Surgery is the most common treatment for rectal cancer. The goal of surgery is to remove the cancer and enough nearby tissues to try to cure the cancer or stop it from spreading, while preserving typical bowel and bladder function when possible.
The type of procedure that's recommended depends on how far the cancer has grown and where it is in the rectum. Sometimes a procedure to reroute stool leaving the body, such as an ileostomy or colostomy, may be needed.
In addition to surgery, your healthcare team might recommend other treatments, such as chemotherapy or radiation therapy. These therapies may be used before, during or after surgery. They can be used to shrink cancer or help kill any remaining cancer cells that were not removed with surgery.
Types
There are many different types of rectal cancer surgery. When making a surgery recommendation, your healthcare team will consider where the cancer is in the rectum and if the cancer has spread outside the rectum.
Types of rectal cancer surgery include:
Local excision procedures
Local excision is typically used when rectal cancer is in an early stage and hasn't spread to the lymph nodes. This type of surgery removes the tumor through the anus, without making cuts in the abdomen. The procedure usually has a quicker recovery than do other similar procedures.
However, local excision doesn't remove lymph nodes or deeper tissues. It may not be enough if the cancer has grown deeply into the rectal wall, isn't completely removed, or shows signs of spreading to lymph nodes or blood vessels. In those cases, additional treatment, such as radiation or chemotherapy, may be needed. Sometimes, a more extensive surgery might be recommended, depending on the type of cancer and location.
Types of local excision include:
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Transanal excision (TAE). TAE uses simple tools to remove cancer through the anus. It's often done as an outpatient procedure.
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Transanal minimally invasive surgery (TAMIS). TAMIS uses laparoscopic tools through a soft port placed in the anus. It also may be done robotically for improved control in tight spaces. The rectum is inflated with gas to create space for the surgeon to operate. TAMIS is a flexible and cost-effective option for early-stage cancer.
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Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR and ESD are often used to remove polyps, especially those limited to the inner layers of the rectal wall. EMR typically is used to remove tumors from the uppermost layer, while ESD allows for deeper dissection into the tissue. ESD is used for larger or more-complex cancers. Sometimes these techniques can be used to remove early-stage cancer.
After local excision of rectal cancer, regular checkups are key to catching any cancer recurrence early.
Resection with sphincter preservation
These surgeries remove the cancer and nearby tissue but try to preserve the muscles that control bowel movements, called the anal sphincter. These surgeries may require a temporary or permanent ostomy procedure, such as an ileostomy or colostomy, which involves making a surgical opening in the abdomen for the passage of stool.
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Total mesorectal excision (TME). TME is considered the gold standard surgical procedure for rectal cancer. This procedure involves making an incision in the abdomen to remove the affected part of the rectum along with surrounding fatty tissue, called mesorectum, and lymph nodes. TME offers excellent cancer control and survival outcomes, though recovery may involve bowel irregularities and sexual dysfunction. Most people recover in 3 to 6 weeks.
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Transanal total mesorectal excision (taTME). This procedure is a newer way to do TME through the anus, rather than through incisions in the abdomen like traditional TME. TaTME may allow easier removal of the tumor through the anus, especially when the cancer is located low in the rectum and hard to reach through the abdomen.
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Low anterior resection (LAR). LAR is a sphincter-sparing surgery for mid-to-upper rectal cancers. It involves removing the cancer, nearby tissue and lymph nodes. The colon is then reconnected to the rectum, so a permanent colostomy usually is not needed. However, sometimes a temporary ileostomy is needed. Recovery may take 3 to 6 weeks.
Sometimes when the cancer is very close to the anus, the surgeon connects the colon directly to the anus, sewn by hand, to help avoid a permanent colostomy.
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Proctocolectomy. This procedure removes both the colon and rectum. Proctocolectomy may be used to treat rectal cancer that is multifocal, recurrent, or linked to inherited syndromes such as familial adenomatous polyposis (FAP) or other conditions such as ulcerative colitis or Crohn's disease.
After removing the colon and rectum, surgeons may create a pouch from the end of the small intestine and connect it to the anus. This procedure allows for bowel movements without the need for a permanent stoma. This is known as total proctocolectomy with ileal pouch-anal anastomosis (TPC-IPAA). TPC-IPAA, also known as J-pouch surgery, is a sphincter-sparing procedure. J-pouch surgery avoids the need for a long-term opening in the abdominal wall for passing stool.
Another type of proctocolectomy is known as total proctocolectomy with end ileostomy (TPC-EI). TPC-EI may be done if J-pouch surgery is not possible or if anal sphincter function is poor. In this procedure, the small intestine is connected to a permanent opening in the abdomen to allow waste to leave the body.
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Colectomy. A colectomy removes all or part of the colon. It may be done if the cancer involves both the rectum and colon or if someone has a condition with a high risk of rectal cancer, such as FAP or Lynch syndrome. After removing the affected section of the colon, the remaining bowel is reconnected. Stool then leaves your body as before.
If all of the colon is removed, the surgeon may attach the remaining colon or the small intestine to an opening created in the abdomen. This allows waste to leave the body through an opening, called a stoma. The procedure to attach the colon to the stoma is called a colostomy. The procedure to attach the small intestine to the stoma is called an ileostomy.
Resection without sphincter preservation
Sometimes the cancer is too low or too close to the anal sphincter muscles. When this happens, the surgeon must remove the anus and rectum. The surgeon also needs to make a permanent opening in the abdomen for stool to pass through, called a colostomy or an ileostomy.
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Abdominoperineal resection (APR). APR is used when the cancer is in the lowest part of the rectum and the sphincter can't be saved. This procedure removes the lower part of the colon, rectum, anus and surrounding tissue. This is followed by an ostomy procedure called a colostomy. Recovery may take 3 to 6 weeks.
For men, APR may cause sexual issues, such as trouble getting an erection or trouble reaching orgasm. Fertility also may be affected. For women, APR may cause increased pain during sex, decreased lubrication and decreased arousal.
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Pelvic exenteration. This is a major surgery that removes the rectum and nearby organs, such as the bladder, uterus or prostate, and sometimes the bone at the base of the spine, called the sacrum. Pelvic exenteration is used when the cancer has spread to these areas.
Colostomy or ileostomy
Depending on your procedure, you may need a temporary or permanent ostomy after your surgery. Ostomy types include:
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Colostomy. In a colostomy, the end of the colon is brought through the abdominal wall to create a stoma. Stool passes through the stoma into a bag worn outside the body. A colostomy may be permanent or temporary, depending on the surgery.
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Ileostomy. An ileostomy is similar to a colostomy, but it uses the end of the small intestine, called the ileum, instead of the colon. It's often used when the entire colon is removed or when the rectum needs time to heal after surgery.