Minimally Invasive Surgery for the Treatment of Colon Cancer
Colon cancer is the third most commonly known cancer in both men and women. Large bowel tumors are the most common type of digestive cancer and account for a large proportion of all gastrointestinal (GI) surgeries. Colon cancer is mostly treated with surgery to remove the tumor. Over the past few decades, there are many new advances, such as the use of laparoscopic methods, and there is a drastic improvement in laparoscopic-based diagnostic and screening procedures. Furthermore, advances in genetics now carry the exciting promise of earlier diagnosis and more accurate prediction of survival.
What are the symptoms of colon cancer?
Depending on the location of the tumor, symptoms of colorectal cancer include:
- Changes in bowel movements like alternating diarrhoea/constipation
- Rectal bleeding
- Cramping in rectum during defecation
- Dark patches of blood in or on the stool
- Belly discomfort or bloating sensation
- Long, thin, stringy “pencil stools”
- Fatigue, weakness or feeling tired soon
- Loss of appetite and weight loss with no clear cause
- Pelvic pain
What is the surgical approach for colon cancer?
Surgery is the optimal treatment approach for colon cancer. The results turn out to be good depending on the preoperative preparation, performing an appropriate and safe operation, and postoperative care. The choice of surgery is based on the anatomic location of the lesion.
The surgical procedure requires the removal of the tumor and also the surrounding healthy tissue. This is also called surgical resection. It is the foremost treatment for colon cancers in the early stages. A surgical oncologist is a specialist in treating cancer using surgery. The type of surgery employed depends on the stage and location of cancer. Any type of colon surgery shall be performed on a clean and empty colon. Until surgery, the patient may have to take a strict diet and will need to use laxative drinks and enemas to get all the stool out of the colon. The preparation of the intestines is much like the one before a colonoscopy.
Principle points to be considered before the surgery of colon cancer include:
- Early proximal ligation of vessels
- Accomplishing an anatomic resection
- Minimal tumor manipulation
In addition to surgical resection, the options of surgical treatment for colon cancer include:
- Laparoscopic surgery: Some of the patients may undergo laparoscopic surgery for colon cancer. This procedure brings multiple viewing scopes into the abdomen when a patient is under anesthesia. The incisions are smaller, and therefore the healing time is shorter than the standard colon surgery. Laparoscopic surgery is as effective as conventional surgery in eliminating cancer.
- Colostomy/Ileostomy: A person with rectal cancer may need to undergo an ileostomy or colostomy less frequently. This is a surgical opening, through which the ileum/colon is connected to the abdominal surface providing the exit for waste which is collected in the pouch worn by the patient. The colostomy is often a temporary technique allowing the rectum to recover, but it can also be permanent. Along with the advanced surgical methods and the use of radiation therapy and chemotherapy before surgery as necessary, most people undergoing rectal cancer care do not need a permanent colostomy.
What are the treatment options available depending on colon cancer stage?
There are different stages of colon cancer. These stages 0, I, II, and III are usually often curable with surgery. Most people with stage III colon cancer, and those with stage II, are undergoing chemotherapy after surgery to increase the chance of eliminating cancer. Patients with rectal cancer in stage II and III can also undergo chemotherapy radiation therapy, either before or after surgery. Stage IV is not always curable, but it is treatable and can control cancer growth and disease symptoms.
- Stage 0 colon cancer: The most often treatment in this stage is polypectomy. It is the removal of a polyp during the colonoscopy. There is no alternative or additional surgery unless the polyp is removed completely
- Stage I colon cancer: Surgical removal of the tumor and lymph nodes is the most often treatment needed.
- Stage II colon cancer: The first choice of treatment at this stage is surgery. Patients with stage II colon cancer should discuss with their doctor whether there is a need for further care after surgery as certain patients receive adjuvant chemotherapy. Adjuvant chemotherapy is post-operative treatment to attempt to destroy any cancer cells remaining. However, the cure levels are relatively high with surgery alone, and there are few advantages of adjuvant care for patients with this stage of colon cancer.
- Stage III colon cancer: At this stage, treatment involves surgical removal of the tumor followed by adjuvant chemotherapy.
- Metastatic (stage IV) colon cancer: When cancer spreads from where it originated to another part of the body it is called metastatic cancer. Colon cancer may spread to other distant organs, such as the liver, lungs, peritoneum lining the abdomen, or ovaries of a woman. Doctors can have different opinions on the best standard treatment plan. The treatment options may involve a combination of surgery, radiation therapy, immunotherapy, and chemotherapy which can be used to delay disease progression and also shrink a cancerous tumor temporarily. Furthermore, palliative care will be necessary to help relieve symptoms and side effects.
At this stage, surgery cannot cure cancer, but it can help relieve the blockage of the colon or other problems related to cancer. There is a possibility of a complete cure if colon cancer has only spread into the liver and if surgery is necessary before and after chemotherapy. Also, if cancer cannot be cured, surgery can be of great help to add months or even years to the life of a patient.
What are the surgeries performed to treat colon cancer?
Polypectomy and local excision
A colonoscopy can remove some early colon cancer (stage 0, and some early stage I tumors) and most polyps. This technique uses a long and flexible tube with a small video camera on the end which is inserted in the rectum of the person and the entire colon is visualised. These surgeries may be conducted during a colonoscopy:
- Cancer is removed as part of a polyp cut at the stalk (a portion that looks like the stem of a mushroom) for polypectomy. This is usually accomplished through the colonoscope by passing the wire loop to cut the polyp off the colon wall by electric current.
- Local excision is a procedure that is slightly more involved. The colonoscope uses devices for removing small cancers on the inside of the colon along with a small amount of healthy surrounding tissue in the colon wall.
The doctor need not cut into the abdomen when cancer or polyps are taken this way.
A colectomy is a surgery that removes all or part of the colon along with the nearby lymph nodes. If only part of the colon is cut it is called hemicolectomy or partial colectomy or segmental resection. The surgeon removes the section of the colon with cancer on either side and a small portion of the normal colon. Depending on the size and location of cancer, about one-fourth to a third of the colon is normally removed. The rest of the colon sections are then reattached. At least 12 lymph nodes in the area are also removed to check for cancer.
If the entire colon is removed, it is called a total colectomy. It is mostly used when there is another problem in the colon with cancer, such as hundreds of polyps or inflammatory bowel disease like ulcerative colitis.
How is it performed?
A colectomy can be performed in two ways:
- Open colectomy: This procedure is performed by a single long incision in the abdomen.
- Laparoscopic-assisted colectomy: The procedure is performed through several smaller incisions and special tools. A laparoscope is a long, thin light tube with a small camera on the end which gives the surgeon a glimpse into the abdomen. It is placed in one of the small cuts and long, thin instruments are inserted in the others to remove part of the colon and the lymphatic nodes.
Since the incisions are smaller than in an open colectomy in a laparoscopic-assisted colectomy, patients often recover more rapidly than in the aftermath of open colectomy. However, this kind of procedure involves a skilled, trained and experienced doctor and may not be the right choice for all. In general, survival rates and the risk of cancer recurrence between an open colectomy and a laparoscopic colectomy are almost the same. The removed portion of the colon is extracted through a small incision using a wound protector.
That is a procedure that removes the anus, rectum and sigmoid colon. It needs a permanent colostomy as the anus is removed.
In this surgery, the diseased section of the rectum and sigmoid colon is removed.
It is the most extensive bowel procedure carried out and includes both the rectum and the colon removal. When the surgeon can leave the anus and it functions properly, an ileal pouch can be created. However, a permanent ileostomy is often required, particularly when anus has to be removed, or is weak, or damaged.
What is the surgery performed to prevent metastatic/advanced colon cancer?
Metastatic colon cancers are the one that spread to other parts of the body and also have tumors blocking the colon. The surgery may be done to remove the blockage without removing the part of the colon with cancer. Instead, the colon is given an incision through the tumor and attached to a stoma to expel stool. This is called a diverting colostomy. This can help the patients to recover and start with other treatments such as chemotherapy to avoid recurrence of colon cancer.
Colostomy or Ileostomy: What to choose?
Some patients require colostomy (or ileostomy) after surgery temporarily or permanently. This may take a while to get used to and may require changes in lifestyle. A patient needs to learn how to manage if they have a colostomy or ileostomy. This may be achieved by specially qualified ostomy nurses or enterostomal therapists. They normally see the patient before the procedure in the hospital to address the ostomy and mark the opening site. They can go to the patient’s house or visit them in an outpatient setting to provide with more training after the procedure.
What are the possible side effects of colon cancer surgery?
There are many considerations to the possible complications and side effects of the surgery, chemotherapy or radiation therapy including the duration of the procedure and general health before the surgery. Problems can include vomiting, infection and blood clots on the legs during or shortly after surgery.
- Changes in bowel and sexual function
- A leak where the ends of your colon are joined
- Nausea or Vomiting
- Peripheral neuropathy
- Hand and Foot Syndrome
- Temporary or permanent stoma
Compared to traditional open surgery treatment for colon cancer, the advanced methods such as Robotic Surgery involves smaller incisions which help many cancer patients to recover faster and aid in the speedy return of their bowel function.
- Colon cancer, Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/syc-2035366, Accessed on 16th March 2021.
- Surgery for Colon Cancer, American Cancer Society, https://www.cancer.org/cancer/colon-rectal-cancer/treating/colon-surgery.html, Accessed on 16th March 2021.
- Colon Cancer Surgery: What to Expect, Johns Hopkins Medicine, https://www.hopkinsmedicine.org/health/conditions-and-diseases/colon-cancer/colon-cancer-surgery-what-to-expect, Accessed on 17th March 2021.
- Colorectal Cancer Surgery, WebMD, https://www.webmd.com/colorectal-cancer/surgery-treat-colorectal-cancer, Accessed on 17th March 2021.
About Author –
Dr. K. Sreekanth, Consultant Surgical Oncologist, Yashoda Hospital, Hyderabad
MS, M.Ch (Surgical Oncology)