OPEN COLON RESECTION

The local excision or polypectomy discussed in the polypectomy section is a good option for very early cancers that have not invaded the wall of the colon. But if the tumor is large, or has invaded the bowel wall, you will need a more extensive surgical procedure.

Scott L. Baker, MD, FACS – “Ninety percent of the time, there is no need for a colostomy…”

Colon resection, colectomy, or partial colectomy are different names given to a type of surgery that consist of removing a part, or all, of the colon through an incision in the abdomen. This is the most common approach to treating large polyps or cancers that have grown into the wall of the colon.

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Unlike a polypectomy, which can be performed in an outpatient facility by a gastroenterologist, a colon resection is done in a hospital operating room, by a surgeon.

If the tumor is in the rectum and is full-thickness (T3 or T4) or has spread to lymph nodes, your physician may recommend neoadjuvant treatment—radiation therapy along with chemotherapy before surgery— in order to shrink the tumor so it can be removed more effectively, and decrease the chance that you will need a permanent colostomy.

An exciting development is the introduction of laparoscopic surgery and robotic-assisted surgery. Both of these techniques offer several important advantages over conventional, or open, colectomy.

Facing Surgery

Understandably, the prospect of facing major surgery might be daunting. To ease your anxiety, you may want to talk to other patients who had the same type of surgery, and learn from their experiences.

Before Surgery Checklist

Stop smoking and using recreational drugs as soon as possible.

Stop drinking alcohol.

Stop all medications that interfere with blood clotting, such as aspirin containing medications, a week before surgery. This includes Advil, Motrin, etc..

Discuss with your internist the stoppage of blood thinners like Coumadin.

Stop taking vitamins, unless you clear them with the surgeon or the surgical nurse.

Check your health and disability benefits and schedule time off.

Recruit help—even simple household chores may be more than you can handle for a while after surgery.

Consider banking your own blood for possible transfusions.

Make sure you discussed with your surgeon whether you are a candidate for the Minimally Invasive Surgery option.

Most importantly, try to concentrate on the thought that surgery is the best way to cure colorectal cancer. In other words, you are taking the step that will give you the best chance of successful treatment. Before long the discomfort of surgery will be gone and the incisions will be healed, and you will have the satisfaction of knowing that you took the best step toward a total cure.

For a colectomy, just as for the polypectomy or transanal excision described earlier, your colon needs to be as clean as possible. Your surgeon will give you specific prep instructions. More than likely, they will include being on a clear liquid diet for two days, and a potent laxative, followed by a large amount of fluids the night before the procedure. In addition, you may be started on some antibiotics to remove as much bacteria from your colon as possible.

Sometimes colon surgery requires a blood transfusion, especially if you are already anemic prior to the operation. If you want to avoid receiving blood bank products, ask your surgeon about donating and storing your own blood before surgery.

On the day of the surgery, you’ll first go through an admission process at the hospital. Your surgeon will have already reviewed with you all aspects of the procedure, and the possible risks and complications. The hospital staff will ask you to sign an informed consent form.

Informed Consent Form

• You understand the type of the procedure and the purpose for it.

• The risks of the surgery and the anesthetic have been explained to you.

• You understand that intravenous medication, anesthesia, and blood transfusions, will be administered.

• Any tissue removed during surgery may be examined and disposed.

Make sure you feel comfortable with what you are signing. If there is anything that you don’t understand, ask to see your doctor.

After you check in, an anesthesiologist or a nurse anesthetist will meet with you and select a general anesthetic that is best suited to your medical condition. Before they can make a recommendation, they need to know about all aspects of your health.

The anesthesia team will ask you about:

• Your medical history and any problems with your heart or lungs.

• Current conditions such as skin infections, colds, or tooth decay.

• Allergies to medications or food.

• Prescriptions, over-the-counter medications, or drugs that you may be taking, including herbal supplements.

• Smoking and drinking patterns.

Once you are in the staging area, the anesthesiologist will start an intravenous line (an “IV”) in one of your arms, and perhaps give you something to help you relax.

The Surgical Procedure

When the surgical team is ready, you will be taken to the operating room. Several devices will be attached to you, such as an automatic blood pressure cuff, a heart monitor, and a blood oxygen monitor.

The anesthesiologist will inject a drug into your vein through the tubing, and you will fall asleep almost immediately. A tube will be placed in your throat to maintain a clear way for you to breathe during the surgery. Your blood pressure, pulse, and breathing will be closely monitored during the entire procedure. Afterwords, you will be placed on antibiotics.

An open partial colectomy takes between one and four hours. The operation in-volves making an incision through your abdominal wall and removing the part of your colon containing the cancer, along with a short section of normal colon tissue surrounding the tumor.

In addition, the surgeon will remove all of the lymph nodes near the part of the colon affected by the cancer. Both the segment of colon and the lymph nodes will be sent to the pathologist for examination under a microscope for evidence of tumor spread.

In particular, the pathologist will verify that no cancer cells are found near the cut margins of the specimen—ideally no closer than half an inch. If cancer cells extend to the margin, there may be a possibility that some of the tumor was left behind, and you may need additional treatment.

If cancer cells are found within the lymph nodes, then it is possible that the tumor has begun to spread to other organs. In this case, your healthcare team will discuss the possibility of adding a systemic treatment, such as chemotherapy, to the surgical treatment.

In most cases, the surgeon will reconnect the remaining ends of your colon together (this is called anastomosis) so stool can pass out of your body in the usual way.

Risks and Complications

As with any surgical procedure, there are risks associated with colon resection. In general, these include the following: Your surgeon will describe to you in detail the procedure and the complications that are possible:

• Reaction to anesthesia

• Blood clots

• Bleeding from the operative site into the abdomen

• Infections, including pneumonia and formation of an abscess inside the abdomen or the colon

• Bowel content leakage into the abdomen

• Injury to other structures in the abdomen

• Formation of a fistula—an unwanted connection between the skin and the intestines.

Will I Need a Colostomy?

A colostomy is a procedure that creates a connection between the bowel and the outside of the abdomen, so stool can pass through and be collected into a bag attached to the skin of the abdomen.

The issue of a colostomy is a major concern for most patients. In general, a colostomy is required only if the cancer is in the lower rectum and the anus needs to be removed.

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If you required an urgent operation, a temporary colostomy may also be necessary due to your condition or the condition of your large intestine at that time.

With today’s advances in early diagnosis and improved treatment of colorectal cancer, most patients being treated for cancer that is in the colon, rather than the rectum, will not need a permanent or temporary colostomy.

Recovery After Open Colectomy

After surgery, you’ll be taken to the recovery room. As you wake up from the anesthetic, you may feel cold, and your throat may be sore from the tube used for anesthesia. You may fade between waking and sleeping for several hours.

You will have a tube in your urethra, called a Folley catheter, to help you urinate after surgery. This tube will be removed within a few days.You will not need a tube in your nose, called an NG tube.

Most patients like to have a friend or relative meet them after the operation. You can ask your surgeon how long it will take before you will be brought to your room after surgery, and to arrange with the hospital to allow that person to meet you there.

To avoid overstressing your bowels, for the first 24-48 hours you will be restricted to sips of water. Your surgeon will be looking for your ability to pass gas from your rectum as an indication that your bowels are recovering and starting to move normally. Generally, you will soon be allowed to eat more substantial fare such as soups and applesauce.

Each patient reacts to surgery differently. Most patients will stay in the hospital for four to seven days after an open colectomy.

What determines how long you will stay in the hospital? Your medical team will want to be sure of three things: that you can tolerate a normal diet, that you can ambulate independently, and that your pain can be controlled with oral medications. Get a passing grade on all three, and you will be free to go home.

One of the usual side effects of surgery and anesthesia is partial blockage or collapse of the breathing sacs within the lungs. Someone on your healthcare team will teach you how to do breathing exercises. Their purpose is to force your lungs to re-expand. Be diligent about these breathing exercises—they will help speed your recovery. Continue them even after you go home.

You will probably have incision pain for days after surgery. Do not hesitate to take the pain medications prescribed. Accepting pain unnecessarily leads to added fatigue, prevents you from breathing freely, and may interfere with healing. This is a case where the saying “No pain, no gain” does not apply.

One of the most common concerns to most patients undergoing surgery is fatigue—a feeling of tiredness. You too will probably feel more tired than usual for a while. Don’t be discouraged. You’ve just been through general anesthesia and major surgery, and less than perfect performance is to be expected. Do not push yourself. When your body has recovered, your energy will return on its own.

As soon as you can, start a walking program. Walking is probably one of the best exercises for you at this time. It helps to keep blood clots from forming in your legs, improves bowel function, and returns your lungs to their pre-surgery state.

It is normal to expect to be limited to taking sponge baths for a few days after surgery so that your incision can heal. Most patients will be ready for a shower prior to leaving the hospital. Follow your surgeon’s instructions on changing bandages. When showering, gently wash around the incision, and don’t take a bath until your wound closes completely.

Immediately after surgery, you’ll probably have trouble moving. Use your body as tolerated, but avoid active movements until you get your doctor’s approval. Don’t be afraid to enlist the help of a friend or relative until your strength returns.

Many people return to normal activities within four to six weeks. If your job requires heavy lifting or strenuous physical work, you may need to change your activities until you have fully regained your strength.

Before you decide to have surgery to treat colon cancer, make sure you understand the following:

• What kind of surgery will be done.

• What you need to do to prepare for the surgery.

• How long it will take for you to recover from the surgery.

• The possible risks and complications associated with the surgery.

• What additional treatment you may need after surgery.

• How the surgery may affect your daily activities.

• The cost of the surgery and the drugs, treatments, and hospital stay associated with the surgery.

• Who will pay for the surgery and its associated costs.

Diet

You may have a consultation with a dietitian before you go home from the hospital. You will be told to drink at least eight glasses of water a day to stay hydrated.

Most patients who have had colon surgery find that their bowel habits have changed. This may include softer or more frequent stools. These changes can generally be managed with medications or with bulking agents and improve with time.

A bowel management program may be as simple as slowing down your digestion process by avoiding large meals or hot liquids at meal time, or by retraining the colon to empty itself fully at a specific time during the day that is convenient for you. Your healthcare team will give you specific instructions to help make sure that colon surgery has a minimal impact on your quality of life.

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