Colorectal surgery repairs damage to the colon, rectum, and anus through a variety of procedures that may have little or great long-term consequence to the patient. It may also involve surgery to the pelvic floor to repair hernias.
Purpose
Colorectal surgery is performed to repair damage to the colon, rectum, and anus, caused by diseases of the lower digestive tract, such as cancer, diverticulitis, and inflammatory bowel disease (ulcerative colitis and Crohn's disease). Injury, obstruction, and ischemia (compromised blood supply) may require bowel surgery. Masses and scar tissue can grow within the rectum, causing blockages that prevent normal elimination of feces. Other diseases such as diverticulitis and ulcerative colitis can cause perforations in the rectum. Surgical removal of the damaged area or areas can return normal bowel function.
Demographics
Colorectal cancer affects 140,000 people annually, causing 60,000 deaths. Polypectomy (the removal of polyps in the colon), usually performed during a routine diagnostic test (colonscopy or flexible sigmoidoscopy), has been a factor in the declining incidence of this cancer. However, incidence of the disease, as reported in the Journal of the National Cancer Institute in 2001, differed among ethnic groups, with Hispanics having 10.2 cases per 100,000 people, to African Americans having 22.8 cases per 100,000. Surgery is the optimal treatment for colorectal cancer, resulting in cure in 80% of patients. Recurrence due to surgical failure is low, from 4% to 8%, when surgery is meticulously performed.
Crohn's disease and ulcerative colitis, both chronic inflammatory diseases of the colon, affect approximately 1,000,000 young adults. Surgery is recommended when medication fails patients with ulcerative colitis. Usually, surgery is drastic, removing the colon and rectum and creating an interior or exterior pouch to collect body wastes. Nearly three-fourths of all Crohn's patients face surgery to removed a diseased section of the intestine or rectum.
Diverticulosis, the growth of pouches in the walls of the intestine, occurs in nearly half of all Americans by the time they reach age 60 and in practically everyone over 80. Sometimes these diverticuli become infected and diverticulitis occurs. Diverticulitis may also require surgery to remove part of the colon if there have been recurrent episodes with complications or perforations.
Description
Colorectal surgery is a necessary treatment option for colorectal cancer, ulcerative colitis, Crohn's disease, and some cases of diverticulitis, often resulting in major reconstruction of the intestinal tract. Other bowel conditions that may require surgery to a lesser extent are hemorrhoids, anal fissures (tears in the lining of the anus), rectal prolapse, and bowel incontinence. Most of these surgeries repair tears, remove blockages, or tighten sphincter muscles. Patients with anal fissures, for example, experience immediate relief, with more than 90% of them never having the problem recur.
Some colorectal surgeons also treat pelvic floor disorders such as perineal hernia and rectocele (a bulging of the rectum toward the vagina).
Types of surgery
There are a variety of procedures a colorectal surgeon may use to treat intestinal disorders. Until 1990, all colorectal surgery was performed by making large incisions in the abdomen, opening up the intestinal cavity, and making the repair. Most of these repairs involved resection (cutting out the diseased or damaged portion) and anastomosis (attaching the cut ends of the intestine together). Some were tucks to tighten sphincter muscles or repair fissures, and others cut out hemorrhoids. Some colorectal surgeons perform a strictureplasty, a new procedure that widens the intestine instead of making it shorter; this is used with patients with extensive Crohn's disease.
Often colorectal surgery involves creating an ostomy, which is an opening from the inside of the body to the outside, usually to remove body wastes (feces or urine). There are several types of ostomy surgeries that colorectal surgeons do. A colostomy is a surgical procedure that brings a portion of the large intestine through the abdominal wall, creating an opening, or stoma, to carry feces out of the body to a pouch. An ileostomy removes the entire colon, the rectum, and the anus. The lower end of the small intestine (the ileum) becomes the stoma.
For all ostomies, a pouch will generally be placed around the stoma on the patient's abdomen during surgery. During the hospital stay, the patient and his or her caregivers will be educated on care of the stoma and the ostomy pouch. Determination of appropriate pouching supplies and a schedule of how often to change the pouch should be established. Regular assessment and meticulous care of the skin surrounding the stoma is important to maintain an adequate surface on which to attach the pouch. Some patients with colostomies are able to routinely irrigate the stoma, resulting in regulation of bowel function; rather than needing to wear a pouch, these patients may need only a dressing or cap over their stoma. Often, an enterostomal therapist will visit the patient in the hospital or at home after discharge to help the patient with stoma care.
Most colostomies and ileostomies are permanent. Temporary colostomies are created to divert stool from injured or diseased portions of the large intestine, allowing rest and healing. Although colorectal cancer is the most common indication for a permanent colostomy, only about 10–15% of patients with this diagnosis require a colostomy.
A new procedure called an ileoanal anastomosis creates an internal reservoir that is sewn to the anus and acts as an artificial rectum. It usually is not used with Crohn's disease patients because their disease often recurs.
Laparoscopic surgery is being used with many diseases of the intestinal tract, including initial cancers. For this surgery, the colon and rectal surgeon inserts a laparoscope (an instrument that has a tiny video camera attached) through a small incision in the abdomen. Other small incisions are made through which the surgeon insertssurgical instruments. This surgery often results in fewer complications, a shorter stay in the hospital, less postoperative pain, a quicker return to normal activities, and less scarring. It is not recommended for patients who have had extensive prior abdominal surgery, large tumors, previous cancer, or serious heart problems.
Diagnosis/Preparation
Some disease or conditions may require a minimally invasive surgery. Other diseases such as inflammatory bowel disease and colorectal cancer may require an ostomy, a more drastic procedure. Determining whether this surgery is necessary is a decision the physician makes based on a number of factors, including patient history, the amount of pain the patient is experiencing, and the results of several diagnostic tests. Due to the lifestyle impact of ostomy surgery, surgeons make that decision with careful input from the patient. Sometimes, though, an immediate decision may be necessary in emergency situations involving injuries or puncture wounds in the abdomen, or intestinal perforations related to diverticulear disease, ulcers, or cancer, which can be life-threatening.
Diagnostic tests
Colonoscopy, flexible sigmoidoscopy, and a lower GI (gastrointestinal) series help determine the condition of the intestinal tract. These tests can identify masses and perforations on bowel walls.
A lower GI series is a series of x rays of the colon and rectum, which can identify ulcers, cysts, polyps, diverticuli (pouches in the intestine), and cancer. The patient is given a barium enema; the barium coats the intestinal tract, making any signs of disease easier to see on x rays.
Flexible sigmoidoscopy, a flexible tube with a miniature camera, is inserted into the rectum so the physician can examine the lining of the rectum and the sigmoid colon, the last third of the intestinal tract. The sigmoidoscope can also remove polyps or tissue for biopsy.
A colonoscopy is a similar procedure to the flexible sigmoidoscopy, except the flexible tube looks at the entire intestinal tract. For the patient's comfort, a sedative is given.
Magnetic resonance imaging (MRI), used both prior to and during surgery, allows physicians to determine the precise margins for resections of the colon, so that they can eliminate all of the diseased tissue. MRI can also identify patients who could most benefit from adjuvant therapy such as chemotherapy or radiation.
Preoperative preparation
The doctor will outline the procedure, possible side effects, and what the patient may experience after surgery. As with any surgical procedure, the patient will be required to sign a consent form. Blood and urine studies, along with various x rays and an electrocardiograph (EKG), may be ordered. If necessary, an enterostomal therapist will be contacted to mark an appropriate place on the abdomen for the stoma and offer preoperative education on ostomy management.
In order to empty and cleanse the bowel, the patient may be placed on a restricted diet for several days prior to surgery. A liquid diet may be ordered for at least the day before surgery, with nothing by mouth after midnight. A series of enemas and/or oral preparations (GoLytely, Colyte, or senna) may be ordered to empty the bowel of stool. Oral anti-infectives (neomycin, erythromycin, or kanamycin sulfate) may be ordered to decrease bacteria in the intestine and help prevent postoperative infection.
Aftercare
Postoperative care involves monitoring blood pressure, pulse, respiration, and temperature. Breathing tends to be shallow because of the effect of the anesthesia and the patient's reluctance to breathe deeply and experience pain that is caused by the abdominal incision. The patient is instructed how to support the operative site during deep breathing and coughing, and given pain medication as necessary. Fluid intake and output is measured, and the operative site is observed for color and amount of wound drainage.
The patient is usually helped out of bed the evening of the surgery and allowed to sit in a chair. Most patients are discharged in two to four days.
The nasogastric tube will remain in place, attached to low, intermittent suction until bowel activity resumes. For the first 24–48 hours after surgery, the ostomy will drain bloody mucus. Fluids and electrolytes are given intravenously until the patient's diet can gradually be resumed, beginning with liquids only, then adding solids. Usually within 72 hours, passage of gas and stool through the stoma begins. Initially the stool is liquid, gradually thickening as the patient begins to take solid foods. The patient is usually out of bed in eight to 24 hours after surgery and discharged in two to four days.
Risks
Potential risks of colorectal surgery are those of any major surgery and usually occur while the patient is still in the hospital. The patient's general health prior to surgery will also be an indication of the potential for risk. Of special concern are cardiac problems and stressed immune systems.
Psychological complications may result from ostomy surgery because of the fear of the social stigma attached to wearing a colostomy bag. Patients may also be depressed and have feelings of low self-worth because of the change in their lifestyle and their appearance. Some patients may feel ugly and sexually unattractive and may worry that their spouse or significant other will no longer find them appealing. Counseling and education regarding surgery and the inherent lifestyle changes are often necessary.
Normal results
Complete healing is expected without complications. The period of time required for recovery from the surgery may vary, depending on the patient's overall health prior to surgery. Dietary changes may be encouraged to prevent future disorders or to manage a current disease.
Morbidity and mortality rates
Mortality has been decreased from nearly 28% to under 6% through the use of prophylactic antibiotics prescribed before and after surgery. Strong indicators of survival outcome or increased complications from surgery for elderly patients are underlying medical conditions. Therefore, the underlying medical conditions of at-risk patients should be controlled prior to a colorectal surgery.
Even among higher risk patients, mortality is about 16%. This rate is greatly reduced (between 0.8% and 3.8%) when the ostomies and resections for cancer are performed by a board-certified colon and rectal surgeon.
The physician and the nursing staff monitor the patient's vital signs and the surgical incision, alert for:
excessive bleeding
wound infection
thrombophlebitis (inflammation and blood clot in the veins in the legs)
Symptoms that the patient should report, especially after discharge, include:
increased pain, swelling, redness, drainage, or bleeding in the surgical area
flu-like symptoms such as headache, muscle aches, dizziness, or fever
increased abdominal pain or swelling, constipation, nausea or vomiting, or black, tarry stools
Stomal complications can also occur. They include:
Death (necrosis) of stomal tissue. Caused by inadequate blood supply, this complication is usually visible 12–24 hours after the operation and may require additional surgery.
Retraction (stoma is flush with the abdomen surface or has moved below it). Caused by insufficient stomal length, this complication may be managed by use of special pouching supplies; elective revision of the stoma is also an option.
Prolapse (stoma increases length above the surface of the abdomen). Most often this results from an overly large opening in the abdominal wall or inadequate fixation of the bowel to the abdominal wall; surgical correction is required when blood supply is compromised.
Stenosis (narrowing at the opening of the stoma). Often this is associated with infection around the stoma or scarring. Mild stenosis can be removed under local anesthesia; severe stenosis may require surgery for reshaping the stoma.
Parastomal hernia (bowel-causing bulge in the abdominal wall next to the stoma). This occurs due to placement of the stoma where the abdominal wall is weak or an overly large opening in the abdominal wall is created. The use of an ostomy support belt and special pouching supplies may be adequate. If severe, the defect in the abdominal wall should be repaired and the stoma moved to another location.
Alternatives
When a colostomy is deemed necessary, there are usually no alternatives to the surgery, though there can be alternatives in the type of surgery involved and adjuvant therapies related to the disease.
BOOKS
Johnston, Lorraine. Colon & Rectal Cancer: A ComprehensiveGuide for Patients and Families. Sebastopol, CA: O'Reilly, 2000.
Levin, Bernard. American Cancer Society Colorectal Cancer. New York: Villard, 1999.
PERIODICALS
Beets-Tan, R. G. H., et al. "Accuracy of Maganetic Resonance Imaging in Prediction of Tumour-free Resection Margin in Rectal Cancer Surgery." The Lancet 357 (February 17, 2001): 497.
"Laparoscopy Could Offer Long-term Survival Benefit over Conventional Surgery." Cancer Weekly (July 30, 2002): 14.
Schwenk, Wolfgang. "Pulmonary Function Following Laparoscopic or Conventional Colorectal Resection: A Randomized Controlled Evaluation." Journal of the American Medical Association, 281 (April 7, 1999): 1154.
Senagore, A. J., and P. Erwin-Toth. "Care of the Laparoscopic Colectomy Patient." Advances in Skin & Wound Care 15 (November–December 2002): 277–284.
Walling, Anne D. "Follow-up after Resection for Colorectal Cancer Saves Lives. (Tips from Other Journals)." American Family Physician, 66 (August 1, 2002): 485.
ORGANIZATIONS
American Board of Colon and Rectal Surgery (ABCRS). 20600 Eureka Road, Suite 713, Taylor, MI 48180. (734) 282-9400. <www.fascrs.org>.
Mayo Clinic. 200 First St. S.W., Rochester, MN 55905. (507) 284-2511. <www.mayoclinic.org>.
United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. <http://www.uoa.org>.
Wound Ostomy and Continence Nurses Society. 2755 Bristol Street, Suite 110, Costa Mesa, CA 92626. (714) 476-0268. <http://www.wocn.org>.
OTHER
National Digestive Diseases Information Clearinghouse. Ileostomy, Colostomy, and Ileoanal Reservoir Surgery. (February 1, 2000): 1.
Janie F. Franz
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Colorectal surgery is performed by general surgeons and board-certified colon and rectal surgeons as in-patient surgeries under general anesthesia.
QUESTIONS TO ASK THE DOCTOR
Am I a good candidate for laparoscopic surgery?
What tests will you require?
What drugs will be given for pain after the surgery?
What will I need to do to prepare for surgery?
What will my recovery time be and what restrictions will I have?
