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Physician Update - Spare the Sphincter

Physician Update Spring 2010

Spare the Sphincter

Date: May 1, 2010

In more cases than ever, colorectal surgeons can preserve function

Jonathan Efron
Colorectal surgeon Jonathan Efron is helping to reduce the need for permanent colostomy bags.

Up until recent years, people with cancers close to the anus faced a 40 percent chance of needing a permanent colostomy. That meant a lifelong commitment to an external bag for eliminating feces. But Johns Hopkins colorectal surgeon Jonathan Efron says a multidisciplinary approach has been making great strides.

“Full colostomies are becoming a rarity,” he says, now occurring in less than 10 percent of cases.

Efron attributes the gains to the rise of specialists in his field, along with neoadjuvant techniques to reduce tumor volumes in advance of surgical approaches that are also becoming more precise and effective. One of the optimal solutions, he says, is the “sphincter-sparing” technique that preserves a patient’s native anal muscles, allowing them to recover full bowel function. 

In the best cases, patients diagnosed with lower colorectal cancers who come to Hopkins expecting full colostomies can be upgraded to the sphincter-sparing procedures after a review by specialists ranging from radiation oncologists to medical oncologists to surgeons. Increasingly, says Efron, the team can devise a plan that reduces the tumor far enough to provide a working margin above the anal muscles.

If the adjuvant therapy is successful, Efron’s group performs a total mesorectal excision of the cancerous bowel, and will always remove lymph node tissues surrounding the rectum.

“We can also tolerate smaller margins distally,” says Efron. Where surgeons previously held the line at a full 2 centimeters, they will now allow down to 1 centimeter and, occasionally, down to 5 millimeters.

Part of the new tool chest, says Efron, is his group’s growing skill at hand-sewing anastomoses between a patient’s abdomen and anus, providing more room to save the anal muscles. When these procedures are successful, Efron says recovering patients might still go through a period of “low anterior resection syndrome,” where they might experience episodes of clustering of the waste, sensations of urgency and incomplete evacuation. In most cases, he says, “it gets better with time.”

Efron says his group performs one or two sphincter-sparing techniques every week, tapping the skills of three colorectal surgeons, along with a host of medical oncologists, radiation oncologists, enterostoma therapists and specialist nurse practitioners.

In his experience, Efron says, most working patients return to their jobs in about three to six months.

Call 410-933-1233 to refer a patient.

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