Surgery

for Colon Cancer

In patients with potentially curable colon cancer, a properly performed surgical operation is essential for optimal results. In the majority of such cases, operative intervention involves a resection (removal) of the primary cancer and regional lymph nodes.

There are several different types of surgical procedures used in the treatment and management of colon cancer. The size and spread of the cancer helps determine the appropriate procedure to ause.

Primary Surgical Management of Colon Cancer

Polypectomy: Some cancers appear to be less aggressive and are limited to the head of a single polyp. These cancers present no evidence of spread to the lymph system, blood vessels and nervous system, and therefore, may be removed with a local excision. In an effort to avoid unnecessary invasive surgery, these cancers can be removed during a colonoscopy. During a colonoscopy, a long flexible tube that is attached to a camera is inserted through the rectum and is used both to view the internal lining of the colon and to perform the removal of a small cancer (local excision.) A properly performed local excision can be a safe and effective procedure.

Conventional surgery (open colectomy): Conventional surgery for colon cancer requires surgeons to create a large opening in the abdomen in order to reach the cancer. This procedure involves the removal of the cancer, along with some of the normal bowel and lymph nodes that were surrounding the cancer. After this removal, the two cut ends of the colon are sewn together. In some instances, a temporary colostomy is created and the two ends of the colon are reconnected at a later time. A colostomy is an opening where the large intestine is attached to the abdominal wall and allows passage of stool into a replaceable bag outside of the patient’s body. In some instances, when the cancer cannot be completely removed, the two ends are not re-sewn together and the patient has a permanent colostomy.

Laparoscopic surgery: Laparoscopic surgery, also called minimally invasive surgery, allows surgeons to do procedures by making only a few small incisions in the abdomen. A small tube that holds a video camera is inserted into the abdomen, creating a live picture of the inside of the patient’s body. This picture is displayed on a television screen so that physicians perform the entire surgery by watching the screen. The cancer is removed through another, slightly larger incision.

Laparoscopic surgery appears to be about as likely to be curative as the standard approach for earlier-stage cancers.1 Potential advantages of the procedure include less pain, a shorter hospital stay, and a quicker recovery. However, there is still limited information from randomized trials about the approach. In addition, laparoscopic surgery requires special expertise and patients need to be treated by a skilled surgeon who has done many of these operations.2

Surgery for Recurrent or Metastatic Disease

At the time of diagnosis, 10 to 20% of patients with colorectal cancer have cancer that has spread (metastasized) to areas of the body that are distant from the area where the cancer started. The most common sites of metastasis and relapse are the liver, lungs, kidneys, duodenum, pancreas and pelvis (including the bladder). In most patients, metastases occur at multiple sites and are treated with systemic chemotherapy for palliation (relief of symptoms but not cure). Some patients who have cancer that has spread to a single area or recurrence near the original site are candidates for surgery to remove the metastases.

Treatment of the liver: When it’s possible to completely surgically remove all liver metastases, surgery is the preferred treatment. Although surgery offers some patients the chance for a cure, a majority of patients with liver metastases are not candidates for surgery because of the size or location of their tumors or their general health. Some of these patients may become candidates for surgery if initial treatment with chemotherapy shrinks the tumors sufficiently. If the tumors continue to be impossible to remove surgically, other liver-directed therapies may be considered. These other therapies include radiofrequency ablation (use of heat to kill cancer cells), cryotherapy (use of cold to kill cancer cells), delivery of chemotherapy directly to the liver, and radiation therapy. Relatively little information is available from clinical trials about the risks and benefits of these other approaches, but they may benefit selected patients.2

Palliative surgery: Palliative treatment is treatment that is intended to relieve symptoms, such as pain, but is not expected to cure disease. The main purpose of palliative treatment is to improve the patient’s quality of life. Palliative surgery to remove a portion of the colon may be recommended for some patients with advanced colon cancer to prevent bleeding, obstruction, and symptoms related to the cancer.

Ostomies

An ostomy is a general term for a surgically created opening from the inside of the body to the outside. For people with colorectal cancer, an ostomy may be necessary after surgery to remove part or all of the colon or rectum. The ostomy provides a way for stool to pass out of the body. There are different kinds of ostomies, and depending on the patient’s situation the ostomy may be temporary or permanent.

Types of Ostomies

Depending on what part and how much of the large intestine has been surgically removed, different approaches may be used to divert stool to the outside of the body.  Each of these approaches involves the creation of a stoma. To create a stoma, the surgeon brings a cut end of the small or large intestine to the surface of the body through an opening in the abdomen. Once at the surface, the end of the intestine is rolled back on itself (somewhat like a turtleneck sweater) and stitched to the wall of the abdomen. This portion of bowel that is visible on the surface of the abdomen is the stoma. Stool leaves the body through the stoma.

Ileostomy: An ileostomy connects the last part of the small intestine (the ileum) to the outside of the body, completely bypassing the colon, rectum, and anus. The waste that leaves the body at this point in the digestive system is only semi-solid. Waste passes through the stoma into a collection bag (an ostomy pouch) that is worn on the outside of the body. This bag must be emptied several times a day.

Colostomy: A colostomy is similar to an ileostomy, but it is a part of the colon that is diverted to a stoma. As with an ileostomy, waste can be collected outside of the body in an ostomy pouch. Some patients may also have the option of irrigation (insertion of water through the stoma) to have more regulated bowel movements.

Continent Ileostomy: This is a procedure that allows some patients to avoid wearing an ostomy bag. After surgery to remove the large intestine, an internal pouch is made from the end of the ileum. The pouch is connected to a stoma. Stool collects in the pouch inside of the body and is drained using a tube inserted through the stoma.

Selecting and Managing a Pouch

One of the primary issues with a colostomy is the selection of a pouch. The type of pouch used to collect stool is important because it protects the skin surrounding the stoma and effectively contains stool, which is essential to quality of life. Pouches may be flexible, rigid, flat or convex. In addition, pouches may have features such as skin barriers, gas filters, belts, or tape borders. With so many options available, patients may find it helpful to consult with a nurse who specializes in caring for patients with colostomies.

When using a pouch, it is important to:

  • Select a pouch that is appropriate for the type of diversion. Depending on the portion of the intestine where the diversion is created, the drainage may be thick or thin and may consist of high or low volumes of output. Pouches may be closed-ended or drainable. Closed-ended pouches are designed for patients with low output diversions who prefer to remove and change the pouch rather than empty it. These pouches may also be good for patients with poor manual dexterity, as they are easier to use than pouches with a closure system. Drainable pouches are more common for patients with fecal diversions and are required for patients with high volumes of output.
  • Match the pouching system to the contours of the abdomen and the height of the stoma. It is critical to maintain the pouch seal to the skin around the stoma. In many cases, the patient will be evaluated in both a lying and sitting position to determine how the stoma is located in the abdomen and if a flexible or rigid pouch would be most effective.
  • Choose the appropriate pouch size. The size of the pouch must minimize the exposed skin. In general, the opening of the pouch should be about one-quarter inch larger than the stoma and provide one-eighth of an inch of clearance on each side.
  • Use protective skin products. Pastes, powders, and barrier rings are designed to provide protection from enzymes contained within the stool that are destructive to the skin.

Managing the Different Types of Colostomy

There are several different types of colostomy, including ileostomy, transverse colostomy, and sigmoid or descending colostomy. These procedures are performed for different reasons and each presents different management issues.

Management Strategies for Ileostomy: An ileostomy is an opening into the small intestine and typically involves removal of the colon and rectum (portions of the large intestines) because of inflammatory diseases or when there is a mass that is obstructing the colon. However, in some cases an ileostomy may be inserted temporarily to allow wound healing within the large intestine. Fortunately, the small bowel contains little bacteria and produces very little gas, so odor prevention is usually manageable with an ileostomy. Patients with ileostomies are faced with four main issues: skin care, dehydration, fiber consumption, and absorption of medications.

  • Skin care: Ileostomies are usually high-volume output diversions, producing 500-1000cc of output per day. The drainage from this diversion typically contains a large amount of enzymes, which makes it critical for patients to practice appropriate skin care to prevent destruction of the skin.
  • Dehydration: On a daily basis, patients with ileostomies may lose 250-500cc of fluids that would have normally been absorbed by the large intestines. As a result, it is important for patients to take precautions against dehydration. Patients with ileostomimes are instructed to increase their daily fluid intake by 1-2 glasses of water per day.
  • Fiber Consumption: Patients with ileostomies should consume a diet that is high in soluble fiber. Soluble fiber should be eaten in small amounts to prevent food blockages created by a mass of insoluble fiber. Patients with ileostomies must be able to recognize the signs of a food blockage, which include no output from the ileostomy, high-volume liquid output with a foul smell, cramping pain, distention and possibly nausea and vomiting.
  • Absorption of Medications: Since many medications are absorbed within the large intestines, patients with ileostomies may poorly absorb many medications. Whenever possible, patients with ileostomies should use liquid forms of medications to ensure absorption.

Management Strategies for Descending/Sigmoid Colostomy: A descending or sigmoid colostomy is typically performed when the rectum is removed. For these patients, the stool is a regular consistency and patients will usually have two bowel movements per day. Major issues for patients with descending/sigmoid colostomies include constipation (and gas and odors) and irrigation.

  • Constipation: Patients with descending/sigmoid colostomies must avoid constipation. Patients should drink adequate fluids and consume a high-fiber diet. Some patients may find it helpful to use bulk laxatives, such as Metamucil® or Citracel ®. Patients can create their own dietary bulk laxative by combining 1 cup of unprocessed millers bran, 1 cup of applesauce and ¼ cup of prune juice. This mixture should be consumed daily (start with 2 tablespoons) and increased by 1 tablespoon daily until soft-formed stools are produced. Acutely constipated patients may use oral laxatives to restore bowel movements.
  • Irrigation: Patients with descending/sigmoid colostomies may need to manage their diversion with routine irrigations of tap water to improve and regulate bowel function. This technique should be taught be a provider skilled in the care of colostomies.

Living with an Ostomy

Ostomy appliances: Many patients with a colostomy or ileostomy will need to wear pouches over their stoma to collect waste. There are several different types and sizes of pouches, and patients may find that they use different types at different times. Some pouches are drainable (able to be opened at the end so that stool can be discarded) and others are closed (meant to be removed and discarded when filled). The pouch is connected to a faceplate that adheres to (and protects) the skin around the stoma. Because there are many different pouching systems available, talk with your doctor or ostomy nurse about the types that will best fit your body and your lifestyle.

Irrigation supplies: Irrigation is a process that allows some patients with a colostomy to regulate their bowel movements. Water is inserted through the stoma and causes stool to be expelled. This process requires specific supplies, and you should work with your doctor or ostomy nurse to learn to use them properly.

Dietary considerations: For several weeks after surgery, your doctor may recommend a limited diet. After this recovery period, however, you will probably be able to gradually return to your regular diet. Some foods are more likely than others to cause gas or odor in stool, so you may want to start with small servings of these foods until you learn how your body reacts to them. Foods that may cause gas, for example, include beans, cabbage, and carbonated beverages. Eating at regular intervals can also help to reduce gas.

Returning to the activities that you enjoyed before: Once you heal from surgery and learn to use your pouching or irrigation system, you are likely to be able to return to the activities that you enjoyed before having an ostomy. These activities may include sex, work, exercise (including swimming), and travel. It’s natural to feel hesitant or self-conscious when you first return to normal activities, but these feelings generally diminish as you become comfortable with your ostomy appliance and learn which pouching systems or ostomy accessories you prefer for which activities. During sex, for example, some people choose small, closed pouches, or use pouch covers.

In some cases, you may need some extra help to get back to your normal activities. After surgery for rectal cancer, for example, some men have difficulty achieving or maintaining an erection, and some women may experience discomfort during intercourse. Sexual problems (as well as other problems that you may experience) can often be effectively managed, so don’t hesitate to discuss your concerns with your doctor.

Ostomy Support

The good news for people with an ostomy is that support networks are available. These networks can provide practical advice on many aspects of living with an ostomy, and can also be an important source of emotional support. Sources of ostomy information and support include ostomy nurses, local support groups within your hospital or community, and national groups such as the United Ostomy Associations of America (www.ostomy.org).3

Next: Radiation Therapy for Colon Cancer

References


1Jayne DG, Thorpe HC, Copeland J et al. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. British Journal of Surgery. 2010;97:1638-45.

2Alsina J, Choti MA. Liver-directed therapies in colorectal cancer. Seminars in Oncology. 2011;38:651-567.

3National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). National Digestive Diseases Information Clearinghouse. Bowel Diversion Surgeries: Ileostomy, Colostomy, Ileoanal Reservoir, and Continent Ileostomy. NIH Publication No. 09-4641. February 2009.