Surgery for large bowel cancer

Surgery is the most common type of treatment for cancer of the large bowel and should be performed by a surgeon who specialises in bowel surgery.

The operation

Your doctor will discuss with you the most appropriate type of surgery, depending on the stage of your cancer and its position in the bowel. Before any operation it is important to discuss it fully with your doctor. Remember, no operation or procedure will be done without your consent.

During the surgery, the piece of bowel that contains the cancer is removed and the two open ends are then joined together (an anastomosis). The lymph nodes near to the bowel are also removed because this is usually the first place the cancer spreads to. If for some reason, the bowel cannot be rejoined then a colostomy or an ileostomy may be needed.

Colostomy

A colostomy is when one end of the bowel is brought out onto the skin of the abdominal wall and the opening of the bowel (on the skin) is known as a stoma. A bag is worn over the stoma to collect the stool (bowel motions). Sometimes a colostomy is only temporary and another operation to rejoin the bowel can be done a few months later.

The operation to rejoin the bowel is known as stoma reversal and CancerBACUP can send you a leaflet about this operation.

If such an operation is not possible, the colostomy is permanent. However, only a small number of people with cancer of the large bowel will need a permanent colostomy.

Ileostomy

Some people need to have an operation called an ileostomy, in which the end of the small bowel (ileum), or a loop of ileum, is brought out onto the right side of the abdominal wall. As with a colostomy, stools are then collected in a bag worn over the stoma.

This is generally a temporary operation for people with cancer of the large bowel. If it is likely that at a later date the bowel will be rejoined and the stoma removed (reversed), your specialist nurse will discuss this with you.

Before your operation

You will probably be admitted to the ward the day before your operation so that the doctors and nurses can do any further tests. To make sure that your bowel is completely empty, you will be asked to follow a strict diet and take a medicine (laxative) to help your bowels to move the day before surgery. Your nurse or the doctor will explain this to you.

Surgery for cancer of the colon

 The type of operation will depend upon the exact position of the tumour in the bowel. Removal of the whole colon is called a colectomy. If only half of the colon needs to be removed this is known as a hemi-colectomy which can be either the left side or the right side.

Some people have  a sigmoid-colectomy, (removal of the sigmoid colon), or a transverse colectomy (removal of the transverse colon).

After surgery to remove a cancer in the colon, you will usually have a wound that goes in a straight line from just below your breast bone (sternum) to just above your pelvis.

A small number of people may have their tumour removed by an operation known as a laparoscopic colectomy. This operation is done through four or five small cuts through which a mini-telescope, called a laparoscope,  is  passed. Recovery from this operation is usually quicker than with more standard operations. However, this is a new operation that is currently being researched to find out its risks and benefits.

Surgery for cancer of the rectum

People who have cancer of the rectum are more likely to need a permanent colostomy than people who have cancer of the colon. This is because it can be more difficult to have enough healthy bowel left in order to join the two ends together again. This is especially true for tumours in the lower third of the rectum.

Radiotherapy or chemoradiation given before surgery may help to reduce the size of the tumour. This can reduce the chance of needing a permanent colostomy.

Two possible operations for a cancer in the rectum are an anterior resection and an abdomino-perineal resection. The choice of operation will depend upon the position of the tumour in the rectum and how far it is from the anal opening (sphincter).

An anterior resection is usually used for tumours in the upper part of the rectum (close to the colon). After this operation you will have a similar wound to a colectomy.

An abdomino-perineal resection is usually used for tumours in the lower end of the rectum. This operation will result in a permanent colostomy because the whole rectum and anus are removed. After the surgery there will be two wounds – an abdominal wound as above and a second wound where the anus has been surgically closed.

Total mesorectal excision (TME) is another operation that may be used to remove a rectal cancer. This involves careful removal of the whole of the rectum as well as the fatty tissue that surrounds it, which contains the lymph nodes. This operation takes between 3 and 5 hours to carry out. People who have this type of operation are less likely to need a permanent colostomy than people who have an anterior resection or an abdomino-perineal resection. Research has shown that a TME is better than other types of surgery at reducing the risk of the cancer coming back.

Surgery may be used to remove cancer cells when a large bowel cancer has spread to another part of the body such as the liver. Sometimes chemotherapy may be given before or after the surgery.

You may find CancerBACUP’s section on secondary cancer in the liver helpful.

After your operation

After your operation you will be encouraged to start moving around as soon as possible. This is an essential part of your recovery and, even if you have to stay in bed, it is important to do regular leg movements and deep breathing exercises.

A physiotherapist or nurse will explain these to you.

As you will not be moving around as much as usual, you may be at risk of blood clots forming. To prevent this you will be asked to wear special stockings and may be given an anti-clotting drug called heparin.

You will be given antibiotics as an injection into a vein (intravenously) just before and after surgery. This is to prevent any infections.

Drips and diet

When you go back to the ward, you will have a drip (infusion), which gives you fluids through a fine tube (cannula) inserted into a vein in your hand or arm. This will be removed once you are able to eat and drink normally again.

You will also usually have a thin tube that passes down your nose into your stomach (nasogastric tube). This allows any fluids to be removed from your stomach so that you don’t feel sick. It is normally taken out within 2 days.

As an anaesthetic slows down the movement of the bowel, it is important that you don’t start drinking until the bowel is working normally again. After about 2 days, you will probably be ready to start taking sips of water. This will be increased gradually over a couple of days until you are able to eat a light diet, usually 4 or 5 days after your operation.

Drains

Often, a small tube (catheter) is put into your bladder and your urine is drained through this into a collecting bag. This will save you having to get up to pass urine and it is usually removed after a couple of days. You may also have a drainage tube in place from your wound, to collect any extra fluid and make sure that the wound heals properly.

Pain

After your operation, you will probably have some pain or discomfort for a few days. There are several different types of very effective painkillers. Always let your doctor or nurse know if you have any pain or discomfort. Your painkillers or their dose can be changed to suit your needs.

After an abdomino-perineal resection, it may be uncomfortable to sit down, but this should ease gradually as the wound begins to heal.

Going home

You will probably be ready to go home about 10 days after your operation. If you think that you might have problems when you go home (for example, if you live alone or have several flights of stairs to climb) let your nurse or the social worker know when you are admitted to the ward. They can arrange help before you leave hospital.

You will be given an appointment to attend an outpatient clinic for your post-operative check-up.

Some people take longer than others to recover from their operation. If you have any problems, you may find it helpful to talk to someone who is not directly involved with your illness.

Diet after bowel surgery

After any operation on the bowel, you may notice that certain foods upset the normal working of your bowel, or your colostomy if you have one.

High-fibre foods, such as fruit and vegetables, may give you loose stools and make you pass them more often than normal. Depending on the type of surgery you have had, you may even have diarrhoea. Tell your doctor or nurse if this happens as they can give you medicine to help control it. It is important to drink plenty of fluids if you have diarrhoea. This is often a temporary reaction and after a while you may find that the same foods do not have any effect.

There are no set rules about the types of food to avoid and each person needs to experiment for themselves. Some foods that disagree with one person may be fine for another.

You may also find that your bowel produces more wind than before, and this can sometimes build up in the abdomen and cause pain. Drinking peppermint water or taking charcoal tablets can help to reduce this. Your doctor can prescribe these for you or you can get them from your chemist.

It can sometimes take months for the bowel movements to get back to normal after surgery, and you will probably need to find out which foods are right for you by trial and error. Some people find that their bowel may always be more active than before their surgery, and that they have to eat carefully to control their bowel movements.

If you continue to have problems, it is important to talk to a dietitian at the hospital, as they can give you specialist advice tailored to your individual situation.

Sex life after bowel surgery

Once you have recovered from the operation, there is usually no medical reason why you should not take up a normal sex life again. However, you may find that you feel self-conscious about the change in your body’s appearance, especially if you have had a colostomy. This may stop you from wanting to make love.

If you have a supportive partner, talking about your feelings may help to lessen your anxieties. You should not feel guilty or embarrassed to talk to your nurse or doctor about what is troubling you. They can refer you for specialist counselling if you think that would be helpful.

Occasionally an operation to the area of the rectum can cause damage to the nerves that go to the sexual organs. If damage occurs, a man may not be able to have or maintain an erection, and may have problems with ejaculation. Women may find that their sexual function or response is also affected. This may improve over time – however sometimes it is permanent.

If you have any problems, your doctor or specialist nurse will be able to discuss them with you in more detail.

CancerBACUP has a section on sexuality and cancer which you may find helpful.

Looking after a stoma

When the nurse is showing you how to look after your stoma it may be helpful for a close relative to be with you in case you ever have any difficulties when you get home.

Before you leave hospital, your nurse will make sure that you have a good supply of stoma bags.

Before you start to change or empty your bag, make sure that you have plenty of bags and cleaning materials to hand. It is a good idea to keep everything you need in one place, so that you don’t have to start searching for things at the last minute. Make sure that you allow yourself plenty of time and privacy, so that you can work at your own pace without any interruptions.

Some people with a colostomy avoid wearing a bag by flushing out (or irrigating) their colostomy about once a day. Although this method does not suit everyone, your stoma nurse will be able to discuss it with you in more detail.

Stoma supplies

When you are at home you can get all your supplies from your chemist. Some chemists do not keep a very large stock, so it is a good idea to order in advance so you don’t run out. Sometimes it is better to get your supplies direct from a local stockist, and the British Colostomy Association has details of these.

The supplies are free but you will need a signed prescription from your GP. If you are aged between 16 and 65, make sure that your doctor signs the form saying that you are entitled to free prescriptions.

Home support

Once you are at home you will still be able to phone the stoma nurse if you have any problems. Your GP may also arrange for a district nurse to visit you for a few days when you first leave hospital to make sure that you are coping at home, or to sort out any problems that you may have with your stoma.

Having a colostomy or ileostomy is a big change in your life and many people find that they are embarrassed by the stoma, and that it affects the way that they feel about their body.

Embarrassment about a stoma can also affect relationships if you are uncomfortable about your partner seeing it.

These feelings are a natural part of coming to terms with the changes that a stoma causes, and usually gradually decrease over time.