A: Some of the most difficult discussions I’ve had with my patients are the ones that involve explaining what a stoma is and what it will mean to their life. I have had many patients state emphatically that they would rather die of their disease than have a stoma. When I hear this, I slow down the discussion and start from the beginning.

Colorectal cancer analogies always seem to relate back to plumbing, so let’s talk about the “long pipe” that makes up the colon and the rectum. Within the bowel itself, a tumour can begin to develop. If there is no spread of disease, our next step is to remove that segment of the pipe (as explained in this blog post). Once that segment of the pipe is removed, we have two ends. Ideally we can connect the two ends to recreate one continuous pipe. However, this is often not possible or safe or even desirable, and in those instances, a stoma is absolutely necessary in order for the gut to work again.

A stoma is a short length of intestine that is brought to the skin’s surface in the best possible, pre-determined location. This can be an ‘end stoma,’ which means the terminal end of the gastrointestinal tract comes out of the skin. Or it can be a ‘loop stoma,’ which means a small loop of intestine is brought to the skin’s surface and opened so the bowel contents exit at the stoma. In a loop stoma, the bowel then dives back into the belly and continues inside.

A stoma can be permanent, in which case no eventual reconstruction is planned or even possible, or it can be a temporary way to divert the flow of waste so it doesn’t pass through the bowel. Often if there is a large cancer in the colon or rectum that begins to block the bowel and not allow stool through, a temporary loop stoma is required in order to divert the stool while chemotherapy or radiation are being given. Once the cancer is removed, these stomas are often reversed. It is important for you to ask the surgeon what type of stoma you (or your loved one) requires and if it will be temporary or permanent.

If there is a cancer that is invading into the anal muscle and the muscle needs to be resected in order to treat the cancer thoroughly, then there is no possibility to reconnect. In this rare but difficult scenario, the entire rectum and anus are removed and a permanent end stoma is created. In order to create any of these stomas, the surgeon must create a passage through the abdominal wall and bring the bowel through the opening. Once it is secured in place and the wounds protected from infection, the surgeon then opens up the bowel and sutures it to the skin and abdominal wall. This is where a bag is affixed, which sticks to the skin around the stoma to capture the waste output in a controlled, odour-free manner.

Creating a stoma is usually the last step in an otherwise relatively complex surgery. It is usually a very straightforward and simple process that is only done in the operating theatre. Usually the creation of a stoma can take about 30 minutes or so.

Invariably, the concept of a stoma is mortifying to many patients. And as I tell people in clinic: I won’t minimize the gravity of the situation but I will tell you that the most common sentiment I hear from patients after a stoma is made is that they have a strange feeling of comfort and relief, and I very often hear the phrase “it is not as bad as I thought”.

The creation of stomas is a quintessential part of being a colorectal surgeon but it certainly cannot be done properly without the expertise of a stoma therapist on the team. As such, there’s a trained advanced practice nurse in most units who is dedicated to stoma therapy, education, and engagement. As patients are introduced to this possible necessity, they are exposed to many different resources in order to learn how to cope with this new ‘bag’. They learn how to change the pouch and empty it through home care services, and they find ways to minimize the way the bag affects their quality of life. In any patient that may have any degree of incontinence after a rectal cancer operation, a stoma is preferable and will certainly offer an improved quality of life in comparison to incontinence.

It’s important to remember as a patient or family member of someone facing a stoma: a stoma doesn’t smell, it doesn’t leak, it isn’t noticeable through clothes, and so although the reality is often difficult to accept, in certain situations it is certainly the preferred option.

I like to remind my patients that the stoma doesn’t define you, it is not rare and you are not the first to live with it. I often say, “If I didn’t know it was there, I wouldn’t even know you have a stoma at all.” Many patients tell me they’ve experienced no significant change to their quality of life and it does not limit them in any way. They can eat anything they like and there is no change to physical activity.

These days we are much more aggressive about avoiding a stoma and reconstructing the normal plumbing. But sometimes a stoma is a necessity. When I am meeting a patient who needs to have their rectum and anus completely removed in an effort to save their life, I explain to them that, yes, life will change; they will have to get used to a new normal and adjust accordingly. But soon that new normal will just be normal, and soon they will get back to doing the things they love doing, stoma and all.

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A: Just a quick refresher: The large intestine, or colon, is the final part of the digestive tract and its job is to absorb water back into the body and create waste. The colon is an average length of about 1.5 metres with the final 15 cm being the rectum and then the final sphincter muscle that controls the stool is the anus.

To answer your question in a nutshell, usually most of the colon is left alone and only the section with the cancer is removed, and the two ends are brought together to create a connection. Imagine it like cutting out a damaged part of a garden hose and reattaching the two ends.

Let’s explore the details of this kind of surgery more below.

Location, location, location

How the colorectal cancer surgery is done is essentially based on location. At the time of the colonoscopy, the colorectal cancer is diagnosed and the exact location is the cancer is identified. This is the critical information the surgeon will use to plan the surgery. There are lots of other factors that determine how much colon should be removed to treat the cancer.

Distance: The most important consideration is the safe distance from the cancer to make absolutely sure that there are no cancer cells left behind; this is called the margin. Studies have shown that in colon cancer, the resection lines should be about 10 cm away from the cancer on both sides. In rectal cancer, if the cancer is low in the rectum and very close to the anus, we accept as little as a 1 cm margin if it means that we can reconstruct the intestine and not remove the anus. If the cancer is at the sphincter muscle and involving the anus or very close to it, than the entire anus must be removed and in those cases a permanent stoma is necessary (which I’ll describe in more detail in another post.)

Lymph Nodes: The colorectal cancer resection also must include all the lymph nodes or glands that surround the tumour. A pathologist examines the removed nodes after the surgery to see if cancer cells had travelled to the nodes. This helps us decide which patients require chemotherapy after the surgery.

Anatomical considerations: There are other things we look at in order to plan the operation, and this is determined by understanding the blood flow to the colon. After a segment of the colon is removed, it is extremely important that the two ends that are used to make the new connection have a very good blood supply in order to make sure they heal to each other and there is no leak from the connection. To be sure the blood supply to the two ends of colon is ideal, there are very defined sections of the colon we remove and we are very particular about the location of the two ends that we bring together. Another critical anatomic consideration that the surgeon must be certain of is that the two ends that are brought together to reconnect are under absolutely no tension whatsoever, as this also may lead to a leak in the connection.

Based on all these factors, the surgeon will decide what segment of the large intestine they will need to remove in order to:

• Be absolutely certain the cancer is completely removed with all its associated nodes.
• Optimize the chances of healthy well-healed reconnection of the two ends.

Therefore the surgery can entail removal of the right or left side of the colon, sigmoid colon, upper rectum, entire rectum, or even the entire rectum and anus. These surgeries are all described here.

Open surgery or laparoscopic?

The surgeries for colorectal cancer removal can be done both open and laparoscopically. Open surgery involves a large vertical incision in the middle of the abdomen and the operation is done through this cut. Laparoscopic surgery involves placing a tiny camera in the belly button (umbilicus) and three tiny incisions in the abdomen. We use long surgical instruments, and do the operation by looking in the abdomen via the camera on a large screen.

When possible and safe, and in the right setting, the laparoscopic approach is, quite frankly, better. Much less pain, shorter recovery, shorter time in hospital and no wound issues. Many large trials have shown that the cancer results are the same for open and laparoscopic surgery, as long as the surgeon is comfortable with that approach and has ample experience and volume of cases. My personal opinion is that laparoscopic surgery for colon cancer should be the standard of care. Having said that, many cancers are not safe to remove laparoscopically because they are too large, or they are stuck to other organs, or the patient has had many other surgeries and there is too much scar tissue. But the laparoscopic approach should always be considered and discussed.

Inside my OR

In my practice about 90 per cent of the surgeries are done laparoscopically so I’ll explain that in a bit more detail:

Step 1 – Insufflation: we insert a small metal tube into the belly button and through it we blow air into the abdomen. This air gives us a working space by separating the abdominal wall from all the organs. We then insert the camera into this space.

Step 2 ­­– Surgical Access: we insert three more small metal tubes into the abdomen. We place our very long, thin surgical instruments through these tubes. We control the instruments from outside the abdomen but they function inside the abdomen. We can see everything in the abdomen through the camera.

Step 3 – Decision Making: we identify the exact area that needs to be removed by looking at the cancer and then considering all the factors mentioned above in order to decide on exactly where we will cut.

Step 4 – Resection: using a tiny mechanical stapler that slides into the metal tubes, we cut both ends of the colon. The stapling device seals the colon closed before cutting, so there is no contamination. We ensure when we remove it that we’ve included all the lymph nodes surrounding it.

Step 5 – Reconstruction: we first cut away any scar tissue to loosen the two ends so they will come together easily now that a segment has been removed. Then with a combination of stapling and sewing, we make a new connection of the two ends of colon.

Step 6 – Extraction: we make a small cut through the skin to remove the diseased segment of the colon from the abdomen and this ends the procedure.

This step-by-step list makes it all sound very straightforward — and it certainly can be for early small cancers in favourable locations. But it can also be very complex and require much more involved surgeries to get the cancer out and create the best possible chance to cure the colorectal cancer. In very rare occasions for cancers that are too close to the end to make a connection, a permanent pouch for stool can be required.

If you have questions about your specific surgery, please feel comfortable to talk to your surgeon. Ask questions until you understand. It is your body, and you have the right to understand what the surgery will entail.

The post I need colon cancer surgery. Tell me how it’s done. appeared first on Your Health Matters.

A: Step 1: don’t panic.

I know that is easier said than done. So let’s take a moment to catch our breath together.

The first thing I tell all my patients when they come to the colorectal cancer clinic is that they will leave the clinic with an action plan. I reassure them that the chaos that has dropped onto their life in the preceding days will gain order and direction; we will make a plan together and the order will bring clarity, and clarity will bring control, and control will – I hope – bring peace.

This sounds vague. But I’ve sat across from hundreds of patients right after their colorectal cancer diagnosis, and listened as they express fears of imminent death and a lack of control. In the vast majority of cases, neither of those two fears will come to fruition.

Most people are told this terrible news right after a colonoscopy that was ordered for either screening or symptoms. After the scope is finished, you are sitting in the recovery area with the analgesia wearing off, and a physician whom you just met that afternoon begins to tell you that they saw a “lump” or a “mass” that has the typical appearance of a cancer and so they did biopsies to confirm. The doctor reassures you that they will make a speedy referral to a surgeon; she does her very best to settle your nerves and present a plan but in the moment, you don’t even know what questions to ask. And on the way home, you can’t remember anything that was said after the word “cancer”. So how can you not panic? How, with so little information and such a terrifying precedent, can you not be completely petrified of the future that lies ahead?

The answer, I have learned, comes with expeditious intervention and a clear understanding of the action plan. Now, I know you can’t control the speed of your referral or treatment. So after a pause and a deep breath, let’s focus on what you can control: understanding the plan. We’ll call this Step 2.

When I meet you as patient for the first time, my goal is to very clearly articulate a plan that makes sense and is linear, so that we can approach the problem step-by-step, with you always knowing the next step, and knowing that you are in the driver’s seat.

To help you take the wheel at your initial visit:

• Bring at least one close family member or friend to support you.
• Assign your companion to write everything down so you don’t have to.
• You can also record the discussion so you can be sure you remember all the details (Some hospital policies differ on this — be sure to always tell your surgeon you are recording!)
• Ask questions about ANYTHING you don’t understand. This is your body and your life; you have to understand what’s going on, and if you don’t, it’s because the surgeon hasn’t explained it well enough yet.
• Ask about minimally invasive surgical options if surgery is being proposed.
• Make sure you are comfortable and have established a trusting, confident relationship with the surgeon. This is a critical step to controlling anxiety.
• Ask for a second opinion if you feel you want more answers or if you’re not fully convinced of the proposed plan.
• If feel extremely anxious, ask your surgeon or nurse navigator for other support services. Most cancer centres have social workers, dietitians, psychologists, psychiatrists and more professionals available to assist you.

Before you leave your initial consultation, be sure you know exactly what tests are next and why you need to undergo them. For any new colon cancer diagnosis, we need to understand the disease both ‘locally’ and ‘distantly’. That means we want to know the exact anatomy of the cancer itself; it’s size, location, proximity to other organs in the body. This is called local staging. We also want to know whether it has spread to other organs. This is called distant staging and cancer that has travelled to other organs is called metastasis. In order to complete this staging, your surgeon will order a CT scan of the chest, abdomen and pelvis. We also need to confirm the exact location in the colon that the tumour is growing. To do this, I’ll often repeat the colonoscopy in order to tattoo the tumour by marking its location from the inside of the colon; the tattoo goes through the wall of the colon to ensure that I can see it’s location from the outside of the colon during the potential operation.

Knowing what tests come next and what your care team will do with the results once they have them can help restore your control.

Once all these initial tests are done, you’ll be seen again in the cancer clinic and a definitive plan will be established. In most cases of newly diagnosed colon cancer, the next step would be a minimally invasive surgery to remove the tumour and restore the bowel’s function. Your plan will be unique to your specific needs.

Hearing the “C” word likely stopped you in your tracks. Take a moment, and take back the driver’s seat: ask as many questions you need to so that you understand what comes next in your treatment plan.

Links to Resources:

Patient and Family Support Program at Odette Cancer Centre

Colorectal Cancer Canada

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I will tell you about Mary*. She had no risk factors or family history of rectal cancer. At 29 years old, this new mom had been bleeding for a few months in small amounts that went largely unnoticed. Cancer was not on her radar. A visit to her doctor eventually led to a colonoscopy that detected the cancer.

Over the course of about a year, Mary received chemotherapy, radiation and surgery. While the cancer was controlled for a short time, it returned.

As a cancer doctor, I have many difficult days sharing in my patients’ sadness. The day I looked Mary in the eyes, her baby in her arms, and told her the cancer had returned was — and still is — the most difficult day of my career. Just when we thought the disease was controlled and Mary would get her life back, we were stopped in our tracks. How brutally I was reminded that day — and each day since — that this disease shows no mercy and knows no boundaries. Mary died just over a year after her diagnosis.

Colorectal cancer is not just a disease of the elderly. It’s a deadly yet preventable — and often treatable — disease that every adult should be aware of, regardless of age.

In fact, Canadian researchers have recently identified an alarming trend in the rates of colorectal cancer in young adults. Looking at data from the Canadian Cancer Registry from 1997 to 2010, the study found that the incidences of colorectal cancer rose by 1 per cent per year in patients in their 40s, 2.5 per cent per year for those in the their 30s, and a shocking 7 per cent for those people in their 20s during that time period.

These increasing trends among younger people are a stark reminder that this disease is definitely not just a disease of the old but rather a growing problem in young adults.

In my own colorectal cancer practice, about 30 per cent of my patients are under the age of 50.

And, sadly, when colorectal cancer strikes in young adults, it is most commonly only diagnosed in its later, more advanced stages. That’s because with no current general screening recommendations in this age group, the diagnosis is only being made once the cancer has advanced enough to cause symptoms like rectal bleeding or weight loss. Even then, younger adults often take longer to have these symptoms checked out by their doctor, leading to an even worse prognosis.

While we don’t yet know why rates among young people are increasing, we need to raise awareness of this disease among that population, and among health-care practitioners who wouldn’t typically suspect colorectal cancer in a young woman with no risk factors.

Awareness is our most powerful tool in identifying and treating this disease early, and ongoing research into whether screening should be started earlier than age 50 is needed. Since Ontario’s colorectal screening program began for patients over age 50, colorectal rates have actually been decreasing (because pre-cancerous polyps can be removed before advancing to cancers).

It’s so important to be vigilant in ensuring that all adults know the signs and symptoms of this disease, as well as the screening guidelines for early detection.

Step 1 is to know your risk. Check out this risk calculator and talk to your family about your family history. Colorectal cancer can strike even those without known risk factors. If you have any changes to your bowel movements, talk to your doctor.

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The Answer: I am sorry to hear that your wife’s colorectal cancer has spread. And I can understand why you are looking at different options outside of standard chemotherapy. Sunnybrook has been offering the DEBIRI treatment (intra-arterial infusion of irinotecan-loaded drug-eluting beads) for about two years and while it extends survival significantly, it is not a cure. On average, the Sunnybrook team performs this procedure once or twice a month.

Eligible patients are those with cancer that has spread to the liver that is not surgically operable and has not responded to at least two standard systemic chemotherapy drugs. Typically, these patients have diffuse tumours on their liver – sometimes in a rain shower pattern – making surgical removal impossible.

With DEBIRI, also known as liver chemoembolization, beads are threaded through a small catheter line from the blood vessel into the artery, located in the groin, that supplies blood to the liver. These tiny beads contain a very highly concentrated dose of the chemotherapy drug irinotecan. With this treatment, the blood vessels are partly blocked with the beads, starving the tumor of its blood supply, while concentrating chemotherapy in high doses to the tumours. This devastating “one-two punch” slows, and in some cases, even halts tumor growth.

A small, single institution phase III of a clinical trial of 74 patients randomly assigned to receive DEBIRI (36) versus systemic irinotecan, fluorouracil and leucovorin (FOLFIRI, 38), found a survival advantage for patients who use the treatment, compared to those who use standard intravenous therapy, according to a 2012 study published in the journal, Anticancer Research. The study, while limited, demonstrates the potential DEBIRI has in the treatment of metastatic colorectal cancer.

“It is hard for me to say whether she is a candidate or not without more details,” said Calvin Law, head of the cancer surgery program at Sunnybrook. “We really think that DEBIRI should be examined on a case-by-case basis.”

A team that includes a radiologist, medical oncologist, radiation oncologist and surgical oncologist select what patients would benefit from the treatment.

“If we all agree,” said Dr. Law, “then the interventional radiologist will look at the picture and tell us if they can put the beads in the right place.”

If the treatment is recommended, it takes place in two sessions, usually weeks apart. Each time, the patient is in hospital for two nights and three days. Return to work is widely variable – from as low to a week to a month or longer.

“Typically, there is more than one treatment and occasionally, there are more than three treatments,” said Dr. Law.

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