Colon and Rectal Surgery

Tufts Medical Center is dedicated to providing our patients and their families with great services and experiences. The surgeons and staff within the Division of Colon and Rectal Surgery value the importance of getting to know you and your needs so that we can determine the best possible treatment plan.

For information about a diagnosis and how our experienced surgical team typically treats specific colon and rectal disorders, please use the resources posted here.

If you or a family member would like to speak with a member of our staff to learn more about our services or to make an appointment, please call 617-636-6190.

Directions:

We want to make sure your visit with us is as easy as possible. To find the best way to get to our offices, view the Medical Center campus maps. 

Once you get here, stop by the information desk and tell them who your appointment is with. They will be able to direct you to the right building and floor. The majority of our clinic visits are conducted on South 4.

What is an abscess?

The anal canal is lined with glands that secrete mucous and other fluids to lubricate the canal and the stool as it passes. Bacteria normally live in these glands. Sometimes the duct that leads to a gland becomes clogged. Then the multiplying bacteria cannot escape which leads to an infection. As the bacteria build up, the body tries to contain the infection by walling it off. This creates a pus-filled cavity — the abscess.

Side effects of an abscess

Pain, swelling, and a soft or firm lump may be felt. Patients may also have a fever or chills. The abscess may spontaneously drain pus or a bloody discharge which may be seen on the underwear or on the toilet paper. 

How is an abscess treated?

The primary treatment of an abscess is adequate drainage. If an abscess does not drain on its own, it should be drained either in the office with local anesthetic or in the operating room using a regional or general anesthetic. As soon as an abscess is recognized, it should be drained. After the procedure, patients should follow the After Anal and Rectal Surgery Instructions carefully for best healing. One half of abscesses will resolve after drainage and one half will recur, either as an abscess or as a fistula.

What is a fistula?

A fistula starts with an abscess. Over time the process burrows a tunnel from the abscess to the skin outside the anus. A fistula may also develop after surgical drainage. A fistula persists if there is an opening inside the anus (where the original duct was located). This internal opening is often closed or scarred over at the onset of the abscess but may reopen as the pressure builds up. A fistula, therefore, is a connection or tunnel between an internal opening in the anal canal and an external opening on the skin. Occasionally, the fistula may run up along the rectum rather than down to the skin. 

Fistulas usually do not heal on their own. Patients with fistulas may have continuous or intermittent drainage, or may suffer cycles of skin healing, buildup of the abscess and subsequent drainage. The fistula tract may run very superficially just beneath the skin, or through or over the anal sphincter muscles. The path of the fistula in relation to the anal sphincter muscles determines the treatment approach.

How is a fistula treated?

Fistulas may be divided into low, mid and high tracts depending on how much of the anal sphincter muscles lie between the tract and the skin. The anal sphincters surround the anal canal like 2 cylinders or donuts. When they contract they close the anal canal and provide control (continence). The internal anal sphincter is smooth or involuntary muscle and it keeps the anal canal closed at rest. The external sphincter is striated or voluntary; it allows you to close the canal by squeezing. Together, they guard against leakage or incontinence.

Low Fistulas

A low fistula crosses from the anal canal to the skin below the muscles or through the lower one third of the sphincter muscles. If the fistula does not involve much sphincter muscle, a simple procedure called a primary fistulotomy is done either in the office with local anesthesia or in the operating room. A primary fistulotomy is performed by placing a thin metal probe in the tract and dividing the tissue from the skin to the tract. This includes skin, fat and, possibly, some anal sphincter muscle. The edges may be trimmed, and the wound is left open to heal from the bottom up. It is very important to keep the wound clean and pack it with gauze so that the skin does not heal over and create another cavity. Healing generally takes from 3 to 12 weeks.

Mid level fistulas

A mid level fistula tract runs through the middle one third of the sphincter muscles. Performing a primary fistulotomy for these fistulas carries a higher risk of incontinence because of the greater amount of sphincter muscle that must be cut. Therefore, a staged fistulotomy is usually performed. In the first stage, the area is examined in the operating roon while you are anesthetized. The exact course of the fistula is determined and then the procedure to be performed is chosen. In the first stage of a staged fistulotomy, the tract is probed, the skin and fat are divided but the muscles are left intact. A circular drain called a seton is placed from the external opening, through the tract and internal opening and brought out of the anal canal. It is then tied to itself as a loop. A seton is usually made from a soft, flexible, Silastic strand similar to a floppy rubberband and is tied with with a black silk suture. The seton allows the fistula and any associated cavity to drain and to contract down. It also keeps the tract and external site open so that a new abscess is much less likely to develop. Over time, the tissue within the seton scars down and thins, and the seton becomes looser. The tissues outside of the seton also contract and fill in up to the seton. When this process is well along, it is time for the second stage fistulotomy. During this procedure the remaining tissue within the seton is divided and the wound is cleaned. Just as in the primary fistulotomy, the wound is then left open to heal secondarily. The second stage may often be performed in the office with local anesthetic. It usually takes about 5-10 minutes. It is very important to keep the wound clean and pack it with gauze so that the skin does not heal over and create another cavity. Healing generally takes from 3 to 12 weeks.

High fistulas

High fistulas are the most difficult to treat since much or all of the sphincter mechanism may be below the fistula tract. This group also includes complex fistulas with multiple tracts or recurrences. Fortunately, these are the least common fistulas. A first stage procedure is often performed for further abscess drainage and delineation of the anatomy. One or more setons may be placed and cavities and tracts are cleaned out (curetted).

 

What are the risks of fistula treatment?

The main risks associated with the treatment of fistulas are incontinence, recurrence of the abscess or fistula, and bleeding. Not treating an abscess or fistula may lead to more extensive destruction of the surrounding tissues including the anal sphincter muscles and eventual incontinence in addition to chronic pain and discharge. Patients with certain risk factors may be treated somewhat differently. These include individuals with diabetes, inflammatory bowel disease, AIDS and other reasons for immunosuppresion such as medications used after transplantation. It may not be possible to know which of these procedures is most appropriate prior to surgery and examination under anesthesia. At that time the actual course of the fistula may be determined along with the amount of sphincter beneath the tract. The exact procedure to be performed is then chosen based on the more accurate information obtained.

This surgery will require you to prepare for the operation at home. Please follow these instructions as closely as possible since poor preparation may mean canceling the procedure or an increased risk of complications. 

Diet

Pre-Surgery-

• Do not eat or drink anything with in 8 hours of surgery
• If your surgery is in the morning, do not drink or eat after 10pm the night before
• If your surgery is later in the day, you may drink clear liquids up to 8 hours before you arrive

One Day Prior-

• A clear liquid diet should be followed
• You are allowed to drink: apple juice, grape juice, tea, coffee, Seven-up, ginger ale, Gatorade, Popsicles and water
• Drink all three meals and continue to drink between meals
• If you are feeling constipated, use this diet two days prior to surgery

* If you are taking daily medications, ask your physician which medications you can take with a sip of water.

Medications

• If you take daily medications, ask your physician whether or not you should take them before surgery
• For 10 days before your surgery, unless told otherwise, you should not take:
  -Asprin
  -Dipyridamole (Persantine)
  -ibuprofen (Advil, Motrin, etc.)
  -Plavix
  -Alleve
  -or other non-steroidal anti-inflammatory medications.
• If you are diabetic, do not take any insulin or oral diabetes medications the day of your surgery. The day before surgery, take one half of your normal dose.

Bowel Preparation

Pre-Surgery

• At your pharmacy purchase:
  -4 Dulcolax laxative tablets
  -1 Fleet (Phosphosoda) enema

One Day Prior

• At 6pm on the evening prior to surgery, take all 4 Dulcolax tablets. You should expect to get diarrhea which will clear your bowels of its contents.

Morning of Surgery

• One to two hours before leaving for surgery, administer the Fleet enema.
  - Lie on your left side with your left leg straight and your right left drawn up
  - Remove the enema from the box and remove the green cap
  - Insert the lubricated tip of the bottle gently into your anus all the way to the bottom of the slender tip
  - Squeeze out the contents of the bottle
  - Remove the cap from the bottle
  - Refill it with luke warm tap water
  - Administer the water the same way as the enema
  - Retain the enema fluid for as long as you can up to 5 minutes
  - Expel enema fluid into the toilet

Arrival

Clinic

• If your appointment is for the 4th floor surgery clinic, please arrive 30 minutes before your scheduled time

Operating Room

• If your procedure is to be performed in Outpatient Surgery, please arrivate one hour and 30 minutes before your appointment.  We ask you to arrive this early because some procedures take less time than others and we may be able to perform your procedure earlier than we originally schedule if you are early.

After Surgery

Anesthesia

• If general or regional anestesia is used, you will be monitored in the recovery room for 1 to 2 hours after your surgery.
• A responsible adult will be asked to accompany you home
• You should not drive or operate machinery for the remainder of the day

 

Regular bowel function includes the easypassage of bowel movements and avoidingconstipation and diarrhea. Following the suggestions in this brochure will improve bowel habits in the large majority of individuals.

A major cause of poor bowel function is a Western type of diet with low fiber and roughage intake and a higher fat content. The colon’s major function is to absorb water and change the liquid stool that enters from the small intestine into a solid stool that is passed out. The colon is very efficient at removing fluid from the bowel contents and will actually remove 9 parts out of 10 as water and electrolytes. If too much water is removed, then the stools become small and hard and are difficult to pass. If not enough
water is removed, stools may be loose and diarrheal. Dietary fiber and fiber supplements or bulking agents function by absorbing water and holding it in the stools, much in the same way as a sponge soaks up water. Therefore, the stools remain moist and soft, instead of becoming dried out as they pass through the colon. Fiber is also good for diarrhea or loose stools because it soaks up the extra water and keeps the stools in a more solid form. Thus, a diet high in fiber is good for both diarrhea and constipation.

High Fiber Diet

A high fiber diet is recommended on a routine basis. You should attempt to include fiber-rich foods in your
daily intake. These include a wide variety of foods. The best source of fiber is wheat bran, although oat, rye and other cereals are also good sources. Bran comes from the outer husk of the grain kernel, whereas the germ is from the core. Thus, the product, “wheat germ,” does not contain bran. White flour and wheat germ have had the bran milled away. Bran cereal, whole wheat breads and miller’s bran are good sources of fiber. A bowl of bran cereal that has 5 to 7 grams of dietary fiber per serving along with a glass of milk and/or juice is a good way to start the day. Each product has the amount of dietary fiber and the number of calories per serving printed on the side of the box. Alternatives include a bran muffin or mixing 2 or 3 tablespoons of miller’s bran in hot cereal. Another information sheet describes the contents of a high fiber diet in greater detail. No one knows exactly how much fiber is enough; however, 25 to 30 grams per day is recommended.

Fiber Supplements

Fiber supplements or bulking agents function in the same way as dietary fiber and bran. They are taken by mouth once or twice a day and are not absorbed. Most of these products contain psyllium which is a seed product. There are also several forms of hydrophilic colloids which also absorb water. Many pharmacies and grocery stores have their own generic brands which are often much less expensive than the name brands. They may come as powders, tablets, or wafers. Some examples are Konsyl, Metamucil, Citrucel, Benefiber and Fibercon.

Powder form
Mix one tablespoon or one pre-measured package in a
glass of water or juice and drink. One wafer is equal to
one tablespoon of the powder.

• each morning
• each morning and each evening

Tablet form
Swallow 4 to 6 tablets with 1–2 large glasses of liquid.

• each morning
• each morning and each evening

Fluids

Since the major function of fiber is to hold fluid in the stool, it is important to take enough water and
other liquids during the day. Like a sponge, fiber will become hard and stiff if it dries out and does not have enough water in it. At least 6 to 8 glasses of water and other liquids should be taken each day.

Stool Softeners

These agents act to lubricate the stools and allow them to pass more easily. They act by increasing the
amount of water in the bowel and thereby softening the stools.Docusate is one of the most commonly used agents in a bowel management program. Several forms are available including Colace (100 mg tablet), which contains sodium (Na) and Surfak which contains calcium (Ca). Generic docusate is available at low cost. These compounds are available without a prescription in any pharmacy or supermarket.

• Docusate Na (eg. Colace)
• Docusate Ca (eg. Surfak)
• Take 2 tablets each day — one in the morning and
  one in the evening.
• Take 4 tablets each day — two in the morning and
  two in the evening.

Polyethylene glycol (PEG) is another common form of stool softener. It comes as a powder which is mixed
with fluid. Miralax is the common brand name, however several generic forms are now available. Mix 17 grams of powder (one capful or one premeasured packet or one heaping tablespoon) in a glass of water, juice, lemonade, tea, etc, and drink.

• Once a day in the morning
• Twice a day — once in the morning and one once
  in the evening

Bowel Movements

1. Regular bowel actions are encouraged; however, it is not necessary to have a movement every single
day. Normal habits range from three movements per day to one movement every three days. Many
individuals will have a daily movement in the morning, but it is not necessary to strive for this. However, it is best to avoid deferring movements. When you feel the urge, respond promptly.

2. Avoid straining and prolonged periods on the toilet. Three to five minutes are usually enough to
pass a soft movement.

3. If you experience soreness, bleeding, swelling or anal irritation and itching (pruritus ani), take a
warm bath after each movement (when possible) and two or three times each day for 10 minutes. Do not use oils or salts in the water. Rinse off and pat dry.

4. Do not use creams, ointments or oils around the anus unless prescribed by your doctor.

5. Laxatives and enemas should rarely be used except when specifically advised by your doctor. Prolonged use of laxatives may actually harm the bowel. With this simple approach, most people will develop regular bowel habits. A small percentage of individuals will have persistent problems and may require further evaluation.

Most cancers of the colon and rectum begin as single cells that lose their ability to control their growth and to respect their neighbors. They start in the inner lining or mucosal layer of the bowel wall and usually develop into a poly or overgrowth of glandular mucosal tissue before becoming true cancers. These polyps may be pedunculated (mushroom shaped and on a stalk) or sessile (flatter with a broad base). Removing these polys markedly reduces the risk of developing colorectal cancer.

Staging of Colorectal Cancer

Staging refers to a method of estimating the likelihood of cure after removing the tumor. If a colorectal tumor recurs most will do so within 2 years of surgery and the vast majority do so within 5 years. Thus, outcome is discussed in terms of 5 year survival free of disease. Several factors have proven to be very important in predicting outcome statistics. The most important ones are the depth of penetration of the tumor through the bowel wall and whether there is any spread to the regional lymph nodes or to distinct sites. The appearance of the tumor cells under the microscope also has some significance. Tumors are generally classified as well, moderatly, or poorly differentiated. Well-differentiated tumor cells look more like normal cells and behave less aggressively than poorly differentiated tumors. However, the majority of colorectal cancers are labelled moderately differentiated.  

Spread of Colorectal Cancer

Cancer has two ways of spreading:

​Direct extension: As these tumors grow they may spread directly into the lumen of the bowel, around the circumference of the bowel wall, or most importantly, through the wall layers and eventually into adjacent tissue such as other loops of intestine, the abdominal wall, the bladder, the uterus or any other abdominal structure.

Metastases: Clumps of cells may break off from the primary tumor and float away in either the lymph fluid that baths the cells or in the blood stream. These cells may then implant at a distant site and start to grow. The most common locations for metastases are the lymph notes in the region around the bowel or distant sites such as the liver or the lungs. 

Risks of the Procedure

Infection (abdomen, wouldn, bladder, lungs, etc), bleeding, splenic injury, transfusion, ureter injury, bladder problems, and others. 

​Risks for men: ​impotence (erectile dysfunction, loss of sensation)

​Risks in women: ​vaginal problems (injury, bleeding, narrowing)

​Risks of an ileostomy: ​hernia, prolapse, retraction, skin problems, etc.

Crohn’s disease (CD) belongs to a group of conditions known as inflammatory bowel disease (IBD). The other common inflammatory bowel disease is chronic ulcerative colitis (CUC). There are also other, less common forms of IBD.  

What causes Crohn's Disease? 

It is not clear what causes these diseases, but they are thought to be due to abnormalities in the immune system. Several genes have been found that are associated with Crohn’s disease and family inheritance, however only a small percentage of patients have the currently known genes.

Inflammation with irritation and ulcers develop in the mucosal lining of the intestine. In ulcerative colitis, this process is limited to the colon. However, the inflammation in Crohn’s disease may affect any part of the intestinal tract from the mouth to the anus. Unlike in CUC, there may be more than one area of diseased bowel with sections of normal intestine in between.

The inflammation in Crohn’s disease often involves the entire thickness of bowel wall which may lead to deep ulcers, abscesses and fistulas. Early in the disease, medication may restore the diseased areas to normal, however over time and with recurrent flares segments may be come scarred and narrowed.

What are the common symptoms?

The symptoms of CD are directly related to the location
as well as the nature of the disease. The most common
complaints are:

Abdominal pain and diarrhea (75%)

Weight loss, fever, and bleeding from the rectum
(40–60%)

Abdominal bloating and nausea (20–30%)

Anal abscess/fistula (10–20%)

Extraintestinal manifestations — skin swelling orulcers, eye problems, arthritis

Patients with Crohn’s disease usually have acute flares of their disease followed by periods of remission.

Is all Crohn's Disease the same?

No. Not only can CD affect different parts of the GI tract in different people, there are different patterns of the disease as well. One, two, or all three of these patterns may exist in any patient at different times.

Inflammatory CD: Areas of inflammation develop within the bowel. During a flare, patients typically experience increased localized abdominal pain and have fever and chills.

Fibro-stenotic CD: Tight, narrowed areas, or strictures, develop within the intestine which impede the normal flow of the GI tract. Typical symptoms include crampy abdominal pain, nausea, vomiting, and even bowel obstruction.

Fistulizing CD: Fistulas are abnormal communications between two different segments of intestine,
or other organs (such as the bladder, vagina or skin). Abscesses, bladder or vaginal infections may occur.

 

What treatments are available?

There are no medical or surgical therapies that will cure Crohn’s disease. Medical therapy is aimed at decreasing intestinal inflammation and symptoms. Medications from several difference classes may be used including anti-inflammatories (often related to aspirin), steroids, broad immune system suppressors (6 MP, azathioprine), and focused immunomodulators (anti-TNF agents — Remicade, Humera, Cimzia).

When a patient is symptom free, they are considered to be in remission. Although there is great variation, remissions can last for months to years.

Surgery is primarily used to treat complications of the disease. This includes urgent/emergent complications such as toxic colitis, bowel perforation, severe bleeding, and cancer or pre-cancerous changes.More commonly chronic problems such as strictures and obstruction, malnutrition, weight loss, dependence on steroid medications, and disease that does not adequately respond to medical treatment are addressed with surgery.

What are the types of surgery?

Surgery for CD commonly involves removal (resection) of a diseased segment, drainage of an abscess, or treatment of fistulas. However, the disease may recur in the same location or at a new location over time. Surgery focuses on safely alleviating disease symptoms and restoring quality of life while attempting to conserve as much healthy bowel as possible. The type of surgery that will be recommended depends on the location and the nature of the disease.

For small bowel disease

Resection

Stricturoplasty

For ileocecal disease

Ileocolic resection

For disease of the colon

Segmental colon resection

Total colon resection with ileorectal
anastomosis or ileostomy

Total proctocolectomy with permanent ostomy

Ileostomy or colostomy, temporary or
permanent

For ano-rectal disease

Abscess drainage

Fistula surgery — fistulotomy (primary or
staged), seton, repair

Ileostomy or colostomy, temporary or
permanent

Abdominoperineal resection (APR) with
permanent colostomy

Will I need to resume Crohn's Disease medications after surgery?

Most patients will take medication after surgery to reduce the risk of recurrence. This medication may be different than that taken prior to surgery.

Eat more fiber. You've probably heard it before. But do you know why fiber is so good for your health?

Dietary fiber, found mainly in fruits, vegetables, whole grains and legumes, is probably best known for its ability to prevent or relieve constipation. But fiber can provide other health benefits as well, such as lowering your risk of diabetes and heart disease.

If you need to add more fiber to you diet, don't worry. Increasing the amount you eat each day isn't difficult. FInd out how muchd ietary fiber you need and ways to include more high-fiber foods into your meals and snacks. 

What is dietary fiber?

Dietary fiber, also known as roughage or bulk, includes all parts of plant foods that your body can't digest or absorb. Fiber is classified into two categories: those that don't dissolve in water(insoluable fiber) and thsoe that do (soluble fiber).

​Insoluble fiber

This type of fiber increases the movement of materials through your digestive system and increases stool bulk, so it can be of benefit to those who struggle with constipation or irregular stools. Whole-wheat flour, wheat bran, nuts and many vegetables are good sources of insoluble fiber.

Soluble fiber

This type of fiber dissolves in water to form a gel-like material. It can help lower blood cholesterol and glucose levels. you can find generous quantities of soluble fiber in oats, peas, beans, apples, citrus fruits, carrots, barley and psyllium.

The amount of each type of fiber varies in different plant foods. To receive the greatest health benefit, eat a wide variety of high-fiber foods.

Benefits of bulking up

Unlike other food components such as fats, proteins or carbohydrates, which your body breaks down and absorbs, fiber isn't digested by your body. Therefore, it passes virtually unchanged through your stomach and small intestine into your colon. Dietary fiber increases the weight and size of your stool and softens it. 

A bulky stool is easier to pass, decreasing your chance of constipation. If you have loose, watery stool, fiber may also help to solidify the stool because it absorbs water and adds bulk to the stool. 

A high fiber diet may lower your irsk of specific disorders, such as hemorrhoids, irritable bowel syndrome and the development of small pouches in your colon (diverticular disease). Fiber, particularly soluble fiber, can also lower blood cholesterol levels and slow the absorption of sugar, which for people with diabetes, can help improve blood sugar levels. A high-fiber diet may also reduce the risk of developing diabetes.

Evidence that dietary fiber reduces colorectal cancer is mixed- some studies show benefit, some nothing and even some greater risk. If you are concerned about preventing colorectal cancer, adopt or stick with a colon cancer screening regimen. Regular testing for and removal of colon polyps can prevent colon cancer.

Boosting your fiber intake

How much fiber do you need each day? The National Academy of Sciences' Institute of Medicine recommendations are 25-35 grams for adults up to age 50 and 20-30 grams for adults over age 50. 

If you aren't getting enough fiber each day, you may need to boost your intake. Choose whole-grain products, raw or cooked fruits and vegetables and dried beans and peas. Refined or processed foods, such as fruit juice, white bread and pasta, and non-whole grain cereals are lower in fiber content.

Whole foods rather than fiber supplements are generally better. Fiber supplements, such as Metamucil, Benefiber and FiberCon, don't provide the vitamins, minerals and other beneficial nutrienets that high-fiber foods do. However, some people may still need a fiber supplement if dietary changes arne't sufficient or if they have certain medical conditons, such as irritable bowel syndrome. Check with your doctor if you feel you need to take a fiber supplement.

Tips for fitting in fiber

Ideas for high-fiber meals and snacks:

• Start your day with a high-fiber breakfast cereal- 5 or more grains of fiber per serving. 
• Add crushed baran cereal to baked products such as meatloaf, breads, and muffins. 
• Switch to whole-grain breads. Look for a brand with at least 2 grams of dietary fiber per serving.
• Substitute whole-grain flour for half or all of the white flour when baking bread.
• Take advantage of ready to use vegetables. Mix chopped frozen broccoli into prepared spagetti sauce.
• Eat fruit at every meal. Apples, bananas, oranges, pears and berries are good sources of fiber.
• Make snacks count. Fresh and dried fruit, raw vegetables and low-fat popcorn are all good chocies.

High-fiber diets are good for your health. But adding too much fiber too quickly can cause intestinal gas, abdominal bloating and cramping. Increase fiber in your diet gradually over a period of a few weeks. Fiber works best when it absorbs water. Without the added water, you could become constipated.

Rectal prolapse is a mechanical problem of loss of internal rectal fixation. Although medical treatment can help produce soft regular bowel movements and decrease the stress on the area, only surgical repair can eliminate the problem.

Surgical Options

Surgical repairs are designed to either remove the prolapsed rectum or to fix the rectum up in the pelvis. There are two main surgical approaches- transabdominal (through the abdomen) or perineal (from the bottom).

Abdominal

• Frykman repair- sigmoid colon resection, rectal mobilization and rectopexy
• Rectoplexy alone- suturing the rectum to the sacrum
• Ripstein repair- anchoring the rectum to the sacrum with a piece of permanent mesh

Perineal

• Altmeier proctectomy & levarteroplasty- removing the prolapsed rectum and tightening up the pelvic floor muscles
• DeLorne produced- stripping the mucosal lining of the prolapsed rectum and plicating the rectal wall muscle
• Thiersch loop- tightens anus by wrapping up with an implanted permanent material