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HOSPITAL FOR SPECIALIST SURGERY QUARTERLY NEWSLETTER

Diet and the Gut Microbiome

The genesis of our gut microbiomeMicrobial colonization of the human gut begins at birth. The infant’s intestines are sterile or contain a very low level of microbes at birth, but the gut is quickly colonized during and after delivery.

As a neonate passes through the birth canal, he or she is exposed to the microbial population of the mother’s vagina. This process influences the development of an infant’s intestinal microbiota, which show similarities to the vaginal microbiota of the mother. Infants who were delivered through caesarean section showed reduced microbial numbers in the gut at one month when compared with those who were delivered vaginally, although these differences do not remain detectable at six months of age.

During the first year of life, the composition of the gut microbiota is relatively simple and shows wide interindividual variations. The infant’s gut microbiota undergo a succession of changes that are correlated with a shift in feeding mode from breast or formula feeding to weaning and the introduction of solid food.

SPRING ISSUE 2017

IN THIS ISSUE

Inflammatory Bowel Disease Part 1: The Management of Ulcerative Colitis (UC)

6

Blocked nose in children8

When is it time to consider obesity (bariatric) surgery for your Patient?

4

by Dr Pran Yoganathan

In this article, we will explore the ability of the host diet to influence our gut bacteria. We will see that our dietary choices directly impact our health through alteration of the gut microbiome.

Non scalpel vasectomy now available at HSS9Test? What test? Imaging of the injured foot and ankle made simple

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Despite the relative similarities of the gut microbiota in mothers and their offspring, the microbiome is also influenced by numerous external and internal, host-related factors. External factors include the microbial load of the immediate environment, type of food eaten, and feeding habits, in addition to the composition of the maternal microbiota.

Microbiome and diseaseThe majority of the microbiome reside within the more distal parts of the digestive tract. They contribute to host health through generation of vitamins and

essential amino acids, as well as generation of important metabolic by-products from dietary components left undigested by the small intestine.

Studies examining the composition and role of the intestinal microbiome in different disease states have uncovered associations with inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS), inflammatory skin diseases such as psoriasis and atopic dermatitis, autoimmune arthritis, Type 2 Diabetes (T2DM), fatty liver, obesity, atherosclerosis and mood disorders.

Microbiol colonization of the human gut begins at birth.

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Health promoting fats are crucial in alleviating risk of chronic disease.

IBD patients tend to have less bacterial diversity as well as lower numbers of Bacteroides and Firmicutes which together may contribute to reduced concentrations of microbial-derived butyrate. Butyrate and other short chain fatty acids (SCFAs) are thought to have a direct anti-inflammatory effect in the gut(1).

Obesity has been characterised by an altered intestinal Bacteroides: Firmicutes ratio, with greater relative abundance of Firmicutes. A recent study also demonstrated that gut bacteria can produce significant amounts of amyloid and lipopolysaccharides, which are key players in the pathogenesis of Alzheimer’s disease(2).

These observations illustrate the important role of microorganisms in human health and suggest that manipulating them may influence disease activity. While the microbiome of a healthy individual is relatively stable, gut microbial dynamics can certainly be influenced by host lifestyle and dietary choices.

Diet and microbiota Protein The effects of dietary protein on the gut microbiota were first described in 1977. A study demonstrated lower counts of Bifdobacterium adolescentis and increased counts of Bacteroides and Clostridia in subjects consuming a high beef diet when compared to subjects consuming a meatless diet(3).

Consumption of whey and pea protein extract has been reported to increase gut-commensal Bifdobacterium and Lactobacillus, while whey additionally decreases the pathogenic Bacteroides fragilis and Clostridium perfringens. Pea protein has also been observed to increase intestinal SCFA levels, which are considered anti-inflammatory and important for maintenance of the mucosal barrier(4). On the contrary, counts of bile-tolerant anaerobes such as Bacteroides, Alistipes and Bilophila were noted to increase with consumption of animal-based protein.

Although high protein/low carbohydrate intake may promote greater relative weight loss, this dietary pattern may pose a detrimental effect to health. One study found that subjects with a high protein/low carbohydrate diet have reduced Roseburia and Eubacterium rectale in their gut microbiota and a decreased proportion of the butyrate in their faeces(5). This is significant in the case of the popular “Ketogenic Diet”; very quickly the diet

Fruits and vegetables are rich in polyphenol content.

"All disease starts in the gut."

- Hippocrates

becomes reduced and limited to a set of foods which are low in carb yet also low in fibre, thus potentially eradicating many healthy bacteria strains from one’s digestive tract.

Fats Consumption of high saturated and trans-fat diets is thought to increase the risk of cardiovascular disease through upregulation of LDL-cholesterol. On the other hand health-promoting fats, such as mono and polyunsaturated fats, are crucial in alleviating risk of chronic disease. The typical Western diet is both high in saturated and trans-fats while low in mono and polyunsaturated fats, therefore predisposing regular consumers to many health problems.

Studies in rats have shown that intake of a high-fat diet results in considerably less Lactobacillus intestinalis and disproportionately more propionate and acetate producing species, including Clostridiales, Bacteroides, and Enterobacteriales. Furthermore, the abundance of Lactobacillus intestinalis is negatively correlated with rat fat mass and body weight(6). These results indicate that gut microbiota may promote metabolic inflammation through Toll Like Receptor signalling upon challenge with a diet rich in saturated lipids.

Carbohydrates Carbohydrates are possibly the most well studied dietary component for their ability to modify the gut microbiome. Carbohydrates exist in two varieties: digestible and non-digestible.

Digestible carbohydrates These are enzymatically degraded in the small intestine and include starches and sugars, such as glucose, fructose, sucrose, and lactose. Upon degradation, these compounds release glucose into the bloodstream and stimulate an insulin response.

Human subjects fed high levels of glucose, fructose, and sucrose in the form of date fruits had increased relative abundance of Bifdobacteria, with reduced Bacteroides. In a separate study, the addition of lactose to the diet replicated these same bacterial shifts while also decreasing Clostridia species. Notably, many Clostridium cluster species have been associated with irritable bowel syndrome.

Lactose supplementation has additionally been observed to increase the faecal concentration of beneficial SCFAs. These findings are quite unexpected given that lactose is commonly thought of as a potential gastrointestinal irritant (e.g. lactose intolerance).

Artificial sweeteners were originally marketed as a health-conscious, no-calorie food option that could be used to replace natural sugar. Recent evidence seems to suggest that, contrary to popular belief, artificial sweeteners may actually be unhealthier to consume than natural sugars.

Non-digestible carbohydrates In contrast to digestible carbohydrates, non-digestible carbohydrates such as fibre and resistant starch are not enzymatically degraded in the small intestine. Rather, they travel to the large intestine where they undergo fermentation by resident microorganisms. Accordingly, dietary fibre is a good source of “microbiota accessible carbohydrates” (MACs), which can be utilized by microbes to provide the host with energy and a

carbon source. In the process, they are able to modify the intestinal environment. This property of fibres warrants their additional designation as prebiotics, which by definition are non-digestible dietary components that benefit host health via selective stimulation of the growth and/or activity of certain microorganisms.

Sources of prebiotics include soybeans, inulins, unrefined wheat and barley, raw oats, and non-digestible oligosaccharides such as fructans, polydextrose, fructooligosaccharides (FOS), galactooligosaccharides (GOS), xylooligosaccharides (XOS), and arabinooligosaccharides (AOS).

A diet that is low in these substances has been shown to reduce total bacterial abundance. On the other hand, high intake of these carbohydrates in obese subjects resulted in an increase

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in microbiota gene richness. The beneficial effect of prebiotics on immune and metabolic function in the gut is thought to involve increased production of SCFAs and strengthening of gastrointestinal-associated lymphoid tissue (GALT) from fibre fermentation.

Polyphenols Dietary polyphenols are actively studied for their antioxidant properties. Common foods with rich polyphenol content include fruits, seeds, vegetables, tea, cocoa products and wine.

The beneficial Bifidobacterium and Lactobacillus are increased in those consuming high levels of these foods. Relative abundance of Bacteroides also was reported to increase in subjects consuming red wine polyphenols.

Benefits such as immune-modulation, cancer prevention, and inflammatory bowel disease management have been recorded. In terms of further health benefits, consumption of cocoa derived polyphenols has been associated with significant increases in plasma HDL and significant reductions in plasma triacylglycerol and C-reactive protein concentrations.

Studies examining the antibacterial activity of fruit polyphenols found high sensitivity to these compounds in the enteropathogens Staphylococcus aureus and Salmonella typhimurium. Moreover, reductions in pathogenic Clostridium species (C. perfringens and C. histolyticum) have been noted after consumption of fruit, seed, wine, and tea polyphenols.

Prebiotics, probiotics and synbioticsProbiotics are live microorganisms that, when given in sufficient amounts, are expected to confer a health benefit on the host. In general, probiotics have been shown to have beneficial effects on human health in a range of clinical

studies. However, it is difficult to compare effectiveness between these studies because key variables are not examined in a standardized way. This makes it difficult to draw definitive conclusions. Nevertheless, the outlook is optimistic as there appears to be a trend towards benefit. The significant advancement in our understanding of the role of microbiota in disease states has inspired the development of next generation of probiotics, including genetically engineered strains that are more targeted and disease specific.

Prebiotic is “a nondigestible compound that, through its metabolization by microorganisms in the gut, modulates composition and/or activity of the gut microbiota thus conferring a beneficial physiological effect on the host.”

There is also a growing interest in Synbiotics, which are in essence a combination of a prebiotic and a probiotic. Synbiotics are meant to enhance the efficacy of a probiotic by including a prebiotic that is thought to specifically support the growth of the probiotic bacteria or, alternately, has a favourable effect on the overall gut microbial community. While in theory this appears to be a reasonable strategy, overall the clinical data are sparse and don’t yet show a definitive advantage over probiotics alone. This will likely change as we improve our current generation of pro and prebiotics.

The currently available pre-, pro- and synbiotics only represent the tip of the iceberg. The therapeutic implications of the microbiome are yet to be fully realized, so hold tight.

SummaryThe gut microbiome is considered to be our second genome. One such important environmental factor is diet. Studies in the last few years

have linked dietary patterns to microbiome composition.

Switching from a Western type diet (animal based) to a traditional African diet (plant based) for a period as short as a few weeks can cause significant changes in the function of the gut microbiome in healthy individuals and at risk groups for colorectal cancer.

Therefore can food be used as a therapeutic intervention? A vast amount of data is emerging on the effects of diet-dependent changes in the microbiota on weight and metabolism, immune function and even cognitive ability. The review of the literature suggests that diet can indeed modify intestinal microbiomes which can have a positive impact on overall health. We are starting to better understand the interplay between genes, phenotype and the microbiome to one day pave the way for “personalised nutrition”.

Of interest to gastroenterologists is the relationship between diet and various digestive diseases such as colorectal cancer and polyps, inflammatory bowel disease, gastrointestinal infections, malnutrition and obesity. Additionally, of interest is the links to disorders outside of the GI tract, such as diabetes and allergic, autoimmune, neuropsychiatric, kidney and bone diseases.

We are also beginning to realize that there are profound individual variations as to how a person and their microbiome responds to dietary interventions. The future will involve personalized dietary interventions designer prebiotics, probiotics, synbiotics and more.

References 1. Lucas et al. The human gastrointestinal

tract and oral microbiota in inflammatory

bowel disease: a state of the science review.

APMIS. 2017

2. Pistollato et al. Role of gut microbiota

and nutrients in amyloid formation

"Let food be thy medicine and medicine be thy food."

- Hippocrates

Chocolate is rich in polyphenol content.

and pathogenesis of Alzheimer disease.

Nutrition Rev. 2016; 74:624–34.

3. Hentges et al. Effect of a high-beef diet on

the faecal bacterial fora of humans. Cancer

Res. 1977; 37:568–71.

4. Kim et al. Gut microbiota-derived short-

chain fatty acids, T cells, and inflammation.

Immune Netw. 2014;14:277

5. Russell et al. High-protein, reduced-

carbohydrate weight-loss diets promote

metabolite profiles likely to be detrimental

to colonic health. Am J Clin Nutr.

2011;93:1062–72

6. Lecomte et al. Changes in gut microbiota

in rats fed a high fat diet correlate with

obesity-associated metabolic parameters.

PLoS ONE. 2015;10:e0126931

7. Diagrams and excerpts taken from - Singh

et al. J Transl Med (2017) 15:73 DOI

10.1186/s12967-017-1175

Dr Pran YoganathanMBChB. (Otago), FRACP

www.northwestgastro.com.au

1300 580 239

Suite 25, 7-9 Barwell Avenue Castle Hill NSW 2154

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If your patient has been unsuccessful losing weight through medical and conservative means, is suffering from the ill-effects of obesity, and meets the criteria on BMI grounds, then an informed discussion about the pros and cons of surgery should be considered.

Eligibility for bariatric surgery (Australian Obesity Management Algorithm): • Patients with a BMI > 40 kg/m2

• Patients with a BMI > 35 kg/m2 with associated co-morbidities such as diabetes, insulin resistance, hypertension, sleep apnoea, joint disease, fatty liver, PCOS, depression etc.

• Patients with a BMI > 30 kg/m2 with poorly controlled type 2 diabetes and increased cardiovascular risk.

What is the most suitable operation?There are three operations commonly performed for weight loss in Australia:

1. Laparoscopic Sleeve Gastrectomy

2. Laparoscopic Gastric Bypass, of which there are two variations:

a. Roux-en-Y Gastric Bypass

b. Single Anastomosis Gastric Bypass

3. Laparoscopic Gastric Banding. (NB Gastric banding rates have fallen dramatically in Australia and internationally due to poor outcomes in comparison with

the Sleeve and Bypass).

Endoscopic procedures for weight loss, such as intra-gastric balloon have poor outcomes long-term as the balloon needs to be removed after six months and has complications. Endoscopic plication is a new variant on an old operation which is only recently TGA approved in Australia with limited efficacy data and no long term data.

Sleeve GastrectomyThe most common bariatric operation performed is Laparoscopic Sleeve Gastrectomy (LSG). It accounts for 70 per cent of bariatric procedures in Australia. Outcomes in terms of weight loss are excellent with average excess weight loss (EWL) between 60 to 70 per cent and durable over the long term. Furthermore the quality of eating is very good with no vomiting and no alteration in bowel function. The main surgical risk is staple-line leak, which leads to internal infection and re-operation. This risk is less than one per cent.

Even though the sleeve gastrectomy is permanent, there are few long-term issues for patients. There is no increased risk of malignancy or malnutrition. B12 and iron absorption may be lowered and need to be monitored long term. GORD/reflux may be seen in 10 per cent and may require PPI’s.

Gastric BypassFor severe obesity (BMI > 50) and for patients with diabetes and/or severe co-morbid conditions,

When is it time to Consider Obesity (Bariatric) Surgery for your Patient?

gastric bypass must be considered. It has the greatest weight-loss of the common bariatric procedures performed.

There are two common forms of gastric bypass performed in Australia - the Roux-en-Y and the single anastomosis gastric bypass (commonly known as the mini gastric bypass and the Omega Loop gastric bypass). Weight loss is very effective with over 70 per cent EWL.

How does surgery work?Restriction: The stomach is made into a small segment approximately 50-100cc in volume. It is completely separated from the rest of the stomach via stapling. The reduced stomach capacity allows patients to become full with small meal portions and therefore allows patients to reduce their caloric intake whilst not feeling hungry. With the gastric sleeve the un-used portion of the stomach is removed from the body at the time of the surgery. With the bypass, the stomach is left inside, retaining its own blood supply but not removed.

Reduced absorption: In the single anastomoses gastric bypass, a loop of small bowel/intestine is brought up from below and joined to the gastric pouch. This bowel represents the ‘’bypassed’’ length of intestine and varies according to need. It is commonly 150-200cm. This results in the small amount of food eaten not being absorbed to the same degree which assists with weight loss.

If patients have pre-existing severe reflux they are best suited to the Roux-en-Y gastric bypass. This involves a second anastomosis of the small intestine to divert the bile and pancreatic secretions away from the gastric pouch and downstream into a distal segment of small intestine.

What are the risks of gastric bypass?The gastric bypass has the same initial surgical risks including staple-line leak and bleeding. Once again these have a low incidence of less than one per cent. However, due to the nature of bowel involvement there are some additional considerations with the bypass.

Diarrhoea / Loose stools:Patients may have loose bowel

motions with increased frequency. This is often worse with high fat meals. Patients may complain of two-three loose bowel motions per day. In time, this settles somewhat.

Malnutrition/vitamin deficiency: Once again B12 and iron absorption are reduced as well as vitamin D. Patients with known osteoporosis are not suitable.

Low protein states can occur.

Dumping:If sugary foods are consumed, lightheadedness and dizziness may occur. Patients feel hot or flushed and have a need to lie down to obtain relief. Avoiding refined carbohydrates is important.

Small bowel obstruction: This is seem primarily in the Roux-en-Y bypass and is one of the main advantages for choosing the single anastomises Gastric Bypass over the Roux-en-Y bypass.

Stomach Ulcer:Smokers are not suitable for gastric bypass.

What can we advise patients with a gastric band?If you have a patient that has had a gastric band, follow-up with an experienced bariatric clinic is essential. Issues such as insufficient weight loss, vomiting, poor quality of eating and reflux can occur years later.

If the patient is not satisfied with their weight loss or continues to have weight related conditions, a bariatric clinic may be able to investigate and adjust the band. Alternatively, there is now the possibility of removing the gastric band and converting to either the gastric sleeve or bypass. This will result in better quality eating and further weight loss. Patients who are looking for further significant weight loss are advised to convert to the gastric bypass. For patients who long for the ability to eat healthily again, converting to the sleeve is a good option.

Conversion surgery is usually performed as a single stage through our clinic.

Dr Brendan RyanMBBS (Hons) FRACS

www. sydneybariatricclinic.com 02 96877019

Westmead Specialist Centre,Suite 9, 16-18 Mons Road,Westmead 2145

Dr Carolyn JamesonMBBS BSc(Hons) PhD FRACS

www. sydneybariatricclinic.com02 96877019

Westmead Specialist Centre,Suite 9, 16-18 Mons Road,Westmead 2145

02 8624 5000 • WWW.HSSAUSTRALIA.COM.AU 5

What is the minimizer ring? This is a new silicon device that can be placed around the gastric pouch of a bypass or sleeve to prevent stretching, one of the causes of late weight regain.

The evidence for the device has been shown in many large studies of patients who have undergone Roux-en-Y gastric bypass and lost more weight than a comparison group of patients who had gastric bypass without the ring.

The main risks of the ring include slip and erosion which have an incidence of less than one per cent. The device is well tolerated by patients and does not usually result in any adverse effects with respect to dysphagia or reflux.

Top five interesting facts about weight loss

1. SET-POINT THEORY

One of the reasons patients struggle to keep weight off after diets and exercise is due to the set-point theory where the body vigorously defends its weight. Following acute weight loss, the gut releases chemicals and hormones that drive hunger and increase appetite until the body gets back to its set-point, often re-setting at a higher level. This is why acute dieting not only fails but leaves that individual worse off with increased weight. By contrast both the sleeve gastrectomy and the gastric bypass are operations which physiologically reduce the set point.

2. GHRELIN, GLP 1 AND PYY

Ghrelin is the ‘’hunger hormone’’ that is increased with diet and acute drops in body weight. It stimulates the brain to drive appetite. Studies have shown that Ghrelin levels fall after sleeve gastrectomy and gastric bypass (but not in gastric banding), decreasing the drive to eat. There are many other hormones such as GLP 1 and PYY which are stimulated by the gastric bypass.

3. GASTRIC BYPASS AND LONG TERM REMISSION OF DIABETES

The immediate improvement in diabetic control within days of surgery has been shown not only to be due to the reduced caloric intake but mainly to the enduring physiological changes the surgery produces, which have a long term beneficial effect on diabetes. This is why bariatic surgery is often referred to as metabolic surgery.

4. HIGH BMI SHORTENS LIFE

Patients with a BMI >40 have a reduction in their life expectancy of 5-7 years, independent of any other co-morbidities. For the first time in history, life expectancy of the community will fall due to the rising incidence of obesity. Bariatric surgery has been shown to improve long term survival.

5. SEVERITY OF OBESITY IS IMPORTANT

The Edmonton Obesity Staging System classifies obesity according to how much it impacts the physical, psychological and functional status of the patient. Some patients with lower BMIs (30-35) may have more metabolically active fat (Metabolic syndrome) and need more aggressive surgical management of their obesity.

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Dr Toufic El-KhouryMBBS (Syd), FRACS, MS (colorectal)

www.drelkhoury.com.au02 9687 0900

Suite G12, 9 Norbrik DriveBella Vista, NSW 2153

Almost 75,000 Australians (one in 250 aged 5-40) are affected by Inflammatory Bowel Disease (IBD). It is projected that 100,000 Australians will be affected by 2022. We have the highest rates of prevalence and incidence in the world. IBD costs $100 million per year in direct hospital costs and over $380 million in productivity loss.

Inflammatory bowel disease (IBD) is a complex lifelong disease with a challenging management that is better faced by a multidisciplinary team with specialised diagnostic and therapeutic skills. At HSS, our IBD trained gastroenterologists and colorectal surgeons closely coordinate the care of those suffering from IBD to optimise the outcomes.

In this first of a two-part series, we will discuss the management of Ulcerative Colitis (UC).

(A) The medical management of UC Both Crohn’s disease (CD) and UC involve inflammation of the gastrointestinal tract. The main difference between the two diseases is the area of the gut affected and the thickness of the gut wall involved by the inflammation. In UC, the inflammation affects only the superficial layers of the colon.

The European Crohn’s and Colitis Organisation (ECCO) and the American College of Gastroenterology define UC using the Montreal classification, based on Truelove and Witts’ criteria as it reflects clinical practice.

Symptoms and diagnosisThe principal symptom of UC is bloody diarrhoea. Associated symptoms of colicky abdominal pain, urgency or tenesmus may be present as UC gets more severe.

The biggest delay in making a diagnosis of UC is as a result of not suspecting it.The diagnosis of IBD is made from the findings of a physical examination, patient history and various tests, including blood tests, stool examination, endoscopy, biopsies and imaging studies. This combination will exclude other causes and confirm a diagnosis so that the most appropriate treatment course can be recommended.

Important role of GPs in early tests GPs have a key role in early diagnosis, supporting the patient with psychological comorbidities, assisting with smoking cessation and managing intercurrent issues such as sexuality, fertility, family planning and pregnancy, iron deficiency and anaemia.

There is no cure for IBD. It is a chronic disease requiring lifetime care, usually starting in early adulthood in otherwise healthy, active people.

Treatment• Aminosalicylates (5-ASA): They are the mainstay of maintaining remission in UC. While they do relieve acute symptoms in mild to moderate colitis, their main use is for long-term maintenance of remission. They act topically on

Inflammatory Bowel Disease: Part 1 Ulcerative Colitis

the colonic mucosa to suppress the production of numerous pro-inflammatory mediators and control inflammation.

• Corticosteroids: For patients with acute flare-ups who are either too sick or who fail to respond to adequate doses of 5-ASA therapy or who cannot tolerate the side-effects, oral steroid therapy should be considered.

Using steroids without also commencing immunomodulators, and without early anticipation of the possible need for biological therapy, may cause these patients to undergo unnecessarily long periods of prednisolone therapy with all its attendant complications and greater periods of disease activity. Additionally it can place patients at increased risk of infectious complications and resections.

• Immunomodulators(azathioprine, 6-mercaptopurine and methotrexate): Drugs that modulate or suppress the immune system are commonly used to help control inflammation and maintain disease remission. However, they are not agents for induction of remission due to their slow onset of action (may take two to three months for response). These agents are used to prevent or reduce corticosteroid dependence in UC.

• Biological agents (infliximab, adalimumab and vedolizumab): Biological agents can only be prescribed by a specialist gastroenterologist. The current criteria specify that they are available to patients with moderate to severe ulcerative colitis who have failed standard therapy.

• Antibiotics: There is no data showing that any antibiotics are effective in UC, but they are used prophylactically in the setting of fulminant colitis in many centres.

(B) Surgery for Ulcerative ColitisSurgery is the cure for UC but it is a complex surgical speciality. In the last two decades, surgery has seen the introduction of laparoscopic, single port and robotic techniques. These are now the standard of care within our colorectal team at HSS. The restorative procto-colectomy with pouch-anal anastomosis is the gold standard. It cures ulcerative colitis with anal preservation.

In Acute Severe UC This is a life threatening condition.

We often use the Truelove and Witts index to assess severity: any patient who has a bloody stool frequency >6/day and one or more of the following: tachycardia (>90bpm), or temperature >37.8°C, or anaemia (Hb <10.5), or an elevated ESR (>30) has severe ulcerative colitis.

Should any clinical deterioration occur, failed second line medical treatment or complications arise, a prompt colectomy should be considered. This is the first of two or three stages.

In stage I, the emergency colectomy with an ileostomy will allow the patient to regain nutrition, allow the patient time to consider carefully the options of pouch versus a permanent ileostomy. It also allows us to clarify the pathology and exclude Crohn’s. A few months later, we usually plan for the complete removal of the rectum, this is stage II. This could be restorative (i.e. forming a pouch) or non-restorative (i.e forming a permanent ileostomy). If the patient has elected to have a restorative pouch surgery then stage III will follow in three months’ time, by reversing the temporary ileostomy.

In Chronic Refractory or Colorectal Cancer complicating UCSurgery for UC in this elective setting has the advantage of optimising of the patient’s general condition prior to surgery, reducing the immunosuppressant medication such as weaning off steroids when possible and improving nutrition. It is usually planned over a few weeks. This will be carried out with a minimally invasive technique. The decision to proceed with elective surgery often involves the patient, the family, the gastroenterologist and the colorectal surgeons.

At HSS our colorectal surgeons and gastroenterologists, along with our dedicated stoma care specialists, work closely together in a multidisciplinary fashion to coordinate and individualise the care for each patient suffering from IBD. This model has been proven to yield the most favourable outcomes and benefits to patients.

Inflammatory Bowel Disease Part 2 will be published in the next issue of this newsletter.

Dr Raghu GillMBBS, FRACP, Advanced Endoscopy (USA)

www.westernsydneygastro.com.au1300 898 632

Level 5, Suite 504,12 Century CircuitBaulkham Hills NSW 2153

02 8624 5000 • WWW.HSSAUSTRALIA.COM.AU 7

REGISTER AT: WWW.HSSAUSTRALIA.COM.AU/TRAINING

Aspects of Women’s Health and Plastic Surgery

Saturday18 November 2017

Full Day Category 1 CPD 40 points

your invitation hospital for specialist surgery continuing professional development seminar

Approved: QI&CPD RACGP 2017-2019 Triennium

Event Sponsors:

As an RACGP accredited provider of Continuing Professional Development (CPD) training, HSS is committed to supporting GPs to provide the best possible care for their patients. We are delighted to invite you to the next free-of-charge event at our world-class facility.

Join us for Aspects of Women’s Health and Plastic Surgery facilitated by leading HSS surgeons and physicians. This full day Category 1 event enables you to engage with the specialists in topical interactive sessions. Attending GPs will receive 40 points towards their individual and vocational CPD requirements.

Sponsors have no input into the content of materials and presentations of this event.

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What problems are caused by a blocked nose in children?In children, a blocked nose can cause many different problems, including some or all of the following:

• Mouth-breathing

• Noisy breathing

• Poor-quality/ restless sleep

• Snoring

• Behaviour changes

• Sore throats

• Dark circles under the eyes

• White patches on the teeth (from drying out whilst mouth-breathing)

• Crooked teeth

• Teeth grinding and clenching at night

• Nose bleeds (from drying out of the nose lining due to turbulent air flow)

• "Nasal" voice

In severe cases, blocked nose may lead to:• Obstructive sleep apnoea

• Irritability/ inattention/ hyperactivity/ disruptive behaviour

• Problems with learning/ problem-solving/memory

• Unhealthy gums

• Dry, cracked lips

• Sinus problems

• Bed-wetting

• Night sweats

Blocked Nose in ChildrenBut most children don’t complain of a blocked nose! Surely, the child's nose can't be blocked if he/ she isn't complaining?Most children won't know they have a blocked nose! Usually, the child's parents don't realise, because they just assume it is normal for some children to mouth-breathe. However, mouth-breathing in children is NOT normal! If you observe some of the symptoms listed above, there is a good chance the child has significant nasal blockage, without the child or parents realising it.

What does a blocked nose have to do with crooked teeth?A clear nasal passage is critical to the development of normal teeth in children. Normally, children should breath through their nose, especially at night. If the nose is blocked, children will breathe through their mouth. This is abnormal. When children mouth-breathe, their teeth can grow crooked, and their maxilla (upper jaw) may become too narrow affecting the shape of their face.

How can parents tell if their child's nose is blocked?Advise parents to watch their child closely during the night when they are asleep. If their mouth is open when they breathe, their nose is blocked!

Other tell-tale signs include those listed above.

What causes a blocked nose in children?In the majority (>95%) of children, blockage is caused by:

• Big adenoids

• Big inferior turbinates

• Hayfever (Allergic rhinitis)

Other causes of blockage in children include:• Deviated septum (much less

common)

Much less common causes of a blocked nose in children include:• Sinusitis

• Objects the child has pushed in to the nose (foreign bodies)

• Other rare causes (birth defects, tumours/cancers (very rare), etc).

How can I find out what is causing a child's blocked nose?• History (mouth breathing,

snoring, teeth grinding, allergy)

• General examination (facial appearance, mouth breathing, white patches on teeth, dark circles under eyes)

• Nasal examination, preferably with headlight

• Nasendoscopy – An ENT specialist will pass a fine camera into the child's nose to look at the adenoids, turbinates and septum (the nose is made numb first using a numbing spray). The parents can watch the nasendoscopy on a TV monitor to see the exact cause of the obstruction.

• Xray of adenoids (Lateral airway) – In general, it is preferable to choose Nasendoscopy instead of

Adenoid Xrays. Nasendoscopy is much more accurate and avoids the risk of unnecessary radiation exposure in young children.

• Allergy tests – Skin prick tests or blood tests (these are usually reserved for older children or those undergoing general anaesthesia)

How will the child's blocked nose be treated?The treatment used will depend on the cause:

• Hayfever (Allergic rhinitis): This can often be treated with nasal steroid sprays, antihistamines or de-sensitisation.

• Anatomical problems can be addressed with surgery. In most cases, this is day-surgery, under general anaesthetic.

• Large adenoids: These are treated with adenoidectomy

• Large inferior turbinates: These are treated with Coblation to the inferior turbinates, or rarely, inferior turbinoplasty

• Deviated septum: This is treated with a Septoplasty procedure, but only when the child's growth has slowed down (usually age 15-16+). Until then, a partial improvement in the nasal blockage is gained with adenoidectomy and Coblation to the inferior turbinates or inferior turbinoplasty.

Dr Narinder SinghMBBS (Syd) MS (Syd) FRACS (ORL-HNS)

www.ents.com.au 02 9680 8800

Suite G6Norwest Private Hospital11 Norbrik Drive, Bella Vista 2153

Adenoidectomy by Dr Singh for Large Adenoids in ChildrenNose

Normal Adenoids

Eustachian tubeopening

Large adenoids cause blocked nose. Dr Singh performs adenoidectomy to unblock the nose and Eustachian tubes

Large Adenoids • Blocked nose, mouth breathing• Snoring, restless sleep• Ear infections• Crooked teeth, orthodontic problems

Normal Adenoids • Clear nose• Good quality sleep• Clear ears and hearing• Straight teeth

02 8624 5000 • WWW.HSSAUSTRALIA.COM.AU 9

Providing orthopaedic and reconditioning inpatient and outpatient services, HSS Rehabilitation boasts a fully equipped gym, a large hydrotherapy pool, and the combined expertise of the best medical professionals - all set in a peaceful, modern environment.

The highly skilled and compassionate multidisciplinary team works closely with each patient to develop programs that are tailored specifically to their needs.

Patient updates are given periodically to non-HSS orthopaedic surgeons and there is close coordination with our Rehabilitation Physicians. GPs are updated on patient’s progress via discharge letters and personal phone calls. For patients with complex medical conditions, our multidisciplinary team of acute specialist consultants including cardiologists, geriatricians and endocrinologists are on hand to assist.

Give your patients access to the best Rehabilitation facilities in Western Sydney

• High staff to patient ratio• Large hydrotherapy pool and spa in a comfortable air-conditioned

environment• Fully equipped gym with the latest in equipment• Generously-sized rooms, many with lake views • Outdoor mobility exercise programmes • Outpatient services through on-site physiotherapy• Ongoing lifestyle and wellbeing programs• Open dining and socialising area on the ward• On-site medical consulting rooms• Large, open corridors to facilitate walking• On-site radiology, pathology and pharmacy• Outstanding catering prepared on-site

Referrals are welcome from: general practitioners, discharge planners, specialist consultants, rehabilitation physicians and other hospitals.

Phone 02 8711 0247, fax 02 8711 0255 or email Rehab@hssaustralia.com.au.

www.hssaustralia.com.au/rehabilitation

When referring patients for rehabilitation, you can’t go past Hospital for Specialist Surgery (HSS).

Nil superficial infection rates 2016/17 for total post op hip and total knee replacements!

Ministry of Health 2017 audit 100% compliance with no recommendations!

Non Scalpel Vasectomy now available at HSS

Prof Howard Lau

MBBS (Syd.), FRACS (Urol)

www.drlauurology.com.au02 9635 5377 Urologist and Transplant SurgeonConjoint ProfessorSchool of MedicineWestern Sydney University

Vasectomy remains the most secure and permanent form of contraception for couples who want permanent contraception. The procedure is safe and not associated with an increased risk of any chronic medical conditions. Patients should be counselled that this is a permanent contraceptive procedure and sterility cannot be achieved immediately due to the back log of sperm that needs to be cleared.

Generally pure sperm only represents two per cent of the total seminal fluid volume. Dividing the vas deferens, hence interrupting the passage of sperm, will not cause any macroscopic difference to the semen. It also has no hormonal effect and will not affect the patients’ sexual function.

Other than the permanent nature and delay in onset of sterility, the

patient needs to be aware of the potential of delayed recanalization of the vas which occurs roughly about one per 1000 cases. The procedure can be performed either under general or local anaesthetic. Keeping the wound dry overnight, supportive underpants and the use of antiseptic cream on the incision site can assist recovery.

Non scalpel vasectomy or incisionless vasectomy involves a small skin puncture using a sharp tip forcep. An incision is not necessary. The vas is dissected free and lifted through the small puncture site where the vasectomy can be done and the vas is returned to the scrotal cavity. This technique was developed in the Chinese military and is now popular worldwide. It is suitable for both general and local anaesthetic procedures. Cosmetic results are generally very satisfactory.

Patients can return to simple exercise after two days. Follow up should include semen count at about three months. Until then the patients should consider themselves “dangerous”.

At HSS a non-scalpel vasectomy is available. Please refer to one of our attending surgeons.

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surgery; every surgery has risk. The time to have the procedure is when you are convinced it’s necessary.

2. Will I be awake?I like to leave this decision up to the anaesthetist. The real question being asked is “Will I be aware and will I be in pain?” Patients will be monitored constantly. The anaesthetist will be present and providing specialist care during the entire procedure. Patients will come to a pre-operative clinic and see the anaesthetist, physiotherapist and rehabilitation team. They will have pre-operative investigations such as bloodwork, chest x-ray, ECG and urine tests. General and regional anesthetic options are available; usually spinal, general and PCA (patient controlled anesthesia). We will always do our best to keep patients comfortable and cared for at all times.

3. Do I keep my own patella?Patients often think we remove the patella however this is not the case.

A resurface procedure takes place 61 per cent of the time. The patella is everted and the superficial 7-8 mm of bone and cartilage are removed. I am selective in choosing which patellas should be resurfaced. Some patellas should be resurfaced such as patients with rheumatoid arthritis. Some should be left such as a thin patella with a high risk of fracture.

4. What is the prosthesis made of?• Metal femoral component

• Plastic insert

• Metal tibia component

• Plastic patella button

• The femoral component is an alloy of chromium, cobalt, molybdenum and nickel.

• The tibial component is an alloy of titanium, aluminum and vanadium.

• The common metal sensitisers are chromium, nickel and cobalt. For these patients we can use titanium.

• Please note metal allergies are very rare.

5. How long will the prosthesis last?In previous years, knee replacements were estimated to have a 10 year survivorship. This statistic has recently been revised to a 15 year survivorship. It is preferred to delay knee replacement surgery in a younger patient (such as a 55 year old patient) for the reason mentioned above. The average age for patients undergoing knee replacement is 65 to 75 years.

1. Do I need the surgery?Knee replacement is an elective procedure. I am not in the habit of convincing patients to have

Total knee replacement surgery FAQs

Dr Edward Graham

MBBS FRACS (Orth)

www. dredwardgraham.com02 9679 7088

HSS OrthopaedicsHospital for Specialist Surgery Suite 1, 17-19 Solent Circuit. Bella Vista NSW 2153

Test? What test? Imaging of the Injured Foot and Ankle made simple

Dr A. Scott NewmanMBBS FRACS(Ortho) FAOA

www.ascottnewman.com.au02 8711 0100

HSS OrthopaedicsSuite 1, Level 117-19 Solent CircuitBella Vista NSW 2153

Exposed to an ever-more-sophisticated arsenal of readily-available diagnostic tools, it’s tempting for the acute care doctor to reach for his referral pad and pass diagnostic decision-making responsibilities over to

his friendly radiologist! But is it always necessary to do a “test” and is the best test always the most sophisticated one?

Let’s look first at a common and sentinel example. Here we fall back on the basic tenets of history and examination and I cannot emphasise too strongly the importance of that most-basic of diagnostic “instruments”: the “examining eye on the end of the finger”. Typically, this diagnosis makes itself, when the patient walks through the door and tells you of the snapping sensation experienced whilst participating in an unaccustomed high impact activity. It’s a tendo achilles rupture, nothing less, until proven otherwise. Diagnostic “game, set and match” is visualising and palpating a tendon defect, accompanied by a loss of normal ankle posture and tone, and a positive Thompson’s test. An ultrasound is never needed, and can indeed be frankly misleading. If it’s a late presentation, when the cardinal signs of rupture become more ill-defined, nothing short of an MRI will do!

On the suspicion of a fractured ankle or foot, appropriate x-ray views are mandatory and an ultasound should never be considered. If plain radiographs don’t reveal the diagnosis, or adequately display it, a fine-slice CT is the next step. MRI is not helpful in this setting.

The patient who presents with a twisting ankle or hindfoot injury will assist you in shortening the differential diagnosis list with a description of where the pain and swelling started. The simple and accurate Drawer Test for a ruptured ATFL could save the health budget millions of dollars annually if it were routinely performed in this setting, as it dispenses with the need for the notoriously inaccurate and unreliable ultrasound! Whilst an x-ray is still necessary in most cases to help rule out a fracture, the history and clinical examination will already have determined that this patient belongs in a CAM Boot. MRI is the investigation of choice later and only if and when symptoms fail to spontaneously resolve, raising the spectre of occult pathology.

Pain and swelling developing atraumatically after unaccustomed or overactivity may well be a stress reaction or fracture, and will only be seen on x-rays of cortical bone after two or three weeks. Otherwise, order a Bone Scan or MRI......... never, you guessed it, an ultrasound!

A twisting, loaded injury when a patient reports pain and swelling about the midfoot should always be x-rayed, but with an eye for subtle avulsive fracture fragments or subluxation, and with projections parallel to the suspicious joints. Weight-bearing views may better reveal the subluxation, and a CT is ideal to map the anatomical detail of this injury, whilst nothing short of an MRI will actually show the infamous Lisfranc ligament whose rupture is so often missed!

When requesting CT and MRI imaging, seek out high resolution options and always ask for a study targeted at the area of concern. There’s no utility in scanning an entire foot when the pathology is clearly in the great toe!

02 8624 5000 • WWW.HSSAUSTRALIA.COM.AU 11

Dr Jeff ChangBsc(Med), MBBS, FRACP - Gastroenterologist and Hepatologist

Dr Jeff Chang is a gastroenterologist who graduated from the University of New South Wales and completed his physician training at Concord hospital. He pursued further training as a clinical/research IBD Fellow at the Western General Hospital Edinburgh, UK before returning to Australia. He is currently completing a PhD in examining intestinal permeability via confocal endomicroscopy in inflammatory bowel disease having been previously awarded a National Health and Medical Research Council (NHMRC) scholarship for his work. He currently holds staff specialist appointments at Nepean Hospital and Concord Hospital.

Ph: 1300 874 325 www.gastrohealthaustralia.com.au

Professor Golo AhlenstielMBBS FRACP MD - Gastroenterologist and Hepatologist

Professor Ahlenstiel graduated from the University of Bonn, Germany, undertook a Liver Fellowship at the world renowned National Institutes of Health (NIH) in the United States, and completed basic and advanced training in Gastroenterology and Hepatology in Australia. Golo is a VMO Gastroenterologist at Hospital for Specialist Surgery and at Blacktown/Mt Druitt hospitals. His practice encompasses all aspects of gastroenterology and liver disease with a particular interest in colorectal cancer screening, pillcam and the management of chronic liver disease including viral hepatitis B and C and liver cancer.

Ph: 02 8711 0160 www.sydneynwgastro.com.au

Dr Eric CheahMBBS, BMedSc, FRACP - Paediatric Gastroenterologist and Hepatologist

Dr Eric Cheah is a paediatric gastroenterologist and hepatologist. He graduated in Medicine from the University of Melbourne, completed paediatric training through the Royal Children’s Hospital in Melbourne, and paediatric gastroenterology/hepatology and paediatric liver transplantation at the Children’s Hospital in Westmead. Eric manages children from newborns to adolescents with gastrointestinal complaints including abdominal pain, functional gastrointestinal disorders, coeliac disease, constipation, diarrhoea, gastro-oesophageal reflux disease, liver disease and failure to thrive with a special interest in eosinophilic oesophagitis, inflammatory bowel disease and cystic fibrosis.

Ph: 1300 874 325 www.gastrohealthaustralia.com.au

Introducing newly accredited doctors at HSS

Dr Guang ChenJP BSc (Med) MBBS (Hons) FRACP FAChAM - Gastroenterologist and Hepatologist

Dr Chen is a gastroenterologist and hepatologist practising in Western Sydney. He graduated from UNSW Medical School before undertaking post-graduate specialist training in gastroenterology and addiction medicine. Guang has an interest in liver disease but manages all aspects of gastroenterology. He is accredited to perform diagnostic and therapeutic endoscopic procedures.

Ph: 02 9633 1820 www.guangchen.com.au

Looking for a specialist? Head over to our new look website to view our Specialist Directory

www.hssaustralia.com.au

Dr Viraj KariyawasamMBBS Hons, MRCP, FRACP - Gastroenterologist and Hepatologist

Dr Viraj Kariyawasam’s practice encompasses all aspects of gastroenterology and liver disease, with expertise in inflammatory bowel disease (IBD), Irritable Bowel Syndrome (IBS) and advanced therapeutic endoscopy (gastroscopy, colonoscopy, endoscopic mucosal resection, stricture dilatation, insertion of stents and capsular endoscopy). He has a special interest in cancer screening with emphasis on prevention and early detection of colorectal, oesophageal and stomach cancer. Viraj takes pride in providing high quality comprehensive patient care, which is highly personalized and readily accessible. He is bilingual (English and Singhalese).

Ph: 1300 874 325 www.gastrohealthaustralia.com.au

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HSS News is produced by the HSS Marketing Department. For feedback please contact the Marketing Manager on 02 8711 0505. If you do not wish to receive further materials from HSS simply email marketing@hssaustralia.com.au or write to Marketing at Hospital for Specialist Surgery at 17-19 Solent Circuit Bella Vista 2153. The HSS Privacy Policy can be found at www.hssaustralia.com.au.

17-19 Solent Circuit Bella Vista 2153. Phone 02 8624 5000. Fax 02 8711 0577. www.hssaustralia.com.au.

Dr Mayuran SuthersanBSc. MBBS (UNSW) MS. (USyd) FRACS - Orthopaedic Surgeon

Dr Suthersan is an orthopaedic surgeon who performs surgery for orthopaedic trauma. He has a special interest in foot and ankle trauma. Mayuran trained in Sydney and currently has appointments at Hospital for Specialist Surgery and Westmead Hospital.

Ph: 02 8660 0028

Dr Hannah NorthMBBS (Hons), BMedSc, DOHNS, MS (ORL-HNS), FRACS (ORL-HNS) - ENT Specialist Surgeon

Dr North is an ENT specialist surgeon who sub-specialises in ear and lateral skull base surgery (neuro-otology) in both children and adults. She treats hearing loss, performs surgery for perforated ear drums, cochlear implants, middle ear surgery, cholesteatoma including endoscopic ear surgery and all tumours of the ear and lateral skull base. Hannah lectures at conferences the world over and is one of the editors for Cochlear Implant International Journal for the British Cochlear Implant Group.

Ph: 02 8805 7499 www.ents.com.au

Dr Chameen SamarawickramaBSc(Med) MBBS PhD FRANZCO - consultant eye surgeon

Dr Chameen Samarawickrama is a Consultant Eye Surgeon with expertise in corneal and anterior segment surgery, complex corneal diseases, keratoconus, corneal transplantation, dry eye, cataract surgery and laser eye surgery. Chameen combines scientific excellence with personalised care and prides himself on clear communication and patient education. His philosophy is to maintain a holistic approach to each person’s vision, from assessment to surgery and after care. Chameen is abreast of the forefronts of ophthalmic developments and technology, and delivers this in a personalised and approachable manner.

Ph: 02 9680 9100

Dr Farid Meybodi MD, MS, FRACS - Specialist Breast Surgeon

Dr Meybodi is a specialist breast surgeon at the Westmead Breast Cancer Institute and Lakeside Specialist Breast Clinic at HSS, and Clinical Senior Lecturer at the University of Sydney. Farid has a special interest in improving outcome in post mastectomy implant based breast reconstruction and oncoplastic breast surgery. He is also involved in the teaching of surgical registrars, postgraduate fellows and medical students at the University of Sydney.

Ph: 1300 652 986 www.drfaridmeybodi.com.au

Dr Anand Suruliraj MS FRACS (OHNS) - ENT Specialist Surgeon

Dr Anand Suruliraj is an ear nose and throat specialist surgeon with special interest in otology and head and neck surgery. Anand is a VMO at Westmead and Auburn Public Hospital and HSS. His practice encompasses both adult and paediatric ENT conditions. He is a member of the Australian Society of Otoloaryngology Head and Neck surgery, The Royal College of Surgeons Edinburgh and Society of Otology.

Ph: 02 8824 7636