Surgery for anal cancer

Surgery is not a common treatment for anal cancer. Most people with anal cancer are more likely to have a combination of chemotherapy and radiotherapy, called chemoradiation. Chemoradiation is more effective at curing the cancer than surgery and usually means that you don’t need to have a permanent colostomy.

Surgery may sometimes be used if your chemoradiation treatment doesn’t completely get rid of the cancer. It may also be used if there are signs that the cancer has come back. Sometimes surgery is used if you can’t have radiotherapy – for example if you have had radiotherapy to the area before. Occasionally, it’s used to relieve symptoms before treatment with chemoradiation.

If you are a woman and want to have children in the future, you may be offered surgery.

Surgery may also be used to remove small tumours.

Your doctor will discuss with you whether surgery is needed and if so, the most appropriate type of surgery for your situation.

When is surgery used for anal cancer?

Surgery is not a common treatment for anal cancer, because chemoradiation is often the only treatment needed.

Surgery may be your main treatment if you have a very small tumour outside the anus (anal margin). This is only if the surgeon can remove it without affecting how you have a bowel motion.

Surgery may also be used:

  • if chemoradiation doesn’t completely get rid of the cancer
  • if there are signs the cancer has come back
  • if you can’t have radiotherapy, for example because you’ve had radiotherapy to the pelvis before
  • to relieve a blockage in the bowel before you have treatment with chemoradiation
  • if you are a woman and want to have children in the future.

If you need surgery, your doctor will talk it over with you. They will advise you about the type of operation and how it will help.

If you smoke, try to stop 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 heal after the operation. Your hospital team or GP can give you advice and support to help you give up smoking.

Types of surgery

Local excision

This operation 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.

Because the anal sphincter isn’t usually affected, you won’t have permanent problems with bowel control after surgery.

Your doctors may recommend you have radiotherapy or chemoradiation after surgery. This is usually when there are some cancer cells in the tissue close to where they removed the cancer.

Abdominal-perineal resection (APR)

This is a major operation to remove the anus, rectum and part of the large bowel (colon). Doctors usually only advise having an APR if:

  • the cancer hasn’t gone completely after chemoradiation
  • the cancer comes back after treatment.

Because an APR involves removing the anus and rectum, it means having a permanent colostomy. The surgeon moves the open end of the bowel to the surface of the tummy (abdomen). The opening is called a stoma. Your bowel motions (stools) then pass out of the body into a colostomy bag.

This can be upsetting and take time to adjust to. Your surgeon and a stoma nurse will talk it over carefully with you before the operation. Your nurse will give you a lot of support, and there are organisations that also help.

Abdominal-perineal resection
Abdominal-perineal resection

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A colostomy bag
A colostomy bag

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After the APR operation, you usually have two wounds. You have a tummy wound and a wound 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.

Sometimes an APR may be done using keyhole surgery (laparoscopic surgery). The surgeon does the operation using only four or five small cuts (about 1cm each) in your abdomen. They use specially designed instruments that can be put through these small cuts. There will still be a wound where the anus has been closed.

Keyhole surgery
Keyhole surgery

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Having a temporary stoma

This is occasionally 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 leakage of your bowel motions (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.

Planning your operation

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 usually have a hospital appointment before your operation to have some tests and make sure you’re fit enough for the operation. This is called a pre-assessment clinic.

We have more information about what happens before surgery.

Enhanced Recovery Programmes (ERP)

Many hospitals follow an enhanced recovery programme. This can help reduce complications after surgery and speed up your recovery. The programme involves careful planning before your operation. This makes sure you are properly prepared and any arrangements that are needed for you to go home are already in place. You will be encouraged to:

  • have high-protein and high-calorie supplements before and after your surgery
  • get as fit as possible before your operation
  • limit the amount of alcohol you drink
  • stop smoking.

You will be given information about what to expect after your surgery and when you can expect to go home.

After your operation, you will be encouraged to start moving around as soon as possible. Sometimes this will be on the day of the operation.

The surgeon will try not to use any tubes or drains unless they need to. Any catheters and fluids that are given through a vein will be removed soon after surgery. You will also be allowed to eat and drink soon after surgery. After you have gone home, you will be seen regularly to make sure you are recovering well.

You can ask your doctor whether you are suitable for this type of recovery programme. Not all hospitals use ERP for surgery and it is not suitable for everyone.

Back to Surgery explained

Who might I meet?

A team of specialists will plan your surgery. This will include a surgeon who specialises in your type of cancer.

If you have a stoma

Adjusting to a stoma takes time but most people manage well with support from their stoma care nurse.