Spring 2015 • Issue 15
A new era in percutaneous treatment
THE MAY FAIR HOTEL
& GROIN WITH SPORT HIP LONDON
THE WELLINGTON HOSPITAL
AN UPDATE ON
THE WELLINGTON HOSPITAL
AN UPDATE ON
ENT CARE FOR GPS
3 SEPTEMBER THE WELLINGTON HOSPITAL
THE MAY FAIR HOTEL
INTRODUCING THE WELLINGTON EVENTS SYSTEM FOCUS ON
A new surgical approach
& GROIN W HIP LON
& GROIN HIP L
ON THE GASTRIC SYSTEM
GASTROENTEROLOGY FOR GPS
THE WELLINGTON HOSPITAL
FOCUS ON THE HIP
FOCUS ON THE HIP
ON THE GASTRIC SYSTEM
& GROIN WITH SPORT HIP LONDON
WORKING TOGETHER 24 JUNE
1 OCTOBER THE WEL HO
THE MAY FAIR HOTEL
AN UPDATE ON
THE WELLINGTON HOSPITAL
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FOCUS ON THE
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ORTHOPAEDI MASTERCLAS LOWER LIMB
THE MAY FAIR HOT
The Wellington Hospital South Building
The Wellington Hospital North Building
Platinum Medical Centre
The Wellington Diagnostics and Outpatients Centre
WELCOME Our spring issue is always a good time to reflect on what we have to look forward to in the coming months. As I complete my first full year as CEO at The Wellington, I am pleased to see the hospital continue its development. In 2014, we launched new groundbreaking units, including the Neuroendocrine Tumour Unit and the Prolonged Disorders of Consciousness Unit, which have seen patients coming from across the world to be treated by London’s leading consultants; proving that the hospital’s 40 year reputation for excellence is stronger than ever. 2015 has already seen us re-launch our educational events programme, which is now held at our new central London location: The May Fair hotel (more about this on page 17). We received great feedback from our first event of the year, which looked at the development of our cardiac services and advancing treatments. With a full schedule for the remainder of the year, you can find out more about these at TWHevents.co.uk IN THIS ISSUE: We are pleased to introduce a new service available at the Platinum Medical Centre, which offers a comprehensive genetic testing service for cancer screening. GeneHealthUK has already begun its clinics here, which you can read more about on page 7. Also in this issue, we look at the surgical advances in urology, colorectal and hepatobiliary surgery, as well as developments in endocrinology and cardiology, plus an update on our Acute Neurological Rehabilitation Unit’s IMTJ award. You can also keep up-to-date with some big announcements which will be rolling out through the rest of 2015 in future editions of Practice Matters, or online at practicemattersmag.co.uk Best wishes,
Neil Buckley CEO
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Editor: Claire McKinson Production & Distribution: Runwild Media Group
CONTENTS 04 | Colorectal cancer surgery: a new approach Mr Jonathan Wilson and Mr Lee Dvorkin
06 | Introducing... the UroLift® System
Mr Ranan DasGupta
07 | Genehealth UK: Genetic screening arrives at The Wellington 08 | Common and not so common swellings at the Distal Interphalangeal Joint (DIPJ)
Miss Barbara Jemec
10 | Vascular resection in patients with pancreatic cancer Mr Giuseppe Kito Fusai
11 | Hypothyroidism and reproductive health Dr Mark Vanderpump
12 | A new era in percutaneous treatment of coronary disease Dr Tim Lockie
14 | Advanced endoscopic options Dr Edward Despott
15 | Case study series: Respiratory Dr Michael Beckles
16 | GP news
18 | Latest news and new consultants 19 | 60 Seconds with...
www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 • 3
COLORECTAL CANCER SURGERY: A NEW APPROACH By Mr Jonathan Wilson and Mr Lee Dvorkin With over 35,000 new cases diagnosed each year, colorectal cancer is the second most common cause of cancer death. Within this statistic, the overall five year survival rate is 50 per cent. The mainstay of treatment for confirmed colorectal adenocarcinoma is surgical resection, removing the tumour and its surrounding lymph node package. Reconstruction of the bowel ends with an anastomosis is usual but a stoma is sometimes needed.
Traditional methods Traditionally, such surgery involves oral bowel preparation to cleanse the colon, a midline laparotomy incision and an average stay of 10-14 days in hospital. With a reported mortality of around four per cent in elective resection, in patients under 80 years old, and eight per cent in octogenarians, there is a significant risk. The most feared surgical complication is anastomotic breakdown, which (while uncommon) imparts significant morbidity and mortality and may require a permanent stoma. Additionally, patient experience whilst undergoing bowel resection is often poor, with pain and reduced mobility both contributing factors.
Improving care Efforts have been made in an attempt to improve the perioperative/postoperative care of these patients. A multi-modal programme of management was described in Denmark in the 1980s, in order to improve the patient experience
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Only 40 per cent of operable cases are performed laparoscopically by reducing the physiological disturbance of surgery; hence the reduction in the length of stay. This is now referred to as an Enhanced Recovery Programme (ERP). The mainstay of any ERP is laparoscopic surgery with a dedicated anaesthetic and nursing team, who are familiar with the
importance of early mobilisation, contemporary perioperative analgesia and early enteral feeding regimes. Despite laparoscopic colorectal surgery first being reported in 1991, nationwide only 40 per cent of operable cancer cases are performed laparoscopically, with a similar number of patients enrolled in a dedicated ERP. Increasingly within the NHS, dual-consultant surgeon operating is becoming commonplace for high-risk individuals, with advantages including quicker operating time and less perioperative bleeding.
Here at The Wellington Hospital GI Unit, Consultant Colorectal Surgeons Mr Lee Dvorkin and Mr Jonathan Wilson, together with a dedicated nursing and anaesthetic team, are leading the way in colorectal cancer surgery, with impressive results. Patient Case Study
Consultant Colorectal Surgeon
An 80 year old man with a history of atrial fibrillation and renal impairment, presented with anaemia. A colonoscopy diagnosed a caecal adenocarcinoma (CT staging T3N0M0). The MDT confirmed the need for a laparoscopic right hemicolectomy. After a pre-assessment check, the patient was judged fit for surgery, but was deemed high risk given his co-morbidities.
This may be considered as a paradigm shift in the care of surgical patients, but we feel that this should now be the gold standard. Although
Mr Lee Dvorkin
The benefits of dual consultant laparoscopic surgery & ERP
Our patient underwent a general anaesthetic with spinal anaesthesia. An oesophageal doppler was used to guide intra-operative fluid replacement, during surgery (contemporary ERP practice). A laparoscopic right hemicolectomy was performed without complication, using a 5cm epigastric incision for specimen extraction. Post-operatively, he required minimal analgesia and only required one night in ICU. Nursing staff and physiotherapists were pleasantly surprised by the speed of recovery afforded by laparoscopic surgery, which also facilitated the establishment of oral intake on day one and removal of the urinary catheter on the second post-operative day. Surgical recovery was complete on day five, when warfarin was re-commenced.
Mr Lee Dvorkin is a Consultant Colorectal Surgeon at The North Middlesex University Hospital where he is Clinical Lead for the Department of Surgery. His interests are laparoscopic colorectal cancer surgery, inflammatory bowel disease and proctology (advanced fistula surgery and neuromodulation for incontinence).
Mr Jonathan Wilson PhD FRCS
Consultant Laparoscopic Colorectal and General Surgeon open laparotomy remains commonplace in the UK, we feel it is to the disadvantage of patients not to be offered the package of care described here, which aims to make this aspect of treatment as dignified and painless as possible.
To find out more about colorectal cancer surgery at The Wellington Hospital, please visit: www.thewellingtongiunit.com
Mr Jonathan Wilson is a Consultant Laparoscopic Colorectal and General Surgeon at the Whittington Hospital, London, where he is the Clinical Lead for colorectal cancer. His interests are laparoscopic surgery for colorectal cancer and inflammatory bowel disease, advanced colonoscopy and proctology (contemporary haemorrhoidectomy “haemorrhoidal artery ligation”).
www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 • 5
THE UROLIFT SYSTEM ®
By Mr Ranan DasGupta
Over the past two decades, prostate treatments have witnessed the extraordinary union of technological progress along with the refinement of surgical technique; leaving urologists with a wide armamentarium for both benign and malignant prostatic disease. Surgical treatment for benign prostate hyperplasia (BPH) has been underpinned by the durability of transurethral resection of the prostate (TURP), itself founded on Harold Hopkins’ description of rod-lens endoscopy. Whereas, ablative therapies, such as transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA) have never challenged the dominance of TURP, more recent challengers such as bipolar energy and laser energy offer the benefits of TURP (removal of obstructive tissue) with some greater safety features (in terms of bleeding, TUR syndrome, etc), reflected by their widespread adoption. However, the main side effect of any of these procedures is retrograde ejaculation, reported in up to 80-90% of patients. This has clearly significant implications, particularly in those who wish to fully preserve active sexual function. This is a key reason why the development of the UroLift® System is an exciting adjunct to existing treatment strategies. It relieves prostate obstruction and opens the urethra directly by retracting the obstructing prostatic lobes without cutting, heating,
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or removing prostate tissue. The device is applied by endoscopic equipment which urologists routinely use, pushing aside the obstructive prostate lobe. Small, permanent UroLift® implants are deployed, holding the lobes in the retracted position, and thus opening the urethra while leaving the prostate intact.
across the various studies, showing rapid relief within two weeks and sustained effect to two years.
What are the benefits of the UroLift® System over traditional TURP or laser procedures? Bleeding is much less than with TURP, with a 0% transfusion rate to date for UroLift® vs. 5%-7% for TURP. Postoperative catheterisation has been shown to be 30%-35% (compared to standard protocol for TURP) with a mean duration of 0.9 days (compared to 1-5 days for TURP). An additional unique benefit is the preservation of sexual function. In all studies to date, there has been 0% incidence of de novo, sustained erectile dysfunction or ejaculatory dysfunction.
In January 2014, the National Institute for Health and Clinical Excellence (NICE) issued an Interventional Procedure Guidance (IPG) approving its use in the UK, gaining CE mark in Europe and FDA clearance in the USA. In the UK, the UroLift® System is indicated for the treatment of outflow obstruction, secondary to BPH, in men aged 50+. The safety and efficacy of the UroLift® System has been demonstrated in numerous studies, including a randomised double-blinded study from the USA, a European retrospective registry, and several open label studies. Improvement in urinary symptoms, as seen through reduction in IPSS (International Prostate Symptom Score), has been consistent
What are the side effects? In our clinical studies to date, the most common adverse events reported included: hematuria, dysuria, micturition urgency, pelvic pain, and urge incontinence. Most symptoms were mild to moderate in severity and resolved within two to four weeks after the procedure. The primary contraindication to the UroLift® System is an obstructive or protruding median lobe of the prostate.
To find out more information about Mr Ranan DasGupta please visit www.practicemattersmag.co.uk/ contributors
GENEHEALTH UK: GENETIC SCREENING ARRIVES AT THE WELLINGTON In March this year, GeneHealth UK began holding regular clinics at the Platinum Medical Centre. Sessions are run by genetic counsellor, Vicki Kiesel, who offers private genetic tests for a range of cancers, including breast, prostate, bowel and ovarian. Although cancer is not often inherited, in some families there may be an increased risk due to a genetic mutation. GeneHealth UK is the leading provider of early detection services and offers clinical diagnostics designed to detect cancer at an early stage, increasing the opportunity for successful treatment. Genetic testing can help determine the risk of cancer within a family and guide appropriate cancer screening for that patient. Specific screening tests are administered depending on the genetic risk of the individual, with risk reducing strategies also considered.
Genetic testing Historically, the remit of genetic testing has been to assess the risk of future cancers. But through the use of Sanger sequencing single genes, this has taken months, even years, to analyse. With the advent of Next-Generation Sequencing, multiple genes can now be simultaneously analysed, providing results within weeks and allowing testing at the point of diagnosis. This has meant that genetic testing is now becoming incorporated into the treatment pathway of cancer patients, guiding their current cancer management and future risk reduction options.
BreastGene and BRCA1 & BRCA2 BreastGene is part of the GeneHealth UK service, and looks at 10 specific genes which cause an increased risk of breast cancer, particularly breast and ovarian cancers, including BRCA1 and BRCA2.
Statistics on genetics • 5-10% of cancer is inherited • BRCA mutations are the cause of approximately 20% of ovarian cancer cases • 1 in 40 people of Ashkenazi Jewish ancestry have a mutation in BRCA1 or BRCA2 • Women with BRCA1& BRCA2 mutations have up to an 85% lifetime risk of breast cancer • Women with BRCA1/BRCA2 have up to a 60% risk of ovarian cancer • Men with BRCA2 have a 25% risk of prostate cancer and a 5-10% risk of male breast cancer • There is no effective ovarian cancer screening, so risk reducing surgery is the only option.
For women who’ve been diagnosed with breast cancer the identification of a BRCA mutation makes a big difference. Instead of a wide local excision followed by radiotherapy, women with BRCA mutations may opt to have a bilateral mastectomy, particularly because studies have now shown this results in a clear survival benefit. It is also important that women with BRCA1-associated triple negative breast cancer have chemotherapy regardless of stage, as this has also been shown to create a survival benefit. All women with BRCA mutations should consider a bilateral salphingo-ophorectomy once they’ve completed their families and are aged 40+. Once a BRCA mutation has been identified it is then possible to offer predictive testing to relatives, with first degree relatives having a 50% chance of also carrying the mutation. Unaffected women can then be offered increased breast cancer surveillance, chemoprevention and risk reducing surgery.
Results for comprehensive BRCA testing are available in 4 weeks. BRCA testing for the Jewish mutation are available within 2 weeks. Cancer panel tests are available in 10 weeks
For further information about genetic testing, please head to GeneHealthUK.com
www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 • 7
HAND AND WRIST UNIT
COMMON AND NOT SO COMMON SWELLINGS AT THE DISTAL INTERPHALANGEAL JOINT (DIPJ) By Miss Barbara Jemec
The mucous cyst The mucous cyst is a ganglion of the distal interphalangeal joint which presents as a swelling of the DIPJ, with a thin overlying skin. It is the most common swelling of this joint, connected with osteoarthritis and usually caused by an osteophyte in the joint. Synovial fluid in the DIPJ forces its way through the joint capsule (in the form of a ganglion), appearing as localised swelling. If the mucous cyst is allowed to discharge spontaneously, it presents an open joint which can lead to infection and consequent destruction of the joint. The cysts are best treated with excision, and the skin reconstructed with a local flap from the dorsum of the digit. Before the capsule is securely repaired, the cyst needs to be chased all the way to the joint, which is then washed out and osteophytes removed.
Heberden’s node These types of swelling are connected with osteoarthritis, and represent an osteophyte formation at the DIPJ. Although surgery brings temporary cosmetic improvement, there is no lasting functional advantage. (Fig 2)
Giant cell tumours These are tumours of the tendon sheath, with the same histology as pigmented villonodular synovitis (PVNS). They present on the fingers - often on the volar surface - and are slow-growing, painless tumours with a high recurrence rate, as they
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grow around tendons. The choice of imaging is ultrasound, but MRI with contrast is often better for investigation. (Fig 3)
Mallet finger Mallet fingers (avulsion of the insertion of the extensor tendon at the DIPJ, with or without a piece of bone) can present with a dorsal swelling of the DIPJ and an extensor lag. They are initially treated with six to eight weeks splinting, which can be attempted even if they present late. Surgery consists of repairing the tendon or re-inserting into the bone, but more often fusion will be used, particularly in late presentations.
Enchondromas These occur as single or multiple tumours of the hand (and foot), with the latter potentially being
part of Ollier’s disease or Maffucci’s syndrome. They present as painless swellings that can become invasive enough to deform or fracture bone. They rarely become cancerous, but are treated with curettage and bone graft. Patients should be followed up, with X-rays, on a regular basis. (Fig 4)
Gout Tophi can present anywhere on the upper extremity, although it mostly occurs around joints. The treatment for this type on condition is excision.
To find out more information about Barbara Jemec please visit www.practicemattersmag.co.uk/ contributors
MEDICAL REHABILITATION SERVICES ACROSS LONDON The Wellington Hospital and The Portland Hospital offer a full rehabilitation service for adults and paediatrics. With both hospital’s acute neurological rehabilitation units delivering the highest standards of care, they are regarded as the premier centre for private rehabilitation in the UK. Together, they offer extensive gym and treatment areas and provide individualised programmes, which are consultant led and delivered by expert multidisciplinary teams.
FOR ADULT REHABILITATION
FOR PAEDIATRIC REHABILITATION
Conditions Treated: • Head Injuries • Spinal Injuries • Stroke • Rehabilitation following Critical Illness • Functional Restoration Programmes • Congenital Disorders
The Team: • Consultants • Dietitians • Language Interpreters • Neurophysiotherapists • Neuropsychologists • Occupational Therapists • Rehabilitation Advisors • Rehabilitation Nurses • Speech and Language Therapists
Conditions Treated: • Acquired Brain Injury • Cerebral Palsy • Neurodevelopment Disorder and Global Development Delay • Surgical Rehabilitation
The Team: • Dietitians • Occupational Therapists • Physiotherapists • Neuropsychologists and Clinical Psychologists • Play therapists • Music therapists
Tel: 020 7586 2462 www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 • 9
VASCULAR RESECTION IN PATIENTS WITH PANCREATIC CANCER By Mr Giuseppe Kito Fusai
In the UK, there are more than 8,000 new cases of pancreatic cancer diagnosed every year, making it the fourth leading cause of death from cancer. The prognosis of this condition is extremely poor, primarily because of the late diagnosis, as symptoms tend to frequently occur when the disease is already advanced. More than half of patients with pancreatic cancer have metastases, with 25% presenting with locally advanced disease at the time of diagnosis. In addition to this, (approximately) 15-20 % of cases have resectable tumours. As surgery remains the only potentially curative option, and the only treatment associated with long-term survival, the definition of ‘operable’ and ‘resectable’ is of crucial importance.
In the last decade a new category has emerged, the ‘borderline resectable’, characterised by the relationship of the tumour with the major vessels, arteries and veins adjacent to the pancreas. The pancreas is deeply located in the retroperitoneal space behind the stomach, lying over the aorta and the inferior vena cava. It is intimately adherent to major vascular structures, particularly the superior mesenteric vessels, the portal vein, the common hepatic artery and the coeliac trunk. The relationship between the tumour, veins and arteries is what determines whether a patient is operable or not. Patients with involvement of the portal vein and superior mesenteric vein should be offered surgery with the view to remove the tumour en-bloc with the vein. Occasionally, this is reconstructed by using a graft to fill the gap left. This type of surgery is complex and is only performed in specialist centres, but has been associated with similar perioperative mortality and complication risk as standard pancreatic resections. Despite the recommendations by several authorities and boards, unfortunately there are still many centres where portal vein resection is not routinely carried out. The resection of the arterial vessels in patients with pancreatic cancer remains more controversial, though some of these cases are also defined
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More than half of patients with pancreatic cancer has metastases, with 25% locally advance disease at the time of diagnosis as borderline, depending on the degree of arterial involvement. In view of our extensive experience with portal vein resection, we have recently started a prospective international study to assess the value of arterial reconstruction during pancreatectomy for cancer. This type of surgery is even more complex and is performed in very few centres in the world, but our preliminary experience is encouraging. As a part of the study protocol, these patients receive some chemotherapy for three months followed by a shorter course of chemoradiation, with the view to shrink or at least stabilise the disease, prior to surgery.
To find out more information about Mr Giuseppe Kito Fusai please visit www.practicemattersmag.co.uk/ contributors
HYPOTHYROIDISM AND REPRODUCTIVE HEALTH By Dr Mark Vanderpump
Thyroid disease is associated with subfertility which affects between 1% and 5% of couples. Thyroid hormones (triiodothyronine (T3) and thyroxine (T4)) have key roles in growth and development. Thyroid disease is common in women of reproductive age, and changes in thyroid function can impact greatly on reproductive function before, during and after conception. Overt hypothyroidism affects 0.5% of women of reproductive age. Mild thyroid failure or subclinical hypothyroidism has a prevalence of approximately 2–4%. It is characterised by raised serum thyroid-stimulating hormone (TSH) of >4.5mU/l in combination with a normal free T4 (9–25pmol/l) and no clinical symptoms or signs of hypothyroidism. Women with subfertility have raised mean serum TSH levels and increased rates of subclinical and overt hypothyroidism compared with controls. Raised serum TSH >2.5mU/l may be associated with reduced rates of fertilisation during assisted conception and reduced pregnancy rates. Improvements in implantation, pregnancy and live birth rates are reported following treatment with levothyroxine (L-T4) in overt and subclinical hypothyroidism. However, even following L-T4 replacement therapy, egg numbers and fertilisation rates,
and implantation, pregnancy and live birth rates appear to be reduced compared with euthyroid controls. Serum TSH levels <2.5mU/l are recommended pre-conceptually in the subfertility setting, in line with the guidelines for first trimester serum TSH. Autoimmune conditions are implicated in subfertility and there has been longstanding speculation over the importance of thyroid autoantibodies in subfertility. Autoimmune thyroid disease (AITD) is the most common cause of hypothyroidism in women of reproductive age. Thyroid autoantibodies are present in almost all patients with Hashimoto’s thyroiditis, two-thirds of those with post-partum thyroiditis and three-quarters of those with Graves’ disease. Thyroid autoimmunity is present in 25% of the general population and is consistently increased in the subfertile population, compared with fertile controls. A proportion of people with AITD have normal serum TSH. Thyroid autoantibodies are an early sign of lymphocytic infiltration and therefore a predictor of thyroid disease. Increased rates of subfertility are seen in euthyroid women with AITD and it is the management of this
group that has created the greatest debate among clinicians. There is little evidence to suggest whether treating euthyroid women with AITD with L-T4 in the assisted reproduction setting improves outcome. It seems reasonable to measure thyroid function routinely in women presenting with subfertility initially by a serum TSH measurement. Given that improvements in reproductive outcomes are observed in serum TSH <2.5mU/l, serum TSH levels should be maintained <2.5mU/l for those with clinical and subclinical hypothyroidism. Subclinical hypothyroidism (serum TSH >2.5mU/l) should prompt a repeat serum TSH level and for thyroid autoantibodies to be checked. If the serum TSH persists >2.5mU/l, treatment with L-T4 is warranted to bring the TSH <2.5mU/l. The dose of L-T4 should be titrated until the serum TSH is brought to 2.5mU/l or less, and during this period monitoring of free T4 and serum TSH every six weeks is warranted. The evidence is lacking over the benefit of commencing L-T4 in those who are euthyroid with AITD. It should, however, prompt close monitoring of thyroid function if pregnancy does result, with monitoring of foetal wellbeing and, subsequently, neonatal review.
To find out more information about Dr Mark Vanderpump please visit www.practicemattersmag.co.uk/ contributors
www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 • 11
A NEW ERA IN PERCUTANEOUS TREATMENT OF CORONARY DISEASE By Dr Tim Lockie
When percutaneous coronary angioplasty was first performed in 1977, it revolutionised the treatment of coronary artery disease. Although it meant that patients were able to undergo myocardial revascularisation, without the trauma of openheart surgery and cardiopulmonary bypass, its outcomes were bedeviled by early lesion failure due to elastic recoil, acute vessel closure due to dissection, and re-stenosis. Since these pioneering days, there have been huge leaps forward in device technology, adjuvant medical therapy, and intravascular imaging and diagnostics that have resulted in major improvements in procedural technique and clinical outcome. Percutaneous coronary intervention (PCI) is now the dominant means of coronary revascularisation in the UK with almost 100,000 procedures carried out last year. Rates of coronary bypass surgery continue to fall, with fewer than 20,000 operations performed over the same period.
dilated artery, sealing the dissection flaps, preventing acute recoil and reducing late restenosis. These early stents were bulky, difficult to deliver and generally only used in cases of bailout or abrupt vessel closure after balloon angioplasty. The early stents were also limited by a high incidence of acute stent thrombosis due to inadequate platelet inhibition, and by high rates of in-stent restenosis in the medium and longer term.
Era 3: Drug-eluting coronary stents Drug-eluting stents (DES) were developed in the early 1990s by coating BMS with anti-proliferative drugs, to overcome rapid, reactive cell growth within the stent. Drug-eluting stents have significantly reduced in-stent restenosis and the need for repeat revascularisation procedures, especially in high-risk groups, such as diabetics, or patients with complex lesions requiring long stents, or bifurcations using multiple stents. This third revolution resulted in a major reduction in complications, and improvements in procedural success. It also coincided with significant advances in adjuvant medical therapy with the advent of powerful antiplatelet drugs such as clopidogrel and ticagrelor, replacing treatment with aspirin monotherapy, ticlopidine, and even warfarin, in the early days.
There have been four distinct eras in the evolution of PCI.
Systematic improvements in PCI techniques were also developed during this time, assisted by highly sophisticated intravascular imaging, and intracoronary physiology measurements to help determine which lesions would benefit from treatments and to optimise results. DES are now used in 90% of PCI procedures.
Era 1 and 2: Balloon angioplasty, and the development of bare metal stents
Era 4: Bioresorbable scaffolds and beyondâ€Ś
After the first revolution of balloon angioplasty in the late 1970s, the second revolution came in the mid-1980s with the development of bare metal coronary stents (BMS). These were used to overcome some of the early shortcomings of balloon angioplasty, by scaffolding the balloon-
An on-going concern of the early DES was the risk of late stent thrombosis, due to metal struts remaining exposed for many months, or even years after implantation. Newer-generation DES encourage the re-growth of the protective endothelial layer over the exposed stent struts
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Illustration of Abbott’s Absorb in Blood Vessel
Illustration of Abbott’s Absorb Being Resorbed
Dr Tim Lockie
MBChB, BSc.Med Sci, PhD, MRCP
The last four decades have changed the way we understand and manage coronary disease beyond recognition and have a considerably improved safety profile. However, these stents still leave a permanent metal implant inside the vessel, with potential future problems and the need for prolonged periods of treatment with dual antiplatelet therapy. Completely bioresorbable stents (referred to as scaffolds) are made from a polymer, with no metallic structural components. They can provide support to the vessel wall (similar to a conventional stent) for a defined period after angioplasty, but are subsequently resorbed. This may be especially important in younger patients keen to avoid the presence of a permanent stent in their coronaries; or those
with a very diffuse pattern of disease; or at ongoing risk of late stent thrombosis. Although still beyond everyday use, such devices may represent the ‘holy grail’ in PCI, whereby it is possible to revascularise a coronary vessel safely, avoiding the acute complications, but then allowing the vessel to heal itself without the ongoing problems of a perpetual foreign body within. The last four decades have changed the way we understand and manage coronary disease beyond recognition. Who knows whether Andreas Gruentzig, the interventional cardiologist who performed the first balloon angioplasty back in 1977, could have imagined how far his groundbreaking work would have led?
To find out more information about Dr Tim Lockie please visit www.practicemattersmag.co.uk/ contributors
Dr Tim Lockie is a Consultant Interventional Cardiologist at the Royal Free London NHS Foundation Trust, and The Wellington Hospital; specialising in complex PCI, primary angioplasty for acute heart attacks, intravascular imaging and coronary physiology. He is the clinical lead for the cardiac catheterisation labs at the Royal Free and in developing local guidelines. He is a regional specialty advisor for the British Cardiac Society and the Royal College of Physicians, representing the North Central London region. He was recently appointed as an Honorary Clinical Senior Lecturer at the Cardiovascular Institute, UCL. Dr Lockie believes in a multidisciplinary and holistic approach to the treatment of patients with cardiac problems involving the latest and most sophisticated investigations and techniques, but also careful clinical assessment, always placing the patient’s needs and concerns at the centre of any management plan.
www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 • 13
ADVANCED ENDOSCOPIC OPTIONS FOR MINIMALLY INVASIVE MANAGEMENT OF SMALL BOWEL AND COLORECTAL PATHOLOGY By Dr Edward Despott
Endoscopic minimally invasive management of small bowel pathology Until recently, the only options for endoscopic assessment of the small bowel (SB) were ‘push’ enteroscopy (which only visualises of the most proximal SB), or the significantly invasive intraoperative enteroscopy (IOE) (which exposes patients to the risks and morbidity of major surgery). More recently, SB capsule endoscopy (SBCE) and double-balloon enteroscopy (DBE) have revolutionised endoscopic investigation and management of SB disease. Although SBCE and DBE are complementary, the role of SBCE is solely diagnostic while DBE also allows tissue biopsy and therapeutic options and is frequently performed following SBCE when abnormalities have been Fig 1
pan-enteroscopy and provides a minimally invasive alternative to IOE. DBE allows for controlled, direct endoscopic characterisation of lesions and tissue biopsy and enables the application of endotherapy, such as treatment of vascular lesions; dilatation of strictures, polypectomy and direct percutaneous endoscopic jejunostomy placement. DBE has been evidenced to be safe and effective (overall complication rates <1%) and has also been shown to obviate the need for operative surgery. It is nonetheless, a complex advanced endoscopic procedure which requires years of dedicated training and is only available in a handful of specialist centres in the UK. The Wellington Hospital is shortly to become the only private hospital in London to provide a DBE service.
Endoscopic minimally invasive management of colorectal pathology
identified. DBE overcomes the challenges of SB anatomy by the employment of a 200cmlong enteroscope, 2 balloons and a stabilising overtube (Figure 1). The 2 balloons allow for gentle traction of the SB wall for plication of the SB onto the overtube during step-wise ‘push-andpull’ manoeuvres. With its ability to be performed via both the oral or rectal routes, DBE facilitates
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Early detection and removal of pre-malignant pathology (adenomata and sessile serrated lesions) by minimally invasive endoscopic techniques at colonoscopy are the evidence-based mainstay of prevention of colorectal cancer (CRC). Although many of these pre-malignant lesions are amenable to simple polypectomy, larger, sessile lesions, such as laterally-spreading tumours (LSTs), usually require advanced endoscopic resection techniques including piecemeal endoscopic mucosal resection (P-EMR) or the more complex endoscopic submucosal dissection (ESD) or hybrid EMRESD techniques (Figure 2). EMR involves the Fig.1. Double-balloon enteroscope (A); Dr Despott performing DBE (B); Fluoroscopic image demonstrating pan-enteroscopy at anterograde (oral) DBE with enteroscope entering the caecum (6.5m distal to the pylorus) (C); Crohn’s disease of the jejunum confirmed by biopsies taken at DBE (D); SB stricture before (E) and during endoscopic dilatation at DBE (F); Coagulation of SB vascular lesions at DBE (G); Direct percutaneous endoscopic jejunostomy (DPEJ) tube flange in situ within the jejunum after placement at DBE (H).
injection of fluid into the submucosal space to raise a mucosal lesion away from the muscularis propria and allow safe resection with a diathermic snare. If deemed suitable for endoscopic resection Fig 2
after careful evaluation with chromoendoscopy, large lesions usually require P-EMR. Although in appropriate cases, P-EMR is usually a relatively safe and effective technique, some pathology (e.g. sessile lesions with a higher intrinsic malignant potential or neuroendocrine tumours of the rectum) may require more complex techniques, including ESD or a hybrid EMR-ESD. ESD requires the use of a dedicated diathermic-knife for dissection of submucosal and fibrotic tissue underlying a lesion. Although the procedure is highly complex and carries a greater risk of complications, in carefully selected cases, it may offer an alternative to major surgery.
To find out more information about Dr Edward Despott, please visit www.practicemattersmag.co.uk/ contributors
Fig. 2. 4cm adenomatous granular laterally spreading tumour (LST-G) of the ascending colon with underlying scarring and fibrosis (A) being resected by a hybrid EMR-ESD technique (B) with end result demonstrating resection site of the same lesion (C); Another LST-G of the rectum after resection by P-EMR (different patient) (D); Small neuroendocrine tumour (NET) of the rectum during ESD (E) and after resection (F) (different patient).
CASE STUDY SERIES: RESPIRATORY By Dr Michael Beckles
The following case history discusses the management, differential diagnoses, and response to treatment, of a young female patient diagnosed with a mucinous cystic adenocarcinoma.
(haemoglobin 103, MCV 69); CRP 42, ESR 20. Urea and electrolytes were normal, as were autoantibodies, complement, liver function tests and blood cultures.
Case History A 32-year-old lady was referred to me for a second opinion. She had been BCG-vaccinated, but believes that she might have been exposed to clients who had active pulmonary tuberculosis. She presented with a three-month history of cough, dyspnoea, night sweats and weight loss. She stopped smoking four years ago, and there was no other family history of note. She had been prescribed courses of Augmentin, Amoxicillin, and Clarithromycin, but her cough persisted. Indeed, her cough worsened after her return from the Caribbean. On examination, there were obvious signs of weight loss, but examination of the fingers, neck and mouth was normal. Cardiovascular examination was normal. Oxygen saturation was 98% on room air, and breath sounds were reduced bilaterally, with some crackles at the right base. The rest of the examination was normal.
Questions: What would you do next? 1. Give a further course of antibiotics? 2. Refer to a thoracic surgeon? 3. Refer to a chest physician?
Discussion She had recently returned from the Caribbean, where there was an outbreak of chikungunya. Chikungunya is a mosquito-borne infection which can be associated with malaise, lethargy, and can persist for between four to six weeks. It is usually self-limiting, and is not often associated with cough and weight loss. Tuberculosis was unlikely and HIV test was negative.
Connective tissue disorders enter the differential diagnosis, but blood tests excluded this. She had already undergone pleural fluid cytological examination, which revealed an exudate, but the pleural fluid cytology was negative for malignant cells.
Her CT scan of the thorax showed bilateral pleural effusions (larger on the left), bi-basal atelectasis and a small pericardial effusion. Blood tests revealed a microcytic anaemia
Therefore I organised for her to undergo a right surgical pleural biopsy (rather than a repeat ultrasound-guided pleural sampling) as surgical
biopsies allow for direct viewing of the pleura to see if there is any evidence of malignancy with seeding, as well as for allowing biopsies of the pleura and lung and further pleural fluid sampling. Histopathology revealed a mucinous cystic adenocarcinoma. This was subsequently also found on the left. She underwent a left-sided talc pleurodesis, and is currently undergoing chemotherapy.
Discussion Points 1. This woman looked unwell, and her symptoms did not respond to multiple courses of antibiotics that were appropriate for a community acquired pneumonia. She therefore required further investigation to obtain a definitive diagnosis. 2. Thoracentesis only revealed an exudate. Pleural fluid cytology is dependent upon the cellularity of the specimen, and often it takes two or three specimens to obtain a diagnosis. Negative pleural fluid specimens can lead to false reassurance.
For more information about Dr Michael Beckles and our respiratory services, please visit www.thewellingtonhospital.com
www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 â€˘ 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
DUTY OF CANDOUR – WHAT DOES IT MEAN FOR GP PRACTICES? This April saw the duty of candour regulation come into effect for GP practices and independent practitioners in England, under the Health and Social Care Act 2008, following its statutory introduction back in November 2014. Although GPs have always had an ethical obligation to be honest and transparent with their patients, it is now a legal duty. We take a look at the main questions surrounding this change to GP practice and what it means for you… Why did this regulation come into effect? It was recommended by The Francis Inquiry report into Mid Staffordshire NHS Foundation Trust, following the trust’s failures of care. What are the regulation’s aims? It intends to ensure that providers are open and transparent with people who use services, and other relevant persons, in relation to care and treatment. It sets out specific requirements that providers must follow when things go wrong with care and treatment. This includes: • Informing people about the incident • Providing reasonable support • Providing truthful information • Offering an apology when things go wrong
What does it mean for GP practices? It means that practices must promote a culture that encourages candour, openness and honesty, at all levels. CQC guidance says that providers should have policies and procedures in place to support this culture, as well as ensuring that all staff follow these. Any concerns and complaints should be able to be raised freely, without fear, and any questions that are asked should be answered. Information regarding the truth about performance and outcomes should be shared with staff, patients, the public and regulators. And, any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or the incident questioned.
What does the regulation constitute as a notifiable safety incident? • • • • • •
The death of the patient, where the death relates directly to the incident, rather than to the natural course of the service user’s illness or underlying condition An impairment of the sensory, motor or intellectual functions of the patient, which has lasted, or is likely to last, for a continuous period of at least 28 days Changes to the structure of the service user’s body The service user experiencing prolonged pain or prolonged psychological harm The shortening of the life expectancy of the service user Requirement for additional treatment to prevent one of the harms described above
Remember to… • Ensure that once the patient is advised verbally of an incident, that this is followed up with a written note of the discussion • Keep copies of all correspondence with patients and make details on the patient’s medical record To read regulation 20 in full, and the accompanying guidance notes, please visit: www.cqc.org.uk/content/regulation-20-duty-candour#guidance
COMMENT & DEBATE Which topics would you like to see covered in coming issues of Practice Matters? You can contact your dedicated GP Liaison Officer directly with your ideas (details on the back cover of this magazine).
Enquiry Helpline: 020 16 • PRACTICE MATTERS SPRING 2015
UPDATE... BOOK ONLINE WITH OUR NEW EVENTS SYSTEM This spring we launched our new online event system: www.twhevents.co.uk. This booking system was created specifically for health professionals to view upcoming major events, book a place at these events and manage certificates of attendance. You can also keep your contact information up-to-date and view past events, topics and speakers. Registering to book online To start using this system, simply log onto www.twhevents.co.uk, and click ‘Register’ where you’ll need to enter the following details: 1. Your name, the practice/clinic you are based at, your job title and contact details 2. How you would like to receive communication about our events 3. How you would like to receive attendance reminders, event invitations and event news 4. Accept our terms & conditions 5. Finally, sign up to attend one of our education events and then you are ready to go. Safe and secure Our event system is secure to use and your personal details are kept safe. For further enquiries, please contact our administrative team: firstname.lastname@example.org
specifically tailored for GPs, with talks given by our leading consultants, speaking on important topics relating to primary care. There is also an opportunity to raise any questions you may have with the guest speakers. The masterclasses are limited to 60 GPs, and spaces are reserved on a first come first served basis. If you would like to attend these exclusive masterclasses, please contact the events team, on email@example.com or register your interest on our new events booking system www.twhevents.co.uk. These exclusive evenings include a drinks reception, followed by a buffet dinner after the lecture. Workshops The GP Liaison team always aim to provide local GPs and their patients with a personal service at The Wellington Hospital. Part of this offer also includes providing GP communities, and their practices, with educational support and training. What do our workshops include? Educational workshops are very popular here at The Wellington. They can include a highly informative presentation (in March, we held a dizziness and balance workshop by our audiology and physiotherapy team, which highlighted the importance of bedside clinical tests), or they may include a demonstration/ practical session (such as our past breast and spirometry workshops). Either way, we’ve found at these workshops are a great way of sharing through teaching, and our attendees have found them hugely beneficial. Members of the GP Liaison Team
We hope that this new online booking system makes booking and attending events at The Wellington Hospital that little bit easier. And we welcome any feedback you may have.
Events newsletter If you would like to subscribe to our events newsletter and mailing list please contact firstname.lastname@example.org or your dedicated GP Liaison Officer. Masterclass Select Series This year sees a new series of masterclasses events exclusively for GPs, at our new venue: The May Fair hotel. These bi-monthly masterclasses are
Talk to us To ensure that our workshops are to your satisfaction and benefit your continual learning, please contact the GP Liaison team: email@example.com to share your opinions and ideas for workshops you would like to see on offer in the future.
www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 • 17
NEWS FROM THE WELLINGTON HOSPITAL
NEWS FROM AN INTERNATIONAL WIN FOR OUR ACUTE NEUROLOGICAL REHABILITATION UNIT Team approach to care Our Acute Neurological Rehabilitation Unit is the largest private unit of its kind in the UK, with 56 (CARF accredited) dedicated rooms for patients requiring complex inpatient rehabilitation. The unit is recognised for its excellence and for promoting a true ‘team approach’ to care. International patient volumes have grown year-on-year and now outnumber UK patients by three to one. The best providers in the industry Chairman of the judging panel and Managing Editor of IMTJ, Keith Pollard, says the awards celebrate the best providers in the industry and aim to encourage others to strive to match them: This April, we saw our Acute Neurological Rehabilitation Unit beat global competition to be named Specialist International Patient Centre of the Year, by The International Medical Travel Journal, at their annual awards ceremony. Recognising hard work and commitment The award was presented to Lesley Pope, Director of Rehabilitation, in recognition of the unit’s success in attracting and serving international patients. The Wellington Hospital triumphed against strong competition from other medical groups around the world to scoop the award. She said:
“Medical travel is an exciting and growing global industry, with many providers delivering excellence in both medical care and customer service. The IMTJ Medical Travel Awards are the first independent awards to recognise those who are the best of the best and hopefully to encourage others to emulate them. The judges wanted to reward innovation and excellence, highlight best practice and celebrate those who are leading the way in the industry and delivering successful outcomes for patients.”
“I am immensely proud to receive such a wonderful accolade on behalf of the Acute Neurological Rehabilitation Unit. This award is a true testament to the team’s hard work and commitment to each patient’s care, day in and day out, as well as all other supporting services at the hospital. We are also delighted to be recognised by the International Medical Tourism Journal.”
NEW CONSULTANTS Cardiology
Dr Fakhar Khan, The Heart Hospital
Dr Shaunak Navalkissoor, Royal Free Hospital
Gastroenterology Dr Andrew Millar, North Middlesex University Hospital
Dr Harvinder Chahal, Imperial College Healthcare Trust
Enquiry Helpline: 020 18 • PRACTICE MATTERS SPRING 2015
Orthopaedics Mr Gurdeep Biring, Buckinghamshire Healthcare Trust Mr Derek Park, Barnet & Chase Farm NHS Hospitals
60 SECONDS WITH...
I love to see patients improve clinically through the delivery of well-managed services, and enjoy helping staff to progress through their careers
Q&A - Andrew Roche, Clinical Services Manager
PM: You’ve recently been appointed as Clinical Services Manager at The Wellington Hospital, what does this role include? AR: As clinical services manager, I am responsible for the delivery of critical care, our acute admissions and cardiology services; I also manage the resuscitation and critical care outreach services. I’m responsible for the patient experience in my clinical areas and work closely with the matrons and staff to identify areas for improvement, based on patient feedback. You’ll also find me working closely with the chief nursing officer, assisting him to lead on safeguarding adults, emergency planning and business continuity.
overly stimulated, and that we allow time for the staff to complete their daily routines, in addition to reducing the flow of people in and out of the unit for infection control purposes. Restricting our visiting hours will also ensure that relatives have time away from the intensive care unit, so that they can sleep and eat properly, which enables them to cope with having a loved one being cared for in the intensive care environment. PM: What is the most rewarding aspect of your job? AR: I love to see patients improve clinically through the delivery of well managed services and enjoy helping staff to progress through their careers. I also get to do a lot of talking, as part of my job is to meet with patients as well as staff. I enjoy talking with patients about their experience and using the feedback to improve the services that we provide. PM: If you weren’t in healthcare, what industry could you see yourself working in? AR: Fashion. I would like to be a personal shopper - shopping with someone else’s money... perfect!
PM: What made you choose a career in healthcare, and what other clinical roles have formed your career background? AR: I worked in intensive care for over 10 years and during that time I performed a number of roles, including an educator role, which I particularly enjoyed. So, after that I led education commissioning and progressed to manage neurosciences and specialist surgery. I was elected as a hospital governor and joined the council of governors for 18 months. During this time I was involved in deciding the direction of travel for the hospital, along with the other members of the council. I have a real passion for improving the experience of patients who use our services here at The Wellington, and have also worked with the Care Quality Commission as an expert adviser, taking part in hospital inspections and reviewing services. PM: There are some changes coming to our intensive care services, do tell us more… AR: We are in the process of increasing the number of intensive care beds available to our patients, to manage our increasingly complex patient caseload, which is a very exciting project. This will enable us to continue to deliver world-class intensive care, all on one floor, improving our patients’ experience. We are now in the final stages of planning and in the process of increasing our establishment. We have also been working hard to establish new visiting times in intensive care. It is important that this is managed carefully, so patients are not
www.practicemattersmag.co.uk PRACTICE MATTERS SPRING 2015 • 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