A Talk Given By A Consultant Colorectal Surgeon From The RSCH.

Notes from the talk given by “JC” at the C-Side meeting on Tuesday 30th October, 2018

JC gave a detailed, personal and informative talk, answering all the questions we had prepared for him:

  • How do surgeons combat tiredness?  What is the limit on hours they can work?
  • Do surgeons get nervous?
  • Regarding long term symptoms : what ought we to worry about?
  • One of our members has a split in the wound following a stoma.  It requires packing every day.  He had no warning that this might be a result of the operation.  How common is this situation?
  • How do you deal with a blocked ileus?
  • Can you explain the research you are doing  in Italy regarding the colon when re-sectioned.
  • What is the current expected waiting times for treatment  and the situation regarding cancellations?
  • How much theatre time are surgeons allotted each week?
  • How are the cuts affecting Bowel cancer operations?
  • Do you have any statistics for the year regarding the number of operations/ survival rates/ costs?

The personal questions provided an insight into the work of JC and his colleagues.  He made the following points:

  • Operations can take between 1.5 and 6 hours, and can last 9- 10 hours.  He can get tired and can deal with two major cases in one day.  There are no limits to the hours that he works, although it is supposed to be 56 hours.
  • He does get nervous as he has an understanding of all that can go wrong.  He downplays these but is often working to within fractions of a millimetre.  Sometimes difficult decisions have to be made such as whether to sacrifice the spleen instead of the bowel.  There is a high level of stress in the operating theatre which is difficult to differentiate with nervousness.

Regarding surgery:

  • There is altered bowel function after surgery that can take anything from 8 weeks to 2 years for the system to settle. Lower rectal surgery can cause difficult day to day functioning.  Complications in the anal canal system has a risk of infection.  Perineal wound surgeries can have more prolonged problems.  This is not something that can always be predicted.
  • Ileum surgery often causes vomiting and there can be a danger of aspirational pneumonia.  The contents of the bowel must be kept out of the lungs.  Tubes are inserted to alleviate vomiting.  Most blockages to the ileum correct themselves and are often twisted or pinched.  If there is a food bolus obstruction this may require surgery.  If there is a parastomal hernia as a result of a stoma where several bits of bowel stick out outside the muscle, it can be decompressed to see if it will settle.  Further surgery may be necessary.
  • Italian research has shown that a fluorescent substance can show up under ultraviolet light indicating blood supply to the bowel during surgery.  This can very effectively show whether there is a sufficient blood supply for an operation, which can reduce the likelihood of failure during  anastomoses (join in the bowel).  Anastomotic failure can be reduced from 10% to 1.5% using this system.  At present the Consultant Colorectal Surgeons are trying to persuade the Trust  to use this technology.  NICE should make it a mandatory part of the surgery.  It also has benefits in other surgeries such as gall bladder surgery.  This massive piece of research adds about 3 minutes to an operation and costs about £10,000 – £100,00 with the higher figure being for a laparoscopic stick.  It makes operations much safer.

Economic and administrative considerations:

  • Brighton does have an issue with waiting times for Colorectal Cancer surgery but is experiencing the best situation for years – diagnosis, decision to treat and date for surgery is approximately 2-3 weeks.  But there are still delays before the decision to operate as this depends on colonoscopies, MRI scans and CT scans.  At present there is a shortage of scanners and radiologists.  Ideally diagnosis to surgery should take 4 weeks.  However, although cancer takes priority, there are cancellations when the hospital is too full or overstretched.
  • In Brighton of 300-400 patients are diagnosed, 70-100 need surgery.  There are  150-250 Bowel surgery operations annually.  4 surgeons are rectal specialists and 6 specialise in colonic surgery (the 4 who do rectal surgery plus 2).  They are audited nationally and outcomes are well within the accepted range of mortality.
  • Fortunately government cuts do not affect serious health problems such as cancer, heart disease and diabetes.
  • As a final note, JC explained that Dukes staging (A, B and C) is now historic.  Now TNM (Tumour, Node and Metastasis) staging is  used to describe where a patient is in his or her bowel cancer.