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Autumn 2014 • Issue 18

Orthopaedics Non-surgical and operative solutions

Minimal invasive technique Mitral valve repair

Gut feeling Causes and treatment of hiatal hernias

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 2014 is drawing to an end, and what a year it has been for The Wellington Hospital. The past 12 months have brought the launch of new units, including the state-of-the-art WellNet Unit headed by Professor Martyn Caplin and more recently, the launch of the PDoC Unit on the 5th floor, South Building, which you can read more about on page 11 of this issue. This has also been a year of great achievements with the attainment of a further three years of full CARF re-accreditation to our Acute Neurological Rehabilitation Unit, accompanied by a glowing report. Our Endoscopy Centre base at the Central Building was also awarded full JAG accreditation, making The Wellington the first private facility in London to receive such a widely recognised accolade. The hard work of all staff has been pivotal in the hospital’s success and the continued growth in its reputation as one of the leading healthcare facilities in the UK. These achievements are set to continue into the New Year and I look forward to sharing these with you in future editions. In this autumn issue, Consultant Cardiothoracic Surgeon, Mr Roberto Casula discusses the developments in minimal invasive mitral valve repair, including the use of pioneering robotic surgery as a course of treatment (page 12). Developments in knee options are a common theme in this autumn issue with Mr Manoj Sood highlighting the advancements in joint preservation (page 14), and an interview with Mr Chinmay Gupte as he discusses both nonsurgical and invasive options for patella instability (page 8). As part of a comprehensive programme of campaigns, we ensure that you are frequently updated with news of developments to our services and the acquisition of pioneering technology. Pages 16-18 include news from The Wellington along with an update from our GP Liaison team, with the events and talks scheduled for the New Year. So, as this year draws to the end, we are already in the throes of plans for the New Year which will ensure that The Wellington Hospital remains at the forefront of the private healthcare sector. Best wishes,

Neil Buckley CEO

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Editor: Hannah Rogers Production & Distribution: Runwild Media Group


Contents 04 | An in-depth look at hiatal hernias Mr Ashish Rohatgi


06 | Gamma knife radiosurgeryan early minimally invasive therapy


Mr Ian Sabin

07 | The late presenting Achilles tendon rupture: What every clinician should know Mr Mark Herron



08 | The non-surgical and invasive options for patella instability Mr Chinmay Gupte

10 | Common injuries to the fingertips Miss Barbara Jemec

11 | Introducing The Prolonged Disorders of Consciousness Unit 12 | Advancements in minimal invasive mitral valve repair Mr Roberto Casula

14 | Joint preservation options in knee arthritis Mr Manoj Sood

15 | Medical approach to nose and sinus disease- treating the cause Professor Douglas Robinson and Dr Harsha Kariyawasam


16 | GP news 18 | Latest news and consultants PRACTICE MATTERs Autumn 2014 • 3

General surgery

An in-depth look at

Hiatal Hernias By Mr Ashish Rohatgi

Over the years, hiatal hernias have been likened to abdominal hernias with overlying pain indicating the need for an operation. Hiatal hernias are actually entirely different, with an operation rarely being the answer for the upper abdominal pain and reflux symptoms. Hiatus hernias occur in 10 per cent of the population • Risk factors : age >50yr, BMI >25kg/m2 and male • Familial – 20-fold increased risk in younger siblings

Anatomy The oesophagus enters the abdomen via the oesophageal hiatus of the diaphragm. There is normally a 2cm segment of intra-abdominal oesophagus anchored to the diaphragm, by the phreno-oesphageal ligament. A hiatus hernia is when there is a herniation of the stomach through the hiatus.

There are four types of hiatal hernia, comprising of: • Type I or sliding hernias (90 percent of cases) whereby the cardia migrates proximally into the thorax. • Type II are rare (3 per cent of cases), these are called true paraesophageal hernia. Here the fundus of the stomach herniates through the hiatus.

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• Type III is a combined hernia with elements of both Type I and II. This (like its lower abdominal counterpart) has a true sac and forms the majority of paraesophageal hernias needing a surgical repair. These are prone to gastric volvulus. • Type IV is the same as a Type III, with the addition of other viscera. As with all hernias, there is progressive enlargement over time.


Fig 1

The majority of patients with Type I are asymptomatic with symptoms normally associated with reflux or pain. However, in general, just having an uncomplicated hiatus hernia will not lead to pain. This symptom is from the effects of reflux, such as oesophagitis, gastritis or ulcers. In some cases, there is no evidence of any of the above, but pain is still present.

Treatment At this stage, non-surgical treatment is more to address the acid reflux, with simple lifestyle changes, such as antacids, avoiding precipitating factors, weight loss, giving up smoking and raising the head ends of the bed. Patients with more moderate to severe disease will require a gastroscopy and eradication of H Pylori (if present) and proton pump inhibitors (ppi). Only patients who fail medical therapy, or those who do not want lifelong ppis, require an operation and objective evidence of reflux with a PH and manometry test, after lifelong ppis.

There are patients who have hiatus hernias and no reflux, or the opposite. With this in mind, only those who meet the criteria for surgery should have an operation for reflux, whether they have a hiatus hernia or not. In fact, Type I hernias are present in only about half of the patients who undergo surgery for gastro-oesophageal reflux. At the time of surgery, the hiatus hernia will be operated on, but it is the combination of all the components of surgery that will fix the reflux and not just the hiatus hernia. The operation for patients who meet the criteria for Type I hiatal hernias is a laparoscopic fundoplication with an overnight stay at hospital.

There are four types of hiatal hernias including: Type I, II, III and IV

The current recommendation for Types II – IV is that they should be repaired surgically, if the patient is fit for an operation. In elderly or frail patients, a more conservative approach can be adopted. The operation is generally performed laparoscopically, but in cases of very large hiatal hernias (with the whole stomach with or without other organs), there is a very high chance of an open procedure. This involves reduction of the stomach and other organs into the abdomen, excision of the sac and closing the hiatus with mesh reinforcement. A fundoplication and a method of fixation of the stomach to the anterior abdominal wall, is also performed. In conclusion, most patients with a simple hiatus hernia (I) need management of the reflux and rarely need an operation. For those with more complex hiatal hernias (II-IV), surgery is usually the best option.

To find out more information about Mr Ashish Rohatgi, please visit contributors PRACTICE MATTERs Autumn 2014 • 5


Gamma Knife Radiosurgery –

an early minimally invasive therapy By Mr Ian Sabin

The Gamma Knife is a radiotherapy tool used predominantly by neurosurgeons to treat a variety of problems, ranging from neoplasms to facial pain. It enables patients to be treated with intracranial tumours without the need to open the skull.

Radiosurgery A high dose of radiation is delivered in up to five fractions to a target identifiable on imaging (MRI, CT, angiography), with a smaller dose to the surrounding structures. Results of the treatment to benign tumours with standard fractionated external beam radiation, show the relative radioresistance of these lesions with slow growth rates, low mitotic rates and preserved DNA repair mechanisms. This makes their response to radiation very similar to the surrounding brain. A dose large enough to damage the tumour risks cerebral radiation damage and possible dementia. The Gamma Knife was the first purpose built stereotactic radiosurgery device with the principle to direct multiple beams of radiation to the lesion being treated, from positions around the head. This gives a dose high enough to treat the target, with reduced radiation exposure to the brain. The current Gamma Knife (Perfexion) achieves this by employing 192 shielded and motorised cobalt-60 sources, arranged geometrically around the head. Each is capable of delivering a ‘pencil beam’ of radiation of different diameters, all

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converging at one point. A frame is fitted to the patient’s head and an MRI scan obtained on the day of treatment. This allows the 3D coordinates of every part of the target to be obtained with accuracy, and then placed at the point of beam convergence by a motorised couch. At the end of the treatment, the frame is removed and the patient is discharged shortly afterwards. Follow up is potentially life-long, depending on the pathology being treated. Cerebral arterio-venous malformations: Selection criteria are strict, but Gamma Knife is now often the treatment of choice. However, a number of cases are now simply observed as the risks of malformation rupture. In young individuals, the lifelong risk of bleeding is considerable, with treatment. Vestibular Schwannoma: Management options include simple observation and surgical resection but Gamma Knife treatment is now generally considered the treatment of choice for tumours 3cm or less in diameter. Meningioma: Although surgical resection remains the gold standard, many tumours are in areas difficult to tackle surgically and resect completely, without causing considerable neurological deficits. Gamma Knife treatment can be extremely effective with control rates more than 90 per cent, for WHO Grade 1 tumours.

Cerebral metastases: Gamma Knife treatment is now challenging the historically used option of whole brain radiotherapy (WBRT). It is possible to treat multiple lesions as a day case procedure, with low radiation exposure to the surrounding brain. This normally achieves excellent local control and potentially avoids the problems of impairment of higher mental function that can occur with WBRT. Trigeminal neuralgia: For patients not suitable for surgical treatment (microvascular decompression) with a five year success rate of 70 per cent, Gamma Knife radiosurgery is an option and achieves pain relief in around 40 per cent of patients at five years. Pituitary adenomas: Surgery is still the best treatment for tumours other than prolactinomas. Radiosurgery is suitable as a second line treatment if the tumour is easily defined on scan, and is not deforming the optic chiasm. Miscellaneous skull base tumours: These include chemodectoma, chordoma, chondrosarcoma and haemangiopericytoma.

To find out more information about Mr Ian Sabin please visit contributors


The late presenting Achilles Tendon Rupture:

What every clinician should know By Mr Mark Herron

The history of an Achilles rupture is classically described as a feeling of a direct impact to the Achilles area with sometimes a very audible ‘crack’ or ‘snap’, heard by the patient. There is an immediate inability to continue with activity and well localised pain. In the vast majority of cases, posterior ankle bruising and swelling occurs rapidly with most patients seeking immediate treatment. However, there are a number of patients who either present late following a complete rupture, or in whom the diagnosis is initially missed. The reasons for this vary, but it is important to be aware that beyond two weeks after a complete rupture, there is usually very little pain anymore. The patient at this stage is likely to complain of weakness of gait, possibly a feeling of instability and may also limp, and not recount a helpful and classical history. It is at this stage that the opportunity for relatively early intervention is missed (or missed again) and where an open mind needs to be kept about diagnosis. Examination starts with an observation of barefoot gait. The patient will invariably walk with a shortened stride and be voluntarily limiting the range of movement. A visual inspection of the posterior ankle is important, as the Achilles is likely to be poorly defined. Getting the patient up onto both tiptoes at the same time is possible, even with a ruptured Achilles (most patients will simply transfer weight to the

uninjured side). A single heel rise on the injured side, however, will not be possible. The most sensitive and specific test for the Achilles rupture is squeezing the injured calf with the patient prone, and the ankle hanging off the end of the examination couch . If there is no plantar flexion on compressing the calf, then this is likely to indicate the presence of a significant injury to the Achilles tendon complex. The tests can sometimes be difficult to perform, due to significant swelling or pain, but an equivocal result should also be recorded in the notes and warrants urgent imaging of the Achilles tendon. The advent of commonly available, good quality ultrasound (and radiologists skilled in the technique) has revolutionised the management of Achilles tendon injuries. The investigation is highly sensitive for detecting ruptures, takes only minutes and, logistically, is often far easier to organise than an MRI scan. An additional and important advantage is that the dynamic nature of the investigation (allowing the radiologist to move the ankle and Achilles actively during the investigation) enables clear advice on a key point with the ruptured Achilles. This is namely whether the ends are easily opposable with the ankle placed into an appropriate plantar-flexion. For clinicians treating a late presenting rupture, there is good evidence that a direct repair of the

Achilles can be carried out up to six, (or possibly 12) weeks after the rupture, with little adverse effect on the outcome. The only thing that delays of this magnitude mean is that the opportunity for conservative treatment is lost. The operation to repair the Achilles tendon is relatively small in itself, with occasional complications of wound infection, wound breakdown, scar adhesion or scar sensitivity. Beyond this timeframe, the tendon ends can become more difficult to mobilise and the tendon tissue less prone to heal, even if surgically re-approximated. A very good salvage procedure for these later presentations (even up to several years post rupture) is to transfer the flexor hallucis longus tendon (which lies immediately adjacent to the Achilles) and weave it between the tendon ends; producing a composite tendon. The functional outcome of such tendon transfer procedures is also likely to be excellent, more dependent on patient age and pre-injury function than anything else. The period of time immobilised post procedure is also the same as for a primary Achilles repair.

Mr Mark Herron FRCS is a Consultant Foot and Ankle Surgeon at The Wellington Hospital Foot and Ankle Unit PRACTICE MATTERs Autumn 2014 • 7


Non-surgical and invasive options for patella instability An interview with Mr Chinmay Gupte

PM: What is patella instability? CG: The patella, ‘glides’ over the femur during knee bending and straightening. Problems occur when this motion is not in a straight line or is causing increased pressure on the patella, which can result in pain and a sensation of instability. There are many potential causes, meaning that determining the correct treatment can be a challenge. PM: How can you determine between patella related pain or instability? CG: Classically, a patient will complain of pain in the front of the knee or under the patella. Patients may experience pain during exercise, going up or down stairs, squatting and getting up from a kneeling position. They may also feel the sensation that the patella is unstable and in danger of dislocating.

Patients may experience pain during exercise, going up or down stairs, squatting and getting up from a kneeling position

PM: What are the causes of patella instability? CG: This can arise from an acute traumatic injury, caused by a direct blow or abnormal twisting movement, or from a chronic problem. Underlying causes include: bone problems such as knock knees (increased “Q angle”) or abnormal patella or femoral trochlea architecture (patellofemoral dysplasia), or patella ligament injury (medial patellofemoral ligament {MPFL} injury). Another very important contributing cause is poor muscle strength and conditioning of the buttock and thigh muscles. PM: How is a diagnosis of patella instability made? CG: This is done with a combination of a detailed history and a thorough knee examination. Sometimes imaging of the joint, in the form of radiographs, MRI scans and occasionally CT scans, are also required.

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PM: What treatment is offered to acute cases? CG: Immediate management involves reduction of the patella, aspiration of the knee joint (if there is a large swelling) and the use of a brace for comfort and to restrict movement. The underlying cause of the dislocation is determined and treatment planned, ranging from bracing to specialist physiotherapy and operation. PM: Which non-operative options are available? CG: Bracing can prevent further dislocation of the patella, but this must be balanced with over stiffening the knee and weakening muscles, due to prolonged bracing. Physiotherapy consists of initial swelling and pain management, followed by gradual bending of the knee and buttock, and quadriceps muscle strengthening exercises. In chronic cases, patella taping has been shown to be beneficial. PM: If the MPFL is injured, can this be treated operatively? CG: Yes it can and there are several procedures that can be done. Using an arthroscope, the tighter structures on the lateral aspect of the patella can be partially released to allow the patella to lie more medially. Alternatively, if the MPFL is badly injured and beyond repair, this can be reconstructed using the patient’s own tendons. The orthopaedic surgeon makes a decision as to whether one procedure is best or if a combination of procedures is required, based on clinical assessment and scan data.

Retraining and building the muscle around the patella with the help of physiotherapy is a vital treatment option

PM: What are the causes of non-traumatic or chronic patella instability? CG: These are slightly more complex and depend on the surgeon performing a thorough examination and imaging studies. Causes can include, the patella lying too high or too low in front of the femur, a mismatch in the shape of the undersurface of the patella and the front of the femur, a mal-alignment of the patella (in relation to the pull of the tendons it lies in) or even arthritis within the patellofemoral joint. PM: How can these cases be treated? CG: Treatment depends very much on the diagnosis. If the patella is lying too high or low, or in a misaligned

position in relation to the pull of the tendons, to the tibial tubercle (to which the patella tendon attaches) it can be transposed to a more desirable position usually medially. If the problem is due to arthritis within the joint or a mismatch between the bone geometry, then a type of patella replacement can be performed. PM: Is surgery the only option for chronic problems? CG: Retraining and building the muscle around the patella with the help of physiotherapy is a vital treatment option. Surgery is usually offered to those patients who fail to make a satisfactory recovery using non-operative methods. As it is complex surgery, this should be performed by orthopaedic knee surgeons who have an interest and expertise in doing these types of procedures.



Mr Chinmay Gupte

PhD, MA (Oxon), FRCS (Tr & Orth), BM BCh

Consultant Knee Trauma Surgeon

*Original interview conducted by Mr Philip Pastides, Orthopaedic Registrar

To find out more information about Mr Chinmay Gupte please visit contributors

Mr Chinmay Gupte is a Consultant Orthopaedic Surgeon and Senior Lecturer in knee and trauma surgery at Imperial College, London, which encompasses St Marys and Charing Cross Hospitals. His main interests are in the treatment of adult and children’s sports knee injuries and knee arthritis, together with trauma and fracture surgery, performing both arthroscopic (keyhole) and open procedures. Mr Gupte has a large research background and continues to build on this in his role as a Senior Lecturer in the Faculty of Medicine at Imperial College. Studies include a particular emphasis in meniscal surgery and knee ligament reconstruction, and also in arthroscopic simulator training, with the aspiration of improving outcomes in patients with knee problems. PRACTICE MATTERs Autumn 2014 • 9


Common injuries

to the fingertips By Miss Barbara Jemec

Many patients will present to their GPs or Minor Injuries Units with damage to their fingers, caused by kitchen appliances, car doors and other daily accidents. A fingertip injury tends to bleed a substantial amount, and as the fingertip is full of nerve endings, an injury can become a very painful problem. In addition to the pain caused, nail bed injuries can produce scarring with splitting or non-adherent nails.

Fig 1

Fig 2

Fig 3

Fig 4

Treatment In all patients, early treatment and meticulous apposition of the tissues is essential for a good outcome. In painful cases, a course of desensitisation with hand therapy can alleviate the problem and return the hand to normal function. Nail bed injuries (fig 1) with concomitant fractures are essentially open fractures and should be cleaned within six hours of injury, with the patient given antibiotics. In these cases, loupe magnification is standard for surgery, and the fracture will sometimes need wiring. For fingertip injuries where the laceration cannot be closed directly and tissue-loss is present, the area can be left to heal by secondary intention, if there is no bone involved. If the bone is exposed, a local flap will be needed. The size of the flap depends on the area of the lost tissue, but is ideally made up from the remaining finger itself, to maintain sensation and the specialised skin of the fingertips. (fig 2)

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Amputation If the available amputated part is very small, it can be replaced as a composite graft. This means that the amputated tissue will pick up the local blood supply when the vessels reconnect, prompting new ingrowth of vessels from the fingertip. This process usually takes 7-10 days, and, even if the composite graft should not take, it will act as a biological dressing. This is only possible in very distal amputations with little tissue amputated. (fig 3) In amputations which include bone, it is usually better to attempt formal replantation (fig 4) rather than replacing the amputated part as a composite graft. The amputated part is transported and stored by wrapping it in a moist gauze, putting it in a plastic bag and then placing the bag in an icebath. Rather than attempting distal finger replants

in the middle of the night, surgeons often wait until daylight hours, due to the very low metabolic requirement of the tissue involved. All patients who have experienced a fingertip injury should make an appointment with a hand therapist, after surgical treatment. The hand specialist will work on a tailored programme of de-sensitisation, sensory re-education and mobilisation to ensure that the best recovery outcome is achieved.

To find out more information about Barbara Jemec please visit contributors


Introducing The Prolonged Disorders of Consciousness Unit at The Wellington Hospital The new Prolonged Disorders of Consciousness Unit (PDoC), based on the 5th floor of the South Building, is a specialist service, providing the next natural step on a patient’s journey to consciousness. The PDoC unit has been established to blend clinical practice with research exploration, to guide patient care. Forging links with international Prolonged Disorders of Consciousness (PDoC) research facilities, the unit seeks to explore assessment and treatment techniques. This includes the clinical use of functional magnetic resonance imaging (FMRI), near infrared spectroscopy (NIRS) and electroencephalogram (EEG) for the benefit of our patients, and to keep us at the forefront of advances in research.

Different levels of consciousness Following severe brain injury, many patients progress through different levels of consciousness, when emerging from a coma: • Coma (Absent wakefulness and awareness) • U nresponsive Wakefulness Syndrome or Vegetative State (Wakefulness with absent awareness) • M inimally Conscious State (Wakefulness with minimal awareness) Some patients will not emerge from a vegetative or

The PDoC team consists of a group of specialists working across intensive care and other acute departments, focusing on the issues facing patients emerging from disorders of consciousness and ensuring continuity of care.

What is a Prolonged Disorder of Consciousness? This is when a person is no longer in a coma but remains in a state of altered consciousness, for more than four weeks after an injury. It is essential for the patient to receive specialist support through this process to give each patient every chance of optimising their recovery.

minimally conscious state.

Service The team uses unit specific, interdisciplinary, integrated PDoC pathways, based on recently published National Guidelines (Royal College of Physicians, 2013), ensuring a structured approach to delivery of care. The PDoC team links with ICU, providing a seamless service, which places the patient on a continuum using specialist evidence based practice: • A ssessment, diagnosis and monitoring • Structured care pathway – acute to longer term management • Management of ethical and medico-legal issues • B est interest decision making

• E nsure best practice in the management and treatment of patients in a prolonged disorder of consciousness. • Family support and education. The unit team ensures that the family is involved in all aspects of care and treatment. • Evidence based intervention programmes • I nter-disciplinary planning and goal setting • S pecialist service • S timulation programmes

The Team Approach Our skilled team ensures a consistent co-ordinated approach to recovery and includes: • Consultant • D ietitian • I nternational Patient Coordinator • N europsychologist • O ccupational Therapist • P DoC Admissions Coordinator • P DoC Nurse • P harmacist • P hysiotherapist • Resident Medical Officer • S peech and Language Therapist

To find out more information about the PDoC Unit, please visit PRACTICE MATTERs Autumn 2014 • 11


Advancements in

minimal invasive mitral valve repair By Mr Roberto P Casula

Mitral valve regurgitation caused by a leaflet prolapse is one of the most frequent, degenerative heart conditions in the Western world. Many patients will remain with little or no symptoms for years, until the deleterious effects of associated left ventricular dysfunction develop. Surgical repair is the only therapy proven to prevent the negative prognostic consequences of heart failure associated with chronic, untreated mitral valve regurgitation.

Asymptomatic patients who undergo early mitral valve repair

Preoperative atrial fibrillation has been found to be an independent predictor of mortality. As a consequence, operative risk is increased if surgery to correct mitral valve regurgitation is delayed, until the onset of atrial fibrillation.

In contrast, these cases benefit from: • normalisation of late survival • improved regression of heart dimensions and overall geometrical remodelling • a better recovery of normal left ventricular ejection fraction, with time

Delaying mitral valve repair in asymptomatic patients with severe mitral regurgitation

Fig 1

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Many patients will remain with little or no symptoms for years, until the deleterious effects of associated left ventricular dysfunction develop

Surgical intervention

This can be done while allowing either: • the left ventricular ejection fraction to fall below 0.60 • an increment of the left ventricular end-systolic diameter beyond 40 mm • or, the onset of symptoms

The unwillingness of asymptomatic patients to submit to an invasive procedure brings great importance in the debate regarding the ideal timing of surgical intervention. This is because asymptomatic patients are generally reluctant to submit to an invasive procedure, due to the perceived drawback in subsequent, temporary functional limitation, during their post-surgical recovery.

However, this delay can unduly expose patients to excess early and late death; after eventual surgical correction.

Median sternotomy is the most frequent surgical approach used to perform mitral valve operations worldwide, and is associated with excellent clinical

Median sternotomy is the most frequent surgical approach used to perform mitral valve operations worldwide Fig 3

Fig 4

stays. There is also a shorter time period in which patients can return to normal daily activities, compared to post-traditional cardiac surgery.

Fig 2

The percentage of the patients operated in specific specialised surgical centres has increased 90 per cent outcomes. More than one in three patients, in both the US and Europe, are presently treated with minimal invasive or robotic strategies which do not require opening the full chest in a traditional way. However, this method must necessitate specific surgical team skills and the use of advanced instrumentation. The percentage of the patients operated in specific specialised surgical centres has increased 90 per cent. The availability of high-definition thoracoscopic imaging, new surgical instrumentation and even robotic technology, has allowed surgeons at The Wellington Hospital to routinely perform mitral surgery through small, right thoracic, soft tissue incisions. This obviates the need for traditionally large chest openings or breast bone fractures.

Benefits of minimally invasive surgical techniques include: diminished post-operative functional limitation, decreased use of pain killers, less bleeding and use of blood transfusion postsurgery, lower infection rates and shorter hospital

A meta-analysis and systematic review published in 2014, (analysing more than 20,000 patients from 45 studies) found that stroke rate and allcause mortality were similar in patients treated via minimal invasive or conventional median sternotomy. The length of stay in the intensive care unit, the time spent on the ventilator postsurgery and the hospital stay were all significantly shorter in the minimal invasive group, where blood losses and blood transfusions were also decreased. In contrast, operation times were longer in the minimal invasive group with the occurrence of new atrial fibrillation after surgery appearing less* For those patients who have been diagnosed with mitral valve disease, they can be reviewed and assessed for suitability for minimal invasive surgery at the Platinum Medical Centre.

*Sundermann et al. Mitral valve surgery: Right lateral minithoracotomy or sternotomy? A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2014:1-7

Figures 1) skin incision in traditional cardiac surgery 2) minimal invasive mitral surgery skin incision 3) traditional cardiac surgery ‘setup’ 4) minimal access mitral surgery ‘setup’

To find out more information about Mr Roberto P Casula, please visit


FOCUS Mr Roberto Casula MD, FETCS, FRCS

Consultant Cardiothoracic Surgeon Mr Roberto P Casula is a Consultant Cardiothoracic Surgeon at The Wellington Hospital and has been a Consultant for over 15 years. He graduated at Padova University Medical School, Italy in 1989 and then trained in The UK in Cardiothoracic Surgery and Thoracic Organs Transplantation. Mr Casula has operated on several thousand cardiac patients since performing his first open heart operation in 1990. He is a pioneer in both robotic-enhanced and minimal access cardiac surgery in the UK and started the robotic cardiac surgical clinical program for the Imperial College, in 2002. He remains the only practicing robotic cardiac surgeon in the UK. Mr Casula’s special areas of interest include minimally invasive cardiac surgery, beating heart cabg, robotic cardiac surgery, key-hole heart valve repair or replacement and mitral valve repair. PRACTICE MATTERs Autumn 2014 • 13


Joint preservation options in knee arthritis

By Mr Manoj Sood

Although the treatment for established knee arthritis is joint replacement, joint preservation, as an alternative, has evolved in recent years.

Medical interventions

injections, where healing cells from the patient’s blood are injected into the knee, can also help improve pain, although more evidence is needed before these can be routinely recommended.

These aim to preserve joint function for as long as possible, without recourse to surgery. As no medical treatments are currently available to slow down or reverse cartilage degeneration, surgical treatment may eventually be required.

Surgical interventions

Physiotherapy and dietary supplements There is good evidence that structured physiotherapy can help relieve some of the symptoms of arthritis, making this an important first step in treatment. Glucosamine and chondroitin sulphate are constituents of normal cartilage matrix and, although some patients who take these experience significant improvement in knee pain, clinical evidence for their effectiveness is mixed.

Arthroscopic debridement This can help relieve the pain of arthritis and is carried out through key-hole surgery (arthroscopy). It involves smoothing over loose cartilage, resecting bony osteophytes and trimming meniscal tears. Although a little controversial in arthritis, leading knee surgeon Steadman has described a very specific and detailed debridement procedure (‘the package’), which resulted in a number of his patients delaying the need for replacement surgery, for a significant period of time.

Injections Steroid injections in patients with significant arthritis can have detrimental effects if a subsequent replacement becomes necessary, and rarely provide long-term benefit. Viscosupplementation injections, comprising hyaluronic acid (which occurs normally in the knee) can give pain relief. They normalise the chemical environment in the arthritic knee. Some have improvement in their symptoms for many months and are happy to have this simple injection repeated, periodically. Platelet rich plasma (PRP)

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As knee replacements have a finite lifespan, especially in the younger and active patient, the aim in joint preservation surgery is to eliminate or delay the need for such surgery.

Re-alignment osteotomy In arthritis confined to one side of the knee, this established technique can take the load off the painful arthritic side and place it on the opposite, normal side. This involves incompletely dividing the bone, realigning it, and securing in this new position with a plate. In appropriate cases, osteotomy can delay the need for joint replacement surgery by 8-10 years.

Kinespring device Is a new and novel device which is being evaluated in appropriate patients, with isolated medial compartment arthritis. The device is a mechanical load absorber placed on the inner side of the knee to offload this part of the joint, and relieve pain. It lies outside the joint and the procedure involves no bone resection and is not a joint replacement, so future options of partial replacement or osteotomy are not compromised. Partial resurfacing This is a new technique being used in patients with large cartilage defects or localised arthritic areas. Through a mini-incision or arthroscopicallyassisted technique, a metal implant, with an overlying artificial plastic cartilage is inserted, restoring the smooth joint surface. There is minimal bone loss and this represents a ‘mini replacement’ of the damaged cartilage area. Thus, a variety of treatment options are available as an alternative to joint replacement in appropriate cases. Joint preservation is an exciting and continuously evolving field.

To find out more information about Mr Manoj Sood, please visit contributors


Medical approach to nose and sinus disease- treating the cause By Professor Douglas Robinson and Dr Harsha Kariyawasam

Medical rhinology Many patients will present to their GPs with symptoms including a blocked nose with excess mucus, loss of smell and taste, and sneezing. However, these signs do not always reveal the sense of malaise and fatigue associated. For people with allergic or medical diseases such as rhinitis and sinusitis, these symptoms are an everyday occurrence with a significant impact on quality of life.

Allergic rhinitis At least 500 million people suffer with allergic rhinitis (AR), making it one of the most common cases seen by GPs. This statistic was heightened this year due to the unusually high pollen count present throughout the hay fever season.

Symptoms and signs of AR nasal • Congestion • Rhinorrhoea • Itching • Sneezing Ocular (rhinoconjunctivitis) • Watery eyes • Itching • Burning (irritability) • Redness and injection of the conjunctiva periorbital oedema

The relationship between nasal-ocular symptoms and allergen exposure, plus demonstration of IgE–specific sensitision, is diagnostic of AR.

In Europe, 71 per cent of patients experience both nose and eye problems, with up to 33 per cent of these diagnosed as moderate or severe. As a result, these symptoms affect quality of life scores more than angina.

Classification of disease The next step in diagnosis is to classify the disease as mild, moderate or severe based on impact within daily life. Moderate to severe patients need an intranasal steroid, whilst immunotherapy (allergen desentisation) can benefit all patients. GPs should also check for asthma, as it is commonly associated with rhinitis and treating the nose can often improve asthma control.


Chronic sinusitis (CRS)- When giving directed therapy, CRS must be considered when two or more symptoms, one of which should be nasal obstruction (blockage, congestion) or nasal discharge (anterior/posterior) along with either facial pressure/pain or reduction or loss of smell, persist beyond 12 weeks. Chronic rhinosinusitis (CRS) is not a distinct disease entity but an ‘umbrella’ term that groups together a spectrum of disorders with distinct immunopathological mechanisms. The type or cause of CRS decides the medical approach, making the treatment more effective. Loss of smell or chronic mucopurulence should alert a specialist to a suspected case of CRS.

The Wellington Hospital is one of the first private hospitals to approach these types of upper airway diseases, including a collaborative approach with medical rhinologists. Non-invasive treatment will often obviate the need for surgery, with this approach helping in the prevention of a rapid recurrence of disease after ear, nose and throat (ENT) surgery.

• Allergy • Immunodeficiency • Cystic Fibrosis • Primary Mucociliary Defects • Anatomical including nasal polyposis • Infection and Vasculitis (Wegeners and Sarcoidosis as examples) • Idiopathic

To find out more information about Professor Douglas Robinson and Dr Harsha Kariyawasam, please visit contributors PRACTICE MATTERs Autumn 2014 • 15


GP news Round-up

In the busy world of General Practice, we look at trending stories and interesting updates from the primary care sector.

2015 Events Knee consultations now extended to our WDOC facility We are pleased to announce that an extension of services from the Knee Unit will soon be available at the Wellington Diagnostics & Outpatients Centre, based in Golders Green. We welcome Consultant Orthopaedic Surgeons, Mr Chinmay Gupte and Mr Rahul Patel, who will be offering consultations for patients in the local area and beyond, with treatments taking place in our St Johns Wood facilities. You can learn more about our Knee Unit services by visiting

As part of the 2015 calendar from The Wellington Hospital, healthcare professionals will shortly be receiving information about scheduled events, which include: • Monthly boardroom seminars- a dedicated GP only seminar • Orthopaedic Masterclass- a series of events presented for health professionals with an interest in orthopaedics • Wellington Diagnostic Outpatient Centre monthly seminars • Basic and advanced life support training • Multi-disciplinary tutorials/series/programmes or WEL [Wellington Education Lectures] If you are interested in receiving further information about our events or would like to attend, please contact your dedicated GP Liaison Officer who will ensure you are on the mailing list and will keep you abreast of upcoming events. Alternatively, please visit our events page on our website events-seminars-talks/

COMMENT & DEBATE Are there any topics and educational seminars/training you would like to see in our 2015 calendar? You can contact your dedicated GP Liaison Officer to discuss future events (details on the back cover of this magazine)

Enquiry Helpline: 020

7483 5148

16 • PRACTICE MATTERs Autumn 2014



update... The GP Liaison team at The Wellington Hospital, answer some of your frequently asked questions:

How do I find out more information about The Wellington Hospital? There are many routes available in which you can receive information about The Wellington Hospital: • Website: •M  ailing list: The GP Liaison and Marketing department often send out event information and updates from the hospital. Please check with your dedicated GP Liaison Officer as to whether we have your correct contact details, including mailing address and e-mail. • Practice visits: If you would like to hear about what The Wellington Hospital can provide to your practice and patients, the GP Liaison team are more than happy to arrange a scheduled face-to-face visit. During this, we can explain vital information such as the referral process, hospital services and available consultants. • Information packs/brochures: If you would like further information on the services The Wellington Hospital provides, please contact the GP Liaison department, who can provide you with the necessary literature. • Practice Matters magazine: A quarterly publication produced by The Wellington Hospital for GPs and Healthcare Professionals. This is available online at, if you would like a print version of this, please contact the GP Liaison department who will be able to provide you and your surgery with copies.

How do I refer a patient to The Wellington Hospital? The Wellington Hospital has a dedicated booking telephone line allowing rapid referrals to named and unnamed consultants. The Enquiry Helpline liaises with GPs, consultants, their secretaries and patients, to provide suitable appointments. Our sites include The Wellington Hospital and its satellite outpatient centres; The Platinum Medical Centre and The Wellington Diagnostics & Outpatients Centre. The service provides support with: • S ame day or next day appointments • GP bookings service for our imaging centre, including MRI, CT and ultrasound scans

Our service is currently available 8.00am – 6.00pm, Monday to Friday and Saturdays until 2pm. To refer a patient, please contact The Wellington Enquiry Helpline team on: 020 7483 5148 or email Please be aware the hospital requires a signed referral form for every GP referred patient. We have a selection of downloadable referral forms available to help when requesting an appointment on: These can either be faxed back to us on 0207 483 5618 or emailed to us on the email address above.

When can I expect to receive my attendance certificate from a recent seminar/event I attended? We aim to send attendance certificates for the purpose of CPD, up to two weeks after the event has taken place. You may receive your certificate earlier if an e-mail address is provided, when confirming your attendance. PRACTICE MATTERs Autumn 2014 • 17

News from The Wellington Hospital

news from

Platinum Medical Centre 3rd floor refurbishment 2014 has been a year of much change at The Wellington Hospital with the arrival of our new CEO, Neil Buckley, and the acquisition of state-of-the-art technology as well as the launch and refurbishment of new services and units. This autumn, the refurbished inpatient unit will be opening on the 3rd floor of the Platinum Medical Centre. Patients will benefit from brand new, spacious rooms supported by the latest technology and a team of multi-disciplinary consultants and nursing staff.

The Wellington Hospital clinical partnership with Hocoma We are now a recognised clinical partner with Hocoma, the company that manufacture the assistive technology used in the Acute Neurological Rehabilitation Unit, North Building gym. The therapy team have submitted two case studies that appear on Hocoma’s “Knowledge Platform”. This enables us to participate in clinical studies and be involved in trialling future developments. This year, new software versions for both the Armeo and Lokomat were trialled in the unit, with feedback from staff and patients provided, enabling Hocoma to finalise the final product. We are the only facility in the UK currently using the Erigo, Armeo and Lokomat as an integral part of our patients’ rehabilitation program. We are currently looking at expanding our research portfolio and are keen to be part of the development of clinical guidelines and education material for the use of robotics and assistive technologies in neurological rehabilitation. The Acute Neurological Rehabilitation Unit at The Wellington Hospital is the largest independent rehabilitation unit in the UK. We provide comprehensive and intensive interdisciplinary inpatient rehabilitation programmes to patients (aged 18 and over) with acquired brain injury, neurological conditions and complex medical disability.

There will be more information on this in the next issue.




Dr Stephen Till, Kings College and Guys and St. Thomas

Mr Christopher Dunn, Basildon University Hospital

Mr Raymond Anakwe, St Mary’s



Mr Sanjay Purkayastha, St Mary’s Hospital

Dr Kwok Hung Tang, Barnet Hospital


General Surgery

Dr Alexander Sirker, The Heart Hospital

Mr Gary Atkin, Barnet Hospital


Dermatology Dr Daniel Glass, North West London Hospitals, NHS Trust

Enquiry Helpline: 020

7483 5148

18 • PRACTICE MATTERs Autumn 2014

Mr Joseph Iskaros, UCLH

Mr Bhupinder Mann, Wycombe Hospital Mr Manoj Sood, Bedford Hospital

Radiology Dr Navin Ramachandran, UCLH

60 seconds with...


Most of our staff are trained in numerous types of procedures, which provides variety, flexibility and a better understanding of the whole cardiovascular system

seconds with...

Q&A- Ruth Altmiks- Cardiac Services Manager

PM: How long have you be part of The Wellington? RA: I started at The Wellington Hospital 21 years ago, back in 1993, and have been the cardiac services manager here for the past 10 years. When I first started at the hospital it was called Humana Hospital Wellington. Back then it only consisted of The Wellington North and South buildings, so the hospital has expanded quite a bit since then!

PM: What does an average day for a cardiac service manager involve, and what do you like most about your role? RA: The great thing about my working day is that it varies depending on clinical workload and our staffing situation. I am also very lucky to manage a very good team, who support me in my role. I am responsible for ensuring the cardiology department provides a high-quality, efficient service for patients undergoing any invasive and non-invasive cardiology procedures. As the department provides the full range of diagnostic and interventional procedures, this keeps my role very interesting. Particularly when you have performed a patient’s echocardiogram, showing certain pathology, which one of our cardiologists then confirms via an angiogram later that day.

PM: What made you choose a career in healthcare? RA: I didn’t set out to work in cardiology, specifically. Before coming to the UK, I worked in Germany in a pathology lab, where I mainly performed clinical chemistry and haematology tests. Part of this role was also to record ECGs and EEGs. I came to the UK to improve my English and only intended to stay for a maximum of one or two years. I applied for a cardiographer position at The Wellington Hospital, as I had experience in recording ECGs and I thought it would give me a chance to improve my English. At that time The Wellington worked closely with various hospitals in Germany to help alleviate their waiting lists. Speaking native German was a huge help and possibly the only reason I was appointed, as my English was so bad at the time! However, after a year I was offered the opportunity to train as a cardiac physiologist, which took four years. I completed my training and then, gradually I was promoted through the ranks, starting from student and ending up as Cardiac Services Manager.

Most of our staff are trained in numerous type of procedures, which provides variety, flexibility and a better understanding of the whole cardiovascular system. PM: What is you like most about working at The Wellington Hospital? RA: It has to be the teamwork, most definitely. Everybody makes an effort to help each other to provide a good service. Not just within their own departments but across the entire hospital. What keeps you going on a difficult day? RA: I used to jog on a regular basis which I find helps me to unwind. Unfortunately, I injured my foot a while ago, so now it’s cycling or walking instead. I also find baking very relaxing, so I like to surprise my colleagues from time-to-time by bringing in a cake or two, without a special occasion.

Public focused defibrillator event In September, The Wellington Hospital held our very first defibrillator training session for the public, demonstrating what a defibrillator is, where you can find them, why they are so important and how members of the public can use one. Over the last few years, The Wellington have been hosting regular defibrillator/CPR training events for medical professionals in the local community, but now, with the increase in availability of these potentially life-saving devices in public spaces, the hospital are extending this popular training session to the public too. The event was a great success with participants learning not only how to use a defibrillator, but also what it does, when to use it and how it helps a casualty suffering from a heart attack. The event also taught attendees about basic CPR on adults, children and infants. We are looking at more public focused events for 2015, and will keep you updated via the blog on upcoming events which may be of interest to your patients. PRACTICE MATTERs Autumn 2014 • 19 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

Practice Matters - Autumn 2014