Comprehensive Communication Regarding CRC Surgery and Postoperative Complications Is Crucial

Andreas M. Kaiser, MD

Colorectal (CRC) cancer surgical management strategies differ between individual patients, and the risk of surgery-related complications demonstrates the importance of thoroughly understanding each patient’s disease and health care history, according to Andreas M. Kaiser, MD.

“Nowadays, we have realized that Enhanced Recovery After Surgery reduces the number of complications and accelerates the recovery of patients,” Kaiser noted in an interview with OncLive® during CRC Awareness Month, which is observed in March. “Still, complications can occur, so when we talk to patients, we need to emphasize that complications can still happen, what they may be, and why it’s [still] important for them to receive the surgery.”

In the interview, Kaiser, a professor and chief of the Division of Colorectal Surgery in the Department of Surgery at City of Hope in Duarte, California, discussed strategies to reduce postoperative complications in patients with CRC, ways that perioperative patient care has changed over the years, and surgical eligibility criteria for patients with locally advanced or metastatic disease.

OncLive: What are strategies to reduce postoperative complications in patients with CRC?

Kaiser: Complications are [not ideal], but [we cannot] 100% promise that patients won’t have complications. We need to try our best to minimize the occurrence of complications, and that starts with having a perfect knowledge of what you will encounter [during the surgery]. You need to conduct appropriate imaging and tests to know what you will most likely encounter, as well as understand patients’ [health] history, particularly their previous surgeries, current anatomy, [etc]. It’s important to ask yourself: ‘If I do this [surgery], how will it affect [the patient’s remaining anatomy], and how can we rearrange [that anatomy as needed]?’

The planning phase of a surgery is extremely important. For example, here at City of Hope, we have weekly meetings where we go over each case and [discuss what we may expect]. That’s important for the surgeons who do the surgery, as well as for the trainees to help sharpen their minds and follow a good strategy.

How might individual patient characteristics and disease factors influence your choices of surgical technique and perioperative care?

As I previously said, minimally invasive surgical approaches are great if they are appropriate. They are not always appropriate. Sometimes there are cases where a laparoscope or a robot are not the right tools and where it’s not wrong to make a big incision. If that’s what provides the best outcome, that’s what we have to do.

We need to strategize what is important. Safety is [our first priority]. Getting rid of the problem areas is [our second priority]. All the other aspects are important, too, for example, whether there is a big incision or small incision or whether there is a colostomy are all relevant [factors], but perhaps a little less relevant than the first 2 aspects.

Then comes the orchestrating of such an operation. At City of Hope, we have a standardized perioperative management [protocol] that entails how the patient gets readied for surgery. They may need to clean out their bowels. They need to drink energy drinks prior to the surgery, so their intestines don’t completely shut down. Then comes the surgery. The process immediately after surgery has changed significantly compared with when I did my training, where patients would not eat food for a week—or until their bowels started to work and there was maybe passage of gas or stool—and then you started to introduce food.

In your practice, how do you determine whether a patient with CRC is eligible for surgery, especially if they have locally advanced or metastatic disease?

As a default, surgery plays a major role for patients with CRC, but there are exceptions. If a patient has metastatic disease, then oftentimes, surgery is not the first [treatment to consider], unless there are complications from that tumor, such as if the tumor completely blocks the passage, or if there is a perforation of the tumor. Those are more emergency-type cases.

However, if [a patient has] a tumor that does not have any of those complications, then rather than taking a localized [surgical] approach where the tumor originated, we need to use systemic treatment with chemotherapy or immunotherapy, where the patient receives treatment by mouth or intravenously, and then we can reassess their responses. That’s important: don’t write off a patient’s [potential surgical eligibility] because there is metastatic disease. We should see how they respond [to systemic therapy]. That’s also a change compared with 20 to 30 years ago. New treatments have made a big difference in patients who would, at their initial presentation, never have been considered candidates for surgery but now often become surgical candidates. We can eliminate the disease, and 5 or 6 years later, they’re still alive.

Lastly, for patients who start with nonsurgical treatments—for example, [those with disease in] the last part of the intestines, the rectum—it’s become standard that we don’t jump into surgery but instead pretreat the field with chemotherapy and radiation therapy, which is smart so we get the best outcome. In approximately 30% of those pretreated patients, the tumor 100% disappears. We can’t see it anymore. We just see a little scar, and that’s it. Those are patients who may even have locally advanced disease [in whom] we do not have to do surgery anymore. We can just watch and wait. We keep monitoring, and if [the disease] comes back, then we need to do surgery.

When patients have disease that is extremely locally advanced but not necessarily metastatic, we still think surgery oftentimes plays a role, [the treatment just] needs to be more aggressive. It could mean we need to remove not just the rectum, but also the bladder or female [reproductive anatomy], and then eliminate the tumor and see if [we can] rearrange [the patients’ remaining anatomy]. The biggest fear that patients have is getting a [colostomy] bag. An even bigger fear is that they need 2 bags: 1 for the stool and 1 for the urine. Often, we can do some form of reconstruction where patients might have a temporary bag that they do not need in the long run.