A surgical site infection is one that happens in the part of the body where an operation has taken place.

Nearly one in five hospital infections happens at the surgical site according to the Centers for Disease Control.

The CDC has tips that can help you and your health care team prevent surgical site infections.  They will tell you what you can do before and after your operation to reduce the risk that you’ll get an infection.

Before your surgery

• Be sure your doctors know about any medical conditions like diabetes or allergies you have.
• If you smoke — stop.  Smokers get more infections.
• Don’t shave near where your operation will take place.  If hair needs to be removed, hospital staff should not use a razor, but electric clippers.
• Stop anyone who wants to shave your skin with a razor.  Ask them to use clippers.
• Check with your doctors to see if you should have antibiotics.

After your surgery

• Ask the health care team if they have washed their hands or used an alcohol-based skin-sanitizers before they touch you or your surgical wound.
• Insist that your family and visitors clean their hands with soap and water or skin sanitizer before and after they visit you.
• Don’t let your visitors touch the surgical wound or dressings.
• Clean your own hands before caring for your surgical wound or touching it.
• Once you are home, if you have signs of an infection at the surgical site — redness, pain, drainage, fever — call your doctor immediately.

CDC Frequently Asked Questions about Surgical Site Infections

Removing the entire colon (subtotal colectomy) is sometimes recommended for patients with Lynch syndrome when colon cancer is diagnosed.  In addition, some people who have an inherited Lynch mutation have their colons removed to prevent colon cancer.

While subtotal colectomy didn’t reduce deaths from Lynch-related colon cancer, it did cut down on additional colorectal cancer diagnoses and the need for other abdominal surgery.

Five years after surgery, 93 percent of patients who had subtotal colectomy were alive compared to 88 percent of those who had more limited operations or no surgery.  This wasn’t a significant difference.  However, 84 percent survived the five years without needing additional abdominal surgery compared to 63 percent of the group who had limited or no surgery.

Researchers analyzed people with Lynch syndrome in the Creighton University database.  Cases included those who had subtotal colectomy, either at the time of colon cancer diagnosis or as preventive surgery. They were compared to controls who had limited operations to remove only part of the colon (segmental colectomy).

In subtotal colectomy the colon is removed and the small intestine is attached to the rectum, which remains in place.

Five years after surgery, comparing those who had subtotal colectomy to those with limited resection:

• 94 percent were alive without another colorectal cancer compared to 74 percent of the controls alive and without subsequent colorectal cancer.
• 84 percent survived without needing abdominal surgery compared to 63 percent of controls.
• 93 percent lived five years compared to 88 percent of controls.
• Time to another colorectal cancer or the need for abdominal surgery was shorter for those who had a limited resection.

Their conclusion:

Even though no survival benefit was identified between the cases and controls the increased incidence of metachronous colorectal cancer and increased abdominal surgeries among controls warrant the recommendation of subtotal colectomy in patients with Lynch syndrome.

Lynch syndrome is a highly increased risk for colorectal and other related cancers caused by an inherited mutation in one of the mismatch repair genes.  People with a Lynch syndrome genetic mutation have a lifetime risk for colorectal cancer as high as 80 percent.

SOURCE: Natarajan et al., Diseases of the Colon and Rectum, Volume 53, Issue 1, pages 72-82, January 2010.

A study from Memorial Sloan Kettering recently showed that patients who have stage IV disease, which means spread to other organs, don’t need to undergo surgery immediately. If the tumor does not cause problems such as obstruction or bleeding, patients appear to do better to start with chemotherapy right away without delay because of the surgery.

Over 230 patients were studied with metastatic colon cancer. and the data showed that patients did very well when started with chemotherapy without surgery for the primary tumor. Only 7 percent required surgery for symptoms during chemotherapy.

Usually, in the conventional approach to treating stage IV disease, patients underwent colon surgery immediately following their diagnosis and would typically start chemotherapy treatments three to six weeks later. The rationale for immediate colon resection was to prevent future symptoms and complications from the primary tumor. It was assumed that the majority of colorectal cancers would have little response to chemotherapy.

However we have now more effective and less toxic chemotherapy  which can shrink both colon tumors and the metastases. We need to caution that of course there are individual exceptions and each of these decisions needs to discuss with the surgeons and medical oncologists.

Patients who have had one operation to remove lung tumors that have spread from cancer in their colon or rectum can have good outcomes with a second and even third lung surgery.

Surgeons in Seoul, South Korea reviewed outcomes for 202 patients who had surgery to remove a colorectal cancer metastasis in their lungs (pulmonary metastasectomy).

After a median follow-up of 28.9 months, 48 patients had a second lung surgery.  Of those, 28 patients had cancer return in their lungs again, and 10 had a third operation to remove lung tumors.

• For the 48 patients who had a second lung surgery, overall survival at five years was 79 percent, with 49 percent of patients having no sign of cancer at that time.
• For the 10 patients with a third surgery, overall survival five years later was 78 percent.

Writing in the Annals of Oncology, J.S. Park and colleagues concluded,

Repeated resection after initial metastasectomy can be carried out safely and provides long-term survival in patients with recurrent pulmonary metastasis from colorectal cancer. Our findings indicate that close follow-up for the early detection of recurrence and parenchyma-saving resection can improve the results after repeated resection.

SOURCE: Park et al., Annals of Oncology, Advance Access, October 27, 2009.

When cancer has spread beyond the colon or rectum, the primary colorectal tumor can safely be left in place with only rare complications.

Surgeons at Memorial Sloan Kettering Cancer Center in New York followed 233 patients who began chemotherapy without surgery to remove their primary colon or rectal tumor. Almost 90 percent never had a problem with their tumor that needed intervention with surgery, radiation, or a stent. Only 7 percent required emergency surgery.

Researchers found among the group of 233:

• 16 patients (7 percent) needed emergency surgery because of an obstruction or bowel perforation.
• 10 patients (4 percent) had radiotherapy or a stent placed to relieve problems.
• 47 had the primary tumor removed at the same time they had surgery to remove metastastes.
• 8 had their colorectal tumor removed with surgery to place a pump in the abdomen to deliver chemo through the hepatic artery.

Use of Avastin, having a rectal tumor, or the number and size of metastatic tumors did not increase the risk of a complication in the primary tumor needing intervention.

Dr. George A. Poultsides and colleagues at Memorial Sloan Kettering concluded,

Most patients with synchronous, stage IV CRC who receive up-front modern combination chemotherapy never require palliative surgery for their intact primary tumor. These data support the use of chemotherapy, without routine prophylactic resection, as the appropriate standard practice for patients with neither obstructed nor hemorrhaging primary colorectal tumors in the setting of metastatic disease.

The study was also presented as a poster at ASCO 2009.

SOURCE: Poultsides et al., Journal of Clinical Oncology, Early Release, June 1, 2009.

I have shared some inspiring stories with you of patients in my practice who I think are examples of how colon cancer therapies have changed. Today when patients walk into my practice with metastases only in liver or lungs, I know that I can cure some of them. The way we look at these patients has completely changed.

I have told you about a young cancer patient in her thirties, diagnosed with metastatic colon cancer with diffuse liver metastases. Only five years ago we would have not thought of cure looking at her.  She was told by her HMO oncologist there there was little he could do and that her life expectancy was about six months. She could not accept this and started to look online for information.

It was Easter three years ago when she emailed Dr. Robert Beart, our colorectal surgeon. to find out if he could help. Within three minutes he answered her and asked her to contact me, which she did. I replied and set her up to come in to evaluate her options.

When we saw her we promised that we would do everything possible to make sure she got the best and most effective therapy. We tested her tumor for genetic markers to help us guide our treatment selection. Of course we did KRAS, which was which was normal wild type, and we also tested for two genes called TS and ERCC-1 which predict efficacy of FOLFOX versus FOLFIRI. We screen all our patients for these genes prior to start of treatment. She was enrolled in a clinical trial — CALGB 80405 — where we choose FOLFIRI and not FOLFOX because she would have not benefitted from FOLFOX. She received Erbitux and Avastin and had an incredible response allowing us to do a liver surgery with the intent to cure her.

Surgery went well, and we removed all the tumors. Since her tumor was all over in her liver, we were worried about it recurring in the liver so we also gave her chemotherapy after surgery and followed her very closely. About eight months later we found one spot in her liver. We treated her again with chemotherapy and were able to resect her again. She now has no evidence of cancer. The moral of this story is that you should never give up. Even when the tumor comes back, we can still beat this disease.

We have cured a number of patients who underwent multiples surgeries for liver or lung lesions and have no evidence of cancer today. We could have easily followed standard thinking that these surgeries are very rarely successful. However with more effective therapies this has changed. We are curing more and more patients, but not all. We should be aggressive, particularly in patients with metastatic disease in one organ.

Colon cancer is one of the few cancers which we can cure with resection of metastases. Selection of the most effective therapy is the first important step. We work closely with Response Genetics who have who developed a colon and lung cancer panel of gene tests.

Happy Easter.

Treated with a combination of three chemotherapy drugs, 1 in 5 patients whose colorectal cancer had spread too far for surgery were able to have operations to remove metastatic tumors.  After five years, a third of them were alive with no sign of cancer.

Doctors in Italy treated 200 stage IV patients with a combination of 5-FU, oxaliplatin, and irinotecan (FOLFOXIRI) during three different clinical trials.  While all three drugs are commonly used to treat colorectal cancer, they are not usually used at the same time.  Initially, all of the patients had cancer that had spread beyond the possibility of having it removed surgically.

After a median time of five and a half months, 20 percent of the patients were able to have surgery to completely remove all visible cancer (R0 resection).   Five years later nearly half (42 percent) were still alive and a third (33 percent) survived eight years.  Almost 1 in 3 (29 percent) had no sign of cancer five years after their surgery.

Although most patients (68 percent) who were able to have surgery had metastatic tumors confined to their livers, some had tumors in other parts of the body that were also removed during surgery.

Gianluca Masi, M.D. and colleagues concluded,

The GONO-FOLFOXIRI regimen allow an R0 surgery in approximately 1 out of 5 unselected patients with initially unresectable metastatic colorectal cancer, and the long-term survival of resected patients is considerable. Neoadjuvant FOLFOXIRI for 3-6 months is safe and not associated with severe liver injury.

SOURCE: Masi et al., Annals of Surgery, Volume 239, Number 3, March 2009.

While some surgical studies are now reporting five-year survival after surgery to remove colorectal cancer tumors that have spread to the liver of 40 to 60 percent, a review of more general national experience for patients enrolled in Medicare  in the United States found lower survival rates.

Among Medicare-enrolled colorectal cancer patients 65 and over who had liver resection, only 26 percent (1 in 4) were alive five years later.

Analyzing 306,000 Medicare beneficiaries who were diagnosed with colon or rectal cancer in the years 2000 through 2004, researchers found 3,657 who had surgery to remove liver mets.  Nearly 9 percent died within the first three months after surgery.

Those eighty and over were almost twice as likely to die within three months after surgery.  Removing both the primary tumor in the colon or rectum and the liver tumors also raised the risk of death in those three months.  Simultaneous resection of both colon and liver tumors increased three-month mortality two and a half times.

Survival at five years was 25.5 percent.  Those at higher risk of not surviving were patients:

• aged 80 and older.
• with other medical conditions besides cancer.
• who had both colorectal and liver tumors removed at the same time (synchronous resection).

Douglas J. Robertson, MD, MPH and his colleagues at the Veterans Affairs Outcomes Research Group in Vermont and at Dartmouth Medical College concluded,

In this national study, short- and long-term survival was worse than that reported in surgical case series. Subgroups at high risk for worse outcomes include the extreme elderly and those undergoing synchronous colon and hepatic resection.

SOURCE: Robertson et al., Cancer, Volume 115, Issue 4, February 15, 2009.

What This Means for Patients

Survival rates after liver surgery for colorectal cancer mets differ between those large, specialized centers and the overall experience of Medicare patients nationally.

Some large studies reporting as many as half their patients living more than five years while nationally only 1 in 4 patients over 65 lives that long.

Finding a skilled and experienced surgeon and surgical team is important.  Ask about the surgeon’s experience with removal of liver mets and survival rates in the hospital where the surgery is planned.

Simultaneous removal of both the colorectal primary tumor and liver mets may not be the best approach.  Discuss the surgical plan carefully with your doctor.

A multidisciplinary team approach to planning treatment for advanced colorectal cancer is always best.

Update from the 2009 Gastrointestinal Cancer Symposium

Combining chemotherapy with Erbitux® (cetuximab) can effectively shrink tumors and enable surgeons to remove formerly unresectable colorectal cancer that has spread to the liver, offering potentially curative treatment.

German doctors randomized patients with unresectable liver metastases to treatment with either FOLFOX with Erbitux or FOLFIRI with Erbitux.  Patients in the study either had five or more tumors in their liver or surgery to remove liver tumors was considered to be technically impossible.

After initial treatment with the combined chemotherapy and Erbitux regimens, 75 percent of patients had tumors shrink, 40 percent were able to have surgery to remove liver metatases, and 35 percent had all visible signs of liver tumor removed.

Median time before surgery became possible was five months.

Thirty-two percent of the patients whose tumors had been considered technically unresectable were able to have all signs of cancer in their liver removed (R0 resection). For those patients with five or more liver mets, 40 percent had an R0 resection.

The most common serious, grade 3 or 4 side effects before surgery were skin rash (33 percent), neutropenia (23 percent), diarrhea (14 percent), and neuropathy (10 percent).

The research team concluded,

The combination of cetuximab with standard chemotherapy has demonstrated high activity (79% in KRAS wild type patients) and an encouraging rate of liver resection.

SOURCE: Gruenberger et al., 2009 GI Symposium, Abstract 296.

When we go to a surgeon, we often don’t ask them how many surgery he has done for the same disease but may be we should.

For colon cancer, there is in fact a specialization fellowship to become a colorectal surgeon. A recent analysis of 17 studies from nine countries has shown that the quality of the surgeon and the surgery is associated with better outcome.

How can you evaluate the surgeon?His reputation is important which is often built on volume and quality of his surgery. We only refer our colon cancer patients to colorectal surgeons. The quality of surgery is shown at the extend of removal of lymph node and low complication after surgery.

University of Southern California Medical Center has one of the lowest complications rate after colon resection in the USA. Studies have repeatedly shown that the more lymph nodes that are removed and examined during surgical treatment of colon cancer, the better the outcome appear to be for patients. The study suggests that removal of the nodes takes away a reservoir for potentially lethal cancer, and that knowing how far a cancer has spread leads to tailored and more beneficial treatment. According to researchers at the University of Texas M. D. Anderson Cancer Center, only about a one-third of colon cancer patients in the United States are getting an adequate lymph node evaluation.

These data are striking and should help support efforts now ongoing by some medical professional societies and expert panels to consider a minimum number of lymph nodes be extracted and examined during the surgery. Patients had significant lower risk of tumor recurrence when they had more than 20 lymph nodes removed compared to the patients with less than 11. Removing colon tissue during surgery in a way that captures all of the tumor-associated lymph nodes requires attentiveness. Patients should ask surgeons how many operations they have done, but I think in this case they should ask how often they do colon cancer surgery.

Studies have found that 70 percent of colon cancer resections are performed by general surgeons who do less than 10 of these surgeries a year, and that colon cancers removed by surgeons who perform colon cancer surgery more frequently are more likely to have more lymph nodes examined.

Please do your homework and make sure your surgeon is qualified to do the colon resection.