Colorectal cancer is among the top five types of cancer diagnosed in the U.S. In 2022, about 106,000 new cases of colon cancer, and nearly 45,000 new cases of rectal cancer, will occur nationwide, according to American Cancer Society estimates. Although older adults are more likely to develop colorectal cancer, cases are increasing among younger adults.
Surgery is the primary treatment for colorectal cancer. Fortunately, screening and early symptom recognition can lead to a successful surgery and a cure.
Colorectal cancer involves tumors in the colon, rectum or both. It’s detected mainly through colonoscopy screening or when symptoms such as blood in the stool or abdominal pain develop.
The colon, rectum and anus make up the large intestine. The colon receives mostly digested food from the small intestine, or small bowel, which receives partially digested food from the stomach.
“The colon is the ‘dryer,'” in the bowels, says Dr. George Chang, chair of the colon and rectal surgery in the division of surgery at the University of Texas MD Anderson Cancer Center in Houston. “The small bowel absorbs all the nutrients and puts liquid stuff into the colon, which absorbs the water, and then you get solid stool.”
Colorectal Cancer Symptoms
Tell your doctor if you experience any of these symptoms that can indicate colon cancer:
— Blood in your stool.
— Rectal bleeding.
— Bowel habit changes — diarrhea or constipation — that persist.
— Changes in stool consistency.
— Abdominal cramps, gas or pain that persist.
— A sensation of incomplete bowel emptying.
You may detect blood in your stool visually or through a positive result from an at-home colon cancer screening test. It’s important to let your primary care providers know. They will ask for a stool sample to do lab tests for hidden blood, or DNA biomarkers for cancer cells, and likely recommend a colonoscopy.
In a colonoscopy exam, the colonoscope — a long, flexible tube with a tiny video camera — is inserted into the rectum, allowing a full view of your colon and rectum. Typically, you’ll have conscious sedation for the painless test, which lasts about a half-hour to an hour.
If colorectal cancer is diagnosed, doctors use imaging tests and lab results to stage your cancer. Cancer is staged by tumor size and how far it goes into the organ’s wall, whether the tumor has spread to the lymph nodes and metastasis to other parts of the body.
After diagnosis, your doctor will discuss treatment options, which may include surgery. Here’s what you should know about colorectal surgery.
What Is Colorectal Surgery?
Colorectal surgery involves resection, or removal, of parts of the colon, rectum or both, to remove cancer. Surgery is most effective when the tumor is diagnosed before it has spread to other parts of the body. For localized colon cancer, the five-year survival rate is 91%, and for localized rectal cancer, the rate is 90%, according to the American Cancer Society.
Colorectal surgery comes with typical surgical risks such as infection at the surgical site, blood clots and delayed healing. Smokers and people who have heart disease, diabetes or obesity are more vulnerable to these complications. In addition, changes in bowel function, pain and other complications can occur depending on the surgery’s extent and nerve involvement.
Who Might Need Colorectal Surgery?
Colorectal surgery is used for patients with certain noncancerous conditions too. Reasons include:
— Colorectal cancer. Surgery is the primary treatment for curable colorectal cancer.
— Large polyps. A polyp is a growth in the colon or rectum.
— Diverticular disease. Diverticulosis, or diverticulitis, involves small sacs or bulges called diverticula that form in the colon. Complications from diverticulosis, such as infections or bleeding, may require surgery.
— Inflammatory bowel disease. Complications from IBD, such as ulcerative colitis or Crohn’s disease may require surgery.
— Volvulus. Abnormal twisting of the intestines can dangerously restrict blood supply to the colon.
— Ostomy reversal. Surgery is used to reattach the colon to the rectum or anus and close off the temporary ostomy.
Patients with colon cancer that has spread to the lymph nodes often receive chemotherapy after surgery. Patients with rectal cancer are more likely to receive radiation, as well as chemotherapy before surgery.
Who Performs Colorectal Surgery?
When choosing a surgeon, it’s best to find a specialist in the field, Chang says. “Experience matters for all cancer surgery, whether it’s colon cancer or rectal cancer, and whether it’s a colon and rectal surgeon, or a surgical oncologist or a cancer specialist who does a lot of surgery on colorectal cancer.”
It’s also worth finding a cancer center that offers multidisciplinary care, one with high ratings and good treatment outcomes. The U.S. News Best Hospitals rankings can help you pinpoint medical centers that meet your needs — for example, you can filter and compare ratings for the best hospitals for colon cancer surgery.
Evidence shows that, in general, centers that perform low volumes of specific procedures tend to deliver worse patient outcomes. Similarly, surgeons who do high volumes of specific operations tend to have better results.
Colorectal Surgery/Procedure Types
Depending on the specific area and extent of colorectal cancer, surgical options include:
— Colonoscopy to remove early-stage cancers/polyps. During procedures used to examine the colon, precancerous polyps (abnormal tissue growths) and small cancers are removed.
— Laparoscopy (minimally invasive). Surgery uses smaller cuts through which a tiny camera and instruments are used to remove the tumor.
— Robotic surgery (minimally invasive). Surgical systems with 3D capability allow more precision than hands-on procedures.
— Laparotomy (open surgery). Surgery is done through an incision in the abdominal area, often to remove larger tumors and surrounding tissue.
Colectomy is the medical term for surgery to remove the area of the colon with cancerous growth plus immediately surrounding healthy tissue. This surrounding tissue, known as the margin, is removed to prevent undetected cancer cells from remaining in the body. Lymph nodes near the tumor are also removed for microscopic analysis to determine if the cancer has spread.
Types of colectomy refer to the specific part of the colon involved such as a left hemicolectomy, right hemicolectomy, sigmoid colectomy and total colectomy.
After the tumor and margin are removed, surgeons attach adjacent parts of the intestine to form a continuous channel. This surgically created connection is called an anastomosis.
It’s usually but not always possible for surgeons to create an anastomosis, for instance, because of the tumor’s location. “If you don’t get an anastomosis, that stool is going to have to go somewhere,” Chang says. “So that’ll be a colostomy.”
What Is a Colostomy?
A colostomy is a surgical procedure that redirects how food waste passes through your body. In cases where your colon needs to be bypassed, surgeons create a new opening in your abdominal wall, called a stoma. Poop leaves your body through this opening and drains into a colostomy bag. Colostomies can be temporary or permanent.
Although a colostomy may be unavoidable, it’s worth seeing a second opinion before having one.
“A lot of people come to MD Anderson because they were told they needed a colostomy and we see them and they don’t need a colostomy,” Chang says. In those cases, he says, “We can do an anastomosis.” In addition to a surgeon’s experience, factors such as tumor characteristics and treatment response determine whether an anastomosis is possible, he adds.
“One reason you need a colostomy is if a tumor is located in a place where there’s no place to reconnect,” Chang says. “Or, after reconnection to allow time for healing, your surgeon may recommend a temporary ostomy, which will then be reversed as a relatively small operation compared to that major resection, after the healing is completed.”
You’re likely to have a temporary colostomy for a few months or so. “Generally, it’s going to be three months or longer, depending on whether the patient is going to get chemotherapy after surgery,” Chang says. Most but not all patients can have their ostomies reversed.
People with permanent colostomies can live full, active lives. However, having a colostomy often involves a physical and emotional adjustment, along with routine management of the ostomy site. Although an ostomy doesn’t affect your sex life, Chang says, body image can be a concern for some people.
How to Prepare for Colorectal Surgery
Before you have colorectal surgery, you’ll undergo a comprehensive evaluation of your overall health, including making sure your heart and lung function is strong enough for surgery. Your health care team will encourage you to quit smoking, exercise and eat healthy before surgery.
You will also get specific instructions on what to do in advance of your scheduled surgery. Although each center is different, preparation typically involves:
— Clear liquid diet. Generally starting the day before surgery, you’ll be asked to avoid solid foods and drink clear liquid only. Water, black coffee or tea without milk or cream, sports drinks with electrolytes, juice without pulp, sodas and clear broth are typically allowed. However, avoid any liquids containing red dye, which can resemble blood in the colonoscope camera view.
— Bowel-cleansing solution. You’ll be instructed to drink a prescribed solution that cleans your bowel of any stool. Beginning the day before surgery, you’ll drink a cup or so of this colon lavage solution at regular intervals.
— Antibiotic. An oral antibiotic may be prescribed for you to take at specified times before your surgery.
Recovering From Colorectal Surgery
Colorectal surgery recovery has been streamlined. Instead of bedrest, patients now get up and move with assistance on the day of or day after surgery. Pain is mostly managed with oral medications although sometimes intravenous pain medication is briefly used.
Patients may now return to solid food faster, rather than traditional recommendations starting with a clear liquid diet and very gradually progressing to a regular diet.
“We may start them on solid food, depending on what kind of surgery was done and how the patient is doing,” Chang says. “No longer do we say: liquids first, and then solid food. You actually can go to light solid food right away.”
Eventually, bowel function largely returns to normal for most people, Chang says. “They might go a little more frequently because you have less colon.” In fact, he says, some people who have had chronic constipation find their constipation has improved after surgery.
The colon’s water-absorbing function mostly happens on the right side of the colon, Chang says. “So, if you have the right side of the colon removed, it could be a little looser, but the colon (adjusts) pretty quickly,” he says. “The left side of the colon does some of the pushing function.”
The rectum has a stool-storage function. “If you have surgery on the rectum, then you won’t be able to store stool the same way,” Chang says. “So you go more frequently, more urgently and you can become more irregular. And all of those are affected by how much rectum remains and whether or not you received any radiation to the pelvis, as an example.”
Younger-Onset Colorectal Cancer
Younger-onset colorectal cancer is defined as cases occurring among people younger than 50. Colorectal cancer rates among younger adults have been rising steadily since the 1990s, according to the National Cancer Institute.
Overall, with better screening and treatments, death rates from colorectal cancer have trended downward for the past 20 years — with one exception. According to the Centers for Disease Control and Prevention, adults ages 45 to 54 have experienced a small but clear rise in death rates from colorectal cancer during that period.
In 2021, the minimum recommended age for routine colorectal cancer screening was lowered from 50 to 45. Improved outcomes for older adults are directly attributable to screening colonoscopies, says Dr. David Liska, a colorectal surgeon and director of the Center for Young-Onset Colorectal Cancer at Cleveland Clinic.
“But for young adults, because they don’t get this routine screening, we have seen the incidence is rising,” Liska says. “And we don’t really know why this is happening.”
Recent well-known cases — such as “Black Panther” star Chadwick Boseman, who died of colon cancer at age 43 in 2020, and Trey Mancini of the Baltimore Orioles, who missed his entire 2020 season to undergo colon cancer treatment — illustrate that the condition can occur among young, seemingly healthy adults.
Meeting Younger Patients’ Needs
Taking care of patients with young-onset colorectal cancer in a comprehensive, coordinated fashion is the No. 1 impetus and role of Cleveland Clinic’s specialty center, Liska says, along with advancing the field through research and education.
Treatment basics are largely similar at any age. “Most patients with colorectal cancer that’s curable will have surgery,” Liska says. “Sometimes they will have chemotherapy if it’s colon cancer. With rectal cancer, the treatment is a little bit more complicated.” Radiation is also used as indicated.
Genetic conditions that can cause colorectal cancer — such as Lynch syndrome and familial adenomatous polyposis — are more common in younger people. “A heritable colorectal cancer syndrome can have implications for not only the treatment of the patient, but also of their family members,” Liska says. “So it’s really important that young people who are diagnosed with colorectal cancer see a genetic counselor so they can have a discussion (about genetic testing).”
Having a disease that predisposes people to colorectal cancer, such as ulcerative colitis or Crohn’s disease, would be another reason for younger adults to be screened earlier than the recommended guidelines.
Limiting Surgery’s Impact
“Reducing the impact of surgery probably has an even more important impact on young people who really need to bounce back from surgery as fast as possible so they can get back to their busy lives,” Liska says. A variety of approaches to help decrease the toll surgery takes at any age include:
— Minimally invasive surgery, such as laparoscopic or robotic, if possible. Minimally invasive surgery with smaller incisions means less pain for patients and is offered at many centers.
— Treatment to avoid surgery altogether. Total neoadjuvant therapy using chemo and radiation is a new way whereby some patients with rectal cancer can be cured without surgery, says Liska, who has been involved with laboratory research and clinical trials on this approach at Cleveland Clinic.
— Enhanced recovery after surgery protocols. ERAS protocols, which exist for various types of surgery, allow people to return to their usual, healthy selves as soon as possible. Minimizing the need for opioid pain medication, minimizing postoperative drains and accelerating ambulation (walking) after surgery are part of the pathway to early recovery.
Relying less on opioid drugs than in the past has several advantages, including recovering bowel function sooner. “Opioids, just like they make a person sleepy, also make the intestines sleepy,” Liska explains.
“We also pre-medicate people with non-opioid pain medication before surgery to treat the pain before it even starts,” Liska says. “We use local anesthetics to numb the muscles of the abdominal wall to reduce the impact of even having a small incision and of pain perception after surgery.”
Fertility and sexual health can be important considerations for younger adult patients undergoing colorectal cancer treatment. For men, options include sperm banking prior to treatment, fertility services after treatment and evaluation for less-common complications like erectile dysfunction. For women, options include fertility preservation services like egg freezing, fertility-preserving surgery and fertility services after treatment.
Coping With an Ostomy
“Young people have a harder time coping with ostomies from a psychological standpoint,” Liska says. “Ostomies: They sound scary, they look scary.” However, he adds, “Most patients will tell me that once they’ve gotten used to it, it’s not as bad as they thought it would be.”
The Cleveland Clinic facility has an ostomy support nursing team to educate and work with patients and increase their comfort level. “Besides the technical aspects of having an ostomy — how to take care of it and how to take care of the skin around it — a lot of it is coping mechanisms,” Liska says. Patient-to-patient support also can help.
“Obviously, we try to avoid an ostomy whenever we can,” Liska notes. “And in most cases, even when we do an ostomy, the vast majority are for temporary ostomy. It’s quite rare nowadays that we have to do a surgery that results in a permanent ostomy.”
Talk to Your Doctor
Talking to your physician about your bowels “is an uncomfortable conversation to have,” Liska says. But it’s important to do so.
“The majority of colorectal cancer can be cured,” Liska says. “And the earlier the stage at which it’s diagnosed, the higher the chance of the cure. If somebody has symptoms, you should bring it to the attention of your physician and it can be diagnosed at an early stage. Don’t be embarrassed or don’t be afraid, because we’re here for that purpose.”
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Everything You Need to Know About Colorectal Surgery originally appeared on usnews.com
Update 07/06/22: This story was previously published at an earlier date and has been updated with new information.