Proctectomy

What is a proctectomy?

Proctectomy is a surgery to remove all or part of the rectum. It's commonly used to treat rectal cancer. The surgery can be done in several ways. The method used depends on things such as how close the cancer is to the anus and how deeply it has spread.

Your large intestine is made up of your colon and rectum. It's the last part of your digestive system. The last 6 inches of your large intestine is your rectum. Stool is stored here until it passes out your anus. Your anus is made of ring-shaped muscles that hold stool in until you relax them to have a bowel movement. Proctectomy may remove all or part of the rectum. In some cases, it may include removing the anal opening.

Why might I need a proctectomy?

The most common reason for proctectomy is rectal cancer. After you are diagnosed with rectal cancer, your healthcare team will try to stage it. The stage of your cancer is how big it is, and how deeply it has spread into and outside of the rectum. Any stage of rectal cancer may be treated with some type of proctectomy.

Proctectomy may also be used to treat an inflammatory bowel disease. This includes:

Ulcerative colitis. This causes ulcers and infections to form on the inside layer of the colon and rectum.
Crohn's disease. This causes inflammation, irritation, and sores that go deep into the colon wall. It can happen anywhere along the digestive tract.

What are the risks of a proctectomy?

Every surgery has risks. The risks of this surgery include:

Bleeding
Pain
Infection at the cut (incision) site or inside the belly (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 passing urine
Trouble having bowel movements
Wound healing problems or opening of the wound
Scar tissue (adhesions)
Sexual problems
Heart or brain injury from anesthesia
Inability to control bowel movements (incontinence)

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

How do I get ready for a proctectomy?

Before a proctectomy, a complete evaluation will be done by your healthcare team. This is done to get an idea of your overall health, stage your cancer, and plan your surgery. It may include imaging tests, blood tests, and an ECG to check your heart. A colonoscopy will be done to look inside your colon and rectum if it has not been done already.

Here's what to expect before surgery:

Your bowels must be empty and cleaned out for the surgery. You'll need to make changes to your food and drink intake on the days before surgery. Follow all of your healthcare team’s directions.
You may need to do bowel prep. This may include a laxative and enemas to clean out your bowel.
You may need to take antibiotics before surgery. This is to help reduce your risk for infection. Sometimes antibiotics are given to you in an IV (intravenous) line. This is done right before surgery and may also be done during surgery.
You may be asked to stop smoking about 2 weeks before surgery. Smoking delays healing and recovery. Ask your healthcare provider if you need help stopping.
Tell your healthcare team about all medicines, vitamins, herbs, and supplements you take. This includes over-the-counter medicines, as well as illegal drugs and marijuana. You may need to stop taking some medicines in the week before the surgery. This includes any medicines that thin the blood.

Your healthcare provider may give you other directions.

What happens during a proctectomy?

You'll be given general anesthesia for the surgery. This is medicine that causes you to sleep and not feel pain during the procedure.

Here are the different types of surgery that can be done:

Minimally invasive laparoscopic surgery. For this method, the surgeons work through a few small incisions on your belly. A tube with a tiny camera on the end is used to look at the inside of your body on a video screen. Special long, thin tools are put into the incisions and used to do the surgery. Laparoscopic surgery can also be robot-assisted. This is when the surgeon uses a computer to control robotic arms to do the surgery.
Local resection or transanal excision. These methods are choices if the cancer can be reached through the anus and hasn't spread too deeply. The surgery is done through the anal opening. An incision in the belly isn't needed.
Low anterior resection (LAR). Cancer that is higher and deeper in the rectum may need an open LAR, which is a different type of surgery. A larger part of the rectum will be removed through an incision made in the lower belly. This approach lets the surgeon look for signs that the cancer has spread inside your belly.
Anastomosis. If there's enough healthy rectum tissue left, the ends are reconnected with this type of surgery. It makes you able to have normal bowel movements through your anus. But the pattern of your bowel movements will likely change. This includes how often you go, and how solid your stools are.
Abdominoperineal resection (APR). This may be done if rectal cancer is large and close to the anal opening. For APR, the rectum is removed and the anal opening is closed. The other end of the colon is attached to an opening (called a stoma) made on your lower belly. This is called a colostomy. Bowel movements are then collected in a bag that covers the colostomy.
Pelvic exenteration. This surgery may be needed in rare cases. For this, nearby organs are removed, such as the bladder, prostate, or uterus. A colostomy is always needed after this surgery.

Even if you don't have a permanent colostomy after proctectomy, a short-term ileostomy might be needed. This is when the last part of your small intestine is connected to a hole made on your belly (called a stoma). Stool comes out the stoma instead of moving through your colon and rectum. This allows your rectum to heal. It also may be done if you need more treatment after surgery, such as radiation therapy. Later, another surgery is done to reconnect the intestines and close the ileostomy.

Your surgeon will talk with you about the kind of surgery to be done. Make sure you know what to expect and how your body will look and work after surgery.

What happens after a proctectomy?

You will need to stay in the hospital for several days after the surgery. You will have a tube (catheter) in your bladder to drain urine. You may also have surgical drains. These are used to keep fluid from collecting in the treated area. You'll be given pain medicine, antibiotics, and a blood thinner to help prevent clots. You may not be allowed to eat for a few days to give your rectum time to heal. You'll be taught how to manage your colostomy or ileostomy.

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

When you go home, follow all the directions for medicines, pain control, diet, activity, bathing, and wound care.

If you have a colostomy or ileostomy, you may need to work with an ostomy nurse or enterostomal therapist. Make sure to keep all your follow-up appointments. This specialist will show you how to use the ostomy pouch, deal with possible side effects, such as skin irritation, 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.

Some other common instructions after proctectomy may include:

Get up and walk as much as possible soon after surgery. This is to help you breathe better and prevent blood clots.
Slowly get back to your normal activities. This may take a few months. Ask your healthcare providers when you can resume bathing, driving, working, and having sex. Don’t do heavy lifting for at least 6 weeks.
Watch your wounds for any sign of infection. This may include swelling, redness, pain, bleeding, or fluid leaking.

Make sure you know what problems to watch for and when you need to call your healthcare provider. Also be sure you know what number to call to get help after office hours and on weekends and holidays.

Have your follow-up appointments made and know what your next steps will be.