Surgery is not often needed to treat anal cancer. This is because chemoradiation is often the only treatment needed.
You may have surgery if you have a very small tumour in the anal margin. This is only if the surgeon can remove it without affecting how you pass stools (poo).
You may also have surgery:
- after chemoradiation, if the chemoradiation does not get rid of all the cancer
- if the cancer comes back after having chemoradiation
- if you cannot have radiotherapy, for example because you have had radiotherapy to the pelvis before
- to relieve a blockage in the bowel before you have chemoradiation.
If your doctor thinks you need surgery, they will explain the type of surgery you need and how it will help.
This surgery only removes the area of the anus containing the cancer cells. It is sometimes used to treat small, early-stage cancers in the anal margin.
You will not have long-term problems with bowel control after this surgery. This is because the anal sphincter is not usually affected.
Abdominal-perineal resection (APR)
This surgery removes the anus, rectum and part of the colon. Doctors usually only advise having an APR if:
- chemoradiation has not got rid of all the cancer
- the cancer comes back after treatment.
You can have an APR as open surgery. This is when the surgeon makes one large cut in your tummy. Or you can have it as keyhole (laparoscopic) surgery. This is when the surgeon makes 3 or 4 small cuts in your tummy. They use special instruments that can fit through these cuts to remove the cancer.
As well as the wound (or wounds) on your tummy, you will have a wound on your bottom where the anus has been closed. The anus may be closed using muscle, fat and skin from another part of the body. This is called a flap.
An APR removes the anus and rectum. This means you will have a permanent stoma (colostomy). A stoma is an opening that is made through the tummy (abdominal) wall. It connects the bowel to the surface of the tummy. This means stools will not pass out of the rectum and anus in the usual way. Instead, it will pass out of the stoma into a disposable bag that is worn over the stoma.
This can be upsetting and takes time to adjust to. Your surgeon and a stoma nurse will talk to you before the operation. You can ask them any questions you have. Your nurse will give you lots of support, and there are organisations that can help. We have more information about having a stoma.
A colostomy bag
Having a temporary stoma
This is sometimes done before chemoradiation. It involves having surgery to make a temporary stoma
After chemoradiation is finished, your doctors assess you to see if the stoma can be closed. This will allow you to pass stools through the anus again.
A temporary stoma may be used to relieve symptoms if:
- the cancer is causing you to have problems controlling your bowel (incontinence)
- there is an opening between the bowel and skin (a fistula)
- there is an opening between the bowel and another organ, such as the bladder or vagina (a fistula)
- there is a risk of a fistula forming
- the cancer is causing a blockage in the bowel.
Your operation will be carefully planned. For an APR, there may be different specialists involved. This could include a plastic surgeon and a gynaecologist if you are a woman.
You will go to a pre-assessment clinic for tests to check you are fit for the operation. These may include blood tests, a blood pressure check and a recording of your heart (ECG).
You will meet a member of the surgical team to talk about the operation. If you are going to have a stoma after the operation, you will also meet a stoma care nurse who will explain what is involved.
This is a good time to share any questions or concerns you have about the operation. If you think you may need help when you go home after surgery, for example because you live alone or care for someone else, tell your nurse as soon as possible. It will help them to plan your care in plenty of time.
Enhanced Recovery Programmes
Some hospitals follow an enhanced recovery programme, which aims to reduce the time you spend in hospital and speed up your recovery. You will also be more involved in your own care. For example, you will get information about diet and exercise before surgery. You may also be given nutritional supplement drinks to take.
Your hospital team will make any arrangements needed for you to go home. Your doctor will tell you if an enhanced recovery programme is suitable for you and if it is available.
If you smoke, try to give up or cut down before your operation. This will help reduce your risk of chest problems, such as a chest infection. It will also help your wound to heal after the operation. Your GP can give you advice and support to help you give up smoking.
You will be encouraged to start moving around as soon as possible. Even if you have to stay in bed, it is important to do regular leg movements and deep-breathing exercises. A physiotherapist or nurse will explain these exercises to you.
To reduce the risk of blood clots, you will wear TED stockings. Your nurse may also give you medication to prevent blood clots. This will be given as injections under the skin.
On the evening of the operation or on the next day, a nurse will help you get out of bed or sit up for a short time. Gradually, you will be able to sit or stand up for longer and to start walking around the ward.
Drips and drains
Depending on the type of operation, you may have some tubes attached to your body. If you had a small operation, you may not have any tubes at all. You may be given fluids into a vein in your hand or arm. This is called a drip or intravenous infusion. It is removed when you are eating and drinking normally again.
You may have a tube put in during the operation to drain urine (pee) from your bladder. This is called a catheter. it is taken out once you are eating and drinking normally and can walk to the toilet.
You may have a nasogastric tube. This is a tube that goes up the nose and down into the stomach. It removes fluid from the stomach until the bowel starts working again.
You may have a tube attached to a bottle close to the operation wound to drain fluid away. A nurse will remove it after a few days, when fluid stops draining.
It is normal to have some pain and discomfort after your operation. Painkillers can help control this. If you still have pain, tell your doctor or nurse. You may need to have your dose or type of painkiller changed. The pain control you need will depend on the type of operation you have had.
You may have a continuous dose of painkiller into the spinal fluid through a fine tube and a pump. This is called an epidural.
Painkillers can also be given through a tube into a vein in your hand or arm (a cannula). The tube is connected to a pump. This is called a PCA (patient-controlled analgesia). You can give yourself an extra dose of painkiller when you need it by pressing a button on the pump. The machine is set so you get a safe dose and are unable to have too much.
Painkillers sometimes slow down your bowel function (constipation). If your bowels are not moving, tell your nurses. They can give you medicines to help.
After an APR it may be uncomfortable to sit down. This will improve as the wound heals.
Before you can go home, your pain needs to be controlled by tablets. You will get a prescription for painkillers you can take at home as needed.
Feeling sick or being sick
The nurse will give you anti-sickness medication if you feel sick or are being sick. If this does not work, tell your nurse. They may give you a different type of anti-sickness medication.
Your wounds may be closed with stitches, clips or staples. A nurse at your GP surgery usually removes these after you go home. Sometimes a district nurse can come to your home to remove them. Some surgeons use dissolving stitches that do not need to be removed.
Sometimes your surgeon may use a flap of tissue to close the wound, instead of stitches or clips. This is more likely if you have already had radiotherapy. If you have a flap, you will not be able to sit on your bottom for 2 to 4 days after your operation. This reduces pressure on your wound and helps it heal.
You will only be able to sit for short periods at first. As things improve, you can slowly increase this. You can lie on your side but will still need to change your position regularly. Your doctor or nurse will give you advice about how often to change position when sitting.
You may be given antibiotics to help prevent any wound infection. While you are in hospital and after you go home, tell your nurse or doctor straight away if your wound:
- becomes hot
- becomes painful
- leaks any fluids.
These can be signs that the wound is infected.
This will depend on the type of operation you had. The most common complications after surgery are:
- a wound infection
- bleeding in the operation area
- a chest infection
- a blood clot.
The nurses will monitor you for these complications. Tell them straight away if you:
- have any bleeding
- feel unwell
- have symptoms of an infection, such as a cough
- have signs of a wound infection
- have swelling and redness in a limb.
Most people who have surgery go home without complications. But if you do have any problems when you get home, tell your doctor straight away.
When you can go home will depend on the type of operation you have had. If it is a small operation, you will be ready to go home after 2 days.
After a bigger operation, it may take up to 2 weeks.
Before leaving hospital, you will be given an appointment to go to at an outpatient clinic for your post-operative check-up.
If you have stitches, clips or staples in your wound, these are usually taken out 7 to 10 days after surgery. A nurse at your GP surgery can do this. If you cannot leave home, a district nurse can visit you.
Recovering from an operation takes time. Some people take longer to recover than others.
Below is a sample of the sources used in our anal cancer information. If you would like more information about the sources we use, please contact us at email@example.com
R Glynne-Jones, PJ Nilson, C Aschele et al. ESMO-ESSO-ESTRO clinical practice guidelines for diagnosis, treatment and follow up for anal cancer. July 2014. European Society of Medical Oncology. Available from www.esmo.org/Guidelines/Gastrointestinal-Cancers/Anal-Cancer (accessed October 2019).
Association of Coloproctology of Great Britain & Ireland (ACPGBI). Volume 19. Issue S1. Guidelines for the management of cancer of the colon, rectum and anus. 2017. Available from: www.onlinelibrary.wiley.com/toc/14631318/19/S1 (accessed October 2019).
R Muirhead, RA Adams, DC Gilbert et al. National guidance for IMRT in anal cancer. December 2016 (accessed October 2019).
D Ryan, C Willett et al. Clinical features, staging, and treatment of anal cancer. Uptodate 2019. Available at www.uptodate.com/contents/clinical-features-staging-and-treatment-of-anal-cancer (accessed October 2019).
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Chief Medical Editor, Professor Tim Iveson, Consultant Medical Oncologist.
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