The following articles provide information to help patients understand the relevant conditions, surgery and recovery.
Anal Fistula
Banding of Haemorrhoids
Cholecystectomy
Hernia Information
Haemorrhoidectomy
A Bowel Tumour
INFORMATION FOR PATIENTS WITH AN ANAL FISTULA
The Symptoms
An anal fistula is an abnormal connection between the inside of the anal canal (back passage) and the skin next to the anal canal. These abnormal connections usually arise because a small gland half way up the anal canal becomes infected and forms an abscess, which then bursts through the muscles and points on to the skin some distance away from the anal canal. In a long established fistula there is a track which leads from a little opening in the skin and if a probe is inserted into this opening it comes out in the anal canal, usually halfway up. Patients with a fistula usually complain of recurrent abscesses near the anal canal. This is because the skin opening closes over as the skin heals and this then causes a build-up of infected material which has to burst out through the opening again. Most anal fistulae will not heal unless an operation is performed.
The Operation
Prior to the operation a small enema is usually given and then the patient is examined under a general anaesthetic. During this examination the exact path that the fistula takes is ascertained by means of passing very fine wire probes. The surgeon attempts to assess the height of the internal opening and also which routes the fistula track takes through the sphincter muscle. This can have important bearings on how the fistula is treated. Most fistulae pass through the sphincter muscle at a very low level and so the treatment in these cases, which probably amounts to over 80% of fistulae, involves cutting through the skin over the wire probe until the fistula is entered and then leaving the wound open to heal naturally. If the internal opening is high up in the anal canal then cutting down on to the probe could lead to cutting quite a lot of sphincter muscle and this could in turn lead to incontinence. If this is the case then one has to think about other ways of treating the fistula. Sometimes a fine thread can be passed through the fistula track and tied in a loop and this can lead to resolution of the fistula as the thread works its way down the anal canal on its own. In other cases more major surgery has to be carried out, but this is very unusual.
Post-Operatively
After the operation there is surprisingly little pain, but patients usually have an open wound and have to wear a pad for about ten days. The wound often takes six weeks to heal up and can take longer than this, but during this time patients are usually quite comfortable.
Anal fistulas are common but can be quite difficult to treat and sometimes require more than one operation. The risk of incontinence following fistula surgery should be discussed in detail with the patient before the operation so that the surgeon is clear how much the patient is prepared to undergo in the way of surgery to cure the condition.
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BANDING OF HAEMORRHOIDS
You have been treated with rubber band ligation. This
means that a tiny rubber band (about 4mm in diameter) has been stretched over a plastic tube about 10mm in diameter, a portion of the lining of the upper part of the back passage has been sucked into the end of the tube, and the rubber-band has been pushed off the end of the tube so that a portion of the lining about 10mm in diameter has been trapped by the band. The purpose of this procedure is to pinch the blood-vessels which run in the lining and supply the pile with blood, thus causing the pile to shrink down. The rubber band will fall off of its own accord in a few days, and because it is so small you will probably not notice it.
You may notice some bleeding immediately after the procedure, but this is quite normal and is nothing to worry about. Sometimes, bleeding can occur several days after the application of the band, at the time when the band falls off (up to a week).
Immediately after application of the band, you may experience a dull, aching pain in the backpassage, associated with a desire to have your bowels open. If the pain builds up, you may need to take painkillers, and the best thing to take is an anti-inflammatory drug such as Ibuprofen or Diclofenac. (If you cannot take either of these you can take Paracetamol as an alternative ).
Usually, if there is going to be any pain, it is apparent within a few minutes of the band being applied. Try and avoid having a bowel-action on the day that the band is applied, even if you feel the desire to do so. The band is more likely to come off prematurely if you do. Try and avoid becoming constipated by using a mild laxative if necessary and eating plenty of roughage.
In the unlikely event that you:
- feel unusually feverish
- lose a large amount of blood
- have difficulty passing urine
- experience swelling around the back-passage
you should contact your General Practitioner immediately.
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FOR PATIENTS HAVING A CHOLECYSTECTOMY
The gallbladder is a thin-walled, pear-shaped sac measuring about 8 to 12 centimetres long and 3 centimetres across, although if it is distended it can become much larger than this. It is attached to the side of the bile duct which drains bile from the liver into the gut. Bile is produced by the liver and one of its functions is to help to digest fat in the diet. When you eat a meal a hormone is released from the stomach which acts on the muscle in the wall of the gallbladder and makes the muscle contract. This causes the gallbladder to empty its contents into the bile duct and thence into the gut, where the bile mixes with the food. The bile in the gallbladder is more concentrated than the bile in the bile duct, and so gallbladder bile helps to digest very fatty food. It does this by helping to form the fat in the diet into an emulsion which is a suspension of fat droplets in water, and this enables the fat to be absorbed through the wall of the gut. Some people liken this to squirting Fairy Liquid into the washing-up bowl when it is full of greasy utensils.
Nowadays we do not eat as much fat in our diet as we used to. This is because we do not need to take in as much energy as in years gone by. We do not perform as much physical exercise as previously, and as most homes are centrally heated we do not need as much energy to keep warm. It has therefore been found that removal of the gallbladder does not affect our digestion in any significant way, although patients who have had their gallbladder removed notice that if they have a very fatty meal they will have diarrhoea for a short time afterwards, because of failure of absorption of some of the fat.
The gallbladder can become diseased, and the commonest problem with the gallbladder is that the bile in the gallbladder forms tiny crystals which then grow and form the basis of stones. Stones can be just a millimetre or so across or can measure several centimetres. They can be solitary or multiple, and some patients have been found to have several thousand stones in the gallbladder. The stones cause a problem by blocking the outlet of the gallbladder, which is a very narrow tube attached to the main bile duct. If the outlet is blocked and the patient eats a fatty meal then the gallbladder tries to empty but cannot do so, and the gallbladder becomes very tense. This can cause severe pain and can also lead to stagnation of the contents, which can become infected. It only takes one gallstone to produce this problem.
Once a patient with gallstones starts getting attacks of pain then they tend to continue to do so, but these attacks may be very intermittent and are sometimes, but not always, triggered by eating fatty food. Another characteristic of the attacks is that they can wake the patient in the night. The pain from these attacks is usually in the middle part of the upper abdomen but can be in the right side of the abdomen and quite commonly is felt in the back, especially just below
the right scapula (shoulder-blade). Sometimes the pain is short-lived but. sometimes it can last for several days, especially if infection becomes a feature.
Many different treatments for gallstones have been tried, but the only really successful one is surgery to remove the gallbladder and the gallstones contained in it. Techniques to break up the stones with shock-wave treatment have been unsuccessful, as have techniques to dissolve the stones using various chemicals. A low-fat diet can help but in the long term often does not cure the problem. Many patients with gallstones in the gallbladder have a non-functioning gallbladder and removal of the gallbladder with the stones in it does not affect the flow of bile from the liver into the gut.
The Operation
Removal of the gallbladder is nowadays usually performed using keyhole surgery. A small hole is made in the umbilicus (tummy-button) and a short metal tube measuring 1 centimetre in diameter is inserted through the hole. A telescope with a light on the end is then inserted through the tube, and gas is pumped into the abdomen to lift the abdominal wall forwards, away from the contents of the abdomen, thus creating space in which to work. Three further small holes are made in the upper abdomen, one measuring 1 centimetre and two measuring 0.5 centimetre each. Instruments are inserted through these holes with which to perform the operation. The gallbladder is dissected off the liver and the small tube which connects the gallbladder to the bile duct is divided, after having sealed it off with tiny metal clips. The gallbladder is then removed through the hole in the umbilicus. Sometimes the hole in the umbilicus has to be enlarged if the stone in the gallbladder measures more than 1 centimetre, but
the wound is usually well-hidden in the umbilicus.
There is a small percentage of patients (about 5%) in whom the operation cannot be completed using the keyhole technique. This is because of difficulty with visibility, bleeding or technical problems with the equipment. In this case a cut has to be made just below the ribs on the right side, measuring about 10cms, and the operation completed through this incision.
Recovery
Patients are usually kept in hospital for one or two nights after the keyhole surgery. On the day after the operation the patient should be able to eat normally, and the small amount of pain can be controlled with tablets. Some patients experience pain in the shoulders which is due to stretching of the diaphragm by the gas which is introduced into the abdomen during the operation. If the operation has to be converted to the open type of operation then the hospital stay is extended to four or five days.
The patient undergoing keyhole surgery should be fully recovered after about a week in most cases, but if the patient has the open type of operation then the post-operative recovery is probably three or four weeks, although these figures are not inflexible. The wounds are closed with absorbable stitches and so no stitches have to be removed.
We advise patients after keyhole surgery that they should not do any heavy lifting or exertion for about a week after the operation, because a major operation has been performed internally even though the wounds on the outside seem very small. Driving is inadvisable for the first three or four days after the operation, and in the case of the open operation driving should probably be postponed for ten days. It is advisable not to eat a high fat diet for one or two weeks after the operation but after that a normal diet can be commenced, and eating a high fat meal may result in some diarrhoea but no pain.
Complications
The two main complications of this operation are internal bleeding, which could lead to a return to the operating theatre shortly after the main operation, and damage to the common bile duct, which again could necessitate further surgery, although not necessarily. Both of these complications are rare (less than 0.5%).
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FOR PATIENTS HAVING A HERNIA OPERATION
A hernia is a weakness in the muscle wall of the abdomen. If it enlarges then loops of bowel can emerge through the weakness and lie under the skin. Sometimes a loop of bowel can become trapped by the edges of the gap in the muscles, leading to a problem with the blood supply. This is called strangulation and is quite unusual but, when it happens, the consequences can be extremely serious. The commonest type of hernia is an inguinal hernia and occurs in the groin. Other types of hernia can occur around the navel (umbilical hernias) and in operation scars (incisional hernias ).
Repair of inguinal (groin) hernias is usually done using a piece of mesh made from polypropylene. A suitable piece is cut to fit the weak area and is stitched in place or fixed with small metal staples. With both methods of fixation, there is no tension in the tissues at the end of the operation.
This has a very high success rate in terms of recurrence of
the hernia (less than 2%) and is less painful than the older forms of repair when the edges of the defect are pulled together with strong stitches under tension.
Anaesthetic
The operation can be carried out under general anaesthetic, where the patient is asleep, or local anaesthetic, with the patient wide awake or slightly sedated. Usually, patient preference determines the type of anaesthetic, but sometimes a local anaesthetic is safer if the patient has significant other problems such as heart disease.
If the operation is carried out under general anaesthetic, local
anaesthetic solution is infiltrated into the wound, so that when you wake up there should be very little pain. When the anaesthetic wears off (after about four hours) you may need a painkilling injection or some tablets.
After the operation
You will be able to move around straight away and will be able to get out of bed to pass urine, although sudden movement will be painful. The day after the operation you will be able to go home, and will need to take painkilling tablets for a few days.
The skin stitches are dissolving and so there are no stitches to take out. The dressing, which was applied in the Operating Theatre, can be removed 48 hours after the operation, and should be kept dry while it is in place. After the dressing has been removed the wound can be wet, but you should have a shower, or a quick bath, as it is probably not a good idea to soak the wound. A thick ridge will form under the wound over the next week or so. This is healing tissue and is quite normal. It will take about six weeks to go away, and eventually there will be no discernible thickening or swelling. You may notice an area of numbness (lack of feeling) in the skin below a groin hernia wound. This is quite common and mayor may not resolve. If it does not, you will not be at all aware of it after a few months.
Do's and Don'ts
You should not drive a car for about five days, because you might not be able to stop in an emergency because of pain.
You should refrain from heavy lifting for a month but, other than that, you can do anything within the limits of the discomfort in the wound, which usually means a week to ten days after the operation.
It is probably best to refrain from repetitive exercise, such as sit-ups, for 2-3 weeks. Once the skin wound has completely healed (about two weeks) you can go swimming.
In the long-term, you should always try and lift heavy weights carefully and avoid sudden jerking movements.
You may experience occasional twinges of pain in the wound for several months after the operation, but this is usually of no serious significance.
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FOR PATIENTS HAVING A HAEMORRHOIDECTOMY
The operation of haemorrhoidectomy involves the surgical removal of tissue in the anal canal (back passage). There are usually three columns of tissue, and these columns extend from the skin at the edge of the anal canal upwards as far as the junction between the anal canal and the rectum (the lowest part of the large bowel), thus the operation involves cutting the skin on the edge of the anal canal as well as cutting the lining membrane of the anal canal. Sometimes dissolving stitches are used, but mostly the wounds are left open. This is to allow the anal canal to stretch during the passage of a motion. There will be anything from one to three open wounds at the edge of the anal canal. These wounds will gradually heal up over the period of 4-6 weeks.
Prior to the operation
You should follow instructions from the Anaesthetist about eating and drinking. You will be given a small enema just before the operation.
Immediately after the operation
Local anaesthetic is injected into the area during the operation, so when you wake up you will not have any pain. A small plug of spongy material is inserted into the back passage but this is dissolving and you will probably not be aware of it, although you may pass it into the toilet a day or so after the operation. There will be some bleeding for which you will have to wear a pad.
The following few days
You may not have your bowels open for two or three days. Please do not worry about this. It is perfectly normal, and is nature's way of allowing some healing to take place. You will be given the following medicines:
- Lactulose - a laxative
- Metronidazole - an antibiotic, to be taken for 5 days after the operation
- Painkillers
- Lignocaine jelly -local anaesthetic
You should start a high fibre diet immediately after the operation.
The first bowel action after the operation will be painful, but after that things should improve. It is helpful to have a warm bath or a shower immediately after a bowel action.
Continue to take laxatives for about a week after the operation, but then you should gradually stop. It is very important that you pass formed motions and not diarrhoea, as this helps to prevent the anal canal from healing up in a scarred and narrow state. This situation can be very difficult to deal with if it does occur. You may notice several irregular swellings around the outside of the anal canal. These are quite normal and, as the skin heals, these swellings will gradually disappear. You will probably have to wear a pad for about 10 days, but after that it will not be necessary, even though the wounds will have not yet healed.
You will be given an appointment to be seen in the outpatient clinic two weeks after the operation, so that a check can be made that healing is taking place in the correct fashion.
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INFORMATION FOR PATIENTS DIAGNOSED WITH
A BOWEL TUMOUR
You have been diagnosed as having a tumour of the colon or rectum (the last part of the colon). What happens next will be a series of stages of investigation and treatment, and the results of the different investigations may determine what treatment you have.
First of all,
biopsies may have to be taken from the tumour, to determine whether it is benign (incapable of spreading to other parts of the body) or malignant (cancerous). The biopsies may or may not determine whether the tumour is malignant, and your surgeon may recommend an operation without a biopsy first, or may recommend an operation even if the biopsies show that the tumour is benign. This is because most benign tumours of the colon have the capacity to turn malignant in time.
The next thing that will be arranged is a
colonoscopy, if this has not already been done. A colonoscope is a long (1.5 M) fibroptic instrument with a light on the end, which is passed through the back-passage and examines the whole colon if possible. By this means it can be ascertained whether the tumour which has been discovered is the only one in the bowel. If the tumour obstructs the passage of the colonoscope, then you will need a full colonoscopy within a few months of your operation.
Next, you will have
scans. If the tumour is in the colon, you will have a CT scan, which is a special form of X-ray, and if the tumour is in the rectum, you will have a CT scan and an MRI scan. An MRI scan uses magnetic fields to produce very detailed pictures of the pelvis, and enables the surgeon to plan his operation in detail. The CT scan will show detailed pictures of the abdomen and the chest, and may show whether the tumour has spread away from the primary site in the bowel. The commonest site for distant spread is the liver, but other sites include the lungs, and the lymph-glands within the abdomen.
If the scans are clear, you will then go on to have an operation to remove a section of the bowel with the tumour in it. The amount removed varies, and can be anything from 10cm to 30cm, but there is usually plenty to spare. If you have a rectal tumour and the MRI scan suggests that the tumour is very near the edge of the tissue that is to be removed, then it may be recommended that you have a short ( 5 day ) course of
radiotherapy to the pelvis just before the operation.
The results of all the above tests will usually be discussed at a special
multi-disciplinary meeting prior to definitive treatment being undertaken. A committee consisting of surgeons, pathologists, oncologists (tumour specialists ), radiologists and nurses will look at all the test results and decide on the best form of treatment for your tumour. The outcome from these discussions will be communicated to you by your surgeon.
It must be stressed that
most patients who have an operation for a colorectal tumour do not have to have a stoma bag (where the bowel is brought out onto the surface of the abdomen and the bowel motions go into the bag). A small proportion may have to have a temporary stoma, which is reversed after a few months, and very occasionally a patient may have to have a stoma if there are complications. If the tumour is right down in the back-passage itself, then a permanent stoma is likely to be needed.
Whether or not you need
chemotherapy will be decided on the results of the pathological investigations of the tumour after it has been removed.
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