Surgery for rectal cancer

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1 This information is an extract from the booklet Understanding rectal cancer. You may find the full booklet helpful. We can send you a free copy see page 12. Contents Enhanced recovery programme (ERP) Before your operation Types of rectal cancer surgery Surgery for advanced rectal cancer After your operation Diet after bowel surgery If you need a colostomoy (stoma) Sex life after bowel surgery Surgery is the most common treatment for rectal cancer and should be carried out by a surgeon who specialises in bowel surgery. You may be given radiotherapy (treats cancer by using high-energy rays to destroy the cancer cells) or chemoradiotherapy (radiotherapy in combination with chemotherapy) before surgery to shrink the cancer and make it easier to remove. The type of surgery you have will depend on the stage of the cancer and where it is in the bowel. Your doctor will discuss this with you. Enhanced recovery programme (ERP) Some hospitals follow an enhanced recovery programme, which can help reduce complications following surgery and speed up your recovery. The programme involves careful planning before your operation. This makes sure you re properly prepared and any arrangements that are needed for you to go home are already in place. Questions about cancer? Ask Macmillan Page 1 of 12

2 You ll be encouraged to take high-protein and high-calorie supplements before and after your surgery. Also you ll be encouraged to start moving around as soon as possible, sometimes on the day of the operation. The surgeon will try not to use any tubes or drains unless absolutely needed. Any catheters and fluids through a vein will be removed soon after surgery. You ll also be allowed to eat and drink soon after surgery. After you ve gone home you ll be regularly reviewed to make sure that you re recovering well. You can ask your doctor whether you will be suitable for this type of surgery. Not all hospitals use the ERP for surgery and it s not suitable for everyone. Before your operation Before your surgery, the doctor and specialist nurses will explain the operation to you. They ll tell you what to expect immediately after the surgery and in the few days after it. This is a good opportunity to ask any questions about the operation. You may be admitted to the ward the day before your operation, so that the doctors and nurses can do any further tests. Some hospitals ensure that all of these tests are done beforehand and admit patients on the day of their surgery. To make sure that your bowel is completely empty, you may be asked to follow a strict diet and take a medicine (laxative) to help empty your bowels the day before surgery. Your nurse or the doctor will explain this to you. You ll be given antibiotics as an injection into a vein (intravenously) just before surgery to prevent infections. Types of rectal cancer surgery Very early-stage rectal cancers that are small and low down in the rectum can sometimes be removed using an operation known as a local resection or a transanal resection. This is when instruments are passed through the anus into the rectum to remove the cancer. The APPEAR technique (this stands for Anterior Perineal PlanE for Ultra-low Anterior Resection) is another technique used to remove rectal tumours that are very low down. This is a specialised technique that reduces the Page 2 of 12 Questions about cancer? Ask Macmillan

3 risk of removing or damaging the anal muscle. There s also a lower risk of needing a permanent stoma afterwards. Your doctor or specialist nurse can give you more information about this technique. When the cancer is higher up in the rectum, an endoscope, similar to the one used to take a biopsy, can be used by a specially trained surgeon to remove the cancer from the wall of the rectum. This operation is sometimes called transanal endoscopic microsurgery (TEM). A pathologist will examine the cells of the cancer. If it s found to be high-grade (the grade of a cancer gives an idea of how quickly it may develop) your surgeon may recommend that you have a second operation. This is done to remove more of the rectum to make sure that no cancer cells have been left behind. Total mesorectal excision (TME) is an operation commonly used to remove a rectal cancer. It involves careful removal of the whole of the rectum as well as the fatty tissue that surrounds it, which contains the lymph nodes. This operation takes from 3 5 hours. Research has shown that a TME is better than other types of surgery at reducing the risk of the cancer coming back. Depending upon the position of the cancer in the rectum, its size, and how far it is from the anus, your surgeon will do the TME operation by using either a low anterior resection, a colo-anal J pouch surgery or an abdomino-perineal resection (see pages 4 5). A low anterior resection is usually used for cancers in the upper and middle parts of the rectum (close to the colon). During the surgery, the piece of bowel that contains the cancer is removed and the two ends are then joined together. The join is known as an anastomosis. Questions about cancer? Ask Macmillan Page 3 of 12

4 Area removed Anterior resection The lymph nodes near the bowel are also removed because this is usually the first place the cancer spreads to. After this operation, you ll have a wound that goes in a straight line from just below your breast bone (sternum) to just above the level of your hipbone. If for some reason the bowel can t be rejoined, the upper end can be brought out onto the skin of the abdominal wall. This is known as a colostomy and the opening of the bowel is known as a stoma. A bag is worn over the stoma to collect the stool (bowel motions). Sometimes a stoma is only temporary and another operation to rejoin the bowel can be done a few months later. The operation to rejoin the bowel is known as stoma reversal. If it isn t possible to reverse the colostomy, the stoma is permanent. Having radiotherapy or chemoradiation before surgery can help reduce the chance of needing a permanent colostomy. Page 4 of 12 Questions about cancer? Ask Macmillan

5 In colo-anal J pouch surgery, the rectum is removed and the colon is attached to the anus. Sometimes the surgeon can make a new rectum from the colon. You may have a temporary stoma during this time to allow the bowel to heal. An abdomino-perineal resection is usually used for cancers in the lower end of the rectum. This operation will result in a permanent colostomy because the whole rectum and anus are removed. After the surgery there will be two wounds: a wound that goes in a straight line from just below your breast bone (sternum) to just above the level of your hipbone a second wound on your bottom, where the anus has been closed. Laparoscopic (keyhole) surgery This operation uses four or five small cuts in the abdomen rather than one bigger incision. A laparoscope (a thin tube containing a light and camera) is passed into the abdomen through one of the cuts and the cancer is removed. Recovery from this operation is usually quicker. This type of surgery is used by some hospitals. Your surgeon will discuss with you if this is appropriate for you. Robotic surgery Robotic surgery is currently still being researched. It involves the use of a robot controlled by the surgeon to perform more difficult procedures. Surgery for advanced rectal cancer Sometimes the cancer is too large to be removed and presses on the rectum, causing it to narrow. If this happens, it may be possible to insert a thin metal tube (a stent) into the rectum to keep it open. The stent is inserted using a colonoscope. You ll be given a mild sedative to help you relax and you may have a short stay in hospital. If the rectal tumour has grown into other organs near the rectum, a bigger operation may be needed to try to remove the cancer. This is called a pelvic clearance, and is only done occasionally. Your doctor will explain more about this procedure if it is appropriate for you. Questions about cancer? Ask Macmillan Page 5 of 12

6 The most common place for rectal cancer to spread is to the liver. Over the last few years, better surgical techniques mean that it s now more possible for surgeons to remove a rectal cancer that has spread to the liver. This can sometimes lead to a cure. Chemotherapy may be given before or after the operation. This treatment is not possible for everyone whose rectal cancer spreads to the liver. Your doctor or specialist nurse can discuss this with you further. Surgery may sometimes be used to remove the cancer when it has spread to the lungs. Sometimes chemotherapy may be given before or after the surgery. We have a booklet about secondary cancer in the liver and a fact sheet about secondary cancer in the lungs. After your operation How quickly you recover from your operation will depend on your age and health, and the type of surgery you ve had. Your doctor and specialist nurse can give you an idea of what to expect. Getting moving After your operation, you ll be encouraged to start moving around as soon as possible. This is an essential part of your recovery. Even if you have to stay in bed, it s important to do regular leg movements and deep-breathing exercises. A physiotherapist or nurse will explain the exercises to you. As you won t be moving around as much as usual, you may be at risk of blood clots. To prevent this, you ll be asked to wear special stockings, and you may also be given injections of a drug (heparin) to prevent blood clots. These are given under the skin (subcutaneously). Drips and diet When you go back to the ward, you will have a drip (infusion) that gives you fluids through a thin tube (cannula) inserted into a vein in your hand or arm. This will be taken out once you re able to eat and drink normally again. Page 6 of 12 Questions about cancer? Ask Macmillan

7 You may also have a thin tube that passes down your nose into your stomach, which is known as a nasogastric (NG) tube. This allows any fluids to be removed from your stomach so that you don t feel sick. It s normally taken out within a few days. You will probably be ready to start taking sips of water on the evening or day after your operation. This will be increased gradually, and you will start a light diet as soon as possible. Drains Often, a small tube (catheter) is put into your bladder to drain urine into a collecting bag. This is usually taken out after a couple of days. You may also have a drainage tube in your wound, to drain any extra fluid and make sure that the wound heals properly. A drain isn t always needed. Pain After your operation, you ll probably have some pain or discomfort for a few days. There are different types of painkillers that can be given to you either at regular intervals or when you need them. You may be given painkillers into a vein in your arm through a pump. The pump can be set to give you a controlled amount of painkiller, or you may be able to control this yourself by pressing a button. This is called patient-controlled analgesia (PCA). You may be given painkillers into the space around your spinal cord through a very fine tube placed in your back during surgery (epidural). The tubing connects to a pump, which gives you a continuous dose of painkillers. Always let your doctor or nurse know if you have any pain or discomfort. The painkillers or their doses can be changed. Some people may continue to have some pain after they go home. Let your doctor or nurse know if you think you might need painkillers to take home with you. Questions about cancer? Ask Macmillan Page 7 of 12

8 Going home Depending on the type of operation you ve had, you ll probably be ready to go home 3 10 days after surgery. If you think that you might have problems when you go home (for example, if you live alone or have several flights of stairs to climb), let your nurse or the social worker know when you re admitted to the ward. They can then arrange help before you leave hospital. You ll be given an appointment to attend an outpatient clinic for your post-operative check-up. At the appointment your doctor will be able to discuss with you whether you need to have any further treatment, such as chemotherapy. Some people take longer than others to recover from their operation. If you have any problems, you may find it helpful to talk to someone who is not directly involved with your illness. Our cancer support specialists on can talk to you, and tell you how to contact a counsellor or local cancer support group. Diet after bowel surgery After any bowel operation, you may notice that certain foods upset the normal working of your bowel (or your stoma, if you have one). High-fibre foods, such as fruit and vegetables, may make your stools loose and make you pass them more often than normal. Depending on the type of surgery you ve had, you may have diarrhoea. Tell your doctor or nurse if this happens, as they can give you medicine to help. It s important to drink plenty of fluids if you have diarrhoea. This is often only temporary, and after a while you may find that the same foods don t have any effect. There are no set rules about the types of food to avoid. Some foods that disagree with one person may be fine for another. You may also find that your bowel produces more wind than before, and this can sometimes build up in the abdomen and cause pain. Drinking peppermint water or taking charcoal tablets can help reduce this. Your doctor can prescribe these for you, or you can get them from your chemist. Page 8 of 12 Questions about cancer? Ask Macmillan

9 It can sometimes take months for your bowel movements to get back to normal after surgery, and you ll probably need to find out which foods are right for you through trial and error. Some people may find that their bowel is always more active than before their surgery, and that they have to eat carefully to control their bowel movements. If you continue to have problems, it s important to talk to a dietitian at the hospital, as they can give you specialist advice for your individual situation. You may find our booklet Eating problems and cancer helpful. If you need a colostomy (stoma) Some people with cancer of the rectum will need to have a colostomy. This can be daunting at first. Learning to look after a stoma takes time and patience, and no one expects you to be able to cope straight away. Like anything new, it will get easier with time and practice. In most hospitals there are specially-trained nurses (stoma care nurses or colorectal nurses) who you ll usually meet before your operation. They will show you how to look after your stoma and help you cope with any problems. You may also find it helpful to talk to someone who has a stoma. Your nurse or doctor can often arrange for a volunteer to visit you and talk to you about the more practical and personal aspects of living with a stoma. This advice can be invaluable, particularly in the first few months after your operation. You can also contact the Colostomy Association (visit colostomyassociation.org.uk). The website Healthtalkonline has information about colostomies (visit healthtalkonline.org). It also has video and audio clips of people who have stomas talking about their experiences. Before your operation, the nurse or doctor will carefully plan the position of your stoma so that your bag stays in place, whether you are sitting, standing or moving around. Questions about cancer? Ask Macmillan Page 9 of 12

10 For the first few days after your operation, the nurse will show you how to look after your colostomy or ileostomy and make sure that the bag is emptied and changed as often as necessary. At first your stoma will be slightly swollen and it can take several weeks before it settles down to its normal size. As soon as you re feeling well enough, the nurse will show you how to clean your stoma and change the bags. There are several different types of bag or appliance available, and the nurse will help you choose a suitable one. Looking after a stoma When the nurse is showing you how to look after your stoma, it may help for a partner or close relative to be with you, in case you have any difficulties when you get home. Before you leave hospital, your nurse will make sure that you have a good supply of stoma bags. Make sure that you have plenty of bags and cleaning materials to hand before you start to change or empty your bag. It s a good idea to keep everything you need in one place, so that you don t have to search for things at the last minute. Make sure you allow yourself plenty of time and privacy, so that you can work at your own pace without any interruptions. Some people with a colostomy avoid wearing a bag by flushing-out (or irrigating) their colostomy about once a day, although this method doesn t suit everyone. Your stoma nurse will be able to discuss this with you in more detail. Stoma supplies There are different ways of getting stoma supplies when you re at home. You can get all your supplies from your chemist. Sometimes it s better to get them direct from a specialised supply company. These may also offer cut-to-fit and home delivery services. The Colostomy Association has details of companies. The supplies are free, but you ll need a prescription from your GP. If you re aged between 16 and 60, make sure that your doctor signs the form saying that you re entitled to free prescriptions. Page 10 of 12 Questions about cancer? Ask Macmillan

11 Home support Once you re at home, you can phone the stoma nurse if you have any problems. Your GP may also arrange for a district nurse to visit you for a few days when you first leave hospital. They can make sure that you are coping at home, and sort out any problems you may have with your stoma. Having a colostomy or ileostomy is a big change in your life. Many people find that they are embarrassed by the stoma, and that it affects the way they feel about their bodies. Embarrassment about a stoma can also affect relationships, and some people are uncomfortable about their partner seeing it. These feelings are a natural part of coming to terms with the changes that a stoma causes, and usually decrease over time. You can contact our cancer support specialists on if you want to talk about any concerns you have. Sex life after bowel surgery When you ve recovered from the operation, there s usually no medical reason why you shouldn t have a normal sex life again. However, you may find that you feel self-conscious about the change in your body s appearance, especially if you now have a colostomy. This may stop you from wanting to have sex. Talking about your feelings may help lessen your anxieties. Try not to feel embarrassed when you talk to your nurse or doctor about what is troubling you. They can refer you for specialist counselling if you think that would be helpful. Sometimes the operation can cause damage to the nerves that go to the sexual organs. If this occurs, a man may not be able to have or maintain an erection, and may have problems with orgasm and ejaculation. Women may also find that their sexual function or response is affected. This may improve over time, but sometimes it s permanent. Questions about cancer? Ask Macmillan Page 11 of 12

12 There are treatments available, such as sildenafil (Viagra ), that can help men get erections. It s important to discuss this with your doctor as soon as you notice a problem, as treatment can often be more effective if started sooner. If you have any problems, your doctor or specialist nurse will be able to discuss them with you in more detail. We have a booklet called Sexuality and cancer, which you may find helpful. More information and support Cancer is the toughest fight most of us will ever face. But you don t have to go through it alone. The Macmillan team is with you every step of the way, from the nurses and therapists helping you through treatment to the campaigners improving cancer care. We are Macmillan Cancer Support. To order a copy of Understanding rectal cancer or one of the other booklets or fact sheets mentioned in this information, visit be.macmillan.org.uk or call We make every effort to ensure that the information we provide is accurate but it should not be relied upon to reflect the current state of medical research, which is constantly changing. If you are concerned about your health, you should consult your doctor. Macmillan cannot accept liability for any loss or damage resulting from any inaccuracy in this information or third party information such as information on websites to which we link. Macmillan Cancer Support Registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). Registered office 89 Albert Embankment, London, SE1 7UQ REVISED IN JULY 2012 Planned review in 2014 Page 12 of 12 Questions about cancer? Ask Macmillan