Colorectal Cancer Surgery

Cancer that begins in the colon is called colon cancer, and cancer that begins in the rectum is called rectal cancer. Together, they are often referred to as colorectal cancer.

The colon, along with the rectum, forms the large intestine, which is the lower part of the body’s digestive system. During digestion, food moves through the stomach and small intestine into the colon. The colon absorbs water and nutrients from the food and stores waste matter (stool). Stool moves from the colon into the rectum before it leaves the body.

Colorectal cancer often begins as a growth called a polyp, which may form on the inner wall of the colon or rectum. Some polyps become cancer over time. Finding and removing polyps can prevent colorectal cancer.

The type of treatment your doctor recommends will depend largely on the stage of your cancer. The three primary treatment options are surgery, chemotherapy and radiation.

 

Symptoms of colorectal cancer

In its early stage, colorectal cancer usually produces no symptoms. The most likely warning signs include:

  • Changes in bowel movements, including persistent constipation or diarrhoea
  • A feeling that your bowel does not empty completely
  • Rectal cramping or bleeding
  • Dark patches of blood in or on the stool; or long, thin, “pencil stools”
  • Abdominal discomfort or bloating
  • Unexplained fatigue, loss of appetite, and/or weight loss
  • Pelvic pain, which occurs at later stages of the disease

 

Diagnosis of colorectal cancer

If you have symptoms, your GP will refer you to specialists who treat colorectal cancer. You will be recommended one or more tests and procedures.

The traditional screening involves a digital rectal exam, during which, the doctor inserts a lubricated, gloved finger into the rectum to feel for any abnormal areas.  Your stool samples may also be tested for traces of blood. Blood tests are done for tumour markers [in case of colorectal cancer these are carcinoembryonic antigen (CEA) and CA 19-9] in the bloodstream.

If anything is abnormal, then you would be referred for a colonoscopy. The colonoscopy is a complete evaluation of the colon and rectum with a long, flexible and slender tube attached to a video camera and a monitor to view your entire colon and rectum. If any suspicious areas are found, your doctor can pass surgical tools through the tube to take tissue samples (biopsies) for analysis.

 

Staging of colorectal cancer

Once you have been diagnosed with colorectal cancer, your doctor will give it a stage to determine your prognosis and the best treatment options.

Your doctor will order tests to determine the extent (stage) of your cancer. Staging helps determine what treatments are most appropriate for you.

Staging tests may include imaging procedures such as abdominal and chest CT scans. In many cases, the stage of your cancer may not be determined until after colon cancer surgery.

The stages of colon cancer are:

  • Stage I – cancer has grown through the superficial lining (mucosa) of the colon or rectum but hasn’t spread outside the colon wall or rectum.
  • Stage II – cancer has grown into or through the wall of the colon or rectum but hasn’t spread to nearby lymph nodes.
  • Stage III – cancer has invaded nearby lymph nodes but isn’t affecting other parts of your body yet.
  • Stage IV – cancer has spread to distant sites, such as other organs — for instance to your liver or lung.

Complications of colorectal cancer surgery depend on the procedures you choose. These may include:

  • Bleeding
  • Infection
  • Blood clots in the legs
  • A hernia
  • Damage to nearby organs during the operation
  • Scar tissue in the abdomen
  • Adhesions that may block the bowel
  • Further surgery

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

 

Before the procedure

  • Your doctor will explain the surgical procedure to you. Ask any questions that you might have about the procedure. Be sure you understand what the extent of the surgery is likely to be and what you should expect afterward.
  • If you’re planning to have radiation therapy after surgery, meet with a radiation oncologist before surgery to discuss benefits and risks.
  • You may be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
  • Ask your doctor if you will possibly need a blood transfusion. If the doctors think a transfusion might be needed, you might be asked to donate blood beforehand.
  • Your doctor will go through your full medical history and additionally may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
  • Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).
  • Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
  • Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
  • Notify your doctor if you are pregnant or suspect pregnancy.
  • It is important that your bowels be empty when the surgery is performed. You must follow your doctor’s instructions on dietary changes and liquid intake on the days leading up to surgery.
  • A day or two before the procedure, your doctor
  •  may give you a bowel preparation that includes laxatives and enemas.
  • You will be asked to fast for eight hours before the procedure, generally after midnight.
  • You may receive a sedative prior to the procedure to help you relax.
  • You may meet with a physical therapist prior to your surgery to discuss rehabilitation.
  • Stop smoking, as smoking can delay wound healing and slow down the recovery period.

Based on your medical condition, your doctor may request other specific tests or examinations.

 

During the procedure

Surgery is the removal of the tumor and surrounding tissue during an operation. Procedures may vary depending on your condition and your doctor’s practices.

Generally, the surgery follows this process:

  • You will be asked to remove clothing and put on a hospital gown.
  • An intravenous (IV) line may be started in your arm or hand.
  • You will be positioned on the operating table.
  • A urinary catheter may be inserted.
  • The surgery will be performed while you are asleep under general anesthesia. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
  • The skin over the surgical site will be cleansed with an antiseptic solution.
  • Depending on the stage of your cancer and overall medical condition, the surgeon       may perform:
  • Colectomy – a surgery that involves removing parts or your entire colon depending on the stage of the cancer. It usually requires other procedures to reattach the remaining portions of your digestive system and permit waste to leave your body. Colectomy can be performed traditionally (open surgery) or through laparoscopy. In open colectomy, the surgeon will make a long incision in your abdomen to access your colon. Your colon will be freed from the surrounding tissue using surgical tools, and either a portion of the colon or the entire colon will be cut out. In laparoscopic colectomy, also called minimally invasive colectomy, many small incisions are made in your abdomen. Your surgeon passes a tiny video camera through one incision and special surgical tools through the other incisions. The surgeon watches the inside of your abdomen on the screen in the operating room, takes out the colon through one small incision, fixes it, and places it back through the incision.
  • Once the colon has been repaired or removed, your surgeon will reattach your digestive system to allow your body to expel waste. This is done by:
  • Rejoining (stitching) the remaining portions of your colon together, creating what is called an anastomosis. Stool then leaves your body as before.
  • Attaching your colon (colostomy) or small intestine (ileostomy) to an opening created in your abdomen. This allows waste to leave your body through the opening (stoma). You may wear a bag on the outside of the stoma to collect stool. Sometimes, the colostomy is only temporary to allow the rectum to heal, but it may be permanent. With modern surgical techniques and the use of radiation therapy and chemotherapy before surgery when needed, most people who receive treatment for rectal cancer do not need a permanent colostomy.
  • Using a portion of your small intestine to create a pouch that is attached to your anus (ileoanal anastomosis). This procedure is used if both the colon and the rectum are removed (proctocolectomy). This allows you to expel waste normally, though you may have several watery bowel movements each day. As part of this procedure, you may undergo a temporary ileostomy.
  • Regardless of the type of procedure you have, some tissue and lymph nodes will be sent to a laboratory for analysis.
  • The incision will be closed with stitches or surgical staples.
  • A drain may be placed in the incision site to remove fluid.
  • A sterile bandage or dressing will be applied.

 

After the procedure

In the hospital

Colectomy requires a stay in the hospital. After the surgery, you will be taken to the recovery room for observation. The staff will monitor your blood pressure, pulse, alertness, pain or comfort level, and your need for medications and give you medicine for pain. When they are sure that you are stable, you will be transferred to a room in the hospital.

You will stay in the hospital until you regain bowel function. This may take a couple of days to a week. Initially, you may be put on liquid nutrition through a vein in your arm and then transition to drinking clear liquids. As your intestines recover, you can eventually add solid foods.

If your surgery involved a colostomy or ileostomy to attach your intestine to the outside of your abdomen, you will meet with an ostomy nurse who will show you how to care for your stoma. You will be explained how to change the ostomy bag that will collect waste.

 

At home

Once you are home, it is important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up hospital visit.

If you have undergone a colostomy, then after you go home you will have to take care of the stoma following the instructions were given to you at the hospital. It takes time to become comfortable with a stoma. Empty the stoma once it’s one-third full. You will have to clean the stoma gently every day with warm water only. Then gently pat dry or allow the area to air dry. In the first few weeks after your operation, you may experience excessive flatulence (gas) and unpredictable discharge from your stoma. This should start to improve as your bowel recovers from the effects of the operation.

You will be given prescriptions for pain medication and possibly an antibiotic. Be sure to take only recommended medications.

Notify your doctor to report any of the following: Fever; redness, swelling, bleeding, or other drainages from the incision; increased pain near the incision; and numbness and/or tingling sensation at the surgical site.

You will have to avoid contact sports, heavy lifting or any other strenuous exercise that may put pressure on your abdomen. Your doctor will suggest some activity restrictions.

Your dietician will advise you on the diet if there are any changes. You will generally be advised to avoid foods that cause gas or constipation.

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

 

Recovery

Colectomy is a major surgery. Recovering from it takes time depending on whether you had additional surgeries along with colectomy. You will be able to return to work after your bowels have healed completely. A colostomy may require a longer time to recover.

Walking will help your general recovery by strengthening your muscles, maintaining your blood circulation (thus preventing blood clots), and helping your lungs remain clear. However, you need to check with your doctor before you start lifting weights or doing abdominal exercises after your surgery to reduce your risk of complications. If you have had a colostomy, your doctor or an ostomy nurse might recommend a device to support your abdomen when lifting weights, after your incision has healed fully. All colostomy bags are waterproof, so you can go swimming after consulting with your doctor.

Your doctor will give you a better idea of when you can expect to get back to your normal routine.