Most patients with rectal cancer undergo surgery about eight weeks after finishing chemotherapy and/or radiation therapy. About 20 percent of patients do not go directly to surgery, including those who are too sick to undergo surgery and those for whom the chemotherapy and radiation seem to have completely removed the cancer. Those patients may choose watchful waiting after consulting with their physician, to determine if future surgery is necessary.
Johns Hopkins rectal cancer surgeons specialize in minimally invasive surgeries designed to spare sphincter muscles and to reconstruct the rectum in order to give patients the best quality of life after their procedures.
These surgeries may be assisted with robotic instruments. Johns Hopkins researchers are involved in a large clinical trial to determine whether laparoscopic and robotic surgical results are comparable to abdominal surgical results in treating rectal cancer.
Our surgeons are also experts at treating recurrent rectal cancers, working with specialists to provide radiation during surgical procedures and to remove tumors that have spread to the liver in stage 4, metastatic rectal cancer.
Common Rectal Cancer Surgical Approaches
The type of surgery recommended for patients with rectal cancer depends on the stage of their cancer and the location of their cancer inside the rectum. The part of the rectum closest to the colon is called the upper rectum, while the part of the rectum closest to the anus is called the lower rectum.
- Local transanal resection or excision: This surgery is used to remove early stage rectal cancers in the lower rectum. It is performed by instruments inserted through the rectum. The surgeon removes the cancer from the rectal wall and may remove some of the surrounding rectal tissue.
- Transanal endoscopic surgery: This surgery is used to remove larger cancers that may be higher in the rectum and difficult to remove through local transanal resection. For this procedure, surgeons use special equipment that is inserted through the anus and into the rectum.
- Transanal minimally invasive surgery (TAMIS): TAMIS is performed at Johns Hopkins using standard laparoscopic equipment instead of the specialized equipment required for transanal endoscopic surgery. The laparoscope and other instruments are inserted through a special port placed in the anus to remove early stage cancer from the rectum.
- Low anterior resection: This surgery, for some stage 1, stage 2 and stage 3 cancers in the upper rectum, removes the part of the rectum containing the tumor and then reattaches the colon to the remaining part of the rectum. The incisions for this surgery are made through the abdomen.
- Proctectomy: This surgery, for some stage 1 and many stage 2 and stage 3 cancers in the middle and lower rectum, removes the entire rectum through abdominal incisions. The colon is then attached to the anus, in a procedure called a colo-anal anastomosis. During anastomosis surgery, the surgeon may create a small pouch in the colon to replace the rectum for collecting fecal matter.
- Abdominoperineal resection (APR): This surgery, usually performed for stage 2 and stage 3 cancers in the lower to middle rectum, removes the rectum through abdominal incisions as well as the anus and sphincter muscles through incisions around the anus.
- Total mesorectal excision (TME): In procedures where the total rectum is removed, TME surgery is recommended to remove the tissue next to the rectum that contains lymph nodes and blood vessels. Studies show that removing this tissue can reduce the five to 10-year recurrence rate of rectal cancer to between 5 and 10 percent.
Will I need a colostomy?
A colostomy is a procedure that brings the end of the colon through an opening in the abdominal wall so that fecal matter can be passed out of the body when the rectum has been removed or is temporarily unavailable to store waste. (A similar procedure called an ileostomy brings the end of the small intestine through an abdominal opening.)
Johns Hopkins surgeons work with radiation and medical oncologists to find ways to keep patients with rectal cancer from needing a permanent colostomy after treatment. For instance, pre-surgical radiation therapy is used to shrink tumors in the lower and middle rectum so that the surgeon has to remove less tissue and can avoid removing anal muscles and nerves that help patients pass fecal matter. Our surgeons also specialize in procedures such as colo-anal anastomosis that reattach the colon to the anus or remaining rectum, to help patients pass fecal matter as they did before the surgery.
For some surgical procedures that remove all or part of the rectum, patients may need a temporary colostomy or ileostomy while the rectal area heals. Patients who have the anus and surrounding sphincter muscle removed, as in APR, will need a permanent colostomy. Whether your colostomy is permanent or temporary, our ostomy nurses will help you learn how to manage and take care of your ostomy as part of your overall treatment plan.