Common Myths about Colorectal Cancer Surgery Dispelled

    Close up surgical operation using laparoscopic equipment in the clinic.
    Close up surgical operation using laparoscopic equipment in the clinic.

    A permanent ostomy bag and a very long recovery are often associated with colorectal cancer surgery. But treatment of colorectal cancer has changed. According to Atif Iqbal, M.D., FACS, FACRS, chief of colorectal surgery in the Michael E. DeBakey Department of Surgery at Baylor, advances in the field mean that these concerns could be a thing of the past.

    According to the American Cancer Society (ACS), approximately 4.6% of men (1 in 22) and 4.2% of women (1 in 24) will be diagnosed with colorectal cancer in their lifetime. Lifetime risk is similar in men and women despite higher incidence rates in men because women have longer life expectancy. [1]


    Atif Iqbal, MD., FACS, FACRS, Chief of colorectal surgery in the Michael E. DeBakey Department of Surgery at Baylor

    “[Over the last decade the occurrence and death rates [of colorectal cancer] in patients over 50 is [rapidly] decreasing because we are able to screen and catch colon polyps early,” Iqbal said.

    Unfortunately, results from a study published in Cancer, a journal published by the ACS, shows that when younger patients are diagnosed, the disease is more likely to be in the advanced stages, at 51.6% vs. 40% compared to older patients.[2]

    The decrease in people over 50 years of age is helped by better screening and diagnostics and improvement in surgical procedures. “Colorectal surgery options have evolved quite a bit – not only in terms of techniques but in terms of indications for surgery,” Iqbal added.

    Among the approaches are novel strategies designed to eliminate malignancy, while at the same new technical developments, including minimally invasive surgery, aim to increase patient comfort and health related Quality of Life (hrQoL).

    Dispelling myths
    In our interview Iqbal dispels some common myths and explains how Baylor’s multidisciplinary approach to treating these cancers improves patient outcomes.

    Myth 1: Following colorectal cancer surgery, patients will always have a permanent colostomy bag.

    Fact: Colorectal cancer treatment has evolved to allow surgery without causing abdominal scars or, in some cases, the option to completely avoid surgery. Even if major surgery is needed, newer surgical technologies make a permanent ostomy bag increasingly rare.

    And while some surgeons treat colorectal cancer using a procedure that results in a permanent colostomy bag, restorative colorectal surgeons are more specialized. They are able to reconnect the intestines with the anus using specialized techniques as opposed to making a permanent colostomy bag.

    A surgeon’s Experience
    The experience of “Data suggests that patients of surgeons who perform more surgeries that result in a permanent colostomy bag have a longer length of stay in the hospital, a higher chance of the tumor coming back and a higher chance of death,” Iqbal explained, who also is a member of the NCI-designated Dan L Duncan Comprehensive Cancer Center at Baylor.

    According to Iqbal, who operates at Baylor St. Luke’s Medical Center, there also is data to suggest that a patient with colorectal cancer who is operated on by a colorectal specialist has a lower risk of mortality and return of cancer.

    Myth 2: Recovery from colorectal cancer surgery requires a long stay in the hospital.

    Fact: Recovery has changed quite a bit thanks to enhanced recovery after surgery (ERAS) protocols, which rely on evidence-based medicine to direct patient care and recovery after surgery. While patients used to stay in the hospital for seven to 12 days after major abdominal surgery, the length of stay has now been significantly reduced, usually to between one and three days.

    “The enhanced recovery after surgery protocol starts even before the patient arrives at the hospital. In fact, it starts a couple of weeks before surgery and goes through their postoperative recovery,” Iqbal said.

    Previously, patients were told not to eat or drink starting at midnight on the day of surgery, even if their case was later in the day. Because this can cause dehydration and low-sugar levels before they go into the operating room, patients are now told to continue their liquid diet up to three hours before the surgery. In addition, patients can have a liquid diet immediately following their surgery and can go to a regular diet the next morning. Most patients also are able to avoid tubes in their nose/mouth or drains after surgery.

    Another change in the recovery is that patients do not have to wait for their bowels to start functioning before they are able to eat or before they are able to be discharged from the hospital.

    “We have found that the quicker we feed them, the better the patients do because a portion of the nutrition for the bowel comes from the food within the bowel, so if you’re not feeding the gut, you’re essentially starving the gut itself,” Iqbal noted.

    Pain management and control

    Myth 3: Postoperative pain control will require lots of narcotics, including opioids.

    Fact: The opioid addiction crisis across the country can make many people hesitant to use narcotics to control their pain.

    And while it is true that poorly managed postoperative pain can lead to complications and prolonged rehabilitation and is associated with the development of chronic pain with reduction in quality of life, appropriate pain relief, in contrast, leads to shortened hospital stays, reduced hospital costs, and increased patient satisfaction. As a result, postoperative pain is an increasingly monitored quality measure.[3][4][5][6]

    Most physicians recognize that preoperative patient evaluation and planning is vital to successful postoperative pain management. But providing good postoperative analgesia is multifactorial. Unfortunately, insufficient education, fear of complications associated with pain relief medication, poor pain assessment and inadequate staffing may be among the root causes of poor pain management. With the introduction of enhanced recovery programs for colorectal surgery both physician and patient expectations have changed in terms of perioperative pain management making the reduction of opiate intake a factor in meeting these expectations.

    For example, multimodal pain management may be recommended whenever possible. And unless contraindicated, patients may benefit form an around the clock regimen of NSAIDS or acetaminophen. Such a pre-emptive pain management approach, as well as regional blocks, may be beneficial in an outpatient setting. Pain management with morphine or hydromorphone may be considered appropriate for patients undergoing abdominal procedures under general analgesia. Studies have shown in patients in which this is not  contraindicated, the addition of NSAIDs may lower the narcotic requirement and improve the quality of pain control.

    Iqbal further explained that many surgeons are now giving a combination of different non-narcotic medications to provide pain control in both the postoperative inpatient and outpatient setting.

    ”Most of our patients are not needing any narcotics after surgery anymore, while they continue to have adequate pain control,” Iqbal said.

    Benefit of a multidisciplinary center
    Iqbal says when selecting a center for colorectal cancer treatment, look for a restorative colorectal surgeon and a surgeon and a hospital where a high volume of these cases have been treated – there is data to show that all of these independently impact outcomes.

    “You need to be taken care of by people who do this day in and day out,” Iqbal said.

    The best thing a patient or his or her advocate should do is to seek out a medical center where care is not fragmented. A true multidisciplinary program brings all specialists the patient needs under one umbrella, requiring no separate appointments with different doctors in different locations.

    “Our team works together to explore the best medical or surgical option to ensure the most successful outcome for the patient,” Iqbal noted.

    His approach is to provide combined clinics with medical oncologists for cancer patients and gastroenterologists for IBD patients.

    “We are able to provide a seamless patient experience with good communication between physicians. We see the patients together in the same room and provide an outline of their care to them. Patients can make informed decisions about their care with all members of their treatment team in the same room,” Iqbal said.

    “Additionally, cancer patients are reviewed at weekly tumor board conferences for multidisciplinary input, including discussing of new or experimental treatments. This helps us involve our expert specialists from colorectal surgery, medical oncology, radiation oncology, gastroenterology, pathology, radiology and other specialists as needed in formulating a succinct plan for the patient in a timely fashion,” Iqbal concluded.

    Reference
    [1] Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016;66: 7-30.
    [2] Virostko J, Capasso A MD, Yankeelov TE Recent trends in the age at diagnosis of colorectal cancer in the US National Cancer Data Base, 2004‐2015
    Published Online on July 22, 2019 [Ahead of Print] https://doi.org/10.1002/cncr.32347
    [3] Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome.Br J Anaesth. 2001 Jul;87(1):62-72.
    [4] Kehlet H, Jensen T, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet. 2006 May 13;367(9522):1618-25.
    [5] Kalkman CJ, Visser K, Moen J, Bonsel GJ, Grobbee DE, Moons KG. Preoperative prediction of severe postoperative pain. Pain. 2003 Oct;105(3):415-23.
    [6] Abrishami A, Chan J, Chung F, Wong J. Preoperative pain sensitivity and its correlation with postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2011 Feb;114(2):445-57. doi: 10.1097/ALN.0b013e3181f85ed2.