Information for patients and families

Understanding my surgery for rectal cancer

Read this book to learn about:

• Types of surgery for rectal cancer

• What to expect

• Possible complications

Table of Contents

About this booklet ......................................................................................................1

What kind of surgery will I have for my rectal cancer? ........................................ 1

What is normal? ......................................................................................................... 3

What can happen to my bowel movements after surgery? ................................ 4

Types of surgeries for rectal cancer:

A. Local Excision ..............................................................................................6

B. Anterior Resection ..................................................................................... 9

C. Low/Ultralow Anterior Resection (LAR) ..............................................12

D. Abdominoperineal resection .................................................................17

1

Introduction

You have been diagnosed with rectal cancer. This booklet will help you to learn about the different surgical options. The surgeon will review the procedure that is best for you. In this booklet, you will be able to read about:

• The different surgeries

• How long it takes to do the surgery

• Whether you need to stay in hospital after the surgery

• What to expect after the surgery

• If there are any complications with the surgery

What kind of surgery will I have for my rectal cancer?

Your surgeon will talk with you about the best surgery to remove your rectal cancer. The type of surgery you will have depends on:

• Where the cancer is in your rectum

• The size of the cancer

• If the cancer has spread to other tissues

Stomach

Colon(large bowel)

RectumAnus

Terminal Ileum

Small bowel

Duodenum

2

This is where the cancer is in my rectum:

The types of surgery for rectal cancer are:

A. Local Excision

B. Anterior Resection

• Low (LAR) or ultra-low (ULAR) anterior resection

• With or without colonic J-Pouch

• With or without temporary loop ileostomy

C. Abdominal perineal resection with permanent colostomy

My surgeon has told me that my surgery is:

Write name of surgery

Upper

Middle

Lower

12-15cm

3

Stomach

Colon(large bowel)Small

bowel

Duodenum

What is normal?

The rectum is at the end of your large bowel (colon). Your rectum is about 12-15 centimetres long. It can relax and stretch to store your stool, or can work with other muscles in the pelvis to allow the stool to pass out through your anus (a bowel movement). There are special muscles (sphincters) in the anus that let you control when the stool is passed. There is a part of the anus that can tell you what is in your rectum: solid stool, liquid stool, or gas.

Rectum

Anus

RectumAnus

Terminal Ileum

4

What can happen to my bowel movements after surgery?

The type of surgery you have may mean one of the following:

• Short term changes to your bowel movements (in the first days or weeks after surgery)

• Long term changes to your bowel movements (weeks or months after your surgery)

• Your rectum is replaced with another piece of the large bowel to make a new rectum. This “new” rectum (called a colonic J-Pouch) does not work the same as your “old” rectum.

• Your rectum and anus is removed completely and your bowel movements are through a colostomy

Your surgeon will tell you what change to expect with your surgery.

The change I can expect with my surgery is:

Write type of change to expect

This booklet will explain the different surgeries in more detail.

5

Notes

6

A. Local Excision

• Local = limited to an area in the rectum

• Excision = take out

What is the local excision procedure?

This procedure is chosen when there is a pre-cancerous tumour or when the cancer is small. The cancer is taken out with special instruments that are passed through the anus and into the rectum. The tumor will be cut out with a rim of normal rectal wall. There is no incision (cut) through your abdomen or skin. You will need to have an anesthetic (be asleep) for the procedure.

Rectum

Anus

Stomach

Colon(large bowel)

RectumAnus

Terminal Ileum

Small bowel

Duodenum

7

There are 2 options for local removal of the tumor:

• Option I: Transanal excision (TAE)

• Option II: Transanal Endoscopic Microsurgery (TEMS)

Your surgeon will discuss with you which option is best for you.

How long does it take to do the local excision of the tumor?

The transanal (TAE) excision usually takes about 1 hour.

The transanal endoscopic microsurgery (TEMS) usually takes 1-2 hours.

Do I need to stay in the hospital?

For the TAE, this is usually done as day surgery and you won’t need to stay overnight in the hospital.

For the TEMS, you may need to stay in the hospital overnight.

What can I expect after the procedure?

You may be given pain medications and a stool softener to go home with. You may notice that you have difficulty holding onto gas or stool from your rectum; this should be for a short time only. You may see some old blood with your first bowel movements after the procedure.

8

What are the possible complications with the procedure?

Some possible complications from a local excision may be:

• Bleeding from where the cancer was taken out

• Ongoing difficulty holding onto gas or stool

• Making a hole in the rectum while taking the cancer out

• A narrowing of the rectum with scar tissue

In rare cases, patients may need a colostomy when complications occur.

Your surgeon will talk to you about these complications.

9

Stomach

Colon(large bowel)

RectumAnus

Terminal Ileum

Small bowel

Duodenum

Rectum

Anus

B. Anterior Resection

• Anterior = through the front of your abdomen

• Resection= take out

What is the anterior resection surgery?

This surgery is chosen when the cancer is in the upper part of the rectum, close to the part of the large bowel called the sigmoid colon. This part of the rectum and sigmoid colon is will be taken out during surgery. The 2 ends of the bowel are put back together. The surgery can be done through an open incision (cut) in your abdomen or through keyhole (laparoscopic) surgery. There is a small possibility that you will need a temporary ileostomy. An Enterostomal Therapy Nurse will meet with you to explain the ileostomy.

Sigmoid colon

Sigmoid colon

10

How long does the anterior resection surgery take?

This surgery will take 3-4 hours.

Do I need to stay in the hospital?

You will need to stay in hospital for 4 days. Closer to the time of your surgery, you will be given a booklet that will explain what to expect with your surgery and hospital stay. It is called Enhanced Recovery After Surgery (ERAS). The ERAS program will encourage you to eat and walk early after surgery which will help you to recover faster.

What can I expect after surgery?

You may have some short term changes to your bowel movements. You may have difficulty controlling the bowel movements, or notice a little bit of seepage onto your underwear. You may notice a little bit of old blood with your first bowel movements. It may take a few weeks for your bowel movements to get back to normal, or you may notice some changes to your usual bowel habits.

11

What are the possible complications with the surgery?

There can be complications with the surgery. These include:

• Bleeding

• Infection

• A leak from where the 2 ends of the bowel were joined

• Damage to other organs during surgery

• Difficulty passing urine (peeing)

• A blood clot in the legs or in the lungs

You may need to have an ileostomy to help manage complications.

Your surgeon will talk to you about these complications.

12

Stomach

Colon(large bowel)

RectumAnus

Terminal Ileum

Small bowel

Duodenum

C. Low (LAR) or Ultralow (ULAR) Anterior Resection

• Low/ultralow = down in the rectum

• Anterior = through the front of your abdomen

• Resection= take out

What is the low or ultra-low anterior resection surgery?

This surgery is chosen when the cancer is in the middle to lower parts of the rectum. This part of the rectum will be taken out during surgery. This means a part or all of your rectum will be removed. The surgery can be done through an open incision (cut) in your abdomen or through keyhole (laparoscopic) surgery. You will likely need a temporary ileostomy. An Enterostomal Therapy Nurse will meet with you to explain the ileostomy.

Rectum

Anus

13

There are 2 options for joining your rectum back together:

• Option I Primary Anastomosis (Join): The 2 remaining ends of the rectum are joined together.

• Option II Colonic J-Pouch: A “new” rectum is made from the sigmoid colon.

Your surgeon will discuss with you which option is best for you.

How long does the low/ultralow anterior resection surgery take?

This surgery will take 3-4 hours.

Do I need to stay in the hospital?

You will need to stay in hospital for 4 days. Closer to the time of your surgery, you will be given a booklet that will explain what to expect with your surgery and hospital stay. It is called Enhanced Recovery After Surgery (ERAS). The ERAS program will encourage you to eat and walk early after surgery which will help you to recover faster from the surgery.

14

You will have a temporary loop ileostomy. Your stool will come through the ileostomy and collect in a pouch attached to your tummy. An Enterostomal Therapy Nurse will give you information and will teach you how to look after the ileostomy. The ileostomy will be closed in 3-6 months. You may still pass mucous through your anus while you have the ileostomy. When the ileostomy is closed, you will have bowel movements (BM) through the anus. Once you start having regular BMs, you may have some changes:

• Many BMs, sometimes clustered together

• Smaller BMs

• Not a lot of warning to have a BM

• Difficulty telling the difference between gas and stool

• Feeling the need to bear down to have a BM

• Feeling that you have not passed all of the BM

These changes should improve over a period of 2 years. You may need to make some changes to your diet to help improve your BMs.

What can I expect after surgery?

Option I: Primary anastomosis

(Primary = first anastomosis = joining the bowel)

15

Option II: Colonic J-Pouch

(Colonic = made from colon J-Pouch: new rectum made in the shape of a “J’ from the colon)

You will have a temporary loop ileostomy. Your stool will come through the ileostomy and collect in a pouch attached to your tummy. An Enterostomal Therapy Nurse will give you information and will teach you how to look after the ileostomy. The ileostomy will be closed in 3-6 months. You may still pass mucous through your anus while you have the ileostomy. When the ileostomy is closed, you will have bowel movements (BM) through the J-Pouch and anus. Once you start having regular BMs, you may have some short term changes:

• Not a lot of warning to have a BM

• Difficulty telling the difference between gas and stool

• Feeling the need to bear down to have a bowel movement

• Feeling that you have not passed all of the BM

16

What are the possible complications with the surgery?

There can be complications with the surgery. These include:

• Bleeding

• Infection

• A leak from where the 2 ends of the bowel were joined

• Damage to other organs during surgery

• Difficulty passing urine (peeing)

• Changes in sexual function

• A blood clot in the legs or in the lungs.

Your surgeon will go over these complications with you.

17

Stomach

Colon(large bowel)

RectumAnus

Terminal Ileum

Small bowel

Duodenum

D. Abdominal Perineal Resection

• Abdominal = through the abdomen or tummy

• Perineal = through the buttocks, where the anus is

• Resection = take out

What is an abdominal perineal resection?

This surgery is chosen when the cancer is at the lower part of the rectum, very close to or involving the muscles that control your bowel movements (anal sphincters). The rectum and anal sphincters are removed in the surgery. The surgery is done through 2 incisions or cuts: one through your abdomen and one around the anus. You will have a permanent colostomy. An Enterostomal Therapy Nurse will meet with you to explain the colostomy.

Rectum

Anus

18

How long does the abdominal perineal resection surgery take?

This surgery will take 4 hours.

Do I need to stay in the hospital?

You will need to stay in hospital for 4 days. Closer to the time of your surgery, you will be given a booklet that will explain what to expect with your surgery and hospital stay. It is called Enhanced Recovery After Surgery (ERAS). The ERAS program will encourage you to eat and walk early after surgery which will help you to recover faster from the surgery.

What can I expect after surgery?

Your bowel movements will be through a permanent colostomy. You will need to wear a pouch on your tummy to protect your skin and to contain the stool and gas. You will meet with a with an Enterostomal Therapy Nurse who will help you to learn about the colostomy and the pouch.

What are the possible complications with the surgery?

There can be complications with the surgery. These include:

• Bleeding

• Infection

• Damage to other organs during surgery

• Difficulty passing urine (peeing)

• A blood clot in the legs or in the lungs

• Delayed healing of the wound between your buttocks

Your surgeon will go over these complications with you.

19

Notes

20

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This information is not intended as a substitute for professional medical care. Ask your healthcare provider about this information if you have questions.