By right, being an investigation, there really should not be such a long wait for a colonoscopy. After all, one of the main reason the test is being done is to exclude a bowel cancer.
Why should a public patient wait for such a long time for an investigation? Does anyone have to wait more than 4 weeks for a blood test or any Xray?
Currently there are so many patients on public waiting lists all over Australia. Mathematically, I cannot see how this would get any shorter if the current situation persist. In fact, it will only get longer as the population ages, more and more people leave private insurance and hospital budgets become tighter. Also in public hospitals, the throughtput is much less than in a private endoscopy centre for a number of reasons including:
1. Hospital bureaucracy slowing turnover of patients
2. Working culture
3. Need for trainee anaesthetists and surgeons/gastroenterlogists to learn hands on
4. Financial model in public hospitals do not given any incentives for the hospital to do more scopes(they would go over budget, they can only have a certain percentage of patients are day cases, and only do a certain number of scopes a year) nor do they give incentives for specialists(paid by the hour on a rate far less than what one gets privately, often moral is low due to hospital bureaucracy, most are staying on only out of a duty to care for their patients and to teach the trainees) to increase throughput
Hence in the public hospitals, the average colonoscopes booked to a half day list(with registrars) may be about 6-7 while privately one can have 8-10 cases on a half day list.(Some private centres do even more than that – but doing a colonoscopy too quickly is also not good as polyps may be missed. Ideally, 30min should be allocated for each colonoscopy procedure to allow time to have a careful look on withdrawing the colonoscopy)
The waiting times in public hospitals can be months especially in Melbourne – for Category 2 and 3 patients. A colleague who works in a public hospital in the western suburds says he hardly sees any Category 2 or 3 patients getting onto his endoscopy list.
In smaller country public hospitals, the waiting list is thankfully shorter. This is only fair as country patients do not usually have access to a local private endoscopy centre(where one can pay a small centre fee to have the endoscopy with the endoscopist fees’ bulk billed to Medicare)
Small haemorrhoids can be banded during a colonoscopy procedure(Generally most gastroenterologists do not band the haemorrhoids but refer that on to the surgeons)
The benefits of banding compared to surgery to excise the haemorrhoids are that: 1. It is relatively painless(if the rubber bands are placed high above the anal canal) 2. It does not require any more anaesthesia than the one for the colonoscopy.
It is a relatively quick procedure to perform. A short proctoscope is inserted. The rubber band is loaded onto the suction bander. The haemorrhoids is sucked up onto the suction head and the rubber band is then applied. This rubber band strangulates the neck of the haemorrhoid. This is then repeated on the other haemorrhoids seen.
Complications are uncommon. Sometimes they may be discomfort or feeling or an urge to go to the toilet after the procedure. Occassionally, if the haemorrhoids is large, it can be painful. Bleeding and blood clots may be notice when the haemorrhoids sloughs off over the next 2 weeks.(If there is severe bleeding one should see a doctor immediately – patients on blood thinners and with liver problems are at higher risk of bleeding)
It is terribly important to follow the instructions for the bowel preparation. If not properly followed, there may still be faeculent fluid or worse still, thick faeces covering some of the lining of the large intestine. This could hide a small polyp. Also the procedure becomes longer as the endoscopist has to spend time trying to wash and suck out the faeculent fluid as much as possible. (This wouldalso mean the anaesthetist giving the patient more sedation)
Also it is important to avoid food with seeds in the few days preceeding the colonoscopy. Small seeds are a nightmare to the endoscopist as they become stuck in the suction channel of the scope when the faeculent fluid is sucked out!
Other things that have been seen during a colonoscopy include: pill granules, vegetable material …and even a fruit sticker stuck on the wall of the bowel!
Also the bowel preparation work best when one drinks plenty of fluids in order to “wash” out all the faeces in the colon. So remember to take lots of drinks when taking the bowel prep! (But avoid alcohol or coffee !)
Recently another patient in his early 40s went to see his GP for a skin lesion. The GP suggested he has a FOBT too during the consultation. The FOBT turned out to be positive. He subsequently had a colonoscopy which showed a small caecal cancer. He went on to have a right hemicolectomy. Further scans have not shown any evidence of spread.
Were it not for his GP ordering the FOBT, this patient’s cancer would probably not have been detected until a few years later(usually the patient would either present with anaemia; occasionally one can get a right sided abdominal pain from this that could be the same as an appendicitis type pain). This raises the dilemma for the all doctors – how aggressively does one screen the patient and from what age? Also is there enough resources to do this especially in the public system?