Hemorrhoids affect 30-40% of the population in western countries. They are engorged blood vessels of the perianal area covered by bowel lining or skin and are caused by chronic constipation and low-fiber diets. Internal hemorrhoids originate higher up within the rectum above the anatomic landmark of the dentate line, while external hemorrhoids form further down towards the anus, below the dentate line (Picture 1).
Small hemorrhoids can be asymptomatic. Internal hemorrhoids usually cause painless bleeding that is bright red and can be profuse. External hemorrhoids can cause pain and, less frequently, bleeding or itching. Internal and external hemorrhoids can coexist and result in mixed symptoms. Diagnosis
Hemorrhoids are diagnosed on clinical examination that includes proctoscopy. Patients with bleeding may require colonoscopy to exclude colorectal cancer that can also result in bleeding.
All patients with hemorrhoids should increase fiber intake and avoid constipation. This will alleviate acute symptoms and also prevent recurrence after treatment. Various local remedies can occasionally relieve pain but will not cure hemorrhoids themselves and hence have no long-term therapeutic role.
Laser hemorrhoid coagulation
Early-stage internal hemorrhoids that bleed and will not respond to conservative measures can be treated with the use of laser energy to destroy hemorrhoidal feeding blood vessels.
Patients with larger hemorrhoids can be treated using a similar method that involves the insertion of catheters into the hemorrhoid itself, using laser energy to destroy the feeding blood vessel and shrink the hemorrhoid at the same time (Pictures 2 and 3).
Large hemorrhoids are removed surgically with the modified Milligan-Morgan technique using the Harmonic Ace® device that divides tissue in a bloodless fashion and avoids the use of sutures. This technique has the lowest recurrence rate.
Jutabha R, Jensen DM, Chavalitdhamrong D. Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids. Am J Gastroenterol. 2009;104:2057-64.
Giordano P, Overton J, Madeddu F, Zaman S, Gravante G. Transanal hemorrhoidal dearterialization: a systematic review. Dis Colon Rectum. 2009;52:1665-71.
Zampieri N, Castellani R, Andreoli R, Geccherle A. Long-term results and quality of life in patients treated with hemorrhoidectomy using two different techniques: Ligasure versus transanal hemorrhoidal dearterialization. Am J Surg. 2012;204:684-8.
Anal fissure is a painful linear ulcer of the anus, usually at the midline. It is caused by a vicious cycle of constipation and local injury by hard stool, which then leads to pain at defecation and anal sphincter spasm, followed by more severe constipation and so on (Picture 1). Anal fissure can become a chronic condition.
The main symptom is acute and very severe perianal pain at the time of defecation that can last for a few hours after and is occasionally accompanied by minor bleeding.
Diagnosis requires physical examination only.
Treatment is initially non-surgical and aims at (1) relieving constipation using fiber supplements and laxatives and (2) topical preparations that relax the internal anal sphincter. This strategy can be successful in 70-80% of patients when tolerated, the main reason for failure being drug-induced headache that can be severe and affect up to 50% of patients.
Surgical treatment of anal fissure is indicated when the above therapy fails or is not tolerated and involves an outpatient operation under general anesthesia to partially divide the internal anal sphincter (Picture 2).
The fissure itself is not removed and will heal spontaneously within a few weeks. Fiber supplements are continued. Surgical therapy is curative in more than 90% of patients.
Breast cysts (Picture 1) are collections of watery fluid and can affect up to 1 in 14 women, with increasing incidence after the menopause. They can be multiple and vary in size from few millimeters to many centimeters. Size can change during the menstrual cycle. They can appear as a palpable breast lump or be an incidental finding at breast imaging. Breast cancer arising from a cyst is extremely rare and cysts are not a risk factor for developing breast cancer. Cysts large enough to cause symptoms can be aspirated under ultrasound guidance. Surgical removal is only indicated when cyst recur after aspiration or when suspicious cells are found on examination of cyst fluid. Fibroadenomas
Fibroadenomas (Picture 2) are benign tumors usually affecting women under the age of 30 years. The most common and usually sole symptom is a palpable painless lump with well-defined borders. They can enlarge significantly within months. Fibroadenomas are not a risk factor for cancer. Diagnosis is based on physical examination and breast ultrasound findings. Diagnostic uncertainty mandates needle biopsy. Small asymptomatic fibroadenomas do not require surgery while symptomatic ones can be excised surgically. Mastitis and breast abscess
Mastitis is acute breast inflammation that presents with fever, redness, swelling and pain in part of the breast (Picture 3). It usually occurs due to bacteria entering the breast during lactation and is treated with oral antibiotics and pain relief. Despite antibiotic treatment, bacterial mastitis can sometimes lead to abscess formation (Picture 4), which requires drainage. B. Breast cancer Epidemiology and risk factors
Breast cancer is the commonest cancer in women with a prevalence of 1 in 12. Risk factors include family history, starting menstruation at a young age, delayed menopause, hormone replacement therapy, obesity, smoking, radiation exposure and a number of breast conditions (papillomas, atypical hyperplasia). Incidence increases with age.
Breast cancer spreads by local invasion and via lymphatic and blood vessels to lymph nodes, liver, lungs and other organs. It is usually a hormone-dependent tumor, driven by the female sex hormones estrogen and progesterone. Diagnosis
Breast tumors can be diagnosed
(a) before they produce symptoms at screening mammography, which is indicated in women over 45 years of age (American Cancer Society guidelines) (Picture 5).
Screening mammography aims to diagnose breast cancer at an early stage and hence improve the outcome of treatment. Multiple large studies have shown reduce breast cancer-related mortality in women who undergo screening. Suspicious mammography findings are followed by biopsy.
(b) when they become symptomatic, causing a palpable painless breast lump, nipple discharge, skin changes, nipple retraction. Symptoms are followed by imaging studies (mammography, ultrasound) and biopsy if necessary.
(a) Mammography can be used for screening or when symptoms/signs of breast disease develops (diagnostic mammography). A different protocol is used in the latter case. Mammography is less accurate in young women due to increased breast density.
(b) Ultrasound (Picture 6) can accurately diagnose most breast disease, including suspicious axillary lymph nodes. Ultrasound can also guide breast biopsy and aspiration of cysts.
(c) Magnetic resonance imaging (MRI) is usually not used as a in initial test but can be used for diagnosis and follow-up of breast cancer. Breast biopsy
Breast biopsy is required after imaging confirms a suspicious breast lesion. It is performed by removing part of the lesion using a needle under image guidance or by surgically excising an area of breast tissue. Biopsy samples are then examined microscopically to determine diagnosis and need for further surgery.
Surgical treatment of breast cancer
Surgery aims to cure breast cancer and at the same time provide information about cancer spread (i.e. stage) and aggressiveness (i.e. grade) to guide non-surgical treatment (radiotherapy, hormonal therapy, chemotherapy). Hence, surgery is directed towards removing (a) the breast tumor (primary tumor) itself and (b) one or more axillary lymph nodes, where cancer cells initially spread.
(a) The breast tumor itself can be treated by removing the whole breast (mastectomy) or by removing the tumor and a margin of surrounding normal breast (lumpectomy) (Picture 7). In the latter case, remaining breast tissue is irradiated to minimize the chance of local tumor recurrence. Although there are cases when breast-conserving treatment is not possible, patients usually have the option of deciding between the two treatments.
(b) At the same operation when the primary tumor is removed, patients will undergo (i) sentinel lymph node biopsy (SLNB) or (ii) axillary lymph node dissection (ALND)
(i) SLNB (Picture 8) is indicated when there are no palpable axillary lymph nodes or confirmed lymph node metastases. It is a minimally invasive procedure in which only 1-3 lymph nodes are removed from the axilla through small skin incisions, with 95% accuracy in detecting metastases. The lymph nodes removed will be those most likely to contain cancer cells if spread has occurred, thus sparing the patient from removal of all axillary lymph nodes (ALND), a more invasive procedure more frequent and serious complications. Sentinel lymph nodes are localized by injecting the area of primary tumor with blue dye and/or a radioactively labelled chemical. These markers then reach sentinel lymph nodes and render them blue and (weakly) radioactive. Radioactivity is detected by a hand-held probe and determines skin incision placement. Sentinel lymph nodes are microscopically examined for metastases and, depending on findings and primary tumor characteristics, patients might require no further surgical treatment or ALND.
(ii) ALND is indicated when there are palpable or confirmed metastatic axillary lymph nodes. Additional indications exist but are less frequent. It involves removing most axillary lymph nodes through an incision at the lower axillary hair line.
The definition of obesity as a disease is based on the numerical value of the body mass index (BMI). BMI is the quotient of a patient’s body mass in kilograms divided by the square of their height in meters. For example, an individual with weight and height of 100 kg and 1.50 meters respectively has a BMI of 100 kg/(1.5m)2 = 44.4 kg/m2. Normal BMI ranges between 20 and 25. Hence, the patient of the previous example has an ideal weight (BMI=25) of not more than 56 kg and an excess weight of 100-56=44 kg. Obesity is defined as a BMI exceeding 30 and morbid obesity as a BMI exceeding 35. To calculate your BMI, click here
Based on the above definitions, 23% of women and 20% of men in Europe are obese.
Obesity-related morbidity and mortality
Obesity causes premature death and is a risk factor for multiple diseases that affect quality of life such as diabetes, hypertension, high cholesterol, heart disease, stroke, gastroesophageal reflux, osteoarthritis, sleep apnea and many types of cancer. Treatment of obesity
Diet and exercise: Reduced caloric intake and increased physical activity are always recommended in the treatment of obesity, either as the first step towards weight loss or in combination with other treatments. Unfortunately, multiple studies confirm that diet and exercise alone have extremely low rates of long-term success, with most patients initially losing weight followed by return to their original BMI.
Medical treatment: Similarly, drugs have very limited long-term efficacy in the treatment of obesity. They work by suppressing appetite or inhibiting caloric absorption from the small intestine. Treatment has to be continuous and after cessation patients usually regain weight. They can have frequent and serious side-effects, while their financial cost can also be significant. The surgical treatment of obesity
The surgical treatment of obesity (bariatric surgery) is gaining worldwide acceptance because multiple good quality studies have definitively proven that it offers the most reliable long-term results compared to non-surgical treatments. Surgery is the only treatment modality that leads to long-term weight loss in the vast majority of patients. Weight loss starts immediately after surgery and is accompanied by improvement or resolution of all obesity-related diseases (e.g. diabetes, hypertension, high cholesterol, heart disease, stroke, gastroesophageal reflux, osteoarthritis, sleep apnea). However, the most important benefit of weight loss is reduced obesity-related mortality, i.e. increased life expectancy.
Who is a candidate for bariatric surgery?
Accepted obesity criteria for benefit from bariatric surgery are:
BMI over 40
BMI over 35 in the presence of obesity-related diseases such as diabetes, hypertension, high cholesterol, heart disease, stroke, gastroesophageal reflux, osteoarthritis, sleep apnea
BMI over 30 in diabetic patients with difficulty in maintaining acceptable blood sugar levels
Candidates for bariatric surgery must not have a history of eating disorders and should be able to comply with a post-operative diet that includes clear liquids followed by pureed foods for approximately one week. Patients must also be able to adhere to specific life-long dietary restrictions to avoid regaining weight (e.g. avoidance of high-calorie liquids). After surgery, vitamin and mineral supplements are required for life to prevent malabsorption-related deficiency. Bariatric operations
1. Sleeve gastrectomy
Over the last 3-4 years, sleeve gastrectomy has become the most frequent weight loss operation in the U.S. and this trend is continuing. Sleeve gastrectomy is performed laparoscopically and approximately 70-80% of the stomach is removed
Short video of how stomach is divided:
As a result, the shape of the stomach changes from “bag”
By reducing the stomach’s capacity for food, the patient experiences satiety after consuming smaller amounts of food compared to before surgery. In addition, the remaining stomach secretes smaller amounts of the appetite-stimulating hormone ghrelin, hence the patient will feel less hungry. As a result, weight loss after sleeve gastrectomy is achieved by (1) reduced appetite and (2) early satiety. Most patients will lose weight for up to 2 years after surgery.
Sleeve gastrectomy is performed laparoscopically and has an expected 1-2 day hospital stay. It is not indicated in patients with severe gastroesophageal reflux disease.
2. Gastric bypass
Gastric bypass surgery causes weight loss by (1) reducing the stomach’s capacity for food and (2) inhibiting caloric absorption from the small intestine
Hence, as with sleeve gastrectomy, the patient will experience early satiety after consuming smaller amounts of food. In addition, some of the calories contained in this food will pass through the small intestine (Picture 2) without being absorbed and stored as fat. Weight loss is faster compared to sleeve gastrectomy and usually lasts for 12-18 months. According to most studies, gastric bypass has more frequent short- and long-term postoperative complications compared to sleeve gastrectomy. Results
Approximately 18-24 months after bariatric surgery, weight loss will cease at 60-70% of excess weight. These results do not differ significantly between the two types of surgery described above in patients with BMI of 45 or lower. Patients of higher BMI will tend to lose more weight after gastric bypass surgery. In the above example of a patient with an actual weight of 100 kg and an ideal weight of 56 kg, the excess weight of 100-56=44 kg will, on average, decrease by 26-31 kg (60-70%). Therefore, 18-24 months after surgery the patient will weigh 69-74 kg and, most importantly, will not regain weight.
Abdominal wall hernias occur when contents of the abdomen (e.g. fat, bowel) protrude through a hole in the abdominal wall and can be seen or felt under the skin (Picture 1).
In order of decreasing frequency, abdominal wall hernias include groin hernias (inguinal and femoral), umbilical, epigastric and incisional hernias (Pictures 2-6).
For a hernia to occur, a hole in the abdominal wall is required. Such holes can occur spontaneously at congenitally weak parts of the abdominal wall such as the umbilicus and groin or after a surgical incision is created and does not heal adequately (incisional hernia). Pressure inside the abdomen will force fat and/or bowel through the hole and, over months or years, the hole will increase in size and lead to symptoms. Risk factors for hernias include chronically increased abdominal pressure (e.g. chronic cough, constipation), smoking and genetic predisposition. Symptoms
Small hernias may be silent. Once a hernia reaches a certain size, it can cause a feeling of a ‘lump’ underneath the skin that ‘comes out’ when pressure inside the abdomen increases, e.g. when coughing, laughing, straining, and then disappears again (reducible hernia). If a hernia is not fixed surgically, it may permanently protrude through the abdominal wall (irreducible or incarcerated hernia).
Bowel within a hernia can become acutely obstructed, leading to pain at the hernia site and all over the abdomen, vomiting and abdominal distension. In such cases, the blood supply to bowel within a hernia can become compromised (strangulated hernia); this is a surgical emergency. Diagnosis
Abdominal wall hernias are diagnosed based on symptoms and physical examination findings. When there is diagnostic ambiguity or to define a hernia’s size and contents, imaging studies may be necessary (e.g. CT or MR scans). Treatment
Surgery is the only treatment for abdominal wall hernias and is indicated when symptoms are present. When symptoms are absent, lifestyle factors and comorbid medical conditions can also sometimes dictate surgical intervention to prevent a hernia from enlarging or causing bowel obstruction. When left alone, most hernias will slowly increase in size. Hernia surgery
Can be performed by means of ‘open’ or laparoscopic surgery depending on hernia type and size, as well as patient factors. Advantages of laparoscopy include reduced pain, avoidance of wound complications (e.g. infection), better cosmesis and faster recovery.
Can be performed with or without the use of synthetic mesh. Mesh has been shown to reduce hernia recurrence and is used in all abdominal wall hernias except in cases of very small non-recurrent umbilical and epigastric hernias, that are unlikely to recur even without mesh reinforcement.
Speed of recovery depends on hernia size but most patients will feel well enough to ambulate on the day of surgery and will be discharged from hospital after 1 day. There are no diet restrictions. Simple painkillers (e.g. paracetamol and non-steroidal anti-inflammatory medications) are usually adequate and are taken for no more than 7-10 days in most cases. Lifting more than 5 kg is to be avoided for 6 weeks. Complications
Serious complications are rare. Risk of recurrence varies according to hernia type, size, previous hernia surgery, obesity, smoking, diabetes and other patient factors. Mesh and wound infection risks are less than 5% and minimized by using intravenous antibiotics.
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006;295:285-92. http://solvehernia.com http://wehealny.com http://bmihealthcare.co.uk
Dabbas N, Adams K, Pearson, et al. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011; 2:5.
Pilonidal disease usually affects young men and is caused by hair and bacteria forming a blind-ending tract (sinus) underneath the skin at the natal cleft (tailbone) area (Pictures 1 and 2).
This tract can become infected, creating a collection of pus (abscess). Over time, the blind-ending tract can develop a second skin opening and create a ‘tunnel’ (fistula). Symptoms
A pilonidal abscess will cause pain, swelling, redness and drainage of foul-smelling purulent fluid from the affected area. Fever can occur as well. When an abscess is not present, a fistula or sinus can cause minimal symptoms, such as a skin dimple with occasional fluid discharge. Treatment
Pilonidal disease is treated surgically, usually under general anesthesia. An abscess requires drainage and sometimes antibiotics. The abscess cavity is left open to prevent infection of a closed wound and dressing changes are performed until it heals. The patient returns to his usual activities including showering, exercise, etc within days after abscess drainage.
Chronic fistulas are removed surgically. In these cases infection (pus) is absent and the wound can be closed with sutures over a drain which is left in place for a few days. The midline at the natal cleft is moved laterally to prevent recurrence (Picture 3).
Most patients do not require hospitalization and are seen as outpatients for drain and suture removal. Treatment using Fistula Laser Closure
In some cases of chronic pilonidal fistula, the tract can be cauterized from within using a laser-emitting probe (Pictures 4 and 5).
This technique does not require a surgical incision but has a higher rate of recurrence compared to the technique described in the previous paragraph.
In all cases, laser hair removal of the affected area and attention to local hygiene are recommended to minimize recurrence.
Sebaceous cysts are soft painless spherical lumps underneath the skin that contain sebum, a toothpaste-like substance that is physiologically produced by sebaceous glands of the skin (Picture 1).
They can affect any body part and tend to enlarge over months or years. They can become infected, creating an abscess. They can be removed under local anesthesia when infected, symptomatic or for cosmetic reasons (Picture 2).
Lipomas are benign tumors of fat-containing cells and are palpable as soft painless swellings underneath the skin (Picture 3). They can be multiple, can slowly enlarge over time and do not cause complications. Lipomas can be removed under local anesthesia if symptomatic.
3. Pigmented nevi (‘moles’) are brown or purple skin lesions that contain pigment-producing cells. They can be removed for cosmetic reasons or when a change in shape, size, color, margins renders them suspicious for malignancy (see below).
4. Keloid and hypertrophic scars result from unregulated scar tissue formation during healing of a surgical or traumatic wound in patients with genetic predisposition (Picture 4).
They rarely cause pain or itching at the scar site, the main problem associated with them being cosmetic. Keloids and hypertrophic scars do not regress spontaneously. Out of numerous suggested treatments, surgical removal under local anesthesia followed by intradermal steroid injections has low (<20%) rates of recurrence and financial cost.
Basal and squamous cell skin cancer (Pictures 5 and 6) [bccagglika, sccagglika] are the commonest malignant tumors worldwide and are mainly caused by sun exposure. They appear as irregular skin outgrowths or ulcers, occasionally cause minor bleeding and can become locally invasive but rarely spread to other tissues. They require removal with healthy margins to prevent recurrence.
2. Melanoma is the most aggressive form of skin cancer and its incidence has increased significantly in recent years (Picture 7).
Risk factors include large ‘moles’, history of sunburn, hereditary factors. Melanomas can spread to other organs and become lethal if not diagnosed early.
(a) Diagnosis: a change in size, shape, color, borders of a pre-existing mole is the most significant sign and should be followed by biopsy (excision of the entire mole or part of it for microscopic examination). Biopsy will confirm diagnosis and provide information about depth of invasion, guiding further treatment. If spread beyond the skin is suspected, imaging studies may be necessary.
(b) Surgical treatment: melanomas are removed with 1-2 cm of surrounding normal skin under local or general anesthesia. Depending on melanoma thickness and other high-risk features, sentinel lymph node biopsy may be also required at the time of melanoma resection. What is a sentinel lymph node biopsy (SLNB)?
SLNB (Picture 8) is a minimally invasive surgical procedure whereby 1-3 lymph nodes are removed from the groin, axilla or neck, to determine if the tumor (melanoma) has spread to lymph nodes. This provides valuable information to guide further treatment. To locate the correct lymph nodes, the area of tumor is injected with a radioactively-labelled chemical and blue dye. Once located, the lymph node is removed through a small skin incision. If lymph node spread is found, further surgery may be required to remove more lymph nodes.
A perianal abscess is a collection of pus (bacteria and inflammatory fluid) in the connective tissues around the anus. It is equally prevalent in men and women, usually occurs after puberty and is a result of blockage of anal glands. Perianal abscesses occur in several anatomic locations (Picture 1). Abscess formation causes pain, swelling, redness and occasionally fever. Immunosuppressed and diabetic patients may not have those typical symptoms and can become severely ill more abruptly.
A perianal fistula is a communication between the perianal skin (external opening) and the lumen of the anus or rectum (internal opening) (Picture 2). It is a complication of perianal abscess formation in approximately 25% of cases within 6 months of abscess drainage. A perianal fistula can lead to abscess recurrence and drainage of purulent fluid from the external opening.
Perianal abscesses and fistulas are usually diagnosed on clinical examination of the affected area. Imaging studies (e.g. MR scanning) are occasionally required. Perianal abscess treatment
A perianal abscess requires surgical drainage under general or regional anesthesia as it will not respond to antibiotics alone. The abscess cavity is left open after drainage and will heal spontaneously from the bottom up. Immunocompromised or diabetic patients will require antibiotic therapy. Drainage results in immediate symptom relief and most patients are discharged within less than 24 hours. Perianal fistula treatment
Depending on its anatomy in relation to the anal sphincters, a perianal fistula is either incised open (low internal opening) or cauterized using laser energy (high opening, Fistula Laser Closure, FiLaC™). Fistula laser closure involves insertion of a laser-emitting catheter within the fistula tract and cauterization of the tract from the inside (Pictures 3 and 4). Rates of successful closure are upwards of 70% and hospitalization is not required. Alternatively, seton treatment is sometimes used in fistulas with a high internal opening to gradually divide the fistula tract open.
The vermiform appendix is a blind-ending structure arising from the large intestine, located in the lower right quadrant of the abdomen. It has no known function in adults.
Acute appendicitis can occur at any age but is commonest in young adults. It is caused by blockage of the appendiceal lumen by intestinal contents, which is followed by appendiceal swelling and infection (Picture 1). If this is not treated, the appendix can rupture, leading to a localized abscess or peritonitis.
The symptoms of appendicitis can vary significantly but usually include acute abdominal pain that is initially central and then moves to the right lower quadrant, nausea, vomiting, fever, lack of appetite. Symptoms will not resolve without treatment.
Diagnosis is usually clinical and confirmed by abdominal ultrasonography or CT scan.
Acute appendicitis is treated by laparoscopic appendectomy through 3 small abdominal incisions (Picture 2). Patients are discharged within 24 hours without dietary restrictions. No antibiotics are required after surgery except in cases of appendiceal rupture, when intravenous antibiotics will be necessary to help prevent abscess formation.
Non-operative treatment of acute appendicitis (without rupture) using intravenous or oral antibiotics has been described. However, although surgery can be sometimes be initially avoided, studies show that
imaging studies can be inaccurate in identifying appendicitis without rupture, leading to patients presenting with complications after failed antibiotic treatment that was never indicated
although patients with acute appendicitis are usually young and have a long life expectancy, no long-term follow-up studies of patients undergoing ‘successful’ antibiotic treatment exists; available data show that within only 1 year of ‘successful’ non-operative treatment, 30-35% of patients treated with antibiotics will have recurrent appendicitis requiring surgery
For these reasons, non-operative treatment of appendicitis is inferior to surgery and is not the current standard of care.
Vons C, Barry C, Maitre S, et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet. 2011;377:1573-9.
Salminen P, Paajanen H, Rautio T, et al. Antibiotic Therapy vs Appendectomy for Treatment of Uncomplicated Acute Appendicitis: The APPAC Randomized Clinical Trial. JAMA. 2015;313:2340-8.
Wilms IM, de Hoog DE, de Visser DC, et al. Appendectomy versus antibiotic treatment for acute appendicitis. Cochrane Database Syst Rev. 2011;CD008359.
The large intestine (colon) is the part of the gastrointestinal tract between the small intestine and anus. It is approximately 1.5 meters long and its function is to absorb water and salt from stool. It is arbitrarily divided into ascending, transverse, descending and sigmoid parts (Picture 1).
The commonest colorectal diseases that can require surgical treatment are tumors (polyps and cancer), diverticular disease, ischemic colitis and angiodysplasia. Polyps
Polyps are small outgrowths from the inner lining of the colon caused by genetic factors as well as a diet high in red meat and saturated fat and low in fiber (Picture 2). Their incidence increases with age, they can occur anywhere in the colon and are usually diagnosed by colonoscopy. Small polyps do not usually cause symptoms.
The commonest polyps (adenomatous polyps) tend to grow in size over time and sometimes progress to cancer, hence the significance of polyps as a disease. Most polyps can be removed at colonoscopy (Picture 3).
Patients with polyps not suitable for colonoscopic excision will require surgery to remove part of the colon. Screening colonoscopy is recommended for all men and women over the age of 50 years for early detection and removal of polyps. This policy has been shown to reduce mortality from colorectal cancer. Colorectal cancer
Colorectal cancer is the second commonest cause of cancer death in western countries. It is commonest in the sigmoid colon and usually starts from adenomatous polyps. Usual symptoms of colon cancer are a change in bowel habits, blood in the stool. Rarely colon cancer will present emergently with bowel obstruction or perforation. Diagnosis requires colonoscopy and biopsy as well as CT scans of the abdomen and chest. If not treated in time, colorectal cancer can spread to lymph nodes, liver and other organs. Surgical treatment involves removing the affected colon part along with its draining lymph nodes. Depending on spread, chemotherapy might also be required. Diverticular disease
Diverticula are small outpouchings of the colonic wall that most commonly affect the sigmoid colon. They are caused by constipation and lack of dietary fiber. Their incidence increases with age (up to 50% of people aged 60 years or older in western countries) but they usually do not cause symptoms and are diagnosed at colonoscopy performed for other reasons. Problems associated with diverticula are
(a) Diverticulitis (Picture 4): diverticula can become inflamed causing abdominal pain, abdominal distension, fever. This condition is diagnosed by abdominal CT scan and usually responds to bowel rest and antibiotics. In a minority of cases diverticula can rupture, leading to stool and bacterial spillage inside the abdomen followed by abscess formation or peritonitis. A communication between colon and other organs (e.g. urinary bladder) can also develop as a result of diverticulitis. In some of these cases, emergent surgery is required to remove the inflamed colon and wash out the abdomen.
Repeated mild episodes of diverticulitis are an indication for elective surgery to remove the affected colon.
(b) Bleeding: a blood vessel adjacent to a diverticulum can sometimes rupture, causing acute rectal bleeding. Treatment can require colonoscopy, angiography, surgery or a combination of these modalities. Angiodysplasias
Angiodysplasias are small areas of dilated on the inner lining of the large intestine. They cause 5-20% of all cases of bleeding from the lower gastrointestinal tract (Picture 5). They usually occur in the ascending colon and their incidence increases with age. Angiodysplasias are diagnosed by colonoscopy and they can be cauterized to prevent or stop bleeding (Picture 6). Acute bleeding from angiodysplasias can also be treated by embolization, whereby feeding blood vessels are occluded from the inside. Surgery to remove the affected part of the colon is sometimes required to treat repeated episodes of minor or acute profuse bleeding.
Laparoscopic colectomy involves resection of part of the colon using 4-5 small lower abdominal skin incisions (Picture 7) and it can be performed for any of the conditions described above. The colon part to be removed is mobilized, exteriorized through an incision measuring a few centimeters and removed; the two free ends of healthy colon are then connected. Benefits of laparoscopic over ‘open’ colectomy include reduced pain, faster recovery, avoidance of incisional complications (infection, hernia). Hospital stay is between 4-7 days and no long-term dietary restrictions are necessary.
The gallbladder is a hollow structure located in the upper right abdomen, underneath the liver (Picture 1). It stores 30-50 ml of bile and contracts to release it into the small bowel to facilitate fat digestion.
Diseases of the gallbladder A. Gallstones
Gallstones are caused by imbalances in bile composition and are usually made of cholesterol and organic salts. This is called cholelithiasis and affects 10-15% of people aged over 40 years, most commonly obese women. Cholelithiasis will not cause symptoms in approximately 80% of patients and, in these cases, treatment is not required. People will gallstones develop new symptoms at a rate of 1-2% per year. Common complications of cholelithiasis are:
Biliary colic (Picture 2): a gallstone blocks gallbladder emptying causing the gallbladder wall to distend and contract intensely to overcome the obstruction. This can cause severe right upper abdominal pain radiating to the back, nausea and vomiting. Pain characteristically comes in waves. The stone eventually changes position unblocking bile flow and symptoms resolve quickly. An acute attack responds to painkillers. Surgery to remove the gallbladder (cholecystectomy) is indicated during such an episode or shortly after to prevent recurrence.
Cholecystitis: this is gallbladder inflammation and originates from the same initial event of gallbladder obstruction by a stone, but is followed by bacterial infection of bile. Symptoms are abdominal pain, nausea, vomiting, fever. Patients can become severely ill if diagnosis is delayed. Treatment is with intravenous antibiotics and cholecystectomy.
Small gallstones can sometimes enter the duct that connects the gallbladder and small intestine. This is called choledocholithiasis and it can cause the following problems, which are significantly less common than biliary colic and cholecystitis:
Cholangitis: a stone obstructs the common bile duct leading to jaundice, abdominal pain, fever. Patients can become severely ill. Treatment consists of intravenous antibiotics, endoscopic stone extraction and cholecystectomy.
Pancreatitis: a stone obstructs the pancreatic duct (Picture 2), leading to acute inflammation of the pancreas, manifesting as abdominal and back pain, nausea, vomiting. Pancreatitis can range from mild to life-threatening. Treatment is initially not surgical and involves removing the gallstone, if still impacted. Cholecystectomy is necessary to prevent further episodes.
Cholelithiasis is diagnosed with abdominal ultrasound. It can be an incidental finding in other imaging studies of the abdomen, e.g. CT scan.
Choledocholithiasis is diagnosed with cholangiography (imaging of the bile ducts using contrast), which requires MR scanning or endoscopy. B. Gallbladder dyskinesia
Gallbladder dyskinesia is caused by an inability of the gallbladder to adequately contract and release bile into the bile duct. It causes symptoms similar to those of biliary colic (right upper quandrant abdominal pain after meals, nausea, vomiting) in the absence of gallstones. It is a disease entity that has been relatively recently described and now accounts for 10-15% of cholecystectomies performed in the U.S.
It is diagnosed by HIDA scan (study of gallbladder emptying) after prior ultrasound rules out cholelithiasis.
Treatment is laparoscopic cholecystectomy. In patients with typical symptoms described above, resolution after cholecystectomy is approximately 95%.
C. Gallbladder polyps
Gallbladder polyps are small protrusions arising from the inner lining of the gallbladder that are usually an incidental finding on ultrasound. They do not cause symptoms, occur in approximately 5% of the general population and may be single or multiple. They consist of (1) cholesterol deposits (cholesterol polyps) or (2) cells of the inner lining of the gallbladder that can rarely give rise to cancer. Cholecystectomy is recommended for polyps larger than 10 mm and follow-up with repeat ultrasound for smaller lesions. Cholecystectomy
Cholecystectomy is almost always performed laparoscopically under general anesthesia with the use of four small upper abdominal incisions (Picture 3). Conversion to ‘open’ surgery is rarely necessary.
Patients ambulate few hours after surgery and are discharged home the same day or after an overnight hospital stay. There are no postoperative dietary restrictions and mild analgesics are required for a few days only.
Society of American Gastrointestinal and Endoscopic Surgeons Guidelines for the Clinical Application of Laparoscopic Biliary Tract Surgery. http://www.sages.org/publications/guidelines/guidelines-for-the-clinical-application-of-laparoscopic-biliary-tract-surgery
DuCoin C, Faber R, Ilagan M, et al. Normokinetic biliary dyskinesia: a novel diagnosis. Surg Endosc. 2012;26:3088-9.
Carr JA, Walls J, Bryan LJ, et al. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19:222-6.
Strasberg SM, Linehan DC. Tumors of the Pancreas, Biliary Tract and Liver. In: ACS Surgery, Principles & Practice. WebMD 2006, New York.