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Specialists in the Field of Colon removal
Information About the Field of Colon removal
What is a colectomy or hemicolectomy?
Colectomy as well as hemicolectomy refer to surgical interventions on the large intestine (colon is latin and describes the part between appendix and rectum), in which organ sections are removed.
The entire colon is removed in a colectomy and specific sections are removed in a hemicolectomy. Right hemicolectomy involves resection of the appendix (cecum) and the ascending colon of the right abdomen; left hemicolectomy entails surgical removal of the descending colon and a part of the sigmoid colon (found within the pelvis representing the terminal part of the colon before the rectum).
If necessary, certain colonic flexures that refer to the transition zones with the transverse part of the colon, may also be removed.
When is a colectomy or hemicolectomy indcated?
There are many known diseases that make removal of the colon or parts of the colon necessary.
Among these are especially tumors, which are frequently colon carcinomas or metastases from other cancers. Depending on the location of the tumor as well as the extent of spread, different parts of the colon have to be resected.
Diverticulitis , which involves inflammation of small outpouchings of the colon wall (called diverticula) can be the reason for such a resection. However, not every patient with diverticula needs to be operated on, but severe cases that don’t respond to medications, recurrent flares of disease and complications (bleeding, perforation, peritonitis) are indicated for surgery.
In specific cases, patients with inflammatory bowel disease can receive surgical treatment. Surgery for Morbus Crohn involves resection of severely inflamed colon portions, but complete cure can not be achieved. This is opposed to surgery for ulcerative colitis , which can be fully cured by resecting the entire colon.
Genetic diseases that are associated with a high chance of colon cancer, such as familial adenomatous polyposis, can be managed with prophylactic colectomy.
Injuries of the colon as in the case of trauma (e.g. car accident) or during endoscopic surgery of the colon more rarely lead to colectomy or hemicolectomy.
Procedure of colon surgery
Furthermore, the patient must be informed about the potential risks of such a surgery as well as possible measure that may become necessary, like for example an artificial bowel outlet.
Colon surgery is carried out under general anesthesia and the patient is not allowed to eat or drink in advance.
Before starting the surgery, patients will receive antibiotic infusions for the purpose of preventing bacterial infection by the colonic flora. The skin of the surgical site is then thoroughly disinfected. Small and easily accessible tumors may also be resected laparoscopically, that means by means of minimally invasive keyhole surgery. However, in most cases the abdomen will be opened with a larger skin incision.
The surgeon will proceed to dissect the colon and the tissue layers covering it until the portion of the colon that has to be resected is exposed. A special tissue layer called mesentery is attached to certain parts of the colon and besides fixing it to the back wall of the abdomen, it transports important blood vessels. These vessels need to be dissected one by one as well as coagulated or stitched (ligated) in order to prevent major bleedings.
Next, the mesentary is stripped and the targeted colonic segment is separated from the rest of the colon. Nowadays, a specialized stapler is applied that is able to separate the segments of colon and at the same time stitch it together as well. After taking out the colonic segment, it is often sent to a laboratory for further tissue investigations.
The next step is to connect the newly created colonic end caps and join them together again (creation of so-called anastomoses), in order to re-establish appropriate passage of content through the colon.
Normally, a segment of small intestine referred to as ileum joins into the appendix. During a right hemicolectomy, the ileum is connected to the transverse colon by creating an anastomosis.To perform a left hemicolectomy, the anastomosis created connects the transverse colon to the remaining sigmoid colon in the pelvis.If the complete colon is resected during a colectomy, the small intestine might be directly anastomosed to the rectum. However, it is more common to create an artificial bowel outlet .
Following all of this, the surgical field is once more evaluated and potential bleedings are checked and. Tissue layers are closed again and the skin is stitched or stapled.
Pros and cons for laparoscopic hemicolectomy or colectomy
Laparocopic procedures , that means minimally invasive keyhole surgery, are state-of-the-art procedures that are nowadays very precise and offer many advantages. Obvious pros include the tiny skin incisions measuring only few centimeters, which generally heal quicker and result in more cosmetically pleasing scars.
Patients recover more quickly, they can be discharged from the hospital earlier and start a rehabilitation program or undergo further treatments. Laparoscopic surgery is known as a more gently and tissue-sparing approach, causing less pain as well as restriction compared to a large abdominal incision.
A limitation to laparoscopic surgery is that it is only feasible if the segment to be resected is well accessible and manageable. For example, large colon cancers, cases where numerous lymph nodes are infiltrated or large scale metastases often call for open surgery.
Direct overview of the surgical site can be netter and the surgeon may feel the tissue better. Due to the specialized equipment necessary for laparoscopic surgeries, they tend to be more expensive. However, such additional costs may be balanced out by shorter hospital stays.
The surgeon first needs a lot of experience and exercise to master laparoscopic surgeries before carrying out bigger operations on the colon. Given the surgeon has the necessary expertise, open laparoscopic surgeries are equal in respect to oncological safety, relapse frequency and survival. Therefore, the decision is often made on an individual basis.
Follow-up care and rehabilitation
Even following larger operations of the intestines, it is recommended that patients are mobilized slowly in stepwise fashion. Recovery is supported by working together with nurses and physiotherapists as well as individually adapting the pain medication.
Special attention should be directed towards acute, changing or increasing pain and such scenarios always require consultation with a doctor. Other important symptoms are fever, abdominal tenderness, vomiting or unusual defecation, so that potential complications are readily recognized and necessary management is initiated as early as possible.
Shortly after the surgery, defecation can be irregular or liquid, therefore sufficient water intake is important. Normally, defecation will normalize within weeks to months. Medications that increase bowel movement, laxatives or medications that alter the stool consistency can be prescribed.
The first days after surgery, the abdomen needs to be regularly palpated and auscultated (that means listened to with a stethoscope) and also abdominal drainage tubes need to be checked before being removed a few days later. In case a stomach tube has been inserted, it can frequently be removed already few days or even the first day following surgery. Regular blood checks and especially inflammatory parameters are checked in regular intervals throughout the hospital stay.
If an artificial intestinal outlet was created, the patients have to be educated about the management of it (stoma education). Usually stitches or staples are removed after approximately 10 days and since patients have oftentimes already been discharged from the hospital, this can be done in an outpatient setting.
The weeks following surgery patients should abstain from lifting heavy objects in order to not increase the pressure applied onto the wounds.
Whether rehabilitation or another secondary therapy is necessary or not depends on the actual disease the patient is suffering from and this decision should be made individually.
Diet after colon resection
Generally, the diet is built up rather quickly following a colectomy if no complications were encountered. Already few hours after the surgery, small sips of clear liquids can be consumed, and drinking water should replace intravenous administration of fluids as soon as possible. If the patients are feeling well on the day of surgery, they are allowed drink tea and clear soup in case they want to.
During the following days, at first mushy foods such as joghurt or blended products, followed by bland diet and finally light form of full diet.
By implementing a speedy progress in diet, the gastrointestinal tract is supposed to be activated and resume its functions as soon as possible.
Products that cause bloating (e.g. legumes, cabbage, onions or overly fresh fruits) as well as very fatty, spicy or acidic food should not be consumed at the beginning. Oats, rice, potatoes, grated apple or banana can have a positive effect on diarrhea.
Generally patients can quickly go back to eating whatever they desire as long as they can tolerate it well.It is important that patients maintain sufficient water intake of about 2-3 liters a day, preferably without gas or added sugars.
Generally, diet is built up within the first 14 days following surgery and the duration is strongly dependent on the individual well-being and food tolerance. Obviously the extent of how much of the colon was removed will dictate the further management.
Because after hemicolectomy parts of the colon remain functional and in place, the changes experienced by patients tend to be less drastic and diet as well as digestion can be regular more timely. Total colectomy patients have to be aware, that normal diet is built slower for them and they might encounter more limitations.
Prognosis and chances of cure
Colon resection is associated with certain risks and potential complications just like any other surgical intervention. Bleedings and wound healing disorders may be encountered and especially infections up to blood poisoning (sepsis) require special attention due to the increased microbial burden caused by the natural gut flora (patients receive prophylactic antibiotics before surgery for this reason).
Injury to adjacent organs, nerves and blood vessels are possible and excessive scarring in the abdomen may develop, which can impair secondary surgeries or may even lead to intestinal obstruction.
A feared complication after colon surgery is the so-called anastomotic insufficiency. It involves leakage from the newly established connection between the two remaining parts of intestine after the pathological colon segment has been removed.
It can lead to escape of gases, liquids or stool that may result in life-threatening infections. Such scenarios often call for a second surgery. Another possible complication are encapsulated accumulations of pus (called abscess), which may have to be drained by puncture.
The individual prognosis after colectomy or hemicolectomy depends largely on the underlying disease and further risk factors attributed to the patient and it is for this reason that there can’t be a universal prognosis.
In colon cancer, for instance, the stage of cancer along with possibly distant metastases play an important role. The earlier colon cancer is detected, the better the prognosis which means also chances of cure after surgery are increased.
For ulcerative colitis, a form of inflammatory bowel disease, colectomy is the surgical treatment of choice to cure it. But also for a case like this, patients should be aware that further problems and complications are possible in the time following surgery, for instance inflammation of the artificial stoma.
Which doctors and clinics are specialists?
General and visceral surgeons are the specialists carrying out colectomies and hemicolectomies, however, they are working closely together with oncologists and gastroenterologists, depending on the underlying disease. Specialized centers may also offer multimodal therapy options, for instance centers focusing on colon cancer.
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