching in all of their joints

∙ Nodules at the proximal interphalangeal joint (Bouchard) and distal interphalangeal joints (Heberden’s nodes) are often noted

∙ Swelling and tenderness in the earlier stages of the disease are common ∙ As the soft tissues become more and more inflamed the hand and wrist tend to go structural changes. These include a prominent distal ulna, metacarpals deviating in an ulna direction, swan neck and Boutonniere deformities as well as tendon ruptures with some deformities

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∙ Patients are generally systemically well with arthritic changes on radiographs. ∙ Patients will initially have swelling and discomfort of small joints particularly DIP and PIP joints

∙ As the arthritis progresses deformity can develop at the interphalangeal joints, metarcarpo- phalangeal joints as well as the thumb ∙ Stiffness is often a problem in patients with osteoarthritis

∙ Vasculitis, skin changes, and neurological deficits associated with other inflammatory conditions must be noted ∙ Early diagnosis is key and referral to a rheumatologist is essential

Management

Osteoarthritis

∙ Pain should be controlled with analgesia, splintage and appropriate therapy ∙ Early surgical referral is imperative as it allows a surgeon to monitor the progress of the disease and preserve or restore function rather than resort to late salvage procedures

∙ Appropriate analgesia is essential to allow the patient to continue with activities of daily living ∙ Therapy often from a specialist hand therapist to maintain function is essential ∙ Appropriate splintage can often be very useful ∙ When function is impaired and pain is intolerable then appropriate surgical referral is recommended

the progression of hand arthritis Treating arthritis Arthritis of the hand is a condition best dealt with by a multi-disciplinary team including a hand surgeon, a rheumatologist and an occupational therapist. It is important to have excellent hand therapy to make sure that patients can maintain residual function with good control of pain relief with safe and appropriate drugs. Information leaďŹ&#x201A;ets including those provided by the Rheumatology Council are often very beneficial.

Treatment starts with strengthening, splintage and occasionally steroid injections. Joint fusion and replacement are part of the surgical treatment plan but must be considered in line with the overall health and goals of the patient.

The general practitioner can assist with initial pain control and prompt referral to hand therapists to optimise hand function.

Delays should be avoided, especially in rheumatoid arthritis where the risk of tendon ruptures must be taken into account.

Osteoarthritis Base of thumb osteoarthritis

Rheumatoid arthritis

MCPJ replacments

Grinding and rotation of the arthritic thumb is painful and should only be done once during an examination.

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Management of shoulder pain in primary care

Mr Rupen Dattani Consultant Orthopaedic Surgeon

The prevalence of shoulder pain in the UK is estimated to be 14%, with 1-2% of adults consulting their general practitioner annually regarding new-onset shoulder pain. Painful shoulders can pose a substantial socioeconomic burden and disability of the shoulder can impair ability to work or perform household tasks and can result in time off work. The diagnosis of the possible causes of shoulder pain is based on taking a focused history combined with a detailed clinical examination.

Important features to document in history: ∙Hand dominance ∙Location, radiation and onset of pain ∙Duration of symptoms ∙Exacerbating and relieving factors ∙Occupation and level of activity or sports ∙History of trauma ∙Patient expectation ∙Involvement of other joints ∙Systemic illnesses and comorbidities ∙Red flags (diagram opposite)

Treatment in primary care ∙ The overall treatment aim for the conditions that cause shoulder pain is to 'improve pain and function'; however, treatment success needs to be defined individually with patients in a shared decision-making process. ∙ Any shoulder 'red flags' (diagram opposite) identified during primary care assessment needs urgent secondary care referral.

(NB: although acute calcific tendinopathy is not a red flag, it can be very painful and mimic malignant pain and usually necessitates an early secondary care referral for more interventional treatment). ∙ Conservative treatment should, in general, include rest, exercise, physiotherapy, analgesics and no more than two corticosteroid injections. ∙ Physiotherapy rehabilitation should usually be for six weeks unless patients are unable to tolerate the exercises, or physiotherapists identify a reason for earlier referral to secondary care. If there is patient improvement in the first six weeks of physiotherapy, then a further 6 weeks therapy is justified. ∙ Imaging: Shoulder X-rays with a minimum of two views can be useful in patients not improving with conservative treatment.

Further imaging with ultrasound (US) or magnetic resonance imaging (MRI) is rarely indicated in primary care. ∙ Failure of these community treatments should prompt secondary care referral.

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Overview of shoulder examination: ∙ Inspection: rotator cuff wasting, scars, swelling, symmetry ∙ Palpation: sternoclavicular (SC) joint, acromioclavicular (AC) joint, long head of biceps in bicipital groove ∙ Range of motion: forward elevation, abduction, external rotation, internal rotation to vertebral height ∙ Special tests: 1 Rotator cuff strength testing a Supraspinatus: Jobe’s test: abduct arm to 90°, angle forward 30° (bringing it into the scapular plane), and internally rotate (thumb pointing to floor). Then press down on arm while patient attempts to maintain position testing for weakness or pain. b Infraspinatus: external rotation strength tested while the arm is in neutral abduction/adduction c Subscapularis: Belly press test patient presses abdomen with palm of hand, maintaining shoulder in internal rotation. If elbow drops back (does not remain in front of trunk) test is positive 2 Impingement: Hawkins Sign: flex shoulder to 90°, flex elbow to 90°, and internally rotate the shoulder.

If painful sign is positive.

3 AC Joint: Scarf test: patient forward elevates the arm to 90° and actively adducts the arm across the body.

4 Long head of biceps pathology: positive when there is pain elicited in the bicipital groove when the patient attempts to forward elevate their shoulder against resistance while they keep their elbow extended and forearm supinated.

5 Instability test: Apprehension test: have the patient lie supine. Apprehension test performed by bringing the arm in 90° of abduction and full external rotation and patient experiences sense of instability.

RED FLAGS: Urgent referral

Is it neck or shoulder?

1 . Trauma, pain and weakness Acute cuff tear?

2 . Any mass or swelling Tumour?

∙Ask the patient to first move the neck and then move the shoulder ∙Which reproduces the pain?

3 . Red skin, fever or systematically unwell Infection?

4 . Trauma / epilepctic fit / electric shock leading to loss of rotation and abnormal shape Unreduced dislocation?

Neck / Back Neck Shoulder

SHOULDER

NECK

History of Instability?

∙Follow local spinal service guidelines

Primary Care YES

REFER

Instability

Common age: 10-35 yrs

∙Does the shoulder ever partly or completely come out of joint?

· Traumatic dislocation

· Physio if alraumatic

∙Is your patient worried that their shoulder may dislocate during sport or on certain activities?

· Ongoing symptoms · Altraumatic with failed physio

Acromioclavicular Joint Disease Common age: +30 yrs

NO

∙Is the pain localised to the AC joint and associated with tenderness?

Instability

Refer to Shoulder Clinic

YES

∙Is there high arc pain

REFER

Acromioclavicular Joint Disease

· Rest/NSA/DS/analgesics · Steroid injection · Physio · X-ray if no improvement

· Refer if transient or no response to injection and physio

∙Is there a positive cross arm test REFER

NO

∙Is there reduced passive external rotation?

Glenohumeral Joint

Glenohumeral Joint

Frozen Shoulder

· If frozen shoulder with normal x-ray - refer if atypical and/or severe functional limitation

Common age: 35-65 yrs Arthritis YES

NO

Common age: >60 yrs

· Refer if arthritis on x-ray and poor response to analgesics and injection

· X-ray - to differentiate

∙Is there a painful arc of abduction?

· Rest · NSA/DS/analgesics · Cortisone injection

∙Is there pain on abduction with the thumb down, worse against resistance

YES

N.B. A history of trauma with loss of abduction in a younger patient: Red Flag

Rotator Cuff Tendinopathy Common age: 35-75 yrs

NO

Other cause of neck or arm pain

Adapted from the British Shoulder & Elbow Society (BESS) to help primary care doctors work through and formulate a treatment plan in the management of the painful shoulder

· Rest/NSA/DS/ analgesics · Subacromial injection · Physiotherapy N.B. Although an ultrasound or MRI scan can be of value, some people over 65 years have asymptomatic cuff tears.

REFER

Rotator Cuff Tendinopathy · Transient or no response to injection and physiotherapy N.B. Massive cuff tears in patients >75 years are generally not repairable

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Chelsea & Westminster Hospital . Private Care Directory . Adult Services

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Chelsea & Westminster Hospital . Private Care Directory . Paediatric Services

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Who’s who: New members of the Private Care Team

Mr Amit Sharma

Ms Hannah Smyth

Service Manager, Chelsea Wing and Paediatrics

Service Manager, ACU and Kensington Wing

Mr Amit Sharma is the new Service Manager for Private Patients. His background spans private healthcare in a commercial and operational capacity. Operationally, Amit is responsible for private adult and paediatric services to ensure our private patients' stays with us are safe, comfortable and personalised to meet their individual requirements.

Ms Hannah Smyth is the Service Manager for the Assisted Conception Unit and Private Maternity Wing at Chelsea and Westminster Hospital. She has previous experience in both the NHS and Private Healthcare sectors and is passionate about providing a bespoke service supported by excellent clinical outcomes and patient experience.

'I’m really excited to be joining Chelsea and Westminster Private Patients Unit as it has access to specialised services not available in other private hospitals, incredibly dedicated staff and consultants who are leaders in their field.

Most importantly I look forward to working with you to accommodate your patients from appointment, admission to discharge.'

Telephone 0203 315 8411 Email amit.sharma@chelwest.nhs.uk

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‘I am absolutely thrilled to be joining the Chelsea and Westminster Assisted Conception Unit and Kensington Wing teams.

I look forward to helping support these wonderful units to grow and develop with the ever changing healthcare market. The dedication and passion from all the staff has really shone through and I know we can all work together to deliver an exceptional service to our patients.’

Telephone 0203 315 3669 Email hannah.smyth@chelwest.nhs.uk

Mr Mohamed Abou Mussaid

Arabic Private Patient Liaison Officer Mohamed Abou Mussaid is the Trust’s Arabic Liaison and single point of contact for embassies and patients from the Gulf states. The Gulf states provides citizens with the right to treatment overseas and we are getting an increasing number of patients from UAE, Qatar, Kuwait, Saudi Arabia, Iraq, Egypt and Libya choosing to be treated at Chelsea and Westminster Hospital. Mohamed helps to ensure that the patients and embassies’ experience goes without a hitch.

'I work very closely on daily basis with our private patients, embassies and health offices in London; ensuring they are receiving an elite professional service and enjoy an outstanding experience whilst being at under our private care.'

Telephone 020 3315 8483 Mobile 078 1633 5327

Email mohamedabou.mussaid@chelwest.nhs.uk

Edited by Justine Currie

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