Surgery for Rectal Cancer

Colorectal surgeon José G. Guillem

Colorectal surgeon José G. Guillem

At Memorial Sloan Kettering, surgery is the most common treatment for many stages of rectal cancer. As with many kinds of cancer, early detection is critical. Surgery alone can often be the only necessary treatment for small tumors that haven’t spread through the bowel wall. In some cases, the tumor can be removed though the anus without the need to remove the entire rectum. Other patients require removal of most or all of the rectum. Cancers that have spread through the wall or to nearby lymph nodes usually require chemotherapy and radiation in addition to surgery.

Surgery for rectal cancer does have some challenges. For example, your pelvic bone contains many narrow parts, making the area difficult to operate on. This region also contains the nerves that control your sexual and bladder function as well as bowel function. Your surgeon will take every precaution to protect those nerves. Another challenge is recurrence — some rectal cancers are likely to come back after surgery.

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Because it’s more challenging to operate within the confines of the pelvis, chemotherapy and radiation therapy may be used to shrink the rectal tumor before surgery, especially in the case of larger tumors. This approach is called neoadjuvant therapy. If you’re a candidate for this therapy, your treatment team will work with you to determine which combination is right for you.

Neoadjuvant therapy is our standard recommendation if you have locally advanced rectal cancer or a low-lying tumor (close to the anus). If your diagnostic tests indicate you have an advanced cancer that has spread to the lymph nodes, chemoradiation before surgery can eliminate microscopic cancer cell growths before they get bigger. This can reduce the risk of the tumor coming back.

The treatment sequence of neoadjuvant therapy, surgery, then chemotherapy gives patients with localized rectal cancer an overall cure rate of more than 70 percent. Less than 10 percent of patients experience recurrence (the cancer coming back).

MSK surgeons are constantly developing new, more effective techniques to protect normal body functions for people who’ve had rectal cancer surgery.

For example, in the past, many patients needed a permanent colostomy. This is a surgical procedure that removes the rectum and brings one end of the large intestine out through the abdominal wall. These patients would spend the rest of their lives fitted with an ostomy pouching system (commonly called a colostomy bag) to collect waste from the intestine. At MSK, the overwhelming majority of our patients can now avoid permanent colostomy thanks to advances in surgical techniques.

Some of the more advanced surgical procedures our rectal surgeons use include:

  • minimally invasive techniques such as laparoscopy and robotic surgery
  • nerve-preserving techniques, which focus on protecting your sexual and urinary function (part of the standard of care at MSK)
  • coloanal reconstruction, a procedure in which your surgeon removes your rectum and connects your upper colon directly to your anus. This option works well for patients who aren’t good candidates for other techniques, such as men with large prostate glands.
  • colonic reservoir, in which your surgeon loops two sections of your lower colon together and opens up the wall between them to construct an internal colon pouch called a J-Pouch. This creates a reservoir for storing waste and allows you to improve your bowel function if you have surgery to remove your rectum.

MSK surgeons have been leaders in incorporating minimally invasive surgical techniques into rectal cancer operations.

Three techniques in particular can help minimize damage to nearby organs and tissues, lower infection risks and blood loss, and speed recovery time:

  • Laparoscopy. This procedure uses a thin, lighted tube with a video camera at its tip, called a laparoscope. It is inserted through a small opening your surgeon will make in your abdominal wall that will allow him or her to operate using special instruments. Our surgeons are helping lead national clinical trials to assess this approach in rectal surgery. Early studies show laparoscopy is safe and feasible. Currently, surgeons usually must make an incision low in the pelvis to complete the surgery.
  • The da Vinci® Surgical System, a state-of-the-art robotic surgical tool that helps your surgeon provide quality treatment and may decrease post-surgery pain and recovery time. Robotic devices have been used successfully to treat other types of cancer, such as prostate and gynecological tumors. At MSK, we are one of the most experienced centers in the world in the use of the da Vinci® Surgical System to treat rectal cancer.
  • Transanal endoscopic microsurgery (TEM), a procedure that involves removing early-stage rectal cancers using a scope that’s inserted into the anus. It typically takes less time than standard abdominal surgery and is ideal for older patients with medical conditions that would make more extensive operations difficult, or for those who don’t want to undergo a standard operation. TEM also minimizes treatment-related complications, reduces recovery time, and spares nearby nerves associated with urinary control and sexual function. Most importantly, TEM patients don’t require a colostomy. They also can go home soon after the procedure, whereas standard abdominal surgical procedures require up to a week of recovery at MSK. Our experienced rectal surgeons have been performing TEM since 2004.