Surgery for early bowel cancer

This is the most common operation. You may have a high anterior resection or an ultra-low anterior resection. As part of the procedure, the surgeon may create a temporary stoma (which will usually be reversed later). 

High anterior resection

The surgeon removes the lower left part of the colon and the upper part of the rectum. Nearby lymph nodes and surrounding fatty tissue are also removed. The lower end of your bowel is rejoined to the top of the remaining rectum.

Ultra-low anterior resection

The lower left part of the colon and all or part of the rectum are removed, along with nearby lymph nodes and surrounding fatty tissue. The end of the remaining bowel is joined to the lowest part of the rectum, just above the anus. In some cases, the surgeon may make a pouch using the remaining colon and join this pouch to the anus to improve ongoing bowel function. This is known as a colonic J-pouch.

This procedure may be recommended if the cancer is near the anal sphincter or it is too low to be removed without causing incontinence (loss of control over bowel movements). After an abdominoperineal resection, you will need a permanent stoma (colostomy). See more details about having a stoma and speak to your surgeon about any concerns you may have.

Abdominoperineal resection or excision (APR or APE)

The sigmoid colon, the entire rectum and the anus are removed. Your surgeon uses the descending colon to create a permanent stoma (known as a colostomy) for faeces to leave the body. The anal area will be stitched up and permanently closed.

Used for larger benign polyps. Some very early cancers that involve only the inner lining of the bowel may be suitable for endoscopic resection (also called endoscopic mucosal resection or EMR). This involves cutting out the tumour during a colonoscopy. A bowel resection may also still be needed.

People who have very early-stage rectal cancer or are not fit for a major operation may have a local excision. The surgeon puts instruments into the anus to remove the cancer from the lining of the rectum, along with a margin of healthy tissue, without cutting into the abdomen. Methods include:

• transanal excision (TAE)
• transanal endoscopic microsurgery (TEMS)
• transanal minimally invasive surgery (TAMIS).

In a small number of people, 2 separate cancers may be found in the large bowel at the same time. The cancers may be discovered through tests or during surgery.

In this case, there are several options for surgery, including to remove:

• 2 sections of the bowel
• one larger section of the bowel that includes both areas with cancer
• all of the colon and rectum (proctocolectomy) to prevent any chance of another cancer forming.

In some locally advanced cancers, other organs that the bowel cancer is attached to may also be removed along with the bowel containing the cancer. The type of surgery your doctor recommends depends on several factors, including your age, where the tumours are in the bowel, genetic and other risk factors, and your preferences.

If only one area of the bowel is blocked or you are not fit enough for major bowel surgery, you may have a small hollow tube (stent) put in to help keep the bowel open and relieve symptoms.

A stent may be permanent, or it can be used to help manage the blockage until you are fit enough to have a colectomy or resection. The stent is inserted through the rectum using a colonoscope.

A dietitian or your surgeon or stomal therapist may suggest you take a stool softener or add more fluid to your diet to help food or waste pass through the blockage or stent more easily. Other people may be advised to eat low-fibre foods. Talk to a dietitian about suitable foods for your situation.

If you are unable to have bowel surgery or a stent, you may be given medicine to help control the symptoms of a bowel obstruction.

• In hospital you will have to wear compression stockings to keep the blood flowing in your legs.
• You will also be given a daily injection of a blood thinner to reduce the risk of developing blood clots.
• Some people also wear special cuffs around the legs to keep the calf muscles moving.
• Some people may have to wear the compression stockings and have the injections for a couple of weeks after the surgery.
• You will need to avoid driving after the surgery until you can move freely without pain. Discuss this issue with your doctor. Check with your car insurer for any exclusions about major surgery and driving.

You will have some pain and discomfort for several days after surgery, but this can be controlled with pain medicines.

Pain medicines may be given:

• by an injection under the skin
• through a drip you can control with a button (patient-controlled analgesia or PCA)
• by an injection near your spinal column (epidural or spinal anaesthetic)
• as pills or tablets
• through little tubes giving local anaesthetic near the wound (transversus abdominis plane or TAP block catheters).

Let your doctor or nurse know if you are in pain so they can adjust the medicines to make you as comfortable as possible. Do not wait until the pain is severe.

• You will be given fluids through a drip (also called an IV or intravenous infusion) until you start drinking and eating again. You may need to have a drip for a few days.
• You may also have other tubes – from your bladder to drain urine (catheter) or from your abdomen to drain fluid from around the surgical area.
• In most hospitals, you will be given water to drink a few hours after the surgery, and you will usually start on solid foods the day after the surgery (or even on the day of the surgery if you feel well). You may also be given nutritional supplements to drink.

• Your treatment team will encourage you to walk the day after the surgery.
• Avoid heavy lifting (more than 3–4 kg) for about 4–6 weeks.
• A physiotherapist will teach you breathing or coughing exercises to help keep your lungs clear. This will reduce the risk of getting a chest infection.
• Gentle exercise has been shown to help people manage some of the common side effects of treatment and help them return to their usual activities faster.
• See an exercise physiologist or physiotherapist for advice. Visit Exercise & Sports Science Australia (ESSA) to find an exercise physiologist, and visit The Australian Physiotherapy Association (APA) to find a physiotherapist.
• Your doctor may advise you to avoid sexual intercourse for a few weeks after surgery. Ask them when you can have penetrative sex again, and explore other ways you and your partner can be intimate, such as massage.

Some people go home with a stoma. A stomal therapy nurse will see you after the operation to teach you how to look after the stoma and attach bags. You will stay in hospital until you feel confident managing the stoma.

You may notice changes to how your bowel and bladder work. These changes usually improve within a few months but, for some people, it can take longer. Internal scar tissue (adhesions) from bowel surgery can increase the risk of developing a bowel obstruction. This may occur even many years after the surgery.

In males, removing the rectum may affect the nerves controlling erections or ejaculation. You may have trouble getting or keeping an erection firm enough for intercourse or other sexual activity. In females, if the rectum is removed, there may be a different feeling in the vagina during intercourse. It may be uncomfortable, as the rectum no longer cushions the vagina.

You may need to change what you eat after treatment or if you have a stoma. 

It is normal to feel tired after surgery. Although it’s a good idea to stay active and do gentle exercise as recommended by your doctor, you may find that you tire easily and need to rest during the day. Take breaks if you feel tired, and follow your doctor’s advice about restrictions, such as avoiding heavy lifting. You might have to remind your family and friends that it may take you several months to recover from surgery.