Dr. Abhishek Jain

MBBS, MS (General Surgery)
FAMAS(Italy), FAAOS(Italy)
FICS (GI Surgery), FISCP (Colo Proctology)
Colorectal Surgery,Advance Laparoscopic Surgery,Abdominal Oncology Surgery, Bariatric & Metabolic Surgery

Anal abscess and fistula

Abscesses can occur anywhere on the body and are due to a collection of bacteria-producing pus. Those that occur around the bottom can also be associated with a connection to the lining of the ano-rectum – this is due to a fistula.

What is an anal abscess?

An anal abscess is a cavity filled with pus found near the back passage (‘anus’). It is a common condition with over 10,000 admissions per year. If you have pain, tenderness, redness and/or a lump in the region of the anus you may be suffering from an abscess. You may also feel ill with a fever.
When the abscess has been treated, it usually heals up and causes no more trouble. Sometimes, it doesn’t fully heal indicating that an anal fistula may have formed.

What is an anal fistula?

An anal fistula nearly always results from a previous abscess. It is a tunnel that connects the lining of the back passage with the skin next to the anus.
Persistent leakage of pus from the opening next to the anus suggests that a fistula has developed.
If this opening partially heals over, pus can build up in the tunnel. This leads to an abscess which discharges itself when the pressure builds up. So a fistula may lead to repeated abscesses occurring at the same site.

What causes an abscess?

An abscess is caused by infection getting in to one of the glands that produces mucus to lubricate the anus.

What causes a fistula?

When an abscess has discharged itself or has been lanced (“drained”), the skin will usually heal over. Sometimes, however, a small hole is left on the outside. This usually means that a tunnel (a “fistula”) has developed between the anal gland and the outside opening.
Only a minority of people who have had an abscess will go on to develop a fistula.

How is an abscess treated?

If the infection is caught very early on, antibiotics may work. However, the majority of abscesses will require to be drained. This usually requires a general anaesthetic (put to sleep) and a short stay in hospital.
It will usually take a few weeks for the abscess cavity (hole) that has been drained to fill up with scar tissue. Sometimes (but often not) the cavity will require “packing” by a district nurse to help the healing process.

How is a fistula treated?

A fistula nearly always requires surgery to cure it.
The majority of fistulae are relatively easy to treat but should preferably be performed by a specialist in colorectal (bowel) surgery.
The surgery usually involves cutting a small part of the anal sphincter muscle away. In this way, the tunnel is opened up (‘deroofed’) to form a trench or groove that heals from the bottom of the trench outwards.
In the same way as for the healing of an abscess cavity, it will usually take a few weeks for the fistula that has been removed to fill up with scar tissue. Once again, the surgery usually requires a general anaesthetic and can be done as a daycase procedure..
It may be necessary for a gauze pad to be worn in the underwear for a week or two after the operation to prevent the drainage from soiling the clothes.
Bowel movements will not affect the healing.
Sometimes the fistula is not the type that can be simply laid open as too much anal sphincter muscle is involved to cut (which may risk incontinence) or there are multiple tracks. In this case a string may be passed through the track (“seton”) and the surgeon will bring you back and discuss further options for your treatment.

What if the problem comes back?

Fistulae can be particularly awkward conditions to treat and can come back. In this case – and for the more complicated fistulae, it may be necessary to do a MRI (magnetic resonance scan) scan of the back passage to check that no other fistulae or “tracks” have been overlooked.
If the fistula is a complicated one, a number of alternative operative approaches are available. Your surgeon will discuss these with you if they are necessary.

How long does it take to recover from this type of surgery?

Discomfort after fistula surgery is moderate for the first week and can be controlled with simple pain killers. The amount of time off work is usually minimal but will depend on the type of job you do.
Bathing or showering two to three times a day helps keep the area clean and comfortable. Laxatives are recommended to minimise the discomfort associated with passing a motion.

Anal fissure

An anal fissure is a common condition where there is a tear in the lining of the anal canal. Fissures may be caused by constipation and passage of hard stool, or diarrhoea and passage of frequent stool.

What are the symptoms?

The symptoms of a fissure are pain, especially when passing a bowel motion, and some bleeding. Occasionally, people experience discharge of abscesses in association with a fissure.

How is the diagnosis made?

The diagnosis is usually made by careful questioning and analysis of symptoms. It will usually be necessary to examine the anus (back passage) with a finger and sometimes it is necessary to examine the anus with a telescope. If this is uncomfortable then it may be performed under a general anaesthetic (put to sleep).

How can it be treated?

At least 50 per cent of fissures heal either by themselves or with non-operative treatment, including application of special medicated cream, use of stool softeners, and avoidance of constipation. Two ointments are commonly used. The first is 0.2% GTN (glyceryl tri-nitrate), which may give you a headache as a side effect. This can be relieved by taking paracetamol half an hour before using the cream.
The second ointment is Diltiazem and the most common side effect of using this is itching around the back passage.

These creams are often used for 6-8 weeks. After this you see the surgeon again to ensure the fissure has healed. A second course of these ointments may be required. Some fissures, if they do not respond to these methods, may require an operation.

What does surgery involve?

A common operation for this condition is to inject Botox (similar to that injected in the face to reduce wrinkles) around the sphincter muscles of the anus. This can help heal the fissure in some cases. Repeated injections may be required to get the fistula to heal. The most common complaint with Botox is an inability to control the passage of wind immediately following the injection and some leakage from the back passage. Another operation commonly used is a lateral anal sphincterotomy. This involves cutting a part of one of the anal muscles which helps the fissure to heal by preventing pain and spasm and which improves the blood supply to the skin. Cutting this muscle rarely interferes with the ability to control bowel movements and can often be performed without an overnight hospital stay. It is often used if botox fails to help the fistula to heal

Anorectal bleeding

Anorectal bleeding refers to any bleeding that occurs from the back passage. It is an extremely common condition. In the large majority of cases, it is coming from the anal canal and is not serious at all. Doctors try to tell the difference between anal bleeding (coming from the back passage) and rectal bleeding (coming from further up the bowel).

What is anal bleeding?

Anal bleeding is nearly always due to benign conditions, usually haemorrhoids (“piles”) or fissures.
The blood is usually bright red and fresh as though you had been cut. It usually occurs when your bowel has been moved but is sometimes seen as a stain on the bedclothes or underwear.
When it occurs with bowel movement, it may be slight (seen as a smear on the toilet paper) or heavier when it discolours the water in the toilet bowl. Sometimes, it will splash the bowl or even drip into the toilet after the motion has passed.

Although the blood may coat the motion, it will not be mixed in with it
Bleeding from a fissure may be quite painful while hemorrhoids are either painless or associated with only mild discomfort.

What is rectal bleeding?

When the blood is dark or clotted or mixed in amongst the bowel motion, it is possible that the blood is coming from further up inside the bowel.
While many of the causes of this type of bleeding are still innocent, it may be due to a more serious disease. The most serious of all is cancer of the bowel but it may also be coming from polyps arising from the bowel lining or inflammation of the bowel.
All of these more serious conditions can be satisfactorily treated and cancers can be cured. However, it goes without saying that the sooner they are identified the more likely it is that they can be effectively treated.

When should you report bleeding from your back passage?

You should report almost any episode of bleeding to your doctor if you have not had prior episodes.
However, if it is bright red and associated with short-lived pain and passing a hard stool, it is highly likely to be due to a small tear in the back passage.
It is particularly important to report if it is associated with a change in your normal bowel pattern or a sense of incomplete emptying of your bowels.

What will your doctor do?

Having asked you a number of questions, he or she will want to examine your back passage.
You will be asked to lie on your left side, to allow the doctor to have a careful look at the skin around the back passage. He will then insert a gloved finger into the back passage. This is done gently and is much less painful than many people imagine.

Depending on whether you are being seen by your GP or by a specialist, further tests may include proctoscopy, rigid sigmoidoscopy, flexible sigmoidoscopy, colonoscopy or CT scans.

What do these tests involve and what are they for?

• Proctoscopy allows direct inspection of the anal canal to see if there are haemorrhoids present. It feels almost the same as the examination with the finger. Many GPs will do proctoscopy in the surgery but may refer to a specialist if they think that one or more of the other tests are required.
• Rigid sigmoidoscopy, flexible sigmoidoscopy and colonoscopy are all tests where the lining of the bowel is inspected directly via a telescope. They differ from each other in how much of the bowel can be seen, how long they take and where they are done. The specialist will advise which of the tests is required and explain what is involved.
• Colonoscopy is a test which allows the doctor to inspect the whole length of the bowel.

Anterior resection

An anterior resection is an operation is to remove the rectum or a part of it.

What is the rectum?

The rectum forms part of the large bowel following on after the colon. It is the lowest part of the digestive system, near your bottom, and it stores waste material. The emptying of the rectum is controlled by the anal sphincter muscles of your ‘back passage’.

What happens during the operation?

Your operation can be done in two ways. It can be done as an ‘open’ operation which means there will be one long incision (cut) down the middle of your abdomen (tummy). The other way is by laparoscopic (keyhole) surgery using a few small incisions.

After removing the portion of the rectum, the surgeon will join the two healthy ends together using either a series of sutures (stitches) or staples. This is called an anastomosis.
Whether you have open or laparoscopic surgery will depend on many things. Each case has to be looked at individually so you will need to discuss your options with your surgeon and find out which way of operating is best for you.

If you have a laparoscopic (keyhole) operation.

Your surgeon will make four or five small (one centimetre) cuts in your abdomen. They will put a telescope camera into one of these small cuts to show an enlarged image of the organs in your abdomen (on a television screen). The other cuts allow the surgeon to use special operating instruments. Your surgeon will make one of the cuts longer (8 to 10 cms) so they can remove the portion of the bowel they have operated on. Sometimes it is not possible or safe to finish the operation using laparoscopic surgery. If so, your surgeon will change to an ‘open’ operation and make a larger incision to deal with this.

Will I need any special preparation before surgery?

You will have investigations and tests to prepare you for your operation. These are to confirm the diagnosis, to see how far the disease has spread, and to assess how fit and well you are for the proposed treatment.
It is likely, though not always the case that you will have to take a special prescribed drink (oral bowel preparation) in the 24 hours before the operation. You may be given this to take at home before you go into hospital, or you may be given it in hospital. If you take the bowel preparation while you are at home, make sure you can get to a toilet easily since it will mean you will need to empty your bowels quite often and you may need to rush to the toilet. You should only drink clear fluids such as water or flat lemonade, although the specialist nurse may give you, high-energy drinks.

Will I need to have a stoma (bowel bag)?

Patients often need to have a stoma, and even more so if they have had chemotherapy or radiotherapy leading up to the planned operation. A portion of the bowel is brought out onto the abdomen to form an opening outside the body, known as a stoma. A stoma bag is then fitted around this opening to collect the contents of your bowel. The stoma ‘rests’ the anastomosis (the join where the bowel is connected back together) allowing it to heal and also provide time for you to fully recover. Despite the presence of a stoma you may pass a little old blood or mucus from your back passage.

The stoma may be permanent or temporary.

If you need a stoma or it is possible that you may need a stoma, you will be seen by a stoma nurse. These specialist nurses are skilled in caring for patients who have a stoma and will be able to answer any questions you may have.

Are there complications with this operation?

The risks of this operation are small and much less likely to affect you than the risk of doing nothing. However, this is a major operation and some people (less than 5%, or fewer than 1 in 20) do not survive the surgery.

There are sometimes complications. These may include:

• Bleeding
• Infection
• A leak from the anastomosis (the join where the bowel is connected back together)
• Injury to other organs within the abdomen (for example, the small intestine, ureter or bladder)
• Problems passing urine (though this is usually only temporary)
• A lack of sexual desire and, in men, a difficulty in achieving an orgasm and maintaining an erection (though this is usually only temporary)
• Deep vein thrombosis (blood clots in the veins in the legs), or
• Pulmonary embolisms (blood clots in the lungs)

You may also experience the following:

• A sore bottom
• If you did not need a stoma, you may have difficulty in controlling your bowels in the first few weeks after surgery, which may mark your underwear. It may be helpful for you to do some pelvic-floor exercises. These will help the muscles in your bottom cope with having a part of your back passage removed. Sometimes it takes several weeks to get back to normal, and occasionally you may have to adjust your diet.
• Anxiety due to the whole situation

What should I expect after surgery?

Immediately after the operation (within the first 24 to 48 hours), you will need:
• Oxygen through a face mask
• A drip into a vein in one of your arms to give you fluid
• A catheter (tube) in your bladder to drain away urine, and
• Medication to deal with pain from the incision – this may be given as an epidural (where the medicine is given through a fine tube in your back) or through the drip
Later (the following day or so), you will need to:
• Start eating again, starting with liquids and gradually introducing solid foods, and
• Move around as soon as possible

If you have laparoscopic surgery, you may well recover more quickly after surgery and go home sooner.

How long will I need to be in hospital?

You will stay in hospital for as little time as possible, usually for between five and seven days. Your surgeon or specialist nurse will discuss with you the daily achievements that you should try to meet. This programme is called ‘enhanced recovery after surgery’ (ERAS).
If, after you leave hospital, you have any new concerns or problems (for example, severe abdominal pain, a raised temperature or bleeding from your back passage) it is important to contact your own doctor (GP) or the hospital. You will be given contact numbers when you leave hospital

Bowel cancer screening

This is a way to pick up bowel cancer when it is relatively easy to cure and before it gives rise to symptoms.

Is bowel cancer important?

YES. After lung cancer, bowel cancer kills more people in Britain each year than any other form of cancer. That is – it kills more people than breast cancer; it kills more people than cancer of the prostate; and it kills more people than cervix cancer. Yet it is often forgotten and rarely talked about.

What is screening and how does it work?

Screening aims to detect a disease before symptoms appear. For cancer, this might mean catching it at an earlier stage, when treatment offers a better chance of cure.

How can you screen for bowel cancer?

Most bowel cancers bleed to a greater or lesser extent. A special test (“faecal occult blood test”) that detects tiny amounts of blood in the bowel motion has been proven to detect cancers at an earlier stage.
We currently have two arms to screening in the UK. The first is a one-off test called bowel scope screening which is currently being offered in England to men and women aged 55 years. During this a thin telescope is passed into the left side of the bowel and it identifies any cancer and allows removal of any growths called polyps that may in the future become cancerous.

The second uses the faecal occult blood test (FOBt) and is offered to men and women aged 60-74 years (with the exception of Scotland where FOBt screening starts at 50). This test is very easy to perform. Every 2 years a kit is sent to your home in the post for you to perform and return. After the age of 74 you can request a kit if you wish every two years. If your test is positive you may be called for a telescope test of the bowel called a colonoscopy. For every 1000 people screened only 16 need this procedure and only 2 will have a cancer.

It is important to note that even if your bowel scope test is normal you must still participate in FOBt screening to ensure you get the most benefit out of screening. If following a screen test you notice new symptoms such as change in bowel habit or bleeding you should still see your doctor

Does screening for bowel cancer work?

YES. Many studies have proved that people with bowel cancer detected by screening using “faecal occult blood tests” and bowel scope screening are more likely to be cured than those who wait for symptoms to develop.

What are the benefits of screening?

You may be one of those who has a bowel cancer growing that has not yet produced symptoms. In general, bowel cancers detected by screening have a better outlook than cancers found in people with symptoms.

What are the disadvantages?

It is important to know that the majority of people with a positive bowel motion test have nothing seriously wrong with their bowel. However, once the bowel has been checked out they can have peace of mind.
Although the bowel motion tests are better at predicting cancer than any symptom, sometimes patients with cancer can return a negative test. Therefore, you should always report any worrying bowel symptoms to your doctor.

The most important are: bleeding from the back passage and change in the normal bowel pattern, particularly when these have continued over a six week period or more

Bowel incontinence

Bowel incontinence is when you are unable to control your bowel movements. It is a very common condition that many people suffer from without getting treatment because of embarrassment.

What is bowel incontinence?

Also called faecal incontinence, it is the uncontrolled loss of solid or liquid stools, or the loss of wind (gas) with some leakage.
It is very common. About half a million adults in the UK cannot control their bowels properly. Bowel incontinence (BI) affects 1 in every 70 people over 40 years old. This figure rises to nearly 1 in 40 of those over 65.
It may also affect young people. After having a baby, more than 1 in 10 women have a tear which may result in difficulty in controlling their bowels. Tears are more common in older mothers (over 35), if the baby is large or if assistance with forceps or a suction cup is needed.

Few conditions are more embarrassing or create more anxiety. BI can result in an almost constant fear that another episode may happen. As well as the distress, this fear may restrict what the patient feels able to do during the day. Many people with BI remain untreated for years as they are too embarrassed to ask for help. This is a great pity as for a lot of people there are simple measures to prevent BI as well as treatments to help, or even cure the problem.

What are causes of bowel incontinence?

The causes of incontinence can be divided into a three main categories:

1. Rectal – The rectum is the part of the large bowel that acts as a reservoir, holding faeces until you are ready to go to the toilet. Any problem with the rectum or the way in which it works may lead to incontinence. This may include proctitis (inflammation due to Crohn’s disease or Ulverative Colitis).
2. Anal sphincter – The anal sphincter is the muscle at the very bottom of the anus which keeps faeces within the rectum until we are ready to open our bowels. Damage to the sphincter (as described above during child birth) may cause incontinence.
3. Nerves – Nerves send signals from the rectum to the brain and from both the brain to both the rectum to the sphincter muscles. Any problems with theses nerve pathways may lead to a degree of incontinence.
Sometimes a patient may suffer from a combination of problems occurring together.

How is bowel incontinence investigated?

Often your surgeon will ask you about your symptoms (sometimes you may be asked to complete a questionnaire), and whether you have any other ongoing medical problems. If you are female they may also ask you about your experiences during child birth. It is common for the surgeon to examine you by looking at your anus and the surrounding area to check for scars and carry out a rectal examination (inserting a gloved finger into your bottom). They may also ask you to squeeze your anus around their finger to assess how well the muscles in your anus are working.
There are several investigations that your surgeon may refer you for, including endoscopy (camera test of the bowel to look closely at you rectum in particular), Anal manometry (a probe passed into the anus and used to assess how well the muscles and nerves in and around your rectum are working), Anal ultrasound (ultrasound probe used to detect damage to the sphincter muscles) and defecating or MRI proctogram (a study used to see how you pass stools). A proctogram involves dye, called barium is placed into your rectum. The barium helps make it easier to highlight problems using an X-ray. Once the barium is in place, you’ll be asked to pass stools in the usual way while scans are taken. This test can also be carried out using a magnetic resonance imaging (MRI) scanner instead of an X-ray.

What is the treatment of incontinence?

The treatment of BI depends upon what the actual cause is. Your surgeon will explain what they think the cause is and tailor your treatment accordingly. Most people improve with the use of simple medical treatments or specific exercises aimed at getting your rectum and sphincters to work better together (often called biofeedback). Occasionally patients require surgery. If this is the case your surgeon will explain the type of operation that will be aimed at improving your symptoms

Colonic cancer (bowel cancer)

Colonic cancer can occur anywhere in the colon. The cells that line the colon may become damaged such that they begin to divide in an uncontrolled way. This may lead to the formation of a polyp or eventually a cancer. It is the third most common cancer in men and the second most common cancer in women in the UK with 40,000 cases diagnosed each year.

What are the symptoms?

Common symptoms include:

• Bleeding from the back passage
• A change in the frequency of bowel activity
• Abdominal pain
• Weight loss and poor appetite
However these symptoms are very common and are usually NOT due to colonic cancer.

How is the diagnosis made?

To make a diagnosis of colonic cancer it is essential to examine the colon either with a flexible telescope (flexible sigmoidoscope or colonoscope) or a special test called CT colonography. During colonoscopy if a cancer is seen a tiny portion of tissue (biopsy) is taken from the cancer for laboratory examination and a tattoo is often placed. In addition a CT scan will be arranged to examine the lungs and liver to check that the cancer has not spread.

How can it be treated?

The best chance of curing colonic cancer is with an operation which aims to remove the segment of colon with the cancer in it along with the blood supply and lymph nodes (glands) that supply it. The type of operation will depend on the location of the cancer.

• Right hemicolectomy involves removing the appendix and colon on the right side of the body and joining the small bowel back up to the colon so that the bowel functions normally.
• Left hemicolectomy or sigmoid colectomy involves removing the colon on the left side of the body and joining the bowel back up together so that the bowel functions normally.
• Subtotal colectomy involves removing the whole colon and usually joining the small bowel to the rectum.
These are the commonest types of operations but there are others which may be discussed and can be fully explained by your surgeon.
These operations can be done with single large incision (open surgery) or multiple small incisions (‘key-hole’ or laparoscopic surgery). The way in which the operation is to be performed depends on a number of factors relating to you, the cancer and your surgeon.

Is a stoma necessary?

A colostomy , or artificial opening of the colon on to the abdominal wall is NOT usually necessary in these operations. The possibility of requiring a stoma will be discussed with you and if it is required then you will get all the support that you need.

Are there any other forms of treatment?

Chemotherapy: Once you have recovered from your surgery and the cancer has been thoroughly examined by the pathologist it may be appropriate to recommend a course of chemotherapy. This will depend upon your general state of health and the stage of the cancer. The stage of cancer gives an indication as to whether the cancer has spread to other organs (usually the glands close to the bowel, the liver or lungs). The stage of cancer is assessed by a combination of the tests that you had before your operation (CT) and the pathologist’s opinion when the cancer is examined under the microscope. If chemotherapy is recommended then you will be able to discuss it further with a specialist in this field (oncologist).
Liver surgery: If the cancer has spread to the liver it may still be possible to attempt to cure the cancer by removing a segment of the liver at an operation. If this is recommended then you will be able to discuss it further with a specialist in this field (hepatobiliary surgeon).
Colostomy: Some cancers can cause a blockage to the bowel and it may be recommended that a colostomy be performed to prevent this. This is particularly the case if you are very frail or the cancer has spread to many other organs.
All treatment options will be discussed fully with you and, with your permission the people important to you, before any decisions are made.

What are the chances of cure?

Appropriate surgery offers the best chance of cure possibly combined with chemotherapy. The earlier the cancer is detected and treated then the more likely the cure. In early cancers the cure rate is greater then 90%, in cancers at a more advanced stage then the chances of cure are less than 50%.

Will I need to be seen again?

You will be checked on a regular basis following your treatment. The frequency with which you will be seen will depend on the stage of cancer and will be tailored to your own particular circumstances. This will usually include visits to the clinic, CT scans and colonoscopy

Crohn’s disease

Crohn’s disease causes inflammation in part of the gut, most commonly the lower part of the small bowel, called the ileum, but it can affect any part of the digestive tract from the mouth to the anus. The inflammation can cause pain and make the bowel empty frequently, resulting in diarrhoea.

What causes Crohn’s disease?

Nobody is sure what causes Crohn’s disease. The most popular theory is that the body’s immune system reacts to a virus or bacterium by causing ongoing inflammation of the bowel.

What are the symptoms?

The most common symptoms are abdominal pain, often in the lower right abdomen, and diarrhoea. Rectal bleeding, weight loss and fever may also occur.

How is the diagnosis made?

After listening to you and doing a general examination your consultant will usually examine the rectum (back passage) with a finger. Investigations may include:

• An inspection of the bowel with a telescope (sigmoidoscopy or colonoscopy)
• A laboratory examination of your stool samples to see if there is infection or inflammation
• Blood tests
• A barium x-ray examination of your bowel
• An MRI scan of your bowel

Crohn’s disease is often difficult to diagnose because its symptoms are similar to other bowel disorders such as irritable bowel syndrome or ulcerative colitis.

What is the treatment for Crohn’s disease?

This depends on the location and severity of disease, complications and response to previous treatment. The goals of treatment are to control inflammation, correct any nutritional deficiencies and relieve symptoms. Treatment may include drugs, nutrition supplements, surgery or a combination of these.
Drugs

• Steroids such as prednisolone are often prescribed for moderate to severe attacks of Crohn’s disease to damp down the inflammation. Steroids may be given as tablets by mouth, enemas, rectal foams or suppositories via the back passage. Severe attacks will be treated in hospital with steroids given via a vein into the blood stream.
• Another drug, cyclosporin, is sometimes given with intravenous steroids.
• Sulphasalazine, mesalazine or olsalazine are often given during an attack and for long-term use to keep the disease in remission. These drugs may be given as tablets, enemas or suppositories.
• Azathioprine is used for a few patients with long term active disease who would otherwise need repeated courses of steroids.
• Antibiotics may be used to treat bacterial proliferation in the small bowel caused by bowel narrowing. Diarrhoea may be controlled with drugs that slow the bowel down such as loperamide, or codeine.
Anti-TNF drugs are another group of drugs that can be given to try and prevent inflammation. These drugs are only used in a few patients with severe disease and are given by a Gastroeneterologist.

What problems can occur in Crohn’s?

The most common complication is blockage of the bowel. This occurs because the disease tends to thicken the bowel wall, narrowing the passage. The disease may also cause sores or ulcers that tunnel through the affected area into surrounding tissues such as the bladder or skin. These tunnels are called fistulas and may require an operation to correct.

Will I need an operation?

People with Crohn’s disease may feel well and be free of symptoms for long periods when their disease is not active. Many people with Crohn’s disease will require surgery at some point, either to relieve symptoms that do not respond to medical therapy or to correct complications such as blockage, fistulas, abscess or bleeding. Surgery to remove part of the intestine can sometimes help people with Crohn’s disease but cannot cure it. These operations can be done with single large incision (open surgery) or multiple small incisions (‘key-hole’ or laparoscopic surgery). The inflammation tends to return next to the area of intestine removed. Your Consultant, General Practitioner and Specialist Nurse can give you more information if surgery is contemplated

Is a stoma necessary?

A stoma (colostomy, ileostomy), or artificial opening of the colon/small bowel on to the abdominal wall is NOT always necessary in these operations but can be required either on a temporary or permanent basis. The possibility of requiring a stoma will be discussed with you and if it is required then you will get all the support that you need

Diverticular disease

Diverticular disease is a very common condition affecting the colon. (The colon is often called the large intestine or lower bowel). It is very common. More than half of people aged over 70 in Britain have the condition.

It gets its name because, in this disease, the colon forms many ‘diverticula’. Diverticula are small pouches created when the thin lining of the bowel protrudes through narrow gaps in its wall. The wall is also often thicker than normal. Only a small minority of patients (around 10-20%) develop any problems due to the pouches.

How and why does it develop?

It is likely to be due to our diet. Native African people rarely develop this condition, probably because of their high intake of dietary fibre (‘roughage’).
When there is little fibre in the diet, the stools are often small and hard. This can cause the pressure in the colon to increase forcing the pouches through the bowel wall.

What are the symptoms?

Most people have no symptoms. But, because the wall is thicker, the tube is narrower. This can cause pain in the lower part of the stomach, often on the left side. The bowels may become irregular, sometimes with hard pellety stools and there is often a sensation of bloating. Some patients report loose motion. The pouches can also cause bleeding.

These symptoms can also occur in other important bowel diseases, particularly irritable bowel syndrome (IBS) and bowel cancer.

Is it dangerous?

Occasionally, the diverticula can become infected. This is a condition called ‘acute diverticulitis’. It leads to more severe pain often on the left side and a fever along with feeling unwell. It may require hospital admission but usually gets better with antibiotics.
Very rarely, the infection leads to an abscess (collection of pus) or even perforation (a hole in the bowel) of the bowel. Usually patients with these conditions have severe pain, and require admission to hospital. However surgery for Diverticular Disease is hardly ever required. Out of a hundred people with the condition, no more than one will ever need an operation.

Are tests needed?

Although Diverticular Disease is much more common, the symptoms it causes can mimic those of bowel cancer. So tests are often done mainly to rule out cancer.
The usual test that is done is either a telescope examination (colonoscopy or flexible sigmoidoscopy) or a CT scan. Occasionally both are required.

Is treatment required?

Reassurance that the symptoms are not due to a serious disease like bowel cancer is often enough.
A diet with extra fibre may prevent the condition from getting worse but won’t get rid of the diverticula that are already there.

A high fibre diet often improves the symptoms but occasionally will make them worse. Your symptoms are what count, not how much fibre you are eating.
Several foods are high in fibre – cereals, whole-meal bread, and fruit.
‘Medicinal’ fibre can be bought from the chemist or prescribed by a doctor.

Is an operation ever needed?

Yes, but it is rare. If the bowel tube becomes very narrow (‘stricture’) the symptoms can be severe enough to warrant surgery to prevent a complete blockage.
Occasionally, the bowel sticks to the bladder or vagina and makes an unnatural connection between the two known as a fistula. This occurs rarely but usually requires an operation to fix it. Another reason for surgery is if you have recurrent admissions to hospital due to infections. The decision to operate is made on an individual basis after your surgeon assesses your particular circumstances. These operations can be done with single large incision (open surgery) or multiple small incisions (‘key-hole’ or laparoscopic surgery).
Urgent surgery is sometimes needed for the most serious complications of diverticular disease such as abscess or perforation

Haemorrhoids (piles)

Haemorrhoids are often known as ‘piles’. Normally, ‘vascular cushions’ (blood-filled sacs or veins) act as a seal in the back passage, just like the washer in a tap. When these enlarge, they are known as piles when they can protrude (stick out) and bleed. They are very common. We think that at least one person in three in Britain will suffer from this condition at some stage in their life.

How do piles develop?

When the pressure in the veins of the back passage increase, piles may develop. The pressure may be caused by:

• Constipation, particularly prolonged attempts at straining to pass hard stools
• Pregnancy and childbirth

What ‘types’ of piles are there?

Internal piles: These are inside and may cause no symptoms and are a frequent cause of bleeding from the back passage.
Prolapsing piles: These are sufficiently large that they ‘come down’ during defaecation. They will either spring back after or have to be pushed back.
External piles: These are ‘out’ all the time. They are different from the very common finding of flaps of skin (‘tags’) around the back passage. It is these skin tags that people often refer to as their ‘piles’.

What are the symptoms?

Bleeding from the back passage: This is the commonest symptom. The blood is usually bright red and separate from the stool.
Lumpiness around the back passage: These may occasionally be external piles but are much more likely to be tags of skin. They may swell up and become painful from time to time (‘an attack of piles’). Sometimes they make it difficult to get properly clean after a bowel movement. Often they cause no trouble at all.
Prolapse: The piles sometimes protrude during defaecation. They may need to be pushed back inside.
Pain: Piles often cause discomfort but are not very often acutely painful. If you have a severe pain during defaecation associated with bleeding, it may be due to a tear in the back passage (‘anal fissure’).
Itching and soreness: Although this is a common symptom in people with piles, it is often not due to the piles themselves. It is often due to a skin condition around the back passage rather than the piles.

Are piles dangerous?

No. They can often be troublesome and require treatment but are almost never life-threatening.

Are tests needed?

Although bleeding from the back passage is usually due to piles, bleeding can also be an important warning symptom of bowel cancer. So tests are often done mainly to rule out cancer.
The usual test that is done is either an scan of the bowel (CT scan) or a telescope examination (colonoscopy or flexible sigmoidoscopy).

Is treatment required?

Reassurance that the symptoms are not due to a serious disease like bowel cancer is often enough.
A diet with extra fibre may help those with a tendency towards constipation. This change in diet and stool consistency is often enough to stop the symptoms, particularly if the symptom is bleeding. For persisting troublesome symptoms, the piles can often be treated by applying small rubber bands around the base of the piles (causing them to fall away). This can often be done in the outpatient clinic.

Is an operation ever needed?

If the piles are too big for the banding treatment (or it doesn’t work), the piles can be surgically removed. This is called a ‘haemorrhoidectomy’ and is a simple operation that can often be carried out as a day case procedure.
An alternative procedure is a haemorrhoidal artery ligation operation (HALO). This procedure involves stitching the haemorrhoids blood vessels and part of the inside lining of the bowel to make the haemorrhoids shrink inside the bowel

Having a stoma

A stoma is a term used to describe an external opening of the bowel onto the abdominal (tummy) wall. Faeces (stool) will then leave the body through the stoma into collecting pouch (stoma bag).

How is it created?

The operation is performed by your surgeon. The bowel is brought up to the surface of your abdomen through a small tunnel. The bowel is then opened to expose the inside lining and held in place with absorbable (dissolvable) stitches. Occasionally a small rod or bar may be temporarily placed under the stoma to hold it in place whilst the wound heals. This is usually removed before you go home.

Where is it sited and are there different types of stoma?

Commonly, a stoma will be sited on either side of the abdomen depending upon the type of stoma required and which part of the bowel is used.
There are several different types of stoma. The place and type will depend on the reason for your operation. A stoma created from small bowel is called an ileostomy whilst a stoma created from large bowel is called a colostomy.

Some stomas are temporary whilst others may be permanent, the exact type of stoma you have will be explained to you by your surgeon and a stoma care nurse. A temporary stoma may be sited, at the time of surgery when part of the bowel is removed, so as to rest the bowel anastomosis (join) allowing it to heal more securely. In this case you will have a special x-ray study about 2 months after your operation to confirm that the anastomosis has healed and it is safe for your stoma to be closed. Your surgeon will advise you about this also.

What does it look and feel like?

The stoma is usually round in shape and will be pink and moist rather like the lining of your mouth. It has no nerve supply so it will not be painful. After surgery your stoma may be a little swollen though it will settle quite quickly. Colostomies are flat whilst ileostomies usually protrude 2-4cm from the skin. Both are covered by a bag which will collect any faeces.

Who will teach me to use my bag?

Your stoma care nurse is trained to help and teach you to look after your stoma. Usually, before your operation, you will be shown a stoma bag and the stoma care nurse will mark on your abdomen where it will be placed. After the operation the stoma care nurse will visit you on the ward and help you to learn to look after the stoma and how to change the bag.
Before you go home your stoma care nurse will advise you as to what type of bag you need as well as inform you as to how to order new supplies. These will be prescribed by your GP. You may receive home visits, after discharge from hospital, by the stoma care and community nurses.

How do I clean my stoma?

The stoma can be cleaned with warm water and then the surrounding skin should be dried well. Once you have done this the new bag is applied. You will not need to use soaps or creams as this may cause skin irritation and the bag may not stick. Sometimes it will bleed a little, but this is the sign of a healthy stoma and you should not be alarmed.

Are there different types of stoma bags?

There are many types of stoma bags though it is best to gain confidence by getting used to one type to start with. Your stoma care nurse will be able to advise you as to the best type of bag for you.

Can I go in the shower or bath or swimming after the operation?

Once the wound has healed you should be able to bath and shower and carry out your other normal activities. Stoma bags are waterproof so you may have your bag on or off when you bath or shower. Remember when you clean your stoma to make sure you dry the surrounding skin well before applying your new bag. If you go swimming or on holiday your stoma care nurse can advise you on the best bag to use as there are smaller bags available.

Will I need to have a special diet?

No, not especially. You may be advised to have a restricted diet for the first couple of months but then you should be able to return to your familiar diet of varied foods. However, there are foods that may cause excessive wind and blockages of the bowel and it is best that they are avoided.

What if my stoma bag leaks?

A leak should be a very rare occurrence. If you are having problems like this and are finding that regular leaks are reducing your lack of confidence in being able to go out and about then you should visit your stoma care nurse for a review of the system of bag you are wearing.

What about intimacy/sex?

Patients are often concerned about how their stoma may affect sexual relationships. Having a stoma does not prohibit intimate relations. Open conversations and sharing of your worries with your partner will help overcome most of this hesitance. However, if you have difficulties they can be discussed with your stoma care nurse or doctor.

Can I have children?

Many women with stomas do conceive and have successful pregnancies but it is always advisable to discuss your plans with a stoma care nurse and doctor beforehand. For men, there may be initially problems with erection or ejaculation but these are usually temporary. If these symptoms persist seems, then you may need to talk to your doctor.

How soon should I go back to work?

This normally depends upon you, your general health, the type of surgery you had and the type of work you do. Discuss this with your stoma care nurse for their guidance. It is best to avoid heavy lifting or strenuous exercise until you have built up your strength gently after surgery.

IBD or IBS?

Conditions that cause inflammation of the intestines, such as Crohn’s disease or ulcerative colitis, are known as inflammatory bowel disease (IBD). This shouldn’t be confused with irritable bowel syndrome (IBS), which is a different condition and requires different non-surgical treatment. However, some people with IBD can also have IBS.

Inflammatory bowel disease (IBD)

IBD is a term mainly used to describe two conditions, ulcerative colitis and Crohn’s disease.
Both ulcerative colitis and Crohn’s disease are long-term (chronic) conditions that involve inflammation of the gut (gastrointestinal tract). Ulcerative colitis only affects the colon (large intestine), while Crohn’s disease can affect all of the digestive system, from the mouth to the anus.
It’s sometimes difficult to tell the difference between the two main types of IBD. If this is the case, it’s known as indeterminate colitis.

There are other, less common types of IBD called collagenous colitis and lymphocytic colitis. The inflammation can only be seen using a microscope, and so they’re known as microscopic colitis.

Irritable bowel syndrome (IBS)
IBS is a common, long-term condition of the digestive system. It can cause bouts of stomach cramps, bloating, diarrhoea and/or constipation.
The symptoms vary between individuals and affect some people more severely than others. They tend to come and go in periods lasting a few days to a few months at a time, often during times of stress or after eating certain foods.

You may find some of the symptoms of IBS ease after going to the toilet and opening your bowels.
IBS is thought to affect up to one in five people at some point in their life, and it usually first develops when a person is between 20 and 30 years of age. Around twice as many women are affected as men.
The condition is often lifelong, although it may improve over several years

Laparoscopic colorectal surgery

Laparoscopic colorectal surgery avoids the need for a long incision (cut) in the abdomen (tummy) and so there is significantly less pain after the operation from the wound. It also means that you stay in hospital a shorter time (a matter of days) and can return to normal activities in a few weeks.

What is the colon and rectum?

The colon and rectum refers to the large intestine or bowel. It forms the lowest part of the digestive system after the small bowel and it ends at the anus.

What is laparoscopic colorectal surgery?

Laparoscopic or ‘keyhole’ surgery allows the surgeon to carry out operations through four or five small (one-centimetre) cuts in the abdomen (tummy). A telescope camera, put into one of these small cuts, shows an enlarged image (picture) of the internal abdominal organs on a television screen. The other cuts allow the surgeon to use special operating instruments. In some cases, one of the cuts may be made longer (to eight to 10 cms) to allow a bowel specimen (sample) to be removed and the procedure to be finished.

What are the advantages of laparoscopic colorectal surgery?

Results vary depending on the type of procedure and your overall condition. Common advantages include:
• Less pain after the operation
• A shorter hospital stay
• A quicker return to eating, drinking and bowel function (going to the toilet normally)
• A quicker return to normal activity, and
• Less scarring after the operation

Could I have laparoscopic colorectal surgery?

Although there are many benefits of this type of surgery, it is not always possible for every patient. Each case has to be looked at, so you will need to discuss this option with your surgeon and find out if this way of operating is best for you.

Will I need any special preparation before surgery?

You will have the same investigations and tests to prepare you for your operation as
patients who have ‘open’ surgery. These are to confirm the diagnosis and extent of the
disease and to assess how fit and well you are for the proposed treatment.

How is laparoscopic colorectal surgery performed?

Laparoscopic surgery is the name given to the telescopic method a surgeon uses to enter the abdomen. The surgeon will, through a small cut often close to your tummy button, place a cannula (hollow, needle-like tube) and pass gas (carbon dioxide) through this. The gas fills the abdominal cavity, making a space into which the surgeon can place a laparoscope (a narrow telescope joined to a video camera). The surgeon then sees a magnified or enlarged view of your abdominal organs on a television screen. Other cuts give access (ports) to place specially designed operating instruments inside so the operation can be carried out. If a part of the bowel is to be removed, one of the cuts is enlarged. The surgery usually takes two to three hours.

What happens if the operation cannot be carried out or finished using the laparoscopic method?
For some people, the laparoscopic method cannot be performed safely or well enough. Factors that may increase the possibility of choosing or changing to the ‘open’ procedure during the operation include:

• Being very overweight
• A history of abdominal surgery which has caused a lot of scar tissue
• Where the surgeon cannot see the organs clearly
• Bleeding problems during the operation, and
• Large tumours

Your surgeon will decide to carry out surgery using the open procedure either before or during the operation. You should be prepared for the possibility that the surgeon may have to go back to open surgery during your operation.

What should I expect after surgery?

Immediately (within the first 24 to 48 hours), you will need:
• Oxygen through a face mask
• Intravenous fluid using a cannula (drip) into a vein in one of your arms
• A catheter in your bladder to drain urine, and
• Medication to deal with mild pain

Procedure for prolapse and haemorrhoids (PPH)

This operation is also known as stapled anopexy. A specially designed circular stapling instrument is inserted through the anus (back passage) into the rectum.
The operation pulls the swollen and prolapsing blood vessels of the haemorrhoids (piles) back into their normal position by removing a circumferential section (complete ring) of the internal rectal lining. The wound is inside the rectum causing little pain.

Why do I need operation for piles?

Your surgeon would have discussed with you the various treatment options for piles. Surgery is uncommon. Treatment usually aims at diet improvement by increasing fluid and fibre intake and through avoidance of spending long periods of time or straining when using the toilet. If these measures are unsuccessful then piles can be injected or banded; a procedure performed at an outpatient clinic appointment. When this fails or if the piles start to prolapse then an operation is advised.

Why PPH?

Several studies have shown that the PPH operation is as effective as surgical removal of piles (haemorrhoidectomy) with the additional benefits of being associated with:

• Less post-operative pain
• A faster recovery time
• Shorter hospital stay
• Early return to normal activities and improved patient satisfaction

Do I need bowel preparation?

Yes. You are may be required to have an enema or be given suppositories to insert in your back passage to help empty your rectum before surgery.

Will I need to stay in hospital?

The PPH operation is usually performed as a day case procedure allowing you to return home the same day. Either a general or regional (epidural, spinal) anaesthesia is used. Your surgeon and anaesthetist will discuss these choices with you.

Are there any complications with this operation?

There are risks as with all operations. Approximately, 1 in 15 (5-8%) patients may have further piles in the future. The complications after PPH include:
• Pain
• Bleeding
• A persistent urgent need to go to the toilet with some leakage
• Narrowing of the back passage (stricture)
• Rarely severe pelvic infection, and
• In females, fistula formation (false channel) between the rectum and vagina

What am I to expect, at home, after the operation?

Although the PPH operation is less painful than haemorrhoidectomy surgery, you may have discomfort within the back passage during the first few days after your operation. You will be given simple pain relieving medicine, by your surgeon or a specialist nurse, to take when you are at home. You may have an urgent need to open your bowels even though there is nothing coming out. When you do go to the toilet there may be some bleeding though this usually stops within a few days.

What will happen to the staples?

The titanium staples used are very small; only a few millimetres long. Over a period of weeks and months some of them may pass during a bowel action. Most, though, remain at the operation site for ever. They will not cause difficulties and will not affect metal detectors during security check at airports.

Lateral anal sphincterotomy

Lateral anal sphincterotomy is an operation to treat an anal fissure. An anal fissure is a tear or split in the skin lining of the anus, just inside the back passage.

Is the operation necessary?

Sometimes an anal fissure will not heal, even if you are using the medicated creams and stool softeners recommended by your doctor. You may continue to have uncomfortable symptoms. If this is the case, surgery can help. Your surgeon will discuss this choice with you.

What happens during the operation?

The operation is often done under a general anaesthetic. This means you will be asleep during the procedure and will feel no pain. Your surgeon will first make a small cut in the skin of your anal canal (back passage) to reach the anal sphincter (the muscle around your anal canal). This ring of muscle controls the opening and closing of the anus. The surgeon will then make a small cut in the sphincter to relax it and stop it going into spasm. This will allow the fissure to heal.
The small skin wound may be stitched or left open to heal naturally. Afterwards a pad or dressing will be put onto your anus to help stop the bleeding. Usually you will feel well enough to return home the same day, but sometimes you may need to stay in hospital overnight.

Are there any risks associated with cutting the sphincter muscle?

The cut in the sphincter muscle should not mean that the anus opens too easily, but very rarely the cut may affect your ability to control your bladder and bowels. The effects are usually minor and do not need to be treated.
If the sphincter muscle is damaged during the operation, you may need to have more surgery to correct the problem. This is very rare.

What can I expect after my operation?

You will have some discomfort after the operation. This can be eased using simple pain relievers which you will be given to take home when you leave hospital. You should have a bath the day after your operation – this will help to soak away any dressing. You may bleed a little in the bath. It is important to keep the anus area clean.
For the first few days after your operation try to take a bath or shower, or use the bidet (if you have one), after each time you open your bowels. Once the first few days have passed and you are back to normal activities, you can wipe your anal area using damp cotton wool. You may see a little blood with your stools (poo) or on the toilet paper, usually for seven to 10 days after the operation. If you are a woman, you should remember to wipe the anus area from front to back, away from the vagina.

It will be more comfortable for you to go to the toilet if the stool is soft. Make sure you drink plenty of fluids and eat a high-fibre diet (containing things like vegetables, pulses and bran). You may be given a stool softener (a laxative that makes your stools softer) to take home from hospital.
There may be a small amount of mucous discharge (slime) from your back passage for a few days after the operation. A small pad or panty liner will prevent stains on your underwear. Cotton underwear will be most comfortable.

When can I return to work?

The recovery time will vary but you should feel well enough to return to work after a few days.
If, after you leave hospital, you have any new concerns or problems (for example, severe pain around the anus, a raised temperature or bleeding from the anus) you must contact your own doctor (GP) or the hospital. You will be given contact numbers in case this happens.

Pruritus ani (itchy bottom)

Pruritis ani is a common condition which causes itching or irritation around the anus (back passage).

What are the causes?

Pruritus ani (itchy bottom) has many possible causes, including haemorrhoids (piles) and certain skin conditions. However, the most common cause is a minor discharge from the anus. If small amounts of faeces (bowel movement) or liquid mucus (slime) leaks from the anus, this can irritate the delicate and sensitive skin around the anus.

Can I reduce the irritation?

Yes, though this takes time and patience. It may take many months of gentle care to improve the symptoms.

What can I do to help myself?

The following suggestions in personal hygiene may help:

• Pay special attention to hygiene. Be careful to keep the area as clean as possible, ideally by carefully washing and gently drying the area at least once a day and after each bowel movement. A cool hairdryer could help you do this.
• If you do not have access to a bidet, you may find that sitting on the edge of the bath and using a shower head makes washing easier. If you are at work, take a small plastic bottle of water into the toilet with you to wash with after each bowel movement. Some people find cold water more soothing than warm water.
• Don’t use soap as it can sting. It is best to use water on your hand rather than a flannel.
• Use soft toilet paper or damp cotton wool if this is more comfortable.
• If you have a problem with faeces or mucus leaking from the anus, you could use a small amount of damp cotton wool on your fingertips to gently clean into the anus to make sure there is no residue left behind.
• If your leakage continues after cleaning into the anus, use a small plug of cotton wool in the anus to prevent the faeces or mucus from coming out and irritating the skin.
• Dry the area by gently patting with a soft towel or tissue. Avoid rubbing.
• Try not to scratch the area. If you find that you are scratching in your sleep, wear some cotton mittens in bed. You can get these from your chemist.
• Do not use any creams, deodorants, talcum powder, antiseptics or anything else on your anus, apart from the treatment suggested by your specialist.
• Do not put anything in your bath water. In particular, avoid all antiseptics, bath salts, bath oils and bubble bath.
• Wear loose cotton underwear and change this every day. Avoid man-made fabrics coming into contact with the skin around your bottom. Women should wear stockings or open-crotch tights rather than regular tights to reduce sweating.
• You should also avoid tight trousers or jeans and sitting on plastic chairs for long periods of time. Wash your underwear in non-biological washing powder and make sure that all traces of detergent are rinsed out.

Should I change my diet?

Although there is no specific diet to follow, it is important to try and establish a regular bowel habit.

• A diet that is high in fibre makes the faeces softer and more likely to cause leakage. You can try to make your faeces firmer and so less likely to leak by reducing the amount of fibre in your diet. This means avoiding large quantities of bran cereals, muesli, beans, peas, pulses and nuts. Limit the amount of fruit and vegetables, particularly those with skins, you eat.
• Avoid lagers and flat beers as these can make the problem worse.
• Avoid coffee, chocolate and fruit juices high in citric acid as these too make the pruritis worse

Rectal cancer

Rectal cancer is the third most common cancer in men and the second most common cancer in women in the UK with 40,000 new diagnoses being made each year. The cells that line the rectum may become damaged such that they begin to divide in an uncontrolled way. This may lead to the formation of a polyp or eventually a cancer.

What are the symptoms?

Common symptoms include:

• Bleeding from the back passage
• A change in the frequency of bowel activity
• The passage of mucous or slime
• Weight loss and poor appetite
However, these symptoms are very common and are usually not due to rectal cancer.

How is the diagnosis made?

To make a diagnosis of rectal cancer it is essential to examine the colon and rectum either with a flexible telescope (flexible sigmoidoscope or colonoscope) or a special test called a CT colonography. During colonoscopy a tiny portion of tissue (biopsy) is taken from the cancer for laboratory examination. In addition a CT scan will be arranged to examine the lungs and liver to check that the cancer has not spread. A MRI scan will also be required to help plan the most appropriate course of treatment.

How can it be treated?

The best chance of curing rectal cancer is with an operation which aims to remove the segment of rectum with the cancer in it along with the blood supply and lymph nodes (glands) that supply it. These operations can be done with single large incision (open surgery) or multiple small incisions (‘key-hole’ or laparoscopic surgery). The exact type of operation will depend on the location of the cancer.

Anterior resection: Involves removing the upper rectum and some of the colon on the left of the body and joining the colon back up to the rectum so that the bowel functions normally.

Abdominoperineal resection (APR): If the cancer is very low in the rectum then it is not possible to remove the cancer without damaging the muscles which control the bowel (sphincters). This would lead to faecal incontinence. In such circumstances it is better to remove the rectum and anus and form a colostomy, or artificial opening of the colon on to the abdominal wall.

Transanal Endoscopic MicroSurgery (TEMS): TEMS is an operation, using a specially designed microscope and instruments, to allow surgery to be performed through the anus (back passage) inside the rectum. It requires no cuts on the outside of the anus or abdomen (tummy). Sometimes, TEMS is used to remove small early cancers from the rectum and so avoid major surgery or when the TEMS operation is considered safer than major surgery. Where necessary, your surgeon will explain these choices to you.

These are the commonest types of operations but there are others which may be discussed and can be fully explained by your surgeon.

Is a stoma necessary?

A stoma (colostomy, ileostomy), or artificial opening of the colon/small bowel on to the abdominal wall is NOT always necessary in these operations. Sometimes it is necessary to have a temporary stoma (for 3 months or so) to allow the bowel join to heal. The possibility of requiring a stoma will be discussed with you and if it is required then you will get all the support that you need.

Are there any other forms of treatment?

Radiotherapy: Some rectal cancers respond to a course of radiotherapy before surgery. This may make surgery easier and possibly prevent the cancer coming back at the same place. If radiotherapy is recommended then you will be able to discuss it further with a specialist in this field (oncologist).

Chemotherapy: This can be given together with radiotherapy before surgery or on its own. Once you have recovered from your surgery and the cancer has been thoroughly examined by the pathologist it may be appropriate to recommend a course of chemotherapy. This will depend upon your general state of health and the stage of the disease. The stage of disease gives an indication as to whether the cancer has spread to other organs (usually the glands close to the bowel, the liver or lungs). The stage of disease is assessed by a combination of the tests that you had before your operation (CT, MRI) and the pathologist’s opinion when the cancer is examined under the microscope. If chemotherapy is recommended then you will be able to discuss it further with a specialist in this field (oncologist).

Liver surgery: If the cancer has spread to the liver it may still be possible to attempt to cure the cancer by removing a segment of the liver at an operation. If this is recommended then you will be able to discuss it further with a specialist in this field (hepatobiliary surgeon).
All treatment options will be discussed fully with you and, with your permission the people important to you, before any decisions are made

What are the chances of cure?

Appropriate surgery offers the best chance of cure possibly combined with chemotherapy and radiotherapy. The earlier the cancer is detected and treated then the more likely the cure. In early cancers the cure rate is greater then 90%, in cancers at a more advanced stage then the chances of cure are less than 50%.

Will I need to be seen again?

You will be checked on a regular basis following your treatment. The frequency with which you will be seen will depend on the stage of cancer and will be tailored to your own particular circumstances. This will usually include visits to the clinic, a CT scans and colonoscopy

Right hemicolectomy

A right hemicolectomy operation is to remove the right-hand portion of the colon (approximately half the colon). This will include the caecum, ascending colon and a portion of the transverse colon. It is necessary to remove this much because of the way the blood supply supports the colon, rather than because the disease has spread.

What is the colon?

The colon refers to the large intestine or bowel. It forms the lowest part of the digestive system after the small bowel and it ends with the rectum and the anus.

Transanal endoscopic microsurgery (TEMS)

TEMS is an operation, using a specially designed microscope and instruments, to allow surgery to be performed through the anus (back passage) inside the rectum. It requires no cuts on the outside of the anus or abdomen (tummy).

What conditions is TEMS used for?

Most often it is used to remove benign polyps (non-cancerous growths) from the rectum that cannot be taken away other than by a major operation. Before TEMS; difficult and large, often flattened or ‘carpet-like’, polyps in the rectum required a major operation with removal of the rectum altogether or were incompletely treated by burning or scraping away.
Sometimes, TEMS is used to remove small cancers from the rectum and so avoiding major surgery. This can be done in very early cancers or considered where the TEMS operation is safer than major surgery. Where necessary, your surgeon will explain these choices to you.

Will I need any special preparation before the operation?

You will have investigations and tests to prepare you for your operation. These are to confirm the diagnosis, to see how far the disease has spread, and to assess how fit and well you are for the proposed treatment.
To perform the operation, the rectum needs to be completely empty. You may need to take oral bowel preparation the day before surgery or the back passage may be cleared out using an enema on the day of surgery. A specialist nurse will explain and ensure you are prescribed the preparation you require.

Will I need to have a stoma (bowel bag)?

Very rarely, if you need a stoma or it is possible that you may need a stoma, you will be seen by a stoma care nurse. These specialist nurses are skilled in caring for patients who have a stoma and will be able to answer any questions you may have.

What happens during the operation?

The operation on the rectum is performed through your anus. Using specially designed instruments and viewing the procedure through a microscope your surgeon will precisely cut out the polyp or small cancer ensuring that a cuff of normal surrounding lining is included in the portion of rectum removed. After this, your surgeon will decide if the space left behind needs to be closed by stitching the healthy edges of the rectal lining together or simply left open to heal naturally.

What should I expect after surgery?

You are likely to stay in hospital 1 or 2 days after the operation.
Immediately after the operation (within the first 24 hours), you will need:

• Oxygen through a face mask
• A drip into a vein in one of your arms to give you fluid
• A catheter (tube) in your bladder to drain away urine
• Sometimes a tube is left in the back passage for the first day to drain away any excess fluid
• You may feel some discomfort, though rarely pain, in the back passage
Later, the same or following day you will be able to:
• Eat again, starting with liquids and gradually introducing
• Solid foods, and
• Move around as soon as possible.
• A temperature is common after the operation and you may be given
• Oral antibiotics

When you first start going to the toilet again, your faeces (bowel movements) will be liquid. Sometimes it takes several weeks to get back to normal, and occasionally you may have to adjust your diet.

Are there complications with this operation?

Risks of this operation are small and much less than doing nothing. Also much less than the alternative of a major operation where less than 5% or fewer than 1 in 20 patients may not survive the surgery.

There are sometimes complications. These may include:

• Bleeding
• Infection
• Inflammation of the pelvis: this may occur because the exposed operation site irritates the tissue around the rectum; antibiotic treatment may be necessary
• Incontinence: you might experience staining of underwear or seepage for a few days after the operation because of the slight stretching of the anus required to insert the operating system; this usually returns to normal without the need for further treatment
• Deep vein thrombosis (blood clots in the veins in the legs), or
• Pulmonary emboli (blood clots in the lungs)
• Major surgery: sometimes it is not possible to complete the operation by the TEMS procedure and so major surgery will be required; if this is a possibility it will be explained by your surgeon before the operation

Your operation will be done by either an ‘open’ operation where one long incision (cut) will be made in your abdomen (tummy) or by laparoscopic (keyhole) surgery using a few small incisions.
After removing the portion of the colon, the surgeon will join the two healthy ends together using either a series of sutures (stitches) or staples. This is called an anastomosis. Whether you have open or laparoscopic surgery will depend on many things. Each case has to be looked at individually so you will need to discuss your options with your surgeon and find out which way of operating is best for you.

The laparoscopic operation

Your surgeon will make three or four small (one centimetre) cuts in your abdomen. They will put a telescope camera into one of these small cuts to show an enlarged image (on a television screen) of the organs in your abdomen. The other cuts allow the surgeon to use special operating instruments. Your surgeon will make one of the cuts longer (8 to 10 cms) so they can remove the bowel portion they have operated on. Sometimes it is not possible or safe to finish the operation by laparoscopic surgery. If so, your surgeon will change to an ‘open’ operation and make a larger incision to deal with this.

Will I need any special preparation before surgery?

You will have investigations and tests to prepare you for your operation. These are to confirm the diagnosis, to see how far the disease has spread, and to assess how fit and well you are for the proposed treatment.

Will I need to have a stoma (bowel bag)?

It is very unlikely that you will need a stoma. However, sometimes it is not possible to join the bowel back together again, so the end of the bowel is brought out onto the abdomen (tummy) to form an opening outside the body, known as a stoma. A stoma bag is then fitted around this opening to collect your bowel contents.
The stoma may be permanent or temporary.
If you need a stoma or it is possible that you may need a stoma, you will be seen by a stoma nurse. These specialist nurses are skilled in caring for patients who have a stoma and will be able to answer any questions you may have.

Are there complications with this operation?

Risks of this operation are small and much less likely to affect you than the risk of doing nothing. However, this is a major operation and some people (less than 5% or fewer than 1 in 20) do not survive the surgery.
There are sometimes complications. These may include:

• Bleeding
• Infection
• A leak from the anastomosis (the join where the bowel is connected back together)
• Injury to other organs within the abdomen (for example, the small intestine, ureter, or bladder)
• Deep vein thrombosis (blood clots in the veins in the legs), or
• Pulmonary emboli (blood clots in the lungs)

What should I expect after surgery?

Immediately after the operation (within the first 24 to 48 hours), you will need:

• Oxygen through a face mask
• A drip into a vein in one of your arms to give you fluid
• A catheter (tube) in your bladder to drain away urine, and
• Medication to deal with pain from the incision. This may be given as an epidural (where the medicine is given through a fine tube in your back) or through the drip
Later (the following day or so), you will need to:
• Start eating again, starting with liquids and gradually introducing solid foods, and
• Move around as soon as possible

If you have laparoscopic surgery, you may recover more quickly after surgery and go home sooner.
When you first start going to the toilet again, your faeces will be liquid. Sometimes it takes several weeks to get back to normal, and occasionally you may have to adjust your diet.

Ulcerative colitis

Ulcerative colitis is a form of inflammatory bowel disease that affects the lining of the large bowel (colon) and back passage (rectum). The inflammation may be limited to the rectum (proctitis) but it may gradually move upwards and very occasionally may affect the whole of the large bowel.

What are the symptoms?

The disease can give trouble on and off throughout life. Most of the time sufferers feel well with no symptoms – this means the disease is inactive (in remission). The disease flares up from time to time and becomes active (relapse). The main symptoms are:

• Frequent and urgent need to pass blood and mucous (slime from your back passage)
• Diarrhoea
• Abdominal pain
• A general feeling of tiredness

Occasionally, other symptoms occur and these may include reddening of the eyes, joint pain, skin lesions, loss of appetite, irritability and depression.

How is the diagnosis made?

To make a diagnosis of ulcerative colitis it is essential to examine the back passage and colon with a flexible telescope (flexible sigmoidoscope or colonoscope) which allows direct examination of the lining of the bowel.
Often a tiny portion of tissue (biopsy) is taken from the lining of the bowel for laboratory examination.

How can it be treated?

Ulcerative colitis can be cured by surgical removal of the large bowel. However, for most patients the disease can be controlled by drugs.

• Steroids such as prednisolone are often prescribed for moderate to severe attacks of ulcerative colitis to damp down the inflammation. Steroids may be given as tablets by mouth, enemas, rectal foams or suppositories via the back passage. Severe attacks will be treated in hospital with steroids given via a vein into the blood stream. Another drug, cyclosporin, is sometimes given with intravenous steroids.

• Sulphasalazine, mesalazine or olsalazine are often given during an attack and for long-term use to keep the disease in remission. These drugs may be given as tablets, enemas or suppositories.

• Azathioprine is used for a few patients with long term active disease who would otherwise need repeated courses of steroids.

• Anti-TNF drugs are another group of drugs that can be given to patients with ulcerative colitis to try and prevent inflammation. These drugs are only used in a few patients with severe disease and are given by a Gastroenterologist.

If only the rectum is inflamed, treatment may just be with enemas, rectal foams or suppositories.

When is surgery necessary?

Most people never need an operation. The colon may have to be removed if:
• A very severe attack of ulcerative colitis fails to respond to intensive medical treatment
• Repeated attacks cause ill-health
• Pre-cancerous changes are found in the colon

What operations are available for ulcerative colitis?
There are several operations available for the surgical treatment of ulcerative colitis. All of these operations involve the removal of the large bowel.
For some patients a proctocolectomy with an ileal pouch is suitable. This involves removal of the entire large bowel and the formation of a pouch to replace the rectum. The pouch is made from a segment of the small bowel and joined to the anus. The operation is often done in stages via a single large incision (open surgery) or with multiple small incisions (laparoscopic or ‘key-hole’ surgery). Part of the remaining small bowel (ileum) is brought through the abdominal wall onto the tummy as a spout (ileostomy), which drains into a small plastic bag (stoma). When the pouch has healed the bowel is then reconnected such that the spout is put back into the abdomen.
For some patients including those who do not have a good working muscle around the back passage, the most suitable operation is proctocolectomy. This is where the whole colon and rectum are removed and an ileostomy is formed which is permanent. Specialist nurses train the patient in how to care for the ileostomy.
No operation is perfect. Each has advantages and disadvantages. In each case, the choice of operation has to be made on an individual basis by the patient and surgeon.

Do I need a special diet?

In general people with inflammatory bowel disease can eat what they like but it is important to maintain weight. In a few people, milk can make symptoms worse, but the majority of sufferers can take milk products without harm.

Can ulcerative colitis lead to cancer?

Yes, but the circumstances under which this occurs are well understood. The risks are only substantial in patients with ulcerative colitis if their disease affects most of, or the whole, colon and has been present for many years. It is sometimes possible to detect warning changes (dysplasia) in the bowel before cancer develops. Some doctors advise patients at risk to have regular annual colonoscopic examinations to detect such changes. If they are found, the person is advised to have the colon removed. The cancer risk can be one factor to be taken into account when deciding whether an operation should be advised for long standing colitis.