Colon and Rectal Surgery
Faculty within the Division of Colon and Rectal Surgeons are specialists in the surgical treatment of colorectal cancer, inflammatory bowel disease, motility disorders, benign anorectal conditions, and pelvic floor problems.
We perform a wide variety of advanced surgical procedures such as laparoscopic colectomy, transanal endoscopic microsurgery, anorectal ultrasound, and sacral nerve stimulation. Our faculty teach surgeons from around the country, are extensively involved with research, and speak at national and international conferences.
Our doctors who specialize in this area are:
- Comprehensive Clinic for Gastrointestinal Malignancies
This clinic meets on a weekly basis and is attended by physicians and support personnel who are involved in the care of patients with cancers of the gastrointestinal tract. Included are medical oncologists, radiation oncologists, surgeons, gastroenterologists, radiologists, pathologists, geneticists, and oncology nurses. When patients present for consultation, they meet with all of the physicians who will be involved in their care. Their pertinent x-ray tests and previous biopsy materials (if present) are reviewed in a conference and then a unified, coordinated treatment plan is presented to the patient. This practice model provides convenience for the patient through a single clinic visit.
A special feature of this clinic is counseling regarding screening for colorectal cancer. Approximately 2 percent of average risk individuals in the United States will develop this form of cancer, risk is higher for individuals with a personal history of inflammatory bowel disease (Crohn’s disease, ulcerative colitis) or a family history of colon cancer. The risk continues to climb if more than one family member is affected or if your relative was very young when diagnosed. There are two conditions whereby a person is born with an inherited trait that places them at extremely high risk for colon and rectal cancer, these are known as Familial Adenomatous Polyposis (FAP) and Hereditary non-Polyposis Colorectal Cancer (HN PCC). Recognition of families with these conditions is extremely important so that members at risk can be identified and proper surveillance examinations performed in a timely fashion.
- Multidisciplinary Clinic for Pelvic Floor Disorders
Urinary and fecal incontinence are socially disabling problems as well as frequent reasons for institutionalizing elderly patients. Although both genders are affected, women greatly outnumber men not only with respect to incontinence but also for other pelvic floor problems such as prolapse (rectum, bladder, vagina, uterus), inability to defecate, and chronic pain. Physicians in the Division of Colon and Rectal Surgery have partnered with physicians in the Divisions of Women Reconstructive Surgery (urogynecology), Urology, and Physical Medicine and Rehabilitation in forming a multidisciplinary clinic for women with urinary and fecal incontinence, pelvic organ prolapse, dysfunctional defecation, and chronic pain. Representatives of all of these disciplines attend each clinic session so that patients meet their team of doctors at a single clinic visit. State of the art diagnostic testing is available on an outpatient basis. Although most of the doctors are experts in the surgical treatment of diseases, non-surgical options are also discussed and usually offered as a first line of therapy, reserving surgery as a last resort. Many of the patients seen in this clinic have been affected by their problems for quite some time and have either been told to live with their condition or have failed treatment by other doctors.
- Program for Inherited Susceptibility to Colon and Rectal Cancer
As stated above, some patients may be at especially high risk for colon and rectal cancer because of a genetic disorder or a strong family history. This program is staffed by members of the Division of Colon and Rectal Surgery, Gastroenterology, and Genetics. They meet on a regular basis to consult with patients and their families to discuss not only colorectal cancer, but also other malignancies that may accompany these syndromes.
SPECIAL PROCEDURES OFFERED
Transanal Endoscopic Microsurgery
Most patients with rectal cancer need to undergo treatment that combines a radical abdominal operation with radiation and chemotherapy administered either before or after the surgery. Occasionally, a cancer is found in its earliest stages and does not require this intensive approach. Some of these early tumors can be removed through the anus, in fact, “transanal” surgery, as this method is called, has been practiced for over one hundred years. The benefits of transanal surgery are due to its less invasive approach, the surgeon removes the tumor without doing an abdominal operation, consequently, there is less pain, less disfigurement, no need for a colostomy bag, and a faster return to normal activities, including work. The instruments for performing transanal surgery have their limitations, however, and because they are short, they restrict surgeons to removing tumors just inside the anus and they don’t provide for good visibility. These problems have been fixed with a technique called “transanal endoscopic microsurgery” (TEM).
Pioneered and developed by Professor Gerhard Buess in the early 1980’s, TEM was initially used extensively in Germany and the rest of Europe but was slow to gain popularity in the United States. In the last 10 to 15 years, however, there has been a tremendous increase in interest in TEM technology as proven by the hundreds of articles published in the medical journals. TEM has introduced essentially a new field of surgery in the last couple of years termed “Transanal Endoscopic Surgery”, or TES, which utilizes a variety of instrument systems produced by a number of different companies. The features common to all of the TES systems are superior high definition optics which provide excellent visibility, long shafted instruments for reaching higher tumors, and insufflation of carbon dioxide gas for opening the rectum so that visibility is enhanced.
Virtually any benign polyp can be removed with TEM, however, strict selection criteria must be followed if the surgeon is using it for cancer. Not every tumor is a candidate for TEM, some are just too far advanced or are too large and require a more radical approach. The surgeon will guide the patient through the selection process and this generally requires two office based procedures, namely proctoscopy and ultrasound. The former is a short examination whereby the surgeon inserts a short scope into the anus in order to see the tumor and document the tumors’ location. It is a very fast test. Ultrasound is performed with a short instrument inserted through the anus to determine how deep the tumor has extended and whether there are suspicious lymph nodes. If the tumor is reachable, has not extended into the deeper layers of the rectal wall, and has not spread into the adjacent lymph nodes, then the patient is likely a candidate for TEM.
To prepare for TEM, the patient undergoes a bowel cleansing at home on the day prior to surgery. This can be accomplished with enemas or laxatives. The patient is admitted to the hospital on the day of surgery and will likely stay in for one night. The operation lasts one and a half hours. The patient may return to work generally within a week of the procedure. If the operation is performed for cancer or if the pathologist discovers cancer within a specimen initially thought to be benign, there needs to be discussion with the surgeon. Occasionally, additional treatment is needed after TEM if there are dangerous features of the tumor such as deep penetration, aggressive behavior, or invasion of the blood or lymphatic vessels. Such treatment is usually a transabdominal operation, however, radiation and chemotherapy can be used as an alternative for elderly patients or patients who are not fit enough for a big operation. On the other hand, if a cancer does not possess bad features, TEM may be an acceptable form of treatment.
Loyola University has colon and rectal surgeons trained and skilled in TEM surgery. In fact, its faculty offer training courses for surgeons around the country who wish to acquire this expertise.
Laparoscopic Colon and Rectal Surgery
Until the early 1990’s, general and colon and rectal surgery was performed by making a vertical incision in the midline of the abdominal wall. The surgeon then inserted his/her hands into the abdominal cavity and performed the operation. In medical terms, this was known as a laparotomy or celiotomy. A significant period of time was then invested by the patient in the healing process and the patient was left with a large scar. Initially used by gynecologists, laparoscopy emerged in the 1990’s as a tool for general and colon and rectal surgeons and virtually every operation in existence today can be performed by either laparotomy or laparoscopy. Operations as relatively simple as appendectomy, hernia repair, and gall bladder removal can be performed as well as more complex operations such as liver resection or removal of the colon and rectum. Operations for morbid obesity can be performed with laparoscopic techniques.
Laparoscopy is performed by surgeons who have obtained their skills in a training program (residency or fellowship) that has a high volume of laparoscopic cases. Finding these surgeons is very important if a patient wishes to pursue this form of treatment. Laparoscopy is performed through a series of small incisions, each about a half inch long. The image is obtained with a laparoscope which is inserted into the umbilicus, the scope is then connected to a large television screen via a video cable. The instruments necessary for the operation are then inserted through the remaining small incisions. When it is time to remove the specimen, one of the small incisions is enlarged to two or three inches and the specimen is extracted. The basic steps of a laparoscopic operation are the same as for a laparotomy, what distinguishes a laparoscopic operation is its minimally invasive nature and the fact that visibility is obtained through a scope rather than direct vision.
The advantages of laparoscopy are that recovery is usually faster, there is less pain, hospital stay is shorter, patients return to work faster, and there are fewer wound complications such as infection or hernia. The cosmetic result is better as well, although this should not be the driving force in deciding how an operation should be done. Approximately 20 to 30 percent of the colon and rectal operations performed in the United States are performed with laparoscopy, this number is expected to increase as more surgeons are trained in the technique. Some patients are not candidates for a laparoscopic colon operation, these include the morbidly obese patients, those who have had extensive and multiple prior operations, and those with large tumors. It will ultimately be the surgeon who will decide what is the best approach for any given patient.
The colon and rectal surgeons at Loyola University are skilled in the techniques of laparoscopic surgery. Patients should discuss with their surgeon whether this form of surgery is possible. Remember, healing, resumption of normal activities, and return of normal body function are the main goals of surgery regardless of the technique chosen to achieve these goals.
Sphincter Preserving Operations for Rectal Cancer
One of the most frequent questions asked by patients who are facing surgery for rectal cancer is, “Will I need to wear a bag?” This refers to a colostomy whereby stool is eliminated into a plastic bag worn by the patient on his/her side rather than into a toilet. While permanent loss of the rectum and needing a colostomy is still the necessary operation for some patients, it is fortunately not the most frequently performed operation for this type of cancer. Most patients do not have to lose their rectum but whether or not it is possible to preserve the sphincter muscle and hence the rectum is sometimes determined by the skill of the surgeon. It has been shown that the success of an operation for rectal cancer is dependent on the experience of the surgeon and the hospital in talking care of patients with rectal cancer. A better outcome can be anticipated when the surgery is performed by someone who does this type of work on a frequent basis. It is imperative that the patient chose a surgeon who is trained and experienced in taking care of rectal cancer. In this way, not only can a better cancer outcome be expected but also the best possible chance for avoiding a colostomy. The surgeons in the Division and Colon and Rectal Surgery at Loyola University are experienced in this regard.
Several major medical institutions, including the American Cancer Society, recommend screening for colon and rectal cancer starting at age 50. If a person is at high risk for cancer, the age at which to begin screening is younger. Individual risk for cancer can be discussed with your physician. There are several ways to perform screening but colonoscopy is generally considered the most sensitive and accurate. If an abnormality is seen it may be biopsied or even removed during colonoscopy.
Treatment of Fecal Incontinence
Inability to control stool is a distressing problem for which patients are frequently told that no help or treatment is available. Of course, this is not always true and many patients can be successfully treated. In order to determine the best options for a patient, diagnostic testing is performed and consists of anal ultrasound (is the sphincter intact?), anal manometry (how strong is the muscle), nerve testing (are the rectal nerves functioning properly), and certain X-ray tests (is the anatomy normal and does the rectum empty as expected?). After these tests are performed, your surgeon will determine the best treatment, this may consist of sphincter strengthening exercises or sphincter muscle reconstruction. The latter is frequently performed when the muscle has been torn by previous surgery such as a hemorrhoidectomy or anal fistula repair or after childbirth during which time the muscle may have been cut or torn. Other treatments are available, including new forms of therapy called “sacral nerve stimulation” (SNS) and “injectable agents”. SNS involves surgically implanting a special generator and nerve stimulator near the nerves that govern how our bowel and bladder function. Studies have shown that most patients will experience a reduction in the number of incontinent episodes they experience each week. New medications recently approved by the FDA can be injected directly into the anal sphincter in an attempt to build up the tissue. This is an office based procedure that does not require an anesthetic. Patients usually notice a reduction in the number of incontinent episodes per week. Patients may return to work and other normal activities immediately.
The colon and rectal surgeons at Loyola University Medical Center are experts in the treatment of fecal incontinence. They will determine which tests are necessary and what treatment is best for each patient.
Inflammatory Bowel Disease
The surgeons work very closely with our colleagues in the Division of Gastroenterology in the care of patients with Crohn’s disease and ulcerative colitis. These diseases are closely related but they have distinct differences as well. Both conditions affect young people, are thought to be caused by abnormalities in the immune system, affect body systems apart from the intestinal tract, and are treated with the same medications. Medicine is used as the initial treatment for all patients, surgery is reserved for patients who don’t respond to treatment or experience intolerable side effects of the drugs. Your surgeon will discuss surgical options with you, a laparoscopic approach is a possibility.
Benign Anorectal Conditions
Many people suffer from common conditions such as hemorrhoids, fistulas, abscesses, fissures, and warts. Distinguishing these conditions from each other is very important since treatment will vary. Unfortunately, most patients and primary care physicians attribute symptoms of pain, bleeding, itching, or lumps to hemorrhoids when in fact another condition may be responsible. Consultation with a colon and rectal surgeon is important in order to establish the correct diagnosis and start treatment without delay.
New and innovative forms of treatment for hemorrhoids and fistulas are available which minimize trauma to normal tissue, pose less risk to the sphincter muscle, and speed up recovery. For hemorrhoids, these newer treatments include stapled hemorrhoidectomy and Doppler (ultrasound) guided ligation of the hemorrhoidal artery. For anal fistulas, maintaining sphincter health and integrity is very important, damaging the muscle by surgery will risk causing incontinence. It is extremely important that the surgeon be familiar with all of options available, these include the use of fibrin glue, collagen plugs, placement of a seton suture, creation of a rectal flap, or the LIFT procedure. Your surgeon can discuss the options in depth with you.
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