Surgery for advanced bowel cancer

• A quick guide to what's on this page
• Surgery to control the cancer
• Surgery for a blocked bowel
• Surgery to remove small secondary cancers
• Specialised surgical treatments for secondary liver cancer

Sometimes, when a colorectal cancer comes back in the bowel, it is possible to remove it. This is unlikely to cure the cancer because there are usually cancer cells elsewhere in the body, even if they are too small to show up on a scan. But removing the bowel tumour will relieve any symptoms that you have. And it may be some time before the cancer starts to grow anywhere else.

Sometimes colorectal cancer can grow so that it completely blocks the bowel. This is called a bowel obstruction. The waste from the food you have digested cannot get past the blockage. This causes quite a few symptoms

• Feeling bloated and full
• Pain
• Feeling sick
• Vomiting large amounts
• Constipation

To relieve the symptoms, it is sometimes possible to unblock the bowel by putting in a tube called a stent. You have the stent put in by endoscopy. The surgeon puts a flexible tube with a light at the end into the bowel through your back passage. They can see where the blockage is and push the tube through it so that bowel motions can pass through the bowel again.

Another way of unblocking the bowel is to operate and remove the affected part of the bowel, if you are fit enough. It may be possible to close up the bowel again during this operation or you may need to have a colostomy. There is more about a colostomy in our section on if you need a colostomy.

You may want to talk about whether to have this type of surgery with your close family and friends as well as your doctor and nurse. It is likely to be quite a big operation just when you may be feeling very low. If you choose not to have the operation, your doctors can use medicines to control your symptoms. The drugs somatostatin or octreotide can reduce the amount of fluid that builds up in your stomach and digestive system and so relieve nausea and vomiting. Unfortunately, this treatment is only likely to control your symptoms for a limited time.

If colorectal cancer spreads, it often goes to the liver or lungs.

Sometimes, when the cancer secondaries in the liver or lungs are small and there are only one or two, you can have surgery to remove them. This is not suitable treatment in every situation. It is done more often for liver secondaries than for lung secondaries. If you have this type of surgery, you may also have chemotherapy before and after the operation.

You can only have this type of surgery if you have just a few areas of secondary cancer in either your liver or your lungs. To decide if this treatment is suitable for you, your doctor will look at

• Your general health
• How advanced your cancer was when you were diagnosed
• How quickly your cancer came back
• How many secondaries you have and their size
• Where they are in the liver or lungs
• How close they are to major blood vessels.

You will have scans such as CT, PET or MRI. You may also have a test to look at the blood supply to the area (angiogram), to make sure the operation is possible.

Removing secondary cancers from the liver is very specialised surgery and is done in major liver surgery centres. There are centres throughout the UK, so talk to your own specialist about this if you think it might help you. Your specialist can refer you to your nearest liver surgery centre if this type of treatment is right for you.

Research is looking into the results of removing liver and lung secondaries in colorectal cancer. There are reports showing that this type of treatment can be very successful for some people. The exact results vary. But generally, between 30 and 40 out of every 100 people treated are alive 5 years later. You can even have the treatment again if the cancer comes back in the liver. In fact, you can have more than half your liver tissue removed because the liver tissue can grow back after surgery. Studies show that treatment is least likely to be successful if

• You have cancer in the lymph nodes near the liver
• You have cancer that has spread to another body organ
• Your surgeon is unable to completely remove any of the liver secondaries

There are other types of specialised surgery to destroy secondary liver cancer. If you have a secondary cancer somewhere else in your body, your doctor is unlikely to offer you this type of treatment. They will probably suggest chemotherapy instead because that circulates throughout the body and so treats all areas of secondary cancer.

You may be able to have your secondary liver cancer treated with the following types of surgery

• Radiofrequency ablation (RFA)
• Radiofrequency assisted surgery
• Cryotherapy
• Laser therapy
• Microwave ablation
• Alcohol treatment
• Hepatic artery chemoembolisation

These are still experimental techniques. They aim to kill off the cancer cells without causing too much bleeding or other side effects. Your doctor will take several factors into account before deciding whether any of these types of surgery are possible for you including

• Your general health
• Whether you have secondary cancer anywhere else that cannot be removed
• How quickly your cancer came back after other treatments

Your doctor will discuss with you the possible benefits and risks of the treatments in your situation.

Radiofrequency ablation (RFA)

Radiofrequency ablation uses radiowaves to destroy the cancer cells in the liver by heating them to high temperatures. You usually have a sedative that makes you feel drowsy but some people have a general anaesthetic. If you just have sedation, your doctor injects a local anaesthetic into the skin of your abdomen to numb it. They then push a thin needle through the skin over the liver and into the centre of each tumour. They use a CT or ultrasound scan to make sure the needles are in the right place. Then radiowaves pass through the needle to heat the tumours and destroy them.

The process takes about 10 to 15 minutes and is used to treat tumours up to 5cm (2 inches) in size. Usually, you can go home a few hours afterwards. You may need to have the treatment repeated. The main side effects are pain and a high temperature for a few days afterwards.

In 2004, the National Institute for Health and Clinical Excellence (NICE) issued guidance on the use of RFA for cancer that started in the bowel and has spread to the liver. In that guidance, they said that RFA appears to be safe enough as a treatment. But we need more research into how well it works in helping people to live longer.

Radiofrequency assisted surgery

Radiofrequency assisted surgery uses high frequency radio waves to destroy the cancer, as in radiofrequency ablation. The surgeon uses an ultrasound scan to see where the radiofrequency probe is. When the probe is in the right place, the surgeon uses it to destroy the cancer and the liver tissue around it. Then they surgically remove the dead tissue with the tumour.

The idea is that heating up the tissues with the RFA probe seals blood vessels so that there isn't as much bleeding as there would be with a standard operation to remove cancer from the liver. In February 2007 NICE (the National Institute for Health and Clinical Excellence) issued guidance saying that this procedure appears to be safe and works well enough to be used on tumours in the liver. But there is a higher risk of getting an infection afterwards, and NICE say there isn't enough evidence yet to show that it is any better than other ways of removing liver cancer during an operation.

Cryotherapy

Cryotherapy is also called cryosurgery. It is only suitable for liver tumours which are smaller than 4cm (1½ inches) in size. The procedure takes about 30 to 60 minutes and you have a general anaesthetic. The surgeon makes a cut in the skin over your abdomen. A device called a cryoprobe is inserted into the centre of the liver tumours. They use a CT or ultrasound scan to make sure the probe is in the right place. Liquid nitrogen then passes through the probe. This freezes the surrounding area and destroys the cancer cells. Sometimes the area is thawed for 10 to 15 minutes and then frozen again. You will have some pain afterwards are pain and possibly a high temperature but you will be given painkillers to help. You usually have a short stay in an intensive care unit followed by around 2 days in the specialist liver treatment ward.

Laser therapy

Laser therapy may also be called laser ablation. It uses a laser (a very, very high powered beam of light) to destroy the cancer cells in the liver by heating them to high temperatures. You usually have a sedative that makes you feel drowsy but some people have a general anaesthetic. If you just have sedation, your doctor injects a local anaesthetic into the skin of your abdomen to numb it. They then push a flexible optical fibre tube through the skin over the liver and into the centre of each tumour. They use a CT or ultrasound scan to make sure the tip of the tube is in the right place. Then the laser heats the tumours and destroys them. The process takes about 10 to 15 minutes and is used to treat tumours up to 5cm (2 inches) in size. Usually, you can go home a few hours afterwards. You may need to have the treatment repeated. The main side effects are pain and a high temperature for a few days afterwards.

Microwave ablation

Microwave ablation uses microwave energy to produce heat and kill cancer cells. You can have this treatment for more than one secondary liver tumour. This procedure may be done under a local or general anaesthetic. The doctor puts a thin needle into each tumour. They use a CT or ultrasound scan to make sure the needles are in the right place. The needles are then connected to a microwave generator. The microwaves are released through the needles to destroy the cancer cells.

In May 2007 NICE said that there was not at present enough evidence to support using microwave ablation as a routine treatment for cancer that has spread to the liver from elsewhere. But you may still be offered it as part of a trial. Doctors who want to use this procedure for secondary cancers must make sure that they explain to you all the risks involved, and about other treatments that are available, before you give your consent. We need more research into this procedure to see how well it works.

Alcohol treatment

In this procedure, sterile alcohol destroys the cancer cells. It is only suitable for tumours smaller than 4 to 5cm (1½ to 2 inches). You may have medicine to make you drowsy. The surgeon then injects local anaesthetic into the skin over the liver. They push a thin needle through the skin and into the tumours in the liver. They use a CT or ultrasound scan to make sure the needle is in the right place. They inject the alcohol directly into the tumour. They may treat more than one tumour. The injection can be painful so you will have painkillers to take for a while afterwards. Some people feel drunk for about 10 to 15 minutes after the injection. You usually stay in hospital for a few hours after your treatment in case you have any bleeding or pain. You can have the treatment again some time later if the tumours grow back.

Hepatic artery chemoembolisation

This procedure gives a liquid into the main artery taking blood to the liver. The liquid blocks the blood vessels and creates high chemotherapy levels in the liver. You may have a medicine to make you feel drowsy. The surgeon then injects a local anaesthetic into the skin over a blood vessel at the top of your leg. While using x-ray pictures, the surgeon slides a thin plastic tube into the blood vessel. They push the tube gently upwards until the tip is in the artery that takes blood to the liver. When the tube is in position, the surgeon injects a chemotherapy drug mixed with an oily liquid. They then remove the tube.

The oily liquid creates blood clots in the blood vessels which take blood to the tumour. This stops oxygen and nutrients getting to the tumour. High levels of chemotherapy stay in the tumour for a few hours and this kills some of the cancer cells. The tumour shrinks. The procedure may take from 30 minutes to a couple of hours. You may have some pain afterwards, feel sick or be sick, and have a high temperature.

There is information about other treatments for advanced bowel cancer in this section of CancerHelp UK.