Colon & Rectal Procedures
Office consultation and proctosigmoidoscopy or anoscopy examination
The first step toward diagnosis and treatment of diseases of the anorectum is a visit with your physician. The visit will involve a discussion of the problem and then an exam. Although associated with some anxiety (especially on the first visit), the entire process is usually painless and yields information to enable the beginning of treatment. Commonly a visual inspection of the anus is performed, followed by a digital exam to evaluate the rectum for any abnormalities. In men, the prostate is evaluated at the same time. Commonly, an anoscope or proctoscope is used to visually evaluate the anal and rectal lining and then a stool sample is retrieved to test for microscopic blood in the stool.
Colonoscopy is a procedure used to evaluate the lining of the colon. If polyps or other lesions are discovered, they are usually removed at the time of the procedure. Biopsies can be taken of the colon can be performed to evaluate inflammatory bowel disease. Although there are other ways to evaluate the colon, colonoscopy is generally accepted to be the best test available at this time. Colonoscopy is performed as an outpatient using some form of sedation. It involves a bowel cleansing the day prior to the procedure.
Also commonly known as “endoscopy”, a gastroscopy examines the esophagus, stomach and part of the duodenum (the beginning of the small intestine). Like colonoscopy, polyps can be removed, biopsies can be taken and an evaluation for ulcer disease and Helicobacter Pylori (a stomach infection) can be performed. The procedure is performed with sedation as an outpatient and the only preparation is an overnight fast.
Sphincter sparing (sphincter saving) rectal surgery
Often, a rectal tumor develops in close proximity to the anal sphincter (the muscle that controls continence). Although radical operation such as an abdominoperineal resection may be necessary to remove this type of tumor, it will leave the patient without an anal opening thus necessitating an ostomy (colostomy or ileostomy). Surgeons trained in sphincter sparing operations are able to perform the tumor removal and restore the intestinal continuity, avoiding the need for a permanent ostomy.
Laparoscopic surgery or laparoscopy
Laparoscopy is a means of studying and treating conditions of the intestines and other organs on the inside of the abdomen. Traditionally, surgery has involved a large incision and a long postoperative recuperation. With the advent of laparoscopic surgery, patients are evaluated in the operating room under anesthesia with several small incisions, are treated and usually able to be discharged from the hospital quicker than with traditional surgery. Laparoscopic surgery is used as a diagnostic tool, or used to remove or repair all or part of the colon, parts of the small intestine or to perform an appendectomy. Diseases amenable to laparoscopic treatment are colon cancer, diverticular disease (diverticulosis or diverticulitis), inflammatory bowel disease (ulcerative colitis or Crohn’s disease), intestinal obstruction, rectal prolapse (in which a part of the rectum is stabilized to allow for easier defecation), cholecystectomy (removal of the gall bladder), hernia repair as well as many other conditions. Your physician will provide you with appropriate recommendations and options and will answer all questions prior to any treatment.
Medical hemorrhoid treatment
This is the most common form of treatment for symptomatic hemorrhoids. Various stool softeners and creams can be administered in an attempt to first treat hemorrhoidal symptoms.
Hemorrhoidal sclerotherapy, rubber band ligation, infrared coagulation
These are non-invasive procedures used in many selected cases for hemorrhoidal symptom treatment. They are performed rapidly in your physician’s office and are generally painless. They require no particular preparation and are used when medical measures have been unsuccessful in treating hemorrhoidal symptoms. These modalities have been used for many years and are safe when used by experienced physicians.
P.P.H. (procedure for prolapse and hemorrhoids)
When conservative treatment has been unsuccessful in resolving hemorrhoidal symptoms, a hemorrhoidectomy can be performed. Traditionally, a hemorrhoidectomy involved a considerable amount of postoperative pain and time away from work or the activities of daily life. The PPH has been available for use in the United States since 2000. It is an outpatient procedure and is associated with much less postoperative discomfort and a more rapid return to daily life. It must be performed by a physician with experience and skill in its use. Under sedation in an outpatient setting, the surgeon removes the hemorrhoids using a specialized instrument. Ask your physician for more details or pictures of the procedure.
Anorectal manometry, defacography, pudendal nerve testing and anal ultrasound
These are tests used to study a variety of selected conditions, such as incontinence, constipation and tumors of the anorectum. Your doctor will explain these further if necessary and will perform the appropriate exam for each given condition.
Rectal Pouch (also known as an IPAA or J- Pouch)
Usually performed laparoscopically, this procedure is performed in the operating room under anesthesia when it is necessary to remove the rectum and replace it with a new reservoir. Advantages include a more normal rectal functioning. It is often used in patients with ulcerative colitis who require removal of the entire colon and rectum. The small intestine is fashioned into a pouch and connected to the anus. Obviously this procedure is performed by those specially trained in its use and is a part of a bigger laparoscopic procedure. Your physician will provide more detail when necessary.
Abscess drainage, fistulotomy, fissure treatment, thrombotic hemorrhoid treatment
An anal abscess is much like an infected pimple and often can be opened and drained in the doctor’s office. Occasionally it is performed in an operating room, usually as an outpatient. When the abscess has been opened and does not heal, this is usually a sign of a fistula which is an abnormal connection between the anus and the buttock skin. An operation called a fistulotomy is often required to cure this condition. A fissure is a painful small cut in the lining of the anus. It often bleeds. When all medical measures such as stool softeners, creams and ointments or Botox® have failed, an operation my resolve this condition and is performed as an outpatient under sedation. When a hemorrhoid fills with blood and the blood clots, patients often experience a painful lump. This can be treated in the doctor’s office using local anesthesia. This is highly successful in resolving associated symptoms.
Pelvic floor disorders
Certain conditions such as a rectocele (the pushing of the rectal lining into the vagina), or an enterocele (the condition whereby small intestine descends deep into the pelvis) often cause constipation of the feeling of the need to evacuate even though the rectum is empty. Your physician will diagnose these conditions and advise you of the available treatment options.
Genetic testing and counseling
For appropriate patients, genetic testing is performed searching for a hereditary cause of colon cancer. The testing is done using a mouth wash to obtain sample cells for evaluation. Sometimes a blood test is used. The results can also help to identify family members of the patient who might also be at risk for disease development.
A pilonidal cyst, tract or abscess is a congenital or acquired condition whereby an area over the sacrum or coccyx (tailbone) becomes inflamed or infected and must be opened or treated. This is often performed as an outpatient under anesthesia if the disease does not spontaneously become quiescent.
Anal Cultures and Anal Pap Smears
In those patients with sexually transmitted disease, anal cultures can be performed in the office setting looking for the cause of the infection and thus lead to appropriate counseling and treatment.
In those individuals at risk for anal cancer development, a small brush can be used to collect anal cell samples looking for abnormal cells which might prompt the need for further evaluation. The procedure is painless and rapidly performed in the office. If necessary, anorectal biopsies can be taken using high resolution anoscopy with a special operating microscope to further study the possible causes of an abnormal pap smear.
This in-office procedure is used to relieve the pain associated with anismus or levator spasm. These treatments are painless and administered over several sessions.
Robotic assisted operations to remove rectal tumors is a new procedure and is used for specific types of rectal lesions. Advantages of using robot-guided operations include a clearer operative field and the potential advantage of a more clear visualization of the nerves in the operative area. Your physician will inform you if you are a candidate for robotic assisted surgery.
Transanal Endoscopic Microsurgery (TEM) and Endoscopic Mucosal Resection (EMR)
These are advanced techniques used to remove selected tumors through a colonoscope and thus avoid a major abdominal operation (EMR), or an advanced technique to remove certain rectal tumors without making an incision in the abdominal wall (TEM). Your physician will advise you if you are a candidate for either of these procedures.