Surgery is the most common type of treatment for colorectal cancer and should be carried out by a surgeon who specialises in bowel surgery.
Your doctor will discuss with you the most appropriate type of surgery, depending on the stage of your cancer and its position in your bowel.
During the surgery, the piece of bowel that contains the cancer is removed and the two open ends are then joined together. The join is known as 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, the upper end can be brought out onto the skin of the abdominal wall. This is known as a colostomy and the opening of the bowel 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. If it is not possible to reverse the colostomy, the stoma is permanent. However, only a small number of people with cancer of the colon will need a permanent colostomy.
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.
For people with cancer of the large bowel, this is generally a temporary operation. 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 empty 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 your bowel. Removal of the whole colon is called a total colectomy. If only half of the colon needs to be removed, this is known as a hemi-colectomy. Either the left side or the right side may be removed.
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 laparoscope (a thin, flexible tube containing a light and camera) is passed. Recovery from this operation is usually quicker. However, this is a new operation that is currently being researched to find out its risks and benefits.
Very early-stage bowel cancers can sometimes be removed using an operation called local resection. Using an endoscope, similar to the one used to take a biopsy, the surgeon will remove just the cancer from the lining of the bowel. The cells of the cancer will be examined by a pathologist and if it is then found to be high-grade your surgeon may recommend that you have a second operation. This is done to remove more of the bowel to make sure that no cancer cells have been left behind.
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 leave enough healthy bowel to be able 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 shrink the tumour. This can reduce the chance of needing a permanent colostomy.
Total mesorectal excision (TME) is an operation that is usually 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 from three to five hours. Research has shown that a TME is better than other types of surgery at reducing the risk of the cancer coming back.
Depending upon the position of the tumour in the rectum, its size, and how far it is from the anal opening (sphincter), your surgeon will do the TME operation by using either an anterior resection, an abdomino-perineal resection.
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 and a second wound where the anus has been surgically closed.
Very early-stage anal cancers can sometimes be removed using an operation known as a local resection or a transanal resection. Using an endoscope, similar to the one used to take a biopsy, the surgeon will remove only the cancer from the wall of the bowel. If the tumour is close to the anus, the surgeon may be able to operate without the need for an endoscope. A second operation may be needed to remove more of the bowel around where the tumour was. This will be recommended if the cancer is found to be high-grade as there is a risk that some cancer cells could have been left behind.
Surgery for advanced colon or rectal cancer
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 infections.
Drips and diet
When you go back to the ward, you will have a drip (infusion), which gives you fluids through a thin tube (cannula) inserted into a vein in your hand or arm. This will be taken out 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 two 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 two 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 4–5 days after your operation.
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 taken out after a couple of days. You may also have a drainage tube in your wound, to drain any extra fluid and make sure that the wound heals properly.
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.
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. The nurses at Cancerbackup can talk to you, and tell you how to contact a counsellor or local cancer support group.
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 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 your 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 for your individual situation.
You may find our diet and cancer section helpful.
Sex life after bowel surgery
Once you have recovered from the operation, there is usually no medical reason why you should not have 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 now have a colostomy. This may stop you from wanting to make love.
Talking about your feelings may help to lessen your anxieties. Try not to feel embarrassed talking to your nurse or doctor about what is troubling you. They can refer you for specialist counselling if you think that would be helpful.
Sometimes, 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 orgasm and ejaculation. Women may find that their sexual function or response is also affected. This may improve over time – however sometimes it is permanent. There are treatments available, such as sildenafil (Viagra®) that can help men to achieve erections. It is important to discuss this with your doctor as soon as you notice a problem, as treatment can often be more effective if started sooner.
We have a section on sexuality and cancer which you may find helpful. If you have any problems, your doctor or specialist nurse will be able to discuss them with you in more detail.
If you need a colostomy or ileostomy
Some people with cancer of the large bowel will need to have a colostomy or ileostomy. This can be very daunting at first. Learning to look after a stoma takes time and patience and no one expects you to be able to cope straightaway. Like anything new it will get easier with time and practice.
In most hospitals there are specially trained nurses called stoma care nurses (or colorectal nurses) who you will usually meet before your operation. They will show you how to look after your stoma and help you to cope with any problems.
You may also find it helpful to talk to someone who has already learned to live with a stoma. Your nurse or doctor can often arrange for a volunteer to visit you and talk to you about the more practical and personal aspects, or you can contact the Colostomy Association or the Ileostomy and Internal Pouch Support Group. This advice, which can come only from personal experience, can be invaluable, particularly in the first few months after your operation. The DIPEx website has information about colostomies and ileostomies. It also has video and audio clips of people who have stomas talking about their experiences.
Before your operation, the nurse or doctor will carefully plan the position of your stoma so that your bag stays in place, whether you are sitting, standing or moving around.
For the first few days after your operation, the nurse will look after your colostomy or ileostomy for you and make sure that the bag is emptied and changed as often as necessary. At first your stoma will be slightly swollen and it can take several weeks before it settles down to its normal size. As soon as you are feeling well enough, the nurse will show you how to clean your stoma and change the bags. There are several different types of bag or appliance available and the nurse will help you to choose a suitable one.
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 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 this with you in more detail.
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 to avoid running out. Sometimes it is better to get your supplies direct from a local stockist, and the Colostomy Association has details of these. The supplies are free, but you will need a prescription from your GP. If you are aged between 16 and 60, make sure that your doctor signs the form saying that you are entitled to free prescriptions.
Once you are at home you will 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. They can make sure that you are coping at home, and sort out any problems that you may have with your stoma.
Having a colostomy or ileostomy is a big change in your life. 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 decrease gradually over time.
Cancerbackup nurses can provide you with more information about coping with a colostomy or ileostomy.