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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme No. 3 - Bowel Cancer
RADIO 4
TUESDAY 15TH APRIL 2008
PRESENTER: MARK PORTER
CONTRIBUTORS: NADER FRANCIS
PAULINE WARREN
BRIAN JONES
JONATHAN OKRIM
ROGER KIPLING
LOUISE EVANS
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Health Minister Lord Darzi made the headlines at the weekend thanks to a new surgical robot that could take keyhole surgery a stage further. He plans to use the machine to take diseased or damaged organs out through a patient's mouth leaving no external scars.
It may sound bizarre but it's an entirely plausible step in a technological revolution that has transformed surgery over the last 30 years.
When I was a medical student in the '80s, having your gallbladder out meant a major op, a six inch scar, a week or so in hospital, and no work for at least a month. These days you are likely to be in and out in a day and could be back at your desk within a fortnight.
But fancy keyhole techniques are not the only developments - there has also been a sea change in the way some hospitals prepare their patients for operations, and care for them afterwards. And that's what we are going to explore today.
Yeovil District Hospital, in Somerset, is one a handful of units in the UK using the Enhanced Recovery Programme to treat patients with cancer of the bowel.
Patients on the new programme needn't fast for long periods before their operation, can eat and drink almost immediately afterwards and are normally home within just four to five days. At which stage a conventionally treated patient could be facing up to another week in hospital.
Yeovil has been running the programme since 2002 and it is such a success that it now runs an academy to pass on expertise to other NHS hospitals. I went down to Somerset to meet the team. Nader Francis is one of the consultant colorectal surgeons.
FRANCIS
I saw a patient Christmas Eve and I told her the diagnosis that she does have bowel cancer and that's quite devastating. And all the scans they showed the disease was localised. So I said to her after that that's all the bad news over now, let's just look at the positive side. You have a disease with the most likelihood to be cured by an operation called the enhanced recovery programme which will involve you coming to hospital, not starving - eating and drinking - well nourished, having minimal invasive operation, eat and drink straight after and moving around and I expect you to go home on day four-five. And that's what the patient had.
WARREN
I was getting low abdominal pain about six months ago and then just passing some blood on a few occasions.
PORTER
Pauline Warren is one of a hundred or so patients who have had their bowel cancer treated using the enhanced recovery programme at Yeovil.
WARREN
I thought I had piles to begin with and then I decided that because the blood was altered blood that maybe I just ought to go and get it checked out.
PORTER
And by altered blood you mean?
WARREN
Stale blood.
PORTER
So it wasn't bright red?
WARREN
No.
PORTER
So you went along to see your GP and what did he or she do?
WARREN
He felt along the side of my abdomen and he then decided that he would fast track me to the hospital.
PORTER
And at this stage you were feeling - presumably you were feeling fine, you felt well in yourself?
WARREN
I've always been well all the way through, I haven't - apart from having some abdominal pain that just came and went I never felt ill.
PORTER
And what did you think when your doctor said I'm going to get you on a fast track referral, I mean it's normally good to be seen quickly on the NHS but it can often mean the doctor's worried?
WARREN
Yes, yes, it was a bit concerning to think that it was going to be a fast track because I didn't know what the implications of that was.
PORTER
Were you at the hospital on your own?
WARREN
No my daughter was with me.
PORTER
So that must have been some comfort. I mean were you expecting bad news?
WARREN
Because the word cancer had actually been said to me I had thought more about it. My only mistake was although my daughter had insisted on coming with me I hadn't actually told her that's what it possibly could be.
PORTER
So that was a bit of a shock for her.
WARREN
It was a great shock, very difficult time. Unfortunately my daughter, her best friend's mum had just died of bowel cancer, so for Kylie to hear that about her mum, she was just devastated.
PORTER
How much did you know about bowel cancer before all of this?
WARREN
I know quite a bit about bowel cancer because I actually work as a district nurse but being a district nurse I'm more at the end of their lives rather than the initial treatments of actual bowel cancer.
PORTER
One of the interesting things, presumably, a bit like me, I mean you would have seen a dramatic change in the way that bowel cancer's treated, I mean the programme that you had you were in and out of hospital in five days instead of 10 or 15 days, a couple of keyhole incisions and that's it - was that a surprise to you?
WARREN
It was a completely different way of the operation because when I'd looked after people in hospital then you have nasal gastric tubes and drips and drains and you're in bed for a lot longer. And because you've been starved before surgery then you haven't got the nutrition for wound healing ...
PORTER
And you and I are from a generation, aren't we, of empty bowel and then rest it for ages afterwards, that was always drilled into us, these people with tubes and drips and things, so how did you feel when you took your first sip, within 24 hours I presume?
WARREN
Yeah, I was determined that I was - because of having catheters and everything I wanted to get as much fluid into me because I didn't want infections and because of my nursing background I knew what problems could actually happen and I wanted my bowel back working as quickly as I possibly could.
PORTER
And how long did it take for that bowel to get back to normal?
WARREN
Two days.
PORTER
It must be a great feeling to be honest.
WARREN
It was a great feeling and I also sent text messages to my family to tell them I'd had a poo and they were very impressed.
PORTER
Like many people who develop bowel cancer, Pauline's symptoms could be attributed to other problems. So what does Nader Francis consider particularly suspicious?
FRANCIS
I think bleeding is still kind of the main worry, it is worrying for patients and worrying for clinicians especially if it persists and is different from what the patient recognise as blood on the toilet paper. So definitely bleeding. Altered bowel habits for more than two weeks or persistent abdominal pain.
PORTER
If I as a GP suspect that a patient of mine may have a bowel cancer or has one of those symptoms what sort of fast track referral service do you offer here in Yeovil?
FRANCIS
There is a fast track referral straight into investigation, which in our case at Yeovil District Hospital is a flexible sigmoidoscopy and that's done within two weeks. So the patient comes straight, the letter is faxed to our office and they're start it straight away and the patient get an appointment within two weeks to have flexible sigmoidoscopy.
PORTER
And that's basically a look and see. How far up does a sigmoidoscopy go?
FRANCIS
It doesn't go very high but it covers the last 40, for example, centimetres of the back passage which actually covers quite a substantial proportion of the colorectal cancer - about 60% or 70% have it on the left side sigmoid rectum, so that's quite a substantial proportion actually of them but obviously not exclusive.
PORTER
So say I have a symptom of some worrying bleeding, I come in, I'm fast tracked in, I have my sigmoidoscopy but nothing's found, what happens next?
FRANCIS
We go through a kind of [indistinct words], I usually ask the patient some more leading questions to decide what's the next plan. If I'm still worried about the patients I usually bring them for a colonoscopy which is a full examination of the colon using a longer camera test.
PORTER
Brian Jones, who piloted the Orbiter balloon to become the first person to circumnavigate the globe, had no symptoms. He only discovered something was awry when a private scan picked up a suspicious looking polyp. Most bowel cancers develop in these initially benign growths that hang off the lining of the gut - a process that can take 10 years or more.
JONES
All the way through this I seem to have struck lucky - a. that I went for the scan initially but b. that ended up in Yeovil with Mr Okrim and with the anaesthetist who started off this enhanced recovery programme. And so I didn't know that there was an option of having keyhole or the big cut or indeed I'd heard nothing about this enhanced recovery until I spoke to the anaesthetist.
PORTER
What was involved in your preparation before you came in to have surgery, did you do anything special?
JONES
Well only that I'd been in twice I think - one for a full colonoscopy and one for a sigmoidoscopy.
PORTER
I must ask you what it's actually like having a sigmoidoscopy and/or a colonoscopy - unpleasant?
JONES
No not at all. The sigmoidoscopy was pretty straightforward, I was quite interested, I could look at the camera - not the camera - I could look at the screen.
PORTER
Because the camera's up your ... very difficult to see the edge of the camera. But the camera, I mean, is about the size of your finger isn't it, pushed into your bottom, sigmoidoscopy's a little bit shorter, colonoscopy that much longer. Was there any difference between the two in terms of how you felt yourself?
JONES
No not really except that I'd had an injection, I think diazepam or something, when I had the colonoscopy, no they were both fairly - well pain free certainly. A little unpleasant to feel this sort of camera wiggling around inside of you but no pain.
PORTER
And what does it feel like to see your bowel on a video screen?
JONES
Well ...
PORTER
Were you looking or were you ...
JONES
Yes, no I was looking, I was kind of intrigued and after a while I kind of got a little bored with it actually because it went on a while but it was interesting but I could see how some people really wouldn't want to see that kind of thing.
PORTER
And did you actually see your polyp on the screen?
JONES
Yes I did.
PORTER
So you could see what the offending item was.
JONES
Yes.
OKRIM
My name's Jonathan Okrim, I'm a consultant laparoscopic and general surgeon, I've got an interest in colorectal cancer.
PORTER
Jonathan you've got a patient here, we're part way through an operation to remove a cancer here, this is being done using the keyhole technique but if this had been a conventional approach what would be the main difference - obviously there'd be a big incision?
OKRIM
I know it's not played up but the big incision is one of the big differences. If we were going to start this operation we'd probably have to do a 12 inch incision on this lady, that would take us about half an hour to open the patient up and probably about half an hour to shut her up at the end. And once she's got over the surgery the main problem with her is always going to be that 12 inch incision. And that would take her many weeks, if not months, to heal up from.
PORTER
I can see the obvious advantage of using a keyhole technique, you manage to avoid that, you're operating here through a number of ports and with instruments going into the side but the analogy we've often heard use is that of painting the front door through the letterbox, technically it looks quite tricky.
OKRIM
It is more - it's not more difficult, it's just a different challenge. And you need surgeons that are trained in the technique. The fundamental differences between this and open surgery but the principles are still the same. So the main principle of this, which applies to all types of cancer surgery, is to take the tumour out in its entirety and to take the blood supply of the tumour out with it. And none of that changes using keyhole surgery.
PORTER
Well one of the interesting things of course is you haven't got a big scar to remove the specimen, and we haven't got to that stage in this operation yet, but if - I mean how much of a person's bowel would you typically resect?
OKRIM
It's not as much as you think but it's between 6 and 12 inches of bowel will come out. As you've rightly pointed out the limit is that we've got to remove that bit of bowel but the difference is, is that we can generally remove that bit of bowel through an incision the size of an appendix incision which is three inches, something like that, compared to what we've discussed before, which is 12 inches.
PORTER
How, once you're inside - we've got a picture here of the patient you can see on a video screen, see what's going on down a camera - but how do you actually find the tumour if it's early and inside the bowel because if you're in there with your hands you can presumably feel something?
OKRIM
Absolutely. If the tumour's an early cancer and I hope we'll be getting more of that with screening coming online in this hospital in the next few months what we will do is mark it with an internal tattoo at the time of the colonoscopy. So there'll be two tattoos placed before and after the tumour, it doesn't interfere with the tumour and I can visualise that from the outside. This lady's got a much bigger tumour than that I can actually physically see it from outside the bowel wall during surgery.
PORTER
And technically can you remove the same tumours, laparoscopically, as you can through an open technique, does it give you the same access to all parts of the colon?
OKRIM
Well we're getting better and better. And in this hospital we'll offer everybody a laparoscopic approach, it doesn't mean it's always - we always complete a laparoscopic approach but our figures are running at 94% completion rate for laparoscopic surgery. There's technical areas where we just can't do it laparoscopically, there may be a lot of scarring from previous surgery, maybe operations that patients have had previously that make it impossible. But the vast majority of people should be suitable to have a laparoscopic operation.
PORTER
But it's not just the minimally invasive surgery that allows patients at Yeovil to recover so quickly. The type of anaesthetic and post-operative pain relief used make a huge difference too, as consultant anaesthetist Roger Kipling explains.
KIPLING
Morphine has been used by anaesthetists for many years now and it's enabled us to make fantastic headways in terms of the surgery which we can perform. But we now realise that the side effects of morphine and other opiates are serving to slow down the recovery process.
PORTER
And by side effects you mean they're doing what - I mean they're slowing the bowel and making people feel sick?
KIPLING
Yes, I think there are a number of things really. One is that people feel very drowsy after taking conventional morphine, people can feel sick and occasionally vomit, which is a common complaint after most surgery, and I think the other thing is that it slows down the bowel as well.
PORTER
So what are you doing here that might be different from a conventional approach to try and speed that recovery up?
KIPLING
Most importantly we're making use of modern pharmacology. The pharmaceutical industry has given us some wonderful anaesthetic agents now to keep people asleep but most importantly to allow them to wake up very quickly when we turn everything off. The sort of agents which we commonly employ for day surgery.
PORTER
So how quickly would this patient wake up then when you turn everything off?
KIPLING
This patient could wake up, still on the operating table at the end of the operation, before we transfer him to the bed. We actually use a synthetic analogue of morphine now called Remefentanil which is about 200 times more potent than morphine but the great thing about it is that it wears off so very quickly and it's so potent it has to be given by a slow intravenous infusion.
PORTER
So the patient's waking up pretty quickly but they've now got no painkiller on board, which presents you with another problem is that potentially they could be in agony.
KIPLING
That's a very astute point yes. So we have to have some other plan if Remefentanil's going to wear off so quickly we have another plan to keep them comfortable and this is - one of the important contributions we make is we use an epidural. An epidural is the sort of thing that ladies have during childbirth now and is commonly employed during the course of larger operations like this. It involves an injection in the back and putting some local anaesthetic around the nerves as they leave the spinal cord.
PORTER
And by using that you can do a regional block can you?
KIPLING
That's correct.
PORTER
The midriff effectively in this case.
KIPLING
Exactly. The height of the injection that you put in - up or down the spine - will dictate to some extent exactly the spread of the local anaesthetic solution.
PORTER
Now I can see the pipe work coming out of the patient's back here, connected to the syringe, that's basically giving a continual dose of painkiller via a plastic tube into the spine?
KIPLING
That's right, yes, that is the epidural catheter, the very thin tube that we leave in the epidural space. And having given the first dose of local anaesthetic we then continue it with a slow infusion all the way through the operation to maintain what we call the epidural block and this continues into the post-operative period.
PORTER
And when the patient wakes up, aside from hopefully feeling no pain, what do they actually notice, I mean have they got a numb midriff, can they walk around?
KIPLING
No actually the concentration of agent which we use, because it's combined with a tiny dose of opiate, we're able to achieve a block, as we call it, which is not very profound but it gives plenty of pain relief, it allows the patient to sit out of bed the same day as surgery.
PORTER
And don't feel like they've had an operation?
KIPLING
Not really no, not at all. They might feel a - perhaps a little bit of discomfort but nothing compared with what they would normally have been experiencing.
PORTER
And they can survive on that alone in terms of pain relief they don't need to have anything else?
KIPLING
Indeed, that's true. The plan for most of our patients really is that after the operation they'll go back upstairs to the open ward, where they'll continue to receive this infusion and they'll be comfortable enough to get out of bed and sit in the chair, under supervision, and then the following day they'll be out of bed and walking up and down the corridor, 120 metres, twice a day.
PORTER
But that's got to come out at some stage and at the third or fourth day they're still going to be in as much pain as someone who's had an operation three or four days ago who've had another form of pain relief aren't they?
KIPLING
That's right. Well today's Tuesday and I think on Thursday morning we'd expect most of our patients to have the epidural pump turned off, they'd be reviewed and if everything's fine then they'll have the epidural catheter taken out and they will then be able to mobilise reasonably comfortable on paracetamol and another simple agent like Brufen which they take - both of which they take regularly.
One other area where we've been able to identify some improvements for patient care has been the amount of intravenous fluid we give during the course of the operation and the immediate post-operative period.
PORTER
We can see a drip up here on the patient and what's changed then - are you giving more or less?
KIPLING
No we're giving much less. Previously we used to give rather more in order to maintain blood pressure and obviously to counteract blood loss when it occurred. But nowadays our patients come into theatre very well hydrated and fed and the surgeons, as you can see, are operating in a bloodless field, at the end of this major operation we'll probably lose about 150 ccs of blood. The important thing really is that we've been able to identify a method of using less fluid and this has been a great advantage for the patients because the gut works much more quickly in the post-operative period if you've not given as much fluid as we used to in the past.
PORTER
So if you overdose them with fluid that's another factor that can slow the gut.
KIPLING
It slows things down definitely, it has a very profound effect on the gut and we leave the bags of fluid in the cupboard and the patients are much better for it.
PORTER
Louise Evans is senior sister on the general surgical ward.
EVANS
We learnt fairly early on that the main aim of this is to ensure that very strong teamwork applies and if one cog in the wheel isn't in situ then basically it doesn't work and that's the fundamental principle of enhanced recovery.
PORTER
So the patients are coming into the ward before they go to theatre, how long would they spend on the ward before they go into ...?
EVANS
That can vary, so it can be a matter of a few hours, it can be the day before, it depends also on the type of patient because some patients have more needs than others - if they're diabetic for example.
PORTER
And when they come back from theatre, I mean you must have noticed the difference since the programme's come into force, the way the patients are just looking as they arrive - coming back from the operating theatre.
EVANS
Very much so, it's huge. When I started on this ward about 10 years ago it was not unusual for patients to be in two weeks and they used to come back from theatre, completely flat, they continued on their intravenous fluids and they didn't eat often for about seven or eight days. Now we get them back and they get out of bed six hours after their surgery and also they start eating a normal diet on the day of surgery and we get them sitting up in bed and the main feature is to ensure that their pain is well controlled, there's a big focus on that these days as well with epidurals which we now have patients on the ward.
PORTER
We've been hearing about the epidurals and they seem to work very well, and in your experience they must make your life a lot easier as a nurse on the ward, rather than you running backwards and forwards.
EVANS
It has made a huge difference - epidurals are very, very effective. Obviously patients are getting continuous analgesia rather than intra-muscular injections, which can wear off. Also it does mean, exactly like you say, nurses' time is saved from that point of view. However, we are very carefully monitoring the patients with epidurals and that also involved a huge training programme and quite a lot of safety issues there.
PORTER
Problems being?
EVANS
One of the things that I was most concerned about was, for example, in the middle of the night a patient suddenly drops her blood pressure and obviously they can be quite compromised by that. We used to have patients go to the high dependency unit, once we - all of our staff became fully trained then the anaesthetists were happy for them to come back here.
PORTER
So that's the sort of monitoring that would go on with a woman, for instance, who's in labour who's having an epidural as well, you keep a close eye on their blood pressure and everything. What about manoeuvrability - are they fully - can they walk around on their own okay?
EVANS
It's - very often people think that people with epidurals aren't able to mobilise but obviously a big part of enhanced recovery is mobilisation. So actually our epidurals tend to - they don't tend to hinder the patients too much, occasionally we get a patient that's not able to mobilise very well but they have their four walks up and down every day with their epidurals in situ. So that doesn't seem to be a problem at all.
PORTER
Now we're standing next to something which you don't see very often on a ward - it's a fridge packed full of all sorts of healthy drinks, reinforcing drinks, protein drinks - what's all this about?
EVANS
Well a big part of enhanced recovery actually nutritional aspect and it's not just about patients having high protein drinks, it's also about the mindset and pre- and post-operatively patients are given a lot of verbal and written information about high protein drinks and we actually give these drinks to patients at pre-assessment clinics, so they actually start having them at home, so that they understand the importance of them, they're also then able to choose what type of drinks they like at pre-assessment clinic.
PORTER
You've got lots of different flavours. I've got - what's that - peach and orange flavoured yoghurt style here. And how many of these would the patient be expected to have?
EVANS
Post-operatively we try to get them to have three to four drinks a day. Sometimes some patients are a little bit reluctant to have them because they maybe feel a little bit full as they are eating a normal diet.
PORTER
So they can come and help themselves to those - you're not dishing them out?
EVANS
No, they come and help themselves to them, we obviously make sure when they come to the ward that they're - it's reiterated the type of drinks they need to have, because obviously there are different ones for diabetics - and they're encouraged to come and get their own. And it's also about empowering the patients, a big part of this is about them doing things for themselves, as opposed to nurses doing things to them or getting things for them.
PORTER
But can getting things going so quickly put the newly joined bowel under too much strain? Nader Francis again.
FRANCIS
We tested a system very early with enhanced recovery. In the old fashioned we used to fast the patient for a week. So when the joining of the bowel doesn't work we only get to discover it after a week but now we feed the patient immediately. So I usually, after 48 hours, if the patient is not behaving as they're ready to go home I get worried.
PORTER
So the water-tightness, if you excuse the word, of your stitching is key and that should be there right from when the operation's done, it's not a matter of healing is what you're saying and if it's going to work it's watertight almost immediately?
FRANCIS
That's right actually. Most of the time nowadays actually we use staple guns which is basically staples it all together. And the important aspect of the bowel joining a bowel healing is the two ends of the bowel are healthy and well vascularised and well [indistinct word] the blood supply.
PORTER
What's the first thing you remember after the operation?
JONES
Well after the operation it was exactly as Dr Kipling, the anaesthetist, had described, he said when you wake up you'll feel great. And I thought yeah right. And I did, I woke up in recovery, within two minutes of waking up I drank a glass of water and then went back to the ward, I suppose within 20 minutes of coming round, and immediately back in the ward had a cup of tea and a tuna sandwich. I mean I really felt good.
PORTER
Which is remarkable considering the surgery you'd had done.
JONES
It is remarkable and I remember - I mean the last surgery I had was back in the '70s and I can remember coming round in the ward usually and then just sort of waiting for it and then this wave of pain comes over you and I was kind of expecting that but there was absolutely none, which was extraordinary, actually I felt - I felt good, which is a bit odd thing to say but that's the way it was.
PORTER
How long did you stay in hospital after the op?
JONES
I had the op, I was first on the list on Tuesday morning, I was in theatre until about 12.30 I think, so it was quite a long procedure. The next day two young physiotherapists come and dragged me out of bed and I had to walk 60 metres, which was fine. And then on the Thursday morning I actually went down two floors in the hospital and actually was in a case study of visiting nurses and doctors and I was - I had to describe my experiences.
PORTER
Earning your stay.
JONES
Yes.
PORTER
And this was still with the epidural in?
JONES
This was still with the epidural in yes.
PORTER
So basically they were just topping it up - was it on a pump or did they top it up manually, how did they ...?
JONES
No it was on a time pump.
PORTER
So it's giving a constant supply of medicine to the spine. And when did you go home?
JONES
Friday, so yeah the op finished lunchtime Tuesday, Friday morning I was out of here.
PORTER
I can see the attraction for the patient - it's a more pleasant experience, they're in and out of hospital more quickly. I can see the attraction for the hospital - the patient's out of hospital more quickly, less resources hopefully. But what about the outcome, in these days of evidence based medicine, is it as effective, is it as safe as using the conventional approach?
FRANCIS
It is actually. Enhanced recovery is not just about cutting down the number of hospital stay. Enhanced recovery I think it is about reducing complications and enhancing the whole recovery process and changing the patient's experience of recovery.
PORTER
And the $64,000 question is how do your results compare with one of your peers using the conventional treatment?
FRANCIS
I compare it myself with my previous results without using the enhanced recovery, for example, and it is quite astonishing. Median stay is between four and five days, I had very little complications, in fact one patient out of 60 was wound infection, one patient was a chest infection and there is no mortality at all. And the most rewarding is the patients' experience, that's what I think has transformed actually the service is the patient usually by day two, day three up and about, eat and drinking, bowels are working ready to go home and feeling happy. And you would not guess that they've had any major operation.
ENDS
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