Colorectal Cancer: Surgery to Reduce Risk

Surgery to Lower Colorectal Cancer Risk

This section covers the following topics:

Risk-reducing colectomy	Surgical risks
Types of colectomy	Recovery from surgery
Who should consider surgery?	Screening after surgery

 

What is a colectomy?

Colectomy is surgery to remove some or all of the colon. Colectomy is typically used to treat colorectal cancer or other diseases of the colon. People at very high risk for colorectal cancer may have a risk-reducing colectomy in order to prevent colorectal cancer from developing. 

Colectomy can have risks and long-term health effects, so it's important for people considering a risk-reducing colectomy to speak with cancer genetics and surgical experts in order to learn as much as possible about their colorectal cancer risk and to make an informed decision about the best option for lowering their risk.  

Types of colectomy

Colectomy surgeries vary by how much tissue is removed. 

• Segmental colectomy removes just a portion of the colon to treat cancer or other abnormalities. It is not typically used for prevention of cancer.  
• Total proctocolectomy with ileal pouch and anal anastomosis (TPC IPAA) removes the colon and rectum but spares the anal sphincter (the muscle that controls bowel movement release). People who have this surgery may remain continent with bowel control. The surgeon will use a portion of the small intestine to create an internal pouch, which stores waste until a bowel movement. 
• Total abdominal colectomy with ileorectal anastomosis (TAC-IRA) removes the entire colon but spares the rectum. Not all people are candidates for this surgery, as the intact rectum may still have elevated cancer risk. 
• Total proctocolectomy with permanent end ileostomy (TPC-EI) removes the entire colon, rectum  and anus and creates an ostomy opening at the end of the small intestine.  The end ileostomy is positioned on the abdominal wall and requires the use of an ileostomy bag to manage stool output. 

Colectomy may be performed by open surgery (also known as a laparotomy) where doctors make one long incision in the abdomen to access the colon. Under the right conditions, colectomy may also be done by laparoscopy - where a small incision is made for a small flexible scope with a camera, which is used to see the colon. Addition small incisions are made to insert surgical instruments needed to perform the colectomy. In general, people who have surgery by laparoscopy may heal quicker and spend a shorter time in the hospital than people who have open surgery. Not all colectomies can be performed by laparoscope, so it's important for people to speak with their doctor about which surgery is right for them. 

Expert guidelines on colectomy for people at high risk of colorectal cancer

The National Comprehensive Cancer Network (NCCN), is an organization of cancer experts that creates guidelines on cancer care and updates them yearly. NCCN's guidelines discuss the benefits and limitations of different types of surgery in people with certain inherited mutation linked to very high risk for colorectal cancer. 

Familial adenomatous polyposis (FAP or AFAP)

For people with familial adenomatous polyposis (FAP) or Atypical Familial Adenomatous Polyposis (AFAP) with a mutation in the APC gene, NCCN recommends discussion of colectomy when they first develop polyps. The type of colectomy depends on a person's medical history and preference, but options include: 

• Total proctocolectomy with Ileal Pouch and Anal Anastomosis (TPC-IPAA)  
• Total abdominal colectomy with ileorectal anastomosis (TAC-IRA) 
• Total proctocolectomy with permanent end ileostomy (TPC-EI) 

Lynch syndrome

For people with Lynch syndrome, (inherited mutation in EPCAM, MLH1, MSH2, MSH6, PMS2), the guidelines recommend  discussion about risk-reducing colectomy for people who have been diagnosed with colorectal cancer or for people who are not able to undergo recommended high-risk screenings. For these individuals, total abdominal colectomy with ileorectal anastomosis (TAC-IRA) may be discussed as an option for preventing development of future colon cancers. 

MUTYH associated polyposis (MAP)

For people with MUTYH associated polyposis (MAP), with mutations in both copies of their MUTYH gene, who have polyps that cannot be managed with colonoscopy alone, TAC-IRA surgery is often recommended.  

Other genes

Mutations in other rare genes can increase the risk for multiple polyps. For people whose polyps cannot be managed with colonoscopy, experts may recommend TAC-IRA surgery. 

Surgical risks

Every surgery has potential risks; some are more serious than others. Some possible risks with colectomy include:

• Infection 
• Delayed healing
• Blood loss
• Blood clots
• Internal bleeding
• Hernia
• Intestine blockage
• Intestine leakage
• Damage to other organs

It is important for people to discuss possible surgical risks with a surgeon to understand the seriousness and likelihood of these risks before making the decision to have risk-reducing surgery. 

Recovery

Recovery times after colectomy vary depending on several factors including the type of surgery and the general health of the person having surgery. Average recovery time is 1-3 weeks. 

Screening after surgery

Even after risk-reducing surgery, there may be risk for polyps and cancer in the tissue that remains. NCCN has recommendations for screening of high-risk people after colectomy based on:

• the type of surgery performed
• their gene mutation
• their personal history of cancer