Cancer Follow up
Questions to be asked after an operation to remove bowel cancer.
What can I expect after the operation?
You can expect to be in hospital for up to two weeks after conventional surgery and by the time you leave hospital you will able to eat and drink normally. The usual wound is long and it will take a further month, at least, before you are fully active and able to return to work. The recovery time however, is variable and it will take longer for some patients. Your surgeon will advise you about your diet and lifestyle for the future.
Will I be cured of the cancer?
Yes there will be a good chance of being cured of the cancer if it is detected at an early stage. Overall more than 50% of patients are cured by surgery. Some patients will be advised that they need extra treatment if the cancer has extended beyond the confines of the bowel wall.
Will I develop another cancer?
Experience has shown that a patient who has developed one cancer is at a slightly greater risk than the rest of the community of developing a second cancer and for that reason your surgeon will recommend a programme of "follow-up".
How often should I see my surgeon?
An early post-operative review will be arranged for you from the hospital. This is usually within two-to-four weeks of leaving hospital. From then on the surgeon will recommend a set programme of reviews according to the recommendations of the Colorectal Surgical Society of Australia. These recommendations involve:
- a review at regular and frequent intervals for five years.
- yearly review thereafter.
Will special tests be done?
Yes, for a rectal (low bowel) cancer, the surgeon will perform a sigmoidoscopy at each visit. At the end of the first year after surgery (it will be done earlier if one has not been performed before the surgery) the surgeon will arrange for a colonoscopy (total examination of the bowel) and if that examination is clear it will be recommended that the colonoscopy is repeated at appropriate intervals. Any pre-cancerous lesions (polyps) seen on that examination will be removed at the time of the examination and be tested. The colonoscopy will then be repeated one year later and if the bowel is clear at the next examination, a three-yearly programme is recommended. Some blood tests can provide useful information about the likelihood of the cancer returning and your surgeon may order these from time to time according to the particular circumstances of your case. If a patient has symptoms or signs which might indicate that the cancer is returning, the surgeon may order other tests such as an x-ray or ultrasound of the liver and other areas
For how long should I continue to be checked?
The Colorectal Surgical Society of Australia recommends that a patient should be "followed up" by the surgeon for as long as he/she remains fit to undergo further treatment should a new cancer develop. The following is a summary of the plan recommended by the Colorectal Surgical Society of Australia and New Zealand for "follow-up" of a patient after an operation to remove a cancer of the large bowel.
- Early post-operative colonoscopy, if colonoscopy or barium enema had not been performed before the operation.
- A review at regular and frequent intervals for five years. These visits to be associated with digital and sigmoidoscopic examination depending on the aspects of your case.
- Colonoscopy every three years.
- Other tests to detect cancer according to clinical indications.
This protocol may vary with individual patient pathology and surgical treatment.
Colonoscopy
What Is Colonoscopy?
Colonoscopy is a procedure for diagnosing and treating a variety of problems encountered in the colon (also called the large bowel or large intestine). It is performed using an instrument called a colonoscope which is a flexible tube that is about the thickness of a finger. It is inserted via the rectum into the colon and allows the doctor to carefully examine the lining of the bowel. Abnormalities suspected by x-rays can be confirmed and studied in detail. Abnormalities which are too small to be seen on x-ray may also be identified and colonoscopy is now considered to be a more accurate examination of the large bowel than barium enema x-ray. If the doctor sees a suspicious area or needs to evaluate an area of inflammation in greater detail, the doctor can pass an instrument through the colonoscope and take a piece of tissue (a biopsy) for examination in the laboratory. Biopsies are taken for many reasons and do not necessarily mean that a cancer is suspected.
What Is Polypectomy?
Sometimes colonoscopy is undertaken to locate or remove polyps. These are small growths on the lining of the bowel. They are usually benign but occasionally can contain a small area of cancer. Removal of a polyp is called polypectomy. This is achieved by passing a wire loop through the colonoscope and snaring the base of the polyp, which is then severed from its attachment to the bowel wall by means of an electric current. This current cannot be felt and causes no pain. Early detection and removal of polyps prevents them from becoming malignant, and is therefore an important means of protection from colon cancer, (one of the most common cancers in Australia). The ability to remove polyps with the colonoscope means that the patient can avoid a major operation. After colonoscopic polypectomy the patient is allowed to resume usual activities within a day or two, and can return to a normal diet almost immediately.
Is Any Special Preparation Necessary?
Yes. For a successful colonoscopy, it is essential that the bowel is thoroughly emptied. This will usually mean taking clear liquids as well as a special laxative before the colonoscopy. More specific preparation instructions will be given to you. Occasionally one or more enemas may also be required. This preparation can usually be done at home. Failure to carry out the full preparation may leave solid material in the colon and could prolong the procedure or necessitate a repeat examination at another time. Retrograde pre-colonoscopy preparation (e.g. rectal pulse or colonic irrigation) may be a safe and effective alternative to oral bowel preparation that may be recommended in some cases when available.
What Happens During Colonoscopy?
When you arrive for the colonoscopy you will be asked to change clothes and may be given a small enema. The examination may be performed with intravenous sedation or a light anaesthetic and your particular management will be explained to you. If you are being managed with sedation you will probably sleep during most of the procedure but you may be aware of changes in position, inflation of the colon with air (distension) and temporary abdominal discomfort. Examination of the large bowel lining is made as the instrument is being inserted, and again as it is withdrawn. The examination may take 60 minutes especially if polyps are to be removed.
What Happens After Colonoscopy?
You will be asked to rest for a hour or two until the effects of the sedatives have worn off, and you have passed much of the inflated air. Although most of the effects of the sedative/anaesthetic wear off quickly you should not drive yourself home after your colonoscopy. You should therefore arrange for a friend or relative to accompany you when you leave.
Are There Any Complications From Colonoscopy Or Polypectomy?
Colonoscopy and polypectomy are very safe procedures with a very low risk of complications, although these occur very occasionally. Localized irritation of the arm vein may occur at the site of injections of the sedatives. A lump may develop and remains for several weeks or even months, it will eventually disappear. Perforation of the colon rarely occurs during colonoscopy however this can require abdominal surgery to close the defect in the bowel wall. Great care is taken to avoid this complication.
History
The colonoscope was developed in Japan in the 1960's and was preceded by instruments used to examine the stomach. The first flexible instrument was the gastrocamera and later the gastroscope. The gastroscope was subsequently modified to examine the large bowel (colonoscope). Colonoscopy was first used in Australia in the early 1970's and many technical (and expensive) improvments have occurred since. The image of the bowel interior is now observed on a video screen which allows all members of the colonoscopy team to assist more appropriately. The technique of Colonoscopy is difficult to master and strict guidelines for training now exist to ensure expertise and safety.
The Australian Commission on Safety and Quality in Health Care (ACSQHC) has developed a number of resources to support implementation of the Colonoscopy Clinical Care Standard including useful fact sheets for both consumers and clinicians and videos.
Constipation
What is Constipation?
Almost everyone gets constipated sometime or other - it is a very common condition. Constipation means different things to different people - some regard it as the passage of hard stools whilst other the infrequent passage of normal or hard stool. Some people believe it is vital to have one bowel action every day. The normal range of bowel frequency varies from three bowel actions per day to one bowel action every three days.
When should I see my doctor?
Constipation becomes an abnormal symptom when:
- there is a persistent change in your normal bowel habit
- it is associated with bloating or crampy abdominal pain
- there is bleeding from the back passage
- you find yourself spending long periods of time straining on the toilet
- you need to use your fingers in the back passage, or even the front passage (in women) to get your bowels going
- you have the feeling that there is a "ball" blocking the passage of motion in the back passage
- there is absolute constipation when you do not pass any motion or wind over several days
If you have these symptoms, contact your family doctor who may order some tests or refer you to a Specialist Colorectal Surgeon.
What are the causes of Constipation?
The causes of constipation are many and varied and may be combined together. Most causes of constipation relate to lifestyle issues:
- low fibre high fat diet
- low fluid intake
- sedentary lifestyle (little exercise)
- change in daily routine
- stress and anxiety
Other factors that can aggravate constipation are:
- pregnancy
- overuse of laxative
- side effects of medication especially strong pain killers
Causes of persisting constipation, often associated with other symptoms are:
- blockage in the bowel by a growth or narrowing (bowel obstruction)
- a muscle problem either that the large bowel muscle is sluggish (slow transit constipation) or the anal sphincter muscle (at the back passage) does not relax when you are having a bowel motion (obstructed defaecation)
- Non-specific or functional problem where no immediate cause is obvious
What tests may I need to have?
Your general practitioner may organise these tests or refer you to a Specialist Colorectal Surgeon.
1. Examining the back passage and the inside of the bowel. This is done to determine if there is a blockage and you may need to have:
- Internal examination of the anus with the doctors finger and a rigid telescope (sigmoidoscope)
- Internal examination of the whole large bowel with a flexible telescope - flexible sigmoidoscopy or colonoscopy
- X-ray examination of the large bowel - barium enema
2. Tests to determine if there is a muscle problem
- A whole gut transit time. This is performed either by you taking a tablet containing markers, then having a series of x-rays or having a nuclear medicine scan after taking combined liquid and solid meal (containing Radio Isotope) and scans are then taken. These tests require x-rays or scans over a period of 5-6 days.
- Muscle test on the back passsage (Ano-rectal manometry). A catheter is placed in the anus and measurements of your muscles made including a balloon test
- Electrical tests on the muscle (EMG). These tests may be uncomfortable but they are occasionally necessary.
How is Constipation treated?
Maintaining a healthy diet and lifestyle.
- low fat/high fibre diet
- regular fluid intake
- regular exercise
What is fibre?
Fibre is in the cell walls of plants and in the bowel remains undigested. It acts like a sponge soaking up water into the bowel adding bulk to the bowel content and increasing the passage of digested food through the bowel.
How much fibre do we need?
Most Australians eat about 20gms of fibre per day but the recommended daily intake to remain healthy and have a regular bowel habit is 30gms per day.
Which foods are high in fibre?
- Breads
- Cereals
- Fruit
- Vegetables
- Nuts, seeds, legumes (lentils/beans)
- Foods that are high fibre are generally low in fat. A high fibre low fat diet is ideal.
What else can I do to help my bowels?
Fluids - drink plenty of water (2 liters per day). This increases the sponge effect of the fibre. Fitness - have regular exercise, 20 minutes, three times per week - walking is best. This stimulates bowel function. Fibre supplement - many natural fibre products are available at your pharmacy to add extra fibre. A formula for fighting constipation - the 5 F's
- HighFibre
- LowFat diet
- Fluid
- Fitness
- Fibre Supplement
What may my doctor do to treat Constipation?
Blockage or bowel obstruction
Surgery may be required to remove the affected part of the bowel causing the blockage. Your Colorectal Surgeon will explain the details of these procedures.
Bowel Muscle Problem (Slow Transit Constipation)
Majority of patients can be treated by a combination of dietary manipulation and laxatives. Occasionally surgery may be required to remove the large bowel (the sluggish bowel) and join the small bowel to the rectum. A stoma bag is very rarely required.
Sphincter Muscle Problem (Obstructed defecation)
Treatment is a combination of diet, laxatives and bio feedback - exercises involving pelvic floor rehabilitation (retraining the sphincters to relax), usually under the supervision of a physiotherapist.
Non-specific
Often despite all investigations performed no specific cause can be found for the constipation though the symptoms persist. This can be frustrating both for yourself and the doctor but usually a combination of change in lifestyle, diet and laxatives will improve the situation.
General Advice
Should you be concerned about any symptoms or the information contained in this brochure, please feel free to discuss this with your Specialist Colorectal Surgeon or your General Practitioner.
Crohn's Disease
What Is Crohn's Disease?
Crohn's disease is a type of chronic inflammatory condition that usually involves the small and/or large bowel. The cause is unknown but many theories exist.
Incidence
A rare disease, Crohn's affects males and females equally at the rate of about 5 per 100,000 of the population. Occasionally more than one family member is affected. Children and adults of any age may suffer from Crohn's disease, but there are slightly increased peaks of incidence around 25 and 65 years of age. How Does Crohn's Disease Affect The Bowel The inflammation occurs in a patchy manner and can produce areas of ulceration and narrowing of the small and/or large bowel lining, resulting in localised and general symptoms. Bleeding can lead to anaemia and abscesses can form next to the involved bowel and sometimes burst into other organs causing fistulae (abnormal track). If the anus is involved, fissures, fistulae and watery discharge may be present. The bowel ulceration causes diarrhoea and occasionally malnutrition. Narrowed bowel causes pain and symptoms of intermittent incomplete blockage.
Can Other Organs Be Involved?
Rarely other organs can develop problems such as arthritis, skin conditions and inflammation of the eyes. Some of these conditions respond to medical treatment and others only to surgery.
Symptoms
Abdominal pain, diarrhoea, malaise and fever occur in a chronic manner with acute exacerbations. Bleeding may be present and mixed with the stool, but more often it is not obvious and leads to anaemia and iron deficiency. The abdominal pain may be localised to one point, particularly in the area over the appendix and an incorrect diagnosis of appendicitis is sometimes made. Painful mouth ulcers are common, as is weight loss and tiredness.
Diagnosis
This can sometimes be difficult as Crohn's disease can mimic many bowel disorders, particularly the irritable bowel syndrome. Large bowel Crohn's disease (colitis) is best diagnosed by endoscopy (colonoscopy or flexible sigmoidoscopy). Biopsy and barium enema x-rays are sometimes helpful. Small bowel Crohn's disease requires a small bowel barium x-ray series for diagnosis. Rarely an isotope labelled white cell nuclear scan can identify disease. Certain blood tests may be helpful in the assessment of the severity of the illness. It is sometimes impossible to distinguish between Crohn's disease and ulcerative colitis.
Treatment
There is no cure for Crohn's disease. Medication often controls the inflammation, the main drugs being anti-inflammatory, such as Prednisone and Salazopyrine, anti-diarrhoeals and anti-spasmodics, iron and nutritional supplements. Occasionally immune suppressants are used such as Azothiaprine. Where there is a localised complication of Crohn's disease or an area causing troublesome symptoms that don't respond to medication the treatment of choice is surgery. The likelihood of surgery being required is high.
What Operation Might I Have?
The surgical procedure is tailored to the specific problem. If short segments of small bowel are involved a widening operation called stricturoplasty is carried out. If a longer length is involved that section of the bowel is removed and the ends rejoined. A stoma of either the large bowel (colostomy) or small bowel (ileostomy) is sometimes necessary and this can be permanent if the anus has been removed; or temporary, if it has been made to allow the residual bowel inflammation to subside. Abscesses always require surgical drainage and occasionally other organs need surgical attention.
Who Should Do My Surgery?
A surgeon who has specifically trained in the management of inflammatory bowel disease who works closely with your physician and who is interested in your wellbeing and quality of life. The members of the Colorectal Surgical Society of Australia have this expertise.
Is More Than One Operation Likely?
About half the patients who require an operation have a second operation at some stage in the future, often years later, and of these another half will require further surgery. Surgery is used to relieve symptoms and complications of Crohn's disease, and to improve the quality of life.
What About The Future?
Most people with Crohn's disease lead relatively normal lives, working and raising families, playing sport and enjoy a good life expectancy. Pregnancy is not contra-indicated. Patients with chronic colitis should undergo long term surveillance because of a slight increase in the risk of developing colon cancer. Crohn's disease can "bum out" after many years but the clinical course of the condition is always unpredictable.
History
In 1932 at the Mt. Sinai Hospital in New York, Drs. Crohn, Ginzburg and Oppenheimer described 14 specimens of chronic inflammation of the small bowel which they named regional iletis. In 1960 Drs. Lockhart-Mummery and Morson from St. Mark's Hospital, London published a detailed account of the surgical pathology of this condition affecting the large bowel. The inflammation may affect any part of the gastrointestinal tract is now known as Crohn's disease.
The Crohn's & Colitis Australia website can be accessed HERE