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Surgery of the colon

Author/s: Dr. Albert Navarro Luna, Dra. Mª Antonia Lequerica Cabello y Dra. Raquel Sáez Redín

Objective of the operation

The objective of the operation is to resect the portion of the thick intestine encompassing the tumour, as well as the entire territory of lymphatic drainage. Furthermore, the resection must include minimal margins reducing to the maximum the possibilities for regrowth of the tumour in the area. The aim of the surgery is to reduce to a maximum the possibilities of recurrence both at a local site (local recurrence) as well as at a distance (metastasis).

What must I do before the operation?

Your doctor will tell you what you need to do, but as a general rule, before the operation, it is important to run a series of tests to try and find out how far the tumour has gone. These tests are known as “extension study”. Among these tests, we can mention, apart from a fibrocolonoscopy that is done to localise the tumour and rule out the existence of other tumours in the colon, abdominal and thoracic CAT in some cases, chest X-ray, abdominal ultrasound and blood test for a specific marker that is called CEA. The preoperative study (chest X-ray, electrocardiogram and blood tests with coagulation panel) are essential tests before any surgical procedure is carried out.

The day before of the operation and, unless otherwise contraindicated, your doctor will tell you about a procedure known as colon cleansing or mechanical preparation of the colon, the objective of which is to clean the inside of the colon to minimise the risk of infectious-type complications. It is possible that you may have been subjected to a cleansing of the colon before for the colonoscopy and thus you will be familiar with the procedure.

For the actual operation, you will have had to be on an empty stomach for about 6 to 8 hours with no food whatsoever. Your doctor will tell you the time when you will be no longer allowed to have any food.

Another way to reduce to a maximum infection-related complications is by administering antibiotics that are usually given just before or during the actual procedure Whether or not antibiotics are prescribed after the operation is a decision to be taken by your doctor after he or she sees how the procedure is developing. It must be pointed out that if antibiotic therapy after the operation is not necessary, administering antibiotics will not provide any beneficial effect and can, however, cause some unwanted side effects. The decision will be entirely up to the surgeon after the operation.

What will the operation be like if the tumour is in the colon?

Excepting some few cases, the treatment of cancer of the colon is surgery. The tumour can be removed via colonoscopy only in those instances in which it is small or at initial stages. This option is sufficient only after the biopsy confirms that a more radical surgery is not necessary. Another situation in which the operation is not indicated as the initial treatment is when the tumour has spread out and it is better for the patient to start with chemotherapy first.

In general terms, there are three types of surgical procedures, depending on the localisation of the lesion.

-If the lesion is localised in the cecum, right colon or in the part closest to the right side of the transverse colon (hepatic angle) , the operation of choice will be a “right hemicolectomy”, in which the cecum, right colon and another part of the transverse colon, to be determined during the actual procedure. After the resection, a suture line is applied between the end of the small intestine and the transverse colon .

-If the lesion is in the left colon or left portion of the transverse colon (splenic angle) a “left hemicolectomy” will generally be performed. In this procedure, the sigma and the left colon are resected. The suture is applied between the junction of rectum and sigma, and the transverse colon.

– When the lesion is located in the sigma, the upper part of the rectum and sigma will be resected, applying a suture between the left colon and the rectum.

– If the tumour involves the transverse colon (see animation), at the time of surgery, the surgeon will have to decide the best type of resection, that is, to perform an extended right herniocolectomy or an extended left herniocolectomy.

There are other options, the explication of which would entail an unnecessary degree of complexity.

In all these situations, the creation of a stoma or “bag” is NEVER necessary, unless there is a specific reason of a technical nature to do so.

Laparoscopy is a surgical technique that involves the placement of instruments through small orifices to perform, as in colorectal cancer, the resection of the portion containing the tumour. This technique affords less postoperative pain and a shorter hospital stay. The possibility to perform surgery via this laparoscopic technique will be explained to you by your surgeon and will depend on several factors such as the size and location of the tumour for instance. It is very important that this technique provides you with results as good as those afforded by the open approach.

Unfortunately, all surgical procedures always entail some risk of complications, In surgery of cancer of the colon, the main likely complications are the opening of suture lines along the intestine, a condition known as suture failure. Although this occurrence is rare (less than 6% approximately), it is rather severe and generally requires a reintervention. The infection of the skin wound is a more frequent complication but not as severe. It usually gets resolved with regular wound care. Your doctor will inform you about other less frequent complications, depending on each specific case.

What will happen after the operation?

Generally, after surgery, you will have a tube in your nose, a tube to urinate, IV´s, and, on occasions, a drainage line. As days go by, all these tubes will be gradually removed. Intake of liquids is usually started towards the second postoperative day, gradually resuming a normal diet. Hospital discharge is usually on the 7/8th postoperative day if there have been no complications.

Five to seven days after the operation, we will have the results of the biopsies of all the tissues that were removed during surgery and armed with those results, the oncologist will decide if any other treatment is required (radiotherapy or chemotherapy).

After the operation, you will have to be careful not to overexert yourself or perform heavy movements for about 4 to 6 weeks. You will be able to eat almost anything. You may notice a slight change in your evacuations, although this change will depend on the type of surgery performed. In cases where the surgery was motivated due to colon cancer, it is possible some sort of deposition alterations to occur, although this is generally temporary. More rarely, there can be alterations, most of the time, of a temporary nature, when urinating or with sexual function. The surgeon will explain this further, depending on the type of surgery performed.

Surgery of the rectum

Objective of the operation

The objective of the operation is to resect the portion of the rectum encompassing the tumour, as well as the entire territory of lymphatic drainage. Furthermore, the resection must include minimal margins reducing to the maximum the possibilities for regrowth of the tumour in the area. The aim of the surgery is to reduce to a maximum the possibilities of recurrence both at a local site (local recurrence) as well as at a distance (metastasis).

What must I do before the operation?

Your doctor will tell you what you need to do, but as a general rule, before the operation, it is important to run a series of tests to try and find out how far the tumour has gone. These tests are known as “extension study”. Among these tests, we can mention, apart from a fibrocolonoscopy that is done to localise the tumour and rule out the existence of other tumours in the colon or rectum, abdominal and thoracic CAT in some cases, chest X-ray, abdominal ultrasound and blood test for a specific marker that is called CEA. The preoperative study (chest X-ray, electrocardiogram and blood tests with coagulation panel) are essential tests before any surgical procedure is carried out.

The day before of the operation and, unless otherwise contraindicated, your doctor will tell you about a procedure known as colon cleansing or mechanical preparation of the colon, the objective of which is to clean the inside of the colon and rectum to minimise the risk of infectious-type complications It is possible that you may have been subjected to a cleansing of the colon before for the colonoscopy and thus you will be familiar with the procedure.

For the actual operation, you will have had to be on an empty stomach for about 6 to 8 hours with no food whatsoever. Your doctor will tell you the time when you will be no longer allowed to have any food.

Another way to reduce to a maximum infection-related complications is by administering antibiotics that are usually given just before or during the actual procedure. Whether or not antibiotics are prescribed after the operation is a decision to be taken by your doctor after he or she sees how the procedure is developing. It must be pointed out that if antibiotic therapy after the operation is not necessary, administering antibiotics will not provide any beneficial effect and can, however, cause some unwanted side effects. The decision will be entirely up to the surgeon after the operation.

If the tumour is in the rectum.

Surgery of cancer of the rectum is much more complex in all aspects than surgery of the colon. The different types of treatment will depend on the situation of the tumour and the progression stage it is in at the time of diagnosis.

First of all, and as mentioned before, an extension study is performed. If possible, during the extension study, an endorectal ultrasound is performed to ascertain the level of invasion of the tumour. Another option to determine the level of invasion is magnetic resonance.

The rectum is the final part of the large intestine. Depending on the localisation, the level of expansion estimated by the endorectal ultrasound and the existence or not of distant dissemination, the options will be:

1.- Surgery as first treatment with excision of a segment of intestine that will include sigma and rectum Depending on the proximity of the tumour to the anal sphincters and the technical characteristics of the intervention, it is possible to apply a suture or to perform an anastomosis between colon and rectum. . The removal of the anus with creation of a definitive colostomy (stoma or “bag”) might be necessary. When the excision of anus is not mandatory, in some cases it will be necessary to leave a stoma (“Bag”) temporarily for protection for a few months.

2.- Firstly, treatment with radiotherapy and chemotherapy for approximately 5 weeks; followed by excision of the tumour and intestine, as described in the last section.

3.- In very selected cases of very small tumours, local resection through the anus via endoscopy or surgery might be all that is necessary.

Laparoscopy is a surgical technique that involves the placement of instruments through small orifices to perform, as in colorectal cancer, the resection of the portion containing the tumour. This technique affords less postoperative pain and a shorter hospital stay.

The possibility to perform surgery via this laparoscopic technique will be explained to you by your surgeon and will depend on several factors such as the size and location of the tumour for instance. It is very important that this technique provides you with results as good as those afforded by the open approach.

Unfortunately, all surgical procedures always entail some risk of complications, although such risk is generally low. In surgery of cancer of the rectum, the main likely complications are the opening of suture lines along the intestine, a condition known as suture failure. Although this occurrence is rare (less than 6% approximately), it is rather severe and generally requires a reintervention. The infection of the skin wound is a more frequent complication but not as severe. It usually gets resolved with regular wound care. Your surgeon will inform you about other less frequent complications, depending on each specific case.

What will happen after the operation?

Generally, after surgery, you will have a tube in your nose, a tube to urinate, IV´s, and, on occasions, a drainage line. As days go by, all these tubes will be gradually removed. Intake Intake of liquids is usually started towards the second postoperative day, gradually resuming a normal diet. Hospital discharge is usually on the 7/8th postoperative day if there have been no complications.

Five to seven days after the operation, we will have the results of the biopsies of all the tissues that were removed during surgery and armed with those results, the oncologist will decide if any other treatment is required (radiotherapy or chemotherapy).

After the operation, you will have to be careful not to overexert yourself or perform heavy movements for about 4 to 6 weeks. You will be able to eat almost anything. You may notice a slight change in your evacuations, although this change will depend on the type of surgery performed. In cases where the surgery was motivated due to rectal cancer, it is possible some sort of deposition alterations to occur, although this is generally temporary. More rarely, there can be alterations, most of the time, of a temporary nature, when urinating or with sexual function. The surgeon will explain this further, depending on the type of surgery performed.

Contra natura anum

A stoma or “bag” or contra natura anum, is an opening from the intestine into the skin of the abdomen. It is also referred to as colostomy or ileostomy, depending on its location. The intestinal contents will flow directly and without control into a plastic bag, especially designed for that purpose. The patient can lead a completely normal life. The only thing required is to change the plastic bag that is adhered to the skin regularly.

Not necessarily so. A stoma or “bag” is only required when the tumour is at the final end of the rectum. In these situations, the stoma is generally definitive. On occasions, a stoma is created in tumours housing other locations, but most often, it is a temporary situation.

If you need to carry a “bag” or definitive stoma, your life will only change minimally as you will be able to carry on doing the same routines as before, such as doing sports, exercising, bathing, travelling, etc. You would only need counselling from a specialised person in stoma care (stomatherapist).