Colon and Rectal Surgery

Anal Fissures treatment

What is an Anal Fissure?

The anus is the last part of the digestive tract and is lined with contracting muscles that control the removal of stools. An anal fissure is a tear in the tissue lining the anus, and is associated with pain and bleeding during bowel movements. It can occur in almost any one; however, it is more commonly seen in infants.

Anal fissure can be caused because of trauma or injury to the anal canal while passing hard or large stools, constipation, or straining during bowel movements or childbirth. It can occur independently or in association with other conditions like chronic diarrhoea, HIV, anal cancer, tuberculosis, syphilis and herpes. Sometimes, excess stress on the two muscular sphincters (rings) that control the anus can reduce blood supply and lead to development of an anal fissure.

Depending on its severity, anal fissures can be acute or chronic. Anal fissures can be superficial or shallow, making their detection difficult. Therefore, visual inspection may not suffice at all times. In most patients, an anal fissure heals on its own in a few days or weeks (acute), but in cases when it doesn’t heal even after 6 weeks (chronic), medical treatment or surgery may be recommended.

What are the Signs & Symptoms?

The typical symptoms of an anal fissure include pain during and several hours after bowel movement. Even though the tear caused by an anal fissure is small (about 1cm); the condition is painful and may persist for an hour or more after passing faeces. The severe pain may make patients apprehensive to the point of avoiding defecation, which further aggravates the condition. Pain is usually more intense in acute anal fissure.

Other symptoms include:
  • Blood in the stools, on the toilet tissue or in the bowl
  • Muscular spasms at the end of the anus
  • Cracked or ripped anal skin
  • Itchy fissures
  • Yellow discharge that has an unpleasant odour

Chronic anal fissures can grow deeper into the tissue and form ulcers, which can further delay the healing process.

What are the methods of Screening & Diagnosis?

Your doctor will review your medical history and conduct a physical examination of the anal region. Most anal fissures can be diagnosed by viewing the anal region on separating the buttocks. If the tear is visible, diagnosis becomes easy and treatment can be started immediately. If not, a sample of the rectal tissue may be removed for examination.

Anal fissures can be diagnosed by digital rectal examination or using an instrument called an anoscope. Digital rectal examination involves inserting a gloved finger into the anal canal. The anoscope is a short instrument with a lighted tube which can help your doctor view and examine the fissure. If these procedures cause extreme pain, your doctor may wait till the fissure heals or use a topical anaesthetic to reduce the discomfort.

Your doctor will have to rule out other problems that can cause fissures. Anal fissures are characteristically located either on the back or front surfaces of the anus. If your condition is characterised by several fissures, or the fissures are located on the sides of the anus, then you may be suffering from a different condition (inflammatory bowel disease, anal cancer, syphilis or HIV infection). Your doctor will conduct further tests to confirm these conditions.

What are the Treatment Options?

The treatment measure adopted would depend on the nature of the fissure, i.e. if it is acute (lasting up to a few days) or chronic (lasting for more than 6 weeks).

Home remedies such as increasing the intake of fibre and fluids is highly recommended for softening the stools. Foods rich in fibre, like whole grain bread, fruits and vegetables, brown rice and oats, can help heal anal fissures in a few weeks.

Your doctor may also advise you to soak in warm water for 10 – 20 minutes as often as possible, particularly after bowel movements, to relax and reduce the stress on the sphincter muscles. Steroid creams, other topical applications and Botox injections may be prescribed to reduce discomfort, improve blood circulation and relax the sphincter muscles of the anus.

Topical anaesthetics and pain medication may be prescribed to control pain.

Surgery is usually the last resort when other treatments do not provide the needed relief. Some of the surgical procedures include:

  • Lateral internal sphincterotomy: Your doctor may perform lateral internal sphincterotomy, where pain and spasm is reduced by removing a small section of the anal sphincter muscle.
  • Fissurectomy: Your doctor will surgically remove the anal fissure with the surrounding healthy tissue. This method is not commonly used in adults, but is performed mostly in children.
  • Advancement anal flaps: Your doctor will take healthy tissue from a different part of the body to repair the fissure and help improve blood flow. This method is commonly used to treat chronic fissures that have occurred due to injury to the anus, especially after pregnancy.

Anal Fistula Surgery

The anus is an external opening through which faeces is expelled out of your body. There are a number of small glands inside the anus. These glands may sometimes get blocked and form an infected cavity called an abscess. Often, anal abscesses further develop into an anal fistula. An anal fistula is a small channel or tunnel that develops from the infected gland and opens out onto the skin near the anus.

Some fistulae have only one opening, while others are branched out into many openings. Fistulae may sometimes be connected to the sphincter muscles, the muscles that open and close the anus. The ends of the fistulae look like holes on the surface of the skin around the anus. Anal fistulas are commonly treated through surgery.

Signs and symptoms

The commonly observed symptoms of an anal fistula include:

  • Throbbing pain that may get severe when sitting
  • Irritation of the skin around the anus
  • Swelling, tenderness, redness
  • Bleeding
  • Constipation
  • Discharge of pus
  • Pain during bowel movement
  • Fever and fatigue

Diagnosis

Your doctor may review your medical history and conduct a physical examination to find the opening of the fistula. This will help your doctor trace the path of the channel, which can usually be felt as a hard cord-like structure below the skin. A digital rectal examination (insertion of a gloved finger through your anus) may be performed to find the internal opening of the fistula, the presence of any branching and the functioning of the sphincter muscles. Further examinations may be performed with the use of a fistula probe (a tiny instrument inserted into the rectum) and a proctoscope (a lighted device). Your doctor may recommend an ultrasound, CT or MRI scan for complicated fistulae with many branches, to evaluate the exact position of the fistula channels.

Treatment

Fibrin glue is the only non-surgical procedure for the treatment of an anal fistula. The fibrin glue is injected through the opening of the fistula and the opening is closed with stitches. Surgery is suggested when this does not relieve the symptoms of the fistula.

As part of the pre-surgical process, you will be advised to stop smoking, fast for about 6 hours before the surgery, and you will be given an enema an hour before the surgery to empty your lower bowel. Anal fistula surgery is performed under general anaesthesia. The type of operation depends on the position of the fistula.

Fistulotomy: The surgery involves cutting open the fistula across its whole length in order to flush out the contents. It heals into a flattened scar after 1 – 2 months.

Seton technique: The Seton technique involves passing a surgical thread into the fistula tract and leaving it in place for several months or permanently. This helps to keep the tract open and drain the contents of the fistula. This may be considered if you are at a risk of incontinence (inability for you to control your bowel movements), because your fistula crosses your sphincter muscles.

Advancement flap procedures: This procedure is usually preferred if the fistula is complex or if you are at a high risk of developing incontinence. The fistula tract is removed. A small piece of tissue (advancement flap) is removed from the rectum or from the skin around the anus and attached over the opening of the fistula.

Bioprosthetic plug: A cone shaped plug is developed from human tissue. It is used to block the internal opening of the fistula and is sutured in place. The plug does not completely close the opening, allowing the fistula to drain.

Post-operative care

After the surgical procedure, your doctor will discharge you from the hospital on the same day or after a few days based on your condition. It might take 6 weeks for the wound to heal completely. The doctor may prescribe painkillers, antibiotics and laxatives. You will be advised to carefully wash, clean and dry your anal area. You are advised not to sit for long periods and walk much until healing occurs.

Risks and complications

Anal fistula surgery is generally safe with no major risks. However, like most surgeries, anal fistula surgeries may involve complications such as:

  • Infection
  • Narrowing of anal canal
  • Damage of sphincter muscles
  • Re-occurrence of fistula
  • Bleeding

Your doctor will access your condition with utmost detail and recommend the best treatment option.

Colon cancer treatment

What is colon cancer?

Colon cancer is cancer in the lowest part of the digestive system, the large intestine or colon. Cancer occurs when cells in the body grow abnormally out of control. Most colon cancers occur when small, noncancerous (benign) clumps of cells called adenomatous polyps on the inner walls of the large intestine change and transform into cancerous (malignant) tumours over time. Identification of these benign polyps before they become cancerous is therefore especially important and can be done by regular screening tests.

Colon cancer cells lead to many complications by invading and damaging healthy tissues in the vicinity. Also, once malignant tumours form, the cancer cells may travel through the blood and lymph systems, eventually spreading to other parts of the body.

What are the signs and symptoms?

Symptoms of colon cancer depend on the size and location of the cancer. There may be no obvious symptoms in the initial stages of the disease. However, symptoms increase in quantity and degree of severity as the disease progresses.

Colon cancer manifests itself in two forms, local (confined to the colon) and systemic colon cancer (cancer has spread to different parts of the body). There is a variation in the signs and symptoms of these two forms.

Local colon cancer symptoms

These symptoms include a change in bowel habits that include constipation or diarrhoea, feeling of incomplete bowel evacuation, blood (either bright red or very dark) in stools, “pencil stools” (stools thinner than normal) and persistent abdominal discomfort accompanied by cramps, gas or pain. Consult your doctor right away if you are experiencing similar symptoms over a few days.

Systemic cancer symptoms

Characteristic symptoms of systemic cancer include unexplained weight loss, loss of appetite accompanied by fatigue or weakness, nausea, anaemia and jaundice. If you experience any of these symptoms, you should be seen by your health care provider at the earliest.

What are the methods of screening?

Regular colon cancer screenings can detect colon cancer early and potentially save your life. Early detection is advisable as polyps or growths on the lining of the intestine can be found early and removed before they develop into cancer. Colon cancer screening is dreaded by many people as they think it might hurt or they find it embarrassing. It is important to understand your doctor performs these procedures on a regular basis and there is no need to feel embarrassed. Also, you will be kept comfortable during the procedure with anaesthesia and not feel pain.

How is colon cancer diagnosed?

If your symptoms resemble colon cancer, your doctor will review your medical history and order blood tests. The following procedures may be recommended:

  • Colonoscopy- A long and flexible slender tube is attached to a video camera and monitor, and the entire colon is captured on a screen. This helps to detect suspicious areas from where biopsies (tissue samples) can be taken for analysis using surgical tools passed through the tube.
  • Virtual colonoscopy/CT colonography: Multiple CT scan images are combined to create a detailed picture of the inside of your colon. This is usually recommended for people who are unable to undergo colonoscopy.

What are the treatment options?

Your doctor might recommend treatment options taking into account factors such as the stage of cancer (whether it is in the initial or the final stages) and the overall health of the patient. The different treatment options include surgery, chemotherapy and radiation.

  • Surgery for early or initial stage cancer: Your doctor may employ colonoscopy for removing small localised polyps. A procedure called endoscopic mucosal resection may be used for larger polyps. If colonoscopy does not yield the desired result, laparoscopic surgery may be used.
  • Surgery for invasive colon cancer: A procedure called partial colectomy is used if the cancer has moved into or through your colon. This involves removing the cancer containing part of the colon, along with a portion of normal tissue on either side.
  • Surgery for advanced cancer: If the cancer has reached a point of “no cure”, or your general health conditions have dropped considerably, then surgery isn’t done to cure cancer; it is done to bring relief from symptoms such as bleeding and pain.

Chemotherapy

Chemotherapy involves using drugs to destroy cancer cells. It is usually taken up after surgery to relieve the symptoms of cancer that has spread to either lymph nodes or other areas of the body. It can also be used to shrink the cancer before the surgery.

Radiation therapy

Radiation therapy uses high energy radiation such as X-rays to kill cancerous cells. It is usually employed in later stages of cancer and together with chemotherapy it can reduce the risk of cancer recurrence in specific areas.

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