pRACTICE Matters
The Newsletter For GPs From The Wellington Hospital
Come Fly with Me
Is your patient fit to fly?
For or Against?
Should patients undergo surgery for prostate cancer?
Knee-Jerk Reaction
Introducing the same day appointment service from the Knee Unit
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
Welcome It was hard not to notice the big change in town this summer; how did the Olympics and Paralympics affect you? Were you busier, in more demand? Our cover story this issue is the ‘same day’ appointment service, which our prestigious Knee Unit launched earlier this year. With the Games making a big impact this summer, an increase in orthopaedic injuries from both professionals and amateurs is highly likely. This service means your patients can be referred, seen, scanned and diagnosed – all within 24 hours. Turn to pages 6 and 7 for more information. In this issue we unveil our newly reopened Endoscopy Unit on pages 8 and 9; and let the photographers in to showcase this ultra-modern, high tech department. Damian Muncaster, Respiratory Physiologist, asks is your patient fit to fly this summer on page 5. We have two lively debates: Marc Laniado, Consultant Urologist answers questions about the necessity of prostate surgery; and Angus McIndoe, Consultant Gynaecologist, ponders the benefits of the da Vinci robot in ‘Expensive Toy or Essential Tool’. And finally, on page 15, we ask is your practice happy? If you missed the interesting talk by the Integrated Skin-Cancer Service last month, led by Ciaran Healy, we will be hearing from this dynamic unit in the next issue, where we will also be showcasing our new Oncology Unit, which opened this September. You may have noticed that Practice Matters has had a makeover, what do you think? There will be more surprises in store for you next issue as we launch our first online, interactive Practice Matters. If you’re curious and would like to try this version, please email our editor to sign up: claire.allen@hcahealthcare.co.uk. Enjoy this issue, and the rest of the summer!
Keith D Hague CEO
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PRACTIcE MATTERS
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Contents 04 | Deuce‌ When injuries halt your patients’ game, set and match. LHWU manager Melita Ryan looks at tennis elbow
05 | Come Fly With Me Damian Muncaster, Respiratory Physiologist asks is your patient fit to fly?
06 | Knee-Jerk Reaction Introducing the same day appointment service from the Knee Unit
08 | A Step Ahead Showcasing the newly refurbished Endoscopy Unit
10 | For or Against? Is surgery for prostate cancer necessary? Mr Marc Laniado discusses
11 | Expensive Toy or Essential Tool? Mr Angus McIndoe explores
the big question about robotic surgery
12 | Vital Organ, Vital Service The Liver Unit at The Wellington Hospital
14 | The Evolution of Breast Reconstruction Mr Navid Jallalli discusses autologous reconstruction
15 | In Pursuit of Happiness Is your surgery happy?
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16 | GP News The latest news from the primary care sector and The Wellington Hospital
18 | Seminar Listings and New Consultants Plus an interview with outpatient manager Elaine Carson
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Hand and wrist
Deuce . . . when tennis injuries draw your patients’ game to a halt
Continuing our ‘Top Up’ on Hands series, Melita Ryan, London Hand and Wrist Unit Manager, explores the tell-tale signs of tennis elbow.
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ennis elbow is most commonly associated with tennis, however, it can occur as a work related injury or as a result of repetitive strain at the elbow joint. The actual cause of tennis elbow is insidious. Tennis elbow is typically pain at the lateral epicondyle of the elbow, originating from the extensor carpi radialis brevis (ECRB) tendon. Micro tears occur in the common extensor origin from constant repetitive movement. Often, these injuries do not have the chance to heal, as many patients and tennis players push through the pain. Consequently, because of the injury at the extensor origin, wrist extension can be painful and makes gripping difficult.
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Tennis Elbow is diagnosed when: • Pain symptoms last longer than three months • If provocative tests, such as the Cozen’s test, Mills test or resisted middle finger extension are positive • There is pain on palpation of the extensor origin
Grip strength testing will also give you some objective data, as well as the Patient Rated Tennis Elbow Evaluation. An ultrasound can also confirm the diagnosis, and radiographs will rule out other bone injuries. Initial treatment with ice and rest will settle the inflammation, and a good fitting elbow brace that disperses the force at the extensor origin will settle acute pain. Patients with longer-term tennis elbow may require a wrist extension splint to rest the extensor muscles further. Hand therapy will involve strengthening and restoring the muscle imbalance around the elbow. Once symptoms persist longer than
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three months, referral to a specialist is recommended. Steroid injections can be used, however, conservative treatment is the first point of action. For many patients, if their tennis or work tasks are causing the tennis elbow, it is worth looking at their
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Sometimes a simple adjustment to their grip or computer set-up can make the world of difference
forehand or how they perform their work tasks. We often ask patients to bring in their racket or we will try replicating their work environment in therapy. We can then analyse their postures more accurately. Sometimes a simple adjustment to their grip or computer set-up can make the world of difference. Tennis players should check that they have a good grip on their racket and that their strings are tensioned properly. Players shouldn’t push through wrist and elbow pain, and if initial rest and ice doesn’t settle your patient’s symptoms, seek further assessment early.
Introducing our new consultants at the London Hand and Wrist Unit Mr Abhilash Jain MBBS, MRCS, MSc, PhD, FRCS(Plast)
Clinical Senior Lecturer and Consultant Plastic, Reconstructive and Hand Surgeon. Abhilash Jain graduated in 1995 (London) and undertook surgical training to become a Member of the Royal College of Surgeons of England (1998). He then began training in plastic, reconstructive, hand and aesthetic surgery in London teaching hospitals. He was awarded an MSc (Distinction) (University College London) and PhD (Imperial College London) for his research looking at the effects of rheumatoid arthritis on the hand. After training in London and Sydney, he was awarded the Plastic Surgery Specialist Fellowship [FRCS (Plast)] in 2008, and entered into the GMC specialist register for plastic surgery in 2009. He was the first plastic surgeon to win a prestigious HEFCE Clinical Senior Lecturer-NHS award. He is currently a clinical senior lecturer and consultant plastic surgeon at Imperial College London and undertakes all aspects of hand, lower limb reconstruction, general plastic surgery and cosmetic surgery.
Mr Shehan Hettiaratchy MA(Oxon), BMBCh, FRCS(Eng), DM, FRCS(Plast)
Consultant Hand, Plastic, Reconstructive and Cosmetic Surgeon. Shehan Hettiaratchy graduated from Oxford University in 1994, and underwent basic surgical training in London teaching hospitals and obtained FRCS (Eng) in 1998. He won a prestigious research fellowship at Harvard Medical School (USA). While there, he developed the first valid pre-clinical model of limb transplantation without long-term immunosuppression. He was honoured with a Hunterian Professorship from the Royal College of Surgeons of England for this. He obtained FRCS(Plast) in 2007 and was accepted onto the GMC specialist register for Plastic Surgery in 2008. His special interests are upper and lower limb reconstruction, hand surgery and cosmetic surgery. He is currently a consultant and honorary senior lecturer at Imperial College NHS Trust, clinical lead for the Department of Plastic and Reconstructive Surgery, part of the UK Face Transplantation Team and an honorary consultant at the Royal Free Hampstead NHS Trust.
Respiratory
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Come Fly With Me
Pressure (mm Hg)
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patients with cystic fibrosis, history of air travel intolerance with respiratory symptoms (dyspnoea, chest pain, confusion or syncope), co-morbidity with other conditions worsened by hypoxaemia (cerebrovascular disease, coronary artery disease, heart failure, pulmonary tuberculosis; if they are within six weeks of hospital discharge for acute respiratory illness, a recent pneumothorax, at risk of or previous venous thromboembolism and a pre-existing requirement for oxygen or ventilator support. For the majority of these patients it is recommended that they should undergo a hypoxic inhalation test (HIT). This test is regularly performed at the Lung Function Laboratory at The Wellington Hospital. It is a relatively simple test, firstly requiring an earlobe blood gas sample from the patient to assess the baseline oxygen levels. The patient then breathes in a mixture of oxygen and nitrogen, which simulates the cabin environment. Oxygen saturation is monitored and a further earlobe sample is taken to assess the amount of de-saturation. If the oxygen saturation drops to a certain level, then supplemental oxygen is administered until the de-saturation is rectified. A subject is usually judged to require in-flight oxygen if their Pao2 falls below 6.6 kPa (50 mmHg) or if their Spo2 falls below 85%. These figures appear purely arbitrary with no supporting evidence, but many physicians have adopted them as a reasonable compromise. Hypoxic challenge testing is the pre-flight test of choice for patients with hypercapnia.
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Respiratory Physiologist Damian Muncaster asks, are your patients fit to fly this summer? t is estimated that in 2011 over one billion people travelled by air and over the next 20 years that figure is expected to double. With this increase in air travel and an increasingly ageing population, there will be a significant increase in the number of older passengers and those with illness who wish to travel. The physiology of flying, and its impact on a patient’s underlying illness, is important in assessing whether a patient is fit to fly. Modern aircraft fly with a cabin altitude of between 5000 ft and 8000 ft. At 2438 m (8000 ft) the partial pressure of oxygen drops to the equivalent of breathing 15.1% oxygen at sea level. In a healthy passenger, the arterial oxygen tension (Pao2) at 2438 m (8000 ft) is influenced by age and minute ventilation, but will fall to 7.0–8.5 kPa (53–64 mm Hg, Spo2 85–91%). This drop in oxygen saturation is well tolerated by healthy travellers, but for those with underlying cardiac or pulmonary conditions, or anaemia, there could be a problem. Fig. 1 shows the relationship between atmospheric pressure (mmHg) and altitude (ft). Most cardiac conditions can tolerate air travel well, although individual assessment is recommended, but certain respiratory conditions require more detailed investigation. The majority of patients with lung disease who will experience in-flight hypoxia can fly safely with supplemental oxygen, but it’s important that this is assessed first. The following groups should be assessed: severe COPD or asthma; severe restrictive disease (including chest wall and respiratory muscle disease), especially with hypoxaemia and/or hypercapnia,
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Fig. 1 Relationship between atmospheric pressure (mmHg) and altitude (ft)
The BTS grades the results of the HIT as follows: PaO2 > 7.4 kPa (> 55 mmHg)
Oxygen not required
PaO2 6.6-7.4 kPa (50-55 mmHg)
Borderline A walk test may be helpful
PaO2 < 6.6 kPa (< 50 mmHg)
In-flight oxygen (2L/min)
If in-flight oxygen is required most airlines will provide this, although some charge a fee for the privilege. The method of oxygen delivery depends upon the specific aircraft, but the supply is usually from cylinders. In some aircraft, oxygen can be tapped from the ‘ring main’ of oxygen. International regulations allow passengers to use their own oxygen on board aircraft and to carry small, full oxygen cylinders (for medical purposes) with them as baggage, provided they have the approval of the airline concerned - patients must check with the airline first. Of course, respiratory conditions are not the only possible barrier to flying. DVT, recent surgery, haematological conditions, psychiatric issues, infection and the recent application of a plaster cast can all become an obstacle to flying. But in the majority of cases, as long as the cabin crew are aware of the condition, they have clear advice from the relevant physician, and awareness of any medication that is being taken - the flight should be comfortable and emergency free.
www.thewellingtonhospital.com 5
KNEE
Knee -Jerk
Reaction Consultant Orthopaedic Surgeon Mr Howard Ware introduces the same-day appointment service from The Wellington Knee Unit…
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rthopaedic injuries are rife, especially in the warmer months when people are likely to be more active. This tends to translate to busy orthopaedic surgeons and long patient lists. This potential backlog can delay GPs who need to refer a patient quickly and easily, and frustrate your patients who may be busy, in pain and need to be treated fast. However, The Wellington Knee Unit believes it has the solution - introducing the same day appointment service:
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Summarising this innovative service, Knee Surgeon Howard Ware said…
We are delighted to now be offering this unique same day appointment service to our GPs and patients. For the past two decades, The Wellington Knee Unit, which practises from The Wellington South Building, has provided first-class treatment for knee conditions. This same day service brings together years of experience and the vast facilities available at The Wellington. With access to one of the largest imaging departments in the UK, including two MRI scanners, which are vital to being able to offer this service, the unit is also self-contained with its own dedicated team of nursing and secretarial staff on site; making this same day appointment service both efficient and personalised. Specialist orthopaedic knee surgeons are available every day, backed up by a team of internationally renowned specialist sports doctors, radiologists, rheumatologists and experienced nurses. One call to the dedicated helpline - 020
The Wellington Knee Unit provides first-class treatment for all patients with disorders of the knee, ranging from children’s abnormalities and knee ligament to cartilage injuries and arthritic conditions. In recent years, an increasing public interest in sporting activities has meant injuries to the knee have become far more frequent. Fortunately, with greater demands, there have been rapid technological advances in the management of knee ligament and meniscal injuries, resulting in earlier mobilisation and rehabilitation. The Wellington Hospital responded to the increased need for knee disorder management by establishing the Knee Unit as a highly specialised department within the United Kingdom’s private healthcare sector. The Knee Unit is staffed by consultant orthopaedic surgeons experienced in the field of
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knee surgery. Besides expertise in surgery, the unit contains the latest equipment for knee assessment and rehabilitation; including the Cybex 6000 computerised knee rehabilitation system, KT2000 arthometer and 3T MRI. Who is suitable for this same day appointment service? • Any acute knee injury • Patients who have a locked knee • Unstable knees • Infections • Fractures However, we are also happy to see: • Chronic knee problems • Patients for a second opinion • Osteoathritic knees
Treatments • Osteotomies around the knee • Anterior cruciate ligament replacement • Meniscectomy • Total knee replacement • Surgery for chondral damage • Imaging • Multi-ligament injury to the knee
The Team A consultant orthopaedic surgeon is available Monday – Friday every week, and each consultant has considerable expertise in the knee surgery field.
case study Mr K, a 56-year-old patient, highlights how this rapid service works for GPs and their patients. A man in his mid-fifties went to his local casualty department after injuring his leg. He was correctly diagnosed with a complete rupture of his quadriceps muscle, and was advised that he would need surgery. • He telephoned The Wellington Knee Unit later the next day and was seen the following morning. • He was seen early on the Wednesday morning, and after an examination had an ultrasound scan within the hour. • The consultant radiologist then confirmed the diagnoses of a complete rupture of his quadriceps muscle. • The patient was admitted the same day, and later that afternoon the rupture was repaired under a general anaesthetic. The patient was discharged the following day, partially weight bearing with crutches and a knee brace. Outpatient physiotherapy was arranged for him at a physiotherapy practice close to his home. Mr K has since made a full recovery.
www.thewellingtonhospital.com 7
A Step Ahead We take you on a tour around the new Endoscopy Centre
Endoscopy Reception
Since its opening nearly 15 years ago, the Endoscopy Centre at The Wellington Hospital has led the way in providing outstanding diagnostic and therapeutic endoscopy care in Londonâ&#x20AC;&#x2122;s independent sector. Now, after six months of redevelopment and expansion, we unveil the new unit, which reopened this June.
T Decontamination: providing the highest standards of cleanliness
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wo years ago, planning began to expand the Endoscopy Centre and bring this busy department up-to-date, so it could continue to provide the world-class service it is revered for. Expert advice was sought in the planning of the new facility, including advice from JAG (Joint Association of Gastroenterologists), leading consultants, medical architects and experienced endoscopy nurses.
endoscopy
Waiting area
Recovery Bays: bright and spacious surroundings to create a sense of calm
Procedure Room: including the latest state-of-the-art equipment
Equipped with Technology This space now occupies two dedicated floors with three spacious state-of-the-art procedure rooms, 12 recovery bays, room for the latest endoscopic equipment and dedicated X-ray screening. This allows for intricate and highly specialised procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic stenting, to be performed with intense imaging and precision. In recent years, new equipment such as Scope Guide, Narrow Band Imaging, and high-definition scopes have meant consultants can perform procedures faster and more accurately than ever before. At The Wellington, the latest in advanced video endoscopes and ancillary equipment are used to provide accurate viewing of many internal organs in the following procedures:
First Class Facilities The Wellington Hospital prides itself on providing first class patient care and comfort, in keeping with this, 12 specifically designed recovery cubicles have been built in place of a traditional open-style recovery ward. Individual cubicles provide increased privacy, cleanliness and comfort for each patient. They also allow for a patient’s relatives to be with them leading up to their procedure and post procedure. The majority of cubicles are fitted with a private ensuite, making The Wellington Endoscopy Centre the only such private unit with this service. To maintain high levels of cleanliness, the new automatic endoscopic washer disinfectors have to pass through the decontamination facility - keeping the clean and used scopes in separate rooms. The department also has new drying and storage cabinets for the clean processed scopes.
• Colonoscopy • Esophagogastroduodenoscopy (Gastroscopy) • Enteroscopy • Flexible Sigmoidoscopy • Bronchoscopy • Endoscopic Ultrasound • Capsule Endoscopy • Endoscopic retrograde cholangiopancreatography (ERCP) • Endoscopic Bronchial Ultrasound (EBUS)
Dedicated Team Supported by a dedicated team of highly trained endoscopy nurses and technicians, with over 20 leading consultants including: gastroenterologists, colorectal surgeons, upper GI surgeons and respiratory physicians, The Wellington Endoscopy Centre provides exceptional care, alongside exceptional facilities.
www.thewellingtonhospital.com 9
Urology
Foror
Against? Should patients undergo surgery for prostate cancer? Mr Marc Laniado, Consultant Urologist, answers common questions raised by patients and medical professionals, and looks at how new surgical technology plays a key role in enhancing its benefits.
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veryone wants surgery to be painless, with a short hospital stay and a rapid return to work. The development of laparoscopy meant this could be true for many operations, but the complexity of some surgery limited the generalisability to laparoscopy. Robotic assisted surgery is keyhole surgery enhanced by computerisation. The computer creates magnified, three-dimensional images with instrumentation much more finely controlled than is possible via pure laparoscopy. The enhancement becomes more obvious the further inside the body you need to operate e.g. the prostate, rectum or heart. This means that open-surgery techniques that were very difficult to perform by laparoscopic surgery, can now be performed by robotic assisted laparoscopic surgery much more easily. In the UK, the biggest use of robotic surgery is for prostate cancer treatment. Q: Why consider prostate cancer treatment, when the Independent, Telegraph and British Medical Journal recently said, there was little or no benefit to treatment of localised prostate cancer? A: The guidance by the US Preventive Services Task Force has been controversial, and the PIVOT study described in the newspapers was on men aged around 67 years with an average follow-up of 10 years. Men aged 50 or so can expect to live, on average, 26 years, so the follow up in treatment studies needs to be much longer to be relevant to them. Besides, the death rate from prostate cancer
goes up after a 15-year follow-up, and before that, men would have suffered with metastatic disease. Q: What is the benefit of removing the prostate, whether by open or robotic-assisted laparoscopic means? A: What is removed can’t come back. Patients do not need to worry whether the cancer will be sensitive to radiotherapy, or ablative techniques. Biopsies taken from the prostate after non-surgical treatments can show cancer persists despite treatment. If the residual cancer is significant, then salvage surgery is more difficult to perform. If there is cancer outside of the tissue treated, then additional therapy would be required, regardless of the original treatment. Furthermore, super-sensitive PSA tests, i.e. measuring down to 0.001 ng/mL or even lower, after surgery, can predict with greater accuracy whether more treatment will be needed. After radiotherapy or ablative treatments, PSA levels can be much more difficult to interpret and are never as low as after surgery. After surgery you also have the whole prostate for pathological analysis, unlike other treatments where you have to rely on biopsies and MRI. Q: Even though surgery is effective, isn’t part of the problem that the nerves and blood vessels needed for erections get damaged? A: With open surgery, the surgeon’s view is poor, access is difficult and incisions large. Pure laparoscopy is possible but is much less precise than open or robotic surgery. With robotics, you have
Microscope view of mens healthy Prostate Cancer cells in tissue culture showing walls, nucleus and organelles.
10-fold magnification, 3D vision, and scaled motion control - allowing super precise procedures with short hospital stays, less blood loss and the potential for fewer intra or postoperative complications. Utilising specific surgical steps, it’s possible to preserve the nerves and blood vessels giving men erections. In men aged 50 with reliable erections, undergoing nerve-sparing prostatectomy, the recovery rate for erections is high. However, the erections can take a year or two to return, but this is improved with Levitra, Viagra and Cialis. The same is not true for men in their 70’s with poor pre-existing erections. Occasionally, the cancer may extend up to or into the nerves, in which case all treatments including surgery would have to include the nerves. Q: I’ve heard that many men are wet after surgery. If you were 50, that could be potentially distressing. A: Recovery of continence is quick in men in their 50’s who undergo nerve-sparing prostatectomy. The length of time varies, and is quicker than it used to be some time ago. In the last 10 to 20 years, we have developed a greater understanding of what contributes to continence. The dexterity and precision of the robotic instruments means that it’s possible to deploy specific techniques to preserve continence in ways that were not appreciated years ago. After a few months and certainly by one year, the vast majority of men are dry. However, if there is post-micturition dribble before surgery, it can persist after surgery.
If you have any other questions you’d like to ask Marc Laniado on this subject, please email your queries to: claire.allen@hcahealthcare.co.uk Enquiry Helpline: 020
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Gynaecology
Expensive Toy orEssential Tool?
Consultant
FOCUS
Mr Angus McIndoe explores the growing use of robotic techniques, versus laparoscopic and open surgery procedures, particularly in gynaecological surgery.
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inimally Invasive Surgery is very well established in current medical practice, and many studies have shown the advantages for patients, which are well described. However, laparoscopic surgery is not easy. The instruments used for laparoscopic surgery are very long, rigid and lack flexibility. Small movements are amplified and even the smallest tremor can cause a problem. As the instruments move about a fixed entry point, the movement of the handle in one direction results in movement in the other direction. The movements of the instruments are counterintuitive, so it is not surprising that there is a long learning curve for surgeons. In obese patients, these effects are worse, because the anterior abdominal wall acts against any movement of the instruments. The laparoscopic approach also restricts you to two-dimensional vision, and the limited perception of depth increases the rate of errors. Even for experienced surgeons, this is an effect that can’t be overcome with practice; and laparoscopy is something that requires great patience and persistence. What does the robot add? Almost every problem I have just described for laparoscopic surgery is corrected using the robot. The robot has the precision to pick up a grain of rice; making tasks the same regardless of how obese the patient is or where the ports are placed. Flexibility and Comfort The instruments of the robot move exactly like our wrists, and the movement of the instruments follow exactly the same movements of the hands. Relatively large movements by the hands are transformed into delicate movements by the instruments. It really feels like your hands are inside the patient, rather than the instruments. This precision seems to translate into much better outcomes for patients, too. And no matter how you dress it up, two eyes are definitely better than one. Performance with binocular vision is improved by approximately 50%, regardless of whether one is an experienced laparoscopic surgeon or a complete novice. The operating position is improved too. The console adjusts so that the armrests, screens and foot pedals are all in the best possible position for the individual surgeon. If the arms
become uncomfortable, you can press on the clutch and move them back to a better position. In Practice A study by Goldberg and Falcone (Hum Reprod. 2003 Jan;18(1):145-7) showed that the use of the robot in tubal surgery can dramatically improve accuracy, compared to laparoscopy, and that there are many other gynaecological procedures which benefit from the robot, too: • Fibroids A review of surgery for fibroids by Weinberg et al. (Obstet Gynecol Int. 2011;2011:852061. Epub 2011 Nov 28), concluded that the use of the robot was associated with larger and more numerous fibroids being removed. Also, patients who had previous surgery with adhesions were tackled where they may have been denied MIS without the robot. • Radical Hysterectomy Boggess et al. (Am J . Obstet Gynecol, 199:357.e1-7, 2008) compared radical hysterectomy for cervical carcinoma treated with robotic surgery or open surgery. Their lymph node harvest was better in the robotic group, length of stay much shorter and operative time less. • Oncological Survival Cantrell (Gynaecologic Oncology, 117: 260-5, 2010)looked at oncological survival with a three year follow-up after robotic radical hysterectomy was compared with open surgery and showed that survival is equivalent or better in the robotic group. Not for all procedures Despite its brilliance, we do need to remember that sometimes there is a better alternative to robotic surgery. Where vaginal procedures are concerned, that is probably preferable. Vaginal hysterectomy, for example, is an excellent procedure and still stands the test of time. The laparoscopic approach would be the preferred method in the case of a 4 cm ovarian cyst being shelled out, very simply, with “straight stick” laparoscopy. This is such a simple procedure that the use of the robot would add little benefit. Whilst a laparotomy incision is preferred when dealing with a potentially malignant complex ovarian mass, as using a minimally invasive approach could risk spreading the disease.
Mr Angus McIndoe, PhD, FRCS Angus McIndoe is one of the foremost UK consultants working in the field of Gynaecological Oncology. His considerable surgical experience has earned him a strong reputation for complex pelvic surgery. He is one of the first RCOG accredited gynaecological oncologists in the UK. Angus is also a fully accredited colposcopist by the BSCCP/RCOG combined programme. This is an area in which he has also achieved excellent audited treatment results. With over 20 years of experience in the NHS and Private sectors to call on, he also undertakes the training of new colposcopists for both the UK and Europe. Robotic surgery offers patients tremendous advantages in the correct setting, with results superior to open and laparoscopic surgery. In gynaecology, a wide variety of procedures are suitable for this approach, from delicate tubal surgery and careful oncological dissection, to myomectomy, prolapse repair, hysterectomy, endometriosis surgery, and sacrocolpopexy. The most important thing is not the new technology, but rather getting it right for the patient. This depends above all on first class diagnostics and good team communication. The team needs wisdom and experience and appropriate surgical skills. The aim must always be to get the right operation, first time, by making the correct choice regarding the procedure, and using the optimal technique or equipment, and having the right team. Mr McIndoe has now started a new clinic at the Wellington Diagnostics and Outpatients Centre on Monday mornings, in addition to his clinic at the Platinum Medical Centre.
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Vital organ
Vital service With liver disease being the fifth largest cause of death in the UK, it is imperative for the largest private hospital in the UK to have an expert team and state-of-the-art equipment in place to provide the best possible treatment.
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he average age of death from liver disease is 59 years, compared to 82-84 years for heart and lung disease or stroke. The UK is one of the few developed nations with an upward trend in mortality from liver problems. The Wellington Hospital takes a team approach in the management and diagnosis of liver and pancreatic disease, and has one of the most distinguished multidisciplinary Liver/HPB teams in Europe. Supported by one of the largest and most advanced imaging departments in the UK; award-winning intensive care units and the latest equipment, we can provide the best available treatments for all conditions affecting the liver, pancreas and biliary tree. This dynamic unit can also be referred to as an ‘HPB’ service, providing treatment for hepato, pancreato and biliary conditions.
The Team This extensive team of specialists includes: Hepatologists • Professor Andrew Burroughs MBChB Hons FRCP Consultant Physician and Hepatologist, Royal Free Hospital. He is the senior physician of the liver transplant programme and the acute liver failure service. He has an international reputation as a clinical
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and academic Hepatologist and has published widely in all areas of liver disease. He is a full time clinician and has been awarded a personal chair, as Professor of Hepatology in the University of London. • Dr David Patch MBBS FRCP Consultant Physician and Honorary Senior Lecturer, Royal Free Hospital. He shares the liver transplant service at the Royal Free Hospital with Professor Burroughs. He is involved with clinical trials and research in portal hypertension and is a leading expert in the technique of transjugular liver biopsies and TIPSS procedures. He also maintains a broad endoscopic practice. • Dr James O’Beirne MBBS (Hons) MRCP EDICM Consultant Hepatologist, The Royal Free Hospital. He shares the care of the liver transplant patients with other consultants at The Royal Free, in addition to providing a broad endoscopic service including ERCP. He has an interest in intensive care of liver patients and research interests in acute liver failure, variceal bleeding and transplantation outcomes. HPB surgeons • Mr Keith Rolles MA MS FRCS Consultant Surgeon and Senior Clinician, Liver Transplant Unit, Royal Free Hospital. The programme currently performs up to 65 transplants per year. He
Treatments
• Fibroscan • Gall Bladder Stones • Biliary Reconstructive Surgery • TIPSS • Surgery For Pancreatic Cancers • Surgery For Cholangiocarcinomas • Surgery For Liver Cancer • Portal Vein Embolisation • Chemotherapy • Photo Dynamic Therapy • Biliary Stent Insertion • Radiofrequency Ablation • Trans-Arterial Embolisation For Liver Cancer • Liver Transplantation • Biopsies • Endoscopic Procedures • Imaging • Viral Hepatitis • SIRT Therapy For Liver Cancer
has 20 years experience as a Consultant Surgeon in Liver Transplantation as well as complex Hepatobiliary surgery and Endocrine surgery. • Professor Brian Davidson MD FRCS Professor of Surgery, Royal Free Hospital and UCL. He has a particular interest and expertise in liver, biliary tract and pancreatic cancer surgery. Extensive experience in laparoscopic and robotic HPB surgery. Twenty years of experience as a liver transplant surgeon. Expert in the surgical management of gallstones and complex biliary tract and pancreatic disease. • Mr Giuseppe Fusai MS FRCS Consultant Surgeon, Royal Free Hospital, specialising in Hepatopancreatobiliary Surgery and Liver Transplant. He is extensively trained in General and Laparoscopic Surgery including the treatment of
Liver
benign conditions, such as gallstones and pancreatitis. His primary clinical and academic interest is in liver metastases and pancreatic cancer and in the modalities to treat patients with advanced disease, including vascular reconstruction. Radiologists Getting an accurate diagnosis is essential to determine treatment and to facilitate this we utilise the services of specialised radiologists. • Dr Neil Davies MBBS FRCS FRCR Consultant Interventional Radiologist, Royal Free Hospital. His primary interests include hepatobiliary intervention including hepatic artery embolisation, tumour ablation and TIPSS procedures. • Dr James Bell MBBS MRCP BSc FRCR Consultant Radiologist, Royal Free Hospital. He has a special interest in abdominal imaging, and in particular, he has wide experience in cross sectional imaging of the liver, biliary tract and pancreas, and virtual colonoscopy.
Oncologists • Dr Daniel Hochhauser MA MB BS DPHIL FRCP Dr Daniel Hochhauser is Kathleen Ferrier Reader at University College London and a consultant in medical oncology at UCLH. His major interests are in gastrointestinal oncology. Dr Hochhauser has a research programme focusing on novel chemotherapeutic agents and has carried out several early phase clinical trials of new drugs. • Mr John Bridgewater PhD FRCP John Bridgewater is a senior lecturer in medical oncology at the Royal Free and University College Hospitals Medical School. His primary clinical interests are gastrointestinal malignancy and biliary tract malignancies, but also include carcinoma of unknown primary. His research interests cover clinical trials involving studies of new agents. His laboratory work includes the molecular investigation of carcinoma of unknown primary and pancreatic cancer.
Conditions
• Alcohol Damage • Viral Hepatitis A,B,C & D • Auto Immune Conditions • Genetic Conditions • Acute Liver Disease • Pancreatic Cancer • Biliary Cancer • Liver Cancer • Liver Abscesses and Cysts • Budd Chiari Syndrome (BCS) • Gall Stones
Liver Unit
The Liver Unit at The Wellington Hospital unites expert multidisciplinary teams and state-of-the-art equipment, offering your patients the very best in healthcare. This established and respected group of specialists cover all aspects of liver disease, from mild to complex conditions, in some of the finest facilities in the UK. For more information or to organise a referral, please call the Enquiry Helpline on
020 7483 5148
www.thewellingtonhospital.com 13
BREAST
The
Evolution of Breast Reconstruction Mr Navid Jallali, Consultant Plastic, Reconstructive and Cosmetic Surgeon, discusses autologous reconstruction and why they could be the future for breast reconstruction.
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he incidence of breast cancer is increasing and there is also a trend towards detecting this condition at a younger age. The physical and psychological impact of a mastectomy has been a prevailing force in increasing awareness and accessibility to reconstructive surgery. Plastic surgery literature is replete with techniques for breast reconstruction, which can make decision making complex and challenging. Implant based reconstructions appear to have several advantages over other types of reconstruction. They avoid a scar elsewhere on the body, they are quick to perform and recover from and have no associated donor site morbidity. However, implants have a major drawback, in that, they do not provide a permanent solution. Although significant advances have been made in the manufacture and design of breast implants, as with all prosthetic materials, they eventually fatigue and fail. This time until ‘failure’ is considerably shortened in patients who receive adjuvant radiotherapy, meaning that this cohort of patients can expect several implant exchanges in their
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lifetime. This has substantial financial implications for patients and healthcare providers. Thus, there has been a move towards finding an alternative solution to implants by using a patient’s own tissue i.e. autologous reconstructions. The idea of autologous tissue to reconstruct the breast is not new. The first reported case was carried out in 1895 by Czerny, who transferred a lipoma
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Abdominal based flaps are an ideal match in terms of volume and feel for most patients
to the breast. Until the advent of microsurgery, the transfer of tissue from one part of the body to another relied on a pedicle (containing the artery and vein). These pedicled flaps are still in use today but have been largely superseded by free flaps, which grant freedom from the restrictions of the reach of the pedicle. Advances in microscope and suture
technology heralded the era of microsurgery, where tissues could be detached from one part of the body (with the supplying artery and vein) and transferred to a distant site where blood flow is re-established. Better understanding of the blood supply to the integument allowed plastic surgeons to delineate numerous free flaps, and the abdomen emerged as the principal donor site for breast reconstruction. Abdominal based flaps are an ideal match in terms of volume and feel in most patients seeking a reconstruction. However, the harvest of the rectus abdominis muscle (i.e. the TRAM flap) leads to weakness of the anterior abdominal wall, increasing the risk of hernia formation. Furthermore, inexperience in microsurgery led to inconsistent results and a high failure rate and so TRAM flaps were not widely adopted or available. The TRAM flap was further refined to the deep inferior epigastric perforator (DIEP) flap. Although a more technically challenging procedure, the skin and fat of the anterior abdomen is harvested without the underlying rectus abdominis muscle, thus reducing donor site complications. Coupled with the fact that flap failure rates have now reduced significantly, this makes the DIEP flap an ideal option for breast reconstruction in units with microsurgical expertise. The major advantage of the DIEP flap is that it provides a permanent solution for patients, as it will never degrade. Furthermore, it is a superior match in terms of feel and ptosis compared to implants. There is also a financial argument for autologous reconstruction, because despite longer operating times and in-patient lengths of stay, they are as costeffective as implants as they require fewer revisions. Plastic and reconstructive surgeons have a variety of techniques to reconstruct the breast, enabling them to tailor the surgery to the needs of the patient. Refinement of flaps, greater experience, and training in microsurgery has made autologous tissue the primary option in patients seeking breast reconstruction following ablative surgery. Advances in tissue-engineering techniques may provide an alternative method for reconstruction of the breast in the near future.
Practice Managers
In Pursuit of FOCUS www.actionforhappiness.org a movement for positive social change suggests the following for a happier working environment, though some may be obvious, these can all have a big impact on your practice. 5 actions for managers: • Trust people - give them freedom within guidelines • Help people see why what they do matters • Give regular encouragement, praise and thanks • Help people find and play to their strengths • Encourage a healthy balance between work and life
In the UK we are working harder and longer than we have for decades. With economic instability has come a greater emphasis on happiness. And now the issue of happiness and well being, especially during one of the UK’s longest recessions, has become of particular interest to politicians.
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arlier this year, the Office for National Statistics published findings from their Measuring National Well-being Programme. It reviewed the quality of life of people in the UK, including job satisfaction and its affect on wellbeing. The study showed that those who were in employment, on average, felt happier than those who weren’t. Employment provides a sense of purpose and structure, which positively impacts on wellbeing. However, compared to the USA, the UK scored lower across six key areas of wellbeing. The largest difference being in workers’ perceptions of their workplaces: only 35% of UK workers reported having a good work environment. One area of significance that the study picked up on was work-life balance. It showed relatively low satisfaction with work-life balance for employees
in the UK. When we spend such a proportion of our time at work, many people find work can creep into family and social time. This has become more of a battle now smartphones make many people accessible out of office hours. Sickness in the workplace is a big issue for managers, and latest figures show that stress-related sickness is now the foremost reason for long-term illness. People who are happy at work tend to have better health, but happiness can be an ambiguous term, meaning different things to different people. However, there are factors, which most employees agree improve their happiness at work: job security, the opportunity to train and develop, feeling engaged at work, having understanding and respect from your colleagues, being listened to, feeling motivated, but most importantly – receiving a little praise every now and then.
5 general actions for a happier workplace: • Stop to say hello to colleagues and get to know them better • Find ways to make working together more fun and sociable • Make a habit of noting good things that happen each day • Change something that’s making you or colleagues unhappy • Go out of your way to support others and help them feel good The question is: is your practice happy? Do your employees have a sense of wellbeing, satisfaction and fulfilment? What can you bring to your practice that can encourage a happier environment? Job hunting has a tendency to peak in January and then again in September, when people return from their summer holidays. So now is prime time to introduce positive changes in your practice. After all, a happier work place makes a more productive one. Head to the ONS website if you would like to read the full findings of the report (www.ons.gov. uk) or visit www.actionforhappiness.org for more ways of improving workplace happiness.
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GP news Round Up
In the busy world of General Practice, we look at trending stories and interesting updates from the primary care sector.
Can technology transform the NHS? The Guardian Health Network reported on Andrew Lansley’s plans for telehealth, and his belief that it has the potential to redesign the service. Over the past three years, tests of telehealth throughout the country have shown to include, “a 20% cut in emergency admissions, a 14% reduction in elective admissions, and savings that, if replicated nationwide, could reach £1.2bn over five years.” But Andrew Lansley placed emphasis on local NHS organisations rather than central government to move this forward. Read Dr Frank Casey’s article Telehealth: the benefits of video conferencing, at www.guardian.co.uk, for an interesting insight from a consultant paediatrician cardiologist. Or watch The Big Interview with Adam Steventon, Nuffield Trust at www.pulsetoday.co.uk
Social media ‘highway code’ The RCGP and doctors.net.uk reported that there are plans to publish a social media ‘highway code’ for doctors and healthcare professionals. This guide comes at a time where more and more people, especially the health industry, are latching onto the potential of social media. The guide will give medical professionals practical tips and advice on online rules, norms and conventions and how to avoid the ‘potential pitfalls’. The guide will help medical professionals make the most of their online communications and relationships, whilst keeping themselves and their patients safe in terms of privacy, confidentiality and maintaining personal and professional boundaries.
Revalidation: GPs may face fitness-to-practise hearings. GPonline.com highlighted the GMC’s guidance that any ROs who believe GPs haven’t ‘fully engaged’ in revalidation must be referred straight to GMC fitness-to-practise procedures and could potentially be stripped of their licence. The three possible outcomes following a GP’s assessment for revalidation are: • A positive recommendation: the doctor is up-to-date and fit to practise • A request to defer the date of recommendation • A notification of a GP’s non-engagement in revalidation
If a GP has participated in annual appraisals, collected information for revalidation (including multi-source feedback) the RO can make a positive recommendation. The GMC will then make the final decision. However, if a GP is deemed not to have engaged in appraisals and participated in revalidation activities, and all local processes have been tried to rectify the situation – then an RO can give notification to the GMC.
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Comment and Debate Should women over 70 be offered breast screening if they are fit and healthy, and have reasonable life expectancy? Professor Julietta Patnick gives an exclusive interview to Pulse. Head to the ‘News’ section at www. pulsetoday.co.uk. What do you think?
GP NEWS
Designed
For You
Our ‘Consultant Led Practice Talks’ bring the best of The Wellington’s educational programme straight to your practice, and at your convenience.
In The
spotlight Ricardo Pereira | GP Liaison Officer | North West London Area
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here are currently over 70 Wellington consultants, across a range of specialties, who are part of this programme. These specialists are available to give talks at breakfast meetings, lunch breaks or evening discussions on topics of your choice.
Liver Nephrology Neurology
Allergy
Ophthalmology
Cardiology
Orthopaedics
Colorectal and General Surgery
Plastics
Dermatology
Respiratory
ENT
Rheumatology
Gastroenterology
Sports Medicine
General Medicine
Urology
Gynaecology
Vascular
A full list of topics is available to view via the health professionals section at www.thewellingtonhospital.com. If you are interested in arranging a practice talk, please contact the GP Liaison team via the Enquiry Helpline on 020 7483 5148, or via the individual GP Liaison Officer’s numbers listed on the back cover.
My name is Ricardo Pereira; I recently joined the GP Liaison team at The Wellington Hospital in June. I will predominantly look after all practices in north west London and the surrounding areas. As a GP Liaison Officer I am here to support all GPs and practice managers within my geographical area. I will be able to assist surgeries with educational events, which we provide free of charge, such as CPR, spirometry and many more. Most of these events can be provided at your surgery and I’ll even bring lunch along. I will also be looking after all the monthly seminars at the Wellington Diagnostics & Outpatients Centre based at Golders Green, which are conducted by our leading specialists based at the centre. These busy evenings offer a great opportunity for GPs to meet and ask questions regarding a vast range of topics. I am also happy to be contacted about any queries you may have regarding the centre or the main hospital. Alternatively, I can also bring along our specialist consultants for practice-based talks, providing suitable refreshments and certification for the purpose of CPD. Whether I have previously visited your practice or not, or if you are a GP or a practice manager in the north west area of London and would like further information regarding The Wellington Hospital or the Wellington Diagnostics & Outpatients Centre, or the services the GP Liaison team can offer, please do not hesitate in contacting me. It is a very exciting time for the hospital and the centre, as new projects start and new areas open, so do get in touch. I look forward to working with you in the very near future. Ricardo
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NEWS from the
The Wellington Hospital is an advocate for education and professional development; our seminars and events cover a range of topics from a variety of distinguished and experienced specialists. All seminars are free of charge and a certificate of attendance is provided for CPD points.
Event Listings Places go quickly, so please book ahead. Make sure you are on our mailing list, so you will receive our reminders and up-to-date information on events and seminars. 13/09/2012 Physio Seminar: Dancers’ Injuries of the Foot and Ankle, Mr Lloyd Williams; the Wellington Diagnostics and Outpatients Centre; Golders Green
September 06/09/2012 GP Seminar: Lung Cancer Awareness & Cases in North London; The Wellington Hospital, South Building, 5th Floor Boardroom 12/09/2012 Advanced Cardiac Rhythm Management: Interactive Clinical Case Based Learning, Dr Anthony Nathan, Dr Anthony Chow and Dr Prapa Kanagaratnam; Lords Cricket Ground
18/09/2012 GP Seminar: An Update on Prostate Cancer, Amir Kaisary, the Wellington Diagnostics and Outpatients Centre; Golders Green 27/09/2012 Ears and Children: Update on ENT; Lord’s Cricket Ground 29/09/2012 Orthopaedic Masterclass Series: Tutorials in Orthopaedic Surgery; The Knee Unit; Lord’s Cricket
Ground
October
November
04/10/2012 GP Seminar: Cardiology and Diabetes, Dr Robert Greenbaum and Dr Mark Vanderpump; The Wellington Hospital, South Building, 5th Floor Boardroom
01/11/2012 GP Seminar: Neurosurgery and Pain Medicine; Mr Andrew McEvoy and Dr Nigel Kellow; The Wellington Hospital, South Building, 5th Floor Boardroom
20/10/2012 Orthopaedic Masterclass Series: Hand & Wrist Injuries; Lord’s Cricket Ground
06/11/2012 GP Seminar: Cardiology; Dr David Lipkin & Dr Joseph Davar; the Wellington Diagnostics and Outpatients Centre; Golders Green
25/10/2012 GP Seminar: Endocrinology; Dr Pierre Bouloux; the Wellington Diagnostics and Outpatients Centre; Golders Green
15/11/2012 Neurosciences Update by Capital Neurosurgeons; Lord’s Cricket Ground
For more information on the above Events, Seminars & Talks please visit www.thewellingtonhospital.com/Healthcare-Professionals.aspx
NEW CONSULTANTS Cardiology
ENT Surgery
Dr Philip Moore, Consultant Cardiologist, West Herts & Imperial
Mr Saiful Alan Hannan, Consultant Otorhinolaryngologist, Royal Free Hospital
Dermatology
General Surgery
Dr Katie Lacy, Consultant Dermatologist, Guy’s & St Thomas’s
Mr Jason Saunders, Consultant Breast and General Surgeon, Newham University Hospital
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Mr Janindra Warusavitarne, Consultant Colorectal Surgeon, St Mark’s Hospital
Gynaecology Mr Andrew Hextall, Consultant Obstetrician & Gynaecologist, West Hertfordshire Hospital NHS Trust
GP NEWS
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Q &A
A good leader is someone who inspires and motivates you, it is management to an extent, but it’s also management done but not noticed – you can get the best out of staff by nurturing and truly valuing them, by inspiring them you make them expand and flourish. How do you do this? Help your staff come up with the answers independently. Elaine Carson is the Head of Outpatient Services at The Wellington Hospital She is a woman of many talents with extraordinary motivation and energy.
PM: You have worked for The Wellington Hospital for nearly 19 years now; where did it all begin? EC: I qualified and trained in general and psychiatric nursing in Scotland, nearly 30 years ago. I then went to Australia for three years, where I studied nursing – concentrating in orthopaedics and ENT. I moved back to Glasgow where I completed an orthopaedic course, followed by a management course, then moved to London and started to work for The Wellington Hospital, in the Orthopaedic Unit. Other opportunities soon came up and I became an Outpatient Manager (but still nursing). I only really picked up this ‘general manager’ role in the last two years – which includes managing many different specialties. PM: Tell us about your role? EC: My role covers the outpatients, endoscopy, and imaging departments. I make sure everyone is happy, that our staff are well trained, the equipment is working, that bookings are correct and that every patient’s journey is as smooth as possible. It’s a vast but very enjoyable role. What’s really interesting is that having been a nurse, I viewed imaging in a certain way, but now that I manage this department, I have a completely different perception of it.
PM: What outpatient facilities does The Wellington Hospital offer? EC: Our imaging department is one of the biggest in the UK: so we can offer MRI, CT, X-rays, dexa-scanning, fluoroscopy, and interventional radiology. We offer nuclear medicine and have a PET/CT at the Platinum Medical Centre, in addition to the Cardiac Imaging and Research Centre at The Wellington South. At the Platinum Medical Centre we cover all different specialties across 50 consulting rooms, and our new GI Unit offers endoscopy, colonoscopy and bronchoscopy, etc - in stunning state-of-the-art facilities. PM: You clearly enjoy your role, what makes it special for you? EC: As a manager, you are responsible for the delivery of every patient’s care, but you also have the chance to make a difference. Although I don’t get as much personal interaction with the patients as when I was nursing, my new role now allows me to really make a difference to the best of my abilities, for patients and staff. PM: How do you like to spend your time after a busy day at work? EC: When I am not managing people, I am managing my six year old boy! I love picking up my son from school, it’s a real treat for me. PM: Would you picture yourself doing anything else? EC: Well…I was going to go into art, which is completely opposite from what I do now. I used to paint and I was very close to going to Art School but, for some reason, I went into nursing. If I was a rich girl, I would just paint and draw. It destresses me completely.
Neurology
Ophthalmology
Oncology
Dr Carolyn Gabriel, Consultant Neurologist, St Mary’s Hospital
Mr Faisal Ahmed, Consultant Ophthalmologist, Western Eye Hospital, Mr Allon Barsam, Consultant Ophthalmologist, Luton & Dunstable
Dr Ekaterini Boleti, Consultant Medical Oncologist, Royal Free Hospital
Neurophysiology Dr Bryan Youl, Consultant Neurophysiologist, Royal Free Hospital
Oral & Maxillofacial Surgery Mr Kaveh Shakib, Consultant in Oral & Maxillofacial Surgery, Barnet & Chase Farm Hospital
Orthopaedic & Sports Medicine Mr Andrew Goldberg, Consultant Orthopaedic Surgeon, RNOH, Mr William Bartlett, Consultant Orthopaedic Surgeon, Whittington Hospital, Mr Maxim Horwitz, Consultant Orthopaedic Surgeon, Chelsea & Westminster
Paediatric (WDOC, Golders Green only) Dr Benjamin Jacobs, Consultant Paediatrician, RNOH
Urology Mr Darrell Allen, Consultant Urologist, Royal Free Hospital, Dr Liaqat Syed, Consultant Urologist, Scunthorpe General Hospital
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www.thewellingtonhospital.com
For more information about the GP Liaison service, or to make a referral, please contact the GP Liaison Officer for your area: Katy Cross Central London
Ricky McKinson North & East London
Ricardo Pereira North West London
Veronica Brown Hertfordshire
07826 551 318 020 7483 5621
07889 317 769 020 7483 5620
07889 318 336 020 7483 5862
07889 317 774 020 7483 5863
katy.cross@hcahealthcare.co.uk
ricky.mckinson@hcahealthcare.co.uk
ricardo.pereira@hcahealthcare.co.uk
veronica.brown@hcahealthcare.co.uk