Advanced Colorectal Surgical Options
Surgeons at the Division of Colorectal Surgery are able to perform procedures that maintain continence, reverse ostomies, and provide other treatment options not available elsewhere.
Each year, thousands of patients from the United States and around the world travel to NewYork-Presbyterian/Columbia University Medical Center to seek care for complex colorectal conditions. The Division of Colorectal Surgery’s world renowned team offers advanced surgical options including laparoscopic and robotic surgery; continence preservation procedures; procedures to repair previously created pouches; treatment for recurrent or advanced colon and rectal cancer; advanced procedures for complex IBD; intraoperative radiation therapy; transanal endoscopic microsurgery (TEMS) and more.
The following are descriptions of several of the procedures commonly performed by the Division:
The ‘J-pouch’ is an alternative to traditional ileostomy that may be used to treat patients with ulcerative colitis or familial polyposis who need to have the colon and most of the rectum surgically removed. If the anal sphincter is intact, the surgeon can use a part of the ileum (part of the small intestine) to create an internal pouch. The pouch is then connected to the anus just above the sphincter, which is preserved for continence. J-pouch may also be called ileoanal reservoir, ileoanal anastomosis, pull-thru, endorectal pullthrough, pelvic pouch, or ileal pouch anal anastomosis (IPAA).
Also called Koch pouch or continent ileostomy, this is a variation of ileostomy in which the surgeon creates a reservoir pouch inside the abdomen using a portion of the small intestine. A one-way valve that prevents escape of waste is created inside the pouch, and a stoma is connected to the abdominal wall. The valve prevents the opening on the abdomen from leaking any contents, thus avoiding the need for an external appliance (bag). Instead, the patient can insert a catheter into the pouch to drain waste at his or her convenience. Candidates for K-pouch surgery include patients with poor anal sphincter function, and those who have had their sphincters previously removed and have a traditional ostomy but wish to avoid the encumbrance of an external appliance.
Surgeons at NYP/Columbia are often able to reverse ostomies after patients recover from colorectal resection. Please see our article for a full description of this special expertise.
Pouch repair operations
When pouch failure occurs, surgical options may include pouch revision, creation of a redo pouch, or neo-pouch creation. In some circumstances, the conversion of a J-pouch into a continent ileostomy (K-pouch) may be considered to preserve continence and improve patients’ quality of life. NYP/Columbia’s experience and expertise often allows for preservation of the sphincter.
Surgeons at the center can often devise surgical solutions to avoid a permanent ostomy. They are able to do this even in adverse circumstances such as multiple previous operations, complicated or severe inflammatory bowel disease, and advanced colon and rectal cancer. The continent ileostomy reservoir is also an option for some patients with poor sphincter function, when restorative surgery is not feasible or desired, and for those with a permanent conventional ostomy seeking continence.
The Division of Colorectal Surgery provides advanced care to patients with intestinal fistulae and other abdominal conditions secondary to inflammatory bowel disease, benign and malignant colorectal disease. In collaboration with specialists in plastic surgery, urology and gynecology, division surgeons are able to repair the involved organs, restore intestinal continuity, and reconstruct associated tissue including the abdominal wall. Surgeons at the center collaborate with specialists in gastroenterology, nutrition, enterostomal therapy, oncology and radiology, as these challenging conditions require a multidisciplinary approach.
Complex reoperative surgery:
For complicated benign and malignant colorectal conditions, the division performs the full scope of complex procedures such as:
- Ileoanal pouch creation
- Revisional pouch surgery
- Continent ileostomy
- Repair of complex enterocutaneous and intestinal fistulae
- Management of locally advanced and recurrent colon and rectal cancer
- Turnbull Cutait procedure
- Salvage of ileoanal pouches (for patients who develop dysfunction after a previous ileoanal pouch procedure or when pouch failure occurs)
- Specialized perineal and abdominal techniques for pouch-perineal or pouch-vaginal fistulae, pouch sinus, pelvic sepsis related to the pouch, pouch and anastomotic strictures, Crohn’s disease complicating the pouch, and pouch prolapse.
For Crohn’s disease of the small intestine, the division offers extensive experience with bowel resection, stricturoplasty, treatment of enterocutaneous and other fistulae, and the use of reconstructive procedures. When Crohn’s disease involves the large intestine, division surgeons have in-depth understanding of Crohn’s colitis and continence preservation techniques, which allows for the control of disease and prevention of complications while maintaining quality of life. Intestinal continuity frequently can be maintained without a permanent ostomy, even in complex circumstances. For anorectal Crohn’s disease, the surgeons’ expertise in surgical techniques facilitates prompt and effective treatment of abscesses, fissure, incontinence, and simple and complex fistulae while preserving continence.
NYP/Columbia is one of the few centers in New York to offer robotic surgery for the management of benign and malignant diseases of the colon and rectum. This technology provides visualization and maneuverability, and facilitates a minimally invasive surgical approach even in difficult circumstances, such as within the confines of the pelvis.
Operations for pelvic floor dysfunction
NYP/Columbia offers the full spectrum of surgical techniques for patients whose fecal incontinence is caused by damage to the pelvic floor or anal sphincter. Surgery is also appropriate for many patients with internal rectal prolapse. Surgeons at the center regularly use robotic technology that allows them to see inside the pelvis and perform very delicate procedures, including ventral mesh rectopexy. As with laparoscopic surgery, use of the surgical robot reduces scarring, the risk of complications, and post-operative recovery time.
Anal Fissure Protocol
In addition to its surgical capabilities, the division offers innovative non-surgical therapies such as its muscle-sparing procedure for anal fissures.
Anal fissures are small cuts or tears at the skin of the anal opening. They typically cause pain when a person has a bowel movement, and pain can be severe for hours afterwards. Although some anal fissures heal without treatment, some do not, and these go on to cause chronic pain problems. Medical therapy, primarily a muscle relaxant cream applied around the anus, is effective in healing about 70% of anal fissures.
For the 30% of patients who continue to have problems, the colorectal surgery program offers a unique protocol developed by Daniel Feingold, MD, who pioneered the approach based on his observations of effective wound care protocols. Proven to be highly effective, the procedure is performed in the operating room under sedation and includes four steps:
- Gently dilate the anus with special retractors
- Clean out the fissure with curettage to stimulate healing
- Cauterize the wound with electrocautery to seal the wound
- Inject triamcinolone (generic Kenalog), a steroid, into the fissure.
The majority of patients are pain-free within ten days of this procedure. The Kenalog protocol represents an important non-surgical, low-risk alternative to the standard treatment for anal fissures, sphincterectomy. Although considered the gold standard for many years, sphincterectomy entails cutting the sphincter muscle, which can cause undesirable function-related problems such as incontinence.