Medical Forum WA 07/13 Subscriber Edition July 2013 | Page 32

Gastroenterology

Some Things in the Abdomen

Medical Forum looks at some of the important issues occupying the minds of a selection of WA ’ s gut specialists . They are all busy !
Laparoscopes and Inguinal Hernias
Dr Chris Couch focuses on bariatric surgery , hernia repair and gallbladder surgery . As a surgeon , he has seen many changes in hernia repair over the years , particularly inguinal hernia surgery . Patches and laparoscopic repair have been the biggest .
He said patches have become lighter , materials less reactive , and tailor-made versions wrap around the spermatic cord . Laparoscopically , he only uses staples to apply patches about 5 % of the time , having compared 500 cases with and without staples and has found hernia recurrence rates about the same , that is 2 %. Without staples , nerve damage is virtually unknown .
Laparoscopic patching , changing people ’ s attitudes , and the relatively frequent occurrence of contralateral inguinal hernias have all changed what ’ s offered .
First , the laparoscopic dissecting balloon opens up the preperitoneal space across the midline , so applying a patch to the contralateral side really only adds 10-15 minutes to total surgery time .
Second , bilateral surgery adds little to the patient ’ s inconvenience – pain etc .
Third , prior laparoscopic surgery makes repeat access to the preperitoneal space very difficult , making open surgery the chosen option for later contralateral hernia repair ( with all its attendant disadvantages for the patient ).
For these three reasons , he finds himself offering young fit men who do manual work bilateral laparoscopic repair if they decline ultrasound , believing many will be back for surgery on the other side if he doesn ’ t .
Otherwise , he carefully examines the contralateral groin and , if negative , doublechecks with ultrasound using an experienced operator he trusts . Often , subclinical hernias are found , bearing in mind that about 30 % of patients have a lifetime risk of developing a second hernia .
Hepatitis , Now and Then
Dr Sam Galhenage is a gastroenterologist with a special interest in viral hepatitis and advanced liver disease .
“ The main thing is substantially improved cure rates with hepatitis C , from 40-50 % to abut 75 % for genotype 1 patients . And in the next three or four years we are going to move away from more toxic interferon-based therapies to combinations of medications with 90 % cure rates ,” he said .
Hepatitis C treatment costs about $ 80,000 per patient at present and the new protease inhibitors will be more expensive , However , the details of government funding has not been worked out yet . Sam wonders if those with the most advanced liver disease will qualify .
“ But a 90 % cure rate offers a significant degree of cost benefit because of the morbidity associated with chronic liver disease . We are fighting a losing battle to reduce the number of injecting drug users and we need to pool more resources into safe injecting practices and treat these people for hepatitis C while they are being rehabilitated for their drug use . George O ’ Neil ’ s naltrexone clinic in Subiaco is the only facility doing this .”
He said it had taken about four years to get the drugs listed on the PBS , but that happened in April last year . At the moment , injecting drug use precludes treatment in public clinics but it ’ s a subjective call and there are psychosocial issues and more to take into account .
Sam estimates about 30-40,000 people in WA have hepatitis C . He said trips to SE Asia really only risk hepatitis B , which could be prevented by vaccination , although migrants from China and India had higher rates of this
infection ( 8 % of the Chinese population ). He sees this as a future cost burden .
When it comes to FIFO workers and younger people , alcoholic liver disease is his main concern , so community attitudes to alcohol are important . He predicts growing demand in his field and a lack of hepatologists to help out .
Colorectal Cancer Survival
Dr Cameron Platell , colorectal surgeon , talked about his research into adjunct treatments over the last five or six years .
“ We are looking at predicting how cancers respond to chemotherapy and radiotherapy , in particular rectal cancers . We ’ ve looked at the immune and inflammatory responses to cancer and how that influences survival .”
Amongst various immune markers , they have noticed that T suppressor cells can be stimulated by the cancers .
“ Taking into account all the other prognostic factors , these cells just stand out like sore thumbs in terms of their predictive response
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