Colon cancer symptom

INTRODUCTION

By the end of 2003, there will be a total of 105, 500 new cases of colon cancer in the United States with approximately 57,100 deaths from colorectal cancer. While colon cancer is the third most common cancer, incidence rates are declining as screening and polyp removal has increased. Additionally, survival from this cancer is rather impressive as the medical world is learning more everyday. The 1-year, 5-year, and 10-year survival rates of colon cancer are 83%, 62%, and 55% respectively. If the cancer spreads to local organs or lymph nodes, a patient's 1-year survival can drop to 65% and even further down to 9% if distant metastasis occurs.1

For cancer that has yet to spread far from the primary site, surgery has always been the most common treatment for colon cancer, despite the pathology. However since the 1990s, there has been much controversy over which method of colon resection is more beneficial for patients dealing with colon cancer, the latest laparoscopic assisted colcctomy or the conventional open colectomy. To understand what both surgeries mean for a patient's acute recovery, this paper will first summarize the procedures and results of both surgical methods before discussing physical therapy considerations for both types of patients.1

SURGICAL METHODS FOR COLON RESECTION

With both methods of colon resection, the tumor and a portion of the colon on adjacent sides are removed along with nearby lymph nodes, if necessary. When the cancerous portions are removed, the remaining ends are reanastomosed. Surgeons will either do this via a laparoscopic or open colectomy.

As for the laparoscopic-assisted surgery, 5 to 6 small incisions or port sites, measuring

On the other hand, during an open procedure, an incision is made in the midline of the abdomen, measuring on average 10 inches in length. Through this incision, the surgeons manipulate, isolate, cut, and reattach the colon. Like the laparoscopic-assisted surgery, the midline incision is closed using staples or subcutical sutures.3 Also, it is important to note that with either surgery about 15% of patients may need the use of a permanent colectomy bag after surgery if the colon was closed off from the rectum. The patient's bowels will now exit through a stoma in the abdomen rather than through the colon and rectum.

In addition to the incision size and number of incisions, the two surgeries differ in the length of the procedure and in the amount of blood loss. As for the amount of blood loss, Hasegawa et al report a lesser loss of blood in the laparoscopic colectomy when compared to the open colectomy, 58 ml and 137 ml respectively.4 Psaila and his colleagues agree with their report of 474 ml blood loss with the laparoscopic colectomy and a 200 ml increase in blood loss with the open colectomy.5 However while laparoscopic procedures are less invasive and less traumatic to the patient, this surgical method takes up to an additional hour of being in the operating room.4,5

Typically, laparoscopic-assisted colectomies are done only in the supervision of clinical trials; the surgeons' experience with the procedure is also a factor.6,7 However even in these clinical trials, a surgeon has to decide whether or not the patient is an appropriate candidate for laparoscopic colectomy. Open surgery is elected when a patient has any of the following: a large palpable tumor (large is undefined), invasion of the cancer to nearby tissues, severe obesity, or a bifocal tumor.6,8 The reasoning behind these indications has to do more with the limitations of the laparoscopic instruments not being able to manipulate such large tumors, or the instrumentation not being long enough to get through larger layers of skin and fat. Also, if there is any metastasis to adjacent tissue, a surgeon needs a better view to see exactly the locations.

Opposition to Laparoscopic Resections

One of the major points behind the above controversy was the concern for the extent of the resection and adequacy of removing or getting a biopsy of lymph nodes.4 Surgeons questioned whether laparoscopic instruments and cameras were large enough to perform and observe a successful removal of tumorous cells. Many had and still prefer getting a 'hands-on' look at the patients' abdominal contents.

Also, in 1996, it was reported that port site metastasis occurred in 2% to 6% of the patients receiving the laparoscopic method. Fortunately, by 2002, the rate dropped to

Lastly, the comparison of open vs. laparoscopic assisted colcctomies lack long-term results.4 Since this is still a fairly new concept in the treatment of patients with colon cancer, only preliminary 5-year survival rates are discussed in the literature. Finalized results should be published by the end of the year and results beyond the 5-year mark will be studied further. The question remains what the acceptance will be for the laparoscopic procedure after these results are published.

Post-op Symptoms and Differences

When the patient leaves the operating room, several concerns arise as the inpatient care begins. A major concern of any abdominal surgery is whether or not the gastrointestinal system begins to work again so that the patient can return to eating.9 Several patients will experience postoperative ileus, a symptom that reveals a distended abdomen secondary to backup of GI contents in the intestines and stomach. Typical causes are the anesthesia used in surgery, inflammation of the area operated on, and a shutdown of the autonomie system (could be secondary to the use of anesthesia). The Winslow et al study reported that 5.4% of patients receiving laparoscopy will experience post-op ileus, compared to 30.4% of patients receiving open surgery.3 To relieve this symptom, a patient will have a nasogastric (NG) tube for hours or days. Once the first bowel movement occurs, the medical team assumes that the GI system has regained its motility. Agreeing with Winslow's theory that laparoscopic patients experience ileocolic symptoms, Delgado and colleagues showed that these patients' symptoms are over 29.8 hours after surgery, while open surgery candidates are over their symptoms in 48 hours.10 When the symptoms pass and the NG tube is removed, a patient's diet is advanced to clear liquids and then to a general food diet. An oral diet can begin on the second day for laparoscopic patients; open surgical patients see advancements in their diet 3 to 4 days after the operation. If no complications are present, the patient can be discharged home once the new diet is tolerated. With diet as the common limiting factor, the general length of postoperative hospital stay for laparoscopic patients is 60% less than that of open colectomy patients.4,5,10

Unfortunately, complications can occur in 31% of patients with open surgeries and 5.1% of patients with laparoscopic surgeries, postponing the patient's discharge.1" Winslow states that "since the fundamental difference between the laparoscopic and open approaches relates to the less traumatic method of abdominal access, one would expect a lower incidence of wound-related complications, including wound infection and incisional hernialion, to be among the primary benefits of a laparoscopic procedure."3 Winslow's report shows a 2.6% increase in wound infections with the laparoscopic operation. He and his colleagues relate this to the fact that there are more incisions made with laparoscopy, allowing for more risks for bacteria to enter the abdomen.

Likewise, the risk for herniation is higher in laparoscopic patients since there are more openings for the small bowel to exit the abdominal cavity; the risk is 24.3% for laparoscopic patients vs. 19.6% for open surgical patients.1 Despite such a high risk, the incidence for herniation for laparoscopy is 0.1%. The herniation usually presents itself after the drains are removed from a port site that did not close, but can also occur at the midline incisions. Surgeons have learned to prevent this occurrence by making certain to suture the drain site rather than letting the site heal on its own. Also, they take special consideration with elderly and thin patients by making port site incisions

While the acute comparison between the surgeries show several advantages for the use of laparoscopic assisted colectomies, preliminary long-term studies show no significant difference between the groups of the two surgeries. A study by Weeks et al reported that patient reports of their overall health were almost equal. When asked to rate their health from 0 to 100, with 0 being death and 100 being excellent health, patients who received laparoscopy answered on average 76.9, and patients who received open resection answered on average 74.4.11