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Any type of surgery is a serious procedure that has associated risks. There
are great benefits to surgery, including saving life, preventing or curing
cancer, restoring normal function, and making life more comfortable — and this
is best done by having the right surgery performed by expert surgeons in the
best way possible.
Surgery is an essential part of treating inherited colorectal cancer. The
surgeries recommended for familial adenomatous polyposis (FAP) and hereditary
non-polyposis colorectal cancer (HNPCC) are generally different than those
recommended for ordinary colorectal cancer because patients with these inherited
syndromes are at a higher risk of cancer recurrence if the whole colon is not
removed during the first operation.
When operating to treat colorectal cancer, the surgeon's main goal is to
remove all cancer cells. To ensure that all cancer cells are removed, the
surgeon takes out not only the cancer, but as much of the tissue around it as
necessary. Because cancer sometimes spreads into the lymph nodes, operations for
colorectal cancer are designed to remove as many of the lymph nodes in the
cancerous area as possible. By taking out a segment of the colon, the surgeon is
able to better capture all of the cancer; but the chance that there may be a
leak of stool from the place where the bowl has been sewn (or stapled) together
might cause the need for a colostomy or ileostomy, which usually are temporary.
Less than 1 percent of patients with colon cancer need a temporary colostomy,
and less than 10 percent of those with rectal cancer will need a permanent
colostomy.
The following are various surgical options for patients with FAP and
HNPCC:
Partial colectomy — This procedure involves removal of part of the
colon, with anastomosis (or a joining) of the ends that remain. Partial
colectomy usually is not done for patients known to have FAP or HNPCC because of
the high risk of recurring cancer, while those who remain undiagnosed of HNPCC
often have the procedure. After a partial colectomy, the bowel habit is close to
normal.
Total colectomy — This is the removal of the entire colon, with the
small intestine being attached to the rectum. This often is performed for
patients with mild FAP and is the routine operation for patients known to have
HNPCC who have colon polyps or cancer. After a total cholectomy, the average
number of bowel movements per day is four, with stool being soft and somewhat
formed, and with good bowel control. Patients with FAP and HNPCC who have this
operation are at risk of developing polyps or even cancer in the rectum, making
regular checks of the rectum with proctoscopy and removal of polyps necessary.
Total proctocolectomy — This is the most extensive bowel operation possible
and removes the entire colon and rectum. A total proctocolectomy is recommended
for patients with severe FAP or patients with HNPCC who have a rectal cancer. A
permanent ileostomy is needed if the anus must be removed, is weak, or has been
damaged. If the anus can remain and works normally, it is possible to avoid a
permanent ileostomy by constructing an ileal pouch.
Ileal (J) pouch — The ileal pouch is used to replace the rectum after a
total proctocolectomy as a reservoir for stool. There are four forms of the
ileal pouch, named after the shape in which the end of the small intestine (the
ileum) is placed before it is sewn (or stapled) to make a pouch. The most common
form is the "J" pouch, but there is also the "S," the
"H" and the "W" pouch. The pouch is sewn or stapled to the
anus. Pouch surgery is complex and has a relatively high risk of complications.
Because of this, a temporary ileostomy usually is needed, with it being closed
after three months when the pouch has healed. Patients with a J pouch usually
have five to six semi-formed bowel movements per day. This number often is higher in
the first year after surgery and decreases as the pouch enlarges. Control of
bowel movements usually is good, but there may be some leaking of liquid stool
or mucous.
K pouch — The "K" pouch is named after a Swedish surgeon
named Nils Kock, who originated the idea of making a reservoir for stool out of
the small intestine and forming the reservoir continent by adding a nipple valve
(another name for the K pouch is the "continent ileostomy"). This
reservoir is attached to the abdominal wall in the same way as a regular
ileostomy, but because there is no leakage of stool, there is no need for a
"spout" or to make the stoma high in the abdomen. The pouch is emptied
by inserting a stiff catheter through the stoma, which is covered with gauze in
between emptying. The advantage of the K pouch is the freedom from external
pouching that it allows. The disadvantage, and the reason it is not very popular
among surgeons, is that the valve often comes undone, or slips, and further
surgery is needed to repair it.
Stomas — A stoma is an opening of some part of the bowel onto the skin
— making a colostomy, an opening of the colon onto the skin, and an ileostomy, an
opening of the ileum (or small intestine). A colostomy or an ileostomy may be
permanent or temporary. Permanent stomas are made when stool cannot go through
its normal route after surgery. Temporary stomas are made to keep stool away
from a damaged or recently operated area while healing occurs. The stool that
comes out of a stoma is collected in a bag. The bag is attached to the skin
around the stoma by a "sticky wafer," or a thin sheet of paste, that
protects the skin. A hole is cut in the wafer to accommodate the stoma itself.
The fit must be good to prevent stool from getting on the skin and causing
severe irritation. Wafers are changed every three to four days, depending on the kind
of stoma and the nature of the stool.
While having a stoma means making big lifestyle changes, both physically and
psychologically, there are many support systems in place to help patients and
families make the adjustment. People with stomas live normal lives.
Laparoscopy — Up until 1990, all bowel surgery was done through long
abdominal incisions, which resulted in a painful and lengthy recovery. In 1990,
a new approach to surgery using laparoscopes began. A laparoscope is an
instrument through which a physician looks into the abdomen. It has been used to
help diagnose conditions within the abdomen (intra-abdominal) for many years.
The principle of laparoscopic surgery is to perform an intra-abdominal
operation using a laparoscope to see what is happening. Instruments are inserted
through small incisions and are controlled by viewing laparoscopic images on a
TV monitor. The potential advantages of laparoscopic surgery are that it
minimizes incision length, resulting in less pain, and allowing for a shorter
hospital stay and a quicker recovery. Laparoscopic bowel surgery is difficult
and not all patients are suitable for it. Each patient must discuss the use of
laparoscopic techniques with their surgeon on an individual basis.
How do I prepare for surgery?
Patients who are about to undergo surgery are naturally anxious. There often
are fears of the anesthesia, the possibility of cancer, complications,
disfigurement, and pain. These fears are normal and may be relieved by a
supportive family and caring physicians. Anxiety also may be helped by using
relaxation therapy, through emotional support, and by providing the patient with
enough knowledge to remove the fear of the unknown. Anesthesia and surgery are
safer now than they ever have been, and surgical techniques are more
sophisticated than ever. The state of medical knowledge and the range of
treatment options available are always increasing.
The process of surgery starts with a thorough discussion between the patient
and his or her physician that allows the surgeon to explain: the diagnosis; the
need for surgery; treatment options available; the recommended procedure and the
reasons behind the recommendation. The likely outcomes of the surgery also are
discussed, including the risk of complications; the effect of the surgery on
bodily functions, such as bowel habits; the likely length of recovery; and any
restrictions the surgery may cause. When patients have significant diseases in
other organs, appointments are scheduled with specialists who make sure that any
increased risk due to these diseases is minimized. An appointment with
anesthesia also is arranged.
A variety of preoperative tests, including a blood test, EKG, chest X-ray, and
lung function studies may be needed. If a stoma is likely, an appointment with a
stoma therapy nurse allows for preoperative counseling and marking a site for
the stoma.
What are the surgical steps?
When bowel surgery is planned, the bowel is prepared by cleansing the night
before surgery. To do this, the patient is asked not to eat or drink anything
beginning at midnight the evening before the operation. On the day of surgery,
patients report to the pre-surgery center where an IV is inserted, a sedative
may be given, and preoperative antibiotics and heparin may be started. Sometimes
an epidural catheter is inserted for pain relief after surgery.
When it is time for surgery, the patient is taken to the operating room and
moved onto the operating table. Once the patient is asleep, a tube is passed
into the windpipe to control breathing. The surgical team then positions the
patient and a catheter is placed into the bladder to measure the amount of urine
produced during surgery. Stockings that gently squeeze the patient's calves are
used to prevent blood clots in the legs. For bowel surgery, the abdomen is
cleaned with antiseptic and isolated by draping sterile cloths. At this point,
the surgery begins.
The average partial colectomy takes 1Ѕ hours, while a total colectomy may
take 2 to 3 hours. During bowel surgery, a tube is normally inserted through the
nose into the stomach (a nasogastric tube). Its purpose is to drain any fluid
and air that may build up and cause nausea and vomiting. When the patient wakes
up, he or she is moved to the recovery room, where pulse and blood pressure are
carefully monitored for 2 to 3 hours. If all is well, the patient goes to the
nursing unit where the family soon arrives, and the surgeon discusses the
surgery that was performed.
What can I expect in the immediate post-surgery period?
Patients undergoing bowel surgery usually are groggy from the effects of the
anesthetic and sleep for the rest of the day. Pain is eased by an epidural or
intravenous morphine, which is controlled partially by the patient who may push
a button to manage the medication. Pain therapy specialists adjust the dosage to
keep the patient comfortable. Patients are encouraged to breathe deeply to
prevent pneumonia. They may sit in a chair after surgery, and are then
encouraged to walk, increasing their distance each day. When there are signs
that the patient's bowel is working (bowel sounds can be heard, there is no
nausea, gas or stool is passed), the nasogastric tube is removed and the patient
is allowed to drink, and then eat. The urinary catheter is removed when patients
are able to go to the bathroom.
How quickly can I expect to return to more normal life activities?
The speed at which bowel function returns and patients are able to drink and
eat determines the length of the hospital stay needed. After bowel surgery, it
normally takes 3 to 4 days for bowel function to return, and 6 to 7 days to be
discharged from the hospital. Skin sutures or staples are removed in 7 to 10
days. Patients go home with instructions about diet and activity, and an
appointment is scheduled for a follow-up examination in 4 to 6 weeks.
Patients having abdominal surgery may not drive for 10 days, should avoid
lifting objects heavier than 25 pounds for three months and should avoid a lot
of dietary fiber or roughage for four weeks. They should take four to six weeks off
work. Pain medication will be needed for two weeks, and patients will feel tired
for one to three months, depending on how fit they were before surgery.
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