Colleen Reeves, MS, RN, ANP-C, CWOCN
Advanced Practice Nurse
Department of Surgical Oncology
The University of Texas MD Anderson Cancer Center
Good morning. My name is Colleen Reeves. I'm a nurse practitioner at the University of Texas MD Anderson Cancer Center and I'm here today to present Colorectal Cancer Survivorship: Late Effects of Surgery.
My objectives: at the conclusion of this lesson, the participant will be able to identify the difference of acute and late effects of colorectal surgery; discuss surgical late effects in relation to the colorectal surgical procedure; discuss and diagnose management options of surgical long term operations --- [excuse me] --- alterations in the late effects in colorectal cancer; and identify resources available for patients with late effects.
Briefly, going over acute complications, which are seen shortly after surgery, would be: infection, abscess, anastomotic leak, dehiscence and evisceration, and injury to other organs.
Moving on to the late effects of surgery, which will happen or can happen in the surveillance, is hernia, adhesions, sexual dysfunction, body image, and alteration in bowel or bladder function.
Late effects related to the surgical procedure: with a colon resection, a patient may complain of increased stool frequency, adhesions, hernia, which could be incisional or parastomal hernia. Moving on to the rectal area or rectal sigmoid area is a low anterior resection, they can have increased stool frequency and clustering and complaints of sexual dysfunction. With a proctectomy and colorectal --- [excuse me] --- coloanal anastomosis, they can have increased stool frequency and clustering, fecal incontinence, sexual dysfunction, a coloanal stenosis, or even urinary retention. With an abdominal perineal resection and colostomy, patients can have changes in body image, again a hernia which could be a peroneal hernia where the rectum once was and now has been replaced with a flap, or a parastomal hernia, sexual dysfunction, and again urinary retention.
The first late effect discussed will be a hernia. A hernia is a bulge or protrusion of an organ through the structure or muscle that usually contains the organ. You can have different types of hernias. Incisional hernia is a result of an incompletely healed surgical wound. Parastomal hernia can occur at the site of a colostomy, ileostomy, or another stoma which could be a mucus fistula stoma. Perineal hernia may occur after the removal of the rectum in an abdominal perineal resection and a reducible hernia are hernias that occur --- that are a bulge or protrusion and then it returns to the abdominal cavity spontaneously or with manipulation.
Complications that can arise from hernias are a bowel obstruction, the intest --- the intestines can become trapped to the point where it pokes through the abdominal wall and the bowel function can cease or significantly change. An incarceration occurs when a hernia contents become trapped and strangulation occurs when the blood supply of the herniated tissue is cut off and can cause gangrene. Many times you have the incarceration and strangulation occur at the same time. Also, it can affect the body image because they have this growth or protruding bulge that they'll complain about. It's worse with standing. It's difficult to hide or cover and it becomes a cosmetic issue with the patient. Pain can also occur because of the tearing and distention of the stretching of the tissues. It can cause irritations of the nerves in the area.
Diagnosing hernias: some subjective signs; you may not have any complaints by the patient other than a cosmetic issue. If the hernia begins to cause pat --- problems for the patient, they may complain of worsening abdominal pain or an alteration in bowel function. They can complain of an enlarging abdominal bulge or even nausea and vomiting. Some objective signs are on examination, is you find an abdominal bulge or even a rectal bulge. If a patient has been having a long term problem they may even have some weight loss. On imaging, we can use an abdominal pelvic CT scan to detect abdominal pelvic defects and/or bowel obstructions. You can also have a small bowel follow-through to assess for any small bowel obstructions.
With management, it will either be conservative or surgical dependent on the severity of the hernia. Conservative interventions, simply an abdominal binder will provide support. It will not prevent a hernia, but it does provide support for the patient and increase comfort. You also would want to help prevent constipation. You can tell the patient to increase their fiber, increase their fluids. You also want to tell them to avoid heavy lifting, certainly nothing greater than 50 pounds. And usual --- and it may be even less than that if the hernia is severe. Surgical interventions would either be laparoscopic versus open procedures and it would depend on the severity of the hernia.
Intraoperative adhesions is another problem patients complain. Reported in the literature, this occurs postoperatively 50 to 100 percent after an abdominal surgery. Factors that can influence the development of adhesions are complex surgeries, extent of peritoneal trauma, comorbid conditions such as diabetes, poor wound healing, excessive coagulation with tissue necrosis, bacterial infections, intra-abdominal placement of foreign bodies, such as grafts, laparotomy procedures related to dehydration, hypoxia, and exposure to foreign material.
Some complications of adhesions is a patient can have irregular bowel movements, alteration between diarrhea and constipation, or they can have increased constipation. Abdominal pain, this pain they would complain of vague complaints of intermittent, sharp, acute complaints to chronic nagging pain. They can also complain of digestive disorders, increase flatus, reflux, or even nausea, persistent. Intestinal obstructions may cause 65 to 70 percent of small bowel obstructions. Adhesions, colectomy involving a large peritoneal incision carry 11 percent cumulative risk within the first year of surgery.
Diagnosis of adhesions: Patients may complain of nausea, vomiting, pain, or alterations in bowel function. On examination, you may not see anything. There's no laboratory data or imaging to really confirm a diagnosis unless there is a --- a bowel obstruction. Diagnosis of adhesions is rather made by an exclusion of other diseases or cancer.
Management of surgical adhesions: Surgical prevention would be the best. Intra-abdominal adhesions arise from abnormal peritoneal wound healing processes, mesothelial damage by surgical trauma, or bacterial inflammation. Diet: I would encourage a patient high fiber diet if they're to avoid constipation or low residue diet if adhesions are severe and you're concerned about an obstruction. Surgery: you can --- one alternative is placing a camera through a small hole in the skin to confirm adhesions exist. Then they can either cut or release the adhesions. The next is performing a larger incision by laparotomy and directly see the adhesions and treat.
Moving on to body image, there is many things that influence how we view our own body. Influencing factors can be perception. Perception deals with awareness, insight, our own view of things, our experiences, and our own opinions. Self-esteem, we think of self-worth, confidence, self-respect, and education. The other thing that can influence is your surgical procedure the patient will be going under. An abdominal perineal resection, they'll have a permanent colostomy. With a proctectomy, they may have a temporary or they could end up with a permanent ostomy. Family and social support: the patient, are they single, divorced, introvert, or even social dynamics.
Management of body image: patient education. There is many products --- product literature out there available for the patient. American Cancer Society is only one example. Counseling support groups, individual psychotherapy, spiritual or pastoral counseling, or cancer support groups, such as I Can Cope. Alternative and complimentary therapies can also be of assistance. Meditation and prayer, yoga, t'ai chi, dance or movement, exercise, massage, and erra --- aromatherapy.
Sexual dysfunction: Causes of sexual dysfunction, chemotherapy, radiation, as well as a radical surgery. The types of complications that can happen from the above: erectile dysfunction, vaginal dryness and tightness or strictures, loss of desire, decreased libido, vaginal dryness, and difficulty reaching a climax. Research data has mostly been geared more with men than women. But 45 percent of men and 29 percent of women have -- it's been in the literature reported that surgeries made their sex life worse, 53 percent of men and women reported sexual problems. Again, this can be related closely to body image, how someone views themselves. But again, there is support, education, counseling; provide information, and facilitate realistic expectations.
Management: sexual dysfunction may be multifactorial. Factors to consider are age, emotional well-being, partner relationship, and sexual health history. Again, patient education is a key here. There is much literature out there. American Cancer Society again has significant information. There is sexual dysfunction clinics which can provide a comprehensive assessment as well as pelvic floor muscle training is one alternative. Medications: hormonal replacements, intercavernosal injections, sildenafil, vaginal lubricants, moisturizers. Then there is devices: vaginal dilators, penile vacuum constrictures --- constriction, --- [excuse me] ---, devices, penile rings, and implants. And again, there is sexual counseling. The Plissit model is a model that is used by the WOCN nurses and then if they need more intense therapy, psychology therapy.
Bowel and bladder dysfunction: Causes can be rectal strictures, stool clustering and frequency, fecal urgency, fecal and urinary incontinence, constipation, diarrhea, as well as urinary retention.
Diagnosis: subjective findings, patients will come in, they complain of diarrhea and constipation, persistent rectal burning and pain. They can have 10 to greater than 20 bowel movements per day. They can have frequent small amounts which is considered clustering and they can have feelings of urgency as well as incontinence, fecal as well as urinary. Objective findings: you may see perianal rectal irritation, rectal fissures, bleeding, or they may have a stenosis --- anal stenosis. Endoscopic procedures, such as colonoscopy, flexible sigmoidoscopy, balloon dilatation, and digital rectal exams are very important for diagnosing. They may need a urological evaluation, urodyn --- urodynamic evaluation, pressure flow studies, electromyography, urine specimens, bladder scans, cystoscopy, and pelvic exam.
Management: if they have a stenosis, they may need anal dilators. They may simply need bowel/urinary incontinence education. Again, patient education, the WOCN nurses, Wound Ostomy Continence Nurses, or simply teaching them Kegel exercises. Intermittent cauterization for urinary retention. There may be medications needed, lomotil, imodium, fiber, and tincture of opium, or incontinence devices, diapers, pads, clamps, or pouches. And the last resort is fecal urinary diversions, colostomy, ileostomy, urostomy, or continent diversion.
I would like to touch on when you should refer a patient. Patients who have persistent complaints of pain, nausea, alternating bowel function, progressive pain at the site of a hernia. Cosmetic concerns for the hernia would be a --- one option to refer the patient to a specialist. Patients present with acute abdominal pain, nausea, vomiting, absence of bowel sounds, no bowel function. Abdominal distention is an emergent proc--- it's an emergent indication the patient probably should go to an emergency room and see a specialist. Complaints of sexual dysfunction with history of urological or colorectal cancer, rectal/vaginal bleeding would be another indication. Depression or thoughts of suicide and altered bowel function affecting quality of life.
In summary, late effects of surgery raise interesting and unique challenges to the patient as well as to the health care providers. Majority of the time the best assistance to the patient comes from a multib --- multidisciplinary group of professionals working together. Future success may rely on research into new treatment and delivery systems, advances in surgery, and in medical product development. Thank you very much and we welcome your feedback.
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