Surgery for Rectal Cancer

Rectal cancer is a relatively common malignancy of the gastrointestinal tract. It can occur as a result of many causes but the most implicated is the HPV virus (Human papillomavirus). Surgery aims mainly to cure the condition and avoid the spread of the tumor because these can often be very  detrimental to the life expectancy and the quality of life of the patient.

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Surgery for Rectal Cancer

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Rectal cancer is a relatively common malignancy of the gastrointestinal tract. It can occur as a result of many causes but the most implicated is the HPV virus (Human papillomavirus). Surgery aims mainly to cure the condition and avoid the spread of the tumor because these can often be very  detrimental to the life expectancy and the quality of life of the patient.

The surgery involves radical excision of the rectum along with its mesorectum and the associated lymphatic vessels. Even with surgery, the post-operative survival rates are still very low and therefore early diagnosis and high suspicion of this condition upon clinical presentation of symptoms such as per rectal bleeding should be highly considered.
The surgery involves radical excision of the rectum along with its mesorectum and the associated lymphatic vessels. Even with surgery, the post-operative survival rates are still very low and therefore early diagnosis and high suspicion of this condition upon clinical presentation of symptoms such as per rectal bleeding should be highly considered.

Indications

  • The surgery is done to eliminate the clinical signs and symptoms that are congruent to that of rectal cancer such as bleeding per rectum, early-morning diarrhea, and tenesmus.
  • This surgery also aims to reduce the instance of tumor spread through the vasculature, lymphatics and local spread of the tumor, worsening the clinical signs and symptoms.
  • The surgery is done as a measure of palliative care to the patient in advanced stages of the disease. Extreme suffering of the patient seen if the neoplasm remains without being resected.

How is this procedure done?

The aim of this procedure is normally a radical excision of the rectum with the mesorectum and the associated lymph nodes of the rectum. If metastasis is present to the liver, abdomen or lungs among other organs the metastasis should also be excised.
Administration of preoperative chemoradiotherapy is a plus as it increases the chances for curative surgery.
For the surgical procedure;
  • The patient should be assessed if they are fit for the surgery
  • The patient should be well sedated free of any pain. General anesthesia is employed for this.
  • Radical excision of the neoplasm
  • Removal of the mesorectum.
  • There is a high proximal ligation of the inferior mesenteric lymphovascular pedicle
  • Once the rectum has been mobilized well, it is removed and the rectal stump is washed out.
  • Finally the restoration of the continuity through the direct end-to-end anastomosis.

Risk of this procedure

The risks of this procedure are associated with the damage of the pelvic autonomic nerves during the surgery. They include;
  • Disturbances in the sexual function especially impotence
  • Bladder dysfunction
  • Rectal sphincter might not be able to be saved during the procedure based on the extent of the tumor

Patient preparation.

The patient needs to be assessed if they are fit for surgery through a thorough history taking and physical examinations alongside various investigations.
The patient needs to carry the necessary imaging tests such as ultrasound images, CT scan, PET scans to the surgeon who is going to be operating. They are essential in determining the aggressiveness of the surgery to be carried out and if other treatment modalities such as chemotherapy or radiotherapy are required.
The bowel has to be prepared before surgery mainly done through mechanical cleansing using a combination of diet, enemas, and purgatives.. Prophylactic antibiotics could be given before the procedure to minimise the risk of infections.
Patients should get counseling before the procedure on the risks and benefits expected for this surgery.
Patients are required to show up to the health care facility about a day to the surgery. This will give the caregivers enough time to run the lab blood tests required and other tests that might be required before the surgery for the current update of the patient’s health status.
As of any surgical procedure that you’ll be required to be under general anesthesia, the patient is required to fast for about 8-12 hours to avoid complications of the anesthesia.
An Intravenous line is required to feed the required drugs into the body system of the patient. A water drip may or may not be used.
Because of the nature of the surgery, the patient is required to have a temporary urinary catheter to deliver the formed urine from the urinary bladder to prevent the bladder from becoming overfull during the surgery

Recovery after surgery

Depending on the treatment approach, the patient should be discharged for home in about a week.
The patient will take about 2 months to fully recover from the surgery and resume their normal activities. After these two months, the patient should present at the hospital for a reevaluation.
Early mobilization of the patient prevents blood clot formation. The use of blood thinners could also be employed. Adequate analgesia to ensure the patient is comfortable and not in pain should be prescribed especially when the patient goes home.
Advice and instructions on how to use the colostomy bag at home should be given by the nurses before the patients are discharged.

Outcomes

Research as shown that the surgery for rectal cancer has an operative mortality of <5% and about a 50% 5-year survival rate for the patients who have undergone this procedure.
The higher the stage upon diagnosis, the lower the survival rates even with the surgery. There are factors associated with worse prognosis of the disease even with surgery such as
  • The lower a tumor is in the rectum, the worse the prognosis as compared to a higher-up tumor in the rectum.
  • If the histological classification of the tumor shows it an anaplastic lesion, a worse prognosis is expected.
  • Fixed neoplasms in the rectum usually have a far worse prognosis compared to mobile lesions.
Adjuvant chemotherapy helps in increasing the effectiveness of the curative surgery treatment and helps in the improvement of the survival rates in the patients whose lymph node biopsy turned positive for malignancy.
Expect a local recurrence of the condition after surgery with rates of up to 2% to 25% with higher rates expected after abdominoperineal excision as compared to the sphincter-saving procedure