Treatment for Colon and Rectal Cancers usually involves surgery at some point. Although the term ‘Colorectal’ Cancer is used widely, Colon Cancers and Rectal Cancers are approached slightly differently.

The Colon starts from the Cecum and where the small intestine joins the large intestine. It ends at the Sigmoid Colon. The Rectum starts at where the Sigmoid Colon ends and ends at the top of the anal canal (which is the anus). The Recto-Sigmoid Junction is where the Colon and Rectum meet. The terminology is confusing even for many doctors who are not well versed with treatment for Colorectal Cancer.

The reason of this differentiation is that Colon Cancers tend to spread or recur differently from Rectal Cancers. Rectal Cancer treatment can also be much more challenging due to the location in the confines of the pelvis which can be very limited in space, especially in males and obesity.

Local recurrence (recurrence at or around the site of surgery or anastomosis) of Colon Cancers is uncommon and the recurrences and spread tend to be to other organs and areas.

Rectal Cancers recur locally (i.e. at or around the site of surgery in the pelvis or anastomosis – where the joint takes place) more frequently than Colon Cancers. Good surgical techniques are important and are targeted at good and meticulous clearance of the surrounding tissue.

Although overall, local recurrences rates are low, surgery performed by good and experienced Colorectal surgeons are noted to have lower local recurrence rates for Rectal Cancers. Additional Treatment for Rectal Cancers like Radiotherapy and Chemotherapy also have reduced local recurrence rates.

Distant recurrence of Colon and Rectal Cancers are reduced with adjuvant Chemotherapy, and the newer forms of targeted Immunotherapy.

Surgery entails removing the following en-bloc (in 1 piece together):

• The Cancer itself
• Together with an adequate margin of normal colon/rectum without cancer cells
• The surrounding mesentery where the lymph nodes and blood vessels supplying that segment are situated
• Division of the origin of the blood vessels supplying the segment
• The surrounding fat (mesorectum) attached to the rectum in rectal cancers

Conventional Surgery

Conventional Surgery is performed with usually large incisions. This results in more post-operative pain and longer recovery. Many Colorectal Surgical Procedures are now performed Laparoscopically (Key-Hole Surgery). However, sometimes, for various reasons like large cancers, infiltration to surrounding areas, previous surgery causing adhesions etc, conventional surgery may still have to be performed.

Laparoscopic Surgery

Robotic Surgery

Robotic Surgery is a recent modality for performing surgery. Robotic Surgery has been proven superior in Prostate Cancer Surgery. However, its use in many other surgical procedures is still controversial.

In my opinion, Robotic Surgery may have advantages in performing some difficult Rectal Cancer Surgery. However, it may not be essential.

Colostomy / Bag to pass motion into

Perhaps the single factor that concerns many patients when told that they have Colorectal Cancer is the thought of having a permanent Colostomy. A Colostomy is when the colon/intestine is brought out to a hole in the abdominal wall and stools are passed into a bag that is attached to the skin instead of passing stools through the anus.

Many patients, who are unaware, are afraid of having a colostomy. Some patients, who have not been adequately counselled, even go to the extent of declining Cancer Treatment and Surgery because of the possibility that a permanent Colostomy is required.

Permanent Colostomies used to be common. However, with experienced Colorectal surgeons, new technology and surgical equipment, the number of patients who require permanent colostomies have reduced.

The use of a Temporary Colostomy/Ileostomy is fairly common in surgery for mid to low Rectal Cancers and is part of a staged process in surgery. Usually, after the anastomosis (joint of the rectum) has healed, a smaller surgical procedure is performed to close/remove the colostomy/Ileostomy so that the patient can move bowels through the anus again.

Patients are encouraged to discuss openly with their surgeons about colostomies and not be afraid. Although, in present day, many permanent colostomies can be avoided, some patients will still require permanent colostomies to ensure adequate clearance of the cancer. It would be foolish to decline treatment of the cancer purely because a colostomy is required. Patients who do, eventually suffer as the untreated cancer grows or is not treated adequately, and ultimately, do still require a colostomy for complications, but having lost the chance to cure the cancer.

Many patients with colostomies lead almost normal lives. There are strong support groups and allied health professionals who are on hand to assist and support patients faced with a colostomy.

Principles of Colorectal Cancer Surgery

It is important for both surgeons and patients to understand what the important priorities and goals are when treatment for Colorectal Cancer is being planned. It is the duty of the treating doctors to explain not only what is important, but also, what is more important than other factors. Patients should also try to understand what the treatment goals are and to ask questions so that they can fully understand options, risks, and expectations of treatment.

The main principles, in order of importance and priority, of surgery for Colorectal Cancer are:

1. Safety of the patient and minimising risks
2. Clearance of the Cancer with good, oncologically clear margins
3. Restoration of function i.e. with or without a permanent Colostomy Bag
4. Large conventional Incision or Minimally Invasive (Key-hole) Surgery