Coloproctology

The Coloproctology Department of Dongguan People's Hospital was established at the Honglou campus in 2002 and is one of the hospital's second-level clinical departments. The department is staffed by 30 medical personnel, including 7 holding senior professional titles, 1 physician with doctoral training and 5 with master's training, and operates 42 open beds. Its average annual outpatient volume exceeds 20,000 visits, and there are 2,100 inpatient discharges per year. The department performs multiple operations for colorectal tumours every year, all completed with minimally invasive endoscopic (laparoscopic) techniques, and it has become a regional leader in the field of treatment for colorectal and anal diseases.

The department has advanced diagnostic and therapeutic equipment and a full range of examination methods. At present it possesses specialized equipment including an advanced electronic gastrointestinal endoscopy system, rectosigmoidoscopy, anorectal manometry equipment, a Traditional Chinese Medicine (TCM) herbal fumigation and washing therapy device, and a colonic hydrotherapy device, and carries out specialized featured examinations such as defecography, colonic transit studies, and endorectal color Doppler ultrasound.

After years of development, the department's diagnostic and therapeutic scope has expanded from the treatment of simple benign anal diseases to the diagnosis and treatment of benign and malignant colorectal diseases. In particular, with the introduction of laparoscopic radical surgery for colon and rectal cancer and of high-level operations such as difficult pelvic multivisceral resection, pelvic lateral lymph node dissection, total colectomy, transanal radical resection of rectal cancer (TaTME), and repair of congenital anal malformations, the department has risen to reach an advanced level within China.

The department persists in putting patients at the centre and vigorously develops painless minimally invasive surgery, having launched several new minimally invasive techniques, including stapled selective resection of hemorrhoidal mucosa, ligation of the intersphincteric fistula tract, and transanal resection of rectal tumours with an ultrasonic scalpel. These minimally invasive treatments offer the advantages of less trauma, faster recovery and fewer complications, substantially reducing the surgical burden on patients.

In 2018, acting on the initiative of the hospital leadership and the medical affairs department, and following study and a decision by the standing committee of the Colorectal and Anal Disease Branch of the Dongguan Medical Association, the department took the lead in founding the Dongguan Anorectal Specialty Alliance, which is composed of 35 partner institutions and brings together a group of the city's first-class authoritative anorectal experts, academic leaders, and young and middle-aged technical backbone staff. This has achieved true full coverage of the regional specialty medical consortium in Dongguan, and in accordance with the tiered diagnosis and treatment system requirements of the health commission, the department strives to build a treatment pattern in which “minor illnesses are treated within the district and major illnesses within the city.”

In order to remain in step with frontier concepts and techniques, the department has repeatedly sent medical personnel to well-known hospitals for advanced training, including the Sixth Affiliated Hospital of Sun Yat-sen University (Guangdong Provincial Gastrointestinal and Anorectal Hospital), Guangdong Provincial Hospital of Traditional Chinese Medicine, and affiliated hospitals of Southern Medical University. Its staff actively participate in various domestic academic conferences on anorectal diseases and keep abreast of the latest developments in diagnosis and treatment in the field of anorectal diseases, bringing advanced technology and management concepts back and applying them to the improvement of the department.

Scope of Diagnosis and Treatment

Colorectal diseases - Colorectal cancer, colorectal polyps, ulcerative colitis, ischemic colitis, radiation enteritis, Crohn's disease, rectal prolapse, rectal trauma, rectocele, slow-transit colorectal constipation, irritable bowel syndrome, lower gastrointestinal bleeding, and others.

Anal and perianal diseases - Mixed hemorrhoids, anal fistula, perianal abscess, anal fissure, anal canal polyps, anal eczema, anal excrescences, hidradenitis suppurativa, anal trauma, anal stenosis, anal incontinence, anoperineal fistula, and others.

Pelvic floor and other diseases - Descending perineum syndrome, spastic pelvic floor syndrome, puborectalis syndrome, presacral tumours, ischial tuberosity cysts, necrotizing fasciitis, pilonidal sinus, and others.

Featured Nursing Care

In the past two years the department has introduced TCM-featured treatments, applying TCM pattern differentiation and treatment together with measures such as herbal compress packs, moxibustion, auricular acupuncture, wrist-ankle acupuncture and acupoint blockade, which improved treatment outcomes, also reduced complications in patients, and improved patients' quality of life.

In the past two years the department has established pain-free wards and provides enhanced recovery nursing care. For example, on the first day after colorectal cancer surgery patients are encouraged to get out of bed and mobilize, and depending on their situation they resume eating and have their tubes removed as early as possible, enabling faster recovery and achieving higher-quality nursing care.

The department actively develops pain-free wards and uses a pain rating ruler to assess patients' postoperative pain. Based on several grades — no pain, mild pain, pain, severe pain — targeted pain intervention measures are taken to reduce patients' pain and improve their satisfaction.

In addition, the department provides a bedside tablet system and uses an information-based nursing platform to broaden medical education and, at any time, make it convenient for patients to communicate promptly with medical and nursing staff; it has also launched self-service functions such as checking charges.

Featured New Techniques

Laparoscopic-assisted transanal total mesorectal excision (TaTME) for rectal cancer For some patients with a difficult pelvis, conventional laparoscopic or open radical surgery for rectal cancer makes exposure difficult and the operative manipulation demanding. Because it is difficult to judge accurately the distal resection margin of the specimen, this may create such risks as poor completeness of resection or residual cancer, and may even make it impossible to preserve the anus.

TaTME can precisely transect the distal rectum from within the rectal lumen under direct vision or with endoscopic assistance, ensuring the safety of the distal resection margin of the surgical specimen. Using a transanal approach into the pelvis, the operation allows more direct entry into the spaces around the mesorectum of the low rectum and relatively simple mobilization and resection of the distal mesorectum, which helps better ensure the safety of the circumferential resection margin (CRM) of the specimen, obtain a higher-quality surgical resection specimen, and thereby reduce the risk of local recurrence for rectal cancer patients.

TaTME requires no additional abdominal incision for specimen extraction; the specimen can be removed transanally and reconstruction of the digestive tract completed, in keeping with the NOTES concept, with better minimally invasive and cosmetic results. In addition, it avoids the multiple firings of the laparoscopic linear cutting stapler required for the transabdominal transection of the rectum, which can reduce the incidence of anastomotic leakage.

Moreover, because TaTME uses fewer mechanical stapling instruments, it also means that patients' financial burden can be lowered, giving good economic benefits: while patients receive treatment that is more minimally invasive and more cosmetically satisfactory, their economic burden is reduced.

Laparoscopic D+C radical surgery for colon and rectal cancer According to the department, the route taken in its laparoscopic colorectal cancer surgery is not the series of straight lines drawn along blood vessels and organs as described by traditional anatomy, but rather travels between the “membranes” at the borders of the organs; as if following the vine to find the melon, it locates the tumour to be resected and its boundary, and removes the membrane together with the tumour it envelops “in one pot,” causing no injury whatsoever to surrounding tissues, with tumour removal achieved at almost zero bleeding.

Laparoscopic extreme sphincter-preserving surgery (ISR) for rectal cancer Laparoscopic intersphincteric resection for the treatment of low rectal cancer is currently a new technique among sphincter-preserving procedures. Apart from a few puncture ports, the patient has no scars on the abdomen; recovery is fast and there is no wound pain, genuinely achieving a minimally invasive effect. At the same time, the intestinal tube is drawn out through the anus for anastomosis, with almost no anastomotic leakage, and because no stapler is used the costs are lower, which makes the procedure very welcome among patients. However, this technique places very high demands on the surgeon and requires an extremely clear grasp of anorectal anatomy.

Skin grafting for perianal hidradenitis suppurativa Hidradenitis suppurativa, also called apocrine gland inflammation, is a wide-ranging inflammatory disease formed within the dermis and subcutaneous tissue after infection of the apocrine glands located deep in the dermis. It is most often seen in young and middle-aged men and, in Chinese medicine, belongs to the categories of “honeycomb fistula” and “threading-buttocks fistula.”

Modern medicine holds that gluteal hidradenitis suppurativa arises from obstruction and infection at the openings of the gluteal apocrine glands, causing glandular ducts to rupture and producing recurrent inflammation within the dermis and even in the subcutaneous tissue, eventually forming abscesses, sinuses, cutaneous fistulas and scars. Because the extent of the lesion is large, patients have substantial skin defects after surgical excision and the wounds are difficult to heal by first intention. In recent years this department has adopted excision of gluteal hidradenitis suppurativa lesions plus stamp skin grafting to treat a number of such patients, all of whom attained first-intention healing, with no recurrence found.

Rapid recovery technique after colorectal cancer surgery Enhanced recovery after surgery (ERAS) adopts a series of optimized perioperative measures supported by evidence-based medicine in order to reduce the physiological and psychological trauma stress of surgical patients and achieve the aim of rapid recovery; it has also been a hotspot of clinical exploration in China in the past 10 years.

The main content of enhanced recovery includes preoperative patient education, optimized anesthesia, reduction of stress responses, intraoperative warming and prevention of deep vein thrombosis, and effective analgesia, together with intensified postoperative rehabilitation treatment including early mobilization and early enteral nutrition. Its core is the emphasis on a patient-centred diagnosis and treatment philosophy.

Enhanced recovery involves physicians, anesthesiologists, surgical nurses and other personnel, as well as multiple links such as nursing, nutrition, rehabilitation and hospital management, and cannot do without the cooperation of patients and their families. At present, the department has introduced enhanced recovery treatment to promote faster recovery for patients, reduce nursing costs, and improve patients' medical experience.

Stapled selective resection of hemorrhoidal mucosa (TST) Hemorrhoids are a common anal disease; the condition can occur at any age, and prevalence increases gradually with advancing age, making it the most common anal disease.

Stapled selective resection of hemorrhoidal mucosa follows the mechanism of hemorrhoid formation in the human body and is designed in accordance with the physiological and pathological structure of hemorrhoids, aiming to correct the pathophysiological changes of hemorrhoids. It selectively resects prolapsed and redundant rectal mucosa while preserving the normal anal cushions and mucosal bridges, reduces surgical trauma, maximally preserves fine sensation and contractile function of the anus, markedly reduces complications such as postoperative anal discomfort, shortens treatment time, and makes hemorrhoid surgery more minimally invasive.

This technique represents an improvement on stapled circumferential resection of hemorrhoidal mucosa (PPH); it effectively reduces patients' postoperative pain and offers multiple advantages including fewer complications, short recovery time and favourable efficacy.

Excision of the intersphincteric fistula tract Anal fistula, short for anorectal fistula, is a sequela resulting from the rupture of abscesses around the anorectum or from incision and drainage. Most anal fistulas cannot heal spontaneously: on the one hand, fecal residue can enter through the internal opening and cause infection of the fistula tract; on the other hand, because intersphincteric fistula tracts are compressed by the internal and external sphincters, necrotic tissue easily accumulates, drainage is poor, and recurrent infection results.

Excision of the intersphincteric fistula tract not only completely removes the channel through which fecal residue enters the anal fistula, but also eliminates the chance of cancerous change in the fistula tract. Operating through the intersphincteric approach causes no damage to either the internal or the external anal sphincter, thereby protecting anal function and markedly reducing complications such as postoperative pain, anal deformity and anal incontinence.

Transanal resection of rectal tumours Large benign tumours of the low rectum (mainly benign rectal polyps) are difficult to manage with endoscopic surgery, while abdominal surgery is more traumatic. The department removes large benign low rectal tumours through a natural orifice — the anus — with the aid of advanced tools such as laparoscopy, an ultrasonic scalpel and cutting-stapling devices, which has the advantages of fewer complications and preservation of anal function.

With this treatment technique, the intraoperative field of vision is clear, the size and shape of the mucosal resection are easy to control, and the en bloc resection rate is high, effectively reducing residual lesions and recurrence and facilitating accurate postoperative pathological evaluation; it achieves complete resection of early rectal tumours and significantly reduces the injury caused by traditional surgical operations. At the same time, because the procedure is minimally invasive, it is also suitable for elderly and frail patients who previously could not tolerate major surgery, thereby broadening the scope of treatable disease and bringing new hope of treatment to more patients.

Stapled transanal repair of rectocele (STARR) for constipation Rectocele, also known as rectal protrusion, is a common form of outlet obstructive constipation with a relatively high incidence among middle-aged and elderly women. Its main clinical manifestations are difficulty evacuating stool once it reaches the anal opening, so that the patient often needs to push on the perineum or vagina with the hand to assist defecation. Traditional open surgery for rectocele, with its small operative field and difficult manipulation, is often followed by complications such as incomplete repair, postoperative wound bleeding and infection.

The department adopts the STARR technique for treating rectocele, which can greatly reduce the technical difficulty of the operation, shorten operative time, and improve surgical safety.

Excision of pilonidal sinus with flap transfer Pilonidal sinus may occur anywhere from the occiput to the sacrococcygeal area, most commonly in the sacrococcygeal region; it is a chronic sinus or cyst within the soft tissue of the sacrococcygeal gluteal cleft, and harbouring hairs within it is its distinguishing feature. Because there is little subcutaneous tissue in the sacrococcygeal region, large wound defects often occur after surgery; in the past the wound had to be left open for drainage until it healed by scar, so postoperative recovery was prolonged, usually needing 1 to 2 months, which caused considerable inconvenience and suffering for patients.

After modifying the surgical procedure, the hospital's Coloproctology Department performs excision of pilonidal sinus with flap transfer, carrying out flap transfer at the first stage to repair the large surgical wound, thereby gaining the advantages of faster postoperative recovery (generally healing within 2 weeks) and less pain, and considerably lowering patients' treatment burden.

Stapled transanal rectal resection and anastomosis (STARR) Stapled transanal rectal resection and anastomosis uses two PPH staplers to resect separately the redundant and prolapsed mucosa and submucosa of the anterior and posterior rectal walls, reducing the width and depth of the rectocele. The anastomosis creates scar adhesion between the submucosa and the muscular layer, strengthening the anterior wall and lessening the degree of rectocele, thereby eliminating the pouch-like structure formed in the lower rectum during defecation, reconstructing the internal anatomical structure of the middle and lower rectum, and restoring normal rectal function.

Laparoscopic-assisted combined abdominosacral resection of presacral tumours Presacral tumours are tumours arising within the space between the sacrum and the rectum, also called retrorectal tumours. The pathological types of presacral tumours are highly diversified, but most tumours are benign; clinical manifestations include perianal masses, anal heaviness and bearing-down sensation, compressive symptoms, and others.

For the treatment of presacral tumours, conventional open surgery via the rectum or the abdomen has many drawbacks, including difficulty of exposure, extensive trauma, collateral injury and numerous complications. In order to reduce patients' trauma and psychological burden, the department adopts a laparoscopic-assisted combined abdominal and sacral approach, which not only overcomes the drawbacks of conventional surgery but also has the advantages of being less invasive and offering a good surgical field of vision, clean resection and fast recovery, raising patients' satisfaction with medical care.

Department case discussion Department ward round Director Li Xingqian conducting a specialist outpatient clinic