Rectal cancer surgery

Surgery is the most common treatment for rectal cancer. The goal of surgery is to remove the cancer and enough nearby tissues to try to cure the cancer or stop it from spreading, while preserving typical bowel and bladder function when possible.

The type of procedure that’s recommended depends on how far the cancer has grown and where it is in the rectum. Sometimes a procedure to reroute stool leaving the body, such as an ileostomy or colostomy, may be needed.

In addition to surgery, your healthcare team might recommend other treatments, such as chemotherapy or radiation therapy. These therapies may be used before, during or after surgery. They can be used to shrink cancer or help kill any remaining cancer cells that were not removed with surgery.

Types

There are many different types of rectal cancer surgery. When making a surgery recommendation, your healthcare team will consider where the cancer is in the rectum and if the cancer has spread outside the rectum.

Types of rectal cancer surgery include:

Local excision procedures

Local excision is typically used when rectal cancer is in an early stage and hasn’t spread to the lymph nodes. This type of surgery removes the tumor through the anus, without making cuts in the abdomen. The procedure usually has a quicker recovery than do other similar procedures.

However, local excision doesn’t remove lymph nodes or deeper tissues. It may not be enough if the cancer has grown deeply into the rectal wall, isn’t completely removed, or shows signs of spreading to lymph nodes or blood vessels. In those cases, additional treatment, such as radiation or chemotherapy, may be needed. Sometimes, a more extensive surgery might be recommended, depending on the type of cancer and location.

Types of local excision include:

• Transanal excision (TAE). TAE uses simple tools to remove cancer through the anus. It’s often done as an outpatient procedure.
• Transanal minimally invasive surgery (TAMIS). TAMIS uses laparoscopic tools through a soft port placed in the anus. It also may be done robotically for improved control in tight spaces. The rectum is inflated with gas to create space for the surgeon to operate. TAMIS is a flexible and cost-effective option for early-stage cancer.
• Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR and ESD are often used to remove polyps, especially those limited to the inner layers of the rectal wall. EMR typically is used to remove tumors from the uppermost layer, while ESD allows for deeper dissection into the tissue. ESD is used for larger or more-complex cancers. Sometimes these techniques can be used to remove early-stage cancer.

After local excision of rectal cancer, regular checkups are key to catching any cancer recurrence early.

Resection with sphincter preservation

These surgeries remove the cancer and nearby tissue but try to preserve the muscles that control bowel movements, called the anal sphincter. These surgeries may require a temporary or permanent ostomy procedure, such as an ileostomy or colostomy, which involves making a surgical opening in the abdomen for the passage of stool.

• Total mesorectal excision (TME). TME is considered the gold standard surgical procedure for rectal cancer. This procedure involves making an incision in the abdomen to remove the affected part of the rectum along with surrounding fatty tissue, called mesorectum, and lymph nodes. TME offers excellent cancer control and survival outcomes, though recovery may involve bowel irregularities and sexual dysfunction. Most people recover in 3 to 6 weeks.
• Transanal total mesorectal excision (taTME). This procedure is a newer way to do TME through the anus, rather than through incisions in the abdomen like traditional TME. TaTME may allow easier removal of the tumor through the anus, especially when the cancer is located low in the rectum and hard to reach through the abdomen.

• Low anterior resection (LAR). LAR is a sphincter-sparing surgery for mid-to-upper rectal cancers. It involves removing the cancer, nearby tissue and lymph nodes. The colon is then reconnected to the rectum, so a permanent colostomy usually is not needed. However, sometimes a temporary ileostomy is needed. Recovery may take 3 to 6 weeks.

  Sometimes when the cancer is very close to the anus, the surgeon connects the colon directly to the anus, sewn by hand, to help avoid a permanent colostomy.

• Proctocolectomy. This procedure removes both the colon and rectum. Proctocolectomy may be used to treat rectal cancer that is multifocal, recurrent, or linked to inherited syndromes such as familial adenomatous polyposis (FAP) or other conditions such as ulcerative colitis or Crohn’s disease.

  After removing the colon and rectum, surgeons may create a pouch from the end of the small intestine and connect it to the anus. This procedure allows for bowel movements without the need for a permanent stoma. This is known as total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA). TPC-IPAA, also known as J-pouch surgery, is a sphincter-sparing procedure. J-pouch surgery avoids the need for a long-term opening in the abdominal wall for passing stool.

  Another type of proctocolectomy is known as total proctocolectomy with end ileostomy (TPC-EI). TPC-EI may be done if J-pouch surgery is not possible or if anal sphincter function is poor. In this procedure, the small intestine is connected to a permanent opening in the abdomen to allow waste to leave the body.

• Colectomy. A colectomy removes all or part of the colon. It may be done if the cancer involves both the rectum and colon or if someone has a condition with a high risk of rectal cancer, such as FAP or Lynch syndrome. After removing the affected section of the colon, the remaining bowel is reconnected. Stool then leaves your body as before.

  If all of the colon is removed, the surgeon may attach the remaining colon or the small intestine to an opening created in the abdomen. This allows waste to leave the body through an opening, called a stoma. The procedure to attach the colon to the stoma is called a colostomy. The procedure to attach the small intestine to the stoma is called an ileostomy.

Resection without sphincter preservation

Sometimes the cancer is too low or too close to the anal sphincter muscles. When this happens, the surgeon must remove the anus and rectum. The surgeon also needs to make a permanent opening in the abdomen for stool to pass through, called a colostomy or an ileostomy.

• Abdominoperineal resection (APR). APR is used when the cancer is in the lowest part of the rectum and the sphincter can’t be saved. This procedure removes the lower part of the colon, rectum, anus and surrounding tissue. This is followed by an ostomy procedure called a colostomy. Recovery may take 3 to 6 weeks.

  For men, APR may cause sexual issues, such as trouble getting an erection or trouble reaching orgasm. Fertility also may be affected. For women, APR may cause increased pain during sex, decreased lubrication and decreased arousal.

• Pelvic exenteration. This is a major surgery that removes the rectum and nearby organs, such as the bladder, uterus or prostate, and sometimes the bone at the base of the spine, called the sacrum. Pelvic exenteration is used when the cancer has spread to these areas.

Colostomy or ileostomy

Depending on your procedure, you may need a temporary or permanent ostomy after your surgery. Ostomy types include:

• Colostomy. In a colostomy, the end of the colon is brought through the abdominal wall to create a stoma. Stool passes through the stoma into a bag worn outside the body. A colostomy may be permanent or temporary, depending on the surgery.
• Ileostomy. An ileostomy is similar to a colostomy, but it uses the end of the small intestine, called the ileum, instead of the colon. It’s often used when the entire colon is removed or when the rectum needs time to heal after surgery.

Surgery is the main treatment for most people with rectal cancer. This means taking out the cancer along with a small amount of healthy tissue around it, called a margin. The surgeon also removes nearby lymph nodes because cancer can spread there first. This helps give the best chance of curing the cancer.

Rectal cancer surgery carries a risk of serious complications. Minimally invasive approaches, such as laparoscopic and robotic surgery, may have shorter recovery times and fewer complications. But not everyone can have this type of surgery.

Your risk of complications is based on your general health, the type of surgery you have and the approach your surgeon uses to perform the operation.

In general, complications of rectal cancer surgery can include:

• Bleeding.
• Blood clots.
• Infection.
• Trouble controlling bowel movements, called low anterior resection syndrome (LARS).
• Frequent or urgent trips to the bathroom.
• Leaking urine or trouble emptying the bladder.
• Sexual dysfunction, such as trouble getting or keeping an erection for men, or discomfort during sex for women.
• Ongoing fatigue or weakness.
• Formation of scar tissue after surgery, called adhesions, that can cause blockage in the intestine.
• Leaking at the connection site, called an anastomosis, where the healthy ends of intestine were joined.
• Rarely, death.

Some of these complications, such as sexual or urinary dysfunction, happen because nerves in the pelvis can be affected during surgery. The risk depends on the type of surgery, how low the tumor is, and whether you had radiation or chemotherapy before surgery.

Discuss your procedure with a rectal cancer surgeon

Before surgery you meet with a rectal cancer surgeon who can explain what to expect from surgery. Prepare for this meeting by creating a list of questions to ask.

Questions to ask about surgery:

• What are my options for rectal cancer surgery?
• Do you recommend an open or minimally invasive procedure?
• Will I need to have an ostomy procedure, such as a colostomy or ileostomy? If so, will it be temporary or permanent?
• Will I also need to have other types of treatment, such as chemotherapy or radiation?

Questions to ask about risks and recovery:

• What are the risks associated with my surgery?
• What are my options for pain management?
• How much time will I spend in the hospital?
• How much time will I need for recovery?
• How soon can I eat and drink after my surgery?
• What kind of diet should I follow during my recovery? For how long?
• Will I need to limit my activities after surgery?
• When can I return to work?

Questions to ask about an ostomy procedure:

• What does a stoma look like, and how do I care for it?
• How often do I need to change the ostomy pouch?
• Can I follow my typical diet after an ostomy procedure?
• How will an ostomy affect my daily life and routines, such as physical activity or intimacy?
• What are the possible complications or risks associated with an ostomy?
• How do I manage odor and leakage from the ostomy pouch?
• What support and resources are available for help with my ostomy?

Follow your healthcare team’s instructions

During the days leading up to the procedure, your healthcare team may ask that you:

• Stop taking certain medicines. Certain medicines can increase your risk of complications during surgery, so your care team may ask that you stop taking them before your procedure.
• Fast before your surgery. You may be asked to stop eating and drinking several hours to a day before your procedure. Your care team will give you specific instructions.
• Drink a solution that clears your bowels. You may be prescribed a laxative solution that you mix with water at home. You drink the solution over several hours. Follow the instructions from the care team. The solution causes diarrhea to help empty your colon and rectum. Your care team also may recommend enemas.
• Take antibiotics. You may be prescribed antibiotics to suppress the bacteria found naturally in your intestines and to help prevent infection.
• Stop smoking. Smoking makes it harder for the body to heal after surgery. Quitting smoking before surgery can lead to faster healing and fewer complications.
• 保持活躍。 Physical activity before rectal cancer surgery can enhance recovery and overall outcomes. It helps improve cardiovascular fitness, muscle strength and mental well-being. This may reduce complications during surgery and speed up postoperative recovery.

Plan for your hospital stay

You’ll likely spend at least a few days in the hospital after your surgery. How long you stay depends on your situation. Plan for someone to take care of your responsibilities at home and at work. Think ahead to what you might like to have with you while you’re recovering in the hospital.

Things to pack might include:

• Robe and slippers.
• Toiletries, such as your toothbrush and toothpaste and, if needed, shaving supplies.
• Comfortable clothes to wear home.
• Activities to pass the time, such as a book, magazine or games.

During the procedure

What happens during your surgery depends on the specific procedure. Generally, you can expect the following:

• Surgery prep. Members of your healthcare team take you to a preparation room where they monitor your blood pressure and breathing. You may receive an antibiotic through a vein in your arm to prevent infection. You also may receive medicine to prevent blood clots.
• Anesthesia. Care team members take you to the operating room where you are positioned on the surgical table. You receive general anesthesia to put you in a sleeplike state so you won’t feel anything during the operation. Once you are asleep, the surgeon begins the surgery.
• Cancer removal. The surgeon removes the cancer and all or part of the rectum. In most cases, nearby lymph nodes also are removed to check whether the cancer has spread. The exact approach depends on the tumor’s location and stage:
  • For early-stage cancer, the surgeon may use a local excision technique through the anus, without making incisions in the abdomen.
  • For more-advanced cancer, the surgeon may perform a low anterior resection (LAR) or abdominoperineal resection (APR). Each procedure requires abdominal incisions. The procedures may be done using open or minimally invasive techniques, such as laparoscopic or robotic surgery.
• Reconnection or ostomy. If possible, the surgeon reconnects the remaining parts of the bowel to allow for typical bowel movements. If the area needs time to heal or if reconnection isn’t possible, you may need a temporary or permanent ostomy. An ostomy procedure creates an opening in the abdominal wall called a stoma. This allows stools to leave the body through a bag connected to the stoma.

After the procedure

After surgery, care team members take you to a recovery room where they monitor you as the anesthesia wears off. Once stable, you are moved to your hospital room to begin recovery.

• Regaining bowel function. You’ll likely stay in the hospital until you can eat and drink again and your bowel function begins to return. This may take several days. You may be encouraged to start eating a regular diet within 24 hours after surgery. Eating small bites, chewing thoroughly and pausing between bites can help. Early eating may help your bowels begin working sooner.
• Physical activity. You’ll likely be encouraged to walk the first day after surgery. Being physically active right away is linked to faster recovery and fewer complications.
• Wound care. Your healthcare team teaches you how to care for your incision and manage any surgical drains. Team members also can provide instructions on diet, physical activity and signs of complications to watch for.
• Ostomy care. If your surgery involves a colostomy or an ileostomy, a nurse can teach you how to care for your stoma and change the ostomy bag. Some ostomies are temporary and may be reversed after the bowel has healed, typically within 8 to 12 weeks. Others are permanent. It depends on the type and location of the surgery.
• Functional recovery. Bowel habits may change after rectal surgery. Some people experience urgency, frequency or incontinence. These symptoms are known as lower anterior resection syndrome (LARS). LARS symptoms may improve over time, especially with dietary changes and pelvic floor exercises. If you had a very low anastomosis or a straight connection without a pouch, bowel function may take longer to stabilize.

After rectal cancer surgery, your care team reviews the pathology results from the tissue removed during surgery. These results help determine whether more treatment is needed and your follow-up care.

If your results show no signs of cancer remaining, your care team may recommend a “watch and wait” approach with regular follow-up visits and imaging. If cancer cells were found near the margins or in the lymph nodes, additional treatment such as chemotherapy or radiation may be recommended.

Some people may experience long-term effects from treatment, such as changes in bowel or bladder function, sexual dysfunction, or fatigue. These are common and manageable. Your care team can refer you to specialists such as pelvic floor therapists, urologists or counselors to help manage these issues.

Follow-up care

Most people have regular follow-up appointments for at least five years. These may include:

• Physical exams and blood tests every 3 to 6 months for the first two years, then every six months for a total of five years.
• Imaging scans once a year or more often if needed.
• Colonoscopy at one year after surgery, then at three years and then every five years after that if nothing unusual is found.