* What are the advances in hemorrhoids treatment?

Due to this reputation of being a painful operation, advances in hemorrhoid surgery have focused on making it less painful.  One such operation is stapled hemorrhoidectomy. Using a specially-designed, single-use stapler instrument (which was modified from the staplers used to reconnect intestines during major abdominal surgery), the hemorrhoids are excised and the anus repaired from the inside, something which is difficult to do with traditional surgery.  The end result is that the surgical wound is inside, and no wound is visible outside the anus. Scientific studies have proven that this is less painful than traditional surgery, although with a small recurrence rate.

     Stapled Hemorrhoidectomy                           Transarterial Hemorrhoidal Dearterialization (THD)

Another advanced surgical technique is Transarterial Hemorrhoidal Dearterialization (THD).  Using a doppler ultrasound, the blood vessel supplying the hemorrhoid is identified and ligated with stitches.  Deprived of its blood supply, the hemorrhoid then shrinks and shrivels.   Again there is no wound outside and is therefore almost painless.  However, because it is a new technique, not very many studies evaluating its long-term effectiveness have come out.

 All surgical procedures for hemorrhoids, whether traditional or innovative, may sometimes develop complications such as bleeding, infection and stricture. It is important therefore when seeking treatment, to see an expert in anal diseases.

 * What are the forms of treatment – surgical and non-surgical?

Hemorrhoids only require treatment when there are symptoms.  And the type of treatment depends on the severity of symptoms.  Mild symptoms may be managed just by eating a lot of fiber and taking in bulk laxatives such as psyllium to improve the consistency of stools and ease bowel movement.  Some over-the-counter creams may provide symptomatic relief.

Non-surgical and almost painless treatments for hemorrhoids include injection sclerotherapy, infrared photocoagulation (often mislabeled as “laser treatment”), and rubber band ligation, any of which can be done safely in the clinic as an out-patient procedure.  In scientific studies comparing these methods, rubber band ligation was found to be the most effective and cheap, which is why it is the most common non-surgical procedure for hemorrhoids in the world today.

Non-surgical treatment is often ineffective for large, incarcerated or thrombosed hemorrhoids.  Surgery is usually recommended in these situations, and also when non-surgical treatment has failed to relieve symptoms.  Traditional surgery requires cutting out the hemorrhoid using a variety of instruments such as scissors, knives, cautery, and ultrasonic dissectors. Unfortunately, any wound created in the outer skin of the anus results in often Sever post-operative pain, which is responsible for the reputation of hemorrhoid surgery being one of the most painful of operations.

 * What are the symptoms of hemorrhoids? 

Bleeding from hemorrhoids is usually bright red, often dripping into the toilet bowl, or noticed when wiping. The stools themselves are normal looking, indicating that the bleeding is originating only from the anorectal area.  Sludge of dark blood and stool mixed thoroughly together is usually from a source within the small and large intestines and not hemorrhoids. Hemorrhoidal bleeding is painless, and this differentiates it from anal fissures, which is also a very common anal condition that presents with similar bright red bleeding during defecation, but with anal pain.

Hemorrhoids only become painful when they thrombosed or incarcerated.  Thrombosed hemorrhoids occur when blood clots within the hemorrhoids, causing very obvious swelling and pain.  While surgery for this may be effective during the first 4 days of the attack, if left alone the swelling and pain gradually subside and disappear after 2 weeks.  Usually this occurs just once or twice in a person’s lifetime, and it is uncommon to have repeated episodes of thrombosis. 

Doctors often classify patients as to having either external or internal hemorrhoids.  External hemorrhoids are located just outside the anus, and hence are always visible on routine inspection.  Many people have them without suffering from any symptoms, and therefore these may be safely left alone.  Sometimes external hemorrhoids may make cleaning difficult, allowing sweat and anal discharge to hide between folds, resulting in anal itching.

Internal hemorrhoids arise from inside the anus and are therefore only visible when, because of excessive laxity, they protrude outside.  This condition is called prolapsed, and usually occurs during defecation.  When internal hemorrhoids prolapsed they may either slip back inside on their own, or require manipulation by the person for it goes back in.  When the prolapsed hemorrhoids cannot be returned, they become trapped outside, resulting in pain and swelling.  This scenario is called incarcerated hemorrhoids.

* How do hemorrhoids look and feel?

Hemorrhoidal cushions are skin, vascular and soft tissues that line the anal canal, playing a small role in defecation and continence.  Everyone has them, although with our daily travails of straining and movement, they do change over time, becoming more lax or loose as we age. 

Hemorrhoidal disease occurs when these changes result in bothersome symptoms such as bleeding, prolapsed, or pain.  Almost everyone may develop symptoms at some point in their life, but these are not life-threatening, and may be safely observed. Treatment is usually required for those whose hemorrhoidal symptoms impact on quality of life and daily living.

A colonoscopy is an internal examination of the colon (large intestine) and rectum, using a long, flexible, tubular instrument called a colonoscope.

The colonoscope has a small camera attached to a flexible tube.  Unlike sigmoidoscopy, which can only reach the lower third of the colon, colonoscopy examines the entire length of the colon.

The patient will lie on his left side with knees  drawn up toward the chest.  After administering a sedative and pain reliever, the colonoscope is inserted through the anus. It is gently moved into the beginning of the large bowel and sometimes into the lowest part of the small intestine. Air will be inserted through the scope to provide a better view. Suction may be used to remove fluid or stool. Tissue samples may be taken with tiny biopsy forceps inserted through the scope. Polyps may be removed with electrocautery snares, and photographs may be taken.

Espesiyalista ng Malaking Bituka (Colon) At Tumbong (Rectum)

Ang Colorectal Specialists ay isang pangkat na espesiyalistang siruhano (surgeons) na nagsama-sama upang bumuo ng isang grupong propesyonal na ang layunin ay mapalaganap at mapaunlad ang industriyang ito sa buong bansa.

Ang grupo ay may adhikaing gumamit ng mga makabagong pamamaraan na batay sa ebidensiya o katibayang pang-agham at ng konseptong tinatawag na Multidisciplinary Team Approach (MDT). Ang MDT ay isang uri ng pangangalagang medikal na mainam lalo na sa mga may karamdaman tulad ng kanser sa malaking bituka. Ang MDT ay gumagamit ng iba’t ibang uri ng pamamaraan nang paggamot at nangangailangan ng pakikipag-ugnayan sa iba’t ibang eksperto at sangay ng medisina. Ang layunin nito ay upang lubos na mapangalagaan ang lahat nang aspeto ng karamdaman ng maysakit. Ang mga resulta ng operasyon at gamutan  ay patuloy na pinag-aaralan at nirerepaso upang mapaunlad pa at mapadali ang mga susunod na kaso.

Ang aming layunin ay magkapagbigay ng pinakamataas na antas ng pangangalaga kasabay ng aming pagsusumikap na mapabuti pa ang  mga resulta ng operasyon at paggagamutan sa pamamagitan ng sistematikong pagrepaso ng mga kaso, pag-aaral, pagsasaliksik at pagsasanay o pagpapakadalubhasa.Kami ay nakaalinsabay sa pamantayan ng mga siruhano sa buong mundo.

Ang lahat ng aming manggagamot ay pawing nakapasa sa Lupon ng mga Siruhano  at Fellows ng Philippine Society of Colorectal Surgeons.

Colorectal Surgery

Colorectal surgery repairs damage to the colon, rectum, and anus through a variety of procedures caused by diseases of the lower digestive tract, such as cancer, diverticulitis, and inflammatory bowel disease (ulcerative colitis and Crohn's disease). Injury, obstruction, perforation, masses and scar tissues which may cause blockage may also require bowel surgery. Surgical removal of the damaged area or areas can return normal bowel function. Other bowel conditions that may require surgery to a lesser extent are hemorrhoids, anal fissures, rectal prolapsed, and bowel incontinence.

Types of surgery 

There are a variety of procedures a colorectal surgeon may use to treat intestinal disorders. Before, all colorectal surgery was performed by making large incisions in the abdomen, opening up the intestinal cavity, and making the repair. Most of these repairs involved resection (cutting out the diseased or damaged portion) and anastomosis (attaching the cut ends of the intestine together). Some were tucks to tighten sphincter muscles or repair fissures, and others cut out hemorrhoids.

Often colorectal surgery involves creating an ostomy, which is an opening from the inside of the body to the outside, usually to remove body wastes (feces or urine). There are several types of ostomy surgeries that colorectal surgeons do. A colostomy is a surgical procedure that brings a portion of the large intestine through the abdominal wall, creating an opening, or stoma, to carry feces out of the body to a pouch. An ileostomy removes the entire colon, the rectum, and the anus. The lower end of the small intestine (the ileum) becomes the stoma.

Laparoscopic surgery is being used with many diseases of the intestinal tract, including initial cancers. For this surgery, the colon and rectal surgeon inserts a laparoscope (an instrument that has a tiny video camera attached) through a small incision in the abdomen. Other small incisions are made through which the surgeon inserts surgical instruments . This surgery often results in fewer complications, a shorter stay in the hospital, less postoperative pain, a quicker return to normal activities, and less scarring.

Recently, a new and more advanced technique called robotic surgery is introduced. Here

a surgeon performs operation using a computer that remotely controls very small instruments attached to a robot.

Procedures Offered

The services offered by Colorectal Specialists at the Medical City Colorectal Clinic include the following:

A.     Colorectal Cancer

As an integral component of TMC Cancer Center, Colorectal Specialists provides the following services for colorectal cancer patients (in coordination with the corresponding units mentioned).

             1. Screening

·         Immunochemical fecal occult blood test (Laboratory)

·         Diagnostic and therapeutic flexible sigmoidoscopy and colonoscopy (Center for Endoscopy and Physiologic Studies) 

2.     Diagnosis

·         X-rays, CT scans, MRI (Department of Radiology)

·         Bone Scan (Nuclear Medicine)

·         Histopathology (Department of Pathology)

·         KRAS testing (Regenerative Medicine)

·         CEA, CA 19-9 and oyher blood tests (Department of Pathology)

·         Endorectal ultrasound (Center for Endoscopy and Physiologic Studies)

·         Diagnostic and therapeutic colonoscopy including endoscopic submucosal resection(Center for Endoscopy and Physiologic Studies)

3.     Multimodality Treatment

·         Multidisciplinary Team Approach for assuring high quality of cancer care (Cancer Center)

·         Chemotherapy  (Cancer Center)

·         Radiotherapy (Department of Radiation Oncology)

·         Surgery, promoting minimally invasive procedures for early cases.

·         Minimally invasive colorectal surgery procedure offered include: 

-          Laparoscopic Surgery

-          Transanal Endoscopic Microsurgery

-          Robotic Surgery

4.     Post-treatment Cancer Surveillance 

5.     Stoma care and maintenance with the Stoma and Complex Wound Care Clinic

B.     Anorectal Diseases

1.     Hemorrhoidal Diseases

·         Conservative and Medical Management

·         Ambulatory Treatment

-          Rubber band ligation

-          Transanal Hemorrhoidal Dearterialization (THD) 

·           Surgical Treatment

-          Stapled Hemorrhoidopexy

-          Ligasure/Harmonic Hemorrhoidectomy

-          Excisional surgery using conventional methods 

2.     Simple and Complex Anal Fistula 

·         Endoanal ultrasonography

·         Highly specialized sphincter preserving techniques

-          LIFT technique (ligation of intersphincteric Fistula Tract)

-          Endorectal advancement flaps

-          Fibrin plug

3.      Sexually transmitted Anal Disease, including warts (HPV) and HIV (In coordination with I-REACT Clinic)

·         Immunization (HPV Vaccines)

·         Conservative and Medical Management

·         Ambulatory Treatment

Out-patient surgical services, diagnostic and laboratory procedures are offered at the Medicard Colorectal Clinic. Procedures that are not available are referred to the team’s affiliated hospitals. 

What is an Anal Fissure?

An anal fissure (punit sa puwit) is a small tear or cut in the skin that lines the anus. Fissures typically cause sharp pain during and after defecation and often bleed. Fissures are in fact quite common, but are often confused with other causes of pain and bleeding, such as hemorrhoids. Anything that can cut or irritate the inner lining of the anus can cause a fissure. A hard, dry bowel movement is typically responsible for a fissure. Other causes of a fissure include diarrhea or inflammatory conditions of the anal area.

What are the Symptoms of an Anal Fissure?

The typical symptoms of an anal fissure are pain during or after defecation and bleeding. Patients may try to avoid defecation because of the pain.

Treatment

Often treating one’s constipation or diarrhea can cure a fissure. An acute fissure is typically managed with non-operative treatments and over 90% will heal without surgery. A high fiber diet, fiber supplements, stool softeners, and plenty of fluids help relieve constipation, promote soft bowel movements, and aide in the healing process. Increased dietary fiber may also help to improve diarrhea. Warm sitz baths for 10-20 minutes several times each day are soothing and promote relaxation of the anal muscles, which can also help healing. Occasionally, special medications may be recommended. A chronic fissure may require additional treatment, likely surgery.