What's New

This portion of the web-site is devoted to a brief description and discussion of newer developments in general surgery and colorectal surgery - developments which hopefully will lead to better surgical care of patients and the restoration of their health.

February 2006

It has been shown that better results are obtained in certain surgical procedures by surgeons who perform the procedures more frequently. These include operations to remove esophageal, breast and pancreatic cancers. Recent similar results have been obtained by surgeons who operate on patients with colon or rectal cancer.

Four hundred eighty-one patients undergoing potentially curative colorectal cancer resections were studied at Western University in Glasgow by Dorrance et. al. Three factors were associated with prolonged survival - early stage disease, absence of vascular invasion on microscopic study of the resected specimen, and specialization in colon and rectal surgery. The authors concluded, “These data show that surgeons with an interest in colorectal cancer achieve lower local and overall recurrence rates compared with vascular or transplant or general surgeons. Difference in local recurrence rates seem to be predominantly related to the extent of resection performed and demonstrate the need to remove an adequate specimen when performing potentially curative colorectal cancer surgery.”1

Surgery for rectal cancer is more difficult than surgery for colon cancer. It carries a risk of local recurrence in the pelvis. Surgery for rectal cancer may result in a permanent colostomy. Surgeons with specialty training in colon and rectal surgery and surgeons with a high volume practice - over 20 rectal resections per year - are associated with a lower rate of local recurrence, an improved disease specific survival, and are more likely to preserve the anal sphincter (i.e. no permanent colostomy).2 These specialists and high volume surgeons also are associated with significant reduction in the total cost of colon or rectal operations.3 Specialization in colon and rectal surgery has also been shown to result in lower in-hospital mortality rates.4

Dr. Steven Wexner, head of Colon and Rectal Surgery at the Cleveland Clinic Florida, has stated “Two ways to confer an optimal outcome (in surgery for rectal cancer) are by the acquisition of specific knowledge or education, and the second is by a practice of higher volume.”

(A surgeon usually has only one chance to “get it right.” Therefore it behooves patients to inquire about a surgeon’s training, board certification and membership in the American College of Surgeons. A surgeon should be willing to share his personal experience with patients facing major surgery, including surgery for colorectal cancer. RLB)

1 Dorrance HR, Doherty GM, O’Dwyer PJ. Effect of Surgeons Specialty Interest on Patient Outcome After Potentially Curative Colorectal Cancer Surgery. Diseases of the Colon & Rectum 2000; 43: 492-502.
2 Porter GA, Soskolne CL, Yakimets WW, Newman JC. Surgeon Related Factors and Outcome in Rectal Cancer. Annals of Surgery 1998; 227: 157-167.
3 Latalippe J, Potenti FM, Weiss EG, et. al. Impact of Colorectal Board Certification on Colorectal
4 Rosen L, Stasik JJ, Reed JF, et. Al. Variations in Colon and Rectal Surgical Mortality. Diseases of the Colon & Rectum 1996; 39:125-135

July 2005

Dr. Stephen Clark has joined our group for the practice of colon and rectal surgery. Dr. Clark graduated from Grissom High School in Huntsville, Alabama in 1989. He attended Auburn University and UAB School of Medicine. Dr. Clark has completed a general surgery residency at the University of Tennessee-Memphis and a fellowship in colon and rectal surgery at LSU-Shreveport. Dr. Clark has written several papers and given presentations on complex anal fistulas and brings the latest advances in management of this difficult problem to Huntsville. Although he is trained in all aspects of colon and rectal surgery, Dr. Clark developed, during his fellowship, a particular interest in the management of fecal incontinence. Dr. Clark is also trained in techniques of laparoscopic colon resection for benign and malignant disease processes and intends to continue in this discipline in private practice.

Dr. Clark is married to Lacey Langston Clark, M.D., a native of Birmingham, Alabama. Dr. Lacey Clark also attended UAB School of Medicine and has competed a pediatrics residency. She was in private practice in Memphis, Tennessee for three years and is currently investigating practice opportunities in Huntsville.

The Clarks have one son, Christian Taylor Clark, who is four years old.

Outside of medicine, Dr. Clark's interests include antique Ford Mustangs, model trains, mountain biking, and folk music. On Saturdays this fall, Dr. Clark will line up with the fans of the Auburn Tigers.

February 2005

It is estimated that between two and eight percent of adults suffer from some degree of fecal incontinence (FI). This may significantly affect their quality of life.

The most common cause of FI is an injury occurring to women at the time of childbirth - either an injury to the anal sphincter or to the pudendal nerve. Other causes of FI include anorectal surgery - especially incision and drainage of an abscess or anal fistulotomy, traumatic injuries to the sphincter muscle, neurological disorders such as multiple sclerosis, and diabetes mellitus. In some cases there is no apparent cause of FI.

Conservative treatment of FI includes dietary modulation, pharmacological treatment (bulking and anti-diarrheal agents), Kegel exercises, and biofeedback. In patients who fail conservative treatment and a defect is demonstrable in the sphincter, surgical sphincter repair is indicated. Women with a history of sphincter injury at the time of childbirth and who have an anterior defect are frequently treated by an overlapping sphincteroplasty. An artificial bowel sphincter is available, but not widely used. The treatment of last resort in a patient with incontinence is colostomy.

Recently a new form of treatment of FI has emerged - the Secca procedure. This technique delivers radio-frequency (RF) energy to the anal canal. RF energy results in heating of the tissues (about 85C) which in turn causes collagen contraction, wound healing with the appearance of fibroblasts, and shrinkage or tightening of the tissues. This leads to improvement of symptoms in some, but not all, of patients thus treated. The Secca procedure does not preclude additional surgery.

The Secca procedure for FI came about because of success using the technique on the lower esophageal sphincter in patients with symptoms of gastrointestinal reflux.

The Secca procedure is performed under IV sedation - versed plus a narcotic. Local anesthesia may be used to supplement the IV sedation. The procedure is performed in an outpatient setting.

Complications of the procedure are uncommon. Postoperative bleeding and skin ulceration have been reported. Temporary worsening of the incontinence may occur. Some patients have postoperative pain and require a short course of an analgesic.

The Secca procedure works by causing shrinkage and tightness of the tissues, thereby increasing the barrier function of the sphincter. A second possible mechanism is that RF treatment decreases the distention  volume of the rectum. Patients perceive the urge to defecate earlier and have additional time to reach bathroom facilities.

All patients with FI should be treated conservatively. In those who fail conservative therapy and have a demonstrable sphincter defect, surgery - overlapping sphincteroplasty - should be offered. Most of these patients are women who sustained a sphincter injury at the time of childbirth or have had surgery for an anterior fistula.

In patients with FI who fail conservative treatment and who have no demonstrable sphincter defect - those with nerve dysfunction (pudendal nerve) for example - or patients who want to avoid surgery, the Secca procedure may be the next logical step. Also, surgical sphincter repair is not always successful. Patients with a failed sphincter repair are ideal candidates for the Secca Procedure.

Thus far, results of the Secca procedure indicate that most patients obtain an improvement in continence and in quality of life. However, some patients continue to be incontinent and studies are underway to identify those patients with FI who will benefit from the Secca procedure.

1. Efron JE, Corman MC, Fleshman J, et.al. Safety and Effectiveness of Temperature Controlled Radio-Frequency Energy Delivery to the Anal Canal (Secca Procedure) for the Treatment of Fecal Incontinence. Dis Colon Rectum 2003; 46:1606-1618.

2. Takahashi T, Garcia-Osogobio S, Valdovinos MA, et.al. Radio-Frequency Energy Delivery to the Anal Canal for the Treatment of Fecal Incontinence. Dis Colon Rectum 2002; 45: 915-922.

(If any patient or doctor is interested in learning more about the Secca procedure, please contact Dr. Javad Golzarian in our office - 256-533-6070. RLB)

January 30, 2005

In the December issue of Diseases of the Colon & Rectum, revised guidelines for the management of anal fissures were published. An anal fissure is a common problem seen by primary care physicians and surgeons. Anal fissure refers to a superficial (acute) or deep (chronic) ulcer that occurs at the anal verge. It causes moderate to severe pain at the time of defecation.

The authors performed a Medline literature search and made the following recommendations. (1) Conservative therapy should be the first line of treatment because healing results in up to 50% of patients. Conservative therapy includes fluid and fiber intake, stool softeners, and warm tub soaks. Topical anesthetics may be used for patient comfort.

(2) Anal fissures may be appropriately treated with nitroglycerin ointment because it can relieve pain. However, nitroglycerin is only marginally better than conservative therapy in healing chronic anal fissures and it causes headache in 20-30% of patients.

(3) Anal fissures may appropriately be treated with topical calcium channel blockers which may lead to healing of chronic fissures by reducing resting anal canal pressure. However, there are too few studies available to conclude that they are superior to conservative therapy in healing fissures.

(4) The surgical treatment of choice for refractory anal fissure is lateral internal sphincterotomy (LIS).

(5) Surgery may be offered to patients after a trial of conservative therapy and without a trial of pharmacological treatment. Patients should be cautioned about the potential complications of surgery, namely a slight risk of incontinence.

(Anal fissures are most commonly due to increased resting pressure of the internal anal sphincter and failure of the internal sphincter to relax properly during defecation. This can be demonstrated by anal manometry. The surgical procedure, lateral internal sphincterotomy, divides a portion of this muscle and reduces the increased pressure. Healing of fissures follows in over 95% of cases. The authors state, and it has been our experience, "that incontinence sufficient to cause any measurable impairment in quality of life seems to be uncommon." RLB)

Orsay C, Rakinic J, Perry WB, et.al. Practice Parameters for the Management of Anal Fissure (Revised). Dis Colon Rectum 2004; 47: 2003-2007.

Robert L. Baird

January 30, 2005

More than 10 million gastrointestinal endoscopic procedures - esophagogastroduodenoscopy, colonoscopy, etc. - are performed each year in the United States and the question is frequently asked concerning the possibility of transmission of infectious diseases, especially AIDS and hepatitis C. In a review of 265 articles published in 1993, there were 281 cases of pathogen transmission reported between 1966 and 1992. It was determined that each case was due to a breech in currently accepted guidelines for the cleaning and disinfection of endoscopes or due to defective equipment.

Guidelines have been established for the cleaning and disinfection of endoscopes and it is required that healthcare facilities and manufacturers report to the FDA any injury to a patient caused by an endoscope or its accessories. Since 1993, only five cases of pathogen transmission during endoscopy have been identified; all occurred outside the United States.

In the October issue of General Surgery News, Dr. Douglas Nelson, Associate Professor of Medicine at the University of Minnesota, said, in commenting on a review of 316 reported cases of pathogenic transmission between 1966 and 2002, "to my knowledge, every single case reported has been associated with failure to clean or disinfect an endoscope as they were supposed to." Dr. Nelson concluded that "the lifetime risk of developing colon cancer is 5% and the risk (of pathogen transmission) is miniscule and is far outweighed by the benefits."

Mrs. Kathy Dykes, RN, President of the Society of Gastroenterology Nurses and Associates said that "the risk (of pathogen transmission) is easily minimized by simply following an endoscope manufacturer's cleaning and disinfection instructions explicitly." These guidelines for reprocessing flexible gastrointestinal endoscopes have been published in the April 2004 issue of Diseases of the Colon & Rectum.

1. General Surgery News, October 2004, Pathogenic Transmission From Endoscope Rare but Real.
2. Nelson DB, Jarvis WR, Rutala WA, et.al. Multisociety Guidelines for Reprocessing Flexible Gastrointestinal Endoscopes. Dis Colon    
    Rectum 2004; 47: 413-421

January 30, 2005

We have established two links to the website of The American Society of Colon & Rectal Surgeons. http://ascrs.affiniscape.com/displaycommon.cfm?an=1&subarticlenbr=21 provides patients with online brochures which discuss common colon and rectal problems. The other link http://ascrs.affiniscape.com/displaycommon.cfm?an=1&subarticlenbr=73 allows patents to assess their risk of colorectal cancer and provides guidelines for screening. These links can also be accessed under Medical Links. Click on The American Society of Colon & Rectal Surgeons and either Colorectal Cancer Screening or Colon & Rectal Diseases and Procedures.

Robert L. Baird

October 2004

October 17, 2004. There have been two recent articles in the surgical literature that recommend repeating colonoscopy when a patient is referred for surgical removal of a polyp. Polyps are abnormal growths originating in the lining of the large intestine (colon). Most polyps are benign, but may be the site of development of colon cancer and should be removed, usually at the time of colonoscopy. Occasionally a polyp will be referred to a surgeon for operative removal. The reasons for this include that the polyp is too big or that it is in a difficult position or that it is a flat polyp.

In the two studies, patients were reviewed who had repeat colonoscopy the day before surgery. In one study, from the University of Connecticut Health Center, Farmington, 23 of 71 patients had their surgery cancelled because surgeons were able to remove the polyp during colonoscopy.

In the second study, from the Cleveland Clinic, 43 of 58 patients were able to avoid surgery. James Church of the Cleveland Clinic states, "Before submitting patients to surgical resection of a colon polyp, a second opinion by an examiner who is experienced in snare excision of such lesions is worthwhile. From a patient's point of view such a second opinion is mandatory."

1. General Surgery News. September 2004.

2. Church JM. Avoiding surgery in patients with colorectal  polyps. Dis Colon Rectum 2003; 46:1515-1516

(Surgeons are more likely to attempt the removal of difficult polyps at the time of colonoscopy because they can immediately operate on the patient should problems arise. Also, a benefit of colonoscopy the day before surgery is the accurate localization of the polyp, thereby decreasing the operating time and morbidity. RLB)