Rectal Cancer Surgery

At which stage surgery is possible

The timing and extent of surgery depend on how deeply the tumor has grown into the bowel wall, whether lymph nodes are involved and how close it is to the sphincter. MRI distinguishes three situations.

• Early tumor. If it has not spread beyond the submucosal layer and has favorable histological features, in some patients local excision through the anal canal is possible — without bowel resection, under strict criteria and with mandatory follow-up.
• Tumor within the bowel wall or slightly beyond it, with no threat to the mesorectal fascia. In some of these patients, primarily with tumors of the middle and upper rectum, surgery is performed right away.
• Locally advanced tumor. The tumor board usually prescribes radiation therapy or chemoradiation first, in some patients together with chemotherapy, and only then surgery.

Liver metastases in themselves do not rule out surgery: if they can be removed, the bowel and the liver are operated on at the same time or in sequence. More about the diagnosis, tests and treatment before surgery is on the page “Rectal cancer”.

Types of operations for rectal cancer

Which operation is needed is determined above all by the height of the tumor — the distance from its lower edge to the sphincter.

How the operation is performed

The standard for tumors of the middle and lower rectum is total mesorectal excision: the bowel with the tumor is removed as a single block together with the mesorectum — the fatty tissue with lymph nodes around the bowel — within its own fascia. It is this technique, rather than a “wide margin” along the bowel, that lowers the risk of local recurrence. For tumors of the upper rectum, partial removal of the mesorectum with a sufficient margin below the tumor is possible.

While the bowel is being mobilized, the autonomic pelvic nerves are preserved: bladder and sexual function after surgery depend on them.

When the location of the tumor, the anatomy of the pelvis and the extent of resection allow, the operation is performed laparoscopically — through several small punctures. Some patients — with large tumors, a narrow pelvis or previous operations — need open surgery. The approach is chosen before the procedure. The duration of the operation depends on its extent and the approach; I will be able to say more precisely after reviewing the MRI.

Will there be a stoma

Not always. A permanent colostomy is needed when the tumor invades the sphincter or lies so low that it cannot be removed with clear margins while preserving continence.

In other cases the bowel can usually be rejoined. If the anastomosis is low, especially after radiation therapy, a protective ileostomy is often created: it diverts bowel contents away from the anastomosis while it heals. It is planned as temporary and is closed in a separate operation once the anastomosis has healed — but closing it is not always possible.

Hospital stay, recovery and consequences

After surgery, care follows the enhanced recovery (ERAS) protocol: early mobilization, early return to eating, controlled pain relief. The length of the hospital stay depends on the extent of surgery and the approach — after a laparoscopic procedure it is usually shorter.

After a low resection the bowel works differently for some time: urges are more frequent and urgent, bowel movements are fragmented, and incontinence of gas or stool is possible. This is an expected condition; in most patients it gradually decreases over the first one to two years, in some it persists longer. Diet, pelvic floor training and, if needed, medication help. If a stoma has been created, you are taught to care for it while still in the hospital.

Whether chemotherapy is needed after surgery is decided based on the stage, the histology report of the removed tumor and the treatment already given.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The main ones are:

• anastomotic leak — when the join in the bowel does not heal; it can lead to abdominal infection and a repeat operation, and a protective ileostomy reduces the severity of the consequences;
• urinary and sexual dysfunction — if the pelvic nerves are damaged; that is why they are preserved while the bowel is mobilized;
• changes in bowel function after a low resection — more frequent and urgent urges, fragmented bowel movements, incontinence of gas or stool;
• general surgical complications — bleeding, wound infection, thrombosis.

The likelihood of each depends on the height of the tumor, previous radiation therapy, other conditions and the extent of surgery. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost of surgery depends on its extent, the approach, the number of days in the hospital and the tests before surgery. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

Which documents are needed and how to book

• pelvic MRI and CT discs — the discs with the images, not only the reports;
• the colonoscopy report describing the distance of the tumor from the anal verge;
• the histology report and, if available, the blocks and slides and the MMR/MSI test result;
• records of previous treatment: doses and dates of radiation therapy, chemotherapy regimens, operative reports;
• recent blood tests, including a complete blood count and CEA.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.