Colorectal Cancer Surgery

The colon is the initial part of the large intestine. It is about 5 feet long and is involved in the absorption of fluids and the removal of waste material from the body. 

Immediately following the colon are the anal canal and the rectum, which make about the latter 6-8 inches of the large intestine. The colon is connected to the anal canal by the rectum.

When abnormal growths (polyps) develop in the colon or rectum and give rise to cancer, it is known as colorectal cancer (CRC). It should, however, be noted that not all polyps develop into cancer.

Colorectal cancer ranks third among the common cancers and fourth among deaths caused by cancer. It is the result of a mutation (change occurring in the DNA sequence) in specific genes, namely tumour suppressor genes (genes that prevent cancer), oncogenes (genes that cause cancer), and genes associated with DNA repair mechanisms.

Depending on the stage and spread of the cancer, surgery can be performed on the colon and the rectum. Surgery is beneficial in early-stage cancers.

• Surgery for colon cancer can be done by local excision and colectomy.
• Surgery for rectal cancer is more complicated and can be performed in different ways like local resection, total mesenteric excision, anterior resection or abdominoperineal resection.

Your doctor may recommend this surgery if you have been diagnosed with colorectal cancer and the doctor thinks the cancer can be treated/managed through excision of the affected tissue.

The symptoms of CRC include:

• Bleeding in stools or from the anal opening
• Change in bowel habits such as loose stools or constipation
• Weight loss
• Decreased appetite
• Abdominal pain, which may get worse with meals
• A swelling or lump in the tummy
• Tiredness
• Bloating
• A definite rectal mass (the presence of suspected abnormal tissue within the rectum)

While selecting the appropriate treatment for CRC, many criteria are assessed, e.g., the extent and spread of the cancer and the staging (tumour progression).

Surgery, while a preferred treatment method for colorectal cancer, can be risky. Several factors need to be considered when determining if surgery is a suitable option for the individual – the age of the individual, the ability to withstand the surgery (frailty), quality of life after surgery, the benefit of the surgery versus its cost, pre-existing medical conditions, and stage of the cancer.

Based on the stage of the CRC, surgery may be indicated in the following individuals:

• Group 0: In individuals with no spread of the cancer (metastatic disease) to the liver or lung and who have good chances of recovery (good prognosis), the recommended treatment consists of surgical removal of the cancer.
• Group 1: Surgery is indicated in individuals in whom the cancer has spread (metastasised), but is removable (also called resectable). First, such individuals are treated with induction chemotherapy to bring down the number and size of the metastases in preparation for better removal by surgery.

Surgery may not be a good option for the following individuals:

• Group 2: In individuals with a greater spread of the cancer that is also not easily resectable, the treatment includes cytotoxic (toxic to the cells) agents. The agents selected for this group of individuals are focused on easing their symptoms to better their quality of life rather than curing the cancer.
• Group 3: Chemotherapy is advised to individuals with unresectable disease, also having a low risk of deterioration. This treatment prevents tumour progression and allows prolongation of life with minimal treatment.

The following preparations are needed before the surgery.

• You will undergo a preoperative physical examination before the surgery to ensure that you are otherwise fit enough for the procedure.
• Avoid eating or drinking anything in the night, after midnight, before your surgery, including water.
• Discuss all ongoing medications, especially blood thinners, with your doctor and follow their direction about taking or avoiding them. 
• Inform your doctor if you have any latex or medicine allergies or a history of kidney diseases.
• Do not smoke the night, after midnight, before the surgery. Read more: Effects of smoking on health
• Do not wear any make-up or apply lotions or powders.
• Do not apply nail polish or wear artificial nails as your nails will be observed during surgery to check for oxygen and blood circulation.
• Carry a list of all your medications and their doses to the hospital on the day of the surgery.
• For bowel preparation, two enemas are used. First, 2 hours after dinner and second in the morning before surgery, if surgery is to take place in the morning. If surgery is to happen in evening or afternoon, two enemas are used in the morning of procedure with a gap of 1 hour.

On the day of the surgery:

• You will be asked to change into hospital clothes.
• The surgeon will answer any last-minute questions you may have.
• Your vital signs will be checked and, you will receive intravenous line to give you antibiotics, anaesthesia, and pain medications.
• You will be given general anaesthesia to make you sleep through the procedure,
• A urinary catheter will be inserted in your bladder to collect urine.
• A nasogastric tube will be passed through your nose down your throat and into your stomach. This will allow secretions released in the stomach to be eliminated so that you do not have nausea or vomiting when you awaken.

Colon surgery can be performed in two ways.

• Local excision: In very early stages of the cancer, a small portion of the lining may be removed from the colon wall.
• Colectomy: A portion of the colon is removed in this surgery. It can be done in the following three ways:
  • An open colectomy: A large incision (cut) will be made in your abdomen and the affected section of your colon will be removed.
  • A laparoscopic or keyhole colectomy: A number of small cuts will be made in your abdomen and with the aid of special tools and the help of a camera, the affected section of your colon will be removed.
  • Robotic surgery: It is a type of keyhole surgery where robotic technology will be used to remove the cancer.

Rectal surgeries are carried out through the bottom without making any abdominal incisions.

• Local resection: It is performed through the anal opening. The surgeon will insert an endoscope into your body through your anus to remove the cancer from your rectal wall. The procedure is useful for very early-stage cancers.
• Total mesenteric excision: This procedure is carried out when a larger section of the rectum needs to be removed, along with a border of normal rectal tissue and fatty tissue, including the tissue that attaches the intestine to the abdominal wall (mesentery).
• Low anterior resection: It is a procedure to treat cancer in the rectum that is away from sphincters that control bowel action. For this surgery, the surgeon will make an abdominal incision and remove a part of your rectum along with some adjoining tissues. He/she will then attach your colon to the lowest part of your rectum or the upper region of the anal canal.
• Abdominoperineal resection: Abdominoperineal resection is a procedure to treat rectal cancer in the lowest section of the rectum. Often the entire rectum and nearby tissues need to be resected, and the anal opening is closed off. The surgeon will make a separate structure called a stoma by bringing a piece of your bowel out through your abdominal wall and attaching it to your skin. You will have to wear a bag over the opening and the faeces will be collected therein. The stoma will be permanent.

After the surgery, you will be taken to the recovery room until you are stable, after which you will be moved into your room. The recovery period in the hospital can be anywhere from 4 to 14 days.

You will be discharged from the hospital once you start eating adequately, have normal bowel movements (from the anus or the stoma) and are able to tolerate pain medications orally. Often bowel functions undergo a change after surgery, e.g, people who have had rectal cancer surgery may need to void their bowels more often; however, this settles down with time.

You will need to care for yourself in the following aspects after your colorectal cancer surgery:

• To prevent infections. keep your incision dry. Do not take a bath or swim until advised by your doctor.
• If you have had a stoma placed, you will need to learn to care for your stoma. You can join a patient support group for people who have a stoma or will be having one.
• If a part of your bowel has been removed, it will take some time for bowel function to come back to normal. Initially, you may need to move your bowels as frequently as 6-8 times a day. You may also experience the need to void your bowels urgently to avoid leaking.
• You may feel fatigued or weak for some time. You can gradually return back to your regular activities; however, avoid lifting heavy things for many weeks or until advised by your doctor.
• Diet: your doctor will discuss your diet with you before discharge from the hospital. It will be several weeks before you can go back to your regular diet.
• You may not be able to drive for some time. 

When to see the doctor?

You should visit a doctor immediately if you have any of the following symptoms:

• Any signs of unusual bleeding from the incision sites or the stoma.
• A high temperature, redness or swelling at the surgical site, shivering, or feeling unwell
• Feeling dizzy, chest pain, shortness of breath, or coughing up blood.
• Bloating, nausea, vomiting, hiccups, gas cramps that worsen with time and cause pain.

Colorectal surgery has the following risks and may have the following complications:

• Soreness near the anal canal due to frequent bowel movements
• Infections – urine, wound, or chest infection
• Bleeding at the surgical site
• A leak at the junction where the colon is resected to join the ends together
• Breathing or heart problems
• Blood clots may develop, generally in the legs (deep vein thrombosis; a condition where clots form in veins located deep in the body) and pulmonary embolism (clots in lungs)
• Damage to the nerves controlling sexual and urinary function

For individuals with CRC, regular follow-ups are very crucial especially in the early detection of the recurrence of cancer (cancer that comes back despite treatment and surgery). Your doctor will advise you on the schedule of follow-up care.

The first five years are the most important in the follow-up care. In this duration, the doctor will advise some tests, physical examinations, colonoscopies (where using endoscopic probes, polyps are looked for in your colon and rectum), and CT scans. In some individuals, with advanced stages of CRC, the doctor may administer chemotherapy or radiotherapy as a precautionary measure.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.