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HEMORRHOIDS OFFICE MANAGEMENT

A common misconception is that hemorrhoids are varicose veins and thus acquired over time.

In fact, hemorrhoids are a natural part of the anal canal aiding one’s anal continence.  Usually 3-4 cluster or columns, they are in fact composed of both arteries and veins. Hence at times blood passage is bright red.

The condition ‘Hemorrhoids’ become symptomatic when bleeding, protrusion, mucus discharge or soilage occurs. Contributing factors to these symptoms are life style influences that enlarge and cause descent or protrusion from the anal canal.  Prolonged sitting on the toilet (minimizing reading on the toilet commonly referred to as the ‘porcelain library’ and avoid answering those emails) , weight gain, constipation with bearing down to defecate or heavy lifting associated with straining.

Not everyone who has hemorrhoids has symptoms but when symptoms occur it is time to address the condition. General tips include: Dietary fiber and adequate liquid intake aids making the consistency of stool easier to pass.  Decreasing toilet time and responding to the call to defecate in a timely manner helps.

If symptoms persist, especially bleeding, the majority of patients can be treated painlessly in the office, once the diagnostic cause is confirmed to be hemorrhoids.  As internal hemorrhoids do not have nerve endings to sense pain, they commonly present as ‘painless rectal bleeding’. However, since bleeding can be an ominous sign, it is important to have it evaluated by a physician.  The good news is that if hemorrhoids are found to be the source, many office therapies are available, which are determined by anoscopy (looking inside the anal canal 1-2 inches).  These therapies are directed at the INTERNAL hemorrhoids which do not have pain sensing nerve endings.  These include SCLEROTHERAPY (injecting the internal hemorrhoids inside the anal canal, where the hemorrhoids are insensate, to chemically shrink them); INFRARED THERAPY (using a device to direct spot heat to the hemorrhoid which cauterizes the hemorrhoid causing a shrinkage of the blood channels within the hemorrhoid), and tying off the hemorrhoid thus incorporating the internal hemorrhoid by RUBBER BAND LIGATION, thus diminishing the blood flow to the hemorrhoid.  These are NONSURGICAL effective office treatments.  To minimize any discomfort the COLON and RECTAL specialist will initiate OFFICE treatment and have the patient comeback to complete the treatment. Often benefit is dramatic after the initial session and continues to improve with the follow up session.

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TAMIS

TAMIS

I have previously released a brief, introductory video introducing the use of TAMIS (Transanal Minimally Invasive Surgery) in the treatment of rectal tumors.  I’d like to go into a little more detail in this informal and, hopefully, educational forum.

Some background:  the gold-standard for treatment of rectal tumors (whether they be benign polyps, rectal cancer or other, rarer tumors of the rectum, such as carcinoid) is surgical excision.  Depending on the size, stage and other characteristics of the tumor this may be coupled with pre- or post-operative radiation with or without chemotherapy…but the mainstay of treatment remains surgical removal.

This usually requires radical resection of the tumor, the rectum and its entire blood/lymphatic supply in the form of a large, abdominal surgery termed a Low Anterior Resection (LAR).  This is a major surgery, requiring significant hospital stays even when performed laparoscopically (i.e. minimally invasive approach).  Luckily, with the advent of TAMIS, a subset of carefully selected patients may have tumors that lend themselves to local excision and can be spared major abdominal surgery.

TAMIS was invented and then popularized by Drs. Attalah, Albert and Larach in 2009, when they created a technique for using minimally-invasive laparoscopic tools previously used for abdominal surgery to achieve trans-anal access to the rectum instead.  An access port is placed into the anal canal (yes, you are completely asleep throughout the entire procedure), the rectum is filled with air and standard laparoscopic equipment is used to excise the lesion, while leaving the remainder of the rectum intact.  This allows us to remove pre-cancerous lesions and early rectal cancers via a laparoscopic, trans-anal approach without removing the entire rectum.  This technique is reserved for the treatment of either large, non-cancerous polyps or small, early tumors which can be safely treated with local excision.  Unfortunately, larger, more advanced tumors still require resection of the entire rectum.

So what’s the big deal?  What’s the difference between an abdominal surgery and one performed trans-anal?  In my opinion, the greatest benefits of the trans-anal approach are:

1)    No abdominal incisions.  By performing the surgery via the trans-anal route, we achieve “incision-less” surgery and that is as close to “pain-less” surgery as we can get.  By avoiding abdominal incisions, we reduce the risk of its associated complications such as post-operative hernias, sexual dysfunction, bleeding and intra-abdominal scarring (adhesions).  This results in a shorter hospital stay and quicker recovery for you.

2)    Your rectum is still intact.  This means you should not have any change in bowel habits after this surgery, such as diarrhea/urgency which can complicate Low Anterior Resections.

In the appropriate patient, TAMIS offers us a truly minimally-invasive option to treat pre-cancerous lesions and early rectal cancers without the sacrifice/complications of a major abdominal surgery.   The choice of surgical approach will be thoroughly discussed on an individual basis during your consultation.

Best Health,

David Magner, MD

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New Innovative Technique in Treating Hemorrhoids


(Click on the image to watch a video).

Everyone has hemorrhoids…we are born with them. Roughly, 50% of adults with suffer from hemorrhoids over their lifetime.   We have 2 very different types of hemorrhoids.  External or outside hemorrhoids are cushions of tissue containing small blood vessels under the skin all the way around the outside of the anus. When they are flared up, typical symptoms include pain and swelling.  Internal hemorrhoids are cushions of blood vessels just inside the anus that are like the inside of your mouth, red and wet.   The inside hemorrhoids are above an area where there are no nerve endings so when they are exacerbated bleeding, protrusion and mucous drainage occur but rarely pain.  Common causes of hemorrhoids include constipation, diarrhea, straining, sitting on the toilet for long periods of time and pregnancy.

Minor symptomatic hemorrhoids can be treated many times in the office with simple office-based treatments such as sclerotherapy or rubber-band ligation.  For some, over time, hemorrhoids can engorge and become more inflamed requiring surgical intervention.  The traditional surgery involves excision of all the hemorrhoidal cushions and closing the areas with sutures.  Traditional hemorrhoidectomy is famous for having the most painful 2-3 week recovery period. This type of surgery has been reserved for patients with significant severe hemorrhoid symptoms.

Transanal Hemorrhoidal Dearterialization (THD) is a novel treatment for internal hemorrhoids that are bleeding and protruding.  There is no cutting of tissue thus significantly reducing pain.  The technique uses a special Doppler or ultra-sound to identify the small artery that keeps the hemorrhoidal cushion enlarged and bleeding.  This artery is tied off to cause shrinkage of the hemorrhoid and then the hemorrhoid is sutured back up to where it normally belongs. THD is a less traumatic and less invasive surgical treatment with less pain and discomfort.  THD is performed in the outpatient setting and a patient can resume normal activities within 4 days.  Over 20,000 cases are performed annually with excellent results.  THD devices are FDA approved.

Caution:  All rectal pain and bleeding should be evaluated by an experienced doctor.

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Why I Prefer Robotic-assisted Surgery: A Surgeon’s Perspective

Robot assisted

When I graduated medical school in 1999 and started on my path as a surgeon, laparoscopy was still coming into acceptance.  I always felt fortunate to have trained during the advent of laparoscopic, minimally-invasive surgery because I feel equally comfortable using the open, traditional approach as well as the laparoscopic, minimally invasive approach. For me, the two are complementary approaches and in fact each skill set augments the other.  Knowing laparoscopy has made me a better open surgeon and vice versa.

Despite this, even when I was in training, many of my mentors would say to me, “Mari, if I ever need surgery, I want it done open!”  Why did they say this? In making the transition from the large incision of traditional surgery to the minimally- invasive approach, we made sacrifices.  We lost 3-D visualization to the 2-D of our laparoscope (the camera used during surgery).  We lost some of our visual field since initially, the cameras could only look straightforward.  We also lost a significant amount of dexterity. The long thin instruments of laparoscopic surgery can be rotated, opened and closed, but that’s it.   As a result, at the start, there were many conversions to an open, traditional incision if the surgeon felt that laparoscopy compromised the quality or safety of an operation for the patient.  Most surgeons would only remove a gallbladder laparoscopically. The more complex operations were still largely performed open.

Over time, the surgical community’s experience with laparoscopy grew and our ability to perform increasingly complicated operations, such as colon resections increased.  Our cameras became high definition, improving what we saw and magnifying it. The cameras also became angled and then flexible, allowing us to “see around corners” that had been initially cut off from us with the early cameras. We learned to adapt our operative techniques to the instruments we had available successfully and safely. We progressed to the point that if given a choice between a laparoscopic and open colon resection for myself or a loved one, I would pick laparoscopic every time, even though we still had only 2-D visualization and the instrumentation was limited.

Enter robotic-assisted* surgery… With the three-dimensional camera, the surgeon regains depth perception and then some.  We can now see up to 10-fold magnification of our operation! Our operating instruments now have wrists, allowing us now SEVEN degrees of motion instead of only two. Our movements can be scaled from 1.5:1 down to 3:1 for small places and delicate dissection. We have regained what we, as surgeons, lost in the conversion from open to laparoscopic, minimally invasive surgery.

We have also gained. Ask most surgeons, if they could have anything they wanted in the operating room, what would it be? A third arm!  I’ll explain: all of our operations are done with an assistant to hold things and help the surgeon see what needs to be done.  The more experienced the assistant, the better the help they provide in the operating room, but even the best assistant in the world cannot read the mind of the operating surgeon, until now, where I am my own assistant!

Oh sure, there are some sacrifices we’ve had to make yet again.  We can no longer complain that the camera is in the wrong place (the surgeon controls that) or that it’s moving when we don’t want it to (the robotic arm holds the camera rock-steady).  We can no longer complain about the way something is held (the surgeon is holding it). We don’t wake up sore in the morning from the physical demands of yesterday’s surgery. It’s a tough day when a surgeon runs out of reasons to complain, but I know they are working on that too!

So go ahead and ask me… If I ever need part of my colon or rectum removed, I want my surgeon to use the robot.

* to be clear: the surgeon controls the robot, the robot does not operate independently and therefore the term robotic-assisted surgery is more accurate than robotic surgery.

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Dr. Madsen Performs Colonoscopy on DollarShaveClub.com’s founder and CEO

Dr. Mari A. Madsen, renowned colon and rectal surgeon of California Colorectal Surgeons will perform a colonoscopy on Michael Dubin, DollarShaveClub.com’s founder and CEO, at the recommendation of his family doctor. Dubin has a family history of colon cancer and is at high-risk for the disease and this will be his first colonoscopy.

Dubin will share his personal journey of the preparation for his colonoscopy along with the actual procedure on March 19 at 10:00 a.m. PST. During the procedure, DollarShaveClub.com will try to reach the 23 million Americans over age 50 who have not received the recommended screening for colon cancer that could save lives.

Read more about this at: http://globenewswire.com/news-release/2014/03/10/617150/10071985/en/COLON-CANCER-ALLIANCE-TEAMS-UP-WITH-DOLLARSHAVECLUB-COM-TO-WIPE-OUT-COLON-CANCER.html

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Hemorrhoids

The problems that get blamed on hemorrhoids are multiple: rectal bleeding, rectal pain, lumps, itching and the list continues. But before we move on, what are these lowly hemorrhoids that may be anything from an anal fissure, to an abscess, to cancer or are legitimately blamed for causing problems in the anal area?

The hemorrhoids are the elastic tissue that line the anal canal and have a very rich blood supply.  Believe it or not, hemorrhoidal tissue has some very important functions to perform that help us on a daily basis.  The hemorrhoids provide some of the seal to prevent leakage from the anal canal.  They also participate in the “anal sampling reflex”, which is how we know if we need to pass solid, liquid or gas.  We take these functions for granted, but the hemorrhoids certainly help us to function in society!

Often, when one experiences a problem in the anal area, the blame on the hemorrhoids is justified. Sometimes it is not. Being evaluated by a colon and rectal surgeon is important because if it is hemorrhoids, we can help you.  We can perform office-based procedures or for more severe hemorrhoids, there is surgery.  Happily, many of the office based procedures and newer operations to treat the hemorrhoids are relatively painless.  More importantly, in the instances that symptoms are not caused by hemorrhoids, we can diagnose the real problem and help get you on the road to recovery.

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Diverticulosis and Diverticulitis

Most adult people have in their colons (large intestine) small outpouchings that bulge through weak places in the large intestinal wall.  This outpouching or ‘pouch’ is a diverticulum. The condition of having diverticula is called diverticulosis. One third of the American population will develop diverticulosis by age 50 and more than two thirds of the population over age 80 will have this condition. 10-25% of these patients will develop diverticulitis in their lifetime.  This risk increases with age.  The vast majority, > 90%, of diverticulitis arises in the sigmoid colon (the segment above the rectum on the left side of the abdomen).

Diverticular disease can be classified as ‘asymptomatic diverticulosis’, ‘acute diverticulitis’, and ‘complicated diverticulitis’.  It is believed that a low fiber diet is the main cause of diverticular disease. The basis, physiologically, is the segmentation contractions of the colon to push fecal material toward the rectum.  A low fiber diet does not have sufficient bulk and increased channel pressure has to be generated to propel the stool forward.  This leads to constipation and the colon wall muscles have to strain to move the stool.  This leads to excess pressure within the colon lumen (channel) and leads to outward bulging creating the diverticular pouches. Diverticulitis occurs when the diverticula become infected and inflamed.

Symptoms : Most who have diverticulosis have little or no symptoms . Occasional mild cramps, bloating and constipation can occur.  The most common symptom of diverticulitis is abdominal pain, generally left sided in the lower abdomen.  If the infection progresses it can cause fever, nausea , vomiting , chills, and cramping.

Complications of diverticulitis: Can lead to bleeding, abscess, perforation and peritonitis, fistula (an abnormal connection of the colon to another organ (colon to bladder = colovesical; colon to skin =colocutaneous; colon to bowel = coloenteric; and colon to vagina = colovaginal fistua) and finally intestinal obstruction.

Diagnosis and Evaluation: The classic triad of presentation is left lower quadrant abdominal pain, fever and leucocytosis (elevated white blood cell count). Most commonly after clinical exam a CAT SCAN xray of the abdomen is obtained.

Conservative Therapy:  If the event is uncomplicated then bowel rests and antibiotics are administered. If symptoms do not improve after a few days then one must consider abscess formation and extracolonic (outside the colon wall) gas are predictors of failure of conservative medical management.

50-70 percent of patients treated for a first episode of acute diverticulitis will respond and have no further problems.  About 20 percent of patients who develop a first bout of diverticulitis will develop complications.  Patients who have recurrent episodes of diverticulitis have a 60 percent risk of complications; thus a rationale traditionally has held for surgical treatment after TWO documented episodes of diverticulitis.

Previously it was common that patients with a first bout of diverticulitis at an age < 50 should have surgical corrections.  This has been challenged and if uncomplicated, then dietary and lifestyle management is often instigated with benefit.

Pericolonic diverticular abscess should be managed by CAT SCAN guided percutaneous drainage of the abscess and antibiotics.  This can convert an emergent surgery, often requiring an interim diverting colostomy (external bag) for collection of feces to an elective operation.  Eventually a reoperation to reunite (anastomose) the bowel can be conducted.  By percutaneous drainage of the abscess this can facilitate a more elective surgery to resect and reunite the bowel in one stage without fecal diversion.

Bleeding: Lower gastrointestinal bleeding is felt to be associated with diverticulosis rather than diverticulitis. This occurs in 15-20% of cases and the majority will stop spontaneously.   However, today angiographic localization of the bleeding vessel can allow embolization of the vessel without the need for surgery.

Surgery:  Most cases of elective diverticular surgery can be accomplished with laparoscopic techniques and a mini incision to extract the disease segment.  Acute emergent perforated diverticulitis usually requires an open surgery and often a temporary diverting stoma (ostomy).  One caveat of open or laparoscopic surgery of sigmoid diverticular disease is to insure that the re-hook up (anastomosis) is made between the colon and rectum rather than resecting a portion of sigmoid colon and reuniting it to a distal segment of sigmoid.  It is the intervening segment between that new anastomosis and the rectum where recurrence is highest.

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What?, Why?, and When? (aka “the in’s-and-out’s”) of your Screening Colonoscopy

So what exactly is involved in a colonoscopy?

  • First off, if you’ve been checking with your insurance company, you may have heard of “screening” versus “diagnostic” colonoscopy.  The procedure is the same.  The difference lies in why we are performing the procedure.  A person who is having symptoms (i.e. bleeding, abdominal bloating, discomfort, etc.) and undergoes a colonoscopy to help discover the reason behind their symptoms is having a “diagnostic colonoscopy”.   A person who is undergoing a “screening colonoscopy” has no symptoms, but is undergoing the procedure in order to detect polyps (potentially pre-cancerous lesions), with the intent of preventing a future cancer.
  • The procedure itself involves inserting a thin, flexible, camera-tipped tube into the anorectum and advancing it under direct visualization throughout the entire colon and into the cecum (the beginning of the colon) or terminal ileum (the end of the small intestine).  Gas is used to distend the colon to allow for better visualization.  Small instruments can then be passed through the colonoscope and used to remove/biopsy any polyps or other lesions.  The process usually takes from 30 – 45 minutes and is very safe (complications are rare, usually less than 2%).   If this sounds somewhat uncomfortable, well, you’re correct…but only if you’re awake — we perform these after you’re asleep, thanks to our anesthesia colleagues, and there is little, if any, discomfort.

Why should I have one done?

  • To find and remove pre-cancerous growths in your colon (i.e.  SO YOU DON’T GET COLORECTAL CANCER!).
  •  Colon and rectal cancers have been found to progress through a series of steps starting as abnormal growth of a given cell to the formation of a polyp and ultimately to the development of cancer.  The vast majority of colorectal cancers take several years to develop.  This provides us with ample opportunity to remove the pre-cursor polyp before it ever becomes a cancer and, therefore, allows us to prevent cancer (rather than relying on a detect-and-treat approach).
  • Colonoscopy is the best method to detect and remove pre-cancerous lesions.

When should I look forward to having this done?

  • Yes, I did say “look forward to”.  This is a painless, low-risk procedure that provides you and your family with piece of mind and could save your life.  If your colonoscopy is completely normal you won’t need another one for 5-10 years.  If you do have a polyp, or even a cancer, it is ALWAYS BETTER TO FIND OUT EARLY RATHER THAN LATER.  Early diagnosis gives us the widest range of options and the best chance at cure.  Don’t stick your head in the sand, follow the guidelines below and get your scope done.
  • General Guidelines:
    • Initial screening colonoscopy should be performed at 50 years old (45 years old for African Americans, who tend to develop polyps earlier)
    • If a first degree relative has been diagnosed with colon cancer, you should have your first colonoscopy  10 years prior to the age at which they were diagnosed.
    • If you have multiple family members with colon, rectal or associated cancers, you should be assessed for Inherited Colorectal Cancer Syndromes and tested accordingly.
  • Of course, any and all suspicious symptoms (bleeding per rectum, unintential weight loss, anemia, change in bowel habits, abdominal pain/bloating, dark-black colored stools, etc.) should be investigated immediately and this takes priority over the general guidelines listed above.

Best Health,

-Dave Magner, MD

California Colorectal Surgeons

 

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Rectal Pain

Most people have suffered from rectal pain at least once in their lifetime.  Rectal pain can vary from minor pain with the passage of a hard bowel movement to severe constant pain.  The severity of rectal pain varies widely depending on the cause.  Fairly common causes of rectal pain include hemorrhoids, fissures or skin problems such as dermatitis.  More serious causes include abscess, sexually transmitted diseases, inflammatory bowel disease such as ulcerative colitis, Crohn’s disease, or cancer.  Rectal pain can be associated with other symptoms such as bleeding, change in bowel habits or a mass.

In many circumstances, the cause of rectal pain can be determined by a history and physical examination performed by a colorectal doctor.  Office-based examinations may include anoscopy or proctoscopy to look inside the anus or rectum.  Occasionally, imaging studies such as a CT scan or MRI may be warranted.

It is very difficult for anyone to really look back there and see what is going on.  If your rectal pain does not resolve with the use of over-the-counter medications within 24-48 hours, you should be evaluated by a physician.  If you are experiencing rectal pain that persists take it seriously. Call California Colorectal Surgeons today for a confidential consultation at: (310) 854-3580.

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Rectal Bleeding

Rectal bleeding is the passage of blood from the rectum.  Bleeding may be bright red, maroon, black or hidden/occult blood.  Rectal bleeding may show up as blood in your stool, on the toilet paper or in the toilet bowl.  The severity of bleeding varies widely depending on the cause of bleeding.  Anorectal disorders such as hemorrhoids or fissures are the most common cause of minor rectal bleeding.   Many people tell me if it is bright red blood it is not serious so you don’t need to get an evaluation.  Most of the time they are correct, but don’t be fooled;  rectal cancer or polyps can present with bright red bleeding.  Anyone experiencing rectal bleeding should be seen and evaluated by a doctor.  Causes of more significant bleeding include diverticulosis, angiodysplasia, colon cancer or polyps or colitis.  Bleeding can also be caused from the stomach or small intestine.

Rectal bleeding is often ignored because people think it is their hemorrhoids or they are afraid to find out what is causing it.  When you see blood after have a bowel movement, it can be very scary.  Getting evaluated by a doctor is very important to determine if the bleeding is a mild problem such as hemorrhoids or a more serious or life threatening problem such as cancer.  If there is something more serious, early diagnosis  can result in better  treatment options and cure than later diagnosis.   If you are experiencing significant bleeding and/or experiencing dizziness, lightheadedness, fainting or shortness of breath, call 911.

The origin of bleeding is determined by a history and physical exam, blood tests and diagnostics tests such as anoscopy, flexible sigmoidoscopy, and/or colonoscopy.   Occasionally imaging studies such as an angiogram or blood-tagged scan may be needed to find the source.

All rectal bleeding should be evaluated by a doctor to determine the cause.  Taking control of your health can prevent a little problem from being a big problem and save your life.  If you see bleeding, take it seriously. Call us today for a confidential consultation at: (310) 854-3580.

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