ANTERIOR RESECTION YOUR OPERATION EXPLAINED

ANTERIOR RESECTION YOUR OPERATION EXPLAINED Information Leaflet Your Health. Our Priority.

of 10 Introduction This leaflet explains the procedure known as an Anterior Resection. It includes what is involved, including common complications associated with this surgery. It is not meant to replace the discussion between you and your Consultant or Colorectal Nurse Specialist but as a guide to be used in conjunction with what is discussed. This leaflet is appropriate for both benign (noncancerous) and malignant (cancerous) conditions. At this point you should be aware of the reasons why surgery is required. What is it? An Anterior Resection is basically to remove an area of the rectum and/or left side of the bowel that is affected by disease. The rectum is divided into three sections (upper, mid and lower). Your procedure may be referred to as a high or low anterior resection. Low specifically removes the lower two thirds of the rectum and high refers to removal of more of the large bowel (sigmoid colon/descending colon). The operation will remove the left hand side of the bowel and rectum and a length of normal bowel at either side of the disease. As indicated by the diagrams below the shaded area highlights the approximate area of bowel and rectum to be removed. Where possible the two ends of healthy bowel are then re-joined together (anastomosed) by stitching or stapling the ends together. The wound on the abdomen maybe closed with clips, stitches or skin glue. Shaded areas indicate approximate section of bowel to be removed Laparoscopic or Open Surgery There are two ways that surgery can be performed. Open (Laparotomy) where the surgeon makes a large incision in your abdomen (tummy) to remove the affected area of bowel and Laparoscopic (Keyhole), where a number of small incisions in your abdomen are made and specialist instruments guided by a camera are used to remove a section of your large bowel. Both techniques are believed to be as equally effective in removing the cause of your condition and risks of complications are the same. Recognised benefits of keyhole (Laparoscopic) surgery include: Faster recovery time and earlier discharge Reduced post operative pain Minimised scarring

of 10 Early return of bowel function The choice of surgical approach will be discussed and decided between you and your Consultant. The approach used often depends on your general health and medical conditions, fitness and BMI (Body Mass Index). It is important to note that if you are to undergo laparoscopic surgery sometimes operations may begin laparoscopically but then convert to an open procedure for technical reasons. Depending on the surgical approach, the wounds on the abdomen are closed differently. For open surgery the wound is often large and runs down the middle of the abdomen, this is generally closed with clips which are removed approximately 10 days after surgery. For laparoscopic surgery, keyhole sites and/or smaller wounds running down the middle of the abdomen are often closed using skin glue. In this instance the skin glue dries and falls off naturally over time. In either situation stitches maybe used, some are dissolvable and some require removal approximately 10 days following surgery. Your ward nursing staff will assess this and advise on the type of stitches which have been used. Will I have a stoma? (Colostomy, ileostomy, sometimes called a bag ). As with any surgery on the left hand side of the bowel there may be a need for stoma formation. The surgeon may decide that the bowel needs time to heal before it can be reattached or that too much of the bowel has been removed to make reattachment possible. In this case it is necessary for waste products to be removed from your body without the stools passing through your anus and this is achieved by using a stoma. Stoma formation involves the surgeon making a small hole in your tummy and a section of the bowel is brought to the abdominal surface (tummy) and stitched to your skin, the bowel waste comes out of the stoma and collects in a bag that covers it. In the case of an Anterior Resection you may have a stoma (specifically an ileostomy) formed, where a stoma is made on the right hand side of your abdomen formed from a loop of small bowel. In some instances this can be a colostomy, which is formed from the large bowel and may be positioned on the left hand side/upper abdomen. At the pre-operative assessment clinic you will be seen by the Stoma Nursing team where they will discuss this with you and also mark a suitable site on your tummy in case a stoma is needed. In most cases the stoma will be temporary and can be put back together at a later date, this involves a second operation when you and your bowel have healed and recovered from the effects of the initial surgery. The timing of this is variable, whether a stoma is likely to be permanent or temporary, or when a stoma will be reversed, can be discussed with you by your Surgeon, Colorectal and/or Stoma Nurse. Before your operation your Consultant or Colorectal Nurse will explain the procedure involved although details will vary according to individual cases. It is important to note that sometimes during the operation the disease or operation is more complicated than first anticipated, the type of surgery may then have to be changed to achieve the desired result. This may mean removing more bowel, or part of nearby organs such as the bladder. The consent form will address this option which you will need to sign to confirm that you agree to have surgery.

of 10 Benefits of surgery The condition affecting part of your rectum and/or large bowel will be removed. In most cases this will give you the best chance of a cure or a significant improvement in your bowel problems. Surgical complications Most will not experience any serious complications from their surgery; however risks do increase with age and for those who already have established medical conditions such as heart, chest, diabetes, obesity or who smoke. As with any surgery there are risks of complications which are unusual but can occur. To reassure, these are rapidly recognised and dealt with by nursing and surgical staff. Although risks are often very small it is important that you are aware of them so you have all the information you need prior to agreeing to the operation. Potential short term complications/risks specific to Anterior Resection surgery:- Stoma formation - the surgeon may decide the bowel needs to heal before it can be reattached or that too much of the bowel has been removed to make reattachment possible. This may also be necessary if complications have occurred post operatively and emergency surgery is required. Ileus - temporary stoppage in bowel movement. The bowel is often slow to start working therefore your bowel needs to be rested (restricted fluid intake orally and no food), you will be given intravenous fluids via a drip to replace fluids lost and instead of drinking you may need a nasogastric tube (tube placed via the nose into the stomach) inserted to prevent vomiting. This would remain in place until the bowel recovers and starts to work. Anastomotic leak (an-as-tom-ot-ic) - is a breakdown along the join in the bowel (anastomosis) which causes fluids or faeces to leak, potentially causing severe infection. For those who have had an ileostomy formed, treatment with antibiotics through the vein is usually successful. For those who have not, resting the bowel and antibiotic use is required (restrict oral fluid intake and no diet); in some cases this can be serious or if there is no improvement in your condition further surgery to form a stoma may be necessary. Damage to the bowel can occur due to surgical instruments and close proximity of other organs. Repair will be undertaken at the time of surgery, if necessary. Loss of capacity - normally the rectum stretches to hold stool until you can get to a toilet; an anterior resection involves the removal of part of your rectum. The remaining rectum/bowel has then lost the capacity for storing stool as it cannot stretch as much to hold the stool. Your bowel will require some time to compensate for this and the ability to compensate varies from person to person. Additionally, rectal/pelvic surgery, radiation treatment and inflammatory bowel disease can cause scarring that makes the walls of the rectum stiff and less elastic. This may be a short and long term complication. Stoma retraction/perfusion - retraction describes a stoma that has sunk below skin level. Perfusion refers to the blood supply affecting the stoma. After surgery nursing/surgical staff are required to observe the colour (perfusion) of the bowel, dark tissue often indicates poor

of 10 blood supply. Dependent on the severity of the affected blood supply, in some instances surgery is necessary to correct this. This may be a short and long term complication. Potential long term complications/risks specific to Anterior Resection surgery:- Nerve damage - operations that are close to muscle in the back passage (anal sphincter) may cause bruising or damage to nerves in this area. In the early days following surgery this may lead to loss of sensation which in turn can trigger slight incontinence (soiling) of wind and/or faeces. This situation may be improved over time as the body heals. Sexual dysfunction - the operation occurs close to the nerves affecting sexual function, in which they may become disturbed. This is high risk in males who may experience problems including erections (partial or none), ejaculation and dry ejaculation. For males who have had radiotherapy prior to surgery there is approximately 60-70% chance that you will experience some form of sexual dysfunction. Women may find discomfort or dryness during sex. Specifically for those that have a rectal cancer, some may develop a narrowing of the vaginal canal causing this. In both males and females fertility may be affected, where cancer treatments have been given. If this is relevant to your situation, further information is available. Bladder/ureter damage - similarly the operation is close to the urinary system affecting bladder and ureter (muscular tubes transporting urine from kidneys to the bladder) function. Some may have problems passing urine following surgery; again often this is temporary and will improve with time. Anastomotic stricture (an-as-to-mot-ic) - a narrowing in the diameter of the bowel which can lead to a blockage. This generally is not an immediate complication following surgery and can occur in the months following. Symptoms such as a feeling of permanently wanting to open your bowels although only passing a small amount each time, discomfort when having your bowels opened or a bloated feeling in your tummy caused by a hold up of stool, in some cases it may be necessary for you to have a minor procedure to stretch the narrowed area. Bowel obstruction refers to blockage of bowel movement. Generally resting the bowel (restricted oral fluid and no diet intake) will resolve this issue. If no improvement, a further operation maybe required. This may occur at an early or late stage in your recovery. In the majority of cases a bowel obstruction is caused by adhesions (scar tissue), which may restrict bowel activity or narrow the width of the colon. There is a leaflet available explaining Adhesions. Please ask your Colorectal nurse if you would like to read one. General complications/risks following any major bowel surgical procedure, short term:- Chest infection - anaesthetics and surgery can interfere with the normal way in which the lungs clear secretions and prevent infections. Pain from surgical wounds and reduced mobility can make breathing and coughing more difficult, increasing the risk of infection. We encourage cooperation with the physiotherapists, deep breathing exercises and if you smoke to stop.

of 10 Retention - the inability to urinate (pass urine). This is often temporary and is relieved with a urethral catheter. Following your surgery you will have a catheter, your surgical team will assess the need for this to stay and when it can be removed. In some cases due to the surgery and preoperative treatments you may have received, you may be unable to pass urine following the catheter removal. In this case the catheter would be re inserted and you may be discharged home with the catheter insitu, you would return a few weeks later to have this removed. UTI (Urinary tract infection) - bacterial infection affecting any part of the urinary tract. Haemorrhage - this can occur from the wound or operation site (internal bleeding). This may be due to pre-operative anticoagulants or unrecognised bleeding. Blood transfusion may be required and very rarely further surgery to control bleeding. Wound infection - all clinical practice in both surgery and nursing are geared towards infection prevention and control. However, there is an increased risk of wound infections with any bowel surgery due to the nature of the surgery itself. Wound infections tend to present with localised pain, redness and slight discharge. Wound dehiscence - generally this refers to the failure of a wound to heal completely, becoming apparent between 7 and 10 days. It is separated into two groups, full thickness and superficial. Full thickness refers to the breakdown of the whole wound, this is a serious complication requiring surgical intervention to re-suture the abdomen. Superficial refers to a partial breakdown of the wound and is managed with dressings only. This may take several weeks/months for full healing to occur Risk to life - major surgery can carry risk to life and this will be discussed with you. For an Anterior Resection this is approximately 5%. DVT (Deep vein thrombosis) - major surgery carries risk of clot formation in the leg. Many cases are silent but may present with swelling of the leg, tenderness of the calf muscle and/or increased warmth of the calf. A DVT can occur following surgery or some weeks later. Preventative measures: heparin given as a daily injection, compression stockings and movement as much as possible. PE (Pulmonary embolism) - is a blood clot stuck within the blood vessels of the lungs, usually having travelled from the deep veins of the legs. Symptoms include shortness of breath, chest pain, confusion, expectoration of blood (haemoptysis). Preventative measures are the same as above. PE can occur following surgery or some weeks later. General complications/risks following any major bowel surgical procedure, long term:- Parastomal hernia - is the bulging of bowel underneath the stoma incision. A hernia can be any size or shape and distorts the position of your stoma, making pouch appliance and management of the stoma difficult. Changes in appliance or a support belt can often improve circumstances; however dependent on your individual situation, health and surgical risks, surgery to repair the hernia may be an option.

of 10 Incisional hernia - presents as a bulge in the abdominal wall close to the wound site. This occurs in 10-15% of abdominal wounds and usually appears within the first year following surgery but can be later. Usually they provide little trouble but can sometimes cause pain/discomfort or increase in size over time. Adhesions (scar tissue) - scar tissue that forms between tissues and organs after any operation. Typically scar tissue begins to form within the first few days of surgery, but they may not produce symptoms for months or years. In some cases these can cause complications such as pain, affect the activity of the bowel leading to hospital admission or further surgery. Aches and pains - you may experience numbness around the wound for 2-3 months and general abdominal aches and pains for approximately 6 months following surgery as you and your body recovers from surgery. If you are concerned about any of these risks, have any questions or would like further information and advice please speak to your Consultant, Anaesthetist or Colorectal Nurse Specialist. Your bowel function post operatively Following any bowel operation the function of the bowel can change. It is often difficult for healthcare professionals and yourselves to predict what your bowel function will be like as everyone is different. The rectum is the storage place for faeces until you need to go the toilet. As previously highlighted an Anterior Resection involves the removal of part of your rectum, therefore removing the capacity for storing stools. Following this procedure you may experience: Constipation or diarrhoea. Increased frequency - needing to go more often. Increased urgency - when you need to go, you ve got to go now. Stool fragmentation - when you need to pass a lot of stool but only pass small volumes. Faecal incontinence (soiling) - leakage of faeces or mucous, possibly throughout the day and during sleep. Persistent wind or bloating - losing the ability to distinguish between wind/stools. Sore skin around the back passage (anus) - usually due to soiling. If you have a stoma formed during this procedure, you may find that you still have a feeling of needing to go to the toilet and may experience rectal discharge. Following a period of recovery your bowel function returns but is unlikely to be the same as it was before your surgery. During the first few weeks your bowel function maybe erratic and it can take a period of a few weeks or months to settle into a pattern. It is recognised that each situation is different, with very different outcomes and experiences. We therefore encourage you to be honest, speak openly and seek advice from your Consultant, Colorectal Nursing Team and/or Stoma Care Nursing Team. There are numerous remedies to trial.

of 10 For patients who undergo a Colonic J Pouch formation Increasingly patients who undergo Low Anterior Resection Surgery are having colonic J pouch construction. In some instances individuals who have had a Low Anterior Resection and the two ends of the bowel re-joined (anastomosed) have resulted in poor bowel function following surgery. Although continuity of the bowel is returned by the join, the normal capacity of the rectum to store faecal matter is removed and not adequately restored. The Colonic J Pouch is an internal reservoir (pouch) which is formed from the end of the colon in order to replace the function of the rectum that has been removed. In the event of Colonic J Pouch construction you are likely to need a temporary stoma to allow this pouch to heal effectively, following reversal of this stoma if you have a colonic J pouch you will hopefully have more control and less frequent bowel movements after surgery. Your Consultant will advise on your individual case. If there are any questions which arise from this leaflet please do not hesitate to contact us. Further information is available regarding; ERAS - Enhanced Recovery after Surgery Programme (pre- and post- operative care expectations), Stoma Reversal and Rectal Discharge. Contact us Consultant Secretaries Mr M Saeed Secretary: 0161 419 4267 Mr E Clark Secretary: 0161 419 2028 Mr S Rai Secretary: 0161 419 4268 Mr F Reid Secretary: 0161 419 4275 Mr M Marsden Secretary: 0161 419 4265 Colorectal Cancer Nurse Specialist Team Doreen Dooley, Jill Taylor, Rebecca Costello 24 hour answer phone: 0161 419 4088 (please note we will try to return your call on the same day, however we do not work evenings, weekends or bank holidays). Alternatively contact them on their mobile through the switchboard on : 0161 483 1010

of 10 Stoma Care Nurse Specialist Team Jean Sellars, Caroline Dowson, Janet Land 24 hour answer phone: 0161 419 5052 Pager through switch: 0161 419 5059 Contact via switchboard: 0161 483 1010

of 10 If you would like this leaflet in a different format, for example, in large print, or on audiotape, or for people with learning disabilities, please contact: Patient and Customer Services, Poplar Suite, Stepping Hill Hospital. Tel: 0161 419 5678 Information Leaflet. Email: PCS@stockport.nhs.uk. Our smoke free policy Smoking is not allowed anywhere on our sites. Please read our leaflet 'Policy on Smoke Free NHS Premises' to find out more. Leaflet number SUR83 Publication date November 2014 Review date November 2018 Department Surgery and Critical Care Location Stepping Hill Hospital