We took the time to break down some basics about rectal cancer surgery. Dr. Jonathan Mitchem of the University of Missouri provided some expert tips and advice to help you prepare for surgery and recovery.
The Basics: Types of Rectal Cancer Surgery
If you have been diagnosed with rectal cancer, there’s a good chance you’ll have surgery. The extent of the surgery and whether or not you’ll receive additional treatment (like chemotherapy or radiation therapy) depends on your stage at diagnosis.
Oftentimes, care teams will have a nurse navigator or lay navigator which is really helpful leading up to surgery and in the early period after surgery. These folks are there to help guide patients through the process. If you feel like your questions or concerns are not being addressed, don’t feel bad about stating this to anyone on the care team. Often there is some simple misunderstanding that is easily remedied.
Early-stage rectal cancers can sometimes be surgically removed using instruments through the anus. This means no abdominal incision necessary. However, only on pre-cancers or very early cancers may be considered for removal in this way.
This highlights the critical need for screening, as most patients that present with symptoms (bleeding, pain, etc) have tumors that have passed this point.
For many stage I and most stage II patients, a surgery called “protectomy” (fancy way of saying resection of the rectum) is required. This comes in two varieties:
- Low Anterior Resection (LAR)
- Abdominoperineal resection (APR).
Dr. Mitchem explains the difference:
In a LAR, the part of the rectum containing the tumor is removed with a margin of healthy tissue and the colon is typically re-connected to what is left of the rectum or the anus. Most patients that undergo a LAR with a reconnection will have a loop ileostomy (a small intestine ostomy) that is reversible to protect the connection and give it time to heal.
After patients recover from the LAR and/or receive any post-surgery therapy (adjuvant therapy), the surgeon will check the new rectum connection and if it looks okay, reconnect the small intestine so there is no more ostomy. For some patients, depending on their health and other factors prior to surgery, no reconnection is made and a colostomy is required.
In an APR, the whole rectum and anus are removed and the patient does not have a reconnection. This means a permanent ostomy. An APR is typically required if the tumor is so “low” it cannot be removed with an adequate margin of normal tissue without removing the anus. For this surgery, the part of the rectum where the tumor is located is completely removed. For some, the colon is reattached to the part of the rectum that is left intact, and for others, the colon is not reattached and a colostomy is needed.
For some patients, the entire rectum needs to be removed. This is done so that the lymph nodes near the rectum are also removed. The colon is reconnected to the anus and sometimes a J-pouch is formed.
This is a colon J-pouch, not to be confused with the ileal (small intestine) J-pouch that patients get after all the colon and rectum is removed typically for patients with Familial Adenomatous Polyposis or Ulcerative Colitis.
A “J-pouch” is made by folding a short segment of the colon on itself (like a “J”) and creating a connection where it is folded over to create a “pouch” that will act like a reservoir instead of creating a straight connection. There is some research that suggests creating a colon J-pouch provides better function than a straight connection, but this is a matter of some debate and there does not really seem to be a difference in the long-term (at 5 years).
Creating a J-pouch is often not possible due to either the amount of space in the pelvis or the length of the colon remaining. In this case, sometimes surgeons will hook the side of the colon to the end of the rectum, again trying to create a reservoir, but this, again, is often not possible due to the anatomic constraints presented by rectal surgery.
For patients who have a T4 tumor, or patients with stage IV cancer which has reached other organs near the rectum, the surgery may be more extensive with the removal of nearby organs that are affected by cancer.
How to prepare for your surgery
Consider your surgery as a marathon – it’s best to show up feeling as prepared as possible, and armed with a plan. Here are some tips for preparation:
- Prehabilitation: There is research that suggests “pre-hab” can minimize complications from colorectal cancer surgery AND help patients build their energy back faster. Talk to your surgeon about this, and if they agree, start a program prior to your surgery.
- Ask questions.. Here are some you’ll want to ask your surgeon before your surgery:
- What is the purpose of this surgery and what are the goals?
- If you discover that my cancer is more widespread than you anticipated, what will you do?
- What are my risks for complications, based on my age and overall health?
- What kind of changes will I have in my lifestyle or my bowel habits?
- Will I need to do any bowel prep or fasting before my surgery?
- How many lymph nodes do you plan to take and why?
- Will you use drains? If so, how long do you usually leave them in?
- Will I have a bladder catheter or nasogastric tube (NGT) (it is fairly uncommon to use an NGT after elective colorectal surgery these days, but you can expect a catheter)? For how long?
- When can I eat again and what can I eat?
- What types of supplies do I need to have at home to help with my recovery?
- What are my options for pain management after surgery?
- How soon can I walk after surgery?
- When can I go back to work, specific activities, etc? Are there any limitations?
- Will I have an ostomy? If so, will it be permanent? Can I talk to an enterostomal therapist (ostomy nurse) before my surgery?
Try to get some downtime. We know this sounds like a difficult thing to do at such a high-stress time, however, relaxation can have great benefit to your mental health.
I think the best things to do before surgery, from a mental perspective, are to think about what you want to do after you recover (set goals) and discuss expectations with your family and your surgeon so that everyone is on the same page.
Bumps in the road are common, but if you have a good understanding of what is achievable over a given time frame and what is needed to get there everyone will be happier. From a physical perspective, eat healthy (no need to go overboard), exercise at least three times a week, and above all, if you are a smoker, stop smoking! Just two weeks after giving up cigarettes there are measurable improvements in lung function and healing after surgery.
The Healing Process
Your recovery time will depend on the type of surgery you have had. You’ll want to make sure that you have support at home, a friend or family member, who can help you during this time. Here are a few other things to consider:
- Have a pain management plan. Talk to your doctor before the surgery to line up any medications you may need and get tips on other ways to manage it.
- Care for your surgery site well. Make sure you’re clear on what you need to do for wound care, and of course, talk to an ostomy nurse if needed!
- Move your body. Do what feels comfortable for you – take a short walk. Don’t overdo it, though! Talk to your doctor about when you can start to be more active.
I generally tell patients to be as active as they can be with the only limitation really being high-intensity exercise, lifting more than 15-20 lbs for a month after surgery, and any pushing, pulling, etc.
I will also, depending on the circumstances, tell patients they can walk on the treadmill, use an elliptical or stationary bike two to three weeks on low resistance after surgery. The patient will, generally speaking, get fatigued much more easily than before surgery for two to three months as it takes some time to fully recover.
For patients who’ve undergone APR:
Showering with gentle soap and water and pat dry is the general rule. NO swimming, hot tubs, or tub baths for at least a month. And do not use ring pillows–they can compromise blood flow to the healing area. Regular pillows are generally okay.
Occasionally, patients will need either an abdominal muscle (rectus abdominis) or leg muscle (gracilis) flap to help close up their perineal wound (where the anus was) and the reconstruction surgeons will sometimes have very specific requirements. Again, I think the biggest thing for these patients is speaking with an enterostomal therapist before surgery to discuss their future stoma.
Always call your doctor if something seems wrong or if you have questions about your recovery. Call your doctor if you have a fever, are unable to urinate 12 hours after surgery, have excessive bleeding or blood clots, or if you have any questions or concerns.
Listen to your body and be patient with yourself as you heal. Your treatment team is there for you, so don’t hesitate to reach out with any questions.