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Surgical Procedures for Colorectal Cancer

Removal of the cancer is the most common treatment if it has not spread far. The goal is to remove as much of the cancer as possible while keeping as much colon and/or rectum as is safe. It is common to combine surgery with radiation therapy and/or chemotherapy. It will increase the chance that all the cancer is removed.

Surgery may need to be done on the colon, rectum, or both.

 

Colon Surgery

Polypectomy and Local Excision

A scope is placed through the anus and rectum, up into the colon. The scope allows the doctor to see inside the colon. Tools are passed through the scope to remove polyps and/or early stage cancer. It cannot be used for cancer that has invaded deep into the colon wall. Tissue samples of the colon will also be taken for biopsy.

Partial Colectomy

An area of the colon is removed during a partial colectomy. It may be done to remove cancer that is deep in colon wall. The tumor, health colon around it, and nearby lymph node may all be removed. The healthy parts of the colon (and rectum) can often be reconnected. That means the colon and anus can continue to work.

Laparoscopic-assisted Colectomy

A laparoscopic surgery uses small incisions to access the area. This can lead to faster recovery than open surgery. This surgery will also remove the tumor, healthy tissue around it, and nearby lymph nodes. All tools will be passed through small incisions in the belly.

Total Colectomy

A total colectomy is the removal of the entire colon. The end of the small intestine may then be connected to the rectum. This will let stool pass through the rectum. Sometimes, a pouch may be made at the end of the small intestine. It will be used to make a colostomy.

Surgical Resection of a Colorectal Tumor Mass

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Colostomy

A colostomy may be needed if the intestine cannot be reattached to the rectum. A colostomy is a surgical opening through the wall of the belly. The small intestine or remaining colon will be attached to the opening. Waste can then pass through the opening into a pouch. A colostomy may be temporary and just used while the intestines recover. It may also be permanent if too much intestine was removed or the rectum was damaged.

 

Rectal Surgery

Rectal surgery is more complex. This surgery involves other nearby tissue, such as urinary system tissue.

Polypectomy and Local Excision

A scope is passed into the anus and rectum. The scope allows the doctor to see inside the rectum. Tools are sent through the scope to remove polyps and/or early stage cancer. It is only helpful for cancer that has not invaded into the deeper layers of the rectum. Tissue samples of the rectum can also be taken for biopsy.

Local Transanal Resection

This procedure is also called a full-thickness resection. A scope is passed into the anus, and into the rectum. The surgeon removes both the cancer and some surrounding healthy tissue. Local transanal resection is used for early stage cancers that are small and closer to the anus.

Transanal Endoscopic Microsurgery (TEM)

TEM is a highly specialized procedure. It can be used for early stage cancers that are farther away from the anus. A magnifying scope and tools are placed through the anus, and up to the rectum. The cancer and some surrounding healthy tissue will be removed. The hole in the wall of the rectum will then be closed.

Low Anterior Resection

Low anterior resection is used to remove cancers that are high in the rectum, closer to the colon. Incisions are made in the belly. Part of the rectum where the cancer is will be removed. Nearby lymph may also be removed. The colon is then reattached to the remaining part of the rectum.

Chemotherapy or radiation therapy may be used before this procedure. In this case, a temporary ileostomy may be needed. An ileostomy brings the last portion of the small intestine out through a hole in the belly wall. This will allow waste to pass out of the body into a pouch and let the rectum rest. The procedure may then be reversed.

Proctectomy with Colo-Anal Anastomosis

The entire rectum is removed. This is often done if the cancer is in the middle or lower third of the rectum. Once the rectum is removed, the colon is then attached to the anus. In some cases, a small pouch is made from the colon to store stool.

A temporary ileostomy may be necessary. Stool will pass from the small intestine through the stomach wall to a bag outside of the body. This allow the bowel time to heal. The bowel may then be attached to the anus at a later date.

Abdominoperineal (AP) Resection

An AP resection may be done if the cancer has spread from the rectum into the anal area. The surgeon removes the anus, the anal sphincter muscle, and surrounding tissue. A permanent colostomy will be needed with this surgery.

Pelvic Exenteration

Local organs may need to be removed if the cancer has spread beyond the rectum. The rectum, along with the bladder, prostate, or uterus may all be removed. After this procedure, a permanent colostomy will be necessary. If the bladder is removed, a urostomy will also be done. A urostomy is an opening in the belly wall that lets urine pass out of the body.

Surgery for Metastatic Colorectal Cancer

Metastatic colorectal cancer cannot be cured with surgery. Surgery may help to prolong life by treating tumors in other parts of the body. It is most often used for cancer that has spread to the liver, but it can also be used on other tumor sites. Options include:

Ablation

Ablation is the destruction of cancer cells without removing the tumor from the body.

  • Radio frequency ablation —A probe is inserted through the skin and into the belly. The probe emits high energy radio waves which kill cancer cells with high heat.
  • Ethanol ablation —Concentrated alcohol is injected directly into the tumor with a needle. This may also be called a percutaneous ethanol injection (PEI).
  • Cryosurgery —An ultrasound-guided probe is inserted through the skin into the abdomen. Cancer cells are killed by freezing them.

Embolization

Tumors grow and spread using the body's blood supply. During embolization, substances are injected to slow or stop blood flow to the tumor. It can slow or stop growth of tumor.

  • Arterial embolization —A catheter is threaded through an artery in the thigh to the liver's main artery. A substance is injected into the artery to block blood flow.
  • Chemoembolization —Tiny beads with chemotherapy drugs are threaded through the catheter and into the artery in the liver. The drugs will eventually block blood flow.
  • Radioembolization —Tiny beads with radiation are placed near the tumor. Over a period of time, the beads release radiation and kill the tumor.

Depression is a common symptom of colorectal cancer. During a hospital stay, psychotherapy may be part of the treatment plan.

REFERENCES:

Benson AP, Venook AB, Cederquist L, et al. Colon Cancer. Version 2.2017. In: National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology (NCCN Guidelines). NCCN 2017 Mar from NCCN website.

Colon cancer treatment option overview. National Cancer Institute website. Available at: https://www.cancer.gov/types/colorectal/patient/colon-treatment-pdq#section/_135. Updated January 30, 2020. Accessed February 27, 2020.

Colorectal cancer. American Cancer Society website. Available at: http://www.cancer.org/acs/groups/cid/documents/webcontent/003096-pdf.pdf. Accessed February 27, 2020.

Colorectal cancer. EBSCO DynaMed website. Available at:https://www.dynamed.com/condition/colorectal-cancer. Updated January 22, 2020. Accessed February 27, 2020.

Glynne-Jones R, Wyrwicz L, Tiret E, et al. Rectal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2017 Jul 1;28.

Last reviewed December 2019 by Mohei Abouzied, MD  Last Updated: 2/27/2020