General Surgery update

To the future: Chinese health in New Zealand

方 思凌

Dr Sze-Lin Peng, FRACS

University of Auckland 1999

FRACS 2008

CSSANZ fellowship

Royal Adelaide Hospital

Middlemore Hospital

Auckland Colorectal Centre

The Chinese in NZ

Lack of specific research in surgical problems

Should not be grouped together with other Asians? (Indians are greatly disparite)

Currently fare better than NZ Europeans on many health indicators

More likely to have English as a language barrier

Approximately 22% of Chinese people compared to 10% Indians

Gala G. Health Needs Assessment for Asian People in CountiesManukau. Counties Manukau District Health Board; March 2008.

Similar to Europeans

Mortality for stroke and diabetes

Adult hospitalisations for myocardial infarction (MI), diabetes, chronic obstructiverespiratory disease (CORD) and kidney/urinary infections

Intervention rates for angioplasty, coronary artery bypass grafting (CABG), total knee replacement,

cholecystectomy, hysterectomy and prostatectomy

Cancer mortality

Cultural expectations

“ People like myself and people from China, we’re so used to having an injection to give us immediate intervention if we have a high fever....So here if you are seeing a GP within the first few days they actually say there’s nothing they can do, just take Panadol. So from an Asian perspective, a lot of us expect practical things or something a bit more substantial.”

Mehta S, Health needs assessment of Asian people living in the Auckland region. Auckland Northern DHB Support Agency, 2012. http://www.asianhealthservices.co.nz

Less is More

Breast

Thyroid

Colorectal

DisclosuresMy subspeciality is colorectal surgery

Acknowledgments to Drs.Magdalena BIGGAR

David MOSS

Breast cancerTrend towards identifying patients where LESS aggressive surgery is safe

ACOSOG Z11 trial

Axillary recurrence is very low after positive sentinel node biopsy in SELECTED patients (still have XRT and chemo)

Size of margins may not influence recurrence as long as the margin is CLEAR

Less re-excisions

Better cosmesis

Trend towards preoperative chemotherapy to ‘downstage’ disease

Improved breast conserving surgeryMoran et al. Society of Surgical Oncology–American Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer. JCO February 10, 2014Ahmed, Duek. What is the future of axillary surgery for breast cancer? Ecancermedicalscience. 2013; 7: 319

Thyroid incidentalomasNON – palpable lesions common 30-60%

Cost, psychological impact and morbidity of investigations outweigh any benefit in early detection of thyroid cancer

Most SMALL thyroid cancers are not clinically significant even without treatment

Increased detection is not necessarily associated with improved survival

Vassiliadi, Tsagarakis. Endocrine Incidentalomas- Challenges imposed by incidentally discovered lesions. Nature reviews 2011.Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer 2009.

Thyroid lesions <1cm (<2cm if not entirely solid)

Factors prompting further investigationPalpable symptomatic

Family history thyroid CA

Previous history of radiation

Suspicious USS features (e.g microcalcifications)

Without adverse features – follow-up neck palpation enough

Diverticulitis

Diverticulitis – what we used to knowOutdated principles based on data from the 1960s

Elective resection after 2 attacks of uncomplicated diverticulitis

With each recurrent attack the patient is less likely to respond to medical therapy

Patients who have recurrent episodes of diverticulitis have a 60 per cent risk of complications

Young patients should have resection after ONE attack

Perforations were always resected

Always do a follow-up colonoscopy to rule out carcinomaJanes, Meagher, Frizelle. BJS 2004. Elective surgery after acute diverticulitis.

Diverticulitis -what we know now

After 1 episode of diverticulitis 1/3 patients have recurrent symptoms; after a 2ND episode 1/3 have a subsequent episode

Perforation is commonest during the 1st episode

After recovering from an episode of diverticulitis the risk of requiring an urgent Hartmann’s procedure is 1 in 2000 patient-years of follow-up.

Surgery for diverticular disease has a high complication rate

25 %of patients have ongoing symptoms after bowel resection - many had ‘normal’ histology

Diverticulitis -what we know now

Young patients Only 2-5% of patients are > 40yearsSEEMS to be increasing especially in the OBESEThe clinical course is the same as older patients

NO difference in severity/ need for emergency operation

Longer life expectancy so the accumulated risk is greaterNot treated differently

Diverticulitis -what we know now

The incidence of cancer within the segment of diverticular disease

1-3% uncomplicated (the same as that in asymptomatic population (i.e like screening)5-10% complicated

Diverticulitis-what happens now

ACUTECT abdomen

(if treated empirically consider CTC or colonoscopy)

Up to 30% of diagnosis changes with CT

Localised perforation – with abscess percutaneous drainFree perforation

Feculent peritonitis = emergency Hartmann’s

Purulent peritonitis = or anterior resection +/- defunctioning stoma

Laparoscopic lavage Some evidence this is adequate for highly selected

‘Incidental’ cases

Diverticulitis-what happens now

‘Chronic’Not those with fistulous complicationsCT evidenceRaised inflammatory markersCancer excludedCareful history taking, realistic informed consent

Surgical complications are small but SIGNIFICANT

Individual take on quality of life

Laparoscopic anterior resectionSometimes technically more demanding than cancerValue of diagnostic laparoscopy

Diverticulitis-what happens now

COLONOSCOPYOnly in cases of perforation, persistent diseaseOther risks factors need to be reviewedWait at least 6 weeks

NO colonoscopyAll CT scans should be reviewed with radiologistAll uncomplicated patients with no risk factors

Diverticulitis in AsiansRight sided disease is more common

20% in asymptomatic (4x more common)Up to 80% of all cases of diverticulitis in AsiansOften hard to distinguish from appendicitisRight sided diverticuLITIS more common < 50yrsLow risk of recurrent diseaseMajority treated non-operatively

Left sided diseaseOlder patients and tend to be more severe

Tan, KK et al. ANZ J Surg. 2014 Mar;84(3):181-4. Colonic diverticulitis in young Asians: a predominantly mild and right-sided disease.

Diverticulitis

Colonic resection mostly avoided

In uncomplicated cases, follow-up colonoscopy is NOT mandatory

Less is more

Increasing emphasis on QUALITY of life

Increasing patient education/ informed consent needed

These complex discussion are probably best held with subspecialists

Language /cultural differences exist and may contribute to lack of trust/ compliance