Surgery for rectal cancer
Surgery is the most common treatment for rectal cancer and should be carried out by a surgeon who specialises in bowel surgery.
In this video a clinical nurse specialist for stoma care talks about having a stoma after surgery for cancer.
The information in this video was correct as of 9 April 2014.
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You may be given radiotherapy or chemoradiotherapy before surgery to shrink the cancer and make it easier to remove.
The type of surgery you have will depend on the stage of the cancer and where it is in the bowel. Your doctor will discuss this with you.
Enhanced recovery programme (ERP)
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Some hospitals follow an enhanced recovery programme, which can help reduce complications following surgery and speed up your recovery. The programme involves careful planning before your operation. This makes sure you’re properly prepared and any arrangements that are needed for you to go home are already in place. You’ll be encouraged to take high-protein and high-calorie supplements before and after your surgery. Also you’ll be encouraged to start moving around as soon as possible, sometimes on the day of the operation.
The surgeon will try not to use any tubes or drains unless absolutely needed. Any catheters and fluids through a vein will be removed soon after surgery. You’ll also be allowed to eat and drink soon after surgery. After you’ve gone home you’ll be regularly reviewed to make sure that you’re recovering well. You can ask your doctor whether you will be suitable for this type of surgery. Not all hospitals use the ERP for surgery and it’s not suitable for everyone.
Before your surgery, the doctor and specialist nurses will explain the operation to you. They’ll tell you what to expect immediately after the surgery and in the few days after it. This is a good opportunity to ask any questions about the operation.
You may be admitted to the ward the day before your operation, so that the doctors and nurses can do any further tests. Some hospitals ensure that all of these tests are done beforehand and admit patients on the day of their surgery.
To make sure that your bowel is completely empty, you may be asked to follow a strict diet and take a medicine (laxative) to help empty your bowels the day before surgery. Your nurse or the doctor will explain this to you. You’ll be given antibiotics as an injection into a vein (intravenously) just before surgery to prevent infections.
Types of rectal cancer surgery
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Very early-stage rectal cancers that are small and low down in the rectum can sometimes be removed using an operation known as a local resection or a transanal resection. This is when instruments are passed through the anus into the rectum to remove the cancer. The APPEAR technique (this stands for Anterior Perineal PlanE for Ultra-low Anterior Resection) is another technique used to remove rectal tumours that are very low down. This is a specialised technique that reduces the risk of removing or damaging the anal muscle. There’s also a lower risk of needing a permanent stoma afterwards. Your doctor or specialist nurse can give you more information about this technique.
When the cancer is higher up in the rectum, an endoscope, similar to the one used to take a biopsy, can be used by a specially trained surgeon to remove the cancer from the wall of the rectum. This operation is sometimes called transanal endoscopic microsurgery (TEM).
A pathologist will examine the cells of the cancer. If it’s found to be high-grade your surgeon may recommend that you have a second operation. This is done to remove more of the rectum to make sure that no cancer cells have been left behind.
Total mesorectal excision (TME) is an operation commonly used to remove a rectal cancer. It involves careful removal of the whole of the rectum as well as the fatty tissue that surrounds it, which contains the lymph nodes. This operation takes from 3–5 hours. Research has shown that a TME is better than other types of surgery at reducing the risk of the cancer coming back.
Depending upon the position of the cancer in the rectum, its size, and how far it is from the anus, your surgeon will do the TME operation by using either a low anterior resection, a colo-anal ‘J pouch’ surgery or an abdomino-perineal resection.
A low anterior resection is usually used for cancers in the upper and middle parts of the rectum (close to the colon). During the surgery, the piece of bowel that contains the cancer is removed and the two ends are then joined together. The join is known as an anastomosis.
The lymph nodes near the bowel are also removed because this is usually the first place the cancer spreads to. After this operation, you’ll have a wound that goes in a straight line from just below your breast bone (sternum) to just above the level of your hipbone.
If for some reason the bowel can’t be rejoined, the upper end can be brought out onto the skin of the abdominal wall. This is known as a colostomy and the opening of the bowel is known as a stoma. A bag is worn over the stoma to collect the stool (bowel motions).
Sometimes a stoma is only temporary and another operation to rejoin the bowel can be done a few months later. The operation to rejoin the bowel is known as stoma reversal. If it isn’t possible to reverse the colostomy, the stoma is permanent. Having radiotherapy or chemoradiation before surgery can help reduce the chance of needing a permanent colostomy.
In colo-anal ‘J pouch’ surgery, the rectum is removed and the colon is attached to the anus. Sometimes the surgeon can make a new rectum from the colon. You may have a temporary stoma during this time to allow the bowel to heal.
An abdomino-perineal resection is usually used for cancers in the lower end of the rectum. This operation will result in a permanent colostomy because the whole rectum and anus are removed. After the surgery there will be two wounds –
a wound that goes in a straight line from just below your breast bone (sternum) to just above the level of your hipbone
a second wound on your bottom, where the anus has been closed.
Laparoscopic (keyhole) surgery
This operation uses four or five small cuts in the abdomen rather than one bigger incision. A laparoscope (a thin tube containing a light and camera) is passed into the abdomen through one of the cuts and the cancer is removed. Recovery from this operation is usually quicker. This type of surgery is used by some hospitals. Your surgeon will discuss with you if this is appropriate for you.
Robotic surgery is currently still being researched. It involves the use of a robot controlled by the surgeon to perform more difficult procedures.
Surgery for advanced rectal cancer
Sometimes the cancer is too large to be removed and presses on the rectum, causing it to narrow. If this happens, it may be possible to insert a thin metal tube (a stent) into the rectum to keep it open. The stent is inserted using a colonoscope. You’ll be given a mild sedative to help you relax and you may have a short stay in hospital.
If the rectal tumour has grown into other organs near the rectum, a bigger operation may be needed to try to remove the cancer. This is called a pelvic clearance, and is only done occasionally. Your doctor will explain more about this procedure if it is appropriate for you.
The most common place for rectal cancer to spread is to the liver. Over the last few years, better surgical techniques mean that it’s now more possible for surgeons to remove a rectal cancer that has spread to the liver. This can sometimes lead to a cure. Chemotherapy may be given before or after the operation. This treatment is not possible for everyone whose rectal cancer spreads to the liver. Your doctor or specialist nurse can discuss this with you further.
Surgery may sometimes be used to remove the cancer when it has spread to the lungs. Sometimes chemotherapy may be given before or after the surgery.
You may find our sections on secondary cancer in the liver and secondary cancer in the lungs helpful.