Stage IV Colorectal Surgery

Surgical therapy for Stage IV colorectal cancer is performed in most cases after an individual has completed their chemotherapy regimen.  In some cases surgery may be done prior to chemotherapy if the tumor is causing a blockage in the colon.  Your multi-disciplinary medical team at Johns Hopkins will work with you to develop a customized treatment plan incorporating the proper timing of chemotherapy and surgery.

A variety of types of colorectal surgeries are possible depending on where the cancer occurs. The surgical techniques for colon cancer differs signficantly from the surgical techniques for rectal cancer.  At Johns Hopkins we have a team of surgeons who specialize in colon and rectal cancer surgery.  By coordinating your care with experts in medical and radiation oncology, patients at Johns Hopkins receive the full benefits of a multidisciplinary team approach.  Clinical trials are options for all stages of colorectal cancer patients at Johns Hopkins and may be fully explored with your team of experts.  The strength of our cancer program ensures that patients receive the most advanced, effective, and safe treatments. 

To make a surgical appointment at Johns Hopkins please call (410) 933-1233 

The goals of surgical therapy for Stage IV coloectal cancer are to:  

  • Relieve any blockage in the colon or rectum caused by the tumor
  • Remove the cancer completely with clear margins.
  • Resect adjacent draining lymph node.
  • Avoid excessive disruption or spillage of tumor cells.
  • Reconstruct the bowel, if possible, in order to achieve intestinal continuity and normal or near normal bowel function postoperatively.

The type of resection depends on a variety of factors including: the location of the tumor, the presence of other associated cancers or polyps, the stage of the cancer, the risk of development of other colon cancer in the future, and finally, the patient’s preference. The method of reconstruction of the colon resection can vary. Some surgeons use manual suturing either in one or two layers, others prefer one of various stapling techniques.

A variety of types of colorectal resections are possible depending on where the cancer occurs. The surgical techniques for colon cancer differs signficantly from the surgical techniques for rectal cancer. 

Please choose the location of your cancer to view the corresponding surgical techniques:

Colon Resection

Rectal Resection

Colorectal resection, including regional lymph nodes, is based on the blood supply to the bowel (Figure 20).

Figure 20. Arterial blood supply to the colon.

Surgical Treatment of Stage IV Colon Cancer

A right hemicolectomy (Figure 21) is the surgical procedure performed for patients with cancer between the cecum and ascending colon.

Figure 21. Right hemicolectomy with ileocolic anastomosis.

A transverse colectomy (Figure 22) is performed for tumors in the transverse colon. The middle colic artery is ligated and the ascending and descending colon are anastomosed.

Figure 22. Transverse colectomy with anastomosis of ascending and descending colon.

Extended right colectomy is performed in cases in which the cancer is located in the proximal or mid transverse colon (Figure 23). This resection requires removal of the terminal ileum , cecum, ascending colon, hepatic flexure and a portion of the transverse colon.

Figure 23. Extended right colectomy with ileocolic anastomosis.

Left hemicolectomy (Figure 24) is the procedure for tumors of the descending colon. The left colic artery is ligated, the splenic flexure and descending colon removed and the transverse and upper sigmoid colon are joined (anastomosed).

Figure 24. Left hemicolectomy with transverse and sigmoid colon anastomosis.

Sigmoid colectomy removes tumors of the sigmoid colon (Figure 25). The upper rectum and descending colon are joined (anastomosed).

Figure 25. Sigmoid colectomy with anastomosis of descending colon and upper rectum.

Surgical Treatment of Stage IV Rectal Cancer

The surgical management of rectal cancer can be particularly complicated, depending on the location of the tumor. There are a variety of surgical procedures that are available to patients with rectal cancer ranging from local excision to radical abdominoperineal resection. Accurate preoperative staging determining depth of invasion and lymph node involvement is essential in selection of the appropriate operative procedure. CT or MRI and endorectal ultrasound are diagnostic tests used for staging of the tumor.

The two options for management of Stage IV rectal cancers include:

  •  restorative anterior or low anterior resection,
  •  abdominal perineal resection with permanent colostomy.

The low anterior resection is suitable for lesions located in the upper two-thirds of the rectum. This sphincter-sparing operation can be performed for cancers in the middle and lower third of the rectum with low coloanal anastomosis at the level of the pelvic floor (Figure 25).


Figure 26. Low anterior resection for tumors in the upper two thirds of the rectum. A, Temporary colostomy; B, subsequent colorectal anastomosis; C, restoration of GI tract continuity.



Colorectal anastomosis or coloanal reconstructions are alternatives to permanent colostomy. Construction of a colon J-pouch creates a neorectal reservoir that can reduce frequency and urgency of bowel movements and nocturnal bowel movements in selected cases (Figure 27).



Figure 27. A, Low anterior resection; B,C, coloanal anastomosis; D, j pouch construction creating a reservoir.



These radical “transabdominal” resections are recommended for most cancers at risk for recurrence (higher than stage T1 or poorly differentiated with lymphatic or vascular involvement). The selection of surgical procedure should be guided toward the prevention of pelvic recurrence. Total mesorectal excision with a low anterior resection or an abdominoperineal resection is the optimal surgical procedure for rectal cancer. Total mesorectal excision removes the rectal mesentery as an intact unit. This reduces local recurrence along with preserving sexual function, urinary function, and continency.

Abdominoperineal resection is used when the lesion is in the lowest part of the rectum (Figure 28) typically involving the anal musculature. A colostomy allows for drainage of waste through an opening in the abdominal wall.


Figure 28. Abdominoperineal resection with colostomy.


Treatment for Advanced (Unresectable) Rectal Cancer

Endoscopic Therapy
For patients with obstructive unresectable rectal cancer, endoscopic therapy using the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser is an alternative to recanalize the rectal lumen. Electrofulguration using a heater probe has also been used for palliative therapy.

Another approach for patients who are poor surgical candidates is photodynamic therapy(PDT). In this procedure, patients are sensitized with a hematoporphyrin derivative, which is taken up preferentially by the tumor cells. At this point, phototherapy is performed using a laser beam applied through a flexible optical fiber directed at the tumor. The laser sensitizes the protoporphyrin ultimately inducing apoptosis of the tumor cells. This technique is still considered experimental.

Complications associated to endoscopic therapy with Nd:YAG laser are bleeding and perforation.