In patients with potentially curable colon cancer, a properly performed surgical operation is essential for optimal results. In the majority of such cases, operative intervention involves a resection (removal) of the primary cancer and regional lymph nodes.
There are several different types of surgical procedures used in the treatment and management of colon cancer. The size and spread of the cancer helps determine the appropriate procedure to use.
PRIMARY SURGICAL MANAGEMENT OF COLON CANCER
Polypectomy: Some cancers appear to be less aggressive and are limited to the head of a single polyp. These cancers present no evidence of spread to the lymph system, blood vessels and nervous system, and therefore, may be removed with a local excision. In an effort to avoid unnecessary invasive surgery, these cancers can be removed during a colonoscopy. During a colonoscopy, a long flexible tube that is attached to a camera is inserted through the rectum and is used both to view the internal lining of the colon and to perform the removal of a small cancer (local excision.) A properly performed local excision can be a safe and effective procedure.
Conventional surgery (open colectomy): Conventional surgery for colon cancer requires surgeons to create a large opening in the abdomen in order to reach the cancer. This procedure involves the removal of the cancer, along with some of the normal bowel and lymph nodes that were surrounding the cancer. After this removal, the two cut ends of the colon are sewn together. In some instances, a temporary colostomy is created and the two ends of the colon are reconnected at a later time. A colostomy is an opening where the large intestine is attached to the abdominal wall and allows passage of stool into a replaceable bag outside of the patient’s body. In some instances, when the cancer cannot be completely removed, the two ends are not re-sewn together and the patient has a permanent colostomy.
Laparoscopic surgery: Laparoscopic surgery, also called minimally invasive surgery, allows surgeons to do procedures by making only a few small incisions in the abdomen. A small tube that holds a video camera is inserted into the abdomen, creating a live picture of the inside of the patient’s body. This picture is displayed on a television screen so that physicians perform the entire surgery by watching the screen. The cancer is removed through another, slightly larger incision.
Laparoscopic surgery appears to be about as likely to be curative as the standard approach for earlier-stage cancers.1 Potential advantages of the procedure include less pain, a shorter hospital stay, and a quicker recovery. However, there is still limited information from randomized trials about the approach. In addition, laparoscopic surgery requires special expertise and patients need to be treated by a skilled surgeon who has done many of these operations.2
SURGERY FOR RECURRENT OR METASTATIC DISEASE
At the time of diagnosis, 10 to 20% of patients with colorectal cancer have cancer that has spread (metastasized) to areas of the body that are distant from the area where the cancer started. The most common sites of metastasis and relapse are the liver, lungs, kidneys, duodenum, pancreas and pelvis (including the bladder). In most patients, metastases occur at multiple sites and are treated with systemic chemotherapy for palliation (relief of symptoms but not cure). Some patients who have cancer that has spread to a single area or recurrence near the original site are candidates for surgery to remove the metastases.
Treatment of the liver: When it’s possible to completely surgically remove all liver metastases, surgery is the preferred treatment. Although surgery offers some patients the chance for a cure, a majority of patients with liver metastases are not candidates for surgery because of the size or location of their tumors or their general health. Some of these patients may become candidates for surgery if initial treatment with chemotherapy shrinks the tumors sufficiently. If the tumors continue to be impossible to remove surgically, other liver-directed therapies may be considered. These other therapies include radiofrequency ablation (use of heat to kill cancer cells), cryotherapy (use of cold to kill cancer cells), delivery of chemotherapy directly to the liver, and radiation therapy. Relatively little information is available from clinical trials about the risks and benefits of these other approaches, but they may benefit selected patients.2
Palliative surgery: Palliative treatment is treatment that is intended to relieve symptoms, such as pain, but is not expected to cure disease. The main purpose of palliative treatment is to improve the patient’s quality of life. Palliative surgery to remove a portion of the colon may be recommended for some patients with advanced colon cancer to prevent bleeding, obstruction, and symptoms related to the cancer.
1 Jayne DG, Thorpe HC, Copeland J et al. Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. British Journal of Surgery. 2010;97:1638-45.
2 Alsina J, Choti MA. Liver-directed therapies in colorectal cancer. Seminars in Oncology. 2011;38:651-567.