Colon Cancer Surgery

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Ask whether anything should happen before the operation

Chemotherapy given first, a stent for a blocked bowel, and a few weeks of preparation for a frail patient are three decisions that only exist before surgery and cannot be revisited afterwards. Send the colonoscopy report with the biopsy result, the staging scans of chest, abdomen and pelvis with their reports, the tumor location and how far it sits from the anal verge if that was measured, your blood results including hemoglobin and the tumor marker, your medication list, and a note of any previous abdominal surgery. A colorectal surgeon and a medical oncologist review the file together and set out what the sequence should be. No fee, no obligation, and a coordinator replies in your own language, usually within the same working day.

Four decisions first

Colon cancer surgery removes the segment of bowel containing the tumor along with the fatty tissue and lymph nodes that drain it, then joins the two cut ends back together. That description covers almost every operation done for this disease. Four decisions sit underneath it, and they are answered in this order.

Diagnosis to operating room

Five things happen between the biopsy result and the anesthetic, and knowing the sequence tells you where you are in it.

Keyhole or open

Few questions in surgery have been settled as thoroughly as this one. When keyhole colon surgery appeared, the fear was that it would compromise the cancer operation, and three large randomized trials were run to find out. An American trial randomized 872 patients across 48 institutions and found recurrence at three years of 16 percent after keyhole surgery against 18 percent after open, with a hazard ratio of 0.86, and three year survival of 86 against 85 percent. Hospital stay was five days against six.

The European counterpart randomized 1,248 patients and reported blood loss of 100 against 175 milliliters, with the keyhole operation taking thirty minutes longer and the number of lymph nodes retrieved no different, which is the measure that most directly reflects whether the cancer operation itself was compromised. At a median follow-up of 53 months, disease-free survival at three years was 74.2 percent against 76.2 percent and overall survival 81.8 against 84.2 percent. Its authors noted that formal non-inferiority was not quite met, because the upper bound of the confidence interval slightly exceeded the margin they had set in advance, while judging the difference clinically acceptable and recommending the technique in experienced hands. The British trial covering both colon and rectal cancer followed 794 patients for a median of nearly five and a half years and found no significant difference in overall or disease-free survival, which is a third independent randomized answer to the same question and the reason surgeons now treat the argument as closed.

Robotic surgery has far less evidence behind it. The only randomized comparison this page could find in colon cancer covered 71 patients having right-sided operations at a single center, where five year disease-free survival was 77.4 percent robotic against 83.6 percent laparoscopic, a difference that fell well short of statistical significance in a trial of that size. The robotic operation took 195 minutes against 129 and cost more. That is not evidence against the robot. It is an accurate description of how thin the evidence for it currently is in this particular disease, and anybody presenting robotic colon surgery as proven to be better is going beyond what has been shown.

The conversion finding

One result from those trials deserves separating out, because it is the only thing in this comparison that changed how surgeons behave. In the British trial, 29 percent of the patients started on keyhole surgery were converted to an open operation partway through. Ten years later, the long-term analysis looked at what happened to those patients.

In colon cancer, being converted from keyhole to open surgery during the operation was associated with worse overall survival at a hazard ratio of 2.28 and worse disease-free survival at 2.20. Starting open was fine. Starting keyhole and having to change was not.

Read that carefully, because it is easy to misread as an argument against keyhole surgery, when the likeliest explanation is that the patients who get converted are the ones with the most difficult tumors, and difficult tumors do worse whichever way they are approached. What it means practically is that the decision about which approach to use should be made honestly at the start, with the anatomy and the body habitus and the size of the tumor all weighed before the first incision instead of discovered halfway through. A surgeon who converts occasionally is a surgeon who is selecting properly. A unit that claims never to convert is either operating on very easy cases or is not telling you.

How much comes out

Once the approach is settled, the real surgical argument is about how radical the lymph node clearance should be. It has recently been tested properly for the first time.

The operation itself

Two to three hours, four or five small cuts, and one slightly larger one to lift the specimen out.

The join and the leak

One complication dominates this operation, and unusually it appears to affect not only your recovery but your cancer outcome.

Chemotherapy, and when

For colon cancer the traditional order is surgery first and drugs afterwards. Both halves of that have been questioned by good trials in the last few years.

Six weeks of treatment before the operation

An international trial randomized 1,053 patients with operable colon cancer either to six weeks of chemotherapy before surgery followed by eighteen weeks afterwards, or to twenty-four weeks entirely afterwards. Ninety-six percent of those assigned to have it first were able to start and 87 percent completed it, and complete removal of the tumor at operation was then achieved in 94 percent of them against 89 percent of the patients who went straight to surgery. Residual or recurrent disease within two years occurred in 16.9 percent against 21.5 percent, a rate ratio of 0.72. Four percent of the patients treated first developed obstructive symptoms that required their surgery to be brought forward, which is the real risk of this approach. Little benefit appeared in tumors with the mismatch repair deficient subtype, which is why that test belongs at the beginning. Adding a targeted antibody drug to those six weeks changed nothing at all, a useful reminder that more treatment before surgery and better treatment before surgery are separate questions.

Three months afterwards instead of six

Six trials pooled 12,834 patients to ask whether three months of treatment is as good as six, because the drug involved causes cumulative nerve damage that in a proportion of people never fully resolves. Across everybody, three months failed to be confirmed as non-inferior, with a hazard ratio of 1.07, and the answer then split by regimen and by risk, with one of the two common regimens non-inferior at three months and the other falling short of it. In lower risk disease, three year disease-free survival was 83.1 against 83.3 percent and three months was enough. In higher risk disease it was 64.4 against 62.7 percent and six months did better. That is an individualized answer instead of a rule, it depends entirely on what your pathology report says about the depth of invasion and the number of involved lymph nodes, and it is a conversation worth having with that report open in front of both of you.

The trials that moved practice

Six trials account for most of what has changed in this disease in twenty years. The table is a map of them, so that when a doctor mentions one you know which question it answered.

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A blood test that decides

The hardest conversation in stage two colon cancer has always been about chemotherapy that most patients do not need. The disease is cured by surgery alone in the great majority, but a minority relapse, and until recently nobody could tell which. A trial randomized 455 patients to have that decision made by a blood test looking for fragments of tumor DNA at four or seven weeks after the operation, or by the standard clinical judgment.

Chemotherapy was given to 15 percent of the blood-test group and 28 percent of the standard group. Recurrence-free survival at two years was 93.5 against 92.4 percent, a difference of 1.1 percentage points, meeting the trial's standard for non-inferiority. Roughly half as many people had chemotherapy and they did just as well.

Two qualifications belong with it. Among the patients whose blood test was positive and who were treated on that basis, three year recurrence-free survival was 86.4 percent, against 92.5 percent among those who tested negative and had nothing, so a positive result identifies a higher-risk group instead of a group the chemotherapy rescues completely. And this applies to stage two disease, where the question is whether to treat at all, so ask whether the test is available where you are being treated, because the answer varies enormously between hospitals and it is the sort of thing that goes unmentioned unless somebody asks about it directly.

If the bowel is blocked

A substantial minority of colon cancers announce themselves by obstructing the bowel, and that changes the operation considerably. There is a real choice here even in an emergency.

• A stent can open the bowel first. A metal mesh tube placed through a colonoscope opens the blockage, the crisis passes, and the operation happens days or weeks later as a planned procedure rather than in the middle of the night on an unprepared bowel.
• It roughly halves the chance of a stoma. Pooling the randomized trials, an upfront operation to bring out the bowel end rather than joining it was needed in 39.1 percent of emergency surgery patients against 23.4 percent of those stented first, a relative risk of 0.61. Successful joining of the two ends was achieved in 69.75 percent against 55.07 percent.
• And it reduces complications. Overall complications after surgery occurred in 32.74 percent of the stented group against 48.25 percent of those operated on immediately, a relative risk of 0.61. Mortality did not differ significantly between the two approaches, at a relative risk of 1.06.
• What it does not do is improve the cancer outcome. Recurrence and long-term survival did not differ significantly between the two, on the limited follow-up available from those trials. The case for stenting rests on avoiding a stoma and a complication, and it stops there.
• It is not always possible. A stent has to be passed across the blockage and that fails in a proportion of attempts, and it suits a left-sided obstruction better than a right-sided one. Ask whether it is being considered and, if the answer is no, ask why in your case.

Stomas

Stomas frighten patients more than anything else about this operation, and the reassurance usually offered is too glib. Four things are true at once.

1. Most planned colon operations do not involve one. Where the operation is elective, the bowel is prepared and the patient is stable, the two ends are joined and nothing is brought out to the skin. That is the ordinary course of events and it is worth saying plainly.
2. Emergencies are different. In the pooled randomized data, an operation bringing out the bowel end was needed in 39.1 percent of patients operated on immediately for an obstruction. That is the single strongest argument for the stent discussed above.
3. Temporary does not always mean temporary. Among 155 Dutch patients who had an emergency resection for an obstructing left-sided cancer with a join protected by a temporary stoma, 32.9 percent still had that stoma after a median of more than four years. The word temporary is doing a lot of work in most consultations.
4. And what predicts it is known. In that study, a low hemoglobin carried odds of 4.79 for the stoma never being reversed, poor kidney function 4.64, and disease that had already spread 6.12. Those are the patients who should hear the word temporary with a qualification attached, and asking directly where you sit on that list is reasonable.

Recovery and flying home

Recovery from bowel surgery has been studied more carefully than recovery from almost any other operation, and structured programs have measurably changed it. Pooling 16 randomized trials covering 2,376 patients, a formal recovery program reduced overall complications at a relative risk of 0.60 and shortened hospital stay by an average of 2.28 days without increasing readmissions.

• Hospital. Four to six nights after a keyhole operation and longer after an open one. The trials that established the keyhole approach reported five days against six, and modern recovery programs have shortened both.
• Eating and moving. Both start early and deliberately. Sitting out of bed on the day of surgery, drinking the same evening, and eating within a day or two are part of the protocol rather than signs of exceptional progress.
• The bowels waking up. The slowest part. Wind before stool, and several days is normal. Persistent vomiting and a swelling abdomen after the fourth day is a different matter and needs assessing.
• Flying. Generally cleared at around ten to fourteen days after a keyhole operation, later after an open one, and only once the pathology report is in your hands. A leak typically declares itself between the third and seventh day, which is the reason for those numbers rather than caution for its own sake.
• Back to ordinary life. Desk work at around three weeks after a keyhole operation, physical work at six to eight. No heavy lifting for six weeks because of the specimen extraction wound, which is the one most likely to develop a hernia later.
• Get in touch about. A heart rate that climbs and stays up, pain that worsens after the third day, a fever, vomiting that will not stop, or a wound that reddens and discharges. The first of those is the one that matters most and it needs to be seen the same day.

What can go wrong

Colon resection is major abdominal surgery and the list is longer than for most operations on this site. Reading it is not the same as expecting it.

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Follow-up afterwards

Two large randomized trials asked whether watching people more closely after surgery makes them live longer, and their answers are more sobering than most follow-up schedules imply.

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If it has already spread

Colon cancer that has spread to the liver is not automatically incurable, which is the single most important thing to know about it. Where the liver disease can be removed completely, surgery is done with the intention of cure, and the question then becomes whether to remove the colon and the liver at the same operation or in two. Pooling 23 studies covering 4,862 patients found no significant difference between the two approaches in total complications, complications of the bowel or the liver specifically, perioperative death, five year disease-free survival or five year overall survival. Doing both at once meant significantly less blood loss and a total hospital stay shorter by 5.43 days. Almost all of that evidence is observational, with a single randomized trial among the 23, which the authors flagged themselves. What that means in practice is that the choice between one operation and two usually turns on your fitness, on the size of the liver resection being contemplated and on the experience of the team, and it is a conversation to have with a liver surgeon actually in the room.

Spread to the lining of the abdominal cavity is a different situation and a more difficult one, and for years the standard at specialist centers was to remove every visible deposit and then wash the abdomen with heated chemotherapy. A French trial randomized 265 patients who had already had a complete removal to receive that heated wash or not, and followed them for a median of 63.8 months. Median overall survival was 41.7 months with the heated chemotherapy and 41.2 months without it, a hazard ratio of exactly 1.00, while serious adverse events at sixty days were significantly more common in the group that received it, at 26 against 15 percent. Its investigators concluded that the surgery itself should be the cornerstone of treatment and that the heated wash added nothing to it. That is a rare thing in medicine, a large trial that removed a treatment instead of adding one, and it is worth knowing about if the wash is offered to you.

Two things nobody mentions

Both of these come up months later, and both are easier to live with when somebody has said them out loud beforehand.

Your bowels behave differently, especially on the right

Swedish investigators surveyed 517 patients a year after a segmental colon resection and found significant bowel dysfunction in 20.6 percent of those who had a right-sided operation against 15.6 percent of those who had a left-sided one, an odds ratio of 1.45 that held after adjusting for age and sex. It correlated with worse quality of life. The right colon absorbs water, so removing it means looser and more frequent stools for a good number of people, sometimes permanently. The anatomy explains it. Nobody made a mistake, it settles over the first year in most people, and knowing about it in advance changes how frightening it is when it happens. Ask before the operation which side yours is on and what that usually means for the first year, because the answer is concrete, the surgeon will know it, and it is much easier to hear at a clinic appointment than to work out alone at home.

Some early cancers never needed an operation

Danish investigators followed 1,749 patients with the earliest invasive stage of colon cancer through their national registry. Fifty-eight percent had it removed at colonoscopy first, 31 percent of those removals had cancer at the edge of the specimen, and among the patients who then went on to a colectomy, 58.3 percent turned out to have no cancer left in the removed bowel at all. Lymph node spread was found in 11.5 percent overall, and it was no more likely in those with a recognized risk feature than in those without, at 10.6 against 8.9 percent, which undermines the basis on which these decisions are currently made. The authors concluded that current tools for deciding which of these patients need a colectomy are insufficient, and that is an unusually direct admission to find in a surgical journal. So if your cancer was found and removed at colonoscopy and an operation is being recommended afterwards, understand that decision in detail before agreeing to it, and ask specifically what the estimated chance of lymph node involvement is in your case and how that estimate was arrived at.

Questions to ask

Start with sequence rather than technique. Ask whether chemotherapy before surgery has been considered and why it was or was not chosen, since a randomized trial of 1,053 patients found residual or recurrent disease at two years of 16.9 against 21.5 percent with that approach. Ask whether the tumor has been tested for mismatch repair, because that result changes the answer. If your bowel is blocked, ask whether a stent is possible, given that it roughly halved the chance of an upfront stoma in the pooled trials.

Then ask about the operation and afterwards. Whether it is planned as keyhole and what would prompt a conversion. Whether oral antibiotics are part of the bowel preparation, since combining them with mechanical preparation was associated with an odds ratio of 0.57 for a leak and 0.40 for wound infection. Whether a stoma is expected and what would make one necessary. Then, once the pathology report exists, how many lymph nodes were examined, whether it reached twelve, and whether the blood test for tumor DNA is available to help decide about chemotherapy. And ask what the follow-up schedule is and what each part of it is looking for, because two randomized trials found more testing did not translate into more people surviving.

Reading a quote

No figure appears on this page, and cancer treatment is a sequence rather than an event, so a number quoted for the operation alone answers a smaller question than the one you are asking. Seven things belong in writing. Which operation the quote covers, named as a right hemicolectomy, a left hemicolectomy or a sigmoid resection rather than as bowel surgery. Whether the staging scans and the colonoscopy are inside the number or expected to have been done already. Whether the pathology examination of the whole specimen is included, which is the report every later decision depends on. How many nights are budgeted and what an extra night costs, since a leak declares itself in the first week and extends a stay considerably. Whether the operation becoming open partway through changes the price. Whether stoma supplies and stoma nurse teaching are included if one is needed. And whether chemotherapy afterwards is inside the quote, alongside it, or expected to happen at home.

Your own file moves the total more here than in most operations. Which segment is being removed, whether the operation is elective or an emergency, whether the liver is being operated on at the same sitting, and whether a stoma is part of the plan are the four variables that decide the number.

Packages published by Turkish hospitals and medical travel agencies for colon cancer surgery generally include the airport transfer, pre-operative testing, the surgeon and anesthesia fees, the operating room, the planned nights, the pathology, an interpreter and the review before departure. They generally exclude flights, insurance, chemotherapy, treatment of a complication, extra nights, stoma supplies, gene or tumor DNA testing and any follow-up beyond the first weeks. Read what arrives against both lists.

Coming to Istanbul

Fourteen to eighteen days covers assessment, the operation and the pathology report for somebody arriving with the staging complete, and that is longer than for most operations on this site for two specific reasons. A leak at the join typically declares itself between the third and seventh day, and the pathology report that decides whether you need chemotherapy takes one to two weeks. Leaving before either of those is settled means leaving at the wrong moment. Send the colonoscopy report with the biopsy result, the staging scans of chest, abdomen and pelvis with their written reports, the mismatch repair result if it has been done, your recent blood results including hemoglobin and the tumor marker, your medication list, and details of any previous abdominal surgery. If a colonoscopy could not be completed because the tumor blocked the scope, say so in the first message, because that single fact changes what has to happen and in what order, and it is exactly the sort of detail that gets lost inside a forwarded radiology report.

Say in your first message whether your bowel is currently obstructing, or partly obstructing, and whether you have been vomiting or unable to pass wind, because that is the one piece of information that changes everything about the timing and it deserves stating plainly. Say too who will give any chemotherapy afterwards and where, because that is usually done at home and the handover is the part of cross-border care most likely to fail. Only one coordinator holds your file from the first message to discharge, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish, with other languages arranged on request. Ask in your first message if you would prefer a female physician. Someone can stay overnight with you on the ward, where the rooms carry a companion bed. Meals from the hospital kitchen cover halal, vegetarian and diabetic diets and a prayer room is available. The international patients office books accommodation for both of you, arranges the airport transfer and daily transport, and prepares the appointment confirmation and the invitation letter naming the hospital and your treating doctor for a medical visa application, around ten days before travel.

Take home the pathology report itself and not a summary. It should give the tumor type and grade, how deeply it invaded, the margins, the number of lymph nodes examined and the number containing cancer, whether cancer was seen in small vessels, and the mismatch repair result. Every one of those decides something about the next year. Take the operation note as well, which should name the segment removed and how the join was made, and take the multidisciplinary meeting conclusion with its recommendation about chemotherapy. Address the file to a medical oncologist near you and book that appointment before you fly, because the interval between surgery and chemotherapy is where cross-border care most often goes wrong. Once you are back home, your coordinator stays reachable on the same WhatsApp number, so a question about a wound or a line in the report reaches somebody with your notes in front of them.

Colon cancer surgery FAQ