The colon and rectum (known as the large intestine or large bowel) are parts of the digestive system. The colon is the first 4 to 5 feet of the large intestine, and the rectum is the last six inches. The purpose of the colon is to absorb water from the digestive system and to hold stool (waste). The rectum is the last 6 inches of the large intestine (colon). The waste is then excreted from the anus.
Colon and Rectal cancer is one of the most common cancers in the United States (3rd most), in 2012 more than 103,000 people in the United States were diagnosed with colon and rectal cancer. Roughly 5% of Americans will develop colon or rectal cancer. A cancer is when normal body cells transform during the normal body process of cell turnover into an aberrant type of cell known as a cancer cell. These cancer cells grown and proliferate causing the condition of "cancer". They can spread to distant organs and lymph nodes as well. A cancer that starting in the colon is known as "colon cancer", likewise, if the cancer comes from the rectum it is a "rectal cancer".
Unfortunately, the actual cause of colon and rectal cancer is unknown. However, through our current medical research, physicians have learned a great deal about the factors that historically increase a patients' change to develop colon and rectal cancer. We know for certain that you cannot "catch" the disease from someone, however there is a strong family association with colon and rectal cancer.
For the most part, colon cancer is largely preventable. The most important step in preventing colon cancer is getting a screening test. Colon cancers are thought to be slow growing so a screening colonoscopy should be able to detect most early cancers and unwanted polyps. Addressing the risk factors that affect each patient are important and will guide each physician in their prevention strategies.
There is some evidence that a high fiber, low fat diet might help prevent colorectal cancer.
Many cancers are without symptoms. The most common symptom of colorectal cancer is a change in bowel habits (ie: change in the size or consistency of stool).
Symptoms of colon cancer may include:
Typically, early cancer does not cause pain. Patients with the above symptoms should consult their doctor.
colonoscopy is the most common method for diagnosing colon. During the colonoscopy, biopsies can be taken and sent to a pathologist. The confirmation of colon cancer is then made. Currently, there are no reliable blood tests for diagnosing colon cancer. Often times for rectal cancer an in-office proctoscopy is performed to measure the distance from the tumor to the opening of the anus.
Yes, however, more than 95% of all colorectal cancers are called adenocarcinomas. These cancers arise from cells in the lining of the colon or rectum. Other much less common tumor types include carcinoid tumors, gastrointestinal stromal tumors (GISTs), lymphomas and sarcomas.
Once the diagnosis of colon cancer is made, a cascade of workup modalities are undertaken. Typically, patients will have a CT Scan of the chest, abdomen, and pelvis to look for distance sites of cancer spread. Colon and Rectal cancer typically spread to the surrounding lymph nodes, liver, and lungs. Additionally, blood tests are performed to look for the CEA level (carcinoembryonic antigen) which is useful to trend for the recurrence of cancer. In low rectal cancers MRI and PET may be used to help with surgical staging. Finally, a consultation to a surgeon is conducted. The final staging is obtained once the cancer is surgically removed and reviewed by the pathologist.
Colorectal cancer is staged in this format:
Often, final staging is not complete until after surgery to remove the tumor, when the lymph nodes can be evaluated for cancer under a microscope.
Surgery is the standard of care. For colon cancer, usually surgery is performed with the possibility of chemotherapy and or radiation (rarely) after surgery. For low rectal cancers, chemotherapy and radiation my be used both before and after surgery.
Surgical removal is the standard of care and most common treatment for colorectal cancer. The two main surgical approaches are:
Under the care of Dr. Schultzel, 99% of patients will have a Minimally Invasive Surgical resection. Dr. Schultzel has a conversion rate of less than 1%. Dr. Schultzel is a world expert in Single Incision Surgery. He also employs the use of the robot for Robotic Surgery as well. During surgery, small incisions (or one very small incision) will be made. With a special camera and special tools, the cancer will be surgically removed. After the cancer is removed the colon and or rectum is reconnected to the digestive system. In some cases (rare) an ileostomy is required in order to protect the new connection. In some patients whom are too high risk for a connection, a colostomy bag can be created. In addition to advanced minimally invasive surgery, Dr. Schultzel performs specialized ultrasound guided nerve blocks in order to reduce pain after surgery. The TAP Block (transverse abdominus plane), provides significant decrease in post-surgical pain after surgery. Dr. Schultzel is one of the only surgeons in the region personally performing these blocks.
In up to 20% of operations Nation-wide for colon and rectal cancer, the surgery cannot safely be accomplished with laparoscopy, so an open operation is performed or a laparoscopic surgery is converted to an open surgery at the same time as the laparoscopic operation.
Dr. Schultzel employs two advanced minimally invasive techniques for the treatment of very low rectal cancers: TAMIS and TATME. Dr. Schultzel is the only private surgeon in San Diego who performs the TATME procedure.
Transanal minimally invasive surgery (TAMIS) is a technique that was originally devised as a hybrid between Transanal Endoscopic Microsurgery (TEM) and single-site laparoscopy for resection of rectal lesions. Patients whom are appropriate candidates for TAMIS may not require a rectal resection or even entrance into the abdomen for surgery. Inquire with your physician if you are a candidate.
Transanal Total Mesorectal Excision (TATME) is a technique that combines abdominal and transanal endoscopic approach to overcome limitations and facilitate standard laparoscopic total mesorectal. Patients whom are appropriate candidates for TATME may not require a permanent colostomy bag. This surgery is typically performed for patients whom have a lesion very low in the rectum near or involving the anus. Inquire with your physician if you are a candidate.
On average you will remain in the hospital from roughly 2-4 days. You pain will be controlled via the Enhanced Recovery After Surgery protocol (ERAS). Dr. Schultzel will perform a TAP Block (Transverse Abdominus Plane) on the patient while under anesthesia. This will allow for a significant decrease in post-operative pain after surgery and will facilitate a more comfortable stay in the hospital. Typically, most patient will return home between 2-4 days after surgery. The national average length of stay is 5-9 days. After surgery patients are placed on a clear liquid diet and ware walking the same day of surgery. Once the patient begins passing gas their diet is advanced and they may be discharged.
Overall, surgery for colon cancer is very safe, with survival in the immediate period after surgery of over 95%.
Per nation wide date roughly 1 in 5 patients can have a complication from surgery. These can range from minor to serious complications. The most common complications are wound infections, bleeding, damage to surrounding structures within the abdomen, Deep vein thrombosis, intra-abdominal infection, and breakdown or failure of the anastomosis (intestinal leakage). Some patients may require blood transfusions, antibiotics, or repeat surgery if a complication occurs.
Under the care of Dr. Schultzel, less than 1% of patients will have a complication. This includes, bleeding, infection, anastomotic leaks, risk to surrounding structures. Complications are not likely, however, they can happen even under the best circumstances.
Patients in whom colon cancer is found in the lymph nodes (stage III) or distant locations (stage IV) are normally recommended to undergo chemotherapy after surgery if medically-fit. Some patients may require radiation (rarely for colon cancer, more likely for rectal cancer). Dr. Schultzel works closely with his Oncology colleagues and will help coordinate the surgical after care.
Primarily staging. Early staging carries a better prognosis. Other factors such as colon perforation or obstruction, or cancer involvement of other organs, lead to a worse outcome. Additionally the cell type, makeup, and differentiation all weight into the algorithm for treatment outcomes. For rectal cancer where the cancer is located and its distance to the opening of the anus has a significant impact on surgical treatment and outcome.
After surgery most patients will follow up with Dr. Schultzel between 10-14 days. After this visit the patient will have a follow up with their oncologist. Usually post-surgical treatments occur around a month after surgery. Dr. Schultzel will see his a patients a second time one month after surgery. Then based on the type and location of the cancer, the patient will be seen in close follow up every 3-6 months with Dr. Schultzel. A separate schedule with the oncologists will be set up as well where typically lab tests (CEA test), colonoscopy, x-rays, CT scans, or other tests. Routine exams generally occur every 3-6 months for a few years, while CT scans or other imaging tests and colonoscopy are performed 1 year after surgery. The frequency of subsequent exams is based upon results of the prior exam.
Colon and Rectal cancers are very common malignancies that affect a great number of Americans. They are largely preventable through our current screening methods. Survival has been greatly improved due to advances in both medical and surgical treatment modalities. Dr. Schultzel looks forward to providing care to those suffering from these terrible conditions.