Bowel or Colorectal cancer is the second commonest cause of cancer and cancer related deaths in the western world. The incidence of bowel cancer is low in India but is fast rising in Asian countries. This is probably related to urbanisation and adoption of western diets. With rapid urbanisation in India associated with the ever expanding middle class it is predicted that bowel cancer will become more common.  

Symptoms of bowel cancer
Rectal bleeding
Constipation
Diarrhoea
Weight loss
Lump in abdomen
Anaemia
Abdominal pain

Investigations for suspected bowel cancer
Proctosigmoidoscopy
Flexible sigmoidoscopy
Colonoscopy
Barium Enema
CT scan
MRI Scan

Surgery is the main treatment for cancer of the large bowel. It may be used either alone or in combination with radiotherapy and chemotherapy. Cancers affecting the colon and those affecting the rectum are usually treated in slightly different ways. It is important that you discuss your treatment with your doctor or nurse who is looking after you and that you understand why a particular type of treatment has been recommended for you. Your doctor will take into account a variety of factors; your age, your general health, type and size of the tumour and whether it has spread beyond the bowel, prior to planning any treatment for you. Even though a number of cancer specialists work together as a team to decide on the most suitable treatment, you may want to have another medical opinion. Most doctors will be pleased to refer you to another specialist for a second opinion if you feel this will be helpful. The second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will provide useful information. Before you have any treatment, whether it be surgery, chemotherapy or radiotherapy, your doctor will explain the aims of the treatment and you will usually be asked to sign a form saying that you give permission (consent for the hospital staff to give you the treatment). No medical treatment can be given without your consent and before you are asked to sign the form you will be given full information about the type and extent of the treatment you are advised to have, the advantages and disadvantages of the treatment, any possible alternative that may be available, and any significant risks or side effects of the treatment. If you do not understand what you have been told, let the staff know straight away so they can explain it again. Some cancer treatments are complex, so it is not unusual for someone to need their treatment to be explained more than once. You are entitled to a permanent record of the consultation you had with your doctor in outpatients with regard to the treatment options offered to you. Please ask the doctor at the time or your nurse specialist for a copy of this letter. Other people who have had bowel cancer may be receiving different treatments and this will be because their illness takes on a different form and has different needs. Remember not to compare yourself to someone else who has had treatment, as cancer varies in each person. If you have any questions, do not be afraid to ask your doctor or nurse looking after you. It often helps to make a list of questions (there is space in this diary for this) prior to visiting your doctor and to take a close friend or relative with you.



UNDERSTANDING BOWEL SURGERY
Your Consultant Colorectal Surgeon will discuss with you the most appropriate type of surgery, dependant on the site, type and size of the tumour (cancer). Before any operation, the surgery will be discussed with you but it is important that you understand what will happen, so please do not hesitate to ask a member of the clinical team. The specialists meet regularly with each other to discuss your treatment. .

Surgery is the most common form of treatment for cancer of the large bowel. Usually the section, containing the cancer, is removed and the two open ends of the bowel are then joined together.

Right Hemicolectomy for Caecal/Right Colon Cancer





Left Hemicolectomy for Left Colon Cancer






Sigmoid Colectomy for Sigmoid Cancer





Anterior Resecetion for Rectal Cancer




Abdominal Perineal Excision of Rectum for Very Low Rectal Tumours




During the operation the blood vessels and lymph nodes supplying the area will also be removed because this is the first place to which the disease may spread.






Examining them enables us to gain a clear idea as to the extent of the disease. If for some reason the bowel cannot be rejoined, it can be brought out onto the skin of the abdominal wall. This is known as a colostomy and the opening of the bowel is known as a stoma. A bag is worn over the stoma to collect the stool or motions.

Colostomy

Sometimes a colostomy is only temporary and a further (smaller) operation can be done a few months later to revert the bowel to its normal state. If closure is not possible, the colostomy is permanent. If your tumour is situated very near the back passage, it may not be possible to treat the cancer properly without removing the muscles which control your back passage. It is then not possible to rejoin the bowel. If we are removing a tumour from the middle part of your rectum, we may join the bowel back together but bring a part of the bowel to the abdominal wall to form an ileostomy. This allows the stitches in the large intestine to heal without faeces in the bowel. As with a colostomy, stools are then collected in a bag worn over the stoma. An ileostomy is usually only kept for a few months. If we have not discussed the formation of a stoma with you in the clinic then it is unlikely that one will be necessary. If your cancer is in your rectum, your Consultant may suggest a course of radiotherapy (x-ray treatment) and chemotherapy (drug treatment) before surgery to shrink the cancer, which may make it easier to remove during the operation. The decision is made depending on the size, type of tumour, your general health and any biopsy or test results that have been obtained. If you have chemotherapy with radiotherapy before surgery there will be a time period when you finish these treatments before you will actually come to have your surgery.

RISKS CONNECTED WITH BOWEL SURGERY
Fortunately most people have no complications at all, although some problems can happen with any operation. Some of the more common problems are listed below:
• The bowel can take a few days to work normally following surgery due to handling of the bowel and anaesthetics. It can take several days before the bowel action returns to normal. Passing wind is a sign that the bowel is working again.
• To avoid you developing a chest infection within the lungs, you should try to do deep breathing exercises regularly, cough up any secretions to keep the chest clear. The physiotherapists will advise you on deep breathing and coughing exercises.
• Deep vein thrombosis (blood clots in the legs) and pulmonary embolus (blood clots in the lungs) are also potential risks. You may be given special stockings to wear, blood thinning injections or both during your hospital stay. They will help to reduce blood clots forming.
• Some people may develop a wound infection. You will be given antibiotics in this event.
• In less than 10% of patients the join of the bowel can leak. This can lead to complications such as abscess formation or peritonitis. This may require further surgery and the formation of a temporary stoma. This will allow the bowel to rest and heal. If it is a small leak it may be sufficient to rest the bowel by not eating and drinking for a few days. You will have fluids through a drip in the meantime.
• During low pelvic surgery the nerves responsible for sexual function may be damaged. This is due to the closeness of these nerves to the tumour. Research has shown that up to 30% of those sexually active pre-operatively, will have some sexual problems after surgery. No operation is risk free, but these risks are relatively small. You need to speak to your consultant or specialist nurse about your planned surgery to ensure you are fully aware of the benefits, as well as the risks.

The risks of a general anaesthetic General anaesthetics have some risks, which may be increased if you have chronic medical conditions, but in general they are as follows:
• Common temporary side-effects (risks of 1 in 10 to 1 in 100) include bruising or pain in the area of injections, blurred vision and sickness (these can usually be treated and pass of quickly)
• Infrequent complications (risks of 1 in 100 to 1 in 10,000) include temporary breathing difficulties, muscle pains, headaches, damage to teeth, lip or tongue, sore throat and temporary difficulty speaking.
• Extremely rare and serious complications (risk of less than 1 in 10,000). These include severe allergic reactions and death, brain damage, kidney and liver failure, lung damage, permanent nerve or blood vessel damage, eye injury, and damage to the voice-box. These are very rare and may depend on whether you have other serious medical conditions.

BEFORE YOUR OPERATION
Your Consultant Colorectal Surgeon will have discussed the most appropriate type of operation with you. The next stage is that you will be asked to attend the hospital one or two weeks before your surgery date, to have your heart and lungs checked, also blood tests to ensure that everything is satisfactory before you come in for your surgery. This normally involves attending the outpatient clinic for approximately two hours to do these tests (this is called pre-assessment) You will be given a date for your surgery and you will be admitted to hospital the day before your operation. Most people are allowed to have breakfast and a light lunch the day before their surgery and allowed to drink freely, but the nurses who are caring for you will advise you on what you will be allowed.

AFTER YOUR OPERATION
After your surgery you will be encouraged to start moving around as soon as possible. This is an essential part of your recovery to reduce your risk of blood clots and risk of chest infection. You will wake up with various drips, drains and tubes. This is normal, you should not become alarmed. These tubes are necessary to assist with your recovery. You will be allowed to drink freely when you return to the ward, as long as you are not feeling sick, also commence eating as you are able. The drip (which gives you fluid through a fine tube inserted into a vein in your hand/arm) will be removed once you are able to eat and drink normally again. Drains Often a small tube (catheter) is put into your bladder, your urine is drained through this into a collecting bag. This is usually removed after a couple of days. Sometimes a drainage tube is inserted near your wound to collect any extra fluid and make sure the wound heals properly. Pain After your operation you will probably have some pain or discomfort for a few days. There are several different types of very effective painkillers. Always let your doctor or nurse know if you have any pain or discomfort. Your painkillers or their dose can be changed to suit your needs.

IF YOU NEED A COLOSTOMY OR ILEOSTOMY
Some people with cancer of the bowel will need to have an colostomy or ileostomy. This can be very daunting at first. Learning to look after a stoma takes time and patience and no one expects you to be able to cope straight away. Like anything new it will get easier with time and patience. Your surgeon will introduce you to specialist trained nurses called stoma care nurse specialists who you will have met prior to your surgery and who will also support you after surgery to look after your stoma and help you cope with any problems. It is worth noting that people of all ages successfully manage temporary and permanent stomas, and are able to undertake work and leisure activities as normally.

DIET AFTER BOWEL SURGERY
After your operation on the bowel you may notice that certain foods upset the normal working of your bowel or your colostomy, if you have one. High fibre foods such as fruit and vegetables may give you loose stool and make you pass them more often than normal. Depending on the type of surgery you have had, you may even have diarrhoea. Tell your doctor or nurse if this happens, as they can give you medicine to control it. It is important to drink plenty of fluids if you have diarrhoea. This is often a temporary reaction and after a while you may find that the same food does not have any effect. Some foods that disagree with one person may be fine for others. It can sometimes take many months for the bowel movements to get back to normal after surgery, and you will probably need to find out which foods are right for you by trial and error. Some people find that their bowel may always be more active than before their surgery, and they will have to eat carefully to control their bowel movements. If you continue to have problems it is important to talk to the dietician at the hospital, as they can give you specialist advice tailored to your individual situation.

GOING HOME
There is no set time that you remain in hospital after surgery. Your medical team will make the decision as to when you can go home. Some people are ready for home after 4 days, others may need longer. If you think that you may have problems when you go home (for example, if you live alone or have several flights of stairs to climb), let your nurse know when you come in for your pre-assessment visit.

WHAT HAPPENS WHEN I GO HOME
When you go home you will probably feel very tired and worn out. You may even feel quite emotional at first. This is quite normal and you must bear in mind that you have been through a big operation. Although it is important that you rest adequately, it is also important that you keep active. Try to walk each day, gradually increasing the distance. You should also refrain from any heavy lifting for up to six weeks, including any heavy shopping or housework. Try to accept offers of help with jobs around the house or shopping until you feel well enough. You need time to recover before you start to drive again. This is usually about 6 weeks, but may vary depending upon your recovery. You must be capable of safely doing an emergency stop without any abdominal pain before you drive again. Car insurance may be invalid if you have an accident. You also need to feel well enough to drive.

SEX LIFE AFTER BOWEL SURGERY
Once you have recovered from the operation there is no reason why should not take up a normal sex life again. Some people find that their libido (sex drive) decreases, this is not unusual. Many people will get back to normal once they are fully recovered. In some cases an operation to the area around the rectum can cause damage to the pelvic nerves that lead to the sexual organs. If damage does occur a man may have problems with erections or ejaculation. This is a condition that will sometimes resolve. In other cases drug therapy may be required. Women may also encounter problems due to their uterus (womb) changing position within the pelvis. This can lead to a change in the position of the vagina, making intercourse difficult and painful in some cases. This may also lead to unpleasant vaginal secretions. If you do experience problems you should inform your consultant or specialist nurse who can then offer you advice and support.

WORK
Everyone’s recovery occurs at different rates and depends upon their illness and operation. Your operation will also influence how soon you can return to work. In general, return to work is about six to twelve weeks.

Management and follow up following bowel cancer surgery

Chemotherapy & Radiotherapy for bowel cancer