Download A Surgeon`s View of Gastroenterology and Practice

A Surgeon’s View of Gastroenterology and Practice
by Thomas L. Largen, M.D., FACS
1989
As a board-certified general surgeon in private practice for 30 years, I have performed numerous
surgical procedures. But one of my favorite subjects is gastroenterology, that branch of medical science
concerned with the study of the stomach, intestines, and related structures, including the esophagus,
liver, gallbladder, and pancreas.
The Gastroenterology Team
The advent of endoscopy and the specialization of gastroenterology have certainly made the field of
GI surgery a more interesting one. Gastroenterologists are medical doctors trained in the treatment of
diseases involving the gastrointestinal tract and trained in the use of flexible endoscopes to study the
esophagus, stomach, pancreatic ducts, biliary ducts, the entire colon, and sometimes the distal small
bowel.
Gastroenterologists and surgeons work as a team. A patient’s presenting problem is first assessed by
one of the gastroenterologists. If medical treatment methods are found to be unsuccessful—as in
controlling hemorrhage, for example—then I am called upon to carry out definitive surgery. From a
surgeon’s viewpoint, it is a tremendous help to know exactly what I can expect to find when I begin the
surgery, and the information from the gastroenterologist enables me to plan accordingly.
The Miracle of the Modern Endoscope
An endoscope is a long hollow tubes with a light source that can be inserted into a hollow organ to
view and assess the condition of the organ. In gastroenterology, there are three categories of
endoscopes: the esophagogastroscope, the sigmoidoscope, and the colonoscope.
When I was a resident in the early 1950s, only rigid endoscopes existed. The rigid esophagoscope
of that era was a very dangerous instrument. It could easily perforate the esophagus, which in essence is
a flimsy, thin-walled tube. Additionally, it was of little value in examining the stomach because it could
not negotiate the curves and corners of the organ. The rigid sigmoidoscope of the 1950s was about 10
inches, or 25 cm, in length, and it too had its limitations. Because it was short it didn't allow much
exposure, and because it was rigid there was the danger of perforating the lower colon.
Then in the early 1970s, Japan introduced the first fiberoptic flexible endoscope. That event alone
drastically changed the direction and practice of gastroenterology. It was not all that long ago, most
gastroenterology work was performed by general surgeons.
With the advent of flexible fiberoptics, medical doctors began to specialize in diagnosis, treatment,
and procedures of the GI tract, and the field of gastroenterology became a specialty. Today, most
endoscopes utilize state-of-the-art flexible fiberoptics.
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Endoscopic Diagnosis and Treatment
This is an exciting time in gastroenterology practice. With the introduction of the flexible
endoscope, new treatment modalities have evolved. People who present with gastrointestinal
hemorrhage from either the upper GI tract (the esophagus, stomach, or duodenum) or the lower GI tract
(the colon) are frequently diagnosed by means of upper and/or lower endoscopy. Bleeding sites can be
controlled by application of a heat probe through the endoscope or injection of a sclerosing (hardening)
agent through a long needle passed through the endoscope. Bleeding esophageal varices, a serious
medical condition, are often controlled by sclerosing these dilated varicose veins through the
esophagoscope.
Patients who have had strokes or other medical problems are sometimes unable to swallow or eat
properly and require a temporary alternative means of securing nutrition. There are now techniques
whereby a feeding tube can be inserted into the stomach by way of an esophagogastroscope, eliminating
the need to do open surgery for this purpose. Endoscopes are also useful in removing foreign bodies
from the esophagus, and occasionally from the stomach or duodenum.
Today, surgical procedures can actually be performed through endoscopes. For example, an
experienced gastroenterologist can do a sphincterotomy through the scope (cutting the sphincter of
Oddi, which is located in the second portion of the duodenum through which the pancreatic duct and the
common bile duct enter the small intestine). Retained gallstones in the biliary ducts can be extracted
using a wire basket-type catheter placed through the scope, eliminating the need for the patient to
undergo an open operation.
There is a gastroenterologist in England who is so good at manipulating the
esophagogastroduodenoscope that he can actually go through the sphincter of Oddi, into the common
bile duct, then into the cystic duct and into the gallbladder to remove stones! Unfortunately, this is more
a feat of showmanship than practical application, because gallstones always come back if you do
nothing but simply remove them.
Polypectomies (the surgical removal of outgrowths) are frequently performed to remove polyps in
the stomach and colon. A wire snare is connected to an electrosurgical unit, placed through the
endoscope, and the polyp is removed and the bleeding base coagulated. Polyps are a common
occurrence and may or may not be malignant. President Reagan underwent such a procedure for colon
polyps a few years ago.
Endoscopes are leading the way to early diagnosis and treatment of malignancies. Directed laser
beams can be used through the endoscope for palliative surgery such as burning a hole through a
malignant tumor in the esophagus to allow a patient to swallow. Malignancies of the stomach and colon
are diagnosed much earlier, thanks to endoscopes, and are increasing our chances for curing neoplasms
of the entire Gl tract.
Other Advances
Although the use of flexible fiberoptic endoscopes dominates modern gastroenterology practice,
other diagnostic modes are also utilized. It may come as a surprise that the value of traditional contrast
media studies (upper Gl series, air-contrast barium enema) rests entirely with the radiologist. It takes a
dedicated, interested radiologist to produce a diagnostic exam.
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I had the good fortune to work with one of the finest radiologists in the country. He once spent a
great deal of time doing a Gastrografin enema on a patient of mine, massaging and filling the small
bowel for a retrograde study. The radiologist was able to diagnose an intussusception of the distal small
bowel, a feat which I have never seen before or since. His diagnosis was absolutely correct, as I proved
that evening in surgery. Most radiologists would have missed this diagnosis.
Ultrasound (visualizing internal body structures by recording the reflections of ultrasonic waves) is
useful in diagnosing biliary tract disease and pancreatic disease. Nuclear studies such as the DISIDA
scan are helpful in identifying biliary tract involvement. There is also a nuclear scan that localizes
gastrointestinal bleeding sites. Computerized tomography (CT) scans can help diagnose pancreatic and
liver masses. Magnetic resonance imaging (MRI) studies are yet to be of much help in evaluating the
gastrointestinal tract, although arteriography is of great help in localizing bleeding sites, and even
therapeutically stopping a bleeding vessel by plugging (embolizing) the vessel with small debris, such
as Gelfoam.
The use of mechanical bowel preparations and preoperative and perioperative antibiotics has
markedly decreased postoperative wound infections and leaks. However, there is no substitute for good
surgical technique. The gastrointestinal contents should never be allowed to spill into the wound or
abdominal cavity. Gloves and instruments should be changed immediately upon completing a
gastrointestinal anastomosis (sewing two ends together) and proceeding with closure of the surgical
wound.
The advent of surgical staplers, originally introduced in Russia, has made gastrointestinal surgery
safer, quicker, and more fun to do. Resections of various parts of the GI tract used to take two to three
hours; now a resection can be accomplished in 30 to 45 minutes in most cases.
The Esophagus
The esophagus is the vital structure that carries swallowed foods and liquids from the mouth to the
stomach. It extends from the pharynx to the stomach and is approximately 9-10 inches in length. The
gastroenterologist frequently encounters patients with esophageal complaints.
Carcinoma. Carcinoma of the esophagus is a dreaded diagnosis because it carries a poor prognosis;
however, with early diagnosis and more radical treatment, survival rates have improved. The entire
esophagus can be removed with reestablishment of continuity by bringing the stomach all the way up
into the neck for reanastomosis, or by using a segment of either the right or the left colon to anastomose
to the cervical esophagus and residual stomach.
Bleeding esophageal varices. Esophageal varices (varicose veins in the esophagus) are most
frequently encountered in patients with cirrhosis of the liver, and they can bleed profusely. It used to be
one of the most frightening events I had to encounter because the condition was difficult to control and
many patients ultimately bled to death.
Before the development of sclerosing injection procedures, treatment for bleeding esophageal
varices was complicated and often ineffective. A tube containing two balloons was passed through the
nose, down into the stomach. The first balloon was inflated in the stomach and pulled up rather snugly
against the esophagogastric junction. The second balloon, shaped like a sausage, was blown up in the
esophagus itself to tamponade the bleeding varices. The tube was held in place under tension by placing
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a football helmet on the patient’s head and taping the tube to the helmet facemask. It looked very
painful, and it was.
When the balloon procedure failed, as it often did, major surgery was required. An emergency
splenorenal or portacaval shunt had to be undertaken. This is a procedure whereby the blood flow from
the liver is diverted to the renal vein or the inferior vena cave, because the liver is so scarred that blood
cannot flow back through it. This was a formidable procedure associated with massive blood loss and a
relatively high mortality rate. Even when patients survived surgery and bleeding was stopped, many
developed central nervous system problems due to high levels of ammonia in their blood and often died
from liver failure.
Zenker’s diverticulum. A rather dramatic, albeit infrequent, surgical procedure is excision of
Zenker’s diverticulum of the cervical esophagus. A Zenker’s diverticulum occurs when a patient has a
weakness in the cricopharyngeus muscle of the posterior wall of the esophagus, through which some of
the lining of the esophagus herniates and becomes a diverticulum. It can become large and filled with
food, causing dysphagia (difficulty swallowing). Diverticula are easily excised through a neck incision
along the anterior border of the sternocleidomastoid muscle.
The Stomach
The main function of the stomach, of course, is to act as an organ of digestion. The stomach lies
below the esophagus and diaphragm, partly under the liver and spleen. It has a fundus, or round part; a
body, or middle portion; and a small end, or pyloric portion.
The stomach has two openings. The upper opening, called the upper (cardiac) orifice, opens into the
esophagus, and the lower (pyloric) orifice opens into the duodenum. The duodenum is the first part of
the small intestine and connects with the pylorus of the stomach.
Ulcer disease. An ulcer is simply an open sore of the mucous membrane. “Stomach ulcers” can be
either gastric or duodenal. Prior to the introduction of endoscopes and H2 antagonists (medications that
block the production of gastric acid secretions), surgery was frequently carried out to treat gastric and
duodenal ulcers. Because peptic ulcers are usually the result of overactive stomach secretions, treatment
often included a radical subtotal gastrectomy—excision of 75-80 percent of the distal stomach to
remove acid-bearing cells.
In the mid to late 1950s, it was shown through animal experimentation that hyperacidity of the
stomach could be markedly reduced by simply cutting the two vagus nerves that go from the brain to
the stomach. This procedure is called a vagotomy. Unfortunately, when vagus nerves are cut, the
sphincter muscle at the end of the stomach becomes paralyzed and the stomach will not empty.
To counteract this problem, a surgical procedure to cause the stomach to empty was devised. It was
discovered that when the pyloric sphincter is deliberately divided lengthwise and closed transversely,
the stomach will empty. This procedure is called a pyloroplasty. Some surgeons preferred to do a
gastrojejunostomy, in which the stomach is sewn to the jejunum (the second portion of the small
bowel).
These procedures were the mainstay treatment for peptic ulcers until the advent of Tagamet and
Zantac. These two drugs are H2 antagonists and work by halting the production of excess acid by the
parietal cells of the stomach. These, along with a third drug, Pepcid, have dramatically decreased the
incidence of surgery in peptic ulcer disease.
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With the use of H2 antagonists and management by the gastroenterologist, most ulcers will heal.
The only reason we still operate on peptic ulcers is for perforation, obstruction due to scarring, and
massive, uncontrollable hemorrhage that does not respond to heat probe or injection of epinephrine or
adrenalin into the ulcer base.
Pyloric stenosis. Pyloric stenosis—severe narrowing of the lower stomach—occurs in newborns,
most often the firstborn male. Symptoms occur around the fourth or fifth week of life and include
projectile vomiting and an olive-sized mass in the right upper quadrant of the abdomen. Although
surgical correction of the condition is imperative, the surgery itself is rather simple. The pyloric
sphincter muscle is cut right down to the mucosa of the lumen of the stomach, thus effectively
correcting the stenosis.
Carcinoma of the stomach. For a time, cancer of the stomach seemed to be decreasing in
frequency in the United States, although it continued to have a high incidence in Japan. Cancer of the
stomach is difficult to cure because it is usually far advanced before symptoms develop. With the use of
the endoscope and early detection, however, cure rates are increasing.
Gastric stapling. Obesity is a health problem that plagues many Americans, and several surgical
procedures have been developed to help the morbidly obese control their weight.
Fifteen or twenty years ago a procedure called a jejunoileal bypass was in vogue. The proximal
jejunum was deliberately anastomosed to the distal ileum, thereby allowing food to bypass most of the
small bowel, where it is normally absorbed. Unfortunately this procedure was fraught with
complications. Patients were left with chronic diarrhea, malnutrition, and frequently developed liver
damage. One of my patients described it thus: “I’m so busy going to the bathroom with diarrhea that I
don't have time to eat.”
The latest surgical therapy for morbid obesity is gastric stapling. In this procedure the stomach is
stapled so that it will hold only 2 or 3 ounces of food at a time, with a very small opening for food to
empty into the rest of the intestinal tract.
I do not like obesity surgery. It has been my experience that obesity is due to two factors, generally
speaking: It is often genetic in nature, and that cannot be changed. Emotional problems contribute to
obesity, and surgery cannot help.
While I did do obesity surgery for several years, I found that most patients found a way to get
around whatever obstacle I created for them. One patient simply stayed awake and ate tiny amounts
continuously, almost 24 hours a day. The happiest day of my surgical life was when my malpractice
insurance carrier refused to insure me for obesity surgery.
The Gallbladder
The gallbladder is a pear-shaped sac on the undersurface of the right lobe of the liver. It is
approximately 3-4 inches long and 1 inch in greatest diameter. The gallbladder’s function is to hold bile
from the liver until discharged through the cystic duct, and it can hold about 1-1/2 pints of bile. The
gallbladder concentrates bile by removing the water content.
In the past, gallstones were traditionally classified according to their composition, and this
information was then used to demonstrate the cause of the stone formation. Today this is no longer
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considered valid. Gallstone formation is believed to be due to an abnormality in the wall of the
gallbladder itself.
Surgery on the gallbladder continues to be the most common operation that I do on the
gastrointestinal tract. Many years ago, prior to the advent of modern anesthesia techniques, surgeons
often opened the gallbladder and removed only the stones. In this way it was discovered that stones
rapidly reform, and this method of treatment has been totally abandoned.
There is an ongoing effort by many medical centers to develop a drug that can be taken by mouth
that will dissolve gallstones. To date, the three drugs in use are successful in only 35 percent of cases.
These medications must be taken over the course of a lifetime, because as soon as the drugs are
discontinued, the stones reform. Additionally, these drugs are toxic and may cause severe injury to the
liver.
With the discovery of lithotripsy to break up kidney stones, whereby ultrasonic waves are used to
crush stones so that they may be easily removed, it was thought that lithotripsy could be used to break
up gallstones as well. However, the same limitations pertain to this technique as to gallbladder drugs:
simple removal of the stones is not curative in nature. Gallstones always reform.
The only way to cure gallstones is to remove the gallbladder totally and permanently. However,
ultrasonography and lithotripsy can be successfully utilized in locating and removing stones in the
common bile duct in patients who have already had a cholecystectomy.
Hiatus Hernia
A surgery that has come a long way in the last 15 years is surgical repair of an esophageal hiatus
hernia. This condition occurs when a part of the stomach protrudes up into the chest through the
diaphragm. Gastric juices are then free to reflux up into the esophagus, most frequently at night when
the patient is lying flat.
The esophagus is lined with squamous epithelial cells and is easily burned with stomach acid, while
the stomach is lined with columnar epithelial cells which are meant to be in contact with stomach acid.
The patient may experience heartburn, sour eructation, or water brash. Although a physician can
prescribe antacids and H2 blocker drugs, the treatment is symptomatic and the condition is never
corrected.
Before the early 1970s, repair of an esophageal hiatus hernia was a difficult surgical procedure. It
was often done through a left chest approach, many times failed, and often the patients had more pain
from the thoracotomy incision than from the hiatus hernia.
Dr. Lucius Hill from the University of Washington in Seattle devised a method of hiatal hernia
repair through the abdomen that has totally changed surgical treatment of this condition. Dr. Hill
noticed that the preaortic arcuate ligament just above the celiac axis runs transversely across the upper
abdominal aorta, and is extremely strong. By placing sutures in this ligament and then suturing them to
the esophagophrenic ligament on the lesser curvature of the stomach, he found that one could fix the
esophagogastric junction below the diaphragm and recreate the acute angle of His between the
esophagus and the fundus of the stomach.
Dr. Nissen of Sweden also devised an antireflux procedure. The fundus of the stomach, which is
rather floppy, is wrapped around the lower end of the intra-abdominal esophagus. The posterior wall of
the fundus is sutured to the anterior wall of the fundus around the esophagus, thus forming a muscular
tunnel. The result is a sphincter-like effect which prevents gastroesophageal reflux.
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Patients treated with either the Nissen fundoplasty or the Hill esophageal hiatus hernia repair
(usually with a modified Nissen fundoplasty) obtain excellent results and are generally symptom-free
for the rest of their lives. These are relatively easy procedures, taking only 30-45 minutes to perform,
with only 4 or 5 days of hospitalization required.
The Pancreas
The pancreas plays an important role in the digestion of food, and secretes the vital hormones,
insulin and glucagon. It is situated behind the stomach and consists of a head (attached to the
duodenum), a tail (reaching to the spleen), and a body (the portion between the head and the tail).
Cancer of the pancreas remains an extremely difficult problem and has a very high mortality rate.
Probably less than 5 percent of all people with cancer of the pancreas are ever cured.
Several decades ago, Dr. Allen O. Whipple of Johns Hopkins University devised an extremely
radical operative procedure for cancer of the pancreas. The Whipple procedure entails surgically
removing the entire duodenum, distal end of the stomach, distal end of the common bile duct, and most
of the pancreas, then reconstructing the gastrointestinal tract by anastomosing the proximal residual
stomach, bile duct, and tail of pancreas to the small bowel. This formidable procedure has many
complications, including pancreatic cutaneous fistulas. Despite this extremely radical surgery, the cure
rate remains extremely low.
In recent years I have tried to avoid the complication of a pancreatic fistula by simply performing a
total pancreatectomy. Doing so, of course, makes the patient diabetic and thus insulindependent.
Fortunately, most patients with a total pancreatectomy require relatively small doses of insulin, usually
in the range of 35-50 units per day.
As with other cancers, the pancreatic carcinoma cure rate could be improved if the diagnosis could
be made earlier. Unfortunately, symptoms do not usually present until the disease is far advanced.
Additionally, the pancreas is closely associated with other important structures, such as the portal vein,
so that wide radical excision is usually impossible. Famous radio/TV performer Jack Benny died from
pancreatic carcinoma.
The Small Intestine (Small Bowel)
The small intestine begins with the duodenum and is approximately 25 feet in length. The
duodenum receives the food mass from the stomach through the pylorus, the bile from the liver and
gallbladder, and the pancreatic juice from the pancreas. It connects with the jejunum at its distal end.
Small bowel obstruction. The small bowel is loosely attached by its mesentery, a broad band of
connective tissue containing its blood supply, and is free to move a considerable amount within the
abdominal cavity.
I like to think of it as a flimsy garden hose. As you know, when you kink a garden hose acutely, it
obstructs. The small bowel does the same. If for any reason the small bowel adheres to either the
abdominal wall or to another loop of small bowel and causes it to kink or bend, you have a small bowel
obstruction.
A small bowel obstruction is very rare in a virginal abdomen, that is, an abdomen that has never had
any type of invasive surgery. In fact, I have seen only 4 or 5 patients in 30 years who had congenital
adhesive bands that caused a small bowel obstruction without any history of previous abdominal
surgery.
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A very infrequent but interesting small bowel obstruction—one that I have seen perhaps ten times—
is when a gallstone becomes impacted in the distal small bowel. This is called a gallstone ileus and
results from neglected gallbladder disease. The gallbladder, containing stones, becomes inflamed and
adheres to the adjacent duodenum. A stone erodes through the wall of the gallbladder into the
duodenum, then passes downward and obstructs in the distal ileum, where the diameter of the bowel is
smaller.
I suspect this condition when a patient has an obvious small bowel obstruction but denies previous
surgery and has no incarcerated hernia or other etiologic factor. Air may be seen in the bile ducts on flat
and erect abdominal x-rays, which indicates an abnormal communication between the lumen of the bile
and the biliary tree.
The treatment, of course, is surgical. The impacted stone is milked away from the point where it is
stuck because there will always be a resulting ulcer where the stone was impacted. Once the stone is
mobilized, an opening in the small bowel is made and the stone is removed. The idea is to simply
relieve the small bowel obstruction and not try to correct the abnormal fistulous opening between the
gallbladder and duodenum at that time. The patient is usually elderly, very sick, and the chances of
infection are markedly increased. Once the patient has recovered from the first surgery, the diseased
gallbladder and hole in the duodenum can be repaired in a separate operation.
Crohn disease. Crohn disease, also known as regional ileitis, is an inflammation of the distal small
bowel. There is no known cause, and often it can lead to strictures of the distal small bowel or actual
perforation and fistula formation between loops of small bowel, or even fistulas into the bladder or
colon. President Dwight D. Eisenhower suffered from regional ileitis.
In the absence of complications, Crohn disease is usually treated medically by the gastroenterologist
with antibiotics and steroids. If obstruction and/or fistulas occur, the area involved is surgically excised.
Unfortunately, this disease frequently recurs, whether surgically treated or not.
Small bowel cancer. Adenocarcinoma of the small bowel is very rare. In 30 years of private
practice and over 16,000 major surgeries, I have seen perhaps half a dozen primary adenocarcinomas of
the small intestine.
Lymphoma, a malignancy of a different type, is not uncommon in the small bowel. Lymphoma in
the GI tract, usually in the stomach or small bowel, is highly amenable to three modalities of treatment:
surgical excision, radiation therapy, and chemotherapy.
Artificial bladder. A remarkable surgery that can be performed on the small bowel is the creation
of an artificial bladder for patients who have had their own urinary bladders removed. The patient’s own
ureters are implanted into an isolated segment of the distal ileum, and the distal ileal segment is then
brought out to the surface of the abdomen to function as an ileostomy.
The Large Intestine (Colon) The large intestine begins with the ileum and extends to the anus and
is about 59 inches in total length. It consists of the cecum and vermiform appendix, colon, and rectum.
The first portion of the ascending colon extends from the cecum to the undersurface of the liver,
where it turns to the left and becomes the transverse colon. That bend is known as the hepatic flexure.
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The transverse colon passes horizontally to the left near the region of the spleen, where it turns
downward as the descending colon. This turn is known as the splenic flexure.
The descending colon continues downward on the left side of the abdomen until it reaches the
pelvic brim and becomes the sigmoid colon, which leads into the rectum. This portion is 4-5 inches long
and passes downward, terminating at the anal opening.
Appendicitis. Appendicitis is probably the best known colon disease. The appendix is a
rudimentary appendage coming off the cecum. It is located in the first part of the large intestine.
Appendicitis is thought by many to be a very simple disease, but there are still patients worldwide who
die each year from complications of appendicitis.
Appendicitis was first described by Sir Reginald Fitz, a pathologist who lived in the 19th century.
Subsequently, Dr. Charles McBurney became famous for describing the physical findings associated
with appendicitis, including point tenderness over a specific area two-thirds of the way from the navel
(umbilicus) to the right anterior hip bone (iliac crest).
To be diagnosed as having appendicitis, patients must meet at least two of the following three
criteria: anorexia (loss of appetite), point tenderness over McBurney point, and pain high on the right on
rectal exam. The patient’s white blood count is generally elevated, but it may not be. The temperature
rarely goes above 100º in the first 24 hours. I personally do not believe there is such a thing as recurrent
attacks of appendicitis; you either have it or you don't.
Appendicitis generally does not perforate in less than 24 hours from the onset of symptoms. After
the initial 24-hour period the patient will likely develop gangrene and/or perforation of the appendix
into the free peritoneal cavity, which is known as generalized peritonitis, or wall off into an abscess,
which is called an appendiceal abscess.
The appendectomy is a simple procedure in most cases; however, it can be an extremely difficult
procedure if there has been perforation and abscess formation.
Colonic bleeding. Bleeding from the large intestine can be from many sources, including growths,
cancer, polyps, AV (arteriovenous) malformations, and a colon condition known as telangiectasis, in
which the capillaries in the wall of the colon become thinned out and start to bleed. Bleeding can also
result from diverticular disease hemorrhoids, anal fissures, and ulcers.
Colonic bleeding will generally cease with conservative medical therapy, but it often recurs, leading
eventually to definitive surgery. Colon polyps can often be removed by means of the colonoscope or
sigmoidoscope; however, if a polyp is broad-based or sessile in nature, it is dangerous to attempt to
remove it using the scope because the bowel wall may perforate.
Ulcerative colitis. Ulcerative colitis is another inflammatory process whereby the mucosa of the
colon develops ulcerations. It primarily involves the large intestine, and it can be devastating. Ulcerative
colitis can sometimes perforate, leading to peritonitis. Its cause is still unknown, but it frequently
develops in the 3rd or 4th decade of life. Ulcerative colitis frequently disposes a patient to cancer of the
colon. In severe cases of ulcerative colitis, surgical removal of the entire colon with a permanent
colostomy is the only treatment.
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Colostomy/ileostomy. A colostomy is the surgical creation of an opening between the bowel and
the surface of the body. It is performed when it is impossible for feces to pass through the colon and out
the anus. The patient wears a bag or pouch over the colostomy opening to contain the feces.
Having to undergo a colostomy is always a disturbing emotional experience. Sometimes
colostomies are temporary in nature and can be closed electively once an infection has subsided or a
fistula has healed. But many colostomies are permanent, such as in patients who have cancers of the
anorectum below 8-10 cm from the anal verge.
Technical advances in colostomy irrigation systems, disposable colostomy bags, and new adhesives
are making colostomy care easier today. In the past, patients were given a reusable bag to hold the
feces. The bags were odoriferous, they leaked, irritated the skin, and in general, people were miserable.
Today a colostomy doesn't have to interfere with a person’s regular activities. The modern-day
colostomy patient, properly instructed, is unidentifiable in the general public.
In the last 15 years or so, primarily through the work of surgeons at the Mayo Clinic, continent
small bowel pouches have been devised where an ileostomy can be emptied at the will of the patient
rather than draining continuously. Surgeons have also devised new methods of creating pouches which
can be anastomosed to the anal canal, thus maintaining bowel continuity and continence.
Hemorrhoids. Simply stated, hemorrhoids are varicose veins of the rectum, and they affect a large
percentage of the general adult population. Hemorrhoid surgery sounds simple, but it is not always. The
surgeon must take care not to injure the anal sphincter which could result in fecal incontinence.
Fistula. A fistula is an abnormal opening between two internal structures. Fistulas of the rectal
canal are bothersome and are difficult to manage. Fistulas between the colon and bladder result in the
sensation of passing air through the urethra, usually a consequence of diverticular disease. Women
occasionally develop fistulae between the rectum and vagina. These are difficult management problems
and sometimes require diverting colostomies to completely divert the fecal stream while the fistula is
repaired, followed by closure of the colostomy.
Diverticular disease. A diverticulum is a protruding pouch in the wall of the colon, a condition
known as diverticulosis. Diverticulosis is often not symptomatic. Occasionally, diverticula become
inflamed (a condition known as diverticulitis) and may require surgery if they bleed massively or
repeatedly, when they perforate and form localized abscesses, or when they perforate into the free
peritoneal cavity and cause acute generalized peritonitis. Occasionally they lead to stenosis or stricture
of the colon and require surgical resection. The world of gastroenterology is a fascinating one. I
particularly enjoy being a gastrointestinal surgeon. It’s like Christmas every day—I open a new package
and I never know for sure what I am going to find!
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