Colorectal Cancer: Proctectomy

Who might have a proctectomy?

A proctectomy can be used at all stages of rectal cancer. How much of your rectum needs to be removed depends on the stage (severity) and location of the cancer. Not everyone with rectal cancer will need a proctectomy. Your healthcare team will work with you to find the treatment that is best for you.

Proctectomy can also treat ulcerative colitis and Crohn's disease.

How to prep for the proctectomy

Before scheduling your proctectomy, your healthcare team may need to do a few tests. These tests will give an idea of your overall health and the stage of your cancer. This will help the team plan for your surgery. You may be asked to get imaging tests, blood tests, an ECG (electrocardiogram), or a colonoscopy.

Once your surgery is scheduled you will need to prep for it. This may include:

• Bowel prep. Your bowels will need to be cleaned out for the surgery. This means you’ll need to make changes to your eating and drinking. You may also need to have laxatives or an enema. Follow all instructions you are given for not eating or drinking before the surgery.

• Antibiotics. You may need to take antibiotics to reduce the potential for infection. You may be given antibiotics through an IV (intravenous) line. This is done right before surgery. It may also be done during surgery.

• Changes in medicines. Be sure to discuss all your medicines. This includes prescription and over-the-counter (OTC) medicines, especially blood thinner medicines. It also means vitamins, herbs, supplements, marijuana, and illegal drugs. You may need to stop taking medicines for a week before your surgery. You also may be asked to stop smoking 2 weeks before surgery. Smoking can delay healing and recovery.

Your healthcare provider will give you prep instructions. You should follow up with any questions and concerns.

What happens during a proctectomy?

During the proctectomy, you’ll be under general anesthesia. This means you won’t be awake or feel pain during the surgery.

Different types of surgery may be done depending on your situation. Ask your provider which type of surgery you will have. Make sure you know what to expect and how your body will look and work after surgery. Options for the surgery include:

• Minimally invasive laparoscopic surgery. During this surgery, your surgeon will work through a few small cuts (incisions) on your belly (abdomen). A tiny camera on the end of a tube is inserted through the cuts to look at the inside of your body on a video screen. Your surgeon uses special long, thin tools to do the surgery. The surgery sometimes is robot-assisted. This is when the surgeon uses a computer to control robotic arms that do the surgery.

• Local resection or transanal excision. This surgery is done through the anus and doesn’t require any belly incisions. You’ll have this surgery if the cancer is lower in your rectum and can be reached through the anus. That means the cancer hasn’t spread too deeply.

• Low anterior resection (LAR). If your cancer is higher and deeper in the rectum, your surgeon may do this surgery. It removes a large part of your rectum through an incision made in your lower belly. This lets the surgeon look for signs that the cancer has spread inside your belly.

• Anastomosis. This is done after parts of your rectum have been removed. It involves reconnecting the ends of healthy rectum tissue. Doing this allows you to have normal bowel movements through your anus. Not everyone can have this surgery. If you have it, the pattern of your bowel movements will likely change. This includes how often you go and how solid your stools are.

• Abdominoperineal resection (APR). If your rectal cancer is close to the anal opening and large, you may have this surgery. For APR, the rectum is removed and the anal opening is closed. This surgery requires you to have a colostomy. That’s a procedure that connects your colon to an opening (stoma) made on your lower belly. Your bowel movements are then collected in a bag that covers the stoma.

• Pelvic exenteration. This surgery is only done in rare cases. It removes organs near the colon, such as the bladder, prostate, or uterus. A colostomy is always needed after this surgery.

Some of these surgeries don’t require a permanent colostomy. But sometimes you’ll need a short-term ileostomy to help with the post-surgery recovery. An ileostomy is a procedure to connect part of your small intestine to a stoma. Your stool then comes out of the stoma instead of through your colon and rectum. You may also need this surgery if you’ll have more treatment, such as radiation therapy. Because it is short-term, you’ll need another surgery later to reconnect the intestines and close the ileostomy.

Having a proctectomy may seem like a lot to deal with. But your surgeon will walk you through all steps of the surgery. Remember, you’re not alone in this.

What should you expect after a proctectomy?

After your surgery, you’ll have instructions to follow both in the hospital and when you go home.

In the hospital

After your surgery, you’ll stay in the hospital for a few days. This allows your healthcare team to watch you and your body as you start to heal.

While there, you may need:

• A urinarycatheter. This tube is placed in your bladder to drain your pee.

• Surgical drains. These are used to keep fluid from collecting in the treated area.

• Pain medicine, antibiotics, and a blood thinner. These are used to decrease your pain and help prevent blood clots.

• Diet changes. You may not be able to eat solid foods for a few days while your rectum heals.

If you have a colostomy or ileostomy, your healthcare team will also teach you how to work with them and get supplies.

Before you go home, the tubes and drains are often removed. Your pain should be under control. You should be able to eat and drink. But keep in mind that you may have special directions. You should be able to walk and take basic care of yourself. But you should plan to have someone stay with you for a week or so.

At home

Going home is an exciting step. While it’s great to be back, you will have to follow directions for medicines, pain control, diet, activity, bathing, and wound care.

Some common instructions include:

• Work with an ostomy nurse or enterostomal therapist. If you have a colostomy or ileostomy, this specialist will show you how to use the ostomy pouch, deal with possible side effects (such as skin irritation), get ostomy supplies, and get back to an active life. With the correct care, the pouch can’t be seen under your clothing. People won’t even know you are wearing it.

• Go for a walk. It’s important to get up and walk as much as possible. This is to help you breathe better and prevent blood clots.

• Ease into your normal activities. This may take a few months. Ask your healthcare team when you can bathe, drive, work, and have sex again. Don’t lift anything heavy for at least 6 weeks, or as advised by your provider.

• Watch your wounds for any signs of infection. These may include swelling, redness, pain, bleeding, or leaking fluid.

• Look out for possible complications. Make sure you know what problems to watch for and when you need to call your healthcare team. These include fever, bleeding, an increase in pain, or shortness of breath.

• Keep your healthcare team’s information handy. Know their office numbers, hours, and the number to call to get help after office hours and on weekends and holidays.

• Stay on top of follow-up appointments. Be sure to go to all your appointments and learn your next steps.

What are the side effects of a proctectomy?

As with any surgery, there are possible risks and side effects. It’s a good idea to keep a side effect journal that you can share with your healthcare team. They will help you to find ways to manage those side effects.

Possible side effects include:

• Bleeding

• Pain

• Infection at the incision site or inside the abdomen

• Blood clots that form in the leg veins and then move to the lungs (pulmonary embolism)

• Leaking inside your body at the joined tissues and vessels

• Trouble peeing

• Trouble pooping

• Inability to control bowel movements (incontinence)

• Wound healing problems or opening of the wound

• Sexual problems

• Reactions to anesthesia

• Scar tissue in the abdomen (adhesions)

There may be other risks, depending on your health. Talk with your healthcare provider before the procedure if you have concerns.

Questions to ask your healthcare team

While meeting with your healthcare team about a proctectomy, it can be hard to remember all your questions.

Before you agree to a test or procedure, make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure and what that person’s qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how you will get the results

• Who to call after the test or procedure if you have questions or problems

• How much you will have to pay for the test or procedure