Transanal Endoscopic Microsurgery
Ileal Pouch-Anal Procedure (IPAP)
Artificial Anal Sphincter

Transanal Endoscopic Microsurgery (TEM)

Most rectal cancers require removal through an abdominal incision, also known as a laparotomy. However, certain early or superficial rectal cancers can be removed through the anus, thereby avoiding a major operation. Usually, benign rectal polyps can be removed in this fashion.

Such tumors should be superficial, well-differentiated (not aggressive or fast growing) and unattached to nearby blood or lymphatic vessels. If a tumor does not meet these conditions, TEM cannot be done due to an increased risk of the cancer spreading. Selecting tumors appropriate for TEM requires the sound judgment of an experienced surgeon. Only a small number of surgeons in the United States have learned TEM. Two colon and rectal surgeons at Rush—Theodore Saclarides, MD, and Marc Brand, MD—have expertise in this procedure.

During the procedure, long shafted instruments are inserted through an air-tight face piece placed on the end of the rectoscope. Carbon dioxide gas is infused into the rectum during the operation, distending the rectum to improve visibility and exposure of the lesion. The surgeon looks through a binocular stereoscopic eyepiece which provides a field of view unequaled by conventional instruments. As a result, we can transanally remove selected cancers and almost all polyps in the rectum that other surgeons cannot reach.

Prior to surgery, patients undergo a bowel cleansing at home and arrive at the hospital on the day of their surgery. The operation is performed under general anesthesia, usually takes about 60 to 90 minutes to complete, and most patients are either discharged the same day or stay overnight in the hospital. If a cancer was removed, it is studied extensively by pathologists to determine if further treatment may be needed. On the other hand, if the tumor does not show any of these features, nothing further is required other than periodic check-ups.

There are few if any complications. Recurrence rates are lower than those seen after conventional transanal excision. There is generally no pain and bowel movement patterns are not altered in the long run.

(back to top)

Ileal Pouch-Anal Procedure (IPAP)

Patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) may be candidates for an operation called the ileal pouch-anal procedure. In general, surgery for UC is required if there is uncontrollable bleeding, perforation, unresponsiveness to medical management, inability to wean steroids, precancerous changes or cancer. For FAP, surgery is generally needed once the diagnosis is made in order to prevent colorectal cancer. There are a number of operations that can be used to treat these diseases, however, the IPAA has emerged as the operation of choice for certain patients. These operations should be discussed in detail with your surgeon.

If IPAA is the procedure chosen, it is generally performed in two stages. Occasionally three operations may be required for sick patients who cannot tolerate an initial big operation. With the two-staged approach, at the first surgery, the entire colon and rectum are removed, a reservoir or pouch is constructed out of the ileum (last portion of the small intestine) and the pouch is then connected to the anus. A temporary ileostomy is placed on the lower abdomen to allow the pouch to heal without stool going through it. When the pouch heals, the ileostomy is closed with a second small operation approximately three months later. If the three-staged approach is chosen, the colon is removed during the first operation and an ileostomy is fashioned. During the second operation, the rectum is removed, the pouch is constructed and connected to the anus, and the ileostomy is left in place. During the third operation, the ileostomy is closed. Compared to the other operations performed for these two diseases, the IPAA more closely restores normal body function and places fewer lifestyle restrictions in terms of social, athletic and sexual activities.

The average patient moves his or her bowels four to six times a day. Through use, the pouch expands and improves in function over the course of the first year following the last operation. Occasionally, anti-diarrhea medications and fiber supplements may be needed to slow down or thicken the stool. Men can father children and women can successfully complete pregnancy and have vaginal deliveries. The most common complication is a condition known as pouchitis, which affects almost half of patients. Symptoms include diarrhea, cramps, pelvic pressure, and muscle and joint pains. We do not know exactly what causes pouchitis, but it can be treated with antibiotics without hospitalization. Pouch failure rates are low and only about five percent of patients need surgery to remove the pouch because of incontinence or complications.

(back to top)

Artificial Anal Sphincter

The colon and rectal surgery program at Rush offers a number of methods for treating fecal incontinence, which refers to the uncontrolled release of gas or stool from the anus. For many patients, fecal incontinence can be treated nonsurgically, through one of the following means:

• Kegel exercises are repetitive efforts to tighten the anal sphincter muscles in an effort to strengthen them and make them more effective. These are performed several times throughout the day and require no equipment. Biofeedback is a method of retraining the existing anal sphincter to function as best as is possible. It involves several training sessions with a special sensor and display to demonstrate how well the muscle is working with certain efforts by the patient.
• Antidiarrheal medicine is often prescribed to patients who have frequent or loose stools which are harder to control.
• Enemas can often be administered prior to a social activity. This treatment is useful in that it partially empties the large intestine of stool at a convenient time (when a bathroom is quickly available).

If initial attempts to control fecal incontinence fail, surgical means of treatment may be considered. Surgery may include sphincteroplasty, a procedure to repair a tear in the anal sphincter, and insertion of an artificial anal sphincter.

A sphincteroplasty is usually performed through an incision in the skin near the anus. The injury to the anal sphincter is identified and the injured muscle edges are freed from surrounding scar tissue. The muscle edges are then brought back together using a series of stitches. The skin is closed with absorbable stitches which do not need to be removed. A small drainage tube is occasionally needed to prevent the accumulation of fluid around the sphincteroplasty, which is removed before you leave the hospital. Sphincteroplasty uses your own muscle, which is meant to control stool. Therefore, there is very little extra training needed to gain the benefit of stool control after this surgery. However, muscles may take several weeks or months to recover from the surgery. Kegel exercises or biofeedback to help retrain and strengthen the repaired muscle may be recommended after the sphincteroplasty has healed.

The artificial anal sphincter device is a modification of an artificial urinary sphincter that has been used since 1972. It is best used after a sphincteroplasty has been tried and failed, or when a sphincteroplasty cannot be performed because sufficient healthy muscle is lacking. The artificial anal sphincter is a totally implantable, simple-to-use device consisting of three components: 1) an inflatable cuff; 2) a fluid reservoir (balloon); and 3) a semi-automatic pump connected between the cuff and balloon. Fluid is placed within the balloon. The entire device is placed beneath the skin and is not visible at any time.

Colon and rectal surgeons at Rush are skilled in the preoperative, operative and postoperative care of patients who have undergone these procedures.

(back to top)