Surgical Treatment of Colorectal Cancer
By Gregory D Kennedy, MD, PhD
Colorectal cancer is the third most common cancer in both sexes and the fourth leading cause of cancer-related deaths in the United States. Risk factors include family history, personal history of polyps, personal history of cancer of the colon, cancer of the ovary, endometrium or breast, and a history of inflammatory bowel disease. In addition, many other factors have been associated with a risk for developing colorectal cancer including a diet that is high in fat or low in fiber as well as age over 65. The symptoms are often innocuous characterized by blood in the stool which at times is invisible to the naked eye. This non‑symptomatic bleeding may lead to shortness of breath, or in extreme cases, patients may have a heart attack. The cornerstone of therapy of colorectal cancer is surgery. This article will thoroughly consider surgical options for colorectal cancer.
How is colorectal cancer treated?
Cancer of the colon and cancer of the rectum are treated differently based on preoperative staging. Staging modalities that all patients should have regardless of cancer location (either in the colon or rectum) include:
Staging for cancer of the rectum include the above, as well as:
Cancers of the colon are treated with surgery before any chemotherapy. Radiation does not play a role in colon cancer and use of chemotherapy after surgery is dictated by the final pathology of the removed specimen.
Cancers of the rectum may be treated with radiation and chemotherapy prior to surgery depending on evidence of invasiveness of the tumor in the rectum. Surgery follows this treatment within 6-10 weeks and chemotherapy may be used depending on the final pathology results.
If preoperative workup demonstrates evidence of metastatic disease (involvement of the liver or lungs), surgery may be delayed and chemotherapy may be used up-front. These are complex decisions that should be made by a multidisciplinary team, including the colorectal surgeon, medical oncologist, radiation oncologist, and gastroenterologist.
Surgery for cancer of the colon and rectum
The principles of surgery for colon or rectal cancer are the same: remove the segment that contains the cancer, the main blood vessel that feeds the cancer, lymph nodes found around the cancer, and keep the cancer completely intact. These principles can be followed using either an open surgery or a minimally invasive surgery (MIS) approach to the operation. An open approach involves making an incision in the abdomen that may extend from the belly button to the pelvic bone, or somewhere else on the abdomen. The surgeon then works through this incision to remove the effected segment of the colon or rectum. While the open approach is still considered an acceptable way to remove the cancer, the minimally invasive approach is now considered the standard of care.
MIS approaches to colon and rectal cancer can utilize different modalities. Laparoscopic- and robotic-assisted surgeries are the two primary minimally invasive approaches for removing colon and rectal cancer today. While the platforms are quite different, there are no differences between laparoscopic and robotic surgery at this time. However, there are significant differences between open surgery and MIS, which should move one to request the minimally invasive approach to colon and rectal cancer.
Why MIS for colon and rectal cancer?
Many studies have been published, by our group and others, examining differences in outcomes between laparoscopic and open surgery for colon and rectal cancer. All of these studies have found that the minimally invasive approach decreases complication rates by more than 50%. Decreased complications result in shorter hospital stays, decreased time of convalescence, and shorter times away from work and activities of daily living. Because of these improvements in patient outcomes, MIS has become the preferred surgical approach for colon and rectal cancer in our institution.
Laparoscopic or robotic?
To date, no study has been published that definitively shows that either approach is better than the other. That being said, robotic surgery has found a solid home for the surgical treatment of rectal cancer. The robotic platform is particularly well suited for rectal surgery as the optics are excellent and the instrumentation is better suited for difficult work in tight spaces.
For more information
Visit us online to learn more about the Colon and Rectal Cancer program at UW Carbone Cancer Center and its multidisciplinary team of colorectal surgeons, medical oncologists, radiation oncologists, and gastroenterologists. To learn more about surgical options for colon and rectal cancer or to refer a patient, visit Colon & Rectal Surgery online.