Types of Surgeries
Surgery for Colorectal Polyps
Polyps are noncancerous growths that can occur throughout the colon and rectum. They are very common and are diagnosed with increasing frequency, due to improved screening and detection. Left untreated, these polyps can grow, causing bleeding, obstruction and, eventually, colon cancer.
Colonoscopy is the treatment of choice for patients who need to have polyps removed. A board-certified pathologist will test the removed growths to make sure that they do not contain cancerous tissue. The specialist will recommend ongoing follow-up to detect and treat any further polyp growth and development.
The colonoscope permits a minimally invasive form of treatment for such colon growths. For colonoscopic polyp removal, patients normally undergo sedation, rather than general anesthesia, and may return home on the same day of the procedure. The procedures are relatively minor and very safe. They generally cause little discomfort.
Should polyps or tumors grow too large (or should the specialist otherwise deem them inappropriate for removal with the colonoscope), the patient may need surgery. To benefit patients with the most modern surgical techniques in these cases, Jefferson Health – Northeast Health offers minimally invasive laparoscopic colon surgery. This surgery only requires several small incisions, through which surgical specialists introduce an endoscope and various surgical instruments. As needed, Jefferson Health – Northeast's colorectal surgery division also offers traditional, open, colorectal surgery. (However, recovery from laparoscopic surgery is much quicker.)
Surgery for Inflammatory Bowel Disease
Experienced gastroenterologists in our Division of Gastroenterology are the best specialists to manage care for patients with inflammatory bowel disease (IBD), Crohn's disease and/or ulcerative colitis. Specialists reserve surgical treatment for patients who have complications of IBD, such as infection, bleeding, or tissue that has become malignant.
Medical treatment for IBD has developed at a rapid pace. Treatments currently include anti-inflammatory compounds, steroids, antibiotics, immune modulators and biologic therapies. The use of monoclonal antibodies has brought rapid improvement to many individuals who have severe disease, including patients for whom surgery would formerly have been required.
But if drug therapy and other noninvasive treatments fail to control IBD, surgery may be needed. In these procedures, surgeons remove sections of abnormal bowel and then reconstruct and reconnect the remaining ends of the bowel to restore the continuity of the digestive tract. The goal is to stop intestinal bleeding, obstruction, or infection and to return the patient to a better state of wellness. Specialized procedures can be added for specific areas such as the perianal and perirectal tissue.
Surgery for more extensive or involved disease can sometimes include other procedures. The use of permanent colostomy to treat IBD has decreased significantly with modern surgical techniques. Surgeons are now able to better judge the amount of bowel to remove, and in many cases, can minimize the amount of bowel lost in surgery. The use of an ileo-anal pouch operation allows surgical specialists to reconstruct an artificial rectum to maintain bowel continuity for patients who have undergone removal of their lower bowel or rectal area. Surgical treatment of IBD may also involve temporary colostomy, perforation repair, abscess drainage, or other procedures.
Surgery is not a cure for IBD, but is used to treat complications. This form of care often allows the patient to return to a more normal lifestyle, weight, appetite and state of well-being.
Patients should discuss with their doctor and specialists all treatment options for IBD.
Surgery for Diverticulitis
In diverticulitis, the colon (or large intestine) develops one or more small diversions or outpouchings that–because of their abnormal shape and position–become irritated and cause painful symptoms or, sometimes, dangerous complications. These bulges, known as diverticula (singular is a diverticulum), cause no symptoms for some patients, while in others they become inflamed or infected. Having diverticula is a condition called diverticulosis. The presence of diverticula or diverticulitis is also referred to as diverticular disease. Today, laparoscopic procedures are rapidly improving surgical treatment for acute and severe diverticulitis.
Most people with diverticulosis will not develop diverticulitis. But about half of all Americans ages 60 to 80, and almost everyone over age 80, have diverticulosis. A significant percentage of them will become symptomatic. The disease is common in developed or industrialized countries–particularly the United States, England and Australia–where diets tend to be lower in fiber. Diverticular disease is rare in countries such as Asia and Africa, where people eat high-fiber diets that are more heavily based on vegetable food sources.
Diverticula are partly the result of increased pressure in the colon, the main cause of which is constipation that, in turn, causes muscles to have to strain to move stool that is hard and compacted. This can force weak spots in the colon to bulge out. These areas are a kind of herniation of the inner intestinal lining through junctures of the muscular wall, forming a protruding pouch on the colon. Physicians do not know what causes infection in some diverticula, but believe it may begin when stool or bacteria are caught in these areas.
Diverticulosis may not cause any discomfort for some people. For still others, it may cause only mild cramps, bloating, or constipation. When the condition develops into diverticulitis, however, abdominal pain and tenderness around the left side of the lower abdomen are usually present. If diverticular bleeding occurs, blood may be apparent in the stool. When diverticulitis causes infection, the patient may experience fever, nausea, vomiting, chills and further cramping or constipation. Less commonly, the diverticuli in the colon can rupture, which results in infection in the tissues that surround the colon, a dangerous condition. Thus, serious complications of diverticulitis can include bacterial peritonitis (abdominal cavity infection), bleeding in the colon, or colon obstruction.
Conservative Therapy, Surgery for Complications
When possible, physicians will always attempt to treat diverticulitis with noninvasive procedures. A change in diet to include more fiber can be a step that increases stool volume and thus prevents constipation. (However, once diverticula are formed, they are generally permanent unless removed surgically.) Bed rest, liquid diet and antibiotics can also help for acute bouts. Diverticulitis can require treatment with medications for pain, infection and inflammation and muscle spasms. Hospitalization or surgery are sometimes needed for acute attacks.
Sometimes, specialists can treat some serious symptoms of diverticulitis, such as bleeding or intestinal blockage, with colonoscopy. But often patients with severe disease, or complications of the disease, will require surgery, using either a laparoscopic approach or open procedure.
Some patients are candidates for surgery because of multiple, severe attacks of diverticulitis in the course of one or more years. Patients who need surgery because of complications also include those who have a diverticulum that has ruptured, infection that has spread into the abdomen or into the blood, an obstructed bowel, or severe bleeding.
Minimizing the Invasiveness of Surgery
In operations to treat these conditions, the surgeon removes the deformed and inflamed portion of the large intestine (an operation called a partial colectomy, sigmoid resection, or segmental resection) and then reconnects the ends of the intestine to restore continuity of the digestive tract. Increasingly, surgeons can offer these procedures laparoscopically. The team makes small incisions at several locations in the lower abdomen and uses these to access the colon with endoscopic equipment. These tools are slender tubes, including a scope with a self-lit lens at the end, that permit the surgeon see and manipulate the colon during the operation. Using laparoscopy, the colorectal surgeon can perform surgery while watching a video monitor of the endoscopic images and of the instruments used to resect and suture the intestine. The skilled surgeon can take advantage of these techniques to resect and repair the colon safely, providing for an easier procedure for patients to undergo, compared to conventional, open surgery.
The laparoscopic approach means less blood loss, a shorter hospital stay, quicker healing, less pain, faster recovery (including of bowel function) and more prompt return to activities, when compared to open colon resection. Patients with more extensive inflammation, however, may need a traditional, open operation.
The surgeon may perform the partial colectomy as one operation or as a two-step procedure used more commonly for patients with extensive inflammation. In the latter case, the surgeon first removes the diseased section of colon and then attaches the upper end of the intestine to a small opening in the abdominal wall (stoma), permitting temporary collection of fecal matter outside the body (an operation called a colostomy) while the inflammation and infection of the intestine subsides and the colon heals. After a number of weeks or months, when the colon and rectum have recovered enough to make the second phase of the operation safe, the surgeon reconnects the ends of the intestine, to re-establish the digestive tract, and closes the ostomy. The two-step approach is also used in cases of emergency, life-threatening abdominal infection.
The surgical team places patients under general anesthesia during a partial colectomy. These operations require several days of hospitalization and several weeks of recovery.
Treatment for diverticulitis can also involve abscess drainage.If the medical team identifies the abscess early enough, it may be able to drain it through the skin as an alternative to surgery.
Surgery for Cancer of the Colon
Surgery is the primary form of treatment for colorectal cancer. Some patients will require only surgery, while some will also undergo chemotherapy or radiation therapy before or after surgery. Recent progress in treating cancer is partly a result of such combined treatments. If the needed surgical aspects of care cannot be adequately addressed by gastroenterology specialists using colonoscopic techniques, one or more operations may be necessary.
Often the surgeon can completely remove the cancer. The survival rate is highest for these complete, curative resections. The type of surgery used for each patient, though, will depend on the location and stage of the cancer.
The surgeon will sometimes remove the tumor, a small margin of surrounding healthy tissue, and adjacent lymph nodes. Other times an entire portion of the colon will need removal. In still other cases, the entire colon will be resected, sometimes including the rectum, sometimes including the anus.
But in many colon resections, the surgeon can remove the cancerous tissue and rejoin the ends or margins of the colon, without loss of function of the colon. In some cases, especially to treat more advanced cancers, the surgery may include a colostomy, in which the surgeon creates an artificial opening through which waste can pass to in an external bag. This arrangement is usually temporary and permits the resected portion of the bowel to heal. Permanent colostomies are rare today.
Laparoscopic Colon Resection
This new and advanced, minimally invasive surgery, allows our surgeons to remove a colon tumor or colon segment without a large surgical opening. The team makes small incisions at several locations in the lower abdomen and uses these to access the colon with endoscopic equipment. These tools are slender tubes, including a scope with a self-lit lens at the end, that permit the surgeon see and manipulate the colon. The surgeon can perform the surgery while watching a video monitor of the endoscopic images and instruments used to resect and suture the large intestine. The skilled surgeon can take advantage of these techniques (referred to as laparoscopic surgery when used in the lower-abdomen or pelvis) to resect tumors and repair the colon safely, providing for an easier procedure to undergo.
The laparoscopic approach means less blood loss, a shorter hospital stay, quicker healing, less pain, faster recovery (including of bowel function) and more prompt return to activities, when compared to open colon resection.
Open Colon Resection
In conventional open surgery of the colon, the surgical team makes a long incision in the lower abdomen. This gives the surgeon direct visual and manual access to the colon to remove a cancerous section or a length of the colon.
Rectal Cancer Surgery
When undergoing surgery for cancer of the rectum, patients are understandably concerned about the possible loss of continence. Today, though, even for cancer in the lower rectum, the skilled surgical team can often remove the cancerous tissue and preserve the nerves and muscles of the anal sphincter, permitting the patient to retain bowel control. Preoperative radiation therapy, combined with precise surgical technique help to remove early stage cancer, helps to preserve the natural functions that control bowel movement.
Intraperitoneal (IP) Chemotherapy
When colorectal cancers have invaded the peritoneal cavity, the knowledgeable cancer team can treat the disease by infusing chemotherapeutic drugs into this area. The surgeon will place a catheter into the pelvic area, allowing the drugs to be introduced for varying periods of time into the peritoneal space and withdrawn. This increases the concentration of drugs acting on the cancer tissue and decreases the amount that reach the rest of body, compared to the conventional intravenous route of administration. The strategy enhances the cancer killing effects of the drugs and decreases their systemic side effects. Typically, patients receive IP chemotherapy after surgery that removes as much of the visible cancer tissue as possible.
Intraperitoneal (IP) therapy can be an effective treatment for pseudomyxoma peritonei, an uncommon condition (also known as malignant appendical tumor) in which cancers cells have broken through polyps on the appendix and caused a spread of mucus-producing tumor cells within the pelvic area.
Sometimes when curative surgery is not possible, surgical treatment can still be beneficial in addressing and reducing symptoms. Colorectal cancers can cause pain or result in obstruction of the digestive tract. Surgery to de-bulk, or reduce the size of, tumors can help to alleviate some these situations. This type of surgery is meant to improve quality of life for the patient.
Another type of palliative surgery is colon resection for patients whose cancer has already spread to other parts of the body at the time of initial diagnosis. The step can help reduce later bleeding, blockages, and symptoms caused by colon masses and by tumor invasion of nearby organs.
Surgery for Metastatic Disease
Surgical treatment for colorectal may also be directed at sites to which the cancer has spread (or metastasized). Common sites for metastatic colon cancer include the liver and brain.
Today, it is possible to remove sections or large segments of the liver when this organ becomes cancerous. After hepatic resection, healthy liver tissue can partly regenerate.
Our team can refer patients for neurosurgical procedures as well.