The condition

The large bowel (intestine) is made up of the colon and rectum (back passage). This part of the digestive tract carries the remains of digested food from the small bowel and evacuate it as waste through the opening to the back passage (anus). Cells that line the colon and rectum may begin to grow out of control, forming a tumour (a growth which can be benign or malignant [cancer]).

The bowel has four sections: the ascending colon, the transverse colon, the descending colon and the sigmoid colon. Tumours can start in any of these areas or in the back passage. Tumours start in the innermost layer and can grow through some or all of the other layers.

The operation

Surgery is the main treatment for tumours of the bowel. Usually, the tumour and a length of normal bowel on either side of the tumour (as well as nearby lymph nodes) are removed. The healthy parts of the bowel are then stitched or stapled together – anastomosis).

If it is not possible to join the bowel back together, an opening (stoma; colostomy or ileostomy) will be made on the outside of the body for waste to pass out of the body into a disposable appliance (bag) which fits securely on the skin.

Sometimes, a temporary stoma (colostomy or ileostomy) is needed until the joined bowel has healed, and then it can be put back. This is done by further surgery. However, in some cases, the stoma is permanent, which means it can never be put back, and there will always be an opening on the skin for bowel waste.

Similar operations may be required for other non-tumour conditions such as diverticulitis, colitis and volvulus (twisting of the bowel).

Types of operation

A number of different surgical procedures are used depending on the site of the tumour. These include:

1. Right Hemicolectomy: removal of the last part of the small bowel, the caecum, ascending colon and a small part of the transverse colon
2. Left Hemicolectomy: removal of the descending colon and sigmoid colon
3. removal of the sigmoid colon

A number of different surgical procedures are available to treat tumours of the rectum (back passage), the choice depending on where the tumour is and how far it has spread:

1. Anterior Resection: used for most tumours of the back passage, except when the tumour is very close to the anal muscles (sphincter). The bowel and the back passage are joined together so that the back passage is not removed.
2. Abdomino-Perineal Resection (APR): this is done when the tumour is in the lowest part of the back passage. The back passage and the opening to the back passage are removed and the area is stitched up and will remain permanently closed. A permanent stoma (colostomy) will then be established.

Most bowel operations for benign or malignant conditions do not require a permanent stoma. Most bowel operations can be performed laparoscopically

Preparation for surgery

Before surgery (exception is the right hemicolectomy), you will be given a medicated drink to help clean the large bowel.

The medicated drink will completely empty your bowel. You will then fast for at least 6-8 hours before your surgery. If you are having a stoma, the surgeon and a stoma nurse will discuss with you the best site for the stoma and will mark the area with a marker pen. It is usually placed below your belt line, away from any other scars you may have and away from your wound.

You will be visited by an anaesthetist to discuss the best form of anaesthetic and postoperative pain control. Most patients will also be seen by a consultant physician for a general check of vital functions eg: cardiac and lung status.

Benefits of having your surgery

Removal of the diseased bowel is the first and possibly the only treatment for a tumour of the bowel. The goal of the surgery is to give you the best chance of cure through total removal of the tumour. However, your recovery depends how far the disease has spread. At the time of your operation surgery can also be used as a measure to ease any symptoms.
Most benign conditions are completely cured by the surgery.

Risks of not having the surgery

Symptoms including pain and bleeding may become worse and your bowel may completely block or burst. Without surgery, if the condition is malignant it may spread to other areas of your body.

Additional treatments

Radiation (adjuvant) therapy has been used for some people as an additional treatment for rectal tumours but is not normally used in colon tumours.
Radiation therapy by itself is not as effective as surgery for malignant disease.

Chemotherapy (use of drugs to treat tumour) is often used together with surgical removal. Sometimes it might be offered as the only treatment.

It is unusual to require any such additional treatment after surgery for benign conditions.

General risks of having an operation

There are risks with any operation including:

1. Secretions collecting in the lungs causing chest infection
2. Clotting may occur in the deep veins of the leg. Rarely part of this clot may break off and go to the lungs (embolus). This can be life threatening.
3. Circulation problems to the heart or brain may occur which could result in a heart attack or stroke.
4. Rarely death is possible during or after an operation due to severe complications.

Specific preventative measures are taken to minimise risks.

Specific risks of this surgery

The Risk	What happens	What can be done about it
Leakage of bowel fluid inside the abdomen	Infrequently leakage of bowel fluid at the site where the bowel was stitched or stapled back together	Further surgery may be required
Ileus	The bowel is paralysed leading to abdominal bloating and vomiting	Treatment is to deflate the bowel with suction, using a tube (nasogastric tube) put via nose, down the back of the throat and into the stomach or bowel.
Wound infection	The wound may become infected	This may be treated with antibiotics. These may be given by a drip into a vein or by mouth. The wound may need to be opened to drain.
Urinary tract infection	Germs enter the tube leading to the bladder and cause inflammation and infection	Mild cases may clear up without treatment. Usually antibiotics are used to treat the infection.
Post operative bleeding	Bleeding inside the abdomen. The wound drain may measure this.	A blood transfusion may be needed to replace lost blood. Sometimes more surgery is needed to stop the bleeding. Very rarely blood can transmit viruses eg. Hepatitis, HIV.
Damage to the ureter (tube from kidney to bladder)	Very rarely during surgery, the ureter, which brings urine from the kidney to the bladder, may be damaged.	This may need more surgery.
Bladder may not empty properly or may empty without warning	A urinary bladder problem where there is abnormal emptying of the bladder. It may empty without warning or may not empty at all.	A tube (catheter) into the bladder may be used to drain the urine away.
Sexual problems	Men may be unable to get an erection or keep an erection. It may also mean that they cannot ejaculate. In women it may cause pain during or after intercourse	For both men and women, time may improve the condition. Treatment for men may include counselling and medication. For women, counselling and use of water-soluble lubricants during intercourse may help.
Possible stoma problems:Loss of blood supply Stoma prolapse Parastomal hernia and local skin irritation (Stoma is the opening of the bowel onto the skin) (Hernia is the same as a rupture)	1. The blood supply to the stoma may fail and cause damage to the bowel2. Stomal prolapse when some of the bowel protrudes too far past the skin.3. Parastomal hernia when the bowel pushes through a weak point in the muscle wall and causes pain and bulging of the skin near the stoma4. Local skin irriation including reddening of the skin and a rash in reaction to the glue used to stick the stoma bag.	1. This may need further surgery. 2. For minor prolapses, no treatment is needed. For more serious cases, more surgery may be needed. 3. Minor hernias may need no treatment. Larger hernias may need more surgery. 4. Changing the type of stomal bag usually treats this
Bowel blockage	Adhesions (bands of scar tissue) may develop inside the abdomen and the bowel may black. This is a short term and long term complication	This condition usually settles without an operation but occasionally surgery is required
Change in bowel habit	Bowel habits will change. Stools may be looser, smaller and more frequent. There may be some leakage of stools particularly at night depending on the type of surgery	In most people this improves with time, without further treatment
Increased risk in obese patients	An increased risk of wound infection, chest infection, heart and lung complications and thrombosis	The risk can be reduced by weight loss, however small, prior to surgery
Increased risk in smokers	An increased risk of wound infection, chest infection, heart and lung complications and thrombosis	Giving up smoking before the operation will help reduce the risk

Recovering from your surgery

After the operation the nursing staff will closely watch you until you have recovered from the anaesthetic. You may be cared for in a high dependency unit (HDU) or intensive care unit (ICU) immediately following your surgery.

The recovery period after colon surgery varies. It usually involves a stay in the hospital from 5 to 10 days in uncomplicated cases. On return from your surgery you will have a catheter (latex tube) in the bladder to measure and drain urine.

After surgery you will be given intravenous fluids (a drip) through which antibiotics may be given. The drip will remain in place until you are able to drink enough fluids.

Diet

During the first few days of recovery, you will not be able to eat until the bowel has begun to work again. You know the bowel has started to work again when you pass wind and/or have a bowel movement. You will then begin to take liquids by mouth and then solid food.

Wound

Your wound will have stitches and/or staples and is usually covered with a dressing, which may be adhesive plaster or a spray-on plastic covering.

If You Have A Stoma (colostomy or ileostomy)

The stoma drains bowel waste from the bowel into the appliance bag. Most stoma waste is softer and more liquid than normally passed bowel waste. The thickness of the bowel waste depends on where the stoma is. You will be taught how to clean around the stoma and change the bag.

The stoma bag sticks to the skin around the stoma with special glue, and can be thrown away when dirty. This bag does not show under clothing, and almost all people learn to take care of these bags themselves with an excellent quality of life.

Drain

You may also have a small tube that drains into a bag or a bottle from near your wound. The drain removes fluid from within the abdomen and helps the healing process. It is taken out when the drainage is minimal.

The Lungs

It is very important after surgery that you start moving as soon as possible. This helps to prevent blood clots forming in your legs and possibly going into your lungs. You will also most likely have blood thinning medication. Also, you need to do your deep breathing exercises. Take ten deep breaths every hour to prevent secretions in the lungs from collecting. If this happens, you may develop a chest infection. At all costs, avoid smoking after surgery as this increases your risk of chest infection.

Exercise

Expect to feel tired for some time after surgery. You need to take things easy and gradually return to normal duties, as you feel able. You should not drive during the first 2-3 weeks. Do not lift any heavy items for at least six weeks after surgery. This is to prevent a rupture where the cuts were made and allow healing to take place inside. It may take up to 3 months or more to feel completely recovered.

When to contact the office

ADVISE DR BRAUN IF YOU HAVE:

1. Large amounts of bloody or pus leakage from the wound
2. Heavy bleeding or blood clots from the anus
3. Fever and chills
4. Pain that is not relieved by prescribed pain medications
5. Swelling, tenderness, redness at or around the cut.

 

To schedule a surgical consultation with Dr Braun, please contact us or call direct on 07 3353 9694