Surgery for colorectal cancer

he types of surgery used to treat colon and rectal cancers are slightly different, so they are described separately.

Colon surgery

Surgery is often the main treatment for earlier stage colon cancers.

Open colectomy

A colectomy (sometimes called a hemicolectomy, partial colectomy, or segmental resection) removes part of the colon, as well as nearby lymph nodes. The surgery is referred to as an open colectomy if it is done through a single incision in the abdomen.

The day before surgery, you will most likely be told to completely empty your bowel. This is done with a bowel preparation, which may consist of laxatives and enemas. Just before the surgery, you will be given general anesthesia, which puts you into a deep sleep.

During the surgery, your surgeon will make an incision in your abdomen. He or she will remove the part of the colon with the cancer and a small segment of normal colon on either side of the cancer. Usually, about one-fourth to one-third of your colon is removed, but more or less may be removed depending on the exact size and location of the cancer. The remaining sections of your colon are then reattached. Nearby lymph nodes are removed at this time as well. Most experts feel that taking out as many nearby lymph nodes as possible is important, but at least 12 should be removed.

When you wake up after surgery, you will have some pain and probably will need pain medicines for 2 or 3 days. For the first couple of days, you will be given intravenous (IV) fluids. During this time you may not be able to eat or you may be allowed limited liquids, as the colon needs some time to recover. But a colon resection rarely causes any major problems with digestive functions, and you should be able to eat solid food again in a few days.

It's important that you are as healthy as possible for this type of major surgery, but in some cases an operation may be needed right away. If the tumor is large and has blocked your colon, it may be possible for the doctor to use a colonoscope to put a stent (a hollow metal or plastic tube) inside the colon to keep it open and relieve the blockage for a short time and help prepare for surgery a few days later.

If a stent can't be placed or if the tumor has caused a hole in the colon, surgery may be needed right away. This usually is the same type of operation that's done to remove the cancer, but instead of reconnecting the segments of the colon, the top end of the colon is attached to an opening (stoma) in the skin of the abdomen to allow body wastes out. This is known as a colostomy and is usually temporary. Sometimes the end of the small intestine (the ileum) is connected to a stoma in the skin instead. This is called an ileostomy. A removable collecting bag is connected to the stoma to hold the waste. Once you are healthier, another operation (known as a colostomy reversal or ileostomy reversal) can be done to attach the ends of the colon back together or to attach the ileum to the colon. Rarely, if a tumor can't be removed or a stent placed, the colostomy or ileostomy may need to be permanent. For more information, refer to our documents Colostomy: A Guide and Ileostomy: A Guide.

Laparoscopic-assisted colectomy

This newer approach to removing part of the colon and nearby lymph nodes may be an option for some earlier stage cancers. Instead of making one long incision in the abdomen, the surgeon makes several smaller incisions. Special long instruments are inserted through these incisions to remove part of the colon and lymph nodes. One of the instruments, called a laparoscope, has a small video camera on the end, which allows the surgeon to see inside the abdomen. Once the diseased part of the colon has been freed, one of the incisions is made larger to allow for removal.

This type of operation requires the same type of preparation before surgery and the same type of anesthesia during surgery as an open colectomy (see above).

Because the incisions are smaller than with an open colectomy, patients may recover slightly faster and have less pain than they do after standard colon surgery.

Laparoscopic-assisted surgery is as likely to be curative as the open approach for colon cancers. But the surgery requires special expertise. If you are considering this approach, be sure to look for a skilled surgeon who has done many of these operations.

Polypectomy and local excision

Some early colon cancers (stage 0 and some early stage I tumors) or polyps can be removed by surgery through a colonoscope. When this is done, the surgeon does not have to cut into the abdomen. For a polypectomy, the cancer is removed as part of the polyp, which is cut at its stalk (the area that resembles the stem of a mushroom). Local excision removes superficial cancers and a small amount of nearby tissue.

Rectal surgery

Surgery is usually the main treatment for rectal cancer, although radiation and chemotherapy will often be given before or after surgery. Several surgical methods can be used for removing or destroying rectal cancers.

Polypectomy and local excision

These procedures, described in the colon surgery section, can be used to remove superficial cancers or polyps. They are done with instruments inserted through the anus, without making a surgical opening in the skin of the abdomen.

Local transanal resection (full thickness resection)

As with polypectomy and local excision, local transanal resection (also known as transanal excision) is done with instruments inserted through the anus, without making an opening in the skin of the abdomen. This operation cuts through all layers of the rectum to remove cancer as well as some surrounding normal rectal tissue, and then closes the hole in the rectal wall. This procedure can be used to remove some T1 N0 M0 stage I rectal cancers that are relatively small and not too far from the anus. It is usually done with local anesthesia (numbing medicine) -- you are not asleep during the operation.

Transanal endoscopic microsurgery (TEM)

This operation can sometimes be used for early T1 N0 M0 stage I cancers that are higher in the rectum than could be reached using the standard transanal resection (see above). A specially designed magnifying scope is inserted through the anus and into the rectum, allowing the surgeon to do a transanal resection with great precision and accuracy. This operation is only done at certain centers, as it requires special equipment and surgeons with special training and experience.

Low anterior resection

Some stage I rectal cancers and most stage II or III cancers in the upper third of the rectum (close to where it connects with the colon) can be removed by low anterior resection. In this operation, the part of the rectum containing the tumor is removed without affecting the anus. The colon is then attached to the remaining part of the rectum so that after the surgery, you will move your bowels in the usual way.

A low anterior resection is like most abdominal operations. You will most likely be instructed to take laxatives and enemas before surgery to completely clean out the intestines. Just before surgery, you will be given general anesthesia, which puts you into a deep sleep. The surgeon makes an incision in the abdomen. Then the surgeon removes the cancer and a margin of normal tissue on either side of the cancer, along with nearby lymph nodes and fatty and fibrous tissue around the rectum. The colon is then reattached to the rectum that is remaining so that a permanent colostomy is not necessary. If radiation and chemotherapy have been given before surgery, it is common for a temporary ileostomy to be made (where the last part of the small intestine -- the ileum -- is brought out through a hole in the abdominal wall). Usually this can be reversed (the intestines reconnected) about 8 weeks later.

The usual hospital stay for a low anterior resection is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Proctectomy with colo-anal anastomosis

Some stage I and most stage II and III rectal cancers in the middle and lower third of the rectum require removing the entire rectum (proctectomy). The colon is then connected to the anus (colo-anal anastomosis). The rectum has to be removed to do a total mesorectal excision (TME), which is required to remove all of the lymph nodes near the rectum. This is a harder procedure to do, but modern techniques have made it possible.

Sometimes when a colo-anal anastomosis is done, a small pouch is made by doubling back a short segment of colon (colonic J-pouch) or by enlarging a segment (coloplasty). This small reservoir of colon then functions as a storage space for fecal matter like the rectum did before surgery. When special techniques are needed to avoid a permanent colostomy, you may need to have a temporary ileostomy opening for about 8 weeks while the bowel heals. A second operation is then done to reconnect the intestines and close the ileostomy opening.

This operation requires general anesthesia (where you are asleep). The usual hospital stay for a colo-anal anastomosis, like a low anterior resection, is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Abdominoperineal resection (APR)

This operation is more involved than a low anterior resection. It can be used to treat some stage I cancers and many stage II or III rectal cancers in the lower third of the rectum (the part nearest to the anus), especially if the cancer is growing into the sphincter muscle (the muscle that keeps the anus closed and prevents stool leakage).

Here, the surgeon makes one incision in the abdomen, and another in the perineal area around the anus. This incision allows the surgeon to remove the anus and the tissues surrounding it, including the sphincter muscle. Because the anus is removed, you will need a permanent colostomy to allow stool a path out of the body.

This operation requires general anesthesia (you will be asleep). As with a low anterior resection or a colo-anal anastomosis, the usual hospital stay for an AP resection is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Pelvic exenteration

If the rectal cancer is growing into nearby organs, a pelvic exenteration may be recommended. This is an extensive operation. Not only will the surgeon remove the rectum, but also nearby organs such as the bladder, prostate (in men), or uterus (in women) if the cancer has spread to these organs. You will need a colostomy after pelvic exenteration. If the bladder is removed, you will also need a urostomy (opening in the front of the abdomen where urine exits and is held in a portable pouch).

Side effects of colorectal surgery

Potential side effects of surgery depend on several factors, including the extent of the operation and a person's general health before surgery. Most people will have at least some pain after the operation, but it usually can be controlled with medicines if needed. Eating problems usually resolve within a few days of surgery.

Other problems may include bleeding from the surgery, blood clots in the legs, and damage to nearby organs during the operation. Rarely, the new connections between the ends of the intestine may not hold together completely and may leak, which can lead to infection. It is also possible that the abdominal incision might open up, becoming an open wound. After the surgery, you might develop scar tissue in the abdomen that can cause organs or tissues to stick together. These are called adhesions. In some cases, adhesions can block the bowel, requiring further surgery.

Colostomy or ileostomy: Some people may need a temporary or permanent colostomy (or ileostomy) after surgery. This may take some time to get used to and may require some lifestyle adjustments. If you have a colostomy or ileostomy, you will need help learning how to manage it. Specially trained ostomy nurses or enterostomal therapists can do this. They will usually see you in the hospital before your operation to discuss the ostomy and to mark a site for the opening. After the operation they may come to your house or an outpatient setting to give you more training. For more information, please see our documents Colostomy: A Guide and Ileostomy: A Guide.

Sexual function and fertility after colorectal surgery: If you are a man, an AP resection may stop your erections or ability to reach orgasm. In other cases, your pleasure at orgasm may become less intense. Normal aging may cause some of these changes, but they may be made worse by the surgery.

An AP resection can damage the nerves that control ejaculation leading to "dry" orgasms (orgasms without semen). Sometimes the surgery causes retrograde ejaculation, which means the semen goes backward into the bladder during an orgasm. This difference is important if you want to father a child. Retrograde ejaculation is less serious because infertility specialists can often recover sperm cells from the urine, which can then be used to fertilize an egg. If sperm cells cannot be recovered from your semen or urine, specialists may be able to retrieve them directly from the testicles by minor surgery, and then use them for in vitro fertilization.

If you are a woman, colorectal surgery (except pelvic exenteration) usually does not cause any loss of sexual function. Abdominal adhesions (scar tissue) may sometimes cause pain or discomfort during intercourse. If the uterus is removed, pregnancy will not be possible.

A colostomy can have an impact on body image and sexual comfort level in both men and women. While it may require some adjustments, it should not prevent you from having an enjoyable sex life.

More information on dealing with the sexual impact of cancer and its treatment is available in our documents Sexuality for the Man With Cancer and Sexuality for the Woman With Cancer.

Surgery and other local treatments for colorectal cancer metastases

Sometimes, surgery for cancer that has spread (metastasized) to other organs can help you live longer or, depending on the extent of the disease, may even cure you. If only a small number of metastases are present in the liver or lungs (and nowhere else), they can sometimes be removed by surgery. This will depend on their size, number, and location.

In some cases, if it's not possible to remove the tumors with surgery, non-surgical treatments may be used to destroy (ablate) tumors in the liver. But these methods are less likely to be curative. Several different techniques may be used.

Radiofrequency ablation: Radiofrequency ablation (RFA) uses high-energy radio waves to kill tumors. A thin, needle-like probe is placed through the skin and into the tumor under CT or ultrasound guidance. An electric current is then run through the tip of the probe, releasing high-frequency radio waves that heat the tumor and destroy the cancer cells.

Ethanol (alcohol) ablation: Also known as percutaneous ethanol injection (PEI), this procedure injects concentrated alcohol directly into the tumor to kill cancer cells. This is usually done through the skin using a needle, which is guided by ultrasound or CT scans.

Cryosurgery (cryotherapy): Cryosurgery destroys a tumor by freezing it with a metal probe. The probe is guided through the skin and into the tumor using ultrasound. Then very cold gasses are passed through the probe to freeze the tumor, killing the cancer cells. This method can treat larger tumors than either of the other ablation techniques, but it sometimes requires general anesthesia (you will be asleep).

Since these 3 treatments usually do not require removal of any of the patient's liver, they are often good options for patients whose disease cannot be cured with surgery or who cannot have surgery for other reasons.

Hepatic artery embolization: This is sometimes another option for tumors that cannot be removed. This technique is used to reduce the blood flow in the hepatic artery, which feeds most cancer cells in the liver. This is done by injecting materials that plug up the artery. Most of the healthy liver cells will not be affected because they get their blood supply from the portal vein.

For this procedure, the doctor puts a catheter into an artery in the inner thigh and threads it up into the liver. A dye is usually injected into the bloodstream at this time to allow the doctor to monitor the path of the catheter by angiography, a special type of x-ray. Once the catheter is in place, small particles are injected into the artery to plug it up.

Embolization also reduces some of the blood supply to the normal liver tissue. This may be dangerous for patients with diseases such as hepatitis and cirrhosis, who already have reduced liver function.

Digestive Disorders Health Center

Diverticulitis - Surgery

Surgery for diverticulitis involves removing the diseased part of the colon. You may decide to have surgery for diverticulitis if you have:

• Repeated attacks of diverticulitis. Surgery to remove the diseased part of the colon often is recommended if you have two or more severe attacks.
• A high risk of repeated attacks (such as in people younger than age 40, or people with an impaired immune system).
• An abnormal opening (fistula) that has formed between the colon and an adjacent organ, most commonly the bladder, uterus, or vagina.

Surgery for diverticulitis, in which the infected part of the colon is removed, may be required if you have complications, including:

• An infected pouch (diverticulum ) that has ruptured into the abdominal cavity, especially if a pocket of infection (abscess) has formed. In some cases, an abscess can be drained without surgery. (See Other Treatment.)
• An infection that has spread into the abdominal cavity (peritonitis).
• A blocked colon (bowel obstruction) or a narrow spot in the colon (stricture).
• Infection that has spread through the blood to other parts of the body (sepsis).
• Repeated problems with bleeding or severe bleeding that does not stop with other treatments.

Overall, fewer than 6 out of 100 people who have diverticulitis need surgery.³

Surgical treatment involves removing the diseased part of the large intestine (partial colectomy ) and reconnecting the remaining parts. Depending on the severity and nature of the symptoms, more than one surgery may be needed to correct the problem. When multiple surgeries are needed, the person usually has a colostomy during the time between surgeries. A colostomy is a surgical procedure in which the upper part of the intestine is sewn to an opening made in the skin of the abdomen. Stool passes out of the body at this opening and into a disposable bag. Usually the colostomy is removed at a later time and the intestine is reconnected.

Surgery choices

Surgical treatment of diverticulitis, called bowel resection, involves the removal of the diseased part of the large intestine.

What to think about

People who have mild, brief attacks and who are willing to try long-term dietary changes may be able to avoid surgery. See the Prevention section of this topic for more information on diet.

If you have multiple attacks of diverticulitis, surgery may be appropriate.

Diverticulitis (Diverticulosis, Diverticular Disease)

Diverticulosis and diverticulitis facts

• Most patients with diverticulosis (diverticular disease) have few or no symptoms.
• Abdominal pain, constipation, and diarrhea, can occur with diverticulosis, which then may be called diverticular disease.
• Diverticulosis can be diagnosed with barium X-rays, sigmoidoscopy, colonoscopy, or CT scan.
• Treatment of diverticulosis can include high fiber diet, and anti-spasmodic drugs.
• When diverticulosis is associated with inflammation and infection the condition is called diverticulitis.
• Complications of diverticulosis and diverticulitis include rectal bleeding, abdominal infections, and colon obstruction.

What is diverticulosis?

The colon (large intestine) is a long tube-like structure that stores and then eliminates waste material left over after digestion of food in the small intestine takes place. Pressure within the colon causes bulging pockets of tissue (sacs) that push out from the colonic walls as a person ages. A small bulging sac pushing outward from the colon wall is called a diverticulum. More than one bulging sac is referred to in the plural as diverticula. Diverticula can occur throughout the colon but are most common near the end of the left colon, referred to as the sigmoid colon, in Western countries. In Asia, the diverticula occur mostly on the right side of the colon. The condition of having these diverticula in the colon is called diverticulosis.

Diverticula are common in the Western world but are rare in areas such as Asia and Africa. Diverticula increase with age. They are uncommon before the age of 40, and are seen in more than 74% of people over the age of 80 years in the U.S. A person with diverticulosis usually has few or no symptoms. The most common symptoms associated with diverticulosis are abdominal pain, constipation, and diarrhea. In some of these patients the symptoms may be due to the concomitant presence of irritable bowel syndrome or abnormalities in the function of the muscles of the sigmoid colon (diverticular disease); simple diverticula should cause no symptoms. Occasionally, bleeding originates from a diverticulum, and it is referred to as diverticular bleeding.

Picture of Diverticular Disease

What is diverticulitis?

When a diverticulum ruptures and infection sets in around the diverticulum, the condition is called diverticulitis. An individual suffering from diverticulitis often has abdominal pain, abdominal tenderness, colonic obstruction and fever.

What are diverticulitis symptoms?

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Most patients with diverticulosis have few or no symptoms. The diverticulosis in these individuals is found incidentally during tests for other intestinal problems. It has been thought s many as 20% of individuals with diverticulosis will develop symptoms related to diverticulosis, primarily diverticulitis; however, the most recent study suggests that the incidence is closer to 5%.

The most common signs and symptoms of diverticulitis include:

• Abdominal pain (left lower abdomen)
• Abdominal tenderness (left lower abdomen)
• Fever
• Constipation or, sometimes, diarrhea.

What causes diverticula, and how do diverticula form?

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The muscular wall of the colon grows thicker with age, although the cause of this thickening is unclear. It may reflect the increasing pressures required by the colon to eliminate feces. For example, a diet low in fiber can lead to small, hard stools which are difficult to pass and which require increased pressure to pass. The lack of fiber and small stools also may allow segments of the colon to close off from the rest of the colon when the colonic muscle in the segment contracts. The pressure in these closed-off segments may become high since the increased pressure cannot dissipate to the rest of the colon. Over time, high pressures in the colon push the inner intestinal lining outward (herniation) through weak areas in the muscular walls. These pouches or sacs that develop are called diverticula.

Lack of fiber in the diet has been thought to be considered the most likely cause of diverticula, and there is a good correlation among societies around the world between the amount of fiber in the diet and the prevalence of diverticula. Nevertheless, studies have not found similar correlations between fiber and diverticuli within individual societies. Many people with diverticular disease have excessive thickening of the muscular wall of the colon where the diverticula form. The muscle also contracts more strongly. These abnormalities of the muscle may be contributing factors in the formation of diverticula. Microscopic examination of the edges of the diverticula show signs of inflammation, and it has been suggested that there may be an inflammatory component to the formation of the diverticula.

What are the more serious complications of diverticulitis?

More serious complications of diverticulitis include:

• Collections of pus (abscess) in the pelvis where the diverticulum has ruptured
• Colonic obstruction
• Generalized infection of the abdominal cavity (bacterial peritonitis)
• Bleeding into the colon

A diverticulum can rupture, and the bacteria within the colon can spread into the tissues surrounding the colon (diverticulitis). Constipation or diarrhea also may occur. A collection of pus can develop around the ruptured diverticulum, leading to formation of an abscess, usually in the pelvis. Inflammation surrounding the colon also can lead to colonic obstruction. Infrequently, a diverticulum ruptures freely into the abdominal cavity causing a life threatening infection called peritonitis. On rare occasions, the inflamed diverticula can erode into the urinary bladder, causing bladder infection and passing of intestinal gas in the urine.

Diverticular bleeding occurs when the expanding diverticulum erodes into a blood vessel within the diverticulum. Rectal passage of red, dark or maroon-colored blood and clots occur without any associated abdominal pain if there is no diverticulitis, but bleeding into the colon also may occur during and episode of diverticulitis. Blood from a diverticulum of the right colon may be black in color. Bleeding may be continuous or intermittent, lasting several days.

Patients with active bleeding usually are hospitalized for observation. Intravenous fluids are given to support the blood pressure. Blood transfusions are necessary for those with moderate to severe blood loss. In a rare individual with brisk and severe bleeding, the blood pressure may drop, causing dizziness, shock, and loss of consciousness. In most patients, bleeding stops spontaneously and they are sent home after several days in the hospital. Patients with persistent, severe bleeding require surgical removal of the bleeding diverticula.

How are the diagnosis of diverticulitis and diverticulosis made?

If suspected, the diagnosis of diverticular disease can be confirmed by a variety of tests. Barium X-rays (barium enemas) can be performed to visualize the colon. Diverticula are seen as barium filled pouches protruding from the colon wall.

Direct visualization of the inside of the colon and the openings of the diverticula can be done with flexible tubes inserted through the rectum and advanced into the colon. Either short tubes (sigmoidoscopes) or longer tubes (colonoscopes) may be used to assist in the diagnosis and to exclude other diseases that can mimic diverticular disease.

In patients suspected of having diverticulitis causing persistent pain, tenderness, and fever; ultrasound and computerized tomography (CT) examinations of the abdomen and pelvis can be done to detect inflammation of the tissues surrounding the ruptured diverticulum or collections of pus.

What is the treatment for diverticulitis and diverticulosis?

Treatment for diverticulitis and diverticulosis include medications to treat abdominal pain due to muscle spasms, oral antibiotics for infection, and liquid or low fiber foods when having a acute attacks of diverticulitis.

Medical treatment of diverticulitis and diverticulosis

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Most patients with diverticulosis have minimal or no symptoms, and do not require any specific treatment. A normal fiber diet is advisable to prevent constipation and perhaps prevent the formation of more diverticula.

Patients with mild symptoms of abdominal pain due to muscular spasm in the area of the diverticula may benefit from anti-spasmodic drugs such as:

• chlordiazepoxide (Librax),
• dicyclomine (Bentyl),
• atropine, scopolamine, phenobarbital (Donnatal), and
• hyoscyamine (Levsin).

When diverticulitis occurs, antibiotics usually are needed. Oral antibiotics are sufficient when symptoms are mild. Some examples of commonly prescribed antibiotics include:

• ciprofloxacin (Cipro),
• metronidazole (Flagyl),
• cephalexin (Keflex), and
• doxycycline (Vibramycin).

Liquid or low fiber foods are advised during acute attacks of diverticulitis. This is done to reduce the amount of material that passes through the colon, which at least theoretically, may aggravate the diverticulitis. In severe diverticulitis with high fever and pain, patients are hospitalized and given intravenous antibiotics. Surgery is needed for patients with persistent bowel obstruction or abscess not responding to antibiotics.

Surgical treatment for diverticulitis

Diverticulitis that does not respond to medical treatment requires surgical intervention. Surgery usually involves drainage of any collections of pus and resection (surgical removal) of the segment of the colon containing the diverticula, usually the sigmoid colon. Surgical removal of the bleeding diverticulum also is necessary for those with persistent bleeding. In patients needing surgery to stop persistent bleeding, it is important to determine exactly where the bleeding is coming from in order to guide the surgeon.

Sometimes, diverticula can erode into the adjacent urinary bladder, causing severe recurrent urine infection and passage of gas during urination. This situation also requires surgery.

Sometimes, surgery may be suggested for patients with frequent, recurrent attacks of diverticulitis leading to multiple courses of antibiotics, hospitalizations, and days lost from work. During surgery, the goal is to remove all, or almost all, of the colon containing diverticula in order to prevent future episodes of diverticulitis. There are few long-term consequences of resection of the sigmoid colon for diverticulitis, and the surgery often can be done laparoscopically, which limits post-operative pain and time for recovery.

What can be done to prevent diverticulitis and diverticulosis?

Once formed, diverticula are permanent. No treatment has been found to prevent complications of diverticular disease.

Diets high in fiber increases stool bulk and prevents constipation, and theoretically may help prevent further diverticular formation or worsening of the diverticular condition. Some doctors recommend avoiding nuts, corn, and seeds, which are thought by some to plug diverticular openings and cause diverticulitis, but there is little evidence to support this recommendation.

Because inflammation has been found at the edges of diverticula, it has been speculated that colonic bacteria may be playing a role in the rupture of diverticula by promoting inflammation. This has led some people to further speculate that changing the bacteria in the colon might reduce inflammation and rupture and to suggest treatment with probiotics; however, there is not enough evidence of a benefit of probiotics yet to recommend treatment with probiotics of patients with diverticular disease.

Thyroid Surgery

General Information

Thyroid operations are advised for patients who have a variety of thyroid conditions, including both cancerous and benign (non-cancerous) thyroid nodules, large thyroid glands (goiters), and overactive thyroid glands. There are several thyroid operations that a surgeon may perform, including:

What is the thyroid gland?
The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. The thyroid’s job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should.

1. excisional biopsy – removing a small part of the thyroid gland (rarely in use today);
2. lobectomy – removing half of the thyroid gland;
3. removing nearly all of the thyroid gland (subtotal thyroidectomy – leaving a small amount of thyroid tissue bilaterally or near-total thyroidectomy – leaving about one gm or cm of thyroid tissue on one side); or
4. total thyroidectomy, which removes all identifiable thyroid tissue.

There are specific indications for each of these operations. The main risks of a thyroid operation involve possible damage to important structures near the thyroid, primarily the parathyroid glands (which regulate calcium levels) and the recurrent and external laryngeal nerves (which control the vocal cords).

Questions and Considerations

When thyroid surgery is recommended, patients should ask several questions regarding the surgery including:

1. Why do I need an operation?
2. Are there other means of treatment?
3. How should I be evaluated prior to the operation?
4. How do I select a surgeon?
5. What are the risks of the operation?
6. How much of my thyroid gland needs to be removed?
7. What can I expect once I decide to proceed with surgery?
8. Will I lead a normal life after surgery?

Why do I need an operation?

The most common reason for thyroid surgery is to remove a thyroid nodule, which has been found to be suspicious through a fine needle aspiration biopsy (see Thyroid Nodule brochure). Surgery may be recommended for the following biopsy results:

1. cancer (papillary cancer);
2. possible cancer (follicular neoplasm); or
3. inconclusive biopsy.

Surgery may be also recommended for nodules with benign biopsy results if the nodule is large, if it continues to increase in size or if it is causing symptoms (pain, difficulty swallowing, etc.). Surgery is also an option for the treatment of hyperthyroidism (see Hyperthyroidism brochure), for large and multinodular goiters and for any goiter that may be causing symptoms.

Are there other means of treatment?

Surgery is definitely indicated to remove nodules suspicious for thyroid cancer. In the absence of a possibility of thyroid cancer, there may be nonsurgical options of therapy depending on the diagnosis. You should discuss other options for therapy with your physician.

How should I be evaluated prior to the operation?

As for other operations, all patients considering thyroid surgery should be evaluated preoperatively with a thorough and comprehensive medical history and physical exam, including cardiopulmonary (heart) evaluation. An electrocardiogram and a chest x-ray prior to surgery is often recommended for patients who are over 45 years of age or who are symptomatic from cardiac disease. Blood tests may be performed to determine if a bleeding disorder is present. Any patients who have had a change in voice or who have had a previous neck operation should have their vocal cord function evaluated preoperatively. This is necessary to determine whether the recurrent laryngeal nerve that controls the vocal cord muscles is functioning normally. Finally, if medullary thyroid cancer is suspected, patients should be evaluated for coexisting adrenal tumors (pheochromocytomas) and for hypercalcemia and hyperparathyroidism.

How do I select a surgeon?

In general, thyroid surgery is best performed by a surgeon who has received special training and who performs thyroid surgery on a regular basis. The complication rate of thyroid operations is lower when the operation is done by a surgeon who does a considerable number of thyroid operations each year. Patients should ask their referring physician where he or she would go to have a thyroid operation or where he or she would send a family member.

What are the risks of the operation?

The most serious possible risks of thyroid surgery include:

1. bleeding that can cause acute respiratory distress,
2. injury to the recurrent laryngeal nerve that can cause permanent hoarseness, and
3. damage to the parathyroid glands that control calcium levels in the body, causing hypoparathyroidism and hypocalcemia.

These complications occur more frequently in patients with invasive tumors or extensive lymph node involvement, in patients requiring a second thyroid surgery, and in patients with large goiters that go below the collarbone. Overall the risk of any serious complication should be less than 2%. However, the risk of complications discussed with the patient should be the particular surgeon’s risks rather than that quoted in the literature. Prior to surgery, patients should understand the reasons for the operation, the alternative methods of treatment, and the potential risks and benefits of the operation (informed consent).

How much of my thyroid gland neds to be removed?

Your surgeon should explain the planned thyroid operation, such as lobectomy or total thyroidectomy, and the reasons why such a procedure is recommended. For patients with papillary or follicular thyroid cancer many, but not all, surgeons recommend total or neartotal thyroidectomy when they believe that subsequent treatment with radioactive iodine might be beneficial. For patients with large (>1.5 cm) or more aggressive cancers and for patients with medullary thyroid cancer, more extensive lymph node dissection is necessary to remove possibly involved lymph node metastases.

Thyroid lobectomy may be recommended for overactive one-sided nodules or for benign one-sided nodules that are causing symptoms such as compression, hoarseness, shortness of breath or difficulty swallowing. A total or near – total thyroidectomy may be recommended for patients with Graves’ Disease (see Hyperthyroidism brochure) or for patients with enlarged multinodular goiters

What can I expect once I decide to proced with surgery?

Once you have met with the surgeon and decided to proceed with surgery, you will be scheduled for your pre-op evaluation (see above) and will meet with the anesthesiologist (the person who will put you to sleep during the surgery). You should have nothing to eat or drink after midnight on the day before surgery and should leave valuables and jewelry at home. The surgery usually takes 2-2½ hours, after which time you will slowly wake up in the recovery room. Surgery may be performed through a standard incision in the neck or may be done through a smaller incision with the aide a a video camera (Minimally invasive video assisted thyroiectomy) Under special circumstances, thyroid surgery can be performed with the assistance of a robot through a distant incision in either the axilla or the back of the neck. There may be a surgical drain in the incision in your neck (which will be removed the morning after the surgery) and your throat may be sore because of the breathing tube placed during the operation. Once you are fully awake, you will be moved to a bed in a hospital room where you will be able to eat and drink as you wish. Most patients having thyroid operations are hospitalized for about 24 hours and can be discharged on the morning following the operation. Normal activity can begin on the first postoperative day. Vigorous sports, such as swimming, and activities that include heavy lifting should be delayed for at least ten days.

Will I be able to lead a normal life after surgery?

Yes. Once you have recovered from the effects of thyroid surgery, you will usually be able to doing anything that you could do prior to surgery. Many patients become hypothyroid following thyroid surgery, requiring treatment with thyroid hormone (see Hypothyroidism brochure). This is especially true if you had surgery for thyroid cancer. Thyroid hormone replacement therapy may be delayed for several weeks if you are to receive radioactive iodine therapy (see Thyroid Cancer brochure).

Carotid Endarterectomy

What is carotid endarterectomy?

Carotid endarterectomy is an operation during which your vascular surgeon removes the inner lining of your carotid artery if it has become thickened or damaged. This procedure eliminates a substance called plaque from your artery and can restore blood flow.

As you age, plaque can build up in the walls of your arteries. Cholesterol, calcium, and fibrous tissue make up this plaque. As more plaque builds up, your arteries narrow and stiffen. This process is called atherosclerosis, or hardening of the arteries. Eventually, enough plaque builds up to reduce blood flow through your carotid arteries, or to cause irregularities in the normally smooth inner walls of the arteries.

Your carotid arteries are located on each side of your neck and extend from your aorta in your chest to enter the base of your skull. These important arteries supply blood to your brain.

Carotid artery disease is a serious issue because clots can form on the plaque. Plaque or clots can also break loose and travel to the brain. If a clot or plaque blocks the blood flow to your brain sufficiently, it can cause an ischemic stroke, which can cause permanent brain damage, or death, if a large enough area of the brain is affected. If a clot or plaque blocks only a tiny artery in the brain, it may cause a transient ischemic attack (TIA), also known as a mini-stroke. A TIA is often a warning sign that a stroke may occur in the near future, and it should be a signal to seek treatment soon, before a stroke occurs.

To remove plaque in your carotid arteries and help prevent a stroke, your physician may recommend a carotid endarterectomy. Carotid endarterectomy is one of the most commonly performed vascular operations, and is a safe and long-lasting treatment.

How do I prepare?

Your physician or vascular surgeon will give you the instructions you need to follow before the surgery, such as fasting.

Before your vascular surgeon performs a carotid endarterectomy, he or she may want to determine how much plaque has built up in your arteries. The most common test used for this purpose is duplex ultrasound. Duplex ultrasound uses painless sound waves to show your blood vessels and measure how fast your blood flows. It can also determine the location and degree of narrowing in your carotid artery. Other tests your vascular surgeon may use include:

• Computed tomography (CT) scan
• Computed tomographic angiogram (CTA)
• Magnetic resonance angiography (MRA)
• Angiography (or arteriography)

Am I eligible for carotid endarterectomy?

You are eligible for the procedure if you have severe narrowing of your carotid arteries, especially if you are experiencing TIAs and are in reasonably good health otherwise. You may be eligible, but at a relatively increased risk, if you have:

• Had a large stroke without recovery
• Widespread cancer with a life expectancy of less than two years
• High blood pressure that has not been adequately controlled by lifestyle changes or medications
• Unstable angina (chest pains)
• Had a heart attack in the last six months
• Congestive heart failure
• Signs of progressive brain disorders, such as Alzheimer's disease

Am I at risk for complications during a carotid endarterectomy?

Having had a stroke in the past increases your chances for complications to a varying degree depending upon its severity, how recently it occurred, and the degree of recovery. Other factors that may increase your chances for problems during a carotid endarterectomy, in addition to those conditions listed above, include:

• The presence of a serious disease, such as severe heart or lung disease
• Plaque your surgeon cannot reach through surgery
• Severe blockage in other blood vessels that supply blood to your brain, such as the carotid artery on the other side
• Having a new blockage in a previous carotid endarterectomy on the same side (recurrence)
• Diabetes
• Cigarette smoking

What happens during a carotid endarterectomy?

You may either be put to sleep or, alternatively, your anesthesiologist or surgeon can numb your neck area and keep you awake so you can communicate with the surgeon during the operation. By staying awake, you may help your physician monitor your brain's reaction to the decreased blood supply. Once you are either asleep or the area around your neck is completely numb, your surgeon will shave the skin on your neck where he or she is going to make an incision, to help prevent infections. Your surgeon then makes the incision on one side of your neck to expose your blocked carotid artery. Next, your surgeon temporarily clamps your carotid artery to stop blood from flowing through it. During the procedure, your brain receives blood from the carotid artery on the other side of your neck. Alternatively, your surgeon can insert a shunt to detour the blood around the artery that is being repaired.

After your surgeon clamps your carotid artery, he or she makes an incision directly into the blocked section. Next, your surgeon peels out the plaque deposit by removing the inner lining of the diseased section of your artery containing the plaque. After removing the plaque, your surgeon stitches your artery, removes the clamps or the bypass, and stops any bleeding. He or she then closes your neck incision and the procedure is complete. Often, a patch is used to widen the artery as part of the procedure. The patch material used can be your own vein, usually from the leg, or a variety of synthetic materials depending upon your particular circumstance. The procedure takes about 2 hours to perform but may seem slightly longer depending upon the anesthetic and preparation time.

What can I expect after a carotid endarterectomy?

After surgery, you may stay in the hospital for 1 to 2 days. During this time, your physician will monitor your progress. Initially, during your recovery, you will receive fluid and nutrients through a small, thin tube called an intravenous (IV) catheter. Because the neck incision is so small, you may not feel significant pain.

After you go home, your physician may recommend that you avoid driving and limit physical activities for several weeks. You can usually begin normal activities again several weeks after the operation.

If you notice any change in brain function, severe headaches, or swelling in your neck, you should contact your physician immediately.

Are there any complications?

You may have complications following any surgical procedure. A stroke is one possible complication following a carotid endarterectomy. This risk is very low, ranging between 1 and 3 percent. Another unusual complication is the re-blockage of the carotid artery, called restenosis, which may occur later, especially if you continue to smoke cigarettes. The chance of developing a restenosis severe enough to require another carotid endarterectomy is usually about 2 to 3 percent. Temporary nerve injury, leading to hoarseness, difficulty with swallowing, or numbness in your face or tongue, is another uncommon, but possible, complication. This usually clears up in less than 1 month and usually doesn't require any treatment. However, the chance of any of these unusual complications is much less than the risk of stroke if a significant carotid blockage is not adequately treated.

What can I do to stay healthy?

Although a carotid endarterectomy can reduce your risk of stroke by removing the offending plaque, and although the procedure is quite durable, it does not completely stop plaque from building up again in susceptible individuals. To minimize the chance of hardening of the arteries occurring again, you should consider the following changes:

• Eat foods low in saturated fat, cholesterol, and calories
• Exercise regularly, especially aerobic exercises such as walking
• Maintain your ideal body weight
• Avoid smoking
• Discuss cholesterol-lowering medications and antiplatelet therapy with your physician

Abdominal Aortic Aneurysms Interventional Radiologists Treat Abdominal Aneurysms Nonsurgically

Interventional radiologists are vascular experts who offer minimally invasive treatment for abdominal aortic aneurysm. An aortic aneurysm is a weak area in the aorta, the main blood vessel that carries blood from the heart to the rest of the body. As blood flows through the aorta, the weak area bulges like a balloon and can burst if the balloon gets too big.

In the past 30 years, the occurrence of abdominal aortic aneurysms (AAA) has increased threefold. AAA is caused by a weakened area in the main vessel that supplies blood from the heart to the rest of the body. When blood flows through the aorta, the pressure of the blood beats against the weakened wall, which then bulges like a balloon. If the balloon grows large enough, there is a danger that it will burst. Most commonly, aortic aneurysms occur in the portion of the vessel below the renal artery origins. The aneurysm may extend into the vessels supplying the hips and pelvis.

Once an aneurysm reaches 5 centimeters in diameter, it is usually considered necessary to treat to prevent rupture. Below 5 centimeters, the risk of the aneurysm rupturing is lower than the risk of conventional surgery in patients with normal surgical risks. The goal of therapy for aneurysms is to prevent them from rupturing. Once an abdominal aortic aneurysm has ruptured, the chances of survival are low, with 80 to 90 percent of all ruptured aneurysms resulting in death. These deaths can be avoided if an aneurysm is detected and treated before it ruptures.

During September, National Peripheral Arterial Disease Awareness Month, individuals may find limited free Legs For Life screening sites. Many interventional radiologists alos offer year-round screenings by appointment and can be found with SIR’s Dr. Finder (choose “Peripheral Arterial Disease” in the Area of Expertise list). Some Legs For Lfie centers also screen for risk of other vascular diseases, such as varicose veins, abdominal aortic aneurysm, or AAA and stroke. Take a test to see if you may be at risk for PAD, AAA or stroke.

Through its national screening program, Legs For Life®, the Society of Interventional Radiology (SIR) has offered free screening for early detection and monitoring of AAA and other vascular diseases. Of those screened, 25 percent have been found to be at risk for AAA.

AAA Prevalence

• Approximately one in every 250 people over the age of 50 will die of a ruptured AAA
• AAA affects as many as eight percent of people over the age of 65
• Males are four times more likely to have AAA than females
• AAA is the 17th leading cause of death in the United States, accounting for more than 15,000 deaths each year.
• Those at highest risk are males over the age of 60 who have ever smoked and/or who have a history of atherosclerosis ("hardening of the arteries")
• 50 percent of patients with AAA who do not undergo treatment die of a rupture

Smoking Is a Major Risk Factor for AAA and Other Vascular Disease

• Those with a family history of AAA are at a higher risk (particularly if the relative with AAA was female)
• Smokers die four times more often from ruptured aneurysms than nonsmokers

AAA Symptoms

AAA is often called a "silent killer" because there are usually no obvious symptoms of the disease. Three out of four aneurysms show no symptoms at the time they are diagnosed. When symptoms are present, they may include:

• Abdominal pain (that may be constant or come and go)
• Pain in the lower back that may radiate to the buttocks, groin or legs
• The feeling of a "heartbeat" or pulse in the abdomen

Once the aneurysm bursts, symptoms include:

• Severe back or abdominal pain that begins suddenly
• Paleness
• Dry mouth/skin and excessive thirst
• Nausea and vomiting
• Signs of shock, such as shaking, dizziness, fainting, sweating, rapid heartbeat and sudden weakness

AAA Diagnosis

In some, but not all cases, AAA can be diagnosed by a physical examination in which the doctor feels the aneurysm as a soft mass in the abdomen (about the level of a belly button) that pulses with each heartbeat.

The most common test to diagnose AAA is ultrasound, a painless examination in which a device (a transducer) about the size of a computer mouse is passed over the abdomen. Sound waves are computerized to create "pictures" of the aorta and detect the presence of AAA. Other methods for determining the aneurysms' size are CT scan (computerized tomography), MRI (magnetic resonance imaging), and arteriogram (real time X-rays).

AAA Treatments

Currently, there are three treatment options for AAA:

Watchful Waiting - Small AAAs (less than 5 centimeters or about 2 inches), which are not rapidly growing or causing symptoms, have a low incidence of rupture and often require no treatment other than watchful waiting under the guidance of a vascular disease specialist. This typically includes follow-up ultrasound exams at regular intervals to determine if the aneurysm has grown.

Surgical Repair - The most common treatment for a large, unruptured aneurysm is open surgical repair by a vascular surgeon. This procedure involves an incision from just below the breastbone to the top of the pubic bone. The surgeon then clamps off the aorta, cuts open the aneurysm and sews in a graft to act as a bridge for the blood flow. The blood flow then goes through the plastic graft and no longer allows the direct pulsation pressure of the blood to further expand the weak aorta wall.

Interventional Repair - This minimally invasive technique is performed by an interventional radiologist using imaging to guide the catheter and graft inside the patient's artery. For the procedure, an incision is made in the skin at the groin through which a catheter is passed into the femoral artery and directed to the aortic aneurysm. Through the catheter, the physician passes a stent graft that is compressed into a small diameter within the catheter. The stent graft is advanced to the aneurysm, then opened, creating new walls in the blood vessel through which blood flows.

This is a less invasive method of placing a graft within the aneurysm to redirect blood flow and stop direct pressure from being exerted on the weak aortic wall. This relatively new method eliminates the need for a large abdominal incision. It also eliminates the need to clamp the aorta during the procedure. Clamping the aorta creates significant stress on the heart, and people with severe heart disease may not be able to tolerate this major surgery. Stent grafts are most commonly considered for patients at increased surgical risk due to age or other medical conditions.

The stent graft procedure is not for everyone, though. It is still a new technology and we don't yet have data to show that this will be a durable repair for long years. Thus, people with a life expectancy of 20 or more years may be counseled against this therapy. It is also a technology that is limited by size. The stent grafts are made in certain sizes, and the patient's anatomy must fit the graft, since grafts are not custom built for each patient's anatomy.

Second Opinion

In order to determine if you are a candidate for the interventional radiology treatment, it's best to get a second opinion from an interventional radiologist. You can ask for a referral from your doctor, call the radiology department of any hospital and ask for interventional radiology or visit the SIR Doctor Finder.

A stent-graft is threaded into the blood vessel where the aneurysm is located. The stent graft is expanded like a spring to hold tightly against the wall of the blood vessel and cut off the blood supply to the aneurysm.

Efficacy and Patient Safety

Interventional repair is an effective treatment that can be performed safely, resulting in lower morbidity and lower mortality rates than those reported for open surgical repair.

Recovery Time

• Patients are often discharged the day after interventional repair, and typically do not require intensive care stay post-op
• Once discharged, most return to normal activity within two weeks compared to six to eight weeks after surgical repair

Benefits of Interventional Repair

• No abdominal surgical incision
• No sutures or sutures only at the groins
• Faster recovery, shorter time in the hospital
• No general anesthesia in some cases
• Less pain
• Reduced complications

Disadvantages of Interventional Repair

• Possible movement of the graft after treatment, with blood flow into the aneurysm and resumption of risk of growth/rupture of the aneurysm
• Probable life-time requirement for follow-up studies to be sure the stent graft is continuing to function

Interventional Radiologists Are Vascular Disease Experts

Interventional radiology is a recognized medical specialty by the American Board of Medical Specialties. Interventional radiologists are board-certified physicians with extensive training in vascular disease diagnosis, management and treatment. Their board certification includes both Vascular and Interventional Radiology and Diagnostic Radiology, which are administered by the American Board of Radiology. This training marries state-of-the-art imaging and diagnostic expertise, coupled with clinical experience across all specialties and in-depth knowledge of the least invasive treatments.

Abdominal Aortic Aneurysm Repair

Procedure overview

What is an abdominal aortic aneurysm repair?

Location of the Aorta and Arteries in the Human Body (Click to Enlarge)

Abdominal aortic aneurysm (AAA) repair is a procedure used to treat an aneurysm (abnormal enlargement) of the abdominal aorta. Repair of an abdominal aortic aneurysm may be performed surgically through an open incision or in a minimally-invasive procedure called endovascular aneurysm repair (EVAR).

What is an abdominal aortic aneurysm?

An abdominal aortic aneurysm, also called AAA or triple A, is a bulging, weakened area in the wall of the aorta (the largest artery in the body) resulting in an abnormal widening or ballooning greater than 50 percent of the vessel's normal diameter (width).

The aorta extends upward from the top of the left ventricle of the heart in the chest area (ascending thoracic aorta), then curves like a candy cane (aortic arch) downward through the chest area (descending thoracic aorta) into the abdomen (abdominal aorta). The aorta delivers oxygenated blood pumped from the heart to the rest of the body.

The most common location of arterial aneurysm formation is the abdominal aorta, specifically, the segment of the abdominal aorta below the kidneys. An abdominal aneurysm located below the kidneys is called an infrarenal aneurysm. An aneurysm can be characterized by its location, shape, and cause.

Infrarenal Aneurysm (Click to Enlarge)

The shape of an aneurysm is described as being fusiform or saccular, which helps to identify a true aneurysm. The more common fusiform-shaped aneurysm bulges or balloons out on all sides of the aorta. A saccular-shaped aneurysm bulges or balloons out only on one side.

The aorta is under constant pressure as blood is ejected from the heart. With each heart beat, the walls of the aorta distend (expand) and then recoil (spring back), exerting continual pressure or stress on the already weakened aneurysm wall. Therefore, there is a potential for rupture (bursting) or dissection (separation of the layers of the aortic wall) of the aorta, which may cause life-threatening hemorrhage (uncontrolled bleeding) and, potentially, death. The larger the aneurysm becomes, the greater the risk of rupture.

Different Types of Aortic Aneurysms (Click to Enlarge)

Because an aneurysm may continue to increase in size, along with progressive weakening of the artery wall, surgical intervention may be needed. Preventing rupture of an aneurysm is one of the goals of therapy.

Types of abdominal aneurysm repair

There are 2 approaches to abdominal aortic aneurysm repair. The standard surgical procedure for AAA repair is called the open repair. A newer procedure is the endovascular aneurysm repair (EVAR):

• Abdominal aortic aneurysm open repair. Open repair of an abdominal aortic aneurysm involves an incision of the abdomen to directly visualize the aortic aneurysm. The procedure is performed in an operating room under general anesthesia. The surgeon will make an incision in the abdomen either lengthwise from below the breastbone to just below the navel or across the abdomen and down the center. Once the abdomen is opened, the aneurysm will be repaired by the use of a long cylinder-like tube called a graft. Grafts are made of various materials, such as Dacron (textile polyester synthetic graft) or polytetrafluoroethylene (PTFE, a nontextile synthetic graft). The graft is sutured to the aorta connecting one end of the aorta at the site of the aneurysm to the other end of the aorta. Endovascular aneurysm repair has replaced open repair as the most commonly done procedure for elective abdominal aortic aneurysm repair.

• Endovascular aneurysm repair (EVAR). EVAR is a minimally-invasive (without a large abdominal incision) procedure performed to repair an abdominal aortic aneurysm. EVAR may be performed in an operating room, radiology department, or a catheterization laboratory. The doctor may use general anesthesia or regional anesthesia (epidural or spinal anesthesia). The doctor will make a small incision in each groin to visualize the femoral arteries in each leg. With the use of special endovascular instruments, along with X-ray images for guidance, a stent-graft will be inserted through the femoral artery and advanced up into the aorta to the site of the aneurysm. A stent-graft is a long cylinder-like tube made of a thin metal framework (stent), while the graft portion is made of various materials such as Dacron or polytetrafluoroethylene (PTFE) and may cover the stent. The stent helps to hold the graft in place. The stent-graft is inserted into the aorta in a collapsed position and placed at the aneurysm site. Once in place, the stent-graft will be expanded (in a spring-like fashion), attaching to the wall of the aorta to support the wall of the aorta. The aneurysm will eventually shrink down onto the stent-graft.

The doctor will determine which surgical intervention is most appropriate, either open repair or EVAR.

Reasons for the procedure

Reasons an abdominal aortic aneurysm repair may be performed include, but are not limited to, the following:

• To prevent the risk of rupture

• To relieve symptoms

• To restore a good blood flow

• Size of aneurysm greater than 5 centimeters in diameter (about 2 inches)

• Growth rate of aneurysm of more than 0.5 centimeter (about 0.2 inch) over 1 year

• When risk of rupture outweighs the risk of surgery

• Emergency life-threatening hemorrhage (uncontrolled bleeding)

There may be other reasons for your doctor to recommend an abdominal aortic aneurysm repair.

Risks of the procedure

As with any surgical procedure, complications can occur. Some possible complications may include, but are not limited to, the following:

• Open repair

  • Myocardial infarction (heart attack)

  • Irregular heart rhythms (arrhythmias)

  • Bleeding during or after surgery

  • Injury to the bowel (intestines)

  • Limb ischemia (loss of blood flow to legs/ feet)

  • Embolus (clot) to other parts of the body

  • Infection of the graft

  • Lung problems

  • Kidney damage

  • Spinal cord injury

• EVAR

  • Damage to surrounding blood vessels, organs, or other structures by instruments

  • Kidney damage

  • Limb ischemia (loss of blood flow to leg/feet) from clots

  • Groin wound infection

  • Groin hematoma (large blood-filled bruise)

  • Bleeding

  • Endoleak (continual leaking of blood out of the graft and into the aneurysm sac with potential rupture)

  • Spinal cord injury

Patients who are allergic to or sensitive to medications, contrast dyes, iodine, or latex should notify their doctor.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

• Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

• You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.

• In addition to a complete medical history, your doctor may perform a physical examination to ensure you are in good health before you undergo the procedure. You may also undergo blood tests and other diagnostic tests.

• You will be asked to fast for 8 hours before the procedure, generally after midnight.

• If you are pregnant or suspect that you are pregnant, you should notify your health care provider.

• Notify your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).

• Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.

• Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.

• If you smoke, you should stop smoking as soon as possible prior to the procedure, in order to improve your chances for a successful recovery from surgery and to improve your overall health status.

• You may receive a sedative prior to the procedure to help you relax.

• Based on your medical condition, your doctor may request other specific preparation.

During the procedure

Abdominal aortic aneurysm repair requires a stay in a hospital. Procedures may vary depending on your condition and your doctor's practices.

Generally, an abdominal aortic aneurysm repair follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.

2. You will be asked to remove your clothing and will be given a gown to wear.

3. You will be asked to empty your bladder prior to the procedure.

4. If there is excessive hair at the surgical site, the hair may be clipped.

5. An intravenous (IV) line will be started in your arm or hand. Additional catheters will be inserted in your neck and wrist to monitor the status of your heart and blood pressure, as well as for obtaining blood samples. Alternate sites for the additional catheters include the subclavian (under the collarbone) area and the groin.

Abdominal aortic aneurysm — open repair

Graft Repair of Abdominal Aneurysm (Click to Enlarge)

1. You will be positioned on the operating table, lying on your back.

2. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, a breathing tube will be inserted through your throat into your lungs and you will be connected to a ventilator, which will breathe for you during the surgery.

3. A catheter will be inserted into your bladder to drain urine.

4. The skin over the surgical site will be cleansed with an antiseptic solution.

5. Once all the tubes and monitors are in place, the doctor will make an incision (cut) down the center of the abdomen from immediately below the breastbone to below the navel or across the abdomen from underneath the left arm across to the center of the abdomen and down to below the navel.

6. The doctor will place a clamp on the aorta above and below the site of the aneurysm. This will temporarily interrupt the flow of blood.

7. The doctor will cut open the aneurysm sac and suture into place a long tube called the graft. This will connect both ends of the aorta together.

8. The clamps will be removed and the doctor will wrap the wall of the aneurysm around the graft, suturing the aorta back together.

Endovascular aneurysm repair — EVAR

Stent Graft Repair of Abdominal Aneurysm (Click to Enlarge)

1. You will be placed in a supine (on your back) position on the operating table or on a procedure table in a radiology suite.

2. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, a breathing tube may be inserted through your throat into your lungs and you will be connected to a ventilator, which will breathe for you during the surgery.

3. The doctor may choose regional anesthesia instead of general anesthesia. Regional anesthesia is medication delivered through an epidural (in the back) to numb the area to be operated on. You will receive medication to help you relax and analgesic medication for pain relief. The doctor will be able to talk to you during the procedure. The doctor will determine which type of anesthesia is appropriate.

4. The doctor will make an incision in each groin to expose the femoral arteries. Using fluoroscopy (a type of X-ray "movie" that transmits images to a TV-like monitor), the doctor will insert a needle into the femoral artery through which a guidewire will be passed and advanced to the aneurysm site. The needle will be removed and a sheath slid over the guidewire.

5. An aortogram (injection of contrast dye to visualize the position of the aneurysm and adjacent blood vessels) will be performed.

6. The doctor will use special endovascular instruments and X-ray images for guidance. A stent-graft will be inserted through the femoral artery and advanced up into the aorta to the site of the aneurysm.

7. The stent-graft, in a collapsed position until after it is inserted, will be advanced up into the aorta and situated at the aneurysm site. The stent graft will be expanded (in a spring-like fashion) and attached to the wall of the aorta.

8. An aortogram will be repeated to check for an endoleak (blood leaking out into the aneurysm sac) of the stent-graft.

9. Once no leak has been determined, the instruments will be removed.

Procedure completion — both methods

1. The incisions will be sutured back together.

2. A sterile bandage/dressing will be applied.

3. After an open procedure, a tube may be inserted through your mouth or nose into your stomach to drain stomach fluids.

4. You will be transferred from the operating table to a bed, then taken to the intensive care unit (ICU) or the postanesthesia care unit (PACU).

After the procedure

In the hospital — open repair

After the procedure, you may be taken to the recovery room before being taken to the intensive care unit (ICU) to be closely monitored. Alternatively, you may be taken directly to the ICU from the operating room. You will be connected to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level.

You may have a tube in your throat so that breathing can be assisted with a ventilator (breathing machine) until you are stable enough to breathe on your own. As you continue to wake up from the anesthesia and start to breathe on your own, the breathing machine will be adjusted to allow you to take over more of the breathing. When you are awake enough to breathe completely on your own and you are able to cough, the breathing tube will be removed.

After the breathing tube is out, your nurse will assist you to cough and take deep breaths every 2 hours. This may be uncomfortable due to soreness, but it is extremely important that you do this in order to keep mucus from collecting in your lungs and possibly causing pneumonia. Your nurse will show you how to hug a pillow tightly against your chest while coughing to help ease the discomfort.

You may receive pain medication as needed, either by a nurse, through an epidural catheter, or by administering it yourself through a device connected to your intravenous line.

You may be on special IV medications to help your blood pressure and your heart, and to control any problems with bleeding. As your condition stabilizes, these medications will be gradually decreased and discontinued as your condition allows.

Once the breathing tube has been removed and your condition has stabilized, you may start liquids to drink. Your diet may be gradually advanced to more solid foods as you are able to tolerate them.

If you have a drainage tube in your stomach, you will not be able to drink or eat until the tube is removed. The drainage tube will be removed when your intestinal function has returned to normal, usually a few days after the procedure.

When your doctor determines that you are ready, you will be moved from the ICU to a postsurgical nursing unit. Your recovery will continue to progress. Your activity will be gradually increased as you get out of bed and walk around for longer periods of time. Your diet will be advanced to solid foods as tolerated.

Arrangements will be made for a follow-up visit with your doctor.

In the hospital — EVAR

You may or may not be taken to the intensive care unit (ICU); however, you may be taken to a postanesthesia care unit (PACU). You will be connected to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level.

You will remain in either the ICU or PACU for a designated period of time and then transferred to a regular nursing care unit.

You will be given pain medication for incisional pain or you may have had an epidural (a type of anesthesia that involves continually infusing an anesthetic medication through a thin catheter (hollow tube) into the space that surrounds the spinal cord in the lower back, causing numbness in the lower body, abdomen, and/or chest) placed during surgery which will help with postoperative pain.

Your activity will be gradually increased as you get out of bed and walk around for longer periods of time. Your diet will be advanced to solid foods as tolerated.

Arrangements will be made for a follow-up visit with your doctor.

At home

Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The sutures or surgical staples will be removed during a follow-up office visit, in the event they were not removed before leaving the hospital.

The surgical incision may be tender or sore for several days after an aneurysm repair procedure. Take a pain reliever for soreness as recommended by your doctor.

You should not drive until your doctor tells you to. Other activity restrictions may apply.

Notify your doctor to report any of the following:

• Fever and/or chills

• Redness, swelling, or bleeding or other drainage from the incision site

• Increase in pain around the incision site

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Surgery for breast cancer

Most women with breast cancer have some type of surgery. Surgery is often needed to remove a breast tumor. Options for this include breast-conserving surgery and mastectomy. The breast can be reconstructed at the same time as surgery or later on. Surgery is also used to check the lymph nodes under the arm for cancer spread. Options for this include a sentinel lymph node biopsy and an axillary (armpit) lymph node dissection.

Breast-conserving surgery

This type of surgery is sometimes called partial (or segmental) mastectomy. It only removes a part of the affected breast, but how much is removed depends on the size and location of the tumor and other factors. If radiation therapy is to be given after surgery, small metallic clips (which will show up on x-rays) may be placed inside the breast during surgery to mark the area for the radiation treatments.

Lumpectomy removes only the breast lump and a surrounding margin of normal tissue. Radiation therapy is usually given after a lumpectomy. If adjuvant chemotherapy is to be given as well, radiation is usually delayed until the chemotherapy is completed.

Quadrantectomy removes more breast tissue than a lumpectomy. For a quadrantectomy, one-quarter of the breast is removed. Radiation therapy is usually given after surgery. Again, this may be delayed if chemotherapy is to be given as well.

If cancer cells are found at any of the edges of the piece of tissue removed, it is said to have positive margins. When no cancer cells are found at the edges of the tissue, it is said to have negative or clear margins. The presence of positive margins means that some cancer cells may have been left behind after surgery. If the pathologist finds positive margins in the tissue removed with surgery, the surgeon may need to go back and remove more tissue. This operation is called a re-excision. If the surgeon can't remove enough breast tissue to get clear surgical margins, a mastectomy may be needed.

The distance from the tumor to the margin is also important. Even if the margins are “clear”, they could be “close”—meaning that the distance between the edge of the tumor and edge of the tissue removed is too small and more surgery may be needed, as well. Surgeons can disagree on what is an adequate (or good) margin.

For most women with stage I or II breast cancer, breast-conserving surgery (BCS) plus radiation therapy is as effective as mastectomy. Survival rates of women treated with these 2 approaches are the same. But breast-conserving surgery is not an option for all women with breast cancer (see the section, "Choosing between breast-conserving surgery and mastectomy" below).

Radiation therapy can sometimes be omitted as a part of breast-conserving therapy. This is somewhat controversial, so women may consider BCS without radiation therapy if they are at least 70 years old and ALL of the following are true:

• They have a tumor that measures 2 cm or less across that has been completely removed (with clear margins).
• The tumor is hormone receptor-positive, and the women are getting hormone therapy (such as tamoxifen or an aromatase inhibitor).
• No lymph nodes contained cancer.

You should discuss this possibility with your health care team.

Possible side effects: Side effects of these operations can include pain, temporary swelling, tenderness, and hard scar tissue that forms in the surgical site. As with all operations, bleeding and infection at the surgery site are also possible.

The larger the portion of breast removed, the more likely it is that you will see a change in the shape of the breast afterward. If the breasts look very different after surgery, it may be possible to have some type of reconstructive surgery (see the section, "Reconstructive surgery"), or to have the size of the unaffected breast reduced to make the breasts more symmetrical. It may even be possible to have this done during the initial surgery. It's very important to talk with your doctor (and possibly a plastic surgeon) before surgery to get an idea of how your breasts are likely to look afterward, and to learn what your options might be.

Mastectomy

Mastectomy is surgery to remove the entire breast. All of the breast tissue is removed, sometimes along with other nearby tissues.

Simple mastectomy: In this procedure, also called total mastectomy, the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast. Sometimes both breasts are removed (a double mastectomy), often as preventive surgery in women at very high risk for breast cancer. Most women, if they are hospitalized, can go home the next day. This is the most common type of mastectomy used to treat breast cancer.

Skin-sparing mastectomy: For some women considering immediate reconstruction, a skin-sparing mastectomy can be done. In this procedure, most of the skin over the breast (other than the nipple and areola) is left intact. This can work as well as a simple mastectomy. The amount of breast tissue removed is the same as with a simple mastectomy.

This approach is only used when immediate breast reconstruction is planned. It may not be suitable for larger tumors or those that are close to the surface of the skin. Implants or tissue from other parts of the body are used to reconstruct the breast. This approach has not been used for as long as the more standard type of mastectomy, but many women prefer it because it offers the advantage of less scar tissue and a reconstructed breast that seems more natural.

A variation of the skin-sparing mastectomy is the nipple-sparing mastectomy. This procedure is more often an option for women who have a small early-stage cancer near the outer part of the breast, with no signs of cancer in the skin or near the nipple. In this procedure, the breast tissue is removed, but the breast skin and nipple are left in place. This is followed by breast reconstruction. The surgeon often removes the breast tissue beneath the nipple (and areola) during the procedure, to check for cancer cells. If cancer is found in this tissue, the nipple must be removed. Even when no cancer is found under the nipple, some doctors give the nipple tissue a dose of radiation during or after the surgery to try and reduce the risk of the cancer coming back.

There are still some problems with nipple-sparing surgeries. Afterward, the nipple does not have a good blood supply, so sometimes it can wither away or become deformed. Because the nerves are also cut, there is little or no feeling left in the nipple. In women with larger breasts, the nipple may look out of place after the breast is reconstructed. As a result, many doctors feel that this surgery is best done in women with small to medium sized breasts. This procedure leaves less visible scars, but if it isn't done properly, it can leave behind more breast tissue than other forms of mastectomy. This could result in a higher risk of cancer developing than for a skin-sparing or simple mastectomy. This was a problem in the past, but improvements in technique have helped make this surgery safer. Still, many experts consider nipple-sparing procedures too risky to be a standard treatment of breast cancer.

Modified radical mastectomy: This procedure is a simple mastectomy and removal of axillary (underarm) lymph nodes. Surgery to remove these lymph nodes is discussed in further detail later in this section.

Radical mastectomy: In this extensive operation, the surgeon removes the entire breast, axillary lymph nodes, and the pectoral (chest wall) muscles under the breast. This surgery was once very common, but less extensive surgery (such as modified radical mastectomy) has been found to be just as effective. This meant that the disfigurement and side effects of a radical mastectomy were not needed, so this surgery is rarely done now. This operation may still be done for large tumors that are growing into the pectoral muscles under the breast.

Possible side effects: Aside from post-surgical pain and the obvious change in the shape of the breast(s), possible side effects of mastectomy include wound infection, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound). If axillary lymph nodes are also removed, other side effects may occur (see the section, "Lymph node surgery").

Choosing between breast-conserving surgery and mastectomy

Many women with early-stage cancers can choose between breast-conserving surgery and mastectomy.

The main advantage of breast-conserving surgery (BCS) is that a woman keeps most of her breast. A disadvantage is the usual need for radiation therapy—most often for 5 to 6 weeks—after surgery. A small number of women having breast-conserving surgery may not need radiation while some women who have a mastectomy will still need radiation therapy to the breast area.

When deciding between BCS and mastectomy, be sure to get all the facts. You may have an initial gut preference for mastectomy as a way to "take it all out as quickly as possible." This feeling can lead women to prefer mastectomy even when their surgeons don’t. But the fact is that in most cases, mastectomy does not give you any better chance of long-term survival or a better outcome from treatment. Studies following thousands of women for more than 20 years show that when BCS can be done, doing mastectomy instead does not provide any better chance of survival.

Most women and their doctors prefer BCS and radiation therapy when it's a reasonable option, but your choice will depend on a number of factors, such as:

• How you feel about losing your breast
• How you feel about getting radiation therapy
• How far you would have to travel and how much time it would take to have radiation therapy
• Whether you think you will want to have more surgery to reconstruct your breast after having a mastectomy
• Your preference for mastectomy as a way to get rid of all your cancer as quickly as possible
• Your fear of the cancer coming back

For some women, mastectomy may clearly be a better option. For example, breast conserving surgery is usually not recommended for:

• Women who have already had radiation therapy to the affected breast
• Women with 2 or more areas of cancer in the same breast that are too far apart to be removed through 1 surgical incision, while keeping the appearance of the breast satisfactory
• Women whose initial BCS along with re-excision(s) has not completely removed the cancer
• Women with certain serious connective tissue diseases such as scleroderma or lupus, which may make them especially sensitive to the side effects of radiation therapy
• Pregnant women who would require radiation while still pregnant (risking harm to the fetus)
• Women with large tumors (greater than 5 cm [2 inches] across) that didn't shrink very much with neoadjuvant chemotherapy (although this also depends on the size of the breast)
• Women with inflammatory breast cancer
• Women with a cancer that is large relative to their breast size

Other factors may need to be taken into account as well. For example, young women with breast cancer and a known BRCA mutation are at very high risk for a second cancer. These women often consider having the other breast removed to reduce this risk, and so may choose mastectomy for the breast with cancer as well. A double mastectomy may be done to treat the cancer and reduce the risk of a second breast cancer.

It is important to understand that having a mastectomy instead of breast-conserving surgery plus radiation only lowers your risk of developing a second breast cancer in the same breast. It does not lower the chance of the cancer coming back in other parts of the body. It is important that you don’t rush into making a decision, but instead take your time deciding whether a mastectomy or breast-conserving surgery plus radiation is right for you.

Lymph node surgery

To determine if the breast cancer has spread to axillary (underarm) lymph nodes, one or more of these lymph nodes may be removed and looked at under the microscope. This is an important part of staging and determining treatment and outcomes. When the lymph nodes contain cancer cells, there is a higher chance that cancer cells have also spread through the bloodstream to other parts of the body. The presence of cancer cells in the lymph nodes under the arm is often an important factor in deciding what treatment, if any, is needed after surgery (adjuvant therapy).

Axillary lymph node dissection (ALND): In this procedure, anywhere from about 10 to 40 (though usually less than 20) lymph nodes are removed from the area under the arm (axilla) and checked for cancer spread. ALND is usually done at the same time as the mastectomy or BCS, but it can be done in a second operation. This was once the most common way to check to see if breast cancer has spread to nearby lymph nodes, and it is still done in some patients. For example, an ALND may be done if a previous biopsy has shown one or more of the underarm lymph nodes have cancer cells.

Sentinel lymph node biopsy (SLNB): Although axillary lymph node dissection (ALND) is a safe operation and has low rates of most side effects, removing many lymph nodes increases the chance that the patient will have lymphedema after surgery (this side effect is discussed further on). To lower the risk of lymphedema, the doctors may use a sentinel lymph node biopsy (SLNB) procedure to check the lymph nodes for cancer. This procedure is a way of learning if cancer has spread to lymph nodes without removing as many of them.

In this procedure the surgeon finds and removes the first lymph node(s) to which a tumor is likely to drain. This lymph node, known as the sentinel node, is the one most likely to contain cancer cells if they have started to spread. To do this, the surgeon injects a radioactive substance and/or a blue dye into the tumor, the area around it, or the area around the nipple. Lymphatic vessels will carry these substances into the sentinel node(s).

A special device can be used to detect radioactivity in the nodes that the radioactive substance flows into or can look for lymph nodes that have turned blue. These are separate ways to find the sentinel node, but are often done together as a double check. The surgeon then cuts the skin over the area and removes the node(s) containing the dye (or radiation). A pathologist then looks closely at these nodes (often 2 or 3). (Because fewer nodes are removed than in an ALND, each one is looked at more closely for any cancer).

The lymph node can sometimes be checked for cancer during surgery. If cancer is found in the sentinel lymph node, the surgeon may go on to do a full axillary dissection. If no cancer cells are seen in the lymph node at the time of the surgery, or if the sentinel node is not checked at the time of the surgery, the lymph node(s) will be examined more closely over the next several days. If cancer is found in the lymph node, the surgeon may recommend a full ALND at a later time.

If there is no cancer in the sentinel node(s), it's very unlikely that the cancer has spread to other lymph nodes, so no further lymph node surgery is needed. The patient can avoid the potential side effects of a full ALND.

Until recently, if the sentinel node(s) had cancer cells, the surgeon would do a full ALND to see how many other lymph nodes were involved. But more recently, studies have shown that this may not always be needed. In some cases, it may be just as safe to leave the rest of the lymph nodes behind. This is based on certain factors, such as what type of surgery is used to remove the tumor, the size of the tumor, and what treatment is planned after surgery. Based on the studies that have looked at this, skipping the ALND may be an option for patients with tumors 5 cm (2 inches) or smaller who are having breast-conserving surgery followed by radiation. Because this hasn’t been studied well in women who have had mastectomy, it isn’t clear that skipping the ALND would be safe for them.

SLNB is done to see if a breast cancer has spread to nearby lymph nodes. This procedure is not done if any of the lymph nodes are known to contain cancer. If any of the lymph nodes under the arm or around the collar bone are swollen, they may be checked for cancer spread directly. Most often, a needle biopsy (either a fine needle aspiration biopsy or a core needle biopsy) is done. In these procedures, the surgeon inserts a needle into the lymph node to remove a small amount of tissue, which is then looked at under a microscope. If cancer cells are found, a full ALND is recommended.

Although SLNB has become a common procedure, it requires a great deal of skill. It should be done only by a surgeon who has experience with this technique. If you are thinking about having this type of biopsy, ask your health care team if they do them regularly.

Possible side effects: As with any operation, pain, swelling, bleeding, and infection are possibilities.

The main possible long-term effect of removing axillary lymph nodes is lymphedema (swelling) of the arm. Because any excess fluid in the arms normally travels back into the bloodstream through the lymphatic system, removing the lymph nodes sometimes blocks the drainage from the arm, causing this fluid to build up. This results in arm swelling.

Up to 30% of women who have a full ALND develop lymphedema. It also occurs in up to 3% of women who have a sentinel lymph node biopsy. It may be more common if radiation is given after surgery. Sometimes the swelling lasts for only a few weeks and then goes away. Other times, the swelling lasts a long time. Ways to help prevent or reduce the effects of lymphedema are discussed in the section, "What happens after treatment for breast cancer?" If your arm is swollen, tight, or painful after lymph node surgery, be sure to tell someone on your cancer care team right away. More information about lymphedema can be found in our document, Lymphedema: What Every Woman With Breast Cancer Should Know.

You may also have limited movement in your arm and shoulder after surgery. This is more common after an ALND than a SLNB. Your doctor may give you exercises to ensure that you do not have permanent problems with movement (a frozen shoulder). Numbness of the skin on the upper, inner arm is another common side effect because the nerve that controls sensation here travels through the lymph node area.

Some women notice a rope-like structure that begins under the arm and can extend down towards the elbow. This, sometimes called axillary web syndrome or lymphatic cording, is more common after an ALND than SLNB. Symptoms may not appear for weeks or even months after surgery. It can cause pain and limit movement of the arm and shoulder. This often goes away without treatment, although some patients seem to find physical therapy helpful.

Reconstructive surgery

After having a mastectomy (or some breast-conserving surgeries), a woman might want to consider having the breast mound rebuilt; this is called breast reconstruction. These procedures are done to restore the breast's appearance after surgery.

If you are thinking about having reconstructive surgery, it is a good idea to talk about it with your surgeon and a plastic surgeon experienced in breast reconstruction before your cancer surgery. This will allow you to consider all reconstruction options. You’ll want your breast surgeon and your plastic surgeon to work together to come up with a treatment plan that will put you in the best possible position for reconstruction in case you decide to pursue it, even if you want to wait and have reconstructive surgery later.

Decisions about the type of reconstruction and when it will be done depend on each woman's medical situation and personal preferences. You may have a choice between having breast reconstruction at the same time as the mastectomy (immediate reconstruction) or at a later time (delayed reconstruction). There are several types of reconstructive surgery. Some use saline (salt water) or silicone implants, while others use tissues from other parts of your body (called an autologous tissue reconstruction).

To learn about different reconstruction options, see our document, Breast Reconstruction After Mastectomy. You may also find it helpful to talk with a woman who has had the type of reconstruction you might be considering. Our Reach To Recovery volunteers can help you with this. You can find out more about our Reach To Recovery program on cancer.org or by calling 1-800-227-2345.

Some things you can expect

For many, the thought of surgery is frightening. But with a better understanding of what to expect before, during, and after the operation, many fears can be relieved.

Before surgery: Usually, you meet with your surgeon at least a few days before the operation to discuss the procedure and your medical history. This is a good time to ask specific questions about the surgery and go over potential risks. Be sure you understand what the extent of the surgery is likely to be and what you should expect afterward. If you are thinking about breast reconstruction, ask about this as well.

You will be asked to sign a consent form, giving the doctor permission to perform the surgery. You might also be asked to give consent for researchers to use any tissue or blood that is not needed for diagnostic purposes. This may not be of direct use to you, but it may be very helpful to women in the future.

Ask your doctor if you will possibly need a blood transfusion. If the doctors think a transfusion might be needed, you might be asked to donate blood beforehand. If you do not receive your own blood, it is important to know that in the United States, blood transfusion from another person is nearly as safe as receiving your own blood.

You will probably be told not to eat or drink anything starting the night before the surgery.

You will also meet with the anesthesiologist or nurse anesthetist, the health professional who will be giving you the anesthesia during your surgery.

During surgery:

You will have an IV (intravenous) line put in (usually in a vein in your arm), which the medical team will use to give medicines that may be needed during the surgery. Usually you will be hooked up to an electrocardiogram (EKG) machine and have a blood pressure cuff on your arm, so your heart rhythm and blood pressure can be checked during the surgery.

General anesthesia (where you are asleep) is used for most breast surgery. The length of the operation depends on the type of surgery being done. For example, a mastectomy with axillary lymph node dissection will usually take from 2 to 3 hours.

After surgery: After your surgery, you will be taken to the recovery room, where you will stay until you are awake and your condition and vital signs (blood pressure, pulse, and breathing) are stable. How long you stay in the hospital depends on the type of surgery being done, your overall state of health and whether you have any other medical problems, how well you do during the surgery, and how you feel after the surgery. Decisions about the length of your stay should be made by you and your doctor and not dictated by what your insurance will pay, but it is important to check your insurance coverage before surgery.

In general, women having a mastectomy and/or axillary lymph node dissection stay in the hospital for 1 or 2 nights and then go home. However, some women may be placed in a 23-hour, short-stay observation unit before going home.

Less involved operations such as breast-conserving surgery and sentinel lymph node biopsy are usually done in an outpatient surgery center, and an overnight stay in the hospital is usually not needed.

You may have a dressing (bandage) over the surgery site that may wrap snugly around your chest. You may have one or more drains (plastic or rubber tubes) coming out from the breast or underarm area to remove blood and lymph fluid that collects during the healing process. You will be taught how to care for the drains, which may include emptying and measuring the fluid and identifying problems the doctor or nurse needs to know about. Most drains stay in place for 1 or 2 weeks. When drainage has decreased to about 30 cc (1 fluid ounce) each day, the drain will usually be removed.

Most doctors will want you to start moving your arm soon after surgery so that it won't get stiff.

How long it takes to recover from breast cancer surgery depends on what procedures were done. Most women can return to their regular activities within 2 weeks after a BCS with ALND, while recovery time is often shorter for BCS plus a SLNB. It can take up to 4 weeks after a mastectomy. Recovery time is longer if reconstruction was done as well, and it can take months to return to full activity after some procedures (for more information about recovery after breast reconstruction, please see our document Breast Reconstruction After Mastectomy). Still, these times can vary from person to person, so you should talk to your doctor about what you can expect.

Even after the doctor clears you to return to your regular level of activity, though, you could still feel some effects of surgery. You might feel stiff or sore for some time. The skin of your chest or underarm area may feel tight. These feelings tend to improve over time. Some women have problems with pain, numbness, or tingling in the chest and arm that continues for a long time after surgery. This, sometimes called post-mastectomy pain syndrome, is discussed in more detail later.

Many women who have breast-conserving surgery or mastectomy are often surprised by how little pain they have in the breast area. But they are less happy with the strange sensations (numbness, pinching/pulling feeling) they may feel in the underarm area.

Ask a member of your health care team how to care for your surgery site and arm. Usually, you and your caregivers will get written instructions about care after surgery. These instructions should include:

• The care of the surgical wound and dressing
• How to monitor drainage and take care of the drains
• How to recognize signs of infection
• Bathing and showering after surgery
• When to call the doctor or nurse
• When to begin using the arm and how to do arm exercises to prevent stiffness
• When to resume wearing a bra
• When to begin using a prosthesis and what type to use (after mastectomy)
• What to eat and not to eat
• Use of medicines, including pain medicines and possibly antibiotics
• Any restrictions of activity
• What to expect regarding sensations or numbness in the breast and arm
• What to expect regarding feelings about body image
• When to see your doctor for a follow-up appointment
• Referral to a Reach To Recovery volunteer. Through our Reach To Recovery program, a specially trained volunteer who has had breast cancer can provide information, comfort, and support (see our document, Reach To Recovery for more information).

Most patients see their surgeon about 7 to 14 days after the surgery. Your doctor should explain the results of your pathology report and talk to you about the need for further treatment. If you will need more treatment, you will be referred to a radiation oncologist and/or a medical oncologist. If you are thinking about breast reconstruction, you may be referred to a plastic surgeon as well.

Chronic pain after breast surgery

Some women have problems with nerve (neuropathic) pain in the chest wall, armpit, and/or arm after surgery that doesn’t go away over time. This is called post-mastectomy pain syndrome (PMPS) because it was first described in women who had mastectomies, but it occurs after breast-conserving therapy, as well. Studies have shown that between 20% and 30% of women develop symptoms of PMPS after surgery. The classic symptoms of PMPS are pain and tingling in the chest wall, armpit, and/or arm. Pain may also be felt in the shoulder or surgical scar. Other common complaints include numbness, shooting or pricking pain, or unbearable itching. Most women with PMPS say their symptoms are not severe.

PMPS is thought to be linked to damage done to the nerves in the armpit and chest during surgery. But the causes are not known. Women who are younger, had a full ALND (not just SLNB), or who were treated with radiation after surgery are more likely to have problems with PMPS. Because ALNDs are done less often now, PMPS is less common than it once was.

It is important to talk to your doctor about any pain you are having. PMPS can cause you to not use your arm the way you should and over time you could lose the ability to use it normally.

PMPS can be treated. Opioids (narcotics) are medicines commonly used to treat pain, but they don't always work well for nerve pain. But there are medicines and treatments that do work for this kind of pain. Talk to your doctor to get the pain control you need.

What Is Deep Vein Thrombosis?

Deep vein thrombosis (throm-BO-sis), or DVT, is a blood clot that forms in a vein deep in the body. Blood clots occur when blood thickens and clumps together.

Most deep vein blood clots occur in the lower leg or thigh. They also can occur in other parts of the body.

A blood clot in a deep vein can break off and travel through the bloodstream. The loose clot is called an embolus (EM-bo-lus). It can travel to an artery in the lungs and block blood flow. This condition is called pulmonary embolism (PULL-mun-ary EM-bo-lizm), or PE.

PE is a very serious condition. It can damage the lungs and other organs in the body and cause death.

Blood clots in the thighs are more likely to break off and cause PE than blood clots in the lower legs or other parts of the body. Blood clots also can form in veins closer to the skin's surface. However, these clots won't break off and cause PE.

Urine Test May Help Spot Dangerous Blood Clots

SUNDAY, May 18, 2014 (HealthDay News) -- Researchers say they've created a simple urine test that detects the presence of dangerous blood clots in the lungs more accurately than the current blood test.

The clot typically forms in the leg, where it is called a deep vein thrombosis, but it can break loose and travel to an artery in the lungs. Once lodged there, the clot, now called a pulmonary embolism, can be life-threatening, the researchers noted.

"The main advantage of our test is that it is noninvasive and can be developed into a urine dipstick test that could have a rapid turnaround time," said lead researcher Dr. Timothy Fernandes, from the division of pulmonary, critical care and sleep medicine at the University of California, San Diego.

"This would be a tremendous boon to patients from the emergency department to the intensive care unit and even to outpatients," he added.

The test measures the levels of fibrinopeptide B (FPB), which is released when a clot forms.

Currently, doctors use a blood test to detect these clots. That test looks for a piece of a protein called D-dimer, which appears in the blood as a clot starts breaking apart.

The new test is not only noninvasive, it is more accurate than the D-dimer test, the researchers said.

The urine test can also track ongoing clot activity, another advantage over the D-dimer test, which finds a clot only once it begins to dissolve, Fernandes said.

The findings were to be presented Sunday at the American Thoracic Society annual meeting in San Diego. Research presented at meetings has not been peer-reviewed and should be considered preliminary.

"Our next steps are to further improve the diagnostic accuracy and performance of the test," Fernandes said. "We plan on evaluating urine FPB in other clinical settings where D-dimer has gained traction, such as for determining risk of venous thromboembolism recurrence after anti-clotting therapy has been stopped."

One expert noted that a better test for spotting clots in the lungs would be a significant advance.

"Pulmonary embolism can be fatal, and accurate detection is critical," said Dr. Gregg Fonarow, director of the Ahmanson-UCLA Cardiomyopathy Center, co-director of the UCLA Preventative Cardiology Program and associate chief of the UCLA Division of Cardiology.

Detecting patients with deep vein thrombosis or pulmonary embolism often relies on screening blood tests and imaging tests, he explained. "A D-dimer blood test is commonly used to screen patients, but has limitations in terms of accuracy," he said.

"These findings, while promising, will need to be replicated in studies involving more diverse patient populations," Fonarow said.

For the study, Fernandes and colleagues tested stored urine from 344 patients who took part in the Pulmonary Embolism Diagnosis Study.

The goal was to measure the sensitivity and specificity of the test. Sensitivity measures how effective the test is in identifying patients who actually have the condition, and specificity measures the test's ability to identify patients who don't.

When they tested the urine for concentrations of FPB, researchers found the results were as sensitive as the D-dimer blood test, but were more specific.

The patent for the test is held by the University of California Board of Regents, which stands to gain financially should the test be approved.

Keeping blood vessels healthy is best way to prevent stroke

Q: My father's doctor wants him to have an ultrasound of his carotid artery. What is the carotid artery? What will the doctor be looking for?

A: The carotid arteries carry oxygen- and nutrient-rich blood from the heart to the brain. These crucial arteries can become narrowed by the cholesterol-filled plaques of atherosclerosis.

Blood clots can form from the plaques, then break off and travel to the brain. There, they can lodge in small arteries, interrupting the vital flow of blood to brain cells.

Brief or partial interruptions of blood flow to the brain can cause transient ischemic attacks (TIAs). TIAs cause temporary symptoms but no permanent damage. But a prolonged or substantial interruption of blood flow to the brain can cause a stroke.

During a stroke, brain cells die, often damaging a person's ability to move, speak, feel or think. A carotid ultrasound can detect whether your father has narrowing, or stenosis, of his carotid arteries. If so, he may be at an increased risk of stroke.

Carotid ultrasound is the most widely used test for carotid stenosis. It is quick and safe. Ultrasound is similar to radar.

Developed just before the beginning of World War II, radar machines sent out and received radio waves: They had both transmitters and receivers. The machine would send out waves that would bounce off an object (like a distant airplane).

The waves that bounced back from the object were picked up by the receiver. The time that elapsed between sending and receiving the radio waves would tell the radar machine that there was an object out there, and how far away it was.

Ultrasound uses sound waves rather than radio waves. During the test, an ultrasound probe on your neck beams sounds waves through your skin, and then through the carotid artery.

A computer translates the sound signals into an image of your carotid artery and the blood flowing through it. It can show a plaque that has slowed blood flow.

Current guidelines recommend against carotid screening for everyone. That's because most people do not have plaques in their carotid arteries, so there would be nothing to see.

The test is reasonably expensive, and it's not perfectly accurate. If your father's doctor wants him to have a carotid ultrasound, I'll bet it's because your father had some symptoms of carotid stenosis. These symptoms are usually temporary. They may include visual abnormalities, weakness, numbness, tingling or slurred speech.

If the ultrasound reveals carotid stenosis, your father will have two treatment options: medication to prevent clot formation, or a procedure to open the narrowed artery. Both treatments will help prevent a stroke.

The best way to prevent TIAs and strokes is to keep your blood vessels healthy:

• Don't smoke.

• Eat a healthy diet.

• Exercise regularly.

• Maintain healthy blood pressure and cholesterol levels.

Family Health: Begin regular screenings for colorectal cancer at 50

Colorectal cancer, or cancer of the colon and rectum, continues to be the second-leading cause of cancer deaths in the United States.

It is estimated that almost 140,000 new cases will be diagnosed in the U.S. in 2014, and more than 50,000 people will die from the disease.

The incidence is slightly higher in men than women, and increases dramatically after age 50, with 90 percent of new colorectal cancer cases found in that age group. Additional risk factors include but are not limited to personal or family history of colon cancer or colon polyps, certain inflammatory bowel diseases, and some hereditary conditions such as familial adenomatous polyposis and hereditary non-polyposis colon cancer. Check with your medical provider for additional guidelines and risk factors.

Colon cancer rates have decreased significantly in some parts of the country over the past 10 years, largely attributed to increased rates of early screening for the disease. The best opportunity for decreasing death rates from this cancer is to prevent it through early screening and detection.

In the vast majority of cases, colorectal cancer begins as polyps, which are small growths that develop in approximately 25 percent to 30 percent of people after age 50. These polyps generally do not cause symptoms, but may, over a period of time, grow and turn into cancer. If the polyps are removed when they are small, the cancer may be prevented.

Since polyps do not cause symptoms, they can only be found with screening tests. The test that has consistently been shown to be the best exam for the detection and removal of polyps is colonoscopy. Various studies have shown that the use of this test can decrease colorectal cancer rates by 60 percent to 85 percent.

A colonoscopy involves the visual examination of the inside of the colon with a colonoscope, and permits removal of most polyps at the time of the procedure. This exam is usually done with sedation and requires a day of preparation and a day off work, although the exam itself usually only takes about 30 minutes.

Other screening tests for colorectal cancer are available, although less effective in prevention than a colonoscopy.

Fecal occult blood tests involve testing a stool sample for the presence of blood. However, as only a small number of colon polyps cause bleeding, and not all bleeding is due to polyps, the test is not very accurate. Flexible sigmoidoscopy is similar to colonoscopy in that it uses a flexible scope to evaluate part of the colon, but it only examines the lower third of the large intestine, and may miss any lesions in the other two-thirds of the colon. Virtual CT colonography is an X-ray test used to evaluate the colon, but does not permit any therapeutic intervention (such as polyp removal) and requires a bowel purge similar to that of a regular colonoscopy. If polyps are seen on this exam, a regular colonoscopy is required to remove them.

Current recommendations are that screening should begin at age 50 and continue at recommended intervals, depending on what screening exam is done. However, it is important to note that if an individual has an increased risk for developing colorectal cancer screening should begin at an earlier age and be done at more frequent intervals. Your medical provider can make specific recommendations based on your history and risk factors.

What are the symptoms of colorectal cancer? Oftentimes, none at all. It can, however, present with bleeding, pain and cramping in the lower abdomen, changes in bowel habits, anemia and/or unexplained weight loss. These symptoms could have other causes, but always check with your doctor.

Some studies have shown a healthy lifestyle, including eating a diet high in fiber and low in saturated fats, plus regular exercise and avoidance of tobacco products can also help reduce your risk of colorectal cancer.

‘Healthy Living’ educational seminars: Colorectal cancer prevention

The American Cancer Society estimates that 136,830 people will be diagnosed with colon cancer in 2014, and that 50,310 will die from it in the United States. That means that we have a one in 20 chance of developing colon cancer in our lifetime. It is the second-leading cause of cancer death in men and women.

Because there are so few reliable symptoms, early detection is important. Educating yourself about your health is one reason why South Bay Hospital provides free health seminars for residents.

Richard and Julie Hochfelder regularly attend health seminars in Sun City Center, especially those sponsored by South Bay Hospital.

“We don’t miss any, if we can help it,” Richard Hochfelder said last week, after he and his wife Julie attended the seminar on colorectal cancer prevention given by gastroenterologist Dr. Ashok Dhaduvai.

The Hochfelders are doing what many say they want to do but never seem to find the time or inclination. They get screened for colon cancer.

Dhaduvai says that the bottom line on who gets and who does not get colon cancer is often found in their family medical history. A person’s genetic makeup is a strong indicator of whether someone will get colon cancer. It is a gene defect, and once you have a family history of colon cancer, you have a higher risk, according to Dhaduvai. That is why making an appointment to get a colonoscopy can make a big difference in the outcome when fighting this particular cancer.

“The incident of colon cancer has come down because of screening,” says Dhaduvai.

It is the high incidence of polyps in the colon that puts someone at risk for colon cancer. Colon polyps are growths on the inner lining of the colon and are very common. They are important because they may become malignant, or cancerous.

It is thought that, based on their size, number and histology, a prediction can be made on which patients are more likely to develop further polyps and colon cancer.

It is all about the polyps. Dhaduvai’s comment is always: “Take out the polyps!”

According to Dhaduvai, no one knows what causes polyps to form inside the colon. And, he says, lifestyle or food choices do not seem to be a reason people get or don’t get polyps or colon cancer.

So when should you get a colonoscopy?

If there is no risk factor of colon cancer in a person’s family history, he or she can have a colonoscopy every 10 years starting at age 50.

With a risk factor, a person should have a colonoscopy every five years, unless that person has had colon cancer.

“In that case, first get one every other year and then every three years,” Dhaduvai said, “to be safe.”

Regular screening can help prevent colorectal cancer

March is the harbinger of spring. It also marks the observance of National Colorectal Cancer Awareness Month. Cancer of the colon and rectum, collectively termed colorectal cancer, is the third most common cancer in this country in both men and women, and the second leading cause of cancer-related deaths.

According to the American Cancer Society (ACS), almost 137,000 new cases of colorectal cancer and 50,000 deaths are estimated for 2014. Actually, that is good news. The ACS notes that the incidence and death rates from colorectal cancer have been decreasing for the past 20 years, largely due to an uptick in screening.

The exact cause of colorectal cancer is not known. But what is known are the many conditions that increase one’s risk for the disease. Age, family or personal history of colorectal cancer, certain genetic conditions, and a history of colon polyps are factors. Those with inflammatory intestinal disorders, such as Crohn’s disease or ulcerative colitis, are also prone.

Polyps, or growths on the inner wall of the large intestine, are common in people over the age of 50. Many of these growths are actually pre-malignant lesions that have a long latency period. If left alone, they can eventually turn into cancer.

Polyps are found and removed during a screening test — more commonly a colonoscopy — in which a lighted tube is inserted into the entire length of the colon and rectum. Since it is not known which polyps will become cancerous, all are removed when detected.

The signs and symptoms of colorectal cancer are varied, but the two strong telltale signs are blood in the stool and a change in bowel habits, such as diarrhea or constipation. Other symptoms may include abdominal pain, fatigue or weight loss with no known reason.

Sometimes there are no symptoms at all. Colorectal cancer is generally silent in the early stages and causes symptoms when it advances. That is why screening is key. If polyps are found and removed during screening, colorectal cancer, unlike most other cancers, can often be prevented. It can also be treated more successfully when found early.

According to the National Cancer Institute, when colorectal cancer is found in the early stages, the five-year survival rate is 90 percent. When it has spread to distant parts of the body, the rate drops to 13 percent.

Massachusetts boasts one of the highest percentages of eligible residents screened. In 2012, almost 70 percent of the state’s adults aged 50 years and older who were surveyed said they have had a sigmoidoscopy or colonoscopy — two screening tests for colorectal cancer. An encouraging note is that more than 67 percent of blacks interviewed reported to have been screened. The Incidence and death rates of colorectal cancer are higher in African Americans than in any other race.

The ACS recommends that people of average risk for colorectal cancer should begin screening at age 50. . The American College of Gastroenterology, however, recommends that African Americans of average risk should begin screening at age 45. People of high risk, such as those with a familial history of the disease, should begin at an earlier age. Your doctor will recommend a schedule that takes into account your risk factors.

There are many screening tests available. Fecal occult blood test looks for blood in the stool, which may be an indicator of cancer, while the barium enema, sigmoidoscopy and colonoscopy look for polyps and cancer.

For many gastroenterologists, doctors that focus on the digestive system and its disorders, colonoscopy is the gold standard. Many cases of colon cancer begin in the right side of the large intestine, a section the sigmoidoscopy misses. A saying oft repeated is that a sigmoidoscopy is like a mammogram on one breast. In addition, a colonoscopy is still required if the sigmoidoscopy or other tests are positive.

While the preparation for a colonoscopy is still a deterrent for most people — the bowels must be completely cleared — cost has become less of a barrier to colorectal screening. The Affordable Care Act, more affectionately known as “Obamacare,” requires coverage of colorectal cancer screening tests at no expense to patients by health plans that started on or after September 23, 2010. Health plans in effect prior to that date are more often under state, rather than federal mandates. Medicare also covers colorectal screening at no cost.

Lifestyle also plays a part in reducing the risk of colorectal cancer. Some research has shown that diets high in fatty red meats and processed meats, such as bacon, ham and sausage, can increase a person’s risk for colon cancer. Lack of exercise, obesity, smoking and alcohol use may also pose a risk.

But health experts are quick to point out that lifestyle changes do not take the place of colonoscopy. Eating well does not mean you can’t get cancer.

Deep Vein Thrombosis

A condition known as Deep Vein Thrombosis kills more Americans every year than Aids and Breast Cancer combined. But not many people know about it.

So vascular experts have set aside the month of March as Deep Vein Thrombosis Awareness Month, hoping to bring more attention to the condition. It can strike anyone at any age.

Deep Vein Thrombosis, or DVT, is a blood clot that forms in a vein deep in the body. The clot is usually in the legs, but can occur in the pelvis or arms.

"The problem with DVT is not just the fact that its blocking the blood flow back to the heart and lungs," Dr. Bud Shuler from the Vascular Association said. "But sometimes those clots can break loose and lodge in the blood vessels that go into the lungs."

Research shows DVT affects 2 million Americans a year, Shuler said.

"There's about 600-900 thousand blood clots that occur in hospitalized patients every year. Up to a third of those 200- to 300 thousand people die because of these clots," he said.

DVT is typically caused by one of three things:
* the blood is thicker than it should be, such as when you're dehydrated.
* The vein the blood travels through is damaged,
* Or the blood is static-- not moving, mostly due to inactivity.

"It's one of the top three to five leading causes of death in the United States, but because it's not easily recognized people don't pick up on it," Shuler said.

It can strike without someone even realizing it, including NBC reporter David Bloom who died while on assignment in Iraq.

“He was cooped up in the back of a Bradley Fighting Vehicle. He was dehydrated because he was in the desert. So he's all cramped up, bloods thicker than normal, He's not active. He steps out of the vehicle to give a report, the blood clot gets squeezed from his legs goes to his heart and lungs and unfortunately he died right there on the spot," Shuler said.

Although it can strike without warning---there are some symptoms.
*Pain or tenderness in the legs, *swelling or discoloration of the affected area, *or skin that is warm to the touch.

Dr. Shuler works closely with local primary care providers. Quickly getting patients into the vascular lab and if they do have a blood clot there are medicines that help right away.

"Most blood clots do not need to be treated in a hospital, They can be treated as an outpatient," Shuler said.

Doctors advise people on long flights to get up periodically and walk. And if you're in the hospital either have a compression machine on your legs or walk.

Myths and facts about diverticular disease

There are a lot of popular myths about diverticular disease – namely diverticulosis and diverticulitis, reports Health Cleveland Clinic.

Patients believe they can’t eat nuts or seeds, one of the most common myths. Below, the most common myths are dispelled.

Myth 1: Diverticular disease always requires treatment

Fact: Patients often confuse the related conditions diverticulosis and diverticulitis.

Diverticulosis generally needs no treatment, while diverticulitis is a more serious condition that may require surgery.

Diverticulosis refers to small pockets that protrude through weak muscle layers in the intestinal wall. Sixty percent of people have them by age 60. Up to eighty percent of people have them by age 80.

Diverticulosis is like having freckles: It’s only a problem if those freckles turn into a mole. We don’t operate, ever, on diverticulosis.

Diverticulitis occurs when one or more of those pockets are blocked by waste and inflammation or an infection occurs, or when pockets rupture and bacteria that are normally in your stool get outside of the intestines and into the surrounding abdominal area.

When this happens, a variety of complications can arise:

You may experience pain and/or a fever.

A painful infection of the abdominal cavity, or what we call peritonitis, occurs. Peritonitis is potentially fatal. Also, while it’s very uncommon, it does require immediate treatment.

Not everybody who has diverticulitis needs surgery, but they should see a physician, either in primary care or the emergency room, to get a proper diagnosis.

Myth 2: If you’ve had diverticulosis that developed into diverticulitis in the past, subsequent bouts of diverticulitis are more likely to perforate (and lead to peritonitis)

Fact: Diverticulitis happens in only 10 – 25 percent of those with diverticulosis. Also the great majority, or 75 percent, of those cases are the less serious type – requiring simple outpatient treatment, and perhaps medication.

Usually, if your body could handle diverticulitis the first time, then the next time, it’s going to react just as well.

Heartburn? Lifestyle Changes to Reduce Acid Reflux Symptoms

We call it heartburn, even though it has nothing to do with the heart. It’s gastroesophageal reflux disease (GERD) and one in five Americans have had it at one time or another.

Although medications can help to control reflux, lifestyle changes often do the trick, says Scott Gabbard, MD, a gastroenterologist and hepatologist.

GERD affects people when the lower esophageal sphincter, which controls the opening between the esophagus and stomach, fails to close after food passes through, and stomach acids travel backward up the esophagus.

Why reflux happens, how to prevent it

Dr. Gabbard lists excess stomach weight, fatty foods, large meals, and intake of alcohol, cigarettes, caffeine, chocolate and peppermint as risk factors for GERD. He says lifestyle changes are most important to help prevent that sphincter from opening in the first place.

Here are his top recommendations to help GERD sufferers:

• Lose weight. There is no other single thing you can do that can have a greater impact on your reflux, Dr. Gabbard says. Losing weight is the most important, and often the hardest thing to do — but the effort is worth it.
• Eat smaller, less fatty meals, especially late in the day. “Fat causes the sphincter to open, as do large meals,” he says. ”No medicine can prevent you from getting reflux if you eat a pepperoni pizza and drink a full pitcher of beer.” 
• Cut alcohol and smoking to start with, and see whether you need to make other dietary changes. “Many patients with reflux tolerate coffee just fine,” Dr. Gabbard says.
• Don’t eat for three hours before bed if reflux hits you hardest at bedtime — and use a 6- to 8-inch incline wedge pillow. “Those can be purchased on the Internet for $30,” he says.
• Wear looser clothes that doesn’t compress your abdomen. This sometimes helps, although that hasn’t been formally studied.
• Take Prilosec® or Nexium® about a half hour before eating. Some patients mistakenly take them at bedtime, which doesn’t provide any benefit. The medications reduce the amount of stomach acid but they don’t help keep the sphincter closed; there is currently no FDA-approved medication that does.

Medications such as Prilosec and Nexium are basically safe over the long term, although studies show they contribute to a slightly increased risk of osteoporosis, pneumonia and colon infections, Dr. Gabbard says. He says GERD sufferers should discuss them with their doctor. He also says to talk to your doctor if reflux symptoms don’t respond to treatment or are severe and persistent.

What is gastroesophageal reflux disease or GERD?

Gastroesophageal reflux disease is a serious, chronic form of gastroesophageal reflux, or GER. Individuals who experience GER more frequently than twice a week for several weeks may have GERD, which can cause more serious complications over time.

Gastroesophageal reflux disease (GERD) occurs when the lower esophageal sphincter becomes weak or relaxed at times when it should not be. This, in turn, causes contents of the stomach to rise into the esophagus.

A hiatal hernia — when the upper part of the stomach moves toward the chest through an opening in the diaphragm — may also cause GERD. Obesity and pregnancy also can induce GERD, as can use of asthma medications, calcium channel blockers, antihistamines, pain killers, sedatives and antidepressants. Smoking or exposure to secondhand smoke are also causes of GERD, which impacts adults and children.

Frequent heartburn is the most common symptom of GERD. However, this symptom fails to occur in some adults. A dry, chronic cough, wheezing, asthma or recurrent pneumonia, nausea, vomiting, a sore throat or laryngitis, difficult or painful swallowing, chest pain, dental erosion or bad breath are also symptoms of this disorder.

GERD is usually diagnosed by a gastroenterologist.

Diet and lifestyle changes are the first treatment strategies for GERD. Decreasing fat intake and eating small frequent meals as opposed to three large meals is a dietary recommendation. If symptoms do not improve with these changes, or if the patient continues to have difficulty swallowing, they should undergo diagnostic testing. However, there is no single test that can accurately diagnose GERD. Instead, clinicians must rely on a series of tests that can confirm diagnosis, including an upper gastrointestinal (GI) series, an upper endoscopy, esophageal pH monitoring or esophageal manometry. The lifestyle changes recommended by clinicians include weight loss if necessary, wearing loose-fitting clothing in the stomach area, remaining upright for several hours after eating, raising the head at least six to eight inches while sleeping and avoiding smoking.

Antacids, H2 blockers, proton pump inhibitors (PPIs), prokinetics and antibiotics are some of the pharmacotherapies that may reduce GERD. If these interventions fail, stronger interventions are available, including fundoplication and endoscopic techniques.

Esophagitis, strictures respiratory problems and Barrett’s esophagus are long-term complications associated with GERD.

References:

http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/#GERD

http://www.mayoclinic.org/diseases-conditions/gerd/basics/definition/con-20025201

http://www.healthline.com/health/gerd/basics

7 common questions about thyroid cancer

Dr. Gregory W. Randolph is the Director of the General Otolaryngology Service and Director of the Thyroid and Parathyroid Surgical Service at Massachusetts Eye and Ear Infirmary.

Dr. Gregory W. RandolphMass. Eye and Ear

Having always been intrigued by endocrinology, Dr. Randolph became interested in the anatomy of the head and neck while he was in medical school at Cornell University. Thyroid and parathyroid surgery bring together his two greatest areas of interest.

In the post below, Dr. Randolph answers seven of the most common questions about thyroid cancer:

1. What is the thyroid and what does it do?

The thyroid gland is a gland in the neck base that is shaped like a bow tie and positioned like one, too. It encircles the breathing tube (trachea) and swallowing tube (the esophagus). It secretes hormones, which regulate the body’s metabolism. The thyroid is commonly the source of benign and malignant growths, which can appear as neck masses and can affect the surrounding structures including the voice box and larynx. Laryngeal exam and voice assessment is critical in the evaluation of thyroid pathology.

2. What causes thyroid problems?

Masses and nodules within the thyroid are very common—about 50% of individuals have thyroid nodules as adults. The majority of these nodules are benign. Fine needle aspiration biopsy is necessary for many nodules to exclude cancer. Nodules can occur in certain families with greater frequency and may also occur in the setting of past-radiation exposure. An example of this is the Chernobyl accident in Russia—such radiation exposure increases the likelihood of those exposed developing nodules and the likelihood that the nodules are malignant.

Mass. Eye and Ear

3. What signs and symptoms can occur if thyroid function is affected?

Most nodules of the thyroid and thyroid cancers are not associated with any abnormality in thyroid function. There are, unfortunately, few if any systemic symptoms associated with thyroid nodules and thyroid cancers. They often appear as a lump in the neck base and are detected by the patient while showering or men while shaving. They can also be detected through a physical exam in your primary care physician’s office or incidentally through x-rays done of the neck for other purposes such as MRI scans done for cervical whiplash, CT scanning of the chest and neck for chronic cough, or carotid arterial ultrasonography.

4. How is the diagnosis of thyroid disease made?

The diagnosis of thyroid nodularity—determining whether it is benign or malignant—is primarily based on ultrasonographic analysis of the thyroid gland and ultrasonographic guided fine illustration biopsy. This topic will be reviewed during the public forum at Mass. Eye and Ear on April 5.

5. What is the treatment for thyroid disease?

Many thyroid nodules can be followed with serial ultrasound once the biopsy is negative. When thyroid cancers are operated on, generally the prognosis is very favorable for patients with the vast majority of thyroid cancer types.

6. How do I know if I have thyroid cancer?

Mass. Eye and Ear

 The diagnosis of thyroid cancer can generally be made following a fine needle biopsy of the thyroid nodule. Once the diagnosis is made, typically additional imaging of the neck is performed to make sure there is no lymph node metastasis of thyroid cancer, which is relatively common occurring in up to a third of patients with thyroid cancer.

7. If thyroid surgery is recommended, how is my voice box—and voice— protected?

Electrophysiologic monitoring of the recurrent laryngeal nerves and nerves adjacent to the thyroid gland to bring electrical cavity to the muscles of the vocal cord can be performed during thyroid surgery. Mass. Eye and Ear researchers recently completed a review of over 3,000 monitored thyroidectomies and found that this electrical monitoring system is tremendously helpful in gaining optimal information regarding neural function and in protecting nerves during surgery.

New Hope for Hemorrhoid Relief

Hemorrhoids. It was the number-one trending and most frequently searched health issue on the Internet for 2012, reported the United States Food and Drug Administration. The painful truth is that up to 75 percent of us will be affected by hemorrhoids at some time in our lives, according to the National Institutes of Health.

The Bottom Line on Hemorrhoids

What are hemorrhoids?
Hemorrhoids are swollen or dilated blood vessels located inside the anus (internal hemorrhoids) or around the exterior of the anus (external hemorrhoids).

What causes hemorrhoids?
Hemorrhoids are often caused by a combination of many things, including straining during bowel movements, frequent constipation or diarrhea, as well as pregnancy and cirrhosis of the liver.

What are the symptoms of hemorrhoids?
Symptoms may include pain and pressure in the anal canal, a grapelike lump on the anus, itching and soreness in and around the anus; and/or blood on underwear, toilet paper, the surface of the stool or in the toilet bowl. Symptoms often get worse after straining during constipation and overly aggressive wiping after a bowel movement.

“It’s not surprising that people are turning to the Internet for answers about hemorrhoids. They’re so common, yet people are embarrassed by the stigma of hemorrhoids,” says General Surgeon Adam Conn, M.D. While some people may joke about the condition, hemorrhoid suffers aren’t laughing. “Having hemorrhoids can be life altering. I’ve seen patients who dread sitting down and patients who avoid going out in public, because they’re so uncomfortable and worried that bleeding from hemorrhoids may stain their clothes,” he says.

Patients also avoid treatment because they’ve heard about the pain and recovery time after traditional procedures, says Dr. Conn. Until recently, traditional treatments were limited to dietary changes, topical ointments or invasive and painful procedures with extensive recovery periods. Eliminating or shrinking hemorrhoids was once limited to procedures like rubber band ligation, which shrinks the blood supply to hemorrhoids using a small rubber band; sclerotherapy involving chemical injections; or a complete hemorrhoidectomy requiring an incision and weeks of painful recovery.

“Thankfully, we now have a new, less traumatic option for treating painful hemorrhoids. With THD, patients can find relief and get back to enjoying life,” says Dr. Conn.