Colostomy Avoidance In Rectal Cancer
Permanent colostomy is a major fear of patients diagnosed with colon or rectal cancer. However, advances in surgical techniques and understanding of tumor behavior have allowed the majority of patients to receive complete treatment of the cancer without the need for a permanent colostomy. A significant portion of our practice is referral from other surgeons for this type of treatment.
Some tumors can be treated with transanal excision, which involves removing the lesion through the anus rather than through an abdominal incision. Rush is a national leader in a procedure called transanal endoscopic microsurgery, an operation to remove cancers that are beyond the reach of conventional instrumentation. This surgery is performed by Dr. Saclarides and Dr. Brand.
Larger, more locally advanced tumors are removed through an abdominal incision. Radiation and chemotherapy may be recommended before surgery to shrink tumors and improve the likelihood that the sphincter muscle can be preserved. It is important that an experienced surgeon does the operation, someone trained in and experienced with pelvic surgery. Several published studies have linked a good outcome and cancer prognosis to the skill of the surgeon.
If you would like to be evaluated for rectal cancer, or for more information, you may contact our office at:
University Surgeons
At Rush-Presbyterian-St. Luke’s Medical Center
1725 W. Harrison, Suite 810
Chicago, IL 60612
312-942-6500
TREATMENT OF CONSTIPATION
Constipation is a common problem in the general population, affection women more often than men by a factor of about eight to one. Patients can be categorized into two groups.
One group consists of those patients who never feel the urge to defecate and cannot more their bowels without the aid of medications. This condition is called colonic inertia, and its cause in unknown.
The other group has obstructed defecation caused by dysfunctional pelvic floor anatomy or muscles. Although the urge to defecate is there, patients simply cannot expel stool. Frequently, they must insert their fingers rectally or vaginally to facilitate defecation.
Assessment of patients includes calculation of colonic transit time through the use of x-rays and evaluation of pelvic floor function with defecography. Treatment is variable and is based on the underlying cause.
Marc I. Brand, M.D. and Theodore J. Saclarides, M.D. are experienced in the diagnosis and treatment of both conditions.
If you would like to be evaluated for chronic constipation, or for more information, you may contact our office at:
University Surgeons
At Rush-Presbyterian-St. Luke’s Medical Center
1725 W. Harrison, Suite 810
Chicago, IL 60612
312-942-6500
LAPAROSCOPIC (MINIMALLY INVASIVE) COLON SURGERY
Selected patients undergoing colon and rectal surgery may benefit from a technique called laparoscopic surgery, which can shorten hospital stays and speed recovery. However, until further study has been completed, we do not believe that laparoscopic resection of cancer should be performed outside of the realm of a research study.
Benign diseases can be addressed laparoscopically as long as the extent of inflammation, which sometimes accompanies these problems, does not jeopardize a safe operation. The decision to proceed with a laparoscopic operation should be the domain of the treating surgeon and should not be driven by insurance companies or industry.
University Surgeons
At Rush-Presbyterian-St. Luke’s Medical Center
1725 W. Harrison, Suite 810
Chicago, IL 60612
312-942-6500
INFLAMMATORY BOWEL DISEASE
CROHNS’ DISEASE
ULCERATIVE COLITIS
Crohns’ disease and ulcerative colitis can be disabling diseases. Although initial treatment is usually nonsurgical, surgery is occasionally necessary because of complications. Dr. Saclarides and Dr. Brand work closely with gastroenterologists both at Rush and at other institutions to provide state-of-the-art, comprehensive care for patients with inflammatory bowel disease.
With regard to surgery for Crohns’ disease, preservation of as much bowel as possible is vitally important to avoid problems with malabsorption and malnutrition. To achieve this, a technique called ”stricturoplasty” is used to relieve obstruction; this may be preferable to resection or removal of the diseased bowel.
For ulcerative colitis, Dr. Saclarides and Dr. Brand are skilled in the technique of restorative proctocolectomy, also known as the “ileoanal pull through operation with J-pouch”. During this operation, the diseased bowel is removed, and a fecal reservoir is created from portions of the small bowel. The J-pouch is then connected to the anus and a temporary ileostomy is usually created to promote healing of the pouch. The ileostomy is generally closed at a second operation three months later.
To arrange a consultation for consideration of surgical options for inflammatory bowel disease, or for more information, you may contact us at:
University Surgeons
At Rush-Presbyterian-St. Luke’s Medical Center
1725 W. Harrison, Suite 810
Chicago, IL 60612
312-942-6500
COLONOSCOPY
What is colonoscopy?
What can I expect during colonoscopy?
How do I prepare for a colonoscopy?
When will I get the results?
What is colonoscopy?
Colonoscopy is a very useful tool in the evaluation and treatment of diseases of the colon and rectum. It is a minimally invasive procedure in which the entire lining of the colon can be examined by directly looking at the lining. Biopsies (samples of the lining) can be taken during colonoscopy. Polyps (small growths in the lining of the colon) can also be removed during colonoscopy. Removal of polyps may help prevent colon cancer before it develops.
What can I expect during colonoscopy?
Colonoscopy is performed in a specially equipped room, usually in an endoscopy suite or lab. An intravenous line (IV) is usually placed before the procedure starts so that medications and fluids can be given to the patient. The procedure begins after sedatives (sleeping medicines, like Valium) are given. Enough medicine is given to make the patient sleepy, but not unconscious. The procedure usually begins with the patient lying on his/her left side. The colonoscope is a long flexible tube with a light and video camera at the tip, and wheels for steering the tip at the other end. It is inserted through the anal opening and advanced to the beginning of the colon. This is done under direct vision, with the doctor watching the scope advance through the colon on a monitor. (The patient can also watch the procedure, if he/she desires and is not too sleepy.) During this insertion phase, the patient may experience cramping, especially as the scope is being pushed around corners. The assistant will often need to push on the patient’s abdomen to help the scope move forward, and the patient may be asked to lie in different positions. Careful inspection of the lining is made during the removal of the scope, and air is blown into the colon to help separate the walls and allow the doctor to see better. Any abnormalities can be biopsied (sampled), and small growths (polyps) can be removed (polypectomy).
How do I prepare for a colonoscopy?
There are several things to do to get ready for a colonoscopy.
1) It is important that the patient be accompanied to the procedure by a friend
or family member. The sedation (sleeping medicine) given during the colonoscopy
makes it unsafe for the patient to drive or travel alone. It is best to make
arrangements for a friend or family member to escort the patient home after
the procedure.
2) Diet restriction the day before the procedure (clear liquids) and medicine
to cause diarrhea (bowel prep) are necessary to clean the colon. This is important
so that the lining of the colon can be seen clearly and the colonoscope inserted
fully to the beginning of the colon.
3) Bleeding is a concern after removal of a polyp. Therefore, it is important
to avoid any medicines that thin the blood and prevent blood from clotting for
one week before the colonoscopy. These medicines include all over-the-counter
pain medications and fever reducing cold remedies, except those that only use
acetaminophen (Tylenol). Additionally, medicines used for poor circulation and
stroke prevention, or for artificial heart valves, such as Coumadin and Plavix
should also be stopped. Finally, there are some herbal medicines that thin the
blood, such as Gingko Biloba, that should also be avoided. It is important to
discuss these medicines with your doctor that prescribed them, or the doctor
that will be doing the colonoscopy, before stopping the medicine.
4) Some patients have medical conditions which may require antibiotics be given
before the colonoscopy. These include artificial heart valves, heart murmurs,
artificial joints, and metal implants for bone support. Most patients who require
antibiotics for dental work will also require antibiotics for colonoscopy. It
is important to discuss this with the doctor that will be doing the colonoscopy
so that it can be arranged.
When will I get the results?
There are two parts to the results from colonoscopy. The endoscopic impression
is based on the visual inspection of the lining of the colon. This is known
immediately after the procedure. The pathologic impression is based on the evaluation
of any tissue samples (biopsies) that may have been taken during the colonoscopy.
These are usually ready in 3-5 business days.
FLEXIBLE SIGMOIDOSCOPY
What is flexible sigmoidoscopy?
What can I expect during flexible sigmoidoscopy?
How do I prepare for a flexible sigmoidoscopy?
When will I get the results?
What is flexible sigmoidoscopy?
Flexible sigmoidoscopy is a very useful tool in the evaluation and treatment of diseases of the colon and rectum. It is a minimally invasive procedure in which the lining of the last third of the colon can be examined by directly looking at the lining. Biopsies (samples of the lining) can be taken during flexible sigmoidoscopy.
What can I expect during flexible sigmoidoscopy?
Flexible sigmoidoscopy is performed in a specially equipped room, usually in a doctor’s office or in an endoscopy suite or lab. Sedatives (sleeping medicines, like Valium) are not necessary. The procedure is performed with the patient lying on his/her left side. The sigmoidoscope is a flexible tube with a light and video camera at the tip, and wheels for steering the tip at the other end. It is inserted through the anal opening and advanced through the rectum and into the colon. This is done under direct vision, with the doctor watching the scope advance through the colon on a monitor. (The patient can also watch the procedure, if he/she desires.) During this insertion phase, the patient may experience cramping, especially as the scope is being pushed around corners. Careful inspection of the lining is made during the removal of the scope, and air is blown into the colon to help separate the walls and allow the doctor to see better. Any abnormalities can be biopsied (sampled), and small growths (polyps) can be seen. If a polyp is seen, colonoscopy should be scheduled to evaluate the entire colon for other polyps and remove any polyps.
How do I prepare for a colonoscopy?
Preparation for flexible sigmoidoscopy is very simple, and that is one of
its advantages.
1) Sedation is not routinely used for flexible sigmoidoscopy. Therefore, it
is
not necessary for the patient to be accompanied to the procedure.
2) Bowel preparation is also very simple. Diet restriction is not necessary.
Two Fleets® enemas are the only preparation needed to clean the colon.
When will I get the results?
There are two parts to the results from flexible sigmoidoscopy. The endoscopic
impression is based on the visual inspection of the lining of the colon. This
is known immediately after the procedure. The pathologic impression is based
on the evaluation of any tissue samples (biopsies) that may have been taken
during the examination. These are usually ready in 3-5 business days.
BOWEL PREPS FOR ENDOSCOPIC EXAMINATIONS
Clear liquids
Fleets® enemas
Golytely®/Colyte® prep
Fleets® Phospho-soda® prep
Visicol® tablets
Clear liquids
Clear liquid diets are usually used in combination with medication that causes
diarrhea (bowel prep). The bowel prep is a very strong laxative which causes
diarrhea and removes solid stool from the colon. The clear liquid diet allows
you to avoid dehydration without creating more solid stool after taking the
bowel prep. This should begin in the morning of the day before the colonoscopy.
Clear liquids have two main characteristics; you should be able to see through
the liquid and, at room temperature, nothing remains on a fork lifting the clear
liquid. Acceptable liquids are water, sodas, popsicles, juices (without pulp),
soups (broth only), and Jello (no fruit).
Fleets® enemas
Fleets® enemas are used to clean the stool from the last third of the
colon. This is usually necessary for limited endoscopic examinations of the
anus (anoscopy), rectum (proctoscopy), and sigmoid colon (flexible sigmoidoscopy).
It is also necessary for many surgical procedures performed in the anal area.
The preparation involves taking two enemas. Some doctors suggest both enemas
be taken at the same time, within two hours of the procedure. Other doctors
suggest one enema be taken the evening before the procedure, and the second
enema be taken within two hours of the procedure. Instructions for enema use
are provided on the package or online (click here).
Golytely®/Colyte® (Prescription only)
This type of bowel prep uses one gallon of a special salt solution to clean
the bowel. This is used to prepare the colon for colonoscopy or surgery. The
gallon is finished over 4 hours (4-8 pm, the night before a procedure) by drinking
an 8 ounce glass every 10 minutes until the gallon is finished. The large volume
of liquid is not absorbed by the intestine. Instead, it completely passes through
the intestine, causing diarrhea. This prep is the safest type of prep for elderly
patients, or those who have heart failure, kidney failure, or are prone to electrolyte
problems. Some people find it helpful to drink the solution chilled and with
a straw placed far back in the mouth, to minimize the taste.
Fleets® Phospho-soda® (Over-the-counter)
This type of bowel prep uses a small volume of a liquid medicine to cause
diarrhea. The majority of the fluid that makes the stool watery is secreted
into the colon from the body or fluid which has been drunk during the prep.
This is used to prepare the colon for colonoscopy or surgery.
The Fleets® Phospho-soda® is taken in two doses. If it is being used
before surgery, the two doses are taken late in the afternoon before surgery,
about two hours apart. If it is being used before colonoscopy, the two doses
are taken on two separate days. The first dose is usually taken the day before
the colonoscopy (in the late afternoon or early evening). The second dose is
usually taken the morning of the colonoscopy (at least three hours before having
to leave the house for the appointment). Each dose is 1½ ounces (3 tablespoons).
It is best taken by mixing one tablespoon in eight ounces of a flavorful clear
liquid (apple juice, ginger ale, etc.) every 10 minutes. In this way, the entire
dose is diluted but still consumed over 20 minutes. It is important to continue
to drink plenty of clear liquids after finishing the full dose. This helps to
make sure the colon is cleared from stool and avoid dehydration.
Visicol® tablets (Prescription only)
This type of bowel prep uses a tablet version of the same medicine as the
Fleets® Phospho-soda® prep to cause diarrhea. This is used to prepare
the colon for colonoscopy. The majority of the fluid that makes the stool watery
is secreted into the colon from the body or fluid which has been drunk during
the prep.
The Visicol® tablets are taken in two doses. The first dose is usually taken
the day before the colonoscopy (in the late afternoon or early evening). The
second dose is usually taken the morning of the colonoscopy (at least three
hours before having to leave the house for the appointment). Each dose is 20
tablets. It is best taken by swallowing 3 tablets with eight ounces of a clear
liquid every 15 minutes. It is important to continue to drink plenty of clear
liquids after finishing the full dose. This helps to make sure the colon is
cleared from stool and avoid dehydration. Some doctors are now using fewer tablets
for the second dose on the morning of the colonoscopy, usually between 8 and
12 tablets.
HERNIAS
What is a hernia?
What does a hernia feel like?
Why does a hernia develop?
Do all hernias require surgery?
What are the surgical options for hernia repair?
Where can I have this surgery done?
What is a hernia?
A hernia is an abnormal weakness, usually in the abdominal wall. When this occurs
there is a bulge you can see and feel, which contains organ or tissue. The most
common hernias develop in the groin, around the navel, or in an incision from
a previous surgery. They can be present from birth, develop slowly over years,
or develop suddenly.
A hernia can be reducible (pressing on it causes it to disappear, and effort causes it to be seen and felt), or non-reducible. There is a danger that a hernia can strangulate (pinch off a portion of the bowel). This is a serious and very painful situation, and must be operated on right away.
What does a hernia feel like?
It may look like a lump in your abdomen or groin. It may go away when you lie
down, or it may not. You may have a dull aching sensation in that area, and
this may be more noticeable when you strain your abdominal muscles, for example,
when you cough or lift something. It can become painful because of the pressure
of tissue, which is pushing its way through the weak area.
If you have already been diagnosed with a hernia and develop sudden severe pain, you should call your physician right away to be sure that an urgent situation has not developed.
Why does a hernia develop?
A hernia can develop where there is a weak area in the body. It can develop
when there is an unusual strain in that area, or because you are born with a
weak area, or due to no apparent cause. Some of the common areas that hernias
develop are:
Umbilical hernia: Around the umbilicus (belly button), where there is
a natural weakness of the abdominal wall.
Inguinal hernia: Around the groin. This is most common in men due to the unsupported
space in the groin that develops when the
testicles descend into the scrotum.
Femoral hernia: At the top of the thigh. This is most common in
women as a result of pregnancy and childbirth.
Incisional or ventral hernia: In the abdominal wall, frequently in an
incision from previous surgery.
Hiatal hernia: A weakness at the top of the stomach that can cause
stomach contents to flow back into the esophagus (GERD,
gastrointestinal reflux disease, or heartburn).
Do all hernias require surgery?
If a hernia is not surgically repaired, it will not get better on its own, although
it may not get worse for months or even years. Techniques such as limiting activity,
reducing weight, avoiding heavy lifting, and wearing a truss or binder have
been known to provide temporary relief. However, you can only cure a hernia
with surgery. Pain and to prevent strangulation are two reasons that would indicate
a need for surgery.
If the hernia is reducible (can easily be pushed back into the abdomen) it is not usually an immediate danger, and you would decide on surgery based on your surgeon’s advice and how much pain you are having.
However, if the hernia is non-reducible, it can become a life-threatening situation, as part of the intestine gets trapped in the hernia. This is called an “incarcerated” or “strangulated” hernia, and this requires immediate surgery.
You should trust your surgeon’s advice when deciding whether nor not to have surgery to repair your hernia. Although any surgery has risks and side effects, today’s surgical treatment options for hernia repairs are vastly improved, with minimal discomfort, quicker recovery, and better long-term effect.
What are the surgical options for hernia repair?
Conventional method:
This type of hernia repair is accomplished by making an incision over the hernia.
The surgeon then returns the tissue to its normal place in the abdomen, and
the hernia sac is removed. The resulting hole (weakness) in the abdominal wall
is then repaired by the surgeon, by sewing together the layers of muscle and
tissue in the abdominal wall. There is no mesh, or implant, that is used in
this repair. This can often be done under local anesthesia. Depending on activity
level, normal recovery for a hernia due to stress or strain that is repaired
by the conventional method is 4-6 weeks. The recurrence rate (reappearance of
the hernia) can be up to 10-15% with this method.
Laparoscopic method:
Tiny openings are made into the abdomen, and an instrument called a laparoscope
is inserted, through which the surgeon can view the hernia on a TV monitor and
reduce the tissue. Usually a patch of “mesh” is used to reinforce
the abdominal wall, which is fastened in place with staples. General anesthesia
is required. This method usually results in less discomfort and shorter postoperative
recovery time. Return to normal activities usually occurs in 7-14 days.
Tension-free mesh technique:
The surgeon makes an incision at the site of the hernia and inserts a piece
of mesh to cover the abdominal wall defect. This procedure is usually done under
local anesthetic. The muscles are not sewn together as they would be in a conventional
repair, but instead the repair is “tension-free”. This allows patients
to get back to normal activities more quickly, and reduces the incidence that
the hernia may reappear to less than 2%. Return to normal activities usually
occurs in 2-3 weeks.
Mesh plug technique:
This procedure allows the patient to be operated on as an outpatient under local
anesthetic. The surgeon makes a small incision and inserts a mesh plug into
the hernia defect. This fills the hole, similar to a cork in a bottle. Another
piece of flat mesh is then placed over the plug to help prevent future hernias
in that area. As the body heals after surgery, tissue grows around and through
the mesh, making a stronger, more permanent repair. There is a shortened recovery
time and less than 1% recurrence rate. Typically the procedure takes less than
an hour to complete, and the patient can go home in less than 1 hour. Return
to normal activities usually occurs in less than 3 days.
How soon can I return to normal activities?
Return to normal activities ranges depending on the surgical technique chosen.
With the mesh plug technique patients are advised to progress at their own pace,
and to return to normal activities as soon as they wish. In most cases this
has been 3 days of less.
As with any surgery, various surgical techniques are required for each patient, and you must be evaluated for a recommendation on which technique is right for your circumstances. Your surgeon will advise you on the best procedure for you.
Where can I have this surgery done?
Keith W. Millikan, M.D. (hyperlink) has been a leader in the development of
new surgical techniques for hernias. His courses and lectures throughout the
United States, Canada and Japan are responsible for the training of many surgeons
in the most recent techniques.
The following doctors at University Surgeons are experienced in all the hernia repair techniques discussed above:
Steven D. Bines, M.D.
Marc I. Brand, M.D.
John L. Butsch, M.D.
Daniel J. Deziel, M.D.
Alexander Doolas, M.D.
Keith W. Millikan, M.D.
Theodore J. Saclarides, M.D.
Norman L. Wool, M.D.
(hyperlink to Davol)
PANCREATITIS
What is pancreatitis?
What causes pancreatitis?
How is pancreatitis treated?
What is done at surgery for pancreatitis?
How will my life be different after surgery for pancreatitis?
What is pancreatitis?
The pancreas is an organ in your body that regulates sugar balance and aids
in digestion. It produces substances called enzymes that break down food. When
the pancreas becomes damaged, the enzymes can escape from the pancreas. This
can happen from trauma, manipulation by a surgeon, alcohol, gallstones, or even
certain drugs. These enzymes will then begin to break down (digest) the tissue
surrounding the pancreas. The pancreas will become inflamed, causing terrible
abdominal pain that can travel to the back. This process will continue until
the enzymes are contained again.
What causes pancreatitis?
The most common causes for pancreatitis are gallstones and alcohol. These account
for 80% of all cases of pancreatitis. Other causes are trauma, drugs, cholesterol,
anatomical variations, and certain infections.
How is pancreatitis treated?
We treat pancreatitis by keeping the patient on IV fluids and not allowing the
patient to eat anything by mouth. This decreases the enzyme production and hopefully
will help the pancreas heal.
In some cases, the process continues and the enzymes will digest the tissue around the pancreas. It is at this point where pancreatitis becomes a serious, potentially fatal disease. The material that is digested by the enzymes can become infected, and when this happens the patient usually needs to be taken emergently to the operating room. At this point pancreatitis can be associated with a high probability of dying. Therefore, pancreatitis is a very serious problem that needs to be treated early by physicians in a hospital setting, so it does not progress to a more serious problem.
What is done at surgery for pancreatitis?
Surgery for pancreatitis is difficult surgery. The surgeon has to remove all
the dead tissue without harming other organs. Many times the part of the pancreas
that is diseased is removed as well. Usually the patient has to go back to the
operating room many times before this improves.
How will my life be different after surgery for pancreatitis?
After surgery for pancreatitis the patient usually has been in the hospital
for many months and will need extensive continued rehabilitation. Patients sometimes
have dysfunction of their pancreas which causes them to be diabetic. They may
also have problems with digestion. These conditions can be controlled with medication.
CRYOSURGERY FOR BENIGN BREAST TUMORS
What is cryosurgery?
What are the benefits and risks of cryosurgery?
How do I know if cryosurgery is the right procedure for me?
Where is cryosurgery being done?
What is cryosurgery?
Cryosurgery is a surgical procedure that destroys tumor cells by freezing. It
is done in the doctors’ office using ultrasound guidance to locate the
tumor. A needle (probe) is placed directly into the tumor after the skin is
anesthetized, and a tumor-killing temperature turns the tumor into an ice ball.
The procedure usually takes about 30 minutes.
The body’s natural immune system sends cells to the site of the dead tumor tissue to dissolve it. The tumor slowly shrinks as the body absorbs the dead cells until the process is complete.
What are the benefits and risks of cryosurgery?
This procedure does not involve dissection of the breast tissue and avoids the
scarring that would be present if an open excision of the tumor were done. There
is less discomfort and it is done in the office as an outpatient procedure,
reducing cost and inconvenience. The risks are the same as they would be for
any procedure that involves the insertion of a needle into the breast, i.e.,
bleeding or infection, etc. This is a uncommon under ultrasound-guidance.
How do I know if cryosurgery is the right procedure for me?
Currently cryosurgery is being done only on benign (non-cancerous) tumors. These
are called “fibroadenomas” and are caused by excess growth of breast
tissue. They can grow to the size of an egg. They are common. Surgeons in the
United States remove approximately 500,000 fibroadenomas each year. They are
most common in women in their 20s and 30s. It is not medically essential that
fibroadenomas be removed, but many women choose to have them removed for various
reasons, including the development of pain, tenderness, and a lump in the breast..
Where is cryosurgery being done?
Darius S. Francescatti, M.D. is one of only a few dedicated breast surgeons who are presently offering this treatment option. We are very excited about the potential this procedure has to meet the needs of women who want to avoid the scarring and costs involved with traditional methods of excision of fibroadenomas.
Read more about Darius S. Francescatti, M.D. in his personal profile on this web site (hyperlink).
For more information, or to make an appointment for an evaluation for cryosurgery, you may contact our office at:
University Surgeons
At Rush-Presbyterian-St. Luke’s Medical Center
1725 W. Harrison, Suite 810
Chicago, IL 60612
312-942-6500
BREAST BIOPSIES CAN NOW BE DONE IN THE SURGEON’S OFFICE
Why do I need a breast biopsy?
Can the doctor do this in the office or do I need to go to the hospital for
a biopsy?
What is the advantage of an office biopsy over an open biopsy?
How is a breast biopsy done in the office?
Will it hurt?
What happens after the biopsy?
How can I get more information?
Why do I need a breast biopsy?
If you or your doctor have discovered a lump in your breast, you have probably
been sent to get a mammogram, perhaps an ultrasound of your breast, and you
have had an opinion from a surgeon about what to do next.
Your surgeon may have told you that your lump is a cyst and will only want to
watch this. Or you may have been told that you have a solid mass, and your surgeon
may have recommended a breast biopsy.
A breast biopsy is a procedure that removes a small piece of tissue from the lump in your breast to see what the cells are. It is important to know prior to surgery if you have a cancerous (malignant) or non-cancerous (benign) tumor. Knowing what kind of tumor you have (a definitive diagnosis) will determine the best way to plan for treatment of the tumor.
Can the doctor do this in the office or do I need to go to the hospital for
a biopsy?
The availability of advanced techniques and instruments has recently made it
possible for many biopsies to be done in the surgeons’ office. It is vitally
important that an adequate sampling of tissue is taken, and this can best be
done with the most up-to-date instruments and techniques. If these were not
available it would be necessary to have an open biopsy done in the operating
room.
What is the advantage of an office biopsy over an open biopsy?
With an office-based biopsy there is no need for a large incision; there are
no stitches placed, eliminating scarring. It is less costly, since there are
no hospital charges involved. The surgeon’s and pathologist’s fees
remain. Office procedures are more convenient to you. Local anesthesia is used,
and the procedure will take less than 30 minutes. There is reduced discomfort
and no need for a lengthy recovery period.
How is a breast biopsy done in the office?
You will be awake throughout the procedure. No sedation is needed, only a local
anesthetic to numb an area of the breast. The surgeon will then use ultrasound
(high-frequency sound waves that locate and define the lump) to guide the biopsy
instrument. He will then make a small nick (3-4 mm, less than the width of a
pencil eraser) over the lump. The biopsy instrument will then be inserted and
guided to the lesion (lump). The biopsy instrument then extracts a sample of
tissue, which will be sent to a pathologist for definitive diagnosis. You will
not require stitches, and only a small bandage will be used to cover the area.
Will it hurt?
Percutaneous (through the skin) breast biopsies are tolerated well, often allowing for continuation of normal daily activities right after the procedure. Mild analgesics are prescribed if needed. Patients rarely experience any significant discomfort during the procedure itself, as local anesthetic is used. This would feel similar to any injection you have received.
What happens after the biopsy?
There may be a little soreness and swelling, but there should be no real discomfort
and you can return to normal activities as you see fit.
Once your biopsy results are received from the pathologist, your surgeon will be able to plan the best treatment course for you.
If the biopsy is benign (not cancerous) a number of options are available, including doing nothing at all, excision to remove the lump or destruction (ablation or cryotherapy, destruction by freezing) – see hyperlink).
If the biopsy is malignant, further treatment is mandatory. A simple excision may be all that is needed. You may need chemotherapy or radiation therapy, and in some cases both. Various treatment options will depend on the particular type of cancer discovered, and will be discussed with you by your surgeon.
How can I get more information?
Darius S. Francescatti, M.D. is a leader in the development of new and convenient treatments for breast problems, and lectures widely to other surgeons on the surgical treatment of breast disease. He is one of only a few surgeons who is currently offering this advanced office technique. Click here for more information about Darius S. Francescatti, M.D. (hyperlink)
For office treatment of breast lumps, you may contact Dr. Francescatti at:
University Surgeons
At Rush-Presbyterian-St. Luke’s Medical Center
1725 W. Harrison, Suite 810
Chicago, IL 60612
312-942-6500
(Hyperlink to Sanarus)
Write a note to whoever handles the approvals for use of the Rush name to visit
our site and let us know if there are any problems.
Screening for Colon and Rectal Cancer
There has been a significant increase in the interests in, and the attention
to, colon cancer in recent years. Colon cancer is deserving of this attention,
since it is the second most common cause of death due to cancer in the United
States. Many celebrities have been affected by colon cancer, and they now are
beginning to share this experience with the public. This is helping to decrease
the fear, embarrassment and “tight-lipped” approach many people
have to colon cancer. These celebrities include:
1. Former President Ronald Reagan, who survived colon cancer during
his presidency;
2. Katie Couric of NBC’s Today Show, whose husband died of colon
cancer in his early 40’s;
3. Baseball stars Darryl Strawberry and Eric Davis;
4. Charles Schultz, creator of the “Peanuts Gang”;
5. Sharon Osbourne, wife of rock star Ozzie Osbourne;
6. President George W. Bush, who has a history of pre-cancerous colon polyps
and took time from the “War on Terrorism” to have his colonoscopy.
Medicare, and other health insurers, recognize the importance of colon cancer and colon cancer screening. Medicare has recently included colon cancer tests as covered benefits for Medicare recipients. Many insurers are following Medicare’s lead, and are also providing coverage for colon cancer screening.
The American Cancer Society has recommended colon cancer screening for everyone 50 years of age or older. Unfortunately, only a small portion of the population receives proper advice and screening related to colon cancer. Screening exams are done before the development of symptoms, since waiting for symptoms is waiting too long. Colon cancer screening is unique in that a pre-cancerous growth can be found and destroyed. This is helpful in preventing cancer, rather than just finding the cancer early. This is a very important advantage of colon cancer screening when compared to breast, cervical, or prostate cancer screening. Therefore, it is important for everyone regardless of the presence of symptoms or family history, to undergo colon cancer screening.
There are three types of colorectal screening programs.
1. The most basic screening program is comprised of a yearly stool test for
blood and a flexible sigmoidoscopy (a short endoscopic examination) performed
every five years. These are the least invasive means of evaluating the colon
and, as such, may miss some tumors. Therefore, this is only appropriate for
patients who have average risk for colon cancer. Average risk is defined as
patients who have reached the age of 50 and do not a personal or family history
of colon polyps, colon cancer, colitis, or symptoms related to the colon (bleeding,
change in bowel habits).
2. The combination of flexible sigmoidoscopy and barium enema examination (x-ray)
of the entire colon is another acceptable screening program. The testing is
more involved and, therefore, has less likelihood of missing tumors. This combination
of tests should be performed at five-year intervals.
3. Colonoscopy is an endoscopic examination of the entire lining of the colon.
This allows the lining to be directly seen. Abnormal areas may be biopsied,
and polyps may be removed during the procedure. Colonoscopy is considered the
most accurate way of examining the colon. It is performed at ten-year intervals
provided that symptoms or family history do not change during that period.
Artificial Anal Sphincter
Definitions
The Problem
Evaluation and initial treatment
Preparation for surgery and postoperativecare
Procedures
Frequently asked questions
Definitions
Fecal Incontinence: the uncontrolled release of gas or stool from the anus.
Anal sphincter: a series of circular muscles, the majority of which are under
voluntary control, which prevent the release of gas or stool from the anus.
Sphincteroplasty: a surgical procedure performed to repair a tear in the anal
sphincter.
Artificial anal sphincter: a device implanted under the skin which is designed
to mimic the natural function of the anal sphincter.
The Problem
Affecting nearly one million people, fecal incontinence is a common problem, most often caused by an injury to the anal sphincter during childbirth. The severity may vary from the infrequent passage of gas to daily passage of solid stool. Severe incontinence often interferes with the ability to work, enjoy social activities and is a frequent reason for nursing home placement. Despite this being a common and significant problem, most people with incontinence are uncomfortable discussing this with their family, friends or doctors. Instead, they suffer in silence not knowing what to do.
Evaluation and initial treatment
1. Initially, fecal incontinence is usually treated through one of the following
means:
Kegel exercises are repetitive efforts to tighten the anal sphincter muscles
in an effort to strengthen them and make them more effective. These are performed
several times throughout the day and require no equipment.
Biofeedback is a method of retraining the existing anal sphincter to function
as best as is possible. It involves several training sessions with a special
sensor and display to demonstrate how well the muscle is working with certain
efforts by the patient.
Antidiarrheal medicine (fiber supplements, Imodium7, Lomotil7) is often prescribed
to patients who have frequent or loose stools which are harder to control.
Enemas can often be administered prior to a social activity. This treatment
is useful in that it partially empties the large intestine of stool at a convenient
time (when a bathroom is quickly available).
2. If initial attempts to control fecal incontinence fail, surgical means of
treatment may be considered. Surgery may include sphincteroplasty and insertion
of an artificial anal sphincter.
The artificial anal sphincter device is a modification of the artificial urinary
sphincter, manufactured by the same company, which has been used since 1972.
It is best used when a sphincteroplasty has been tried and failed, or when a
sphincteroplasty cannot be performed because sufficient healthy muscle is lacking.
Preparation for surgery and postoperative care
Any operation involves three phases to complete the procedure. These are preparation, operation and postoperative care.
1. Preparation: Preparation for sphincteroplasty is designed to reduce the
risk of infection at the sphincter repair site. The large intestine must be
emptied of stool by a " bowel prep," which may take a few days to
complete and require you to take special laxatives, depending on the particular
method your surgeon prefers. Dietary changes (clear liquid diet) are usually
begun at the time the bowel prep is started. You should not eat or drink after
midnight the night before the operation for safety in administering the anesthesia
for the operation. Intravenous antibiotics are given immediately before the
operation to reduce the risk of infection.
2. Operation: To provide access to the anal area, you may be asked to lie on
your back with your legs supported out to the side or on your stomach with a
pad under your hips. The details of sphincteroplasty and implantation of the
artificial anal sphincter are described in the next section.
3. Postoperative care: The major causes for breakdown of the sphincteroplasty
are infection and the passage of a hard stool which can tear the stitches out
of the fragile muscle. To reduce these risks, you may be required to stay in
the hospital for a few days after surgery. You may be asked to follow dietary
restrictions (nothing to eat or drink, or clear liquids only) and antidiarrheal
medicine to bind the bowels. Intravenous antibiotics are often administered
to help lower the risk of infection, and the skin incision is cleansed three
times per day. After a few days, or the passage of stool, the medications are
stopped and a regular diet resumed. At this point, the passage of a hard stool
must be avoided. Stool softeners (Colace) or fiber supplements (Metamucil, Citrucel,
Konsyl) and plenty of water are prescribed to keep the stool soft. Mineral oil
is often used to avoid constipation, and Milk of Magnesia may be used as a gentle
laxative if there has been two to three days between bowel movements. Nothing
should be inserted in the anus (suppository, enema, thermometer) for about six
weeks to avoid injury to the sphincteroplasty. For a period of two to three
months, patients are asked to refrain from sexual intercourse, bicycle riding,
intense physical exercise, heavy lifting and squatting.
Procedures
Sphincteroplasty
A sphincteroplasty is usually performed through an incision in the skin near
the anus. The injury to the anal sphincter is identified and the injured muscle
edges are freed from surrounding scar tissue. The muscle edges are then brought
back together using a series of stitches. The skin is closed with absorbable
stitches which do not need to be removed. A small drainage tube is occasionally
needed to prevent the accumulation of fluid around the sphincteroplasty, which
is removed before you leave the hospital. Sphincteroplasty uses your own muscle,
which is meant to control stool. Therefore, there is very little extra training
needed to gain the benefit of stool control after this surgery. However, muscles
may take several weeks or months to recover from the surgery. Kegel exercises
or biofeedback to help retrain and strengthen the repaired muscle may be recommended
after the sphincteroplasty has healed.
Artificial anal sphincter
The artificial anal sphincter is a totally implantable, simple-to-use device
consisting of three components: 1) an inflatable cuff; 2) a fluid reservoir
(balloon); and 3) a semi-automatic pump connected between the cuff and balloon.
Fluid is placed within the balloon. The entire device is placed beneath the
skin and is not visible at any time.
Two incisions are used to implant the device. One incision is placed between the anus and the vagina or scrotum. This incision is used to place the inflatable cuff around the anal sphincter. The second incision is placed in the lower part of the abdomen in the pubic region. This incision is used to make a space behind the pubic bone where the balloon is inserted. The pump is placed in a small pocket made beneath the skin of the labia or scrotum through the two existing incisions.
The artificial anal sphincter is not activated immediately. Six to eight weeks are allowed for healing from the surgery before the device is activated. Once activated, a few training sessions are usually necessary to learn how to use the device. Following activation, the anal cuff remains inflated in the “resting state.” This places pressure on the anal canal and keeps it closed, preventing the passage of stool. When the urge to have a bowel movement develops, the cuff is temporarily deflated by pressing the pump in the labia or scrotum several times. This moves the fluid from the cuff to the balloon and releases the pressure keeping the anus closed. The balloon automatically reinflates the cuff over the next several minutes. The only part of this process requiring any action is pressing the pump to deflate the cuff when the time for a bowel movement has arrived.
Frequently asked questions
1. How is the anal sphincter damaged? Loss of anal sphincter function is due
to either nerve or muscle damage. Nerve damage may result from trauma to the
nerves (including spinal cord injuries) or medical conditions which affect nerve
function (diabetes, multiple sclerosis). Muscular damage is often caused in
women have had difficult vaginal deliveries (long labor, large baby, forceps
or vacuum assistance, breech delivery, episiotomy or perineal tear). Surgical
procedures on the anal canal for a variety of conditions (hemorrhoids, fissures,
fistulas) may result in cutting of the anal sphincter muscle and incontinence.
Accidents which result in injuries to the pelvis and anal area may also damage
the anal sphincter muscle. Many years may pass between these injuries and the
onset of incontinence.
2. Will I need a colostomy? A colostomy is rarely needed for the first attempt
at sphincter repair or replacement, because infection and the passage of hard
stool can be controlled through medication and diet. However, if a previous
attempt has failed, a colostomy may be recommended.
3. What type of surgeon can perform the operation? Several types of surgeons,
including gynecological, general and colorectal surgeons, can perform a sphincteroplasty.
The most important factors to consider include a surgeon’s training in
the procedure, number of procedures done (total and yearly) and results. In
general, colorectal surgeons will have had the most formal training in the procedure
and will frequently have the greatest experience in performing it.
Very few surgeons are currently trained and approved to implant the artificial
anal sphincter. The FDA has released this device on a Humanitarian Use Device
Exemption. This allows the device to be used outside of a research study prior
to full FDA approval. Strict requirements are placed on surgeons seeking approval
to use this device, which we have met since 1999.
4. What are the results of sphincteroplasty? Results vary case to case, and
often depend on the original cause of incontinence. Patients with normal nerves
and an obvious injury to the sphincter muscle generally will have a better chance
at success than patients with nerve damage or an unknown cause of incontinence.
The range of success (good to excellent control of stool) is from 60 to 90 percent.
5. How effective is the artificial anal sphincter? The artificial anal sphincter
is a simple, and highly successful method to improve stool control. Eighty to
90 percent of patients report improvement in control of stool and rate their
control of stool as good to excellent. The improvement in control of gas is
not quite as good as stool. The major concern with this device is infection
which occurs in about 15 percent of patients and may require removal of the
device. If this occurs, a new device may still be placed once the infection
has cleared and the area has recovered from surgery. It is not yet clear how
long each of the components of the device last and if replacement due to component
failure will be required.
6. What if the sphincteroplasty and/or the artificial anal sphincter fails?
Several options are available if a sphincteroplasty fails. If it is determined
that the repair has fallen apart, a second sphincteroplasty can be attempted.
The next option is the implantation of the artificial anal sphincter. Still
other options are available, but these are much more involved to perform and
have not shown better results than the artificial anal sphincter. These options
include rotating muscle from the buttock (gluteus muscle transposition) or thigh
(gracilis neosphincter) and wrapping it around the anal canal. A temporary colostomy
is often necessary for a few months after a second operation on the anal sphincter.
A colostomy is a good alternative to control stool when no other methods have
been effective and the incontinence causes significant problems with work and/or
social activities.
Marc I. Brand, M.D. and Theodore Saclarides, M.D. were the first colorectal surgeons in the Chicago area to implant the artificial anal sphincter, and there are only a few surgeons nationwide that are currently doing this procedure.
If you would like to be evaluated for implantation of an anal sphincter, or
for more information, you may contact our office at:
University Surgeons
At Rush-Presbyterian-St. Luke’s Medical Center
1725 W. Harrison, Suite 810
Chicago, IL 60612
(312) 952-6500
You may also get more information at the following website:
www.acticon/pages/TagContentasp?SectionsID=#&PageID=309$#what
JUDIE:
I WANT TO ADD THIS DISCLAIMER – IT DEFINITELY NEEDS TO BE PROMINENT ON THE HOME PAGE – WHERE ELSE DO YOU THINK IT SHOULD GO?
The information provided on this University Surgeons web page should be relied
upon only as a source of general medical education. It is not intended to replace
the independent judgment of a physician. The appropriate treatment for any particular
patient may vary from the information provided here due to unknown factors that
affect decisions about the best treatment for your particular condition. Your
best source of information is always your personal physician.
Doctors Favorite Links
In addition to the ones we added last month,
http://www.medicare/gov/health/awareness.asp
Cancer Wellness Center http://www.cancerwellness.org
The following should be included in the articles as indicated, not on the favorite
sites list:
Acticon
Visicol
Sanarus
Fleets phospho-soda
Davol
Msnbc.com/news/378906.asp?cp1=1 (Katie Couric’s colonoscopy) if you are
able to make this link make it from the colonoscopy article
www.bergamon.cor/pass2/prod_lax_fleet_enemas.enema.htm
www.phospho-soda.com?cons/consdefault.asp
www.visicol.com/health_pro.html
dosagePadj.pdf from www.visi