Surgery for colorectal cancer

he types of surgery used to treat colon and rectal cancers are slightly different, so they are described separately.

Colon surgery

Surgery is often the main treatment for earlier stage colon cancers.

Open colectomy

A colectomy (sometimes called a hemicolectomy, partial colectomy, or segmental resection) removes part of the colon, as well as nearby lymph nodes. The surgery is referred to as an open colectomy if it is done through a single incision in the abdomen.

The day before surgery, you will most likely be told to completely empty your bowel. This is done with a bowel preparation, which may consist of laxatives and enemas. Just before the surgery, you will be given general anesthesia, which puts you into a deep sleep.

During the surgery, your surgeon will make an incision in your abdomen. He or she will remove the part of the colon with the cancer and a small segment of normal colon on either side of the cancer. Usually, about one-fourth to one-third of your colon is removed, but more or less may be removed depending on the exact size and location of the cancer. The remaining sections of your colon are then reattached. Nearby lymph nodes are removed at this time as well. Most experts feel that taking out as many nearby lymph nodes as possible is important, but at least 12 should be removed.

When you wake up after surgery, you will have some pain and probably will need pain medicines for 2 or 3 days. For the first couple of days, you will be given intravenous (IV) fluids. During this time you may not be able to eat or you may be allowed limited liquids, as the colon needs some time to recover. But a colon resection rarely causes any major problems with digestive functions, and you should be able to eat solid food again in a few days.

It's important that you are as healthy as possible for this type of major surgery, but in some cases an operation may be needed right away. If the tumor is large and has blocked your colon, it may be possible for the doctor to use a colonoscope to put a stent (a hollow metal or plastic tube) inside the colon to keep it open and relieve the blockage for a short time and help prepare for surgery a few days later.

If a stent can't be placed or if the tumor has caused a hole in the colon, surgery may be needed right away. This usually is the same type of operation that's done to remove the cancer, but instead of reconnecting the segments of the colon, the top end of the colon is attached to an opening (stoma) in the skin of the abdomen to allow body wastes out. This is known as a colostomy and is usually temporary. Sometimes the end of the small intestine (the ileum) is connected to a stoma in the skin instead. This is called an ileostomy. A removable collecting bag is connected to the stoma to hold the waste. Once you are healthier, another operation (known as a colostomy reversal or ileostomy reversal) can be done to attach the ends of the colon back together or to attach the ileum to the colon. Rarely, if a tumor can't be removed or a stent placed, the colostomy or ileostomy may need to be permanent. For more information, refer to our documents Colostomy: A Guide and Ileostomy: A Guide.

Laparoscopic-assisted colectomy

This newer approach to removing part of the colon and nearby lymph nodes may be an option for some earlier stage cancers. Instead of making one long incision in the abdomen, the surgeon makes several smaller incisions. Special long instruments are inserted through these incisions to remove part of the colon and lymph nodes. One of the instruments, called a laparoscope, has a small video camera on the end, which allows the surgeon to see inside the abdomen. Once the diseased part of the colon has been freed, one of the incisions is made larger to allow for removal.

This type of operation requires the same type of preparation before surgery and the same type of anesthesia during surgery as an open colectomy (see above).

Because the incisions are smaller than with an open colectomy, patients may recover slightly faster and have less pain than they do after standard colon surgery.

Laparoscopic-assisted surgery is as likely to be curative as the open approach for colon cancers. But the surgery requires special expertise. If you are considering this approach, be sure to look for a skilled surgeon who has done many of these operations.

Polypectomy and local excision

Some early colon cancers (stage 0 and some early stage I tumors) or polyps can be removed by surgery through a colonoscope. When this is done, the surgeon does not have to cut into the abdomen. For a polypectomy, the cancer is removed as part of the polyp, which is cut at its stalk (the area that resembles the stem of a mushroom). Local excision removes superficial cancers and a small amount of nearby tissue.

Rectal surgery

Surgery is usually the main treatment for rectal cancer, although radiation and chemotherapy will often be given before or after surgery. Several surgical methods can be used for removing or destroying rectal cancers.

Polypectomy and local excision

These procedures, described in the colon surgery section, can be used to remove superficial cancers or polyps. They are done with instruments inserted through the anus, without making a surgical opening in the skin of the abdomen.

Local transanal resection (full thickness resection)

As with polypectomy and local excision, local transanal resection (also known as transanal excision) is done with instruments inserted through the anus, without making an opening in the skin of the abdomen. This operation cuts through all layers of the rectum to remove cancer as well as some surrounding normal rectal tissue, and then closes the hole in the rectal wall. This procedure can be used to remove some T1 N0 M0 stage I rectal cancers that are relatively small and not too far from the anus. It is usually done with local anesthesia (numbing medicine) -- you are not asleep during the operation.

Transanal endoscopic microsurgery (TEM)

This operation can sometimes be used for early T1 N0 M0 stage I cancers that are higher in the rectum than could be reached using the standard transanal resection (see above). A specially designed magnifying scope is inserted through the anus and into the rectum, allowing the surgeon to do a transanal resection with great precision and accuracy. This operation is only done at certain centers, as it requires special equipment and surgeons with special training and experience.

Low anterior resection

Some stage I rectal cancers and most stage II or III cancers in the upper third of the rectum (close to where it connects with the colon) can be removed by low anterior resection. In this operation, the part of the rectum containing the tumor is removed without affecting the anus. The colon is then attached to the remaining part of the rectum so that after the surgery, you will move your bowels in the usual way.

A low anterior resection is like most abdominal operations. You will most likely be instructed to take laxatives and enemas before surgery to completely clean out the intestines. Just before surgery, you will be given general anesthesia, which puts you into a deep sleep. The surgeon makes an incision in the abdomen. Then the surgeon removes the cancer and a margin of normal tissue on either side of the cancer, along with nearby lymph nodes and fatty and fibrous tissue around the rectum. The colon is then reattached to the rectum that is remaining so that a permanent colostomy is not necessary. If radiation and chemotherapy have been given before surgery, it is common for a temporary ileostomy to be made (where the last part of the small intestine -- the ileum -- is brought out through a hole in the abdominal wall). Usually this can be reversed (the intestines reconnected) about 8 weeks later.

The usual hospital stay for a low anterior resection is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Proctectomy with colo-anal anastomosis

Some stage I and most stage II and III rectal cancers in the middle and lower third of the rectum require removing the entire rectum (proctectomy). The colon is then connected to the anus (colo-anal anastomosis). The rectum has to be removed to do a total mesorectal excision (TME), which is required to remove all of the lymph nodes near the rectum. This is a harder procedure to do, but modern techniques have made it possible.

Sometimes when a colo-anal anastomosis is done, a small pouch is made by doubling back a short segment of colon (colonic J-pouch) or by enlarging a segment (coloplasty). This small reservoir of colon then functions as a storage space for fecal matter like the rectum did before surgery. When special techniques are needed to avoid a permanent colostomy, you may need to have a temporary ileostomy opening for about 8 weeks while the bowel heals. A second operation is then done to reconnect the intestines and close the ileostomy opening.

This operation requires general anesthesia (where you are asleep). The usual hospital stay for a colo-anal anastomosis, like a low anterior resection, is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Abdominoperineal resection (APR)

This operation is more involved than a low anterior resection. It can be used to treat some stage I cancers and many stage II or III rectal cancers in the lower third of the rectum (the part nearest to the anus), especially if the cancer is growing into the sphincter muscle (the muscle that keeps the anus closed and prevents stool leakage).

Here, the surgeon makes one incision in the abdomen, and another in the perineal area around the anus. This incision allows the surgeon to remove the anus and the tissues surrounding it, including the sphincter muscle. Because the anus is removed, you will need a permanent colostomy to allow stool a path out of the body.

This operation requires general anesthesia (you will be asleep). As with a low anterior resection or a colo-anal anastomosis, the usual hospital stay for an AP resection is 4 to 7 days, depending on your overall health. Recovery time at home may be 3 to 6 weeks.

Pelvic exenteration

If the rectal cancer is growing into nearby organs, a pelvic exenteration may be recommended. This is an extensive operation. Not only will the surgeon remove the rectum, but also nearby organs such as the bladder, prostate (in men), or uterus (in women) if the cancer has spread to these organs. You will need a colostomy after pelvic exenteration. If the bladder is removed, you will also need a urostomy (opening in the front of the abdomen where urine exits and is held in a portable pouch).

Side effects of colorectal surgery

Potential side effects of surgery depend on several factors, including the extent of the operation and a person's general health before surgery. Most people will have at least some pain after the operation, but it usually can be controlled with medicines if needed. Eating problems usually resolve within a few days of surgery.

Other problems may include bleeding from the surgery, blood clots in the legs, and damage to nearby organs during the operation. Rarely, the new connections between the ends of the intestine may not hold together completely and may leak, which can lead to infection. It is also possible that the abdominal incision might open up, becoming an open wound. After the surgery, you might develop scar tissue in the abdomen that can cause organs or tissues to stick together. These are called adhesions. In some cases, adhesions can block the bowel, requiring further surgery.

Colostomy or ileostomy: Some people may need a temporary or permanent colostomy (or ileostomy) after surgery. This may take some time to get used to and may require some lifestyle adjustments. If you have a colostomy or ileostomy, you will need help learning how to manage it. Specially trained ostomy nurses or enterostomal therapists can do this. They will usually see you in the hospital before your operation to discuss the ostomy and to mark a site for the opening. After the operation they may come to your house or an outpatient setting to give you more training. For more information, please see our documents Colostomy: A Guide and Ileostomy: A Guide.

Sexual function and fertility after colorectal surgery: If you are a man, an AP resection may stop your erections or ability to reach orgasm. In other cases, your pleasure at orgasm may become less intense. Normal aging may cause some of these changes, but they may be made worse by the surgery.

An AP resection can damage the nerves that control ejaculation leading to "dry" orgasms (orgasms without semen). Sometimes the surgery causes retrograde ejaculation, which means the semen goes backward into the bladder during an orgasm. This difference is important if you want to father a child. Retrograde ejaculation is less serious because infertility specialists can often recover sperm cells from the urine, which can then be used to fertilize an egg. If sperm cells cannot be recovered from your semen or urine, specialists may be able to retrieve them directly from the testicles by minor surgery, and then use them for in vitro fertilization.

If you are a woman, colorectal surgery (except pelvic exenteration) usually does not cause any loss of sexual function. Abdominal adhesions (scar tissue) may sometimes cause pain or discomfort during intercourse. If the uterus is removed, pregnancy will not be possible.

A colostomy can have an impact on body image and sexual comfort level in both men and women. While it may require some adjustments, it should not prevent you from having an enjoyable sex life.

More information on dealing with the sexual impact of cancer and its treatment is available in our documents Sexuality for the Man With Cancer and Sexuality for the Woman With Cancer.

Surgery and other local treatments for colorectal cancer metastases

Sometimes, surgery for cancer that has spread (metastasized) to other organs can help you live longer or, depending on the extent of the disease, may even cure you. If only a small number of metastases are present in the liver or lungs (and nowhere else), they can sometimes be removed by surgery. This will depend on their size, number, and location.

In some cases, if it's not possible to remove the tumors with surgery, non-surgical treatments may be used to destroy (ablate) tumors in the liver. But these methods are less likely to be curative. Several different techniques may be used.

Radiofrequency ablation: Radiofrequency ablation (RFA) uses high-energy radio waves to kill tumors. A thin, needle-like probe is placed through the skin and into the tumor under CT or ultrasound guidance. An electric current is then run through the tip of the probe, releasing high-frequency radio waves that heat the tumor and destroy the cancer cells.

Ethanol (alcohol) ablation: Also known as percutaneous ethanol injection (PEI), this procedure injects concentrated alcohol directly into the tumor to kill cancer cells. This is usually done through the skin using a needle, which is guided by ultrasound or CT scans.

Cryosurgery (cryotherapy): Cryosurgery destroys a tumor by freezing it with a metal probe. The probe is guided through the skin and into the tumor using ultrasound. Then very cold gasses are passed through the probe to freeze the tumor, killing the cancer cells. This method can treat larger tumors than either of the other ablation techniques, but it sometimes requires general anesthesia (you will be asleep).

Since these 3 treatments usually do not require removal of any of the patient's liver, they are often good options for patients whose disease cannot be cured with surgery or who cannot have surgery for other reasons.

Hepatic artery embolization: This is sometimes another option for tumors that cannot be removed. This technique is used to reduce the blood flow in the hepatic artery, which feeds most cancer cells in the liver. This is done by injecting materials that plug up the artery. Most of the healthy liver cells will not be affected because they get their blood supply from the portal vein.

For this procedure, the doctor puts a catheter into an artery in the inner thigh and threads it up into the liver. A dye is usually injected into the bloodstream at this time to allow the doctor to monitor the path of the catheter by angiography, a special type of x-ray. Once the catheter is in place, small particles are injected into the artery to plug it up.

Embolization also reduces some of the blood supply to the normal liver tissue. This may be dangerous for patients with diseases such as hepatitis and cirrhosis, who already have reduced liver function.