Surgery for advanced bowel 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 that are too small to show up on a scan. But removing the bowel tumour may relieve symptoms and help you to feel better. And it may be some time before the cancer starts to grow anywhere else.

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

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

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

If you are fit enough, another way of unblocking the bowel is to operate and remove the affected part. It may be possible to close up the bowel again during this operation. Or you may need to have an opening made onto the body surface for your bowel motions to pass into a bag (a colostomy). There is information about having a colostomy in this section.

You may want to talk to your close family and friends, as well as your doctor and nurse, about whether to have this type of surgery. It is likely to be quite a big operation. 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 stop you feeling sick or vomiting. Unfortunately, this treatment is only likely to control your symptoms for a limited time.

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

Sometimes, if there are only 1 or 2 small areas of cancer spread (secondaries) to the liver or lungs you can have surgery to remove them. This is not suitable treatment in every situation. It is done more often for cancer spread to the liver than to the lungs. 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 diagnosed
• How quickly your cancer came back
• How many secondaries you have and their size
• Where the secondaries 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 (an angiogram), to make sure the operation is possible.

Removing secondary cancers from the liver is very specialised surgery and has to be 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. If this treatment is right for you, your specialist can refer you to your nearest liver surgery centre.

Researchers are looking into the results of this type of surgery in bowel cancer. Reports show that removing liver secondaries can be very successful for some people. The exact results vary. But generally, between 30 and 40 out of every 100 people treated (30 to 40%) are alive 5 years later. You can have the treatment again if the cancer comes back in the liver. You can have more than half your liver removed if necessary because 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 cannot completely remove all of the liver secondaries

There are other types of specialised surgery to destroy secondary liver cancer. If your bowel cancer has spread anywhere 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 cancer spread.

If you only have cancer cells in the liver and not in other parts of your body, your doctor may recommend one of the following types of specialised surgery. Hepatic artery chemoembolisation gives a high dose of chemotherapy to the cancer cells in the liver. Radiofrequency ablation, radiofrequency assisted surgery, cryotherapy and microwave ablation have been approved by the National Institute for Health and Clinical Excellence (NICE). But the other types of specialist surgery mentioned here are still experimental.

All of these procedures 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
• How quickly your cancer came back after other treatments
• Whether you have secondary cancer anywhere else that cannot be removed

Your doctor will talk to you about the possible benefits and risks of these treatments in your situation. There is information below about

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

Hepatic artery chemoembolisation

For this treatment, the doctor puts an oily liquid into the main artery taking blood to the liver. The liquid blocks the blood vessels taking blood away from the liver. The liquid also contains chemotherapy.

First, 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 the oily liquid. The surgeon then removes the tube.

High levels of chemotherapy stay in the tumour for a few hours. This kills some of the cancer cells and shrinks the tumour. The treatment takes from 30 minutes to a couple of hours. Afterwards, you may have some pain, feel or be sick, and have a high temperature.

Radiofrequency ablation (RFA)

Radiofrequency ablation uses radio waves to destroy cancer cells in the liver by heating them to high temperatures. You usually have a sedative to make you drowsy but some people have a general anaesthetic. If you have the sedative, your doctor injects a local anaesthetic into the skin of your tummy (abdomen) to numb it. They then push a thin needle through the skin 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 they pass radio waves through the needle to heat the tumours and destroy them.

Doctors use RFA to treat tumours up to 5cm (2 inches) in size. It takes about 10 to 15 minutes. 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.

In December 2009, the National Institute for Health and Clinical Excellence (NICE) issued guidance on RFA for bowel cancer spread to the liver. They say that RFA is safe to use for people who are not well enough to have surgery to remove cancer in the liver (liver resection). They also say that it can be used for people who have already had liver resection. The treatment should be decided by a team of doctors who  specialise in treating cancer in the liver.

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 along with the cancer.

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

Cryotherapy

Cryotherapy is also called cryosurgery. It means removing cancer by freezing it. In 2010 NICE approved cryotherapy as a treatment for small liver secondaries (usually up to 4 cm in diameter). It takes about 30 to 60 minutes. You may have it as part of open surgery under general anaesthetic or using keyhole techniques under local or general anaesthetic.

The surgeon puts one or more cryotherapy probes (called cryoprobes) through a small cut in the skin and into the cancer. The surgeon uses a CT or ultrasound scan to make sure each probe is in the right place. The tip of the cryoprobe is then cooled to below freezing. The probe creates an ice ball within the surrounding tissue that aims to destroy the cancer cells. Sometimes the area is thawed for 10 to 15 minutes and then frozen again. You will have some pain afterwards and possibly a high temperature, but you will have 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.

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. You may have 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. Then they connect the needles to a microwave generator. The microwaves are released through the needles to destroy the cancer cells.

In 2011 NICE approved microwave ablation as a treatment for cancer that has spread to the liver. NICE said that it is safe but we don't yet have much evidence about how well it works and need more research. Your doctor may suggest microwave ablation as part of a trial. Before you have this treatment, your doctor must make sure they explain all the risks involved and tell you about other available treatments.

Laser therapy

Laser therapy is also called laser ablation. The surgeon uses a very high powered beam of light to destroy cancer cells in the liver, by heating them to high temperatures. You usually have a sedative to make you drowsy but you may have a general anaesthetic. If you have the sedative, your doctor will inject a local anaesthetic into the skin of your tummy (abdomen) to numb it. They then push a flexible tube that carries the laser light through the skin over the liver and into the centre of each tumour. The doctor uses 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.

Doctors use laser therapy to treat tumours up to 5cm (2 inches) in size.  It takes about 10 to 15 minutes. 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.

Alcohol treatment

This treatment uses sterile alcohol to destroy cancer cells. It is only suitable for liver 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 using a CT or ultrasound scan to make sure the needle is in the right place. Then they inject the alcohol directly into the tumour. 

You can have this treatment for more than one tumour in the liver. It can be painful, so you take painkillers 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.

You can read about other treatments for advanced bowel cancer in this section.