Colon surgery is general surgery. In 27 years of surgical practice I have performed well over a thousand colon and rectal operations for cancer, diverticular disease, polyps, ischemia, and volvulus. Many advances have been made over that time primarily related to laparoscopic access and rapid return to activity after colon surgery.
Colonoscopy is an important tool for evaluation, screening, and treatment of colon problems. Colonoscopy should be performed and every person at age 50 as a tool in the prevention of colon cancer. Men or women with family histories of polyps or colon or colorectal cancer may need to be screened earlier than age 50 depending on the age at which their relative was diagnosed. There are unusual genetic conditions where polyps may develop early in life and these individuals may need screening from their teens or even earlier.
Colonoscopy may also be used for diagnosis of common problems such as rectal bleeding, diarrhea, or abdominal pain. Common conditions such as diverticular disease, irritable bowel syndrome, or hemorrhoids may require colonoscopy for evaluation of gassiness, stool changes, or bleeding. Bleeding either on the toilet paper or into the stool should never be assumed to be hemorrhoids, colonoscopy is the most valuable tool for the diagnosis of disorders of the lining of the colon.
The testing of a stool sample for screening has recently been introduced. Cologuard and similar products have been advanced as tools for decreasing the number of colonoscopies that are necessary. These tools are valuable in certain people but have significant false positive and false negative failure rates. They should not be used in men or women with family history of polyps or cancer, personal history of polyps, or rectal bleeding. In general, everyone should have a first colonoscopy at age 50, and then depending on the findings, stool studies may be more useful for subsequent follow-up.
We perform colonoscopy in the office setting because it is safe, personal, and much less expensive than in the hospital setting. Most insurance companies pay for screening colonoscopy, but many policies do not pay for the anesthesia (anesthetist or anesthesiologist), leaving the patient with a more significant bill. Moreover if the colonoscopy is being done for the diagnosis of bleeding or other problems, or if it is being done as a follow-up for previous polyps, there may be significant expense with a co-pay or denial. It is not unusual for a hospital colonoscopy to cost between $4000 and $7000, as opposed to an office colonoscopy which is almost always less than $2000.
Esophagogastroduodenoscopy, or EGD, is an important tool in the diagnosis and treatment of reflux disease, ulcer disease, gastritis, and various causes of abdominal pain or digestive problems. During this procedure, a patient is treated with a numbing agent in the mouth and throat, sedated, and the scope introduced through the mouth esophagus stomach and small intestine just outside the stomach. The lining of these structures is evaluated and may be photographed and biopsied. Common disorders such as celiac disease, gastritis, gastric or small intestinal ulcers, hiatal hernia, reflux disease and Barrett’s esophagus can be diagnosed in a 5 to 10-minute procedure. Many times an EGD is valuable to rule out these conditions that can cause abdominal discomfort and lead to further evaluation that may reveal the true cause.
EGD is not a screening procedure. In that sense it is never considered preventative by an insurance company. It will generally always have a co-pay and be significantly more expensive in the hospital setting than in our office.
The gallbladder is an organ attached to your liver whose function is to store bile and release it when certain foods, especially fats, need to be digested. The gallbladder causes problems when stones develop within it or when it does not work properly. Gallstones may then try to pass out of the gallbladder when it releases bile and if the tube from the gallbladder to the main bile duct is blocked this causes a condition called colic, much like labor, the passage of a kidney stone, or appendicitis. That is something to large trying to pass through a tube that’s too small.
The diagnosis of gallbladder disease may require blood tests, ultrasound, a nuclear medicine test called Haida, or CT scan or MRI. Depending on the findings of these tests, the number of episodes of pain, whether the pain is short-lived or on remittance, or whether there are complications will determine whether and what kind of treatment is required for the gallbladder disease.
Biliary colic or pain when it to large stone tries to pass through the gallbladder duct is the most common symptom of gallstone disease. The attacks may last only a few minutes or may last for hours. Many women describe the symptom as being as painful or more so than labor. This symptom will usually bring the patient to their primary care provider or the emergency department. An ultrasound is usually performed and if the situation is typical, stones will be shown in the gallbladder and in particular a stone at or near the outlet to the gallbladder. If the episode has passed, and ultrasound may show stones within the gallbladder and may or may not show some evidence of inflammation in the wall of the gallbladder.
In some cases less intense but still significant pain in the right upper quadrant under the ribs may occur. An evaluation may not show stones but rather sludge or polyps within the gallbladder lumen. In such a situation a test known as Haida scan may be suggested. In this test a substance is injected which the liver processes and secretes into the bile. This substance then fills the gallbladder and a second substance is injected which simulates the effect of a fatty meal on the gallbladder. Depending on how much bile is ejected from the gallbladder and whether a patient’s symptoms are re-created, treatment may or may not be suggested.
Unusual but not rare complications of gallbladder disease may be encountered. If a stone starts through the gallbladder duct and gets stuck, the condition may progress to cholecystitis and even gangrene of the gallbladder. This is a surgical emergency. If a stone passes through the gallbladder duct and into the main bile duct it may become stuck before it reaches the intestine causing jaundice and even infection in the bile ducts parentheses cholangitis)
If the stone becomes trapped at the entry of the bile duct into the intestine, the patient is at risk for pancreatitis since the duct from the pancreas and the duct from the liver joined to form a common channel at that location. Pancreatitis may be mild or can lead to severe illness.
The goals of treatment of gallbladder disease is to relieve symptoms and prevent complications. If a patient has repeated episodes of gallbladder pain either from stones or in less common situations from dysfunction of the gallbladder the accepted treatment is to remove the gallbladder. If a patient has gallstones and repeated symptoms, the goal is to both prevent future episodes of pain and to prevent the three complications listed above that is cholecystitis jaundice and pancreatitis. There are other rare consequences of gallbladder disease including bowel obstruction and cancer, but these are extremely rare.
The removal of the gallbladder laparoscopically (laparoscopic cholecystectomy) is the treatment of choice and has been for nearly 30 years. This procedure involves general anesthesia, four small incisions, and removal of the gallbladder from its attachments to the liver. The gallbladder and its contents are removed through one of the four incisions. Complications are unusual but may include leak of bile from the liver surface, bleeding, injury to the intestine, or, rarely, injury to the main bile duct.
If a stone is found to be in the main bile duct either before, during, or after the operation a second procedure called ERCP may be necessary to remove the stone from the bile duct. This procedure involves anesthesia and approach of the bile duct from the intestinal side. The stone is then removed, the blockage relieved, and the backup of pressure on the bile and or pancreatic ducts is resolved.
Laparoscopic cholecystectomy is typically an outpatient surgery unless it is done for acute infection or one of the other complications. The patient can typically return to work in less than a week and has no restrictions on activity other than what the pain prevents him or her from doing. Side effects from the operation may include intolerance to fatty food for a few weeks and a rare patient may have loose stools for longer than that.
Hemorrhoids are common bothersome causes of banal or rectal pain, bleeding, or hygiene issues. Hemorrhoids may be lifelong companions or develop as a result of pregnancy, chronic constipation, or other medical conditions. The evaluation of hemorrhoids may be as simple as a physical examination and history or require anoscopy or colonoscopy for the evaluation of bleeding.
Hemorrhoids may be treated with topical preparations, banding for solitary or pairs of internal hemorrhoids, excision in unusual cases, or hemorrhoidopexy LINK, or stapling, for bulky prolapsing internal hemorrhoids. Banding or hemorrhoidopexy can often be undertaken at the time of colonoscopy.
Hernia is the most common condition treated with an operation by general surgeons. Hernias may be either congenital or acquired and may occur at several common locations in the abdominal wall or flanks. The most common hernias in both men and women are in the groin, or inguinal area. Hernias at the umbilicus, between the umbilicus and the breastbone (epigastric), or on the sides of the abdominal wall may occur. A second general class of hernias are those which develop after prior abdominal surgeries, or incisional hernias.
Inguinal hernia is the most common type of hernia in women and men. This hernia (indirect inguinal hernia) occurs at a natural weak point in the abdominal wall in men where the spermatic cord leaves the abdominal cavity and travels to the scrotum and in women where the round ligament of the uterus leaves the abdominal cavity and travels to the labium. The second most common type of inguinal hernia (direct inguinal hernia) is a hernia caused by a weakness in the muscles of the pelvic floor allowing abdominal contents to protrude through the wall near the pubic bone. Less commonly in both men and women a weakness may occur where the main artery and vein to the leg (femoral) travel and allow a hernia sac to accompany those structures.
Hernias may cause minor symptoms or become true surgical emergencies. In general, hernias will gradually enlarge over time and may enlarge more rapidly with weight gain, strenuous work or exercise, chronic cough or straining with bowel movements, or in patients with chronic disease. In general, any hernia that is causing symptoms or enlarging should be repaired. Most hernia repairs are performed electively, but a hernia whose contents cannot be replaced into the abdominal cavity with gentle pressure or lying down must be assessed and potentially repaired urgently. This applies to both groin, umbilical, and incisional hernias.
The story of hernia repair is the story of general surgery. There have been numerous repairs proposed and performed over the years and many famous practitioners whose names are attached to various repairs. As the decades have progressed, several principles have become apparent and or important. There is no “best” hernia repair. Any surgeon who has extensive experience, follows tried and true surgical principles, and primarily uses one or two repairs will have excellent results. There are minor differences in incision size, short-term discomfort from the operation, chances of long-term discomfort, and restrictions on return to normal activity between various techniques, but in general all hernia repairs allow return to full unrestricted activity with minimal if any discomfort by 4 to 6 weeks after surgery.
Open hernia repair (one incision) is the traditional approach to hernia repair. It is currently performed with mesh, in a tension-free manner, and may be performed with mild sedation and local anesthetic in most cases. The mesh can be placed in a “traditional” position in front of the abdominal wall muscles or can be placed in the pre-peritoneal or posterior location, theoretically allowing a more secure repair. Return to common sense activities can occur within 10 days to two weeks and full unrestricted lifting and strenuous activity within 4 to 6 weeks.
Laparoscopic hernia repair is performed through 3 to 5 small incisions using laparoscopic instruments. It requires general anesthetic, takes somewhat longer to perform, may require exposure of the abdominal contents to the surgical procedure, and is more expensive. The laparoscopic approach allows placement of the mesh in the preperitoneal or posterior location which theoretically allows a more secure repair. In many studies the laparoscopic approach may involve less short-term discomfort and is more cosmetic.
The laparoscopic approach is clearly advantageous for repairing larger umbilical hernias and incisional hernias and allows better visualization and diagnostic evaluations in the case of suspected hernias that are not clinically evident or are complex. Most such repairs are outpatient though some require hospitalization with observation for at least one night.
Many inguinal, umbilical, and epigastric hernias can be repaired in my office using sedation and local anesthetic. This is much less expensive than repair in the hospital.
Reflux disease is one of the most common medical maladies in the United States. This should be obvious from the volume of anti-acid, anti-gas, and PPI commercials on television and radio. Reflux is common in all age groups, both sexes, and can be a lifelong or acquired problem.
Reflux has four major components:
- the anatomy of the esophagus and diaphragm
- the integrity of the crura
- hiatal hernia
- the lower esophageal sphincter or valve
- In the normal situation the bottom inch or two of the esophagus should reside in the abdominal cavity. The pressure in the abdominal cavity is higher than the pressure in the chest cavity. This is what typically makes it easier to take a deep breath among other functions. When the esophagus is in the abdominal cavity in its normal position, the increased pressure in the abdomen presses against the walls of the esophagus and helps keep it closed in the normal situation.
- The crura are muscles that are extensions of the diaphragm. These two muscles normally fit snugly around the esophagus and cradle it into place. With every breath, cough, left, swallow, or exertion, the crura contract and cradle the esophagus in its normal position.
- Whether from birth in some people, or acquired through life with trauma, pregnancy, weight gain, or chronic stress on the diaphragm, the crura can be stretched apart so that they no longer snugly fit around the esophagus. This anatomic abnormality is the definition of a hiatal hernia. The diaphragmatic hiatus is where the esophagus and aorta enter the abdomen from the chest cavity. The enlargement of this opening can allow the junction of the esophagus and stomach to travel from the high-pressure abdominal cavity to the lower pressure chest. When this happens the higher pressure in the abdominal cavity now presses on the stomach wall instead of the esophagus, and the stomach contents can be forced up instead of being kept in the cavity of the stomach. This is reflux. Most people in this condition experience heartburn as a result.
- In the normal situation the esophagus should contract in an orderly fashion during a swallow. The upper, then middle, then lower esophagus should undergo peristalsis and then when the liquid or food reaches the junction of the esophagus and stomach the valve should open and allow the contents of the esophagus to empty into the stomach. The valve should then close and remained closed until the process repeats. In people with reflux, the valve either opens inappropriately too many times during a day or never generates normal adequate pressure to remain closed. In this situation the contents of the stomach or always at risk for coming into the esophagus.
The spectrum of reflux disease is broad. Some people only have occasional heartburn or feeling of indigestion or reflux. Some people experience this on a weekly, daily, or constant basis. Depending on the level of symptoms and the effects on lifestyle, an individual may need occasional symptomatic, daily, or high-level treatment for their reflux disease. Interestingly, many people, especially women, can suffer what is known as silent reflux. That Is, they may have the same amount of reflux as another individual but not have sensation of heartburn. After some period they may experience difficulty swallowing or upper digestive symptoms like throat clearing, throat pain, cough, or neck discomfort.
Medical treatment for heartburn and reflux symptoms can be occasional, daily, or intense. Depending on the patient’s age, treatment for heartburn can be expected to last for a relatively short period or many years. Depending on the intensity of medical therapy and complications of the reflux disease, it may make more sense to permanently treat the reflux with a surgical procedure. Chronic reflux can lead to changes in the esophagus that are precancerous. This condition is called Barrett’s esophagus or intestinal metaplasia. Chronic treatment with strong anti-acid therapy is increasingly frowned upon because the stomach is designed to be an acid environment. Chronic treatment with strong acid suppressors alters this normal condition. Moreover, there are increasing reports of kidney and bone issues with chronic PPI use.
Surgical procedures that are used to treat reflux disease are designed to anatomic issues outlined above. Through a laparoscopic approach the esophagus is returned to the abdominal cavity, the rural muscles are re-fit snugly around the esophagus, the hiatal hernia is thereby corrected, and a new valve is constructed either using the stomach itself or a magnetic titanium bracelet or LINX. These are typically outpatient or observation overnight surgical procedures that lead to long-term relief of heartburn and regurgitation.
The surgical treatment of colon cancer begins with prevention. This explains the emphasis on colon screening and removal of polyps. It is estimated that 90% of colon cancer is preventable with comprehensive colon screening starting with colonoscopy at age 50 or younger and evaluation of all rectal bleeding using colonoscopy. Screening is especially important in patients who have a family history of polyps or cancer and screening should begin 10 years prior to the age at which the person with polyps or cancer were discovered to have them.
A comprehensive discussion of surgery for colon cancer is beyond this site but links are provided. The principles of surgery for colon cancer include preoperative evaluation, intraoperative treatment, and postoperative follow-up. When a colon cancer is suspected based on findings at colonoscopy or physical examination, a preoperative assessment is set in place. Biopsies of the suspected tumor are performed at the time of colonoscopy. If cancer is discovered, then a preoperative radiologic and blood examination are undertaken to evaluate for spread of disease. Based on these findings and operation is planned to remove the cancer. Depending on the findings, preoperative treatment with either drugs or radiation therapy may be indicated.
The operative treatment of colon cancer focuses on removing the section of colon involved with the cancer along with its blood supply and lymphatic drainage. Clean, or tumor free, margins around the tumor within the: lessen the possibility of the tumor recurring locally in the same area. Removal of the lymph nodes which drain the section of colon to be removed help determine the need for postoperative therapy and give prognostic information. In most situations, the affected section of the colon is removed and the two ends of the remaining colon or the small intestine and the colon are placed back in continuity. This means that in the vast majority of operations for colon cancer no ostomy is necessary. Typically, only emergency operations for obstructing cancers or operations for cancers low in the rectum require postoperative ostomies.
The postoperative treatment for patients with colon cancer may include only follow-up, chemotherapy, radiation therapy, or a combination of chemo follow-up colonoscopy is performed one year after the surgical procedure and then at intervals based on the original history and findings at the recurrent colonoscopy and radiation therapy. These possible treatments depend on the findings in the preoperative evaluation and the pathology report from the operation. The location of the tumor is also critical in these decisions. Radiation therapy is typically only recommended for tumors in the rectum. Chemotherapy is typically recommended in cases where there is lymph node spread of the tumor or spread to other organs such as the liver or lungs.
Diverticular disease of the colon is extremely common. The surgical treatment for diverticular disease of the colon is, thankfully, unusual. Diverticulosis is present in a large percent of the adult US population over 55. Though the exact percentages are unknown, diverticulosis only causes symptoms in a minority of adults. The most common complication of diverticulosis is infection or diverticulitis. The spectrum of diverticulitis spans from mild inflammation requiring no specific treatment, to mild infection requiring antibiotics by mouth, to hospitalization for intravenous antibiotics, to emergency surgery for life-threatening infection.
Recommendations for surgical treatment of diverticular disease have changed over recent decades. In the past, two episodes of diverticulitis requiring hospitalization for intravenous antibiotics in an otherwise young and fit patient was considered an indication for surgical intervention. While to such episodes certainly raise concern about ongoing or repeat episodes of infection, surgical intervention is typically reserved for repeat episodes, chronic discomfort, or complications of diverticulitis. Foremost in a surgeon’s recommendations are that intervention prior to the need for urgent or emergent surgery is necessary to prevent the need for two operations – one to remove and treat an infected colon and form a colostomy, and a second equivalent or more difficult operation to re-create continuity in the colon and remove the ostomy.
Complications of diverticular disease including abnormal connections of the colon to the bladder, the Regina, or the small intestine will require surgical intervention to situations. Other complications such as abscesses may be treated with interventional radiology maneuvers such as drain placement. Bleeding is another unusual complication of diverticular disease that may first be treated radiologically but may lead to the need for surgical removal of the affected colonic segment.