Surgery is the main treatment for cancer of the colon and rectum. The principle is the same in every case: remove the segment of bowel containing the cancer along with the lymph nodes that drain it, then rejoin the two ends. What changes is which segment, and whether the join can be made.
Two questions matter more than the rest, and this page answers both. Which operation you need, and whether you will end up with a stoma.
Colon cancer and rectal cancer are treated differently
They are often grouped together, but the treatment order is not the same.
Colon cancer usually goes to surgery first. Chemotherapy, if needed, is decided afterwards from the pathology report.
Rectal cancer often gets radiotherapy, chemotherapy, or both before surgery. The rectum sits deep in the pelvis with little room around it, so shrinking the tumour first improves the chance of removing it completely and can sometimes make the difference between keeping and losing the anus.
If you have rectal cancer and have been told to start treatment before surgery, this is why. It is not a delay.
The operations
Which one you need is decided by where the tumour sits.
Right or left hemicolectomy
The right or left half of the colon is removed, along with its lymph nodes and blood supply. The two ends are rejoined. There is normally no stoma.
Colectomy
A larger portion, or occasionally the whole colon, is removed. Done when the tumour is extensive, when there are multiple tumours, or in patients with certain inherited conditions that put the rest of the colon at risk.
Anterior resection
For cancer in the upper and middle rectum. The affected part of the rectum is removed and the colon is joined to what remains, so the anus and normal bowel opening are preserved.
Where the join sits very low, a temporary stoma is often created to divert stool while it heals. This is usually reversed after a few months.
Abdominoperineal resection
For cancer very low in the rectum, sitting at or involving the anal sphincter muscles. The rectum and anus are both removed, which means there is no way to rejoin the bowel. A permanent colostomy is created.
This operation is done when clearing the cancer is not possible any other way. Fewer patients need it now than in the past, because treatment given before surgery can shrink some low tumours enough to allow an anterior resection instead.
The stoma question
This is what most patients are actually worried about, so it is worth being direct.
A stoma is not the automatic outcome of colorectal cancer surgery. Most colon cancer operations do not need one at all. In rectal cancer, a stoma is often temporary and reversed once the join has healed. A permanent stoma is required only when the anal sphincter itself has to be removed.
Ask your surgeon three specific things: whether a stoma is planned in your case, whether it is temporary or permanent, and if temporary, roughly when it would be reversed. You are entitled to a clear answer before you consent.
Key-hole or open surgery
Many colorectal cancer operations can be done laparoscopically, through several small incisions rather than one long one. Cancer outcomes are comparable to open surgery when it is performed by a trained surgeon, and recovery is faster, with less pain and an earlier return to eating and walking.
Open surgery is the better choice in some situations, including very large tumours, cancers that have grown into nearby organs, dense scarring from previous abdominal surgery, and emergencies where the bowel is blocked or perforated. A laparoscopic operation is occasionally converted to open partway through, which is a safety decision, not a complication.
Before surgery
You will normally need a colonoscopy with biopsy to confirm the diagnosis, a CT scan of the chest, abdomen and pelvis to check whether the cancer has spread, and a CEA blood test which is used as a baseline for follow-up.
For rectal cancer, an MRI of the pelvis is essential. It shows exactly how close the tumour is to the sphincter and the surrounding tissue plane, and it is what determines whether the anus can be preserved. Rectal cancer surgery should not be planned without it.
Recovery
Most patients stay in hospital between three and seven days, longer for rectal surgery or if a stoma has been created and you are being taught to manage it.
Eating and walking start early, usually within a day. This is deliberate and it speeds up bowel recovery rather than straining it. Full return to normal activity takes around four to six weeks, and heavy lifting should wait longer.
If you go home with a stoma, you will be trained to look after it before discharge, and support continues afterwards. Most people manage it independently within a few weeks.
What to expect afterwards
The pathology report comes back one to two weeks after surgery. It confirms the stage, the number of lymph nodes involved, and whether the margins were clear. Whether you need chemotherapy is decided from this report.
Bowel habit changes are common after rectal surgery. More frequent stools, urgency, and passing stool in several small amounts rather than one movement. This usually improves substantially over six to twelve months, though it may not return exactly to how it was.
An anastomotic leak, where the join between the two ends does not heal properly, is the complication surgeons watch for most closely in the first week. It is uncommon but serious, and it is the reason for the close monitoring and the temporary stoma in low joins.
Urinary and sexual function can be affected after surgery low in the pelvis, because the nerves controlling them run very close to the rectum. Ask about this before surgery rather than after.
Follow-up continues for years, with clinical review, CEA blood tests, scans and surveillance colonoscopy on a set schedule. Recurrence found early is treatable, which is the entire point of the schedule.
Questions worth asking
- Where exactly is my tumour, and which operation does that mean?
- Will I need a stoma, and if so, is it temporary or permanent?
- Should I have chemotherapy or radiotherapy before surgery?
- Can my operation be done laparoscopically?
- Has an MRI been done, if this is rectal cancer?
- What is the plan if the pathology comes back worse than expected?
Frequently asked questions
Will I have to live with a bag?
Not in most cases. Colon cancer surgery usually needs no stoma. In rectal cancer it is often temporary and reversed after a few months. A permanent stoma is needed only when the anal sphincter has to be removed.
Can colorectal cancer surgery be done by key-hole?
Yes for many patients, with cancer outcomes comparable to open surgery and a faster recovery. Some tumours and some emergency situations need open surgery.
How long will I be in hospital?
Usually three to seven days, longer for rectal surgery or if you are learning to manage a new stoma.
Will I need chemotherapy?
That is decided by the pathology report after surgery, not before. Some early cancers need nothing further. Rectal cancer patients may have chemotherapy or radiotherapy before surgery as well.
Will my bowel habit ever be normal again?
After colon surgery, usually yes. After rectal surgery, expect more frequent and more urgent motions initially, improving significantly over the first year.
Why do I need a colonoscopy again later if the cancer was removed?
Because new polyps can form elsewhere in the remaining bowel, and finding them early prevents a second cancer. Surveillance is part of the treatment, not an afterthought.
Consultation
Dr. Ripudaman Singh Lubana holds a Fellowship in Surgical Oncology from Tata Memorial Centre and HBCHRC, Punjab, and a University Diploma in Minimal Access Surgery from IRCAD, France, which covers both the cancer and the laparoscopic side of this work. He has performed over 3500 cancer surgeries.
He consults at Doctor Square Hospital on VIP Road Zirakpur, Trinity Hospital in Zirakpur, Curasia Hospital in Dhakoli, and Adesh Medical College Hospital in Mohri, Ambala Cantt.
Bring your colonoscopy report, biopsy report and scans. Call 8054173528 to arrange a consultation.
This page is for patient education. It is not a diagnosis or a treatment plan. Colorectal cancer treatment differs for every patient depending on the location of the tumour, the stage and individual health. Every patient is examined and assessed individually before any treatment is advised.
