Spring 2014 • Issue 16
Advanced heart care Pioneering cardiovascular imaging
Common perianal conditions
From GP investigation to specialist treatment 1 • PRACTICE MATTER SPRING 2014
Robotically assisted surgery a breakthrough in bariatric treatment
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
Welcome It is hard to believe that we are almost half way through 2014, with summer approaching and many changes already having taken place at The Wellington this year. I took over the role of CEO at The Wellington Hospital from Mr Keith Hague on April 1. I was previously the CEO of The Harley Street Clinic, where I worked for the last fifteen years first as Oncology Pharmacy Manager before becoming Chief Operating Officer. Prior to this, I worked within the NHS as an Oncology Pharmacist at The Brook Hospital and across SE Thames. I am looking forward to continuing Mr Hague and The Wellington team’s excellent work and maintaining the first class reputation of this wonderful hospital. You will be reading about further changes and improvements to the services we offer in future issues of Practice Matters, both in print and online. In this issue, Mr Krishna Moorthy discusses developments in bariatric surgery and just how robotic weight loss surgery has improved patient outcomes. Respiratory is a common theme in this edition as Mr Kalpesh Patel looks at treatment options for common sinus and nasal disease, followed by an article from Robin McNelis on breathing training and how this can change a patient’s life. I look forward to the remainder of 2014 and the great projects we have planned, including new units and services that will firmly keep The Wellington Hospital as the Capital’s foremost private hospital. Best wishes,
Neil Buckley CEO
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Editor: Hannah Rogers Production & Distribution: Runwild Media Group
PRACTICE MATTERS
Contents 04 | A new horizon for sports injuries and complex wound care Mr Haroon Mann
05 | Breathing retraining
06
Robin McNelis
04
06 | Robotically assisted weight loss surgery Mr Krishna Moorthy
08 | Modern management of sinus and nasal disease Mr Kalpesh Patel
15
11
09 | Supporting the international community with a dedicated service 10 | Pioneering cardiovascular imaging at The Wellington Hospital Dr Anand Jeevarethinam, Dr Shreenidhi Venuraju and Professor Avijit Lahiri
11 | Work Related Upper Limb Disorder (WRULD) – How good is your posture? Blair Muir
12 | Common perianal conditions arising in primary care Mr Romi Navaratnam
14 | Shoulder instability Mr Giuseppe Sforza
15 | A new dawn in the treatment of hepatitis C virus
08
Dr James O’Beirne
17 | GP news 18 | Latest news and consultants
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 3
orthopaedics
A new horizon
for sports injuries and complex wound care By Mr Haroon Adam Mann
Consultant Orthopaedic Foot & Ankle Surgeon, Mr Haroon Adam Mann presents the research and treatment available using stem cells The application of stem cells, cell-based therapies and other related biological products to sports injuries have recently had increased attention. There has been a huge focus not only on the basic science and clinical research, but also in the lay press, with reports of high-profile athletes undergoing procedures involving stem cells in Asia, Europe, and Latin America. The unique properties that stem cells pose make them particularly attractive for multiple applications in medicine. Regenerative medicine is the ability to utilise the body’s own cells, to aid the healing and repair process. It combines biomaterials, growth factors and stem cells to repair failing organs. These technologies are being used in a wide range of applications in reconstructive surgery, with numerous trials being undertaken around the world. With the global incidence of obesity increasing, subcutaneous adipose tissue is abundant and readily accessible. Although this material is routinely discarded, the therapeutic potential of using regenerative cells from this lipoaspirate is now being recognised as a potential game changer. Adipose tissue could be one of the most suitable and abundant cell sources for
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Regenerative medicine is the ability to utilise the body’s own cells, to aid the healing and repair process. regenerative therapy. Preliminary studies are promising, with particular attention being paid to prospective, randomised, double blind trials. Looking to the future Adipose-derived stem cells are multi-potent and hold promise for a range of therapeutic applications. Just as individuals around the world altruistically participate in blood donation to donate their circulatory cells for the medical treatment of others, future citizens may undergo liposuction to remove excess adipose tissue in ‘fat donation’. The cells are delivered into an injured or diseased tissue, leading to a change in the local environment that is conducive to healing. This is done by secreting various growth factors and cytokines that promote recovery and regeneration of surviving or new cells. The environment thus recruits endogenous stem cells
to the site, promoting their differentiation along the required cell pathway. In my practice, the typical use for such material is where therapeutic potential holds promise in difficult diabetic wound healing complications for the reconstruction of glabrous tissue in both the heel and plantar region. We are also conducting preliminary trials to use this material in tendonopathies, ligament damage and sportsrelated injuries. This area of medicine is fast growing and cutting-edge
Mr Mann has been working closely with Professors at The Royal Free and University College Medical School, one of the few centres in the world developing expertise in the regeneration of tendons and ligaments using stem cells. Trials are currently in place at the Royal Free Hospital, looking at regenerative medicine, biomaterials and their application in musculoskeletal injuries.
To find out more information about Mr Haroon Mann, please visit www.practicemattersmag.co.uk/ contributors
RESPIRATORY
BREATHING RETRAINING By Robin McNelis
Respiratory Physiotherapist Robin McNelis discusses the symptoms and treatments associated with breathing problems Many patients present to GPs and consultants with a collection of symptoms that, despite exhaustive investigations, do not seem to be attributed to any cardiac, respiratory or neurological condition. Often these patients have an unresolved breathing pattern disorder, which may be triggered by a period of ill-health, a life event or have an inconclusive cause. Breathing pattern disorders fall into two main categories: Dysfunctional breathing pattern refers to a biomechanical problem where the patient is breathing inefficiently by using shoulder and neck muscles to breathe rather than the diaphragm. This uses more energy and gives a greater sensation of breathlessness. Often these patients find practical tasks using their arms particularly challenging. Hyperventilation Syndrome is when someone is physiologically over-breathing at rest or during exertion, resulting in various symptoms including:
• Blurred vision, feeling confused, dizziness, numbness/tingling in fingers, tightness in fingers or around mouth
an unresolved breathing pattern disorder may be triggered by ill-health, a life event or have an inconclusive cause
• Feeling tense or wound up, feelings of anxiety *Most of these are mentioned in the Nijmegen Questionnaire
Many of these symptoms are down to the lowering of carbon dioxide experienced in both acute and chronic hyperventilation. This can initially present like asthma symptoms. Most patients will initially undertake the Nijmegen questionnaire in order to establish cause and severity. If someone scores 23 or above, or score 3 or 4 for three or more questions, they should be referred for breathing retraining. Individualised treatment can include: • Patient education, explanation of symptoms and reassurance • Trigger factor modification • Correction of dysfunction breathing pattern at rest
• Faster breathing, shortness of breath, inability to breathe deeply, frequent yawning/sighing
• Breathing re-education to correct any element of hyperventilation
• Chest pain, chest tightness, palpitations, cold hands/feet, stomach bloating
• Progression of activity whilst maintaining good breathing technique
Common benefits reported by patients include a decrease in the sensation of breathlessness, improvements in breathing pattern and breath hold time, with a reduction in ‘head fuzz’ and increased productivity. There are also often decreased anxiety levels and usage of reliever inhalers, whilst reports of increased activity levels and feelings of control over health, result in fewer GP visits. Other respiratory physiotherapy services also offered at The Wellington Hospital include various lung clearance techniques and one-to-one pulmonary rehabilitation. We also offer the exercise prescription clinic for anyone with any relevant cardiac or respiratory complaints looking for guidance on progressing exercise.
To find out more information about the respiratory services available at The Wellington Hospital, please visit www.thewellingtonhospital.com
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 5
BARIATRIC SURGERY
Robotically assisted weight loss surgery By Mr Krishna Moorthy
Consultant Bariatric and Upper GI Surgeon, Mr Krishna Moorthy discusses the prevalence of robotic surgery in society’s ever-expanding waistline There is a growing realisation that the UK is in the midst of an obesity epidemic, which is likely to worsen over the coming years. Whilst a controlled diet coupled with exercise is often the prescribed treatment, it is well known that surgery is superior for maintenance of weight loss in patients who are morbidly obese (BMI > 35). Surgery is not just an effective weight loss tool, but also improves health by reducing the risk of developing obesity-related diseases, such as Type 2 diabetes, high blood pressure, and conditions such as heart attacks and strokes. The three procedures performed are: • gastric banding • gastric bypass • sleeve gastrectomy Each surgery procedure has a marked effect on the factors that define the metabolic syndrome, including waist circumference, blood pressure and cholesterol. In addition to this, many gastric bypass cases have shown to have a profound effect on diabetes, which is independent of surgery mediated weight loss. Enquiry Helpline: 020 6 • PRACTICE MATTER SPRING 2014
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There are a number of developments planned that will make robotic technology more appealing to patients and improve outcomes. Robotic surgery Gastric bypass surgery is increasingly being performed with the help of the da Vinci Si surgical robotic system. The machine consists of a ‘slave’ cart with one camera arm and three robotic arms (Fig 1) that control the robotic instruments, which are inserted through 7 mm robotic ports. The four robotic arms are controlled by the surgeon who sits at the robotic ‘master’ console (Fig 2). The advantages of the robot in minimally invasive surgery (keyhole surgery) are well established, offering 3D vision and improved precision due to the ability of the robotic system. Not only does the robot remove the surgeon’s natural hand tremor, but it also scales down large movements, making them more precise. In addition to this, the robotic
instruments’ ‘wrists’ mean that the surgeon’s hand movements are completely and accurately reproduced by the robotic instruments (Fig 3). Procedures such as the gastric bypass (Fig 4) are especially suited to robotic surgery as it involves a considerable amount of stitching. Improved visualisation and greater precision means that stitching can be performed more safely and also results in lowering the risk of leakage. The robot is particularly advantageous when operating on obese patients due to the considerable thickness of the abdominal wall, which can induce fatigue in the surgeon increasing the risk of errors. As the robot eases surgical manoeuvres it may be possible to perform a gastric bypass on patients with a higher BMI (>60). Currently these cases are offered a laparoscopic sleeve gastrectomy.
There is a growing realisation that the UK is in the midst of an obesity epidemic, numbers which are likely to increase in the coming years.
The advantages of the robot in minimally invasive surgery (keyhole surgery) are well established, offering 3D vision and improved precision due to the ability of the robotic system.
Consultant
FOCUS Fig 1
Fig 3
Mr Krishna Moorthy MS, MD, FRCS (Ed), FRCS (Gen Surg) Fig 2
Fig 4
Gastric bypass surgery is increasingly being performed with the help of the da Vinci Si surgical robotic system. The cosmetic result after a robotic procedure is better than standard laparoscopy, as the incisions are smaller and often placed on the sides, rather than the front of the abdomen, making them less visible. The future There are a number of developments planned that will make robotic technology more appealing to patients and improve outcomes. The robotic platform is ideal for the performance of single incision or ‘scarless’ surgery as the robotic instruments will address some of the
current problems with single-incision surgery. The only apparent downside to robotic procedures is that it takes slightly longer compared to standard laparoscopy, but most of this extra time is spent in setting up and can be reduced with experience.
For more information and articles on bariatric surgery, please visit www. practicemattersmag.co.uk For more information on Mr Krishna Moorthy, please visit www.obesitysurgeonuk.com
Consultant Bariatric and Upper GI Surgeon Mr Krishna Moorthy is a Consultant Surgeon in Imperial College Healthcare NHS trust and a Senior Lecturer in surgery in Imperial College London. His clinical interests are general surgery, upper gastrointestinal surgery for cancer and bariatric surgery. His regular practice includes laparoscopic gall bladder removal, laparoscopic appendicectomy, laparoscopic groin and abdominal hernia repairs. He regularly performs laparoscopic gastric banding, laparoscopic gastric bypass and laparoscopic sleeve gastrectomy. He also performs single incision surgery (scarless), and performs robotic surgery using the da Vinci robot. He has performed UK’s first robotic gastric bypass and gastric band.
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 7
Ear, nose and throat
Modern management of
sinus and nasal disease By Mr Kalpesh Patel The presence of sinus or nasal disease can have a major impact on some of our basic human functions such as sense of smell and taste. Many conditions can give rise to nasal blockage, with the two most common causes being sinus disease and structural deformities of the nose and septum. Acute and chronic sinusitis We have four groups of sinuses: • Maxillary • Ethmoid • Frontal • Sphenoid Although the actual function is unclear, many disease processes can affect the sinuses. Chronic sinusitis, refractory to primary care medical therapy, is probably the most common reason to refer patients to a rhinologist. Patients present with myriad symptoms and signs that include nasal obstruction, mucopurulent rhinorrhoea, postnasal drip, sinofacial pain or headaches, anosmia, nasal congestion or chronic cough.
Medical management Following confirmation of the diagnosis, usually from a CT scan, many patients will be successfully managed by a robust regime of medical treatment, consisting of a short course of oral steroids together with intranasal steroids combined with a Macrolide antibiotic and an antihistamine. Such aggressive medical treatment has reduced the surgical intervention rate.
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Surgical management Symptomatic patients following failed medical therapy are managed by endoscopic sinus surgery. The obstructive sinuses are converted from being an intricate labyrinthine structure to being an ‘open-plan’ set of cavities draining into the nasal passages and allowing better access for post-operative medical treatment. Care is taken to preserve as much of the turbinate mucosa as possible so as to avoid altering laminar air flow and minimising the risk of damage in the olfactory fibres. Frequently, a septoplasty needs to be carried out at the same time for improvement of the airway and for access to the sinuses.
Balloon sinuplasty This is a relatively new technique which employs the insertion of a guide wire through the natural ostium over which a balloon can be railroaded. Once the balloon is progressed into the frontonasal duct, it can be inflated to 12 atmospheres of pressure. This results in the expansion of the frontonasal duct but without any trauma to the surrounding mucosa thereby minimising the risk of scar tissue formation and re-stenosis. New features include drug-eluting devices which sit in the osteomeatal complex region and deliver a high concentration of
steroids to the surrounding area, minimising oedema and facilitating drainage.
Image guidance surgery In patients who have multiple previous procedures the anatomy of the sinuses can become severely distorted, making trauma to neighbouring structures a real possibility. 3D image guidance techniques reduce the risk of complications by guiding the surgeon to within 2mm of important structures, thereby avoiding complications.
Septo- rhinoplasty Septo- rhinoplasty surgery is well recognised as one of the most complex of facial plastic surgical procedures as the surgeon has to deal with deformities of bone, cartilage and soft tissue. Complex deformities of the nose require an external rhinoplasty approach, utilising an incision between the nostrils, thereby allowing the skin to be elevated off the underlying cartilages. This technique allows full access to the septum and a large range of techniques can be used to straighten the septum and retain its new position. At the same time, manoeuvres can be utilised to provide support for the dorsum and the tip of the nose. Functional rhinoplasty often requires attention to aesthetics as well as creation of physical space for breathing.
To find out more information about Consultant Ear, Nose and Throat (ENT) Surgeon Mr Kalpesh Patel, please visit www.practicemattersmag.co.uk/contributors
INTERNATIONAL SERVICES
International services here at The Wellington Hospital The Wellington Hospital has been welcoming patients from all over the world since it opened over 40 years ago. With an international reputation for the highest standards of care, patients travel to the hospital to benefit from investment in the latest technology and treatments, and to be under the care of some of the most talented consultants in the UK. Overseas visitors will find our experienced International Relations Team on hand to help with every aspect of their visit; from organising their stay to meeting any cultural and religious needs while they visit The Wellington.
We are able to introduce new consultants to the Middle East market and can arrange embassy visits to the hospital. Visiting an unfamiliar place, coupled with a hospital stay, can be an unnerving time. Our team will warmly welcome each overseas patient and their family on arrival and will be there throughout their time at the hospital. The International Relations Team liaise with embassies, help to organise and arrange appointments and urgent referrals and can offer every overseas family a range of services, including:
• Interpreters – We have a group of eight Arabic-speaking interpreters working onsite and we can also provide for a range of languages including Russian, Greek and Polish. • Cultural and religious considerations – The hospital provides a number of facilities and contacts to support patients cultural and religious needs. • Catering – Available seven days a week, our restaurants serve hot and cold snacks for breakfast, lunch and dinner for relatives and visitors. • Accommodation – We can recommend and help organise a hotel or apartment for a patient’s relatives or friends, located close to the hospital. It is our aim to provide the most streamlined and first class service to our patients, ensuring that we are there to support them from referral through to admission and discharge.
The International Relations Team liaise with embassies, help to organise and arrange appointments and urgent referrals
In addition to helping with arrangements prior to a patient’s admission, we can also advise on arranging payment, whether the patient is selffunding or sponsored by an embassy or company. To ensure that we keep an excellent relationship with our international patients and referrers, we strive to keep communication a key part of our services. On a daily basis, the International Relations Team liaise directly with: health and military attaches, medical coordinators, embassy officials and international insurance companies. This year, HCA won the Queen’s Award for the third time, celebrating Enterprise in International Trade, highlighting our achievements not only in investment but also the increase of overseas business. The accolade also celebrates the continual investment in innovation, such as new equipment and technology all supported by leading consultants and specialist teams. We are also able to introduce new consultants to the Middle East market and can arrange embassy visits to the hospital. Overall, the International Relations Team act as the main liaison link between The Wellington Hospital and the Middle Eastern health offices and embassies in London.
The International Relations Team are available: Monday to Friday, 8:00 to 18:00 With an on-call service that runs: Monday to Friday, 18:00 to 23:00 Saturday and Sundays, 9:00 to 20:00
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 9
CARDIOLOGY
Pioneering cardiovascular imaging at The Wellington Hospital
By Professor Avijit Lahiri, Dr Anand Jeevarethinam and Dr Shreenidhi Venuraju.
Pioneering cardiovascular research and clinical imaging was developed by Professor Avijit Lahiri and Dr David Lipkin at the Cardiac Imaging and Research Centre (CIRC) at The Wellington Hospital. This development was supported by the British Cardiac Research Trust Charity and the HCA group. Research from CIRC has made UK and international headlines, and influenced the guidelines of the American Heart Association, European Society of Cardiology and NICE, regarding coronary artery imaging in diabetes and clinical diagnosis of coronary artery disease (CAD). One of the first Electron Beam CT scanners was installed in the UK in 2002 and more than 10,000 patients have been studied. This was followed by the installation of the UK’s first Dual Source and Dual Energy cardiac CT scanner in 2008, along with the Hybrid Nuclear Imaging and CT camera (SPECT-CT). As a result, high quality myocardial perfusion (functional) imaging and simultaneous CT coronary atherosclerosis imaging (anatomy and morphology) can be assessed to improve diagnosis and risk stratification. Led by Professor Avijit Lahiri, the CIRC research team focus on the early detection of CAD in order to halt or reverse the progress of this potentially lethal disease. Diabetic heart disease is often ‘silent’ and goes undetected until it is too late to alter prognosis. A total of 35 important peerreviewed publications in national and international journals have established the considerable contribution made by this department.
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Figure 1 CT Coronory Angiogram shows 98% proximal right coronary artery stenosis with non-calcified plaque (Above) followed by successful PTCA (Bottom)
The Whitehall study is a well known national trial carried out on UK civil servants. Using this study, we were able to improve risk stratification and understanding of silent CAD in this population using CAC imaging. In another landmark trial (RADICAL Trial – Randomised Controlled Trial to Evaluate Clinical and Cost Effectiveness of CT Coronary Angiography in patients from NHS Chest Pain Clinics), CT coronary angiogram was used to evaluate patients attending the rapid access chest pain clinic. The trial revealed that a majority of patients referred to the NHS Chest Pain Clinics can be discharged without risk based on Dual-source CT Coronary Angiography (CTCA). We have shown that CTCA can significantly reduce invasive procedures and cost.
Figure 2 Stress & rest MIBI scan showing extensive Our current research programme (PROCEED inferior Wall ischaemia (Arrow) trial) brings the focus back to Type2 diabetes.
Coronary artery calcium scans (CAC) from a EBCT scanner were combined with myocardial perfusion imaging (MPI) and novel bio-markers to detect ‘silent’ coronary atherosclerosis and prognosis in uncomplicated Type 2 diabetic patients, recruited from three NHS centres in north-west London. Progression of CAD in these subjects was related to an increase in novel bio-markers such as osteoprotegrin.
The study hopes to develop a ‘clinical model’ consisting of risk factors, novel bio-markers and multimodal cardiovascular imaging in the management of Type2 diabetes – a rapidly evolving global problem.
To read more articles on the topic of cardiology, please visit www.practicemattersmag.co.uk
HAND AND WRIST UNIT
Work Related Upper Limb Disorder –
How good is your posture? By Blair Muir Senior Hand Therapist at The Wellington, London Hand and Wrist Unit, Blair Muir discusses the risks associated with Work Related Upper Limb Disorder Many workers are guilty of often pushing their bodies to its limits in order to cope with the high demands of the workplace. With hectic schedules and tight deadlines, we immerse ourselves in our daily tasks, frequently disregarding the risk of work-related injuries. In doing this we fail to anticipate the potential impact of this pain on our ability to function normally, both in and out of the workplace. Work Related Upper Limb Disorder (WRULD) can be classified as any musculoskeletal condition of the upper limb and neck caused or exacerbated by work. In 2011/12 the prevalence of WRULDs was a reported 177,000 cases, a statistically significant decline from 223,000 in 2001/02. The estimated incidence for WRULDs was 60,000 cases in 2011/12, statistically significantly lower than the 87,000 in 2001/02*. The risk of experiencing a WRULD is greatest with high exposure to both physical and psychosocial risk factors. Physical risk factors include poor working patterns or posture, misuse of contractile tissues and physical tightness or weakness. The most significant psychosocial risk factors are a combination of high job demands, lack of control for decision-making and lack of social support; ultimately, stress. The main causes of WRULD seen by GPs in the UK are
manual handling (pulling/pushing and lifting), keyboard work and guiding or holding tools. It is crucial to treat and correct the posture of the upper limb in the workplace in any patient reporting work related upper limb pain. Most suffer from poor posture, including anteriorly rotated shoulders, protruding the neck and slouching. Sitting in this position for long amounts of time tires the musculature and can lead to pain symptoms. Computers, laptops and tablets all have their own demands on a worker’s posture and these must be considered on an individual basis.
posture is a ‘bandaid’ approach. Therapy must be holistic, empowering and informative. Implementing changes in the workplace is imperative and, often underestimated lifestyle changes play a very important role in recovering from a WRULD.
Many workers are guilty of often pushing their bodies to its limits, in order to cope with the high demands of the workplace
If you suspect your patient’s symptoms are work-related then the team at the London Hand and Wrist Unit is here to help. Please phone our team to book a thorough initial assessment which will be the first step to help you on your road to recovery.
Management of these cases requires specialist ergonomic assessment with respect to the bio-psychosocial nature of musculoskeletal symptoms. Just treating the symptoms in the hand or wrist and not considering a patient’s
To find out more information about The London Hand and Wrist Unit Therapy Team, please visit www.londonhandandwrist.com
*(www.hse.gov.uk/statistics/)
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 11
GENERAL SURGERY
Common perianal conditions
ARISING in primary care By Mr Romi Navaratnam Consultant Laparoscopic Colorectal and General Surgeon, Mr Romi Navaratnam discusses the common types of presentations of rectal bleeding and perianal irritation in primary care Haemorrhoids Haemorrhoids (Fig 1) affect 50 per cent of the working population and present with rectal bleeding and prolapse. Bleeding over the age of 35 requires flexible and sigmoidoscopy colonoscopy, over the age of 40. Conservative management involves injection sclerotherapy or banding. Conventional or stapled haemorrhoidectomy and haemorrhoidal artery ligation, have an established but low morbidity and are reserved for refractory symptoms.
Haemorrhoids affect 50 per cent of the working population and present with rectal bleeding and prolapse
applied in combination with a laxative for two months, results in a 75 per cent improvement. Refractory fissures may require botox administration under GA or, failing this, a sphincterotomy. Low pressure fissures in women may require anal advancement flaps, although there is a 50 per cent failure rate.
Fistulae (Fig 2 & 3) Cases usually present with recurrent perianal sepsis or perianal abscess formation. An MRI of the perianal region is usually indicated prior to surgery to exclude a complex fistula. Colonoscopy is considered in recurrent sepsis to exclude Crohns disease. Fistulectomy and seton insertion (Fig 3) is often part of a two stage procedure. Mucous discharge and flatus incontinence (10 - 15 per cent) may arise following surgery in both anal fissures and fistulae. Incontinence to solid and liquid faeces is rare.
Anal fissures
Pilonidal sinus
Patients will present with perianal pain, bleeding and constipation with 90 per cent arising at the posterior anal verge. GTN ointment has a 38 per cent association with headaches, following initial application. Two per cent diltiazem ointment
Management involves maintaining the pilonidal region devoid of hair. Local procedures (e.g. Karydakis flap) have been advocated in recurrent sepsis, Rotational flaps in conjunction with plastic surgeons, are associated with low recurrence rates.
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Fig 1
Fig 2 External opening of fistula
Fig 3 Seton
Patients will present with perianal pain, bleeding and constipation with 90 per cent arising at the posterior anal verge.
Pruritis ani
Consultant
This is a challenging condition with no obvious aetiology. Conservative measures include avoidance of perfumed soaps, gels and toilet roll (substituted with wet wipes) and the regular application of a barrier cream, e.g. Sudocrem or Epaderm. Colonoscopy should be considered in the presence of bleeding or diarrhoea, prior to dermatology referral.
Rectal prolapse: there is a strong presence of these cases in the elderly female population’ Rectal prolapse Common in the elderly female population. Laparoscopic surgery can be considered; however, perineal procedures (e.g. Delorme’s or perineal rectosigmoidectomy (Altemeire’s)) are undertaken under locoregional anaesthesia and are very well tolerated in elderly high-risk patients and associated with excellent outcomes.
Faecal incontinence There are two main types: passive and urge. The latter is common and associated with previous obstetric trauma, often years prior, combined with passive degeneration of the pelvic floor. Management involves endo-anal ultrasound and physiology to assess the anal sphincter integrity, having excluded systemic disease, e.g thyrotoxicosis and proximal colonic pathology. Surgery was previously indicated for isolated anterior sphincter defects. Long term results are disappointing. More recently, biofeedback therapy or neuromodulation (tibial nerve stimulation) have been associated with encouraging results.
FOCUS
Anal canal malignancies Anal canal malignancies are rare. They are primarily squamous cell malignancies, although melanoma and distal rectal adenocarcinoma have been identified. Following histological confirmation, MRI, CT and CT PET, the treatment of choice involves chemoradiotherapy. T1 lesions may be amenable to local resection. Salvage laparoscopic AP resection can be undertaken, where indicated. The management of perianal conditions remains a dilemma. A high index of suspicion needs to be maintained in patients with recurrent symptoms, irrespective of age.
The management of perianal conditions remains a dilemma To find out more information about Mr Romi Navaratnam, please visit www.practicemattersmag.co.uk/ contributors
Mr Romi Navaratnam MS, FRCS
onsultant Laparoscopic Colorectal C and General Surgeon Romi Navaratnam trained in Nottingham, Cambridge, London and Sri Lanka. He was appointed Consultant Laparoscopic Colorectal Surgeon, North Middlesex University Hospital, where he is colorectal cancer lead and Honorary Senior Lecturer at Royal Free Medical School in 2002. He is one of the founding consultants of the GI unit at The Wellington Hospital (2006), widely recognised as an international centre of excellence. Research interests incorporate improving outcomes in laparoscopic surgery and surgical education. Specialist interests include irritable bowel syndrome (IBS), anal conditions, colonoscopy and endoscopy. He undertakes laparoscopic surgery for conditions of the gall bladder, appendix, groin and abdominal herniae, Crohns, diverticular disease and colorectal cancer, with extremely positive outcomes.
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 13
orthopaedics
Shoulder instability By Consultant Orthopaedic Surgeon, Mr Giuseppe Sforza
The shoulder is the most mobile joint of the body, made up of a spherical humeral head articulated with a small, flat and broad glenoid. To allow movement, the bony constrain has to be minimal while a complex mechanism of ligament, cartilage, tendon and muscles help to stabilise the gleno-humeral joint. The different stabilising structures are: • Glenoid labrum,
lesions, so an MRI arthrogram represents the gold standard of diagnostic tools.
• Joint capsule,
Treatment
• Glenohumeral ligaments
Conservative options The approach to a first shoulder dislocation is generally conservative, with the affected arm held in a sling for around three to four weeks, followed by a specific rehabilitation program for six to eight weeks. We suggest to adopt the so-called Jobe protocol in which different groups of muscles that insert around the scapulo-humeral joint are rehabilitated.
• Rotator cuff An acute injury can lead to loss of contact between the humeral head and the glenoid, causing an acute dislocation. This could cause a detachment of the labrum and ligaments, damaging the humeral head and could potentially fracture the glenoid rim. In a low percentage of cases the cartilage and the bony fragment may heal properly with four weeks of immobilisation, but often the consequence of the first trauma is the development of a chronic unstable shoulder.
Diagnostics A patient suffering a shoulder instability will go through a clinical evaluation which includes a careful analysis of patient history, whilst undergoing specific tests that can reproduce signs of instability. An X-ray should highlight bone injuries caused by dislocations, while the MRI defines the damage to the labrum, ligaments and the joint capsule. In cases of instability, an intra-articular injection of radiological contrast can demonstrate even subtle Enquiry Helpline: 020 14 • PRACTICE MATTER SPRING 2014
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When a GP examines a patient after a first episode of shoulder dislocation, they should ensure that the relocation is stable, that there is no rotator cuff weakness or pain and no neurological deficit. These types of deficit are often transitory, but some might represent a severe damage of the nerve that will need surgical exploration and urgent referral. An assessment by the specialist after six to eight weeks of rehabilitation is important in order to test the stability of the shoulder, muscular strength, proprioception and to exclude associated damage that might jeopardise a full recovery. If conservative treatment fails, a further dislocation occurs or the patient starts to complain of persistent shoulder pain; surgery should be considered.
Surgery options Today, many shoulder surgeons favour an arthoscopic approach, particularly if there are no severe bony or soft tissue lesions. Through keyhole surgery, it is possible to reattach the labrum and ligaments in the right place using small titanium or absorbable screws without violating the normal anatomy. In cases of a severe Hill-Sachs lesion, it is possible to add a ‘remplissage’ procedure by arthroscopically filling the impact fracture of the head with the infraspinatus tendon, thus giving more stability to the joint. With severe glenoid bone deficiency or serious capsular damage, a shoulder surgeon can adopt a different surgical open or arthroscopic technique called Laterjet-Patte. The principle of the technique is to fill the glenoid bony damage through the transfer of part of the coracoid process attached to the conjoint tendon, which is then fixed with one or two screws to the anteroinferior glenoid bone. All surgery is followed by a period of immobilisation (4-6 weeks) and a specific rehabilitation programme (8-10 weeks), which allows the Sharpey fibers to grow back into the glenoid bone. In conclusion, arthroscopic (or open) treatment for shoulder instability is an effective, minimally invasive procedure with a very low risk of complications and should be considered in young, competitie or unstable glenohumeral joint (instability).
To find out more information about Consultant Orthopaedic Surgeon Mr Giuseppe Sforza, please visit www.practicemattersmag.co.uk/contributors
LIVER
A new dawn in the
TREATMENT of hepatitis C By Dr James O’Beirne
Consultant Hepatologist, Dr James O’Beirne discusses a major step towards the eradication of HCV Over 130 million individuals worldwide are chronically infected with hepatitis C virus (HCV), maintaining its reputation as a global health problem. A high prevalence of chronic HCV infection has been reported in African, Eastern Mediterranean and Middle Eastern countries. HCV results in chronic hepatitis, which frequently causes advanced fibrosis or cirrhosis, both risk factors for liver failure and hepatocellular carcinoma. This accounts for around 350,000 HCVrelated deaths per year globally and is the leading indication for liver transplantation.
Treatment history Since the discovery of HCV in 1989, the cornerstone of treatment has been interferon- α initially as monotherapy and then combined with ribavarin. Whilst in some patients treatment with interferon and ribavarin can be effective at achieving sustained virological responses (SVR), i.e. cure, these drugs can be difficult to tolerate and, in some cases, give poor response rates. Nearly every patient treated with interferon and ribavarin experiences one or more side effects at some point in therapy. Up to 40 per cent of patients experience psychiatric symptoms with side effects of interferon, such as fever, fatigue and arthralgia, presenting frequently. These side
effects often lead to treatment discontinuation especially in patients with advanced disease. As many as 50 per cent of patients with HCV are deemed interferon intolerant, leaving them with limited treatment options. Previously, monotherapy with interferon was only associated with response rates of 6-16 per cent, but the addition of ribavarin to interferon increased response rates to around 30-40 per cent. It was not until the introduction of first generation protease inhibitors, such as boceprevir and telaprevir, that SVR rates increased to an acceptable level of around 75 per cent. Unfortunately, telaprevir and bocepriver are only suitable for certain types of HCV infection (Genotype 1). Therefore, until recently, the treatment landscape for certain groups of patients was dismal, with lack of efficacy, intolerability and the length of treatment (up to 48 weeks) hampering a reasonable chance of cure.
Solvaldi The recent approval of Sovaldi (Sofosbuvir) has revolutionised the medical landscape for the treatment of HCV. Sovaldi is a nucleotide analogue that acts directly on the virus by inhibiting the NS5B polymerase enzyme. It is active against HCV genotypes 1, 2, 3 and 4 and is the first oral drug to be licensed as part of an
all-oral therapy. In genotype 1 and 4, the addition of Sovaldi to standard pegylated interferon and ribavarin allows treatment time to be reduced from 48 weeks to 12, with an impressive cure rate of 90 per cent. Patients with genotype 2 HCV can be treated without interferon with an all-oral therapy. After just 12 weeks of tablet therapy more than 80 per cent of patients are cured. Genotype 3 HCV is often difficult to treat especially when cirrhosis is present. However, by using Sovaldi and ribavarin as all-oral therapy for 24 weeks, this can result in greater than 90 per cent cure rates. These results are a significant improvement on previous therapies in terms of cure rates and represent a paradigm shift for the treatment of HCV. Sovaldi is very well tolerated with no significant drug interactions meaning that this treatment option can be extended to many groups of patients previously excluded from interferon based therapies due to advanced disease and co-morbidities. The Liver Unit at The Wellington Hospital is very pleased to be able to offer this therapy to patients with HCV infection, after a thorough assessment by a consultant specialist.
To find out more information about Dr James O’Beirne, please visit www.practicemattersmag.co.uk/ contributors
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 15
GP NEWS
GP news Round-up
In the busy world of General Practice, we look at trending stories, interesting updates from the primary care sector and introduce a new service available at the WDOC.
North London Hearing comes to Golders Green We are delighted to welcome North London Hearing to their new home at The Wellington Diagnostics and Outpatients Centre, Golders Green (WDOC). Moving from Hoop Lane and previously known as ’Alan Aaronson Hearing Centres’, relocating to the WDOC has offered North London Hearing improved facilities, with immediate access to state-of-the-art equipment and diagnostic technology. Patients who require additional treatment or referral for their hearing also have the support of the wide range of consultants and specialists available at the WDOC and The Wellington Hospital. Solid reputation Over 25 years of service has built North London Hearing a solid reputation. The majority of their patients come on recommendation, or by referral, from some of the best-known ENT specialists in the UK.
Extending GP hours for nearly 1,150 surgeries across England As part of the government’s GP Access Fund, 1,147 practices across the country will be extending their services to cover out of hours, including evenings and weekends. The money received can be used for investment into technology, updates to existing services and the roll out of seven-day a week practice hours running from 8am-8pm. The move is expected to allow doctors to see over seven million patients in the new additional hours, with services also available via telephone, email and even through video chat. However, some government members are questioning just how beneficial the change will be. Those outside the scheme will still be facing a reduced service with some expecting to wait up to a week for an appointment.
Skilled teams Also part of the Harley Street Hearing Group, the skilled, professional team at North London Hearing offers the latest treatment and therapies for audiology and hearing conditions, which include: • State-of-the-art hearing and balance testing • Hearing therapy • Tinnitus management • Specialist services for musicians (incorporated with Musicians’ Hearing Services ) • Hearing aids • Hearing protection This is complemented by a complete after care service, which offers free annual checks for all their patients for life, and home visits for patients who are unable to come to the centre. Appointments If you would like to make an appointment with North London Hearing please contact them directly on 0208 455 6361. For more information, please visit: www.northlondonhearing.co.uk This news continues a fruitful period at The Wellington Diagnostics and Outpatients Centre, following their new Sunday GP and consultant appointments; and with more developments to come further in the year, 2014 looks set to be a exciting time for the WDOC.
Enquiry Helpline: 020 16 • PRACTICE MATTER SPRING 2014
7483 5148
COMMENT & DEBATE A study by both Nuffield Trust and Health Foundation has found a significant improvement in the services and performance of health services across the UK. In England particularly improvements have been recorded across a number of areas including life expectancy and response times of ambulances. But with drops in nurse staffing levels, are there still areas that could be developed?
GP NEWS
In the
spotlight... The Wellington Hospital’s GP Liaison Officers – in sync with our GP community Practice Matters recently caught up with Veronica Brown, Ricardo Pereira, Ricky McKinson and Supriya Taggar, the GP Liaison team at The Wellington Hospital.
Workshops and training sessions are definitely the most popular type of event within the GP community. PM: Tell us about your roles? VB: All four of us look after different geographical areas, whilst my colleagues work mainly in the London area, I look after the North London periphery of Middlesex, Hertfordshire, Bedfordshire and Buckinghamshire. Our roles are not too dissimilar as we all work towards ensuring that our GP communities are kept abreast of all new developments and services at The Wellington Hospital, whilst maintaining a good patient journey. We pride ourselves on the good relationships with not only our GPs, but, their clinical and non-clinical staff, too. We have a good rapport, particularly with the practice managers, who are generally our focal point of contact. We are able to offer a ‘bespoke’ service to ensure our GPs’ and their colleagues’ educational needs and interests are taken into account. We continually look for different ways to make their ongoing learning as pleasurable and apposite to their requirements, either within their own surgeries, in our Wellington Hospital Boardroom or WDOC. PM: What types of events are most popular with the GPs and their practices? ST: Workshops and training sessions are definitely the most popular. For instance, our practical spirometry workshops for GPs and their practice nurses which incorporate not only a consultant talk, but also our Lung Function Physiology Manager, Damian Muncaster conducts a marvellous practical spirometry and analysis workshop. Robin McNelis, whose article features on page 7 of this edition of Practice Matters, offers a fantastic insight into his hypothetical ‘box of tricks’, an easy and practical guide to breathing retraining exercises for the breathless patient which do not require ‘expenditure’!
PM: You mentioned practice managers and non-clinical staff, what do you undertake on their behalf? RM: We work very closely with the practice managers in our areas on a one -to-one basis and, collectively within their Clinical Commissioning Groups [CCGs] to organise mini-symposiums for practice managers, in accordance with CQC requirements. These include updates on employment law and medico-legal aspects of running a practice. These events are always very well received and are constructed around the needs of the practice managers themselves. In addition, we are able to support their patient participation groups by attending their meetings and bringing along consultants to talk to their patients.
We pride ourselves on the good relationships with not only our GPs but, their clinical and non-clinical staff, too. PM: What do you ask from the GPs? RP: We would ask our GPs to keep an eye on our website and social media sites as we use these forums to continually update our events. Whilst we personally try to email each individual GP who may have an interest in attending our events, many do not update their email addresses so, we would also ask them to always take the time to complete their feedback forms especially providing their current email address and any suggestions for future events. Whenever we organise any educational event a feedback form is always included within the delegates packs for comments and suggestions, which we find really helpful. A great example of this was after a recent ‘Advanced Life Skills for Emergency Care’ training session for our GPs, two GP delegates requested that we organise a workshop in relation to ‘joint injections’. As a result we have our first in a series of ‘joint injection workshop’ scheduled for this year. How’s that for being ‘in sync’ with our GP community.
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 17
News from The Wellington Hospital
news from
The Wellington Hospital Social Committee awarded for fantastic fundraising effort On Wednesday February 3, the 2013 Social Committee from The Wellington Hospital was given an outstanding achievement award for the funds raised during the course of 2013. The Juvenile Diabetes Research Fund (JDRF) hosted the London Awards Evening celebrating the success of select groups and individuals who had raised money for the charity, across the capital.
2014 has brought with it some big changes here at The Wellington. In addition to celebrating 40 years of the hospital, at the end of March we said a fond farewell to Chief Executive Officer, Mr Keith Hague. Read more about it here.
Last year, many successful events were held enabling us to raise a significant amount towards our target. The money raised was part of The Wellington £1million Appeal, launched in 2010, which is split between two deserving charities (JDRF and The British Red Cross). Previous events have included an adrenalin fuelled abseil, a sponsored bike ride to Brussels and the Ben Nevis challenge. With a goal to raise even more money for our two fantastic charities, 2013 had to be bigger and better. Events included several cake sales, with a selection of yummy cakes on sale for hungry staff and visitors, and raffles with a variety of prizes up for grabs. In addition to this, we managed to raise £2,279 for the appeal from the hugely successful Wellington’s Got Talent.
A fond farewell to a visionary CEO This April, The Wellington Hospital said a very fond farewell to Chief Executive Officer, Mr Keith Hague as he retires after 11 years at the helm of the UK’s largest private hospital. Over the last 11 years Mr Hague headed an entire hospital refurbishment and introduced a range of important new services; the most recent of these being the Acute Admissions Unit. In 2008 he expanded the hospital to include an outpatient service at Golders Green and again, in 2011, commissioning the build of the state-ofthe-art Platinum Medical Centre – the largest private outpatient centre of its kind in the country. These select achievements, from a long list of many, have brought The Wellington to its standing today as one of the world’s leading private hospitals, with an international reputation for excellence. He will be greatly missed, but always held in the highest regard, from staff and consultants alike, for his warmth and sincerity, the interest he took in each individual at the hospital and for steering the hospital through tough times to great heights and achievements.
NEW CONSULTANTS Anaesthetics Dr J M Laurence Boss, Guy’s & St Thomas
General Surgeon / Upper GI / Bariatrics
Dr Deborah Braham, Hammersmith Hospital
Mr Ali Alhamdani, The Whittington
Cardiologist
Gynaecologist/Obstetrician
Dr Syed Ahsan, The Heart Hospital
Haematologist
Gastroenterologist Dr Anton Bungay, Kingston Hospital
Enquiry Helpline: 020 18 • PRACTICE MATTER SPRING 2014
Dr Sarah Hussain, private only
7483 5148
Professor Atul Mehta, Royal Free Hospital
Radiologist Dr Panagiotis Gkoutzios, Guy’s & St Thomas
Vitreoretinal Surgeon Mr Mahiul Muqit, Moorfields Hospital
60 seconds with...
60
seconds with...
Carol Robb, Senior Sister of Endoscopy discusses her working career and the Centre’s recent JAG accreditation PM: Tell us about your work background CR: I started as a cadet nurse in 1975, in Boston, Lincolnshire where I began my nurse training in 1977. After qualifying in 1980, I remained in Boston, working in theatres where I got my first taste of endoscopy. From 1983 to 1984, I worked predominantly on male surgical before marrying and moving to work in theatres for a year at St George’s hospital, Lincoln. I had a brief career break to have a family and then worked in nursing homes around my children growing up. In 1999 to 2004 I began working in theatre, minor operations and endoscopy in New Hall private hospital, Salisbury. It was here that I developed my enthusiasm and initial skills in endoscopy. Following this I moved to Salisbury district hospital endoscopy, to widen my skills and knowledge. During my time here I took a year secondment and returned to studying doing a course at Bristol UWE, taking nursing higher diploma course. 2008 -2011 Royal Bournemouth Hospital Endoscopy as band 5 with promotion to band 6. PM: What does your role at The Wellington involve? CR: I am the Senior Sister of endoscopy, a role which combines clinical, managerial and administrative elements. One of my first roles on joining the unit was my involvement in the refurbishment. On completion of this I then started the preparation and working towards gaining JAG Accreditation. PM: What was involved in the endoscopy refurbishment? CR: The unit opened in its present location of the central building in 1998, as a standalone unit. Refurbishment plans started in November 2011, during which the unit relocated to South theatres to enable work to start. The unit was completely gutted and re-designed over two floors during a period of six months, re-opening on July 4, 2011. PM: Who makes up the endoscopy team? CR: The team consists of Michael Lendrum, Modern Matron for outpatient services and endoscopy, Senior Charge Nurse, Senior Staff Nurse, five staff nurses, a Technician for decontamination, a Health Care Assistant, and ancillary staff of Receptionist/Patient Admin, Front of House, Housekeeping and Catering. PM: Can you tell us about the JAG accreditation and how it takes place? CR: JAG is the joint advisory group for GI endoscopy. In order for a unit to gain JAG accreditation, they must complete the accreditation pathway. This process can take 12-24 months. The GRS census is an assessment tool that enables units to assess how well they provide a patient centred service. This is a web based tool with scores automatically calculated from answers. Census comprises of three different layers: • Domains refer to Quality and Safety (Clinical Quality), Customer Care (Quality of Patient Experience) and Workforce. • Items provide more detail of what makes up that domain • Measures require a yes or no answer a statement that the unit has achieved or not and is graded from basic (D) to excellent (A).
I am the Senior Sister, of endoscopy, a role which combines clinical, managerial and administrative elements. The unit complete the GRS census in both April and October, in which they must attain two consecutive scores of all B’s and A’s in order to apply for a JAG visit. As part of the visit requirements, units are requested to provide and upload evidence against their answers to the measures. This has to be completed two months prior to the visit date to enable the assessors time to read through and, if necessary, request additional evidence. The visit lasts for the whole day with two or three assessors, which include a consultant and a nurse. It is conducted to a pre agreed timetable comprising of a presentation on the unit, a walkthrough of the unit simulating a patient journey, following an endoscope through the decontamination process and one to one interviews with staff. The assessors will then review the evidence requested and prepare the draft report. We then receive feedback from the visit and give a recommended result with either criteria met or targets required with time line to achieve this. We were pleased to learn that for our unit the criteria was met on the day and accreditation recommended. The report is them handed to the QA review panel and the unit to approve as accurate and then unit notified by letter of JAG Accreditation awarded. Following awarding the accreditation it will be annually awarded through completion of the April census and an Annual report card completed in October with a five yearly visit. So as you can see the work never stops once you have achieved your initial accreditation, it is continual work in progress. We were excited to discover that The Endoscopy Centre at The Wellington is the first private facility in central London to achieve accreditation. PM: What would you say makes a good team member in Endoscopy? CR: All the staff in the unit are focused on providing excellent and compassionate evidence based patient centred care. This is reflected in the positive patient feedback. As we are only a small team we all pull together and help each other proving we are flexible and can adapt to any situation or task. PM: What would you see yourself doing if you were not doing what you are now? CR: I have always wanted to be a nurse, even at school I knew I wanted to go into nursing. My background is in theatres, I just sort of fell into endoscopy and really like it.
www.practicemattersmag.co.uk PRACTICE MATTER SPRING 2014 • 19
www.practicemattersmag.co.uk For more information about the GP Liaison service, or to make a referral, please contact the GP Liaison Officer for your area: Supriya Taggar Central London 07826 551 318
Ricky McKinson North & East London 07889 317 769
Ricardo Pereira North West London 07889 318 336
Veronica Brown Beds, Herts, Bucks & Middx 07889 317 774
supriya.taggar@hcahealthcare.co.uk
ricky.mckinson@hcahealthcare.co.uk
ricardo.pereira@hcahealthcare.co.uk
veronica.brown@hcahealthcare.co.uk