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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