Archive of ‘Common Disorders’ category

Anal Fissures

Anal fissure are one of the most painful conditions seen in surgical practice.  Fissures develop from a tear in the lining of the anal mucosa, as a result of straining or constipation. Because of the exquisitely sensitive nature of the lining of the anal canal, fissures, or tears in the skin are typically incapacitating. Standard treatment includes a fiber supplement, copious fluids and topical smooth muscle relaxant such as nitroglycerin or nifedipine cream. Smooth muscle relaxants reduce pressure generated by the internal sphincter muscle, so minimizing pain during defecation.

If non surgical treatment of fissures fails, then conservative sphincter-sparing surgery may be appropriate.  Typically, surgeons divide the internal sphincter muscle during surgey, to relax the muscle and reduce discomfort. Research by dr Armstrong has demonstrated that removing scar tissue, tethering the fissure, relaxes the anal canal sufficiently so that the internal sphincter need not be divided. This avoids potential problems with anal incontinence, and other problems such as fistulas. The research performed was published in the surgical journal Dis Colon Rectumin 2013.

Pilonidal Disease

Pilonidal disease is one of the most common and challenging conditions in surgery. Pilonidal (pilo, hair; nidal, nest) is a collection of hairs which accumulate in the intergluteal cleft (above the tailbone), and form a cyst or collection of hairs beneath the skin. Human hair, the underlying source of pilonidal disease, contain microscopic barbs, or “hooks” on their surface, and once the hairs delve beneath the skin surface, they burrow deeper and deeper, forming the collection of hairs, or pilonidal cyst. Oddly enough, the culprit hairs may arise not from the hair around the cyst itself,  but from the patient’s own hair on their head, or even, rarely, their pets hair. One theory proposes that rubbing together of the gluteal muscles during walking, may act as a mini vacuum pump, and suck the hair into the locale, so setting up the scenario for a pilonidal cyst.



The cysts may become infected, and form an abscess, which requires surgical drainage. Although drainage of the abscess and excision of the cyst sound like simple procedures, healing may be problematic and prolonged. Recurrent pilonidal disease may emerge several years after excision. Dr. Armstrong recently described the use of a novel antibiotic compound to treat recurrent pilonidal disease, without the need to resort to surgery. The use of topical 10% metronidazole resulted in healing of recurrent or persistent pilonidal disease in 93% of patients, in a recent research paper submitted by Dr. Armstrong and his research team.

Anal Fistulas

Anal fistulas are one of the most common surgical condition encountered in modern surgical practice, and one of the

Fistulas have been known in mankind since ancient times: Excavation of the ruins of Pompeii, which erupted in 726, unearthed an ancient bronze ‘fistula probe”, in a site known as “The house of the surgeon”.  Improper treatment of fistulas can result in some of the most debilitating complications and a thorough knowledge of the problem is essential, to avoid complications.


Fistulas arise from a ring of glands, located in the lower rectum, known as the “Dentate line”. Once infection arises in one of these glands, an abscess may arise, which enlarges and results in pain, local swelling and fever Once the abscess drains, either spontaneously, or surgically, a residual tract results known as a fistula.

Anal Fistula

Surgical treatment of fistula depend on the depth of the tract: Simple, superficial fistulas may be treated by simple “laying open” or fistulotomy.


Deeper more complex fistulas require a stage approach, since they usually incorporate a significant amount of sphincter muscle, and dividing the muscle may result in some degree of anorectal incontinence.


The first stage in treating Complex fistula involve placing a small surgical drain or “seton” (Greek for “thread”), which typically remains in place for about 3 months.  Once the fistula tract has “matured”, the infection has subsided, and the swelling (edema) subsided, the final corrective procedure can be performed.

The final procedure depends on the depth of the tract: More superficial fistulas may be treated by fistulotomy, since the tract is typically more superficial after the seton has been in place for three months. The deeper tracts may require a biological, absorbable “Fistula Plug”, which is concerted into collagen tissue within the tract, and closes the fistula without cutting any tissue, and without risk of incontinence. The “Fistula Plug” was invented by Dr David Armstrong, and is used throughout the world.

Colon Cancer

Colorectal cancer is a cancer of the colon or rectum.  Starting as a polyp in the inner lining of the colon or rectum and growing to the center.  While most polyps are not cancer, certain types can become cancer.  Removing these polyps early may keep them from developing into cancer.

With more than 200,000 new cases each year, colon cancer is the third most common form cancer in America.

Colon cancer is unique amongst cancers in that it can be cured at an early stage, if discovered during colonoscopy as a polyp, and removed by the simple endoscopic procedure of polypectomy. Under these circumstances, (Stake I colon cancer), 5 and 10 year survival is very high.

Colon cancer and colon polyps. Polyps have the potential to turn into cancer if they remain in the colon. 

Colon cancer and colon polyps. Polyps have the potential to turn into cancer if they remain in the colon.

Colon cancer grows by invading through the colon wall and spreading through the lymphatic system, and is “staged” from the earliest polyps (Stage I), through the more advanced and invasive cancers (Stage IV). If left undiagnosed and unchecked, average survival rate for all stages of colon cancer (I through IV) is 70% at 5 years. Colon cancer is also a very slow growing malignancy: In vitro cell studies estimate that colon cancer takes 10 years to evolve from the earliest genetic defect, to a lesion which can be detected on endoscopy.

The single most important measure to prevent and cure colorectal cancer is the simple act of performing a colonoscopy by the age of 50, so long as there are no strong family history of the disease, and so long as an individual is not experiencing worrisome symptoms such as abdominal pain, a change in bowel habits, rectal bleeding or weight loss.  Every woman and man age 50 or over should have a colonoscopy.  Screening is important as four out of five people with colon cancer have no family history of it.

Colorectal Cancer

This is good news for five million Americans who turn fifty each year.  A colonoscopy is simple, safe and painless procedure when performed by a qualified and experienced surgeon. Absent severe symptoms, the chances of having a normal colon, without polyps or other serious findings are over 90%. If early stage polyps are found, they can be removed, with an almost 90% survival.  Follow up involves having a repeat colonoscopy every 5-10 years as it almost guarantees a life free of colon cancer.


Non Surgical Treatment of Internal Hemorrhoids

Rectal bleeding is one of the most common and worrisome surgical conditions encountered. In the vast majority of cases, rectal bleeding arises form “internal” hemorrhoids, which are vascular cushions (typically three in number), located within the lower rectum. Internal hemorrhoids are normal anatomic features in man, and act as mini “air-bags” under normal circumstances. If these internal hemorrhoids enlarge, due to chronic constipation, the hemorrhoids become engorged and bleed, resulting in rectal bleeding.

Adequate treatment of rectal bleeding requires two procedures: Colonoscopy, to exclude more serious sources of bleeding, such as cancer, polyps or diverticular disease), and “rubber band ligation” of the internal hemorrhoids. Both procedures may be performed at the same setting, making the procedure convenient, safe, and effective and with minimal discomfort.

Typically, humans have three internal hemorrhoids “3, 7 and 11 o’clock”, as seen on a on a clock face. Since rectal bleeding may arise from any one of the three internal hemorrhoids. Common sense dictates that all three should be ligated at the same time, to avoid returning on three separate occasions, to ligate one hemorrhoid at a time.

Traditionally, patients experiencing rectal bleeding undergo a colonoscopy, then return to the physician’s office three times, to undergo ligation of each individual hemorrhoid, once at a time. Dr Armstrong pioneered the procedure of “synchronous” colonoscopy, and three-quadrant hemorrhoidal ligation, performed at the same time, whilst still under sedation. This algorithm is safe, efficient and convenient for patients. Why come to the doctor’s office 4 times, when once will suffice?

After a colonoscopy, to exclude more serious pathology, all 3 internal hemorrhoids are ligated using a suction-ligator, wherein a tiny rubber band is placed around the base of each hemorrhoid, which cuts off the blood supply to hemorrhoid, which the shrivels-up, and drops off after roughly 10 days or so.

Colonoscopy and three quadrant hemorrhoidal ligation is safe, effective and convenient. Typically, patients experience very little discomfort and usually return to work the next day. Importantly, patients should avoid blood thinners, including aspirin, for about 10 days before and after the procedure, to avoid unnecessary bleeding.

Female HEMORRHOIDS concept anatomy x-ray posterior view

Female HEMORRHOIDS concept anatomy x-ray posterior view

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