Surgery of the rectum

author/s: Dr Albert Navarro Luna, Dr M. Antonia Lequerica Cabello, Dr Raquel Sáez Redín

 

What is the objective of the operation?

The objective of the operation is to resect the portion of the rectum encompassing the tumour, as well as the entire territory of lymphatic drainage. Furthermore, the resection must include minimal margins reducing to the maximum the possibilities for regrowth of the tumour in the area. The aim of the surgery is to reduce to a maximum the possibilities of recurrence both at a local site (local recurrence) as well as at a distance (metastasis).

 

What must I do before the operation?

Your doctor will tell you what you need to do, but as a general rule, before the operation, it is important to run a series of tests to try and find out how far the tumour has gone. These tests are known as “extension study”. Among these tests, we can mention, apart from a fibrocolonoscopy that is done to localise the tumour and rule out the existence of other tumours in the colon or rectum, abdominal and thoracic CAT in some cases, chest X-ray, abdominal ultrasound and blood test for a specific marker that is called CEA. The preoperative study (chest X-ray, electrocardiogram and blood tests with coagulation panel) are essential tests before any surgical procedure is carried out.

 

Preparation prior to the procedure.

The day before of the operation and, unless otherwise contraindicated, your doctor will tell you about a procedure known as colon cleansing or mechanical preparation of the colon, the objective of which is to clean the inside of the colon and rectum to minimise the risk of infectious-type complications. It is possible that you may have been subjected to a cleansing of the colon before for the colonoscopy and thus you will be familiar with the procedure.

For the actual operation, you will have had to be on an empty stomach for about 6 to 8 hours with no food whatsoever. Your doctor will tell you the time when you will be no longer allowed to have any food.

Another way to reduce to a maximum infection-related complications is by administering antibiotics that are usually given just before or during the actual procedure. Whether or not antibiotics are prescribed after the operation is a decision to be taken by your doctor after he or she sees how the procedure is developing. It must be pointed out that if antibiotic therapy after the operation is not necessary, administering antibiotics will not provide any beneficial effect and can, however, cause some unwanted side effects. The decision will be entirely up to the surgeon after the operation.

 

If the tumour is in the rectum.

Surgery of cancer of the rectum is much more complex in all aspects than surgery of the colon. The different types of treatment will depend on the situation of the tumour and the progression stage it is in at the time of diagnosis.

First of all, and as mentioned before, an extension study is performed. If possible, during the extension study, an endorectal ultrasound is performed to ascertain the level of invasion of the tumour. Another option to determine the level of invasion is magnetic resonance.

 

What treatment options are there?

The rectum is the final part of the large intestine (see animation). Depending on the localisation, the level of expansion estimated by the endorectal ultrasound and the existence or not of distant dissemination, the options will be:

    1. Surgery as first treatment with excision of a segment of intestine that will include sigma and rectum. Depending on the proximity of the tumour to the anal sphincters and the technical characteristics of the intervention, it is possible to apply a suture or to perform an anastomosis between colon and rectum (see animation). The removal of the anus with creation of a definitive colostomy (stoma or "bag") might be necessary (see animation). When the excision of anus is not mandatory, in some cases it will be necessary to leave a stoma (“Bag”) temporarily for protection for a few months.

    2. Firstly, treatment with radiotherapy and chemotherapy for approximately 5 weeks; followed by excision of the tumour and intestine, as described in the last section.

    3. In very selected cases of very small tumours, local resection through the anus via endoscopy or surgery might be all that is necessary.



Can this operation be done via laparoscopy?

Laparoscopy is a surgical technique that involves the placement of instruments through small orifices to perform, as in colorectal cancer, the resection of the portion containing the tumour. This technique affords less postoperative pain and a shorter hospital stay.

The possibility to perform surgery via this laparoscopic technique will be explained to you by your surgeon and will depend on several factors such as the size and location of the tumour for instance. It is very important that this technique provides you with results as good as those afforded by the open approach.

 

Can there be any complications?

Unfortunately, all surgical procedures always entail some risk of complications, although such risk is generally low. In surgery of cancer of the rectum, the main likely complications are the opening of suture lines along the intestine, a condition known as suture failure. Although this occurrence is rare (less than 6% approximately), it is rather severe and generally requires a reintervention. The infection of the skin wound is a more frequent complication but not as severe. It usually gets resolved with regular wound care. Your surgeon will inform you about other less frequent complications, depending on each specific case.

 

How will I feel the days after the operation?

Generally, after surgery, you will have a tube in your nose, a tube to urinate, IV´s, and, on occasions, a drainage line. As days go by, all these tubes will be gradually removed. Intake of liquids is usually started towards the second postoperative day, gradually resuming a normal diet. Hospital discharge is usually on the 7/8th postoperative day if there have been no complications.

 

After surgery, will I have to undergo any chemotherapy or radiotherapy?

Five to seven days after the operation, we will have the results of the biopsies of all the tissues that were removed during surgery and armed with those results, the oncologist will decide if any other treatment is required (radiotherapy or chemotherapy).

 

Will I be able to lead a normal life after the operation?

After the operation, you will have to be careful not to overexert yourself or perform heavy movements for about 4 to 6 weeks. You will be able to eat almost anything. You may notice a slight change in your evacuations, although this change will depend on the type of surgery performed.

In cases where the surgery was motivated due to rectal cancer, it is possible some sort of deposition alterations to occur, although this is generally temporary. More rarely, there can be alterations, most of the time, of a temporary nature, when urinating or with sexual function. The surgeon will explain this further, depending on the type of surgery performed.

 

Contra natura anum

What is a “bag” or stoma?

A stoma or “bag” or contra natura anum, is an opening from the intestine into the skin of the abdomen. It is also referred to as colostomy or ileostomy, depending on its location. The intestinal contents will flow directly and without control into a plastic bag, especially designed for that purpose. The patient can lead a completely normal life. The only thing required is to change the plastic bag that is adhered to the skin regularly (see animation).

If I need to have surgery due to cancer of the colon or rectum, will I have to carry such a “bag”?

Not necessarily so. A stoma or “bag” is only required when the tumour is at the final end of the rectum. In these situations, the stoma is generally definitive. On occasions, a stoma is created in tumours housing other locations, but most often, it is a temporary situation.

How this will affect my life?

If you need to carry a “bag” or definitive stoma, your life will only change minimally as you will be able to carry on doing the same routines as before, such as doing sports, exercising, bathing, travelling, etc. You would only need counselling from a specialised person in stoma care (stomatherapist).