Professor. IAN T. JONES
FRACS FRCS
COLORECTAL SURGERY
Suite 5, 6 & 7 Tel:9347 4077
Private Medical Centre Fax:9348 2075
Royal Melbourne Hospital Royal Parade Pager: 9387 1000
Parkville VIC 3050
INFORMATION SHEET FOR PATIENTS WITH COLORECTAL CANCER
INTRODUCTION
Colorectal cancer (bowel cancer) is one of the commonest cancers seen in Australians. It occurs in one in eighteen men and one in twenty women who live in Australia. It is rare before the age of 40 years but increasingly common in the fifth and sixth decades of life. In the majority of cases, the cause of bowel cancer is unknown but a variety of conditions can predispose towards the development of bowel cancer. These include a family history of bowel cancer, colonic polyps, colitis that has been present for ten years or more and a previous history of bowel cancer.
The common symptoms of bowel cancer include rectal bleeding, change in bowel habit, persistent abdominal pain or weight loss and anaemia (or low blood count) due to a slow and undetectable amount of blood being lost in the bowel movement on a daily basis. In many cases, the symptoms of bowel cancer can be minor or even absent.
INVESTIGATION AND DIAGNOSIS
A thorough history and physical examination are an important starting point particularly by a specialist who regularly treats bowel cancer such as a colorectal surgeon. Rectal examination, whilst sometimes embarrassing or uncomfortable, is an important part of the assessment of the patients with symptoms of bowel cancer. Investigations that may be ordered include blood tests, x-rays such as CT scan or barium enema and in particular colonoscopy. Colonoscopy is the direct visualisation of the lining of the large intestine by passing a special telescope or endoscope around the colon to detect abnormalities. In some cases, biopsies or removal of small growths called polyps can be undertaken. This is usually performed as a day case procedure and is carried out under intravenous sedation given by an anaesthetist. On occasion special investigations such as MRI or PET scans might be ordered.
TREATMENT
Once the diagnosis of colorectal cancer has been made, a treatment plan is discussed with the patient and family. The management depends on the location of the tumour in the large intestine and its stage i.e. whether it is early or more advanced in growth pattern.
Surgical removal of the tumour is the only way to achieve cure for bowel cancer but in some situations will be supplemented by other treatments (particularly for cancers involving the rectum) such as radiotherapy or chemotherapy. This can be given before or after surgery depending on the individual circumstances of the patient.
Surgical operations for bowel cancer are considered significant abdominal procedures. These operations are performed under general anaesthetic and require an abdominal incision to allow the surgeon to have access to the tumour and to remove the segment of bowel where the tumour is located. In some cases, the bowel resection can be assisted by the use of laparoscopic techniques (keyhole surgery) which may allow a smaller incision to be used with the benefits of reduced postoperative pain and earlier return of intestinal function.
For tumours involving the colon (which is the greater portion of the large intestine that lies within the abdominal cavity), tumours on the right side of the bowel are removed by an operation called right hemicolectomy, on the left side of the bowel by left hemicolectomy and in the lowest part of the colon by sigmoid colectomy. There can be variations to these procedures depending on the location of the tumour but in general, after the removal of the segment of bowel containing the tumour, the bowel ends are rejoined by surgical sutures or staples and this is known as an anastomosis. This means that the continuity of the intestinal tract is restored and bowel function resumes after surgery in the usual way.
The rectum is the last part of the large intestine and predominantly lies in the pelvic region and terminates at the back passage or anus. Surgical removal of rectal cancers is frequently more complex operation than surgery for tumours in the colonic part of the large intestine as surgical access to the pelvis is more difficult and depending on how close the tumour is to the anus, restoring bowel continuity by constructing an anastomosis is technically more demanding. The names of the operations performed for rectal cancer are anterior resection (high, low or ultra low depending on just how low down the rectal cancer lies within the rectum) and abdominoperineal excision of the rectum (which is performed when the cancer is so close to the anal opening that restoring bowel continuity by an anastomosis is not possible in which case a permanent colostomy is required). For low or ultra low anterior resections where the rectal cancer is removed and the bowel ends rejoined, the anastomosis may be “protected” for a period of time by diverting the faecal stream (bowel contents) away from the anastomosis by the use of a temporary ileostomy for two to three months.
POSTOPERATIVE RECOVERY
Postoperatively, patients who have had surgery for bowel cancer are monitored by nursing staff and are visited by the treating doctor at least on a daily basis. Measurement of blood pressure, pulse and temperature are performed regularly as is the amount of urine being passed on an hourly basis. Early in the postoperative period, intestinal function has not yet resumed and so the patient is not allowed to drink fluids or eat food until signs of the return of intestinal function appear such as the passage of flatus or wind in the usual way. Painkillers are given as required typically as doses of narcotic pain killers given through the intravenous line or drip. In most cases the frequency of these doses of pain killer is controlled simply by the patient and this is known as patient controlled analgesic (PCA). For the first few days, a urinary catheter (a tube passed into the bladder to allow the drainage of urine) is used to allow accurate measurement of urine output. Compression stockings for the lower limbs and subcutaneous injections of low dose anticoagulants are given in an endeavour to prevent deep vein thrombosis. Physiotherapy is often provided particularly to promote healthy respiratory function and in all cases, patients are encouraged to mobilise as soon as possible after surgery with the assistance of nursing staff and orderlies.
The length of time spent in hospital after surgery depends on the type of surgery undertaken, the general health and age of the patient and the time take for return of intestinal function which allows the resumption of a normal diet. Somewhere between four and ten days are required in hospital after operations for removal of bowel cancer. In older patients or those with other medical problems, a rehabilitation hospital might be recommended before the patient goes home but in the majority of cases, patients are discharged directly to their own normal residence.
COMPLICATIONS
The vast majority of patients undergoing surgery for bowel cancer have an uneventful postoperative course and are discharged to their own home without ill effect. However, surgery for bowel cancer is major surgery and complications can occur. The most important of these is discussed below.
A.Complications Related To Anaesthesia- anaesthetics carried out by Australian anaesthetists are amongst the safest in the world and serious complications related to anaesthesia are exceedingly rare.
B.Medical Problems- patients with pre-existing medical conditions such as heart disease or asthma have a higher incidence of those conditions occurring in the postoperative period than other patients. Nevertheless, rarely, patients do experience medical problems in the post operative period including heart attack, stroke, deep vein thrombosis, pulmonary embolus or pneumonia. Identification of these problems in the postoperative period may require the use of further tests and consultation with a specialist physician.
C.Infection- the bowel is home to billions of bacteria which can cause infection in some patients undergoing bowel surgery. Efforts are made to reduce the incidence of such infections by the use of bowel cleansing prior to surgery and antibiotics during surgery. Despite these measures infections can occur.
Infections of the abdominal surgical wound occur in fewer than 10% of cases. These infections are not serious but may require the use of antibiotics and dressings and can delay wound healing. In some cases a visiting home nurse may be required to supervise the wound dressing.
Infection is more serious when it occurs within the abdominal cavity or pelvis, particularly when the infection arises due to leakage of intestinal contents at the point where the bowel ends are rejoined (the anastomosis). These infections may require the use of intravenous antibiotics, needle drainage of abscess collections generally carried out by radiologists assisted with ultrasound or CT scan localisation of the infection and finally by re-operation. If the infection is serious, such operations may mean that the anastomosis needs to be dismantled in which case a colostomy may need to be constructed, typically as a temporary measure for some three to six months. Serious infections like these can significantly lengthen the time that the patient stays in hospital and on occasion will require the services of an Intensive Care Unit.
D.Bowel Obstruction- healing after surgical operations within the abdominal cavity proceeds by the development of scar tissue. In some cases, this scar tissue forms adhesions which can obstruct or kink the small intestine. The small intestine as its name implies has a smaller diameter than the large intestine and it is for this reason that it is more prone to obstruction or blockage by scar tissue. Management of such obstructions which can occur in up to 5% of patients after surgery for colorectal cancer is initially conservative with the use of intravenous fluids, cessation of all oral intake and sometimes the use of a nasogastric tube. In many cases, the bowel obstruction will resolve spontaneously but in some cases, further surgery will be required to relieve the obstruction.
E.Ileus - this condition is characterised by a delay in the return of normal intestinal motility and passage of intestinal content along the bowel in the form of normal bowel actions. In this condition, the clinical features can be similar to bowel obstruction although no actual blockage exists and the problem is simply that bowel activity is delayed in resuming after the operation. Treatment is typically conservative by continuing intravenous fluids and not resuming oral dietary intake. Ileus virtually always resolves spontaneously without the need for further surgery.
F.Haemorrhage - bleeding can occur during or after any abdominal operation but is probably more common when surgery for rectal cancer is undertaken as the pelvis contains a large number of blood vessels. Substantial haemorrhage can occur from these blood vessels during operation and sometimes bleeding can occur after surgery. Often, when surgery for rectal cancer is undertaken, a drain tube will be used to allow any residual blood to drain away from the pelvis to prevent a blood clot developing in the tissues which is an occasional cause of infection. If significant bleeding has occurred, a blood transfusion may be recommended.
G.Damage To Adjacent Structures During Surgery - injury to adjacent organs during surgery for bowel cancer is rare. One of the more significant injuries is damage to a ureter which is the tube that drains urine from each kidney to the bladder. The two ureters (one on each side) are more prone to injury when surgery is required for rectal cancer as the last part of the ureters cross close to the rectum in their course through the pelvis towards the bladder.
H.Problems With Bladder Or Sexual Function- in some cases, when the urinary catheter is removed, patients are unable to void urine spontaneously. This is more common in men, particularly those with an enlarged prostate. The problem may require treatment by reinserting the catheter and obtaining the assistance of a specialist urologist. Rarely, prostate surgery may be required. In some cases the urinary catheter may need to be left in place for a longer period of time than usual, up to several weeks.
Sexual problems may also arise particularly after surgery for rectal cancer and more particularly when this is combined with pelvic radiotherapy. In some cases, injury to small nerves in the pelvis during removal of the rectal cancer can lead to difficulties attaining an erection (impotence) or abnormalities in ejaculation. These problems are more common in older men but on occasion may be seen in younger patients as well.
I.Death- any major operation has a small but definite risk of death. Surgical mortality is defined as the failure of the patient to survive the first 30 days after an operation. For patients undergoing surgery for colorectal cancer, the incidence of surgical mortality depends on the patient’s age. Under the age of 70, surgical mortality is less than 1%. Over the age of 80 years, surgical mortality is in the order of 7%.
PROGNOSIS
The outcome or cure rate for patients with colorectal cancer depends on the stage of the tumour when they present to their doctor. In cases of early bowel cancer, surgery may be the only treatment required to eradicate the cancer and when confined to the bowel wall, the cure rate for these patients exceeds 90%. When the tumour is more advanced and in particular when the adjacent lymph glands which are removed during the course of the operation are examined and found to contain cancer cells, the cure rate is less. With surgery alone, patient with colorectal cancer and involved lymph glands have a cure rate of about 50%. This can be significantly improved by giving additional treatment in the form of chemotherapy with or without radiotherapy.
FURTHER INFORMATION
There is no doubt that the best source of information for the individual patient undergoing treatment for colorectal cancer is from that patients doctor and associated medical and nursing staff. The internet is a good source of further information and the following lists includes those from reputable sources with reliable information
- National Health and Medical Research Council
- The Cancer Council of Victoria
- Colorectal Surgical Society of Australasia
A Google search for the websites of the Cleveland Clinic Foundation and the Mayo Clinic will lead to areas on those websites pertaining to colorectal cancer. Again it is emphasised that if you have questions ask your doctor.
CONTACT
For questions or concerns after anorectal surgery performed by Professor Jones, please call him during office hours on 03 9347 4077 or after hours on 03 9387 1000.
Professor Ian T Jones