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Abdominal Aorta Aneurysm - Minimally Invasive Surgery

Abdominal Aortic Aneurysm

What is an abdominal aortic aneurysm (AAA)?

The aorta is the largest artery in your body, and it carries oxygen-rich blood pumped out of, or away from, your heart. Your aorta runs through your chest, where it is called the thoracic aorta. When it reaches your abdomen, it is called the abdominal aorta. The abdominal aorta supplies blood to the lower part of the body. In the abdomen, just below the navel, the aorta splits into two branches, called the iliac arteries, which carry blood into each leg.

When a weak area of the abdominal aorta expands or bulges, it is called an abdominal aortic aneurysm (AAA). The pressure from blood flowing through your abdominal aorta can cause a weakened part of the aorta to bulge, much like a balloon. A normal aorta is about 1 inch (or about 2 centimeters) in diameter. However, an AAA can stretch the aorta beyond its safety margin as it expands. Aneurysms are a health risk because they can burst or rupture. A ruptured aneurysm can cause severe internal bleeding, which can lead to shock or even death.

Less commonly, AAA can cause another serious health problem called embolization. Clots or debris can form inside the aneurysm and travel to blood vessels leading to other organs in your body. If one of these blood vessels becomes blocked, it can cause severe pain or even more serious problems, such as limb loss.

Each year, physicians diagnose approximately 200,000 people in the United States with AAA. Of those 200,000, nearly 15,000 may have AAA threatening enough to cause death from its rupture if not treated.

Fortunately, especially when diagnosed early before it causes symptoms, an AAA can be treated, or even cured, with highly effective and safe treatments.

What are the symptoms?

Although you may initially not feel any symptoms with AAA, if you develop symptoms, you may experience one or more of the following:

• A pulsing feeling in your abdomen, similar to a heartbeat
• Severe, sudden pain in your abdomen or lower back. If this is the case, your aneurysm may be about to burst
• On rare occasions, your feet may develop pain, discoloration, or sores on the toes or feet because of material shed from the aneurysm

If your aneurysm bursts, you may suddenly feel intense weakness, dizziness, or pain, and you may eventually lose consciousness. This is a life-threatening situation and you should seek medical attention immediately.

What causes an abdominal aortic aneurysm?

Physicians and researchers are not quite sure what actually causes an AAA to form in some people. The leading thought is that the aneurysm may be caused by inflammation in the aorta, which may cause its wall to weaken or break down. Some researchers believe that this inflammation can be associated with atherosclerosis (also called hardening of the arteries) or risk factors that contribute to atherosclerosis, such as high blood pressure (hypertension) and smoking. In atherosclerosis fatty deposits, called plaque, build up in an artery. Over time, this buildup causes the artery to narrow, stiffen and possibly weaken. Besides atherosclerosis, other factors that can increase your risk of AAA include:

• Being a man older than 60 years
• Having an immediate relative, such as a mother or brother, who has had AAA
• Having high blood pressure
• Smoking

Your risk of developing AAA increases as you age. AAA is more common in men than in women.

What tests will I need?

Abdominal aortic aneurysms that are not causing symptoms are most often found when a physician is performing an imaging test, such as an ultrasound or CT scan, for another condition. Sometimes your physician may feel a large pulsing mass in your abdomen on a routine physical examination. If your physician suspects that you may have AAA, he or she may recommend one of the following tests to confirm the suspicion:

• Abdominal ultrasound
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI)

How is an abdominal aortic aneurysm treated?

Watchful waiting
If your AAA is small, your physician may recommend "watchful waiting," which means that you will be monitored every 6-12 months for signs of changes in the aneurysm size. Your physician may schedule you for regular CT scans or ultrasounds to watch the aneurysm. This method is usually used for aneurysms that are smaller than about 2 inches (roughly 5.0 to 5.5 centimeters) in diameter. If you also have high blood pressure, your physician may prescribe blood pressure medication to lower the pressure on the weakened area of the aneurysm. If you smoke, you should obtain help to stop smoking. An aneurysm will not "go away" by itself. It is extremely important to continue to follow up with your physician as directed because the aneurysm may enlarge to a dangerous size over time. It could eventually burst if this is not detected and treated.

Open Surgical aneurysm repair
A vascular surgeon may recommend that you have a surgical procedure called open aneurysm repair if your aneurysm is causing symptoms, or is larger than about 2 inches (roughly 5.0 to 5.5 centimeters), or is enlarging under observation. During an open aneurysm repair, also known as surgical aneurysm repair, your surgeon makes an incision in your abdomen and replaces the weakened part of your aorta with a tube-like replacement called an aortic graft. This graft is made of a strong, durable, man-made plastic material, such as Dacron®, in the size and shape of the healthy aorta. The strong tube takes the place of the weakened section in your aorta and allows your blood to pass easily through it. Following the surgery, you may stay in the hospital for 4 to 7 days. Depending upon your circumstances, you may also require 6 weeks to 3 months for a complete recovery. More than 90 percent of open aneurysm repairs are successful for the long term.

Endovascular stent graft
Instead of open aneurysm repair, your vascular surgeon may consider a newer procedure called an endovascular stent graft. Endovascular means that the treatment is performed inside your artery using long, thin tubes called catheters that are threaded through your blood vessels. This procedure is less invasive, meaning that your surgeon will usually need to make only small incisions in your groin area through which to thread the catheters. During the procedure, your surgeon will use live x-ray pictures viewed on a video screen to guide a fabric and metal tube, called an endovascular stent graft (or endograft), to the site of the aneurysm. Like the graft in open surgery, the endovascular stent graft also strengthens the aorta. Your recovery time for endovascular stent grafting is usually shorter than for the open surgery, and your hospital stay may be reduced to 2 to 3 days. However, this procedure requires more frequent follow-up visits with imaging procedures, usually CT scans, after endograft placement to be sure the graft continues to function properly. Also, the endograft is more likely to require periodic maintenance procedures than does the open procedure. In addition, your aneurysm may not have the shape that is suitable for this procedure, since not all patients are candidates for endovascular repair because of the extent of the aneurysm, or its relationship to the renal (kidney) arteries, or other issues. While the endovascular stent graft may be a good option for some patients who have suitable aneurysms and who have medical conditions increasing their risk, in some other cases, open aneurysm repair may still be the best way to cure AAA. Your vascular surgeon will help you decide what is the best method of treatment for your particular situation.

 

Hemorrhoids - Surgery

Most hemorrhoids do not require surgery. It is usually considered only for severe hemorrhoids.

Surgery may be done if other treatments (including home treatment) have failed. Surgery is also considered when symptoms become so bothersome that your lifestyle is affected or when hemorrhoids create a medical emergency, such as uncontrolled bleeding or blood and pus at the anus along with severe rectal pain.

External hemorrhoids

External hemorrhoids usually are not removed with surgery (hemorrhoidectomy) except if they are very large and uncomfortable or if you are having surgery on the anal area for another reason, such as internal hemorrhoids or a tear (anal fissure). If a blood clot develops in the external hemorrhoid, the clot may need to be removed to relieve pain.

Internal hemorrhoids

Surgical removal of hemorrhoids (hemorrhoidectomy) is a last resort for treating small internal hemorrhoids.

Hemorrhoidectomy is considered the most successful way to treat large internal hemorrhoids, especially those that are still a problem after treatments that cut off blood flow to hemorrhoids (fixative procedures) have been tried.

Hemorrhoids: Which Treatment Should I Use?

What to think about

Sometimes, increased pressure on external hemorrhoids causes them to get irritated and to clot. This causes a lump (thrombosed, or clotted, hemorrhoid) to form. You may suffer from severe pain at the site of a clotted hemorrhoid.

A procedure to relieve the pain can be done in a doctor's office or outpatient clinic. The doctor applies local anesthesia and then makes a small incision where the lump has occurred to remove the clot and reduce pressure and pain. The procedure works best if it is done soon after the clot has formed.

If the pain is tolerable, you may choose to wait to see a doctor. The pain usually goes away in a few days. After 4 or 5 days, the pain from cutting and draining the hemorrhoid is usually worse than the pain from the clot.

Hemorrhoids - Other Treatment

Many people who have hemorrhoids find relief from symptoms through home treatment. If medical treatment is needed, fixative procedures are the most widely used nonsurgical treatments.

Other treatment choices

Fixative procedures include:

• Rubber band ligation, a procedure in which the hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow so that the hemorrhoid shrinks and dies and, in about a week, falls off.
• Coagulation with light (infrared photocoagulation), lasers, or electricity, which creates scar tissue, cutting off the blood supply to the hemorrhoid so that it shrinks and dies.

What to think about

Not all doctors have the experience or the equipment to do all types of fixative procedures. This may help you decide which procedure to choose. Ask your doctor which procedure he or she does the most and how satisfied people have been with the outcomes of that procedure.

Hernia Surgical Mesh Implants

In this website, the FDA describes hernias, the different treatment options to repair hernias and recommendations for patients that are considering surgery for their hernias. The FDA wants to help patients make informed decisions about their health care and to facilitate a discussion between patients and their surgeons.

What is a Hernia?

A hernia occurs when an organ, intestine or fatty tissue squeezes through a hole or a weak spot in the surrounding muscle or connective tissue. Hernias often occur at the abdominal wall.  Sometimes a hernia can be visible as an external bulge particularly when straining or bearing down.

Types of Hernias

The most common types of hernias are:

• Inguinal: occurs in the inner groin
• Femoral: occurs in the upper thigh/outer groin
• Incisional: occurs through an incision or scar in the abdomen
• Ventral: occurs in the general abdominal/ventral wall
• Umbilical: occurs at the belly button
• Hiatal: occurs inside the abdomen, along the upper stomach/diaphragm

Causes of Hernias

Most hernias are caused by a combination of pressure and an opening or weakness of muscle or connective tissue. The pressure pushes an organ or tissue through the opening or weak spot. Sometimes the muscle weakness is present at birth but more often it occurs later in life. Anything that causes an increase in abdominal pressure can cause a hernia, including obesity, lifting heavy objects, diarrhea or constipation, or persistent coughing or sneezing. Poor nutrition, smoking, and overexertion can weaken muscles and contribute to the likelihood of a hernia.

Treatment Options for Hernias

Hernia repairs are common—more than one million hernia repairs are performed each year in the U.S. Approximately 800,000 are to repair inguinal hernias and the rest are for other types of hernias.1

• Non-Surgical
  • Watchful Waiting - Your surgeon will watch the hernia and make sure that it is not getting larger or causing problems. Although surgery is the only treatment that can repair hernias, many surgical procedures are elective for adult inguinal hernias. Watchful waiting is an option for people who do not have complications or symptoms with their hernias, and if recommended by their surgeon.
• Surgical
  • Laparoscopic - The surgeon makes several small incisions in the abdomen that allow surgical tools into the openings to repair the hernia. Laparoscopic surgery can be performed with or without surgical mesh.
  • Open Repair - The surgeon makes an incision near the hernia and the weak muscle area is repaired. Open repair can be done with or without surgical mesh. Open repair that uses sutures without mesh is referred to as primary closure. Primary closure is used to repair inguinal hernias in infants, small hernias, strangulated or infected hernias.

Hernias have a high rate of recurrence, and surgeons often use surgical mesh to strengthen the hernia repair and reduce the rate of recurrence. Since the 1980s, there has been an increase in mesh-based hernia repairs—by 2000, non-mesh repairs represented less than 10% of groin hernia repair techniques.

The use of surgical mesh may also improve patient outcomes through decreased operative time and minimized recovery time. However, recovery time depends on the type of hernia, the surgical approach, and the patient’s condition both before and after surgery.

Information found in medical literature has consistently demonstrated a reduced hernia recurrence rate when surgical mesh is used to repair the hernia compared to hernia repair without surgical mesh. For example, inguinal hernia recurrence is higher with open repair using sutures (primary closure) than with mesh repair2.

Despite reduced rates of recurrence, there are situations where the use of surgical mesh for hernia repair may not be recommended. Patients should talk to their surgeons about their specific circumstances and their best options and alternatives for hernia repair.

Surgical Mesh

Surgical mesh is a medical device that is used to provide additional support to weakened or damaged tissue. The majority of surgical mesh devices currently available for use are constructed from synthetic materials or animal tissue.

Surgical mesh made of synthetic materials can be found in knitted mesh or non-knitted sheet forms. The synthetic materials used can be absorbable, non-absorbable or a combination of absorbable and non-absorbable materials.

Animal-derived mesh are made of animal tissue, such as intestine or skin, that has been processed and disinfected to be suitable for use as an implanted device. These animal-derived mesh are absorbable. The majority of tissue used to produce these mesh implants are from a pig (porcine) or cow (bovine) source.

Non-absorbable mesh will remain in the body indefinitely and is considered a permanent implant. It is used to provide permanent reinforcement to the repaired hernia. Absorbable mesh will degrade and lose strength over time. It is not intended to provide long-term reinforcement to the repair site. As the material degrades, new tissue growth is intended to provide strength to the repair.

Hernia Repair Surgery Complications

Based on FDA’s analysis of medical device adverse event reports and of peer-reviewed, scientific literature, the most common adverse events for all surgical repair of hernias—with or without mesh—are pain, infection, hernia recurrence, scar-like tissue that sticks tissues together (adhesion), blockage of the large or small intestine (obstruction), bleeding, abnormal connection between organs, vessels, or intestines (fistula), fluid build-up at the surgical site (seroma), and a hole in neighboring tissues or organs (perforation).

The most common adverse events following hernia repair with mesh are pain, infection, hernia recurrence, adhesion, and bowel obstruction. Some other potential adverse events that can occur following hernia repair with mesh are mesh migration and mesh shrinkage (contraction).

Many complications related to hernia repair with surgical mesh that have been reported to the FDA have been associated with recalled mesh products that are no longer on the market. Pain, infection, recurrence, adhesion, obstruction, and perforation are the most common complications associated with recalled mesh. In the FDA’s analysis of medical adverse event reports to the FDA, recalled mesh products were the main cause of bowel perforation and obstruction complications.

Please refer to the recall notices here and here for more information if you have recalled mesh. For more information on the recalled products, please visit the FDA Medical Device Recall website. Please visit the Medical & Radiation Emitting Device Database to search a specific type of surgical mesh.

If you are unsure about the specific mesh manufacturer and brand used in your surgery and have questions about your hernia repair, contact your surgeon or the facility where your surgery was performed to obtain the information from your medical record. 

Hernias

Many people are surprised to learn that hernias are fairly common in kids. Babies (especially preemies) can even be born with them.

Hernias in kids can be treated (hernia repair is the one of the most common surgeries performed on children), but it's important to recognize their symptoms so that you can get your child the appropriate medical care.

About Hernias

When part of an organ or tissue in the body (such as a loop of intestine) pushes through an opening or weak spot in a muscle wall, it can protrude into a space where it does not belong. This protrusion is a hernia, which may look like a bulge or lump.

Some babies are born with various small openings inside the body that will close at some point. Nearby tissues can squeeze into such openings and become hernias. Unlike hernias seen in adults, these areas are not always considered a weakness in the muscle wall, but a normal area that has not yet closed.

Sometimes tissues can squeeze through muscle wall openings that are only meant for arteries or other tissues. In other cases, strains or injuries create a weak spot in the muscle wall, and part of a nearby organ can be pushed into the weak spot so that it bulges and becomes a hernia.

Types of Hernias

There are different types of hernias, and each requires different levels of medical care.

In many infant and childhood hernias, the herniated tissues may protrude only during moments of physical pressure or strain. A prominent bulge might only be noticeable when a child is crying, coughing, or straining, and it may seem to retract or go away at other times. Hernias in this state are called reducible and are not immediately harmful.

Sometimes tissue can become trapped in an opening or pouch and do not retract. These are incarcerated hernias, and are a serious problem requiring immediate medical attention. For example, a loop of intestine that is caught and squeezed in the groin area may block the passage of food though the digestive tract.

Symptoms of an incarcerated hernia can include pain, vomiting, and irritability. If you touch the bulge it has created, it may feel hard.

A doctor can usually free the trapped tissues by gently squeezing the lump and trying to force it back into the body opening. Because incarcerated hernias can be painful, the doctor usually provides pain medication during this procedure. Surgery is usually required within a few days to prevent development of another incarcerated hernia.

The most serious type of hernia is a strangulated hernia, in which the normal blood supply is cut off from the trapped tissue. Without that blood supply, the strangulated tissue cannot get oxygen and will die. Surgery is required immediately to dislodge the tissue so that oxygen can get to it again.

The two most common hernias in kids are inguinal hernias in the groin area and umbilical hernias in the belly-button area.

Inguinal Hernias

In infants, an inguinal hernia is most often caused by a protrusion of a loop or portion of intestine or a fold of membrane from the abdomen — or in girls, from an ovary or fallopian tube — through an opening into the groin (the area where the abdomen meets the top of the thigh). The opening is caused by the presence of a fold of the peritoneal membrane, which produces a sac. Within this sac, the loop of bowel can protrude.

The hernia is apparent as a bulge in the groin area, especially when the child cries, coughs, or stands.

Sometimes, in boys, the inguinal hernia extends beyond the groin into the scrotum (the sac that holds the testicles). In girls, it can extend to one of the outer labia (the larger lips of tissue around the vaginal opening). In these cases, an enlargement or swelling can be seen that extends from the groin into the scrotum or labium.

More common on the right side, inguinal hernias occur far more often in boys than girls and are most common in preemies, baby boys with undescended testicles, and kids with cystic fibrosis. Kids with a family history of hernias are also at risk.

Other conditions that may look like inguinal hernias, but are not:

• A communicating hydrocele is similar to a hernia, except that fluid causes the bulge rather than protruding tissue. Depending on its location, the hydrocele may be left to disappear in a year or two or it may be treated with surgery. In infants, the hydrocele may not require surgery, as many go away by the second birthday. Some can change size depending on how much fluid goes in and out, and some may appear bluish because the membrane that causes the hydrocele is blue.
• Occasionally, a retractile testicle (a testicle that retracts from the scrotum from time to time) causes a bulge in the groin area. It may not need treatment but should be evaluated by a pediatric specialist.
• A femoral hernia is rare in kids and can be confused with an inguinal hernia. It consists of tissues that have pushed in alongside an artery into the top of the thigh. It appears as a bulge at the top of the thigh, just below the groin.

Umbilical Hernias

Some babies are born with a weakness or opening in the abdominal muscles around the belly button (under the skin) through which some abdominal membrane or small intestine protrudes.

The soft bulge this creates is an umbilical hernia. It is most obvious when the baby cries, coughs, or strains. Umbilical hernias are more common in females, those of African heritage, and low birth weight babies. These hernias range in size from less than ½ inch (2 centimeters) to more than 2 inches (6 centimeters).

In most instances an umbilical hernia causes no discomfort. Usually, a doctor can easily push it back in. An infant's umbilical hernia (unlike an adult's) rarely obstructs or strangulates. In fact, most umbilical hernias, even the larger ones, tend to close up on their own by age 2. That's why the doctor usually advises waiting and watching this kind of hernia in an infant rather than operating.

Surgery is necessary only if the hernia is very large; grows in size after age 1 or 2; fails to heal by age 4 or 5; or the child develops symptoms of obstruction or strangulation, like swelling, bulging, vomiting, fever, and pain. If such symptoms develop, call the doctor immediately.

Signs and Symptoms

If you think that your child may have a hernia, call your doctor immediately. And ask yourself:

• Is the bulge present when your child is straining, crying, coughing, or standing, but absent when your child is sleeping or resting? This could indicate a reducible hernia.
• Is the bulge present all the time, but with no other symptoms? This could be a hydrocele or something else.
• Has the groin area suddenly begun to swell? Do you notice any discoloration of the bulging area or a "swollen" abdomen? Is your child irritable, complaining of pain, constipated, or vomiting? These are signs of an incarcerated hernia, which calls for immediate attention. See a doctor immediately or take your child to the emergency department.
• Is the area swollen, red, inflamed, and extremely painful? Has your child developed a fever? These might be symptoms of a strangulated hernia. Call your doctor and then go directly to the hospital emergency department.

Treatment

Once an inguinal hernia is diagnosed, surgery will be done to prevent it from becoming incarcerated. During surgery, the herniated tissue is put back into its proper space, and the opening or weakness that permitted it to form is closed or repaired.

Surgery to correct inguinal hernias is performed on kids of all ages, sometimes even on premature babies.

Inguinal hernia surgery in kids is usually performed on an outpatient basis with no overnight stay in the hospital, but some kids, particularly young infants, may be kept in the hospital overnight for observation.

The period of recuperation for kids is fairly short. Most can resume normal activities about 7 days after surgery, with the doctor's approval. Until that time, kids should avoid strenuous activity such as bicycle riding and tree climbing. Of course, if you notice any signs of problems after the surgery, such as bleeding, swelling, or fever, call your doctor.

What Is Carotid Endarterectomy?

Carotid endarterectomy is surgery to 

remove fatty deposits (plaque) that are 

narrowing the arteries in your neck. 

These are called the carotid arteries. 

They supply blood and oxygen to your 

brain. If plaque and other fatty materials 

block an artery, it slows or blocks the 

blood flow, and you could have a stroke. 

Carotid endarterectomy is surgery to remove fatty deposits (plaque) that are narrowing the arteries in your neck. These are called the carotid arteries. They supply blood and oxygen to your brain. If plaque and other fatty materials block an artery, it slows or blocks the blood flow, and you could have a stroke. Why do I need it?

Your doctor has given you one or more tests that show 

there is blockage. You may have had transient ischemic 

attacks (TIAs). A TIA is caused by a blood clot that lasts 

only a few minutes and usually causes no permanent 

injury. TIAs can serve as warning signs of a major 

stroke. About one-third of these are followed by a stroke 

in the following year. This operation can stop TIAs from 

happening and can reduce your risk for stroke.

How is it done?

• You’ll get medicine to make you sleep and prevent pain.

• The doctor makes a small cut in your neck at the spot 

where your artery is blocked or narrowed. 

• The doctor opens up the narrowed artery and removes 

the plaque.

• The doctor will make the artery as smooth and 

clean as possible.• The artery and the cut will be closed up.

• The surgery usually takes about 1or 2 hours. 

What about afterwards?

• You’ll wake up in the hospital and may feel confused 

at first.

• Your neck will hurt for a couple of days.

• It may be hard to swallow at first.

• You’ll probably go home in a day or two.

• You shouldn’t lift anything heavy for about three weeks.

• You’ll probably be able to return to work within 

a month.

• You should make healthy lifestyle changes to help 

reduce the chance of new plaque deposits and to lower 

your risk of stroke.How can I reduce my risk of stroke?

• Have your blood pressure checked often and manage 

high blood pressure.

• Don’t smoke, and avoid second-hand smoke.

• Lose any extra weight.

• Get regular physical activity.

• Have your blood sugar tested, and control diabetes if 

you have it.

• Eat less salt, saturated fat and trans fat.

• Limit alcohol to no more than two drinks a day for 

men, one drink a day for women.

Carotid Artery Surgery

Carotid endarterectomy is the surgical procedure to remove fatty plaque from neck arteries. Fatty plaque is deposited on the interior walls of the neck (carotid) atteries as a in a condition known as Carotid Artery Disease. Carotid Artery Disease affects the vessels leading to the head and brain. Like the heart, the brain's cells need a constant supply of oxygen-rich blood. This blood supply is delivered to the brain by the 2 large carotid arteries in the front of the neck and by 2 smaller vertebral arteries at the back of the neck. The right and left vertebral arteries come together at the base of the brain to form what is called the basilar artery. A stroke most often occurs when the carotid arteries become blocked and the brain does not get enough oxygen.

Carotid Endarterectomy Procedure Description

While the patient is under anesthesia, surgeons make an incision in the neck, at the location of the blockage. A tube is inserted above and below the blockage to reroute blood flow. Surgeons can then open up the carotid artery and remove the plaque. Once the artery is stitched closed, the tube is removed. The surgeon may also use an alternate technique that does not require blood flow to be rerouted. In this procedure, the surgeon stops the blood flow just long enough to peel the blockage away from the artery.

Endarterectomy surgery is a treatment that has been proven safe and effective in providing long-term benefits to patients. A Multidisciplinary Consensus Statement from the American Heart Association recently (1995) concluded that carotid endarterectomy, performed in medical centers with documented successful experience in the procedure, in conjunction with aggressive modifiable risk factor management, is beneficial for patients who have an asymptomatic carotid artery disease with more than 60% artery diameter reduction. The Statement also concluded that carotid endarterectomy is of proven benefit for symptomatic patients, including those with single or multiple transient ischemic attacks (TIAs) or those who have suffered a mild stroke within a 6-month interval, who have stenosis of greater than 70%.

Carotid artery disease increases the risk for stroke in 3 ways:

• By fatty deposits called plaque severely narrowing the carotid arteries.
   
• By a blood clot becoming wedged in a carotid artery narrowed by plaque.
   
• By plaque breaking off from the carotid arteries and blocking a smaller artery in the brain (cerebral artery).

What are the symptoms of carotid artery disease?

Although there are no symptoms specific to carotid artery disease, the warning signs of a stroke are a good way to tell if there is a blockage in the carotid arteries. Transient ischemic attacks (TIAs) are one of the most important warning signs that you may soon have a stroke. Sometimes called "mini-strokes," TIAs are temporary episodes of headache, dizziness, tingling, numbness, blurred vision, confusion, or paralysis that can last anywhere from a few minutes to a couple of hours. See a doctor right away if you or someone you know has the symptoms of a TIA.

Other signs or symptoms of a carotid artery blockage may be

• Weakness or paralysis of your arm, leg, or face on one side of your body.
• Numbness or tingling of your arm, leg, or face on one side of your body.
• Trouble swallowing.
• Loss of eyesight, or blurry eyesight in one eye.
• Dizziness, confusion, fainting, or coma.

Surgical Associates of Texas, P.A., the surgical team at the Texas Heart Institute, have more experience than any other cardiovascular surgical group in the world, having performed approximately 100,000 open heart surgeries of all types and degrees of complexity and over 800 heart transplants. Many of our patients have had successful operations and recovery when previously led to believe no further treatment options were possible.

If you are interested in learning more about any of these procedures, please visit our pages on Surgical Procedures . Please visit our page on carotid artery disease to learn more about it.

Can colorectal polyps and cancer be found early?

Regular screening can often find colorectal cancer early, when it is most likely to be curable. In many cases, screening can also prevent colorectal cancer altogether. This is because some polyps, or growths, can be found and removed before they have the chance to turn into cancer.

Colorectal cancer screening tests

Cancer screening is the process of looking for cancer in people who have no symptoms of the disease. Several different tests can be used to screen for colorectal cancers. These tests can be divided into 2 broad groups:

• Tests that can find both colorectal polyps and cancer: These tests look at the structure of the colon itself to find any abnormal areas. This is done either with a scope inserted into the rectum or with special imaging (x-ray) tests. Polyps found before they become cancerous can be removed, so these tests may prevent colorectal cancer. This is why these tests are preferred if they are available and you are willing to have them.
• Tests that mainly find cancer: These test the stool (feces) for signs that cancer may be present. These tests are less invasive and easier to have done, but they are less likely to detect polyps.

These tests as well as others can also be used when people have symptoms of colorectal cancer and other digestive diseases.

Tests that can find both colorectal polyps and cancer

Flexible sigmoidoscopy

During this test, the doctor looks at part of the colon and rectum with a sigmoidoscope − a flexible, lighted tube about the thickness of a finger with a small video camera on the end. It is inserted through the rectum and into the lower part of the colon. Images from the scope are seen on a display monitor.

Using the sigmoidoscope, your doctor can see the inside of the rectum and part of the colon to detect (and possibly remove) any abnormality. Because the sigmoidoscope is only 60 centimeters (about 2 feet) long, the doctor is able to see the entire rectum but less than half of the colon with this procedure.

Before the test: The colon and rectum must be empty and clean so your doctor can see the lining of the sigmoid colon and rectum. Your doctor will give you specific instructions to follow. You may be asked to follow a special diet (such as drinking only clear liquids) for a day before the exam. You may also be asked to use enemas or to use strong laxatives to clean out your colon before the exam. Be sure to tell your doctor about any medicines you are taking, as you may need to change how you take them before the test.

During the test: A sigmoidoscopy usually takes 10 to 20 minutes. Most people do not need to be sedated for this test, but this may be an option you can discuss with your doctor. Sedation may make the test less uncomfortable, but it requires some recovery time, and you’ll need someone with you to take you home after the test.

You will probably be asked to lie on a table on your left side with your knees positioned near your chest. Your doctor should do a digital rectal exam, or DRE (inserting a gloved, lubricated finger into the rectum), before inserting the sigmoidoscope. The sigmoidoscope is lubricated to make it easier to insert into the rectum. The scope may feel cold. The sigmoidoscope may stretch the wall of the colon, which may cause bowel spasms or lower abdominal pain. Air will be placed into the sigmoid colon through the sigmoidoscope so the doctor can see the walls of the colon better. During the procedure, you might feel pressure and slight cramping in your lower abdomen. To ease discomfort and the urge to have a bowel movement, it helps to breathe deeply and slowly through your mouth. You will feel better after the test once the air leaves your colon.

If a small polyp is found during the test your doctor may remove it with a small instrument passed through the scope. The polyp will be sent to a lab to be looked at by a pathologist. If a pre-cancerous polyp (an adenoma) or colorectal cancer is found during the test, you will need to have a colonoscopy later to look for polyps or cancer in the rest of the colon.

Possible complications and side effects: This test may be uncomfortable because air is put into the colon, but it should not be painful. Be sure to let your doctor know if you feel pain during the procedure. You may see a small amount of blood in your first bowel movement after the test. Significant bleeding and puncture of the colon are possible complications, but they are very uncommon.

Colonoscopy

For this test, the doctor looks at the entire length of the colon and rectum with a colonoscope, which is basically a longer version of a sigmoidoscope. It is inserted through the rectum into the colon. The colonoscope has a video camera on the end that is connected to a display monitor so the doctor can see and closely examine the inside of the colon. Special instruments can be passed through the colonoscope to biopsy or remove any suspicious-looking areas such as polyps, if needed.

Colonoscopy may be done in a hospital outpatient department, in a clinic, or in a doctor's office.

Before the test: Be sure your doctor knows about any medicines you are taking, as you may need to change how you take them before the test. The colon and rectum must be empty and clean so your doctor can see their inner linings during the test. You will need to take laxatives (usually a large volume of a liquid, but sometimes pills, as well) the day before the test and possibly an enema that morning.

Your doctor will give you specific instructions. It is important to read these carefully a few days ahead of time, since you may need to shop for special supplies and get laxatives from a pharmacy. If you are not sure about any of the instructions, call the doctor's office and go over them step by step with the nurse. Many people consider the bowel preparation to be the worst part of the test, as it usually requires you to be in the bathroom much of the night before the exam.

You may be given other instructions as well. For example, your doctor may tell you to drink only clear liquids (water, apple or cranberry juice, and any gelatin except red or purple) for at least a day before the exam. Plain tea or coffee with sugar is usually okay, but no milk or creamer is allowed. Clear broth, ginger ale, and most soft drinks or sports drinks are usually allowed unless they have red or purple food colorings, which could be mistaken for blood in the colon.

You will probably also be told not to eat or drink anything after midnight the night before your test. If you normally take prescription medicines in the mornings, talk with your doctor or nurse about how to manage them for the day.

You usually need to arrange for someone to drive you home from the test because a sedative is used during the test that can leave you groggy and affect your ability to drive. Most doctors require that someone you know drive you home (not a taxi).

During the test: The test itself usually takes about 30 minutes, but it may take longer if a polyp is found and removed. Before the colonoscopy begins, you will be given a sedating medicine (usually through your vein) to make you feel comfortable and sleepy during the procedure. You might be awake, but not be aware of what is going on and probably won’t remember the procedure afterward. Most people will be fully awake by the time they get home from the test.

During the procedure, you will be asked to lie on your side with your knees flexed and a drape will cover you. Your blood pressure, heart rate, and breathing rate will be monitored during and after the test.

Your doctor should do a digital rectal exam (DRE) before inserting the colonoscope. The colonoscope is lubricated so it can be easily inserted into the rectum. Once in the rectum, the colonoscope is passed all the way to the beginning of the colon, called the cecum. You may feel an urge to have a bowel movement when the colonoscope is inserted or pushed further up the colon. To ease any discomfort it may help to breathe deeply and slowly through your mouth. The colonoscope will deliver air into the colon so that it is easier for the doctor to see the lining of the colon and use the instruments to perform the test. Suction will be used to remove any blood or liquid stools.

The doctor will look at the inner walls of the colon as he or she slowly withdraws the colonoscope. If a small polyp is found, the doctor may remove it because it might eventually become cancerous. This is usually done by passing a wire loop through the colonoscope to cut the polyp from the wall of the colon with an electrical current. The polyp can then be sent to a lab to be checked under a microscope to see if it has any areas that have changed into cancer.

If your doctor sees a larger polyp or tumor or anything else abnormal, a biopsy may be done. For this procedure, a small piece of tissue is taken out through the colonoscope. The tissue is looked at under a microscope to determine if it is a cancer, a benign (non-cancerous) growth, or a result of inflammation.

Possible side effects and complications: The bowel preparation before the test is unpleasant. The test itself may be uncomfortable, but the sedative usually helps with this, and most people feel normal once the effects of the sedative wear off. Some people may have gas pains or cramping for a while after the test.

In some cases, people may have low blood pressure or changes in heart rhythms due to the sedation during the test, although these are rarely serious.

If a polyp is removed or a biopsy is done during the colonoscopy, you may notice some blood in your stool for a day or 2 after the test. Significant bleeding is slightly more likely with colonoscopy than with sigmoidoscopy, but it is still uncommon. In rare cases, continued bleeding might require treatment.

Colonoscopy is a safe procedure, but on rare occasions the colonoscope can puncture the wall of the colon or rectum. This is called a perforation. It can be a serious complication leading to a serious abdominal (belly) infection, and it may require surgical repair. Talk to your doctor about the risk of this complication.

You can read more about colonoscopy and sigmoidoscopy in our document Frequently Asked Questions About Colonoscopy and Sigmoidoscopy.

Double-contrast barium enema

The double-contrast barium enema (DCBE) is also called an air-contrast barium enema or a barium enema with air contrast. It may also be referred to as a lower GI series. It is basically a type of x-ray test. Barium sulfate, which is a chalky liquid, and air are used to outline the inner part of the colon and rectum to look for abnormal areas on x-rays. If suspicious areas are seen on this test, a colonoscopy will be needed to explore them further.

Before the test: As with colonoscopy, it is very important that the colon and rectum are empty and clean so your doctor can see them during the test. Your doctor will give you specific instructions on preparing for the test. Be sure to follow them. For example, you may be asked to clean your bowel the night before with laxatives and/or use enemas the morning of the exam. You will likely be asked to follow a clear liquid diet for a day or 2 before the procedure. You may also be told to avoid eating or drinking dairy products the day before the test, and to not eat or drink anything after midnight on the night before the procedure. Many people consider the bowel preparation to be the most unpleasant part of the test, as it usually requires you to be in the bathroom quite a bit.

During the test: The procedure takes about 30 to 45 minutes, and does not require sedation. For this test, you lie on a table on your side in an x-ray room. A small, flexible tube is inserted into the rectum, and barium sulfate is pumped in to partially fill and open up the colon. When the colon is about half-full of barium, you are turned over on the x-ray table so the barium spreads throughout the colon. Then air is pumped into the colon through the same tube to make it expand. This may cause some cramping and discomfort, and you may feel the urge to have a bowel movement.

X-ray pictures of the lining of your colon are then taken, allowing the doctor to look for polyps or cancers. You may be asked to change positions so that different views of the colon and rectum can be seen on the x-rays.

If polyps or other suspicious areas are seen on this test, a colonoscopy will likely be needed to remove them or to explore them fully.

Possible side effects and complications: You may have bloating or cramping after the test, and will probably feel the need to empty your bowels soon after the test is done. The barium can cause constipation for a few days, and your stool may appear grey or white until the barium leaves the body. There is a very small risk that inflating the colon with air could injure or puncture the colon, but this risk is thought to be much less than with colonoscopy. Like other x-ray tests, this test also exposes you to a small amount of radiation.

CT colonography (virtual colonoscopy)

This test is an advanced type of computed tomography (CT or CAT) scan of the colon and rectum. A CT scan is an x-ray test that produces detailed cross-sectional images of your body. Instead of taking one picture, like a regular x-ray, a CT scanner takes many pictures as it rotates around you while you lie on a table. A computer then combines these pictures into images of slices of the part of your body being studied.

For CT colonography, special computer programs create both 2-dimensional x-ray pictures and a 3-dimensional "fly-through" view of the inside of the colon and rectum, which lets the doctor look for polyps or cancer.

This test may be especially useful for some people who can't have or don't want to have more invasive tests such as colonoscopy. It can be done fairly quickly and does not require sedation. But even though this test is not invasive like colonoscopy, it still requires the same type of bowel preparation and uses a tube placed in the rectum (similar to the tube used for barium enema) to fill the colon with air. Another possible drawback is that if polyps or other suspicious areas are seen on this test, a colonoscopy will still probably be needed to remove them or to explore them fully.

Before the test: It is important that the colon and rectum are emptied before this test to provide the best images. This is why the preparation for this test is similar to that for a double-contrast barium enema or colonoscopy. You will probably be told to follow a clear liquid diet for a day or 2 before the test. You will also be given instructions for taking strong laxatives and/or enemas the night before or morning of the exam. You will probably be in the bathroom quite a bit.

During the test: This test is done in a special room with a CT scanner, and takes about 10 minutes. You may be asked to drink a contrast solution before the test to help "tag" any remaining stool in the colon or rectum, which helps the doctor when looking at the test images. You will be asked to lie on a thin table that is part of the CT scanner, and will have a small, flexible tube inserted into your rectum. Air is pumped through the tube into the colon to expand it to provide better images. The table then slides into the CT scanner, and you will be asked to hold your breath while the scan takes place. You will likely have 2 scans: one while you are lying on your back and one while you are on your stomach. Each scan typically takes only about 10 to 15 seconds.

Possible side effects and complications: There are usually very few side effects after CT colonography. You may feel bloated or have cramps because of the air in the colon, but this should go away once the air passes from the body. There is a very small risk that inflating the colon with air could injure or puncture the colon, but this risk is thought to be much less than with colonoscopy. Like other types of CT scans, this test also exposes you to a small amount of radiation.

Tests that mainly find colorectal cancer

These tests examine the stool to look for signs of cancer. Most people find these tests easier because they are not invasive and can often be done at home. But they are not as good at detecting polyps as the tests described above, and a positive result on one of these screening tests will probably require a more invasive test such as colonoscopy.

Fecal occult blood test

The fecal occult blood test (FOBT) is used to find occult blood (blood that can't be seen with the naked eye) in feces. The idea behind this test is that blood vessels at the surface of larger colorectal polyps or cancers are often fragile and easily damaged by the passage of feces. The damaged vessels usually release a small amount of blood into the feces, but only rarely is there enough bleeding for blood to be visible in the stool.

The FOBT detects blood in the stool through a chemical reaction. This test cannot tell whether the blood is from the colon or from other parts of the digestive tract (such as the stomach). If this test is positive, a colonoscopy is needed to find the cause of bleeding. Although cancers and polyps can cause blood in the stool, other causes of bleeding may occur, such as ulcers, hemorrhoids, diverticulosis (tiny pouches that form at weak spots in the colon wall), or inflammatory bowel disease (colitis).

This screening test is done with a kit that you can use in the privacy of your own home. Using this kit lets your doctor check more than one stool sample, which is important for screening. An FOBT done during a digital rectal exam in the doctor's office is not sufficient for screening because it only checks one stool sample. Unlike some other screening tests (like colonoscopy), this one must be repeated every year.

People having this test will receive a kit with instructions from their doctor's office or clinic. The kit will explain how to take a stool or feces sample at home (usually specimens from 3 consecutive bowel movements that are smeared onto small squares of paper). The kit should then be returned to the doctor's office or medical lab (usually within 2 weeks) for testing. Read on for more details.

Before the test: Some foods or drugs can affect the test, so your doctor might suggest you avoid the following before this test:

• Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen (Advil), naproxen (Aleve), or aspirin (more than 1 adult aspirin per day), for 7 days before testing. (They can cause bleeding, which can lead to a false-positive result.) Acetaminophen (Tylenol®) can be taken as needed.
• Vitamin C in excess of 250 mg daily from either supplements or citrus fruits and juices for 3 days before testing. (This can affect the chemicals in the test and make the result appear negative, even when blood is present.)
• Red meats (beef, lamb, or liver) for 3 days before testing (Components of blood in the meat may cause the test to show positive.)

Some people who are given the test never do it or don't give it to their doctor because they worry that something they ate may interfere with the test. For this reason, many doctors tell their patients it isn't essential to follow any restrictions in their diet. The most important thing is to get the test done. People should try to avoid taking aspirin or related drugs for minor aches. But if you take these medicines daily for heart problems or other conditions, don't stop them for this test without talking to your doctor first.

Collecting the samples: Have all of your supplies ready and in one place. Supplies will include a test kit, test cards, either a brush or wooden applicator, and a mailing envelope. The kit will give you detailed instructions on how to collect the specimen. The instructions below can be used as a guide, but your kit instructions might be a little different. Always follow the instructions on your kit.

• You will need to collect a sample from your bowel movement. You can place a sheet of plastic wrap or paper loosely across the toilet bowl to catch the stool or you can use a dry container to collect the stool. Do not let the stool specimen mix with urine. After you obtain a sample, you can flush the remaining stool down the toilet.
• Use a wooden applicator or a brush to smear a thin film of the stool sample onto one of the slots in the test card or slide.
• Next, collect a specimen from a different area of the same stool and smear a thin film of the sample onto the other slot in the test card or slide.
• Close the slots and put your name and the date on the test kit. Store the kit overnight in a paper envelope to allow it time to dry.
• Repeat the test on your next 2 bowel movements as instructed. Most tests require collecting more than one sample from different bowel movements. This improves the accuracy of the test because many cancers don't bleed all of time, and blood may not be present in all stool samples.
• Place the test kit in the mailing pouch provided and return it to your doctor or lab as soon as possible (but within 14 days of taking the first sample).

If this test finds blood, a colonoscopy will be needed to look for the source. It is not sufficient to simply repeat the FOBT or follow up with other types of tests.

Fecal immunochemical test

The fecal immunochemical test (FIT), also called an immunochemical fecal occult blood test (iFOBT), is a newer kind of test that also detects occult (hidden) blood in the stool. This test reacts to part of the human hemoglobin protein, which is found in red blood cells.

The FIT is done essentially the same way as the FOBT, but some people may find it easier to use because there are no drug or dietary restrictions (vitamins or foods do not affect the FIT) and sample collection may take less effort. This test is also less likely to react to bleeding from parts of the upper digestive tract, such as the stomach.

The FIT, like the FOBT, may not detect a tumor that is not bleeding, so multiple stool samples still should be tested. And if the results are positive for hidden blood, a colonoscopy is required to investigate further. In order to be beneficial, the test must be repeated every year.

Collecting the samples: Have all of your supplies ready and in one place. Supplies will include a test kit, test cards, long brushes, waste bags, and a mailing envelope. The kit will give you detailed instructions on how to collect the specimen. The instructions below can be used as a guide, but the instructions on your kit might be a little different. Always follow the instructions on your kit.

• Flush the toilet before your bowel movement. After you go, place used toilet paper in the waste bag from the kit, not in the toilet.
• Brush the surface of the stool with one of the brushes, then dip the brush in the toilet water. Dab the end of the brush onto one of the slots in the test card or slide.
• Close the slot and put your name and the date on the test kit.
• Repeat the test on your next bowel movement if instructed. Most tests require collecting more than one sample from different bowel movements. This improves the accuracy of the test because many cancers don't bleed all of the time, and blood may not be present in all stool samples.
• Place the test kit in the mailing envelope provided and return it to your doctor or lab as soon as possible (but within 14 days of taking the first sample).

Stool DNA tests

Instead of looking for blood in the stool, these tests look for certain abnormal sections of DNA (genetic material) from cancer or polyp cells. Colorectal cancer cells often contain DNA mutations (changes) in certain genes. Cells from colorectal cancers or polyps with these mutations are often shed in stool, where tests may be able to detect them.

Although stool DNA tests have been used for colorectal screening in the past, they are no longer available in the US.

What are some of the pros and cons of these screening tests?

Test	Pros		Cons
Flexible sigmoidoscopy		Fairly quick and safe Usually doesn't require full bowel preparation Sedation usually not used Does not require a specialist Done every 5 years		Views only about a third of the colon Can miss small polyps Can't remove all polyps May be some discomfort Very small risk of bleeding, infection, or bowel tear Colonoscopy will be needed if abnormal
Colonoscopy		Can usually view entire colon Can biopsy and remove polyps Done every 10 years Can diagnose other diseases		Can miss small polyps Full bowel preparation needed More expensive on a one-time basis than other forms of testing Sedation of some kind is usually needed Will need someone to drive you home You may miss a day of work Small risk of bleeding, bowel tears, or infection
Double-contrast barium enema (DCBE)		Can usually view entire colon Relatively safe Done every 5 years No sedation needed		Can miss small polyps Full bowel preparation needed Some false positive test results Cannot remove polyps during testing Colonoscopy will be needed if abnormal
CT colonography (virtual colonoscopy)		Fairly quick and safe Can usually view entire colon Done every 5 years No sedation needed		Can miss small polyps Full bowel preparation needed Some false positive test results Cannot remove polyps during testing Colonoscopy will be needed if abnormal Still fairly new -- may be insurance issues
Fecal occult blood test (FOBT)		No direct risk to the colon No bowel preparation Sampling done at home Inexpensive		May miss many polyps and some cancers May produce false-positive test results May have pre-test dietary limitations Should be done every year Colonoscopy will be needed if abnormal
Fecal immunochemical test (FIT)		No direct risk to the colon No bowel preparation No pre-test dietary restrictions Sampling done at home Fairly inexpensive		May miss many polyps and some cancers May produce false-positive test results Should be done every year Colonoscopy will be needed if abnormal

Acid Reflux/GERD Surgery Options

Your doctor first may recommend dietary and lifestyle changes if you have chronic acid reflux, heartburn, or other signs and symptoms of gastroesophageal reflux disease (GERD). Often, simply changing what you eat or the way you sleep can significantly reduce or eliminate GERD symptoms.

Some doctors may recommend certain medications if lifestyle management fails to solve the problem. These usually start with over-the-counter antacids and progress to prescription medicines that reduce or stop acid production in the stomach.

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Patients who see no improvement through lifestyle changes or use of medications may require a third tier of treatment: surgery. Surgery to prevent reflux often involves creating a “valve” where your esophagus and stomach meet to prevent stomach acids from re-entering the esophagus.

Your doctor may recommend surgery in cases of serious GERD complications. For example, stomach acid can cause inflammation of the esophagus, leading to bleeding or ulcers. Scars from tissue damage can constrict the esophagus and make swallowing difficult.

Untreated GERD can also develop into a pre-cancerous condition called “Barrett’s esophagus,” which can lead to cancer over time. There are several surgical options that may help to relieve GERD symptoms and manage complications.

Fundoplication

The standard surgical treatment for GERD is called fundoplication—specifically, Nissen fundoplication. This anti-reflux surgery involves tightening and reinforcing the lower esophageal sphincter. The surgeon will wrap the upper part of the stomach around the outside of the lower esophagus to strengthen the sphincter and prevent reflux.

Fundoplication can be performed as an open surgery, in which the surgeon makes a long incision in your stomach to access the esophagus. It can also be performed as laproscopic surgery, in which the surgeon makes several smaller incisions in your abdomen. The surgeon inserts instruments that hold a tiny camera (endoscope) into the incisions to guide the procedure.

Esophyx Surgery

An Esophyx procedure may be recommended if your doctor determines that fundoplication isn’t right for you. This type of surgery creates a barrier between the stomach and the esophagus to prevent reflux of stomach acid.

During the procedure, the surgeon inserts a device called an Esophyx through your mouth into the stomach to fold the tissue at its base. This creates a replacement for the sphincter that keeps acid from washing into your esophagus. Research is ongoing to determine which types of patients are best suited for this procedure.

Stretta Procedure

Stretta procedure uses an endoscopic device along with electrode energy to heat your esophageal tissue and create tiny cuts in it. The cuts form scar tissue in the esophagus, damaging the nerves that respond to refluxed acid.

The scar tissue that forms as your esophagus heals also helps strengthen the surrounding muscles, improving reflux symptoms. As with Esophyx surgery, researchers are still trying to determine who is best suited for this type of treatment.

Bard EndoCinch System

This system uses an endoscopic device approved by the Food and Drug Administration (FDA) to treat chronic heartburn. The system works by stitching the lower esophageal sphincter. These stitches create small pleats that help strengthen the muscle. The Cleveland Clinic notes that the long-term effects of both the Stretta procedure and the Bard EndoCinch system are yet unknown.

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Linx Surgery

Linx type of surgery involves a new device that the FDA has recently approved to help strengthen the lower esophageal sphincter. A surgeon wraps the Linx device—a ring of tiny magnetic titanium beads—around the junction of your stomach and esophagus during this minimally invasive procedure.

Because the beads are magnetized, they move together to keep the opening between the stomach and esophagus closed to refluxing acid, but allows food to pass through normally.

Enteryx Implant

The FDA recently approved an implant that may help people with GERD avoid more invasive surgery. In this procedure, Enteryx solution is injected during endoscopy. The solution becomes spongy, providing reinforcement to the lower esophageal sphincter to keep stomach acid out of the esophagus. The implant is specified for use by GERD patients who require a class of drugs called proton pump inhibitors (PPIs).

Surgery should be a last resort option used only when diet modification, lifestyle changes, and medicine fail to relieve symptoms of GERD. Surgery may also offer a preferable alternative to a lifetime managing drugs and discomfort. Speak with your doctor for guidance on the best approach to manage and treat your specific condition.

Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease, or GERD, is a digestive disorder that affects the lower esophageal sphincter (LES), the ring of muscle between the esophagus and stomach. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GERD. Doctors believe that some people suffer from GERD due to a condition called hiatal hernia. In most cases, heartburn can be relieved through diet and lifestyle changes; however, some people may require medication or surgery. 

What Is Gastroesophageal Reflux?

Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach's contents back up into the esophagus.

In normal digestion, the lower esophageal sphincter (LES) opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately, allowing the stomach's contents to flow up into the esophagus. 

The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva.

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What Is the Role of Hiatal Hernia in GERD?

Some doctors believe a hiatal hernia may weaken the LES and increase the risk for gastroesophageal reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the abdomen from the chest. Recent studies show that the opening in the diaphragm helps the support lower end of the esophagus. Many people with a hiatal hernia will not have problems with heartburn or reflux. But having a hiatal hernia may allow stomach contents to reflux more easily into the esophagus.

Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.

Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, called a paraesophageal hernia) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

What Other Factors Contribute to GERD?

Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee, or alcoholic beverages, may trigger reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also play a role in GERD symptoms.

Laparoscopic Cholecystectomy

What is laparoscopic cholecystectomy?

The surgery to remove the gallbladder is called a cholecystectomy (chol-e-cys-tec-to-my). The gallbladder is removed through a 5 to 8 inch long incision, or cut, in your abdomen. The cut is made just below your ribs on the right side and goes to just below your waist. This is called open cholecystectomy.

A less invasive way to remove the gallbladder is called laparoscopic cholecystectomy. This surgery uses a laparoscope (an instrument used to see the inside of your body) to remove the gallbladder. It is performed through several small incisions rather than through one large incision.

What is a laparoscope and how is it used to remove the gallbladder?

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A laparoscope is a small, thin tube that is put into your body through a tiny cut made just below your navel. Your surgeon can then see your gallbladder on a television screen and do the surgery with tools inserted in three other small cuts made in the right upper part of your abdomen. Your gallbladder is then taken out through one of the incisions.

Are there any benefits of laparoscopic cholecystectomy compared with open cholecystectomy?

With laparoscopic cholecystectomy, you may return to work sooner, have less pain after surgery, and have a shorter hospital stay and a shorter recovery time. Surgery to remove the gallbladder with a laparoscope does not require that the muscles of your abdomen be cut, as they are in open surgery. The incision is much smaller, which makes recovery go quicker.

With laparoscopic cholecystectomy, you probably will only have to stay in the hospital overnight. With open cholecystectomy, you would have to stay in the hospital for about five days. Because the incisions are smaller with laparoscopic cholecystectomy, there isn't as much pain after this operation as after open cholecystectomy.

Is there any reason why I wouldn't be able to have a laparoscopic cholecystectomy?

If you have previously had surgery in the area of your gallbladder, if you tend to bleed a lot or if you have any problem that would make it hard for your doctor to see your gallbladder, an open surgery may be better for you. Your doctor will decide which type of surgery is best for you.

What are the complications of laparoscopic cholecystectomy?

Complications may include bleeding, infection and injury to the duct (tube) that carries bile from your gallbladder to your stomach. Also, during laparoscopic cholecystectomy, the intestines or major blood vessels may be injured when the instruments are inserted into the abdomen. All of these complications are rare.

Cholecystectomy Index

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Cholecystectomy is surgery to removed the gallbladder. A laparoscopic cholecystectomy is a less invasive way to remove the gallbladder using a laparoscope. Benefits of the laparoscopic cholecystectomy is a shorter recovery time.

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Colorectal Polyps and Cancer

Colorectal cancer is the third leading cause of cancer deaths among American men and women. These cancers arise from the inner lining of the large intestine, also known as the colon. Tumors may also arise from the inner lining of the very last part of the digestive tract, called the rectum.

Unfortunately, most colorectal cancers are "silent" tumors. They grow slowly and often do not produce symptoms until they reach a large size. Fortunately, colorectal cancer is preventable, and curable, if detected early.

How Does Colorectal Cancer Develop?

Colorectal cancer usually begins as a "polyp," a nonspecific term to describe a growth on the inner surface of the colon. Polyps are often non-cancerous growths but some can develop into cancer.

The two most common types of polyps found in the colon and rectum include:

• Hyperplastic and inflammatory polyps. Usually these polyps do not carry a risk of developing into cancer. However, large hyperplastic polyps, especially on the right side of the colon, are of concern and should be completely removed.
• Adenomas or adenomatous polyps. Polyps, which, if left alone, could turn into colon cancer. These are considered pre-cancerous.

Although most colorectal polyps do not become cancer, virtually all colon and rectal cancers start from these growths. People may inherit diseases in which the risk of colon polyps and cancer is very high. 

Colorectal cancer may also develop from areas of abnormal cells in the lining of the colon or rectum. This area of abnormal cells is called dysplasia and is more commonly seen in people with certain inflammatory diseases of the bowel such as Crohn's disease or ulcerative colitis.

What Are the Risk Factors for Colorectal Cancer?

While anyone can get colorectal cancer, it is most common among people over age 50. Risk factors for colorectal cancer include:

• A personal or family history of colorectal cancer or polyps
• A diet high in red meats and processed meats
• Inflammatory bowel disease (Crohn's disease or ulcerative colitis)
• Inherited conditions such as familial adenomatous polyposis and hereditary non-polyposis colon cancer
• Obesity
• Smoking
• Physical inactivity
• Heavy alcohol use
• Type 2 diabetes

Types of biopsy procedures

Each type of biopsy has pros and cons. The choice of which type to use depends on your situation. Some of the things your doctor will consider include how suspicious the tumor looks, how big it is, where it is in the breast, how many tumors there are, other medical problems you might have, and your personal preferences. You might want to talk to your doctor about the pros and cons of different biopsy types.

Fine needle aspiration biopsy

In fine needle aspiration biopsy (FNAB), the doctor (a pathologist, radiologist, or surgeon) uses a very thin needle attached to a syringe to withdraw (aspirate) a small amount of tissue from the suspicious area. This tissue is then looked at under a microscope. The needle used for FNAB is thinner than the ones used for blood tests.

If the area to be biopsied can be felt, the doctor locates the lump or suspicious area and guides the needle there. If the lump can’t be felt, the doctor might use ultrasound to watch the needle on a screen as it moves toward and into the mass. (This is called an ultrasound-guided biopsy.) Or, the doctor may use a method called stereotactic needle biopsy to guide the needle. For a stereotactic needle biopsy, computers map the exact location of the mass using mammograms taken from 2 angles. This helps the doctor guide the needle to the right spot.

The doctor may or may not use a numbing medicine (called a local anesthetic). The needle used for the biopsy is so thin that getting the medicine may hurt more than the biopsy itself.

Once the needle is in place, fluid or tissue is drawn out. If clear fluid is withdrawn, the lump is more likely a benign cyst (not cancer). Bloody or cloudy fluid can mean either a benign cyst or, less often, cancer. If the lump is solid, small pieces of tissue are drawn out. A pathologist (a doctor who is expert in diagnosing disease from tissue samples) will look at the biopsy tissue or fluid under a microscope to find out if it’s cancer.

A fine needle aspiration biopsy can sometimes miss cancer if the needle does not get a tissue sample from the area of cancer cells. If it does not give a clear diagnosis, or your doctor still has concerns, a second biopsy or a different type of biopsy should be done.

If you are still having menstrual periods (that is, if you are pre-menopausal), you most likely know that breast lumpiness can come and go each month with your menstrual cycle. If you have a breast lump that needs to be checked, the doctor will start by taking your history and doing a physical exam, and then setting up breast imaging. If you have a lump that doesn’t go away, or the collected information doesn’t clearly tell what the problem is, the doctor may want to do a fine needle aspiration biopsy to see if it’s a cyst (a fluid-filled sac) or a solid growth (mass or tumor). If an aspiration is done and the lump goes away after it’s drained, it usually means it was a cyst and not cancer. Again, most breast lumps are not cancer.

Talk to your doctor about what type of biopsy is best for you and what you can expect it to be like.

Core needle biopsy

A core needle biopsy (CNB) is much like an FNAB. A slightly larger, hollow needle is used to withdraw small cylinders (or cores) of tissue from the abnormal area in the breast. CNB is most often done in the doctor’s office with local anesthesia (you are awake but your breast is numbed). The needle is put in 3 to 6 times to get the samples, or cores. This takes longer than an FNAB, but it’s more likely to give a clear result because more tissue is taken to be checked. CNB can cause some bruising, but usually does not leave scars inside or outside the breast.

The doctor doing the CNB usually places the needle in the abnormal area using image guidance (ultrasound or x-rays) to be sure it’s in the right place. If the area is easily felt on physical exam, the biopsy needle may be guided into the mass while feeling (palpating) the lump.

Stereotactic core needle biopsy

A stereotactic core needle biopsy uses x-ray equipment and a computer to analyze the pictures (x-ray views). The computer then pinpoints exactly where in the abnormal area the needle tip needs to go. This is often done to biopsy suspicious microcalcifications (tiny calcium deposits) when no mass can be felt or seen on ultrasound.

Vacuum-assisted core biopsy

Vacuum-assisted biopsies can be done with systems like the Mammotome^® or ATEC^® (Automated Tissue Excision and Collection). For these procedures the skin is numbed and a small cut (less than ¼ inch) is made. A hollow probe is put in through the cut and guided into the abnormal area of breast tissue using x-rays, ultrasound, or MRI. A cylinder of tissue is then pulled into the probe through a hole in its side, and a rotating knife inside the probe cuts the tissue sample from the rest of the breast.

These methods allow multiple tissue samples to be removed through one small opening. They are also able to remove more tissue than a standard core biopsy. Vacuum-assisted core biopsies are done in outpatient settings. No stitches are needed, and there is usually very little scarring.

Magnetic resonance imaging (MRI) guided biopsy: Sometimes the biopsy is guided by an MRI, for instance, with the ATEC system discussed above. You lay face down on a special table with an opening that your breast fits into. Computers are then used to find the tumor, plot its location, and help aim the probe into the tumor. This is helpful for women with a suspicious area that can only be found by MRI.

Surgical (open) biopsy

Most doctors will first try to figure out the cause of a breast change by doing a needle biopsy, but in some cases a surgical biopsy may be recommended. A surgical biopsy is done by cutting the breast to take out all or part of the lump so it can be looked at under the microscope. This may also be called an open biopsy. There are 2 types: incisional biopsies and excisional biopsies.

• An incisional biopsy removes only part of the suspicious area, enough to make a diagnosis.
• An excisional biopsy removes the entire mass or abnormal area, with or without trying to take out an edge of normal breast tissue (it depends on the reason for the excisional biopsy).

In rare cases, a surgical biopsy can be done in the doctor’s office, but it’s more often done in the hospital’s outpatient department under local anesthesia (you are awake, but your breast is numb). You may also be given medicine to make you sleepy. This type of biopsy can also be done under general anesthesia (you are given drugs to put you into a deep sleep so that you don’t feel any pain).

The surgeon may use a procedure called wire localization to do an open biopsy if there is a small lump that is hard to find by touch, or if an area looks suspicious on the mammogram but cannot be felt. For wire localization, the breast is numbed with local anesthetic and a thin, hollow needle is put into the breast while x-rays are used to guide it to the suspicious area. A very thin wire is put in through the center of the needle. A small hook at the end of the wire keeps it in place. The hollow needle is then removed, and the wire is left to guide the surgeon to the abnormal area.

A surgical biopsy is more involved than a fine needle aspiration or a core needle biopsy. Stitches are often needed and it will leave a scar. The more tissue removed, the more likely it is that you will notice a change in the shape of your breast. Your doctor will tell you how to care for the biopsy site and what you can and can’t do while it heals.

All biopsies can cause bleeding and swelling. This can make it seem like the breast lump is bigger after the biopsy. This is usually nothing to worry about and the bleeding and bruising go away quickly in most cases.

Biopsy markers

After the doctor has taken out all of the tissue samples needed, a very small, safe marker or clip may be put in your breast at the biopsy site. These clips are tiny, surgical-grade, metal devices that show up on mammograms and are used to mark the biopsy site. The clip cannot be felt and should not cause any problems. It’s used to mark the area in case changes show up on future mammograms.

For Women Facing a Breast Biopsy

Mary’s doctor calls to give her the results of her mammogram. The doctor says, “It’s not normal, and I think we need to biopsy the area in question.” Mary’s first thought is, “Could this be breast cancer?” When she asks, the doctor explains that a biopsy (taking out and testing tissue from the suspicious area of the breast) is the only way to find out.

Another woman, Peg, just found a lump in her breast. She knows that the lump wasn’t there last month. Her first thought: “I probably should see the doctor about this, but I’m pretty sure it isn’t cancer.”

Women react in different ways when they find out that something may be wrong with their breasts. Whatever their feelings and thoughts, at some point most women want to know more about what’s happening.

Women who have had breast lumps, suspicious mammograms, and breast biopsies helped write this. They have gone through something much like what you may be going through now.

Here we will explain the basics of benign (non-cancer) breast conditions, diagnostic tests (such as different types of biopsies), and breast cancer. You’ll also learn more about coping with your concerns and fears, and where to find emotional support. The information here should not take the place of talking to your doctor or nurse. There are many details that we cannot cover here, so in each section there’s a list of questions that you might want to discuss with your doctor and nurse.

We will explain many medical terms that you may hear during testing and diagnosis. As you learn these terms, you’ll better understand what is being said to you. Knowing what these terms mean can help you as you talk with your health care team. We also have a Breast Cancer Dictionary that many women and their doctors find very helpful. Call us at 1-800-227-2345 for a free copy.