Abdominoperineal Resection of Rectum

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Abdominoperineal Resection of Rectum

What do I need to know about this condition?

The large bowel (intestine) is made up of the colon and rectum (back passage). This part of the digestive tract carries the remains of digested food from the small bowel and gets rid of it as waste through the opening to the back passage (anus). Cells that line the colon and rectum may begin to grow out of control, forming a tumour (a growth of cancer cells).

Diagram showing parts of the bowel

The bowel has four sections: the ascending colon, the transverse colon, the descending colon and the sigmoid colon. Tumours can start in any of these areas or in the back passage. Tumours start in the innermost layer and can grow through some or all of the other layers.

What do I need to know about the procedure?

Surgery is the main treatment for tumours of the bowel. Usually, the tumour and a length of normal bowel on either side of the tumour (as well as nearby lymph nodes) are removed. The healthy parts of the bowel are then stitched or stapled together (anastomosis).
If the doctor is not able to join the bowel back together, an opening (stoma) will be made on the outside of the body for waste to pass out of the body.
This is called a colostomy. A colostomy is made to allow waste to pass through an opening in the abdominal wall.

Sometimes, a temporary colostomy is needed until the joined bowel has healed, and then it can be put back. This is done by further surgery. However, in some cases, the colostomy is permanent, which means it can never be put back, and there will always be an opening on the skin for bowel waste to pass through.
A number of different surgical procedures are used depending on where the tumour is.

These include:

Right Hemicolectomy: Removal of the last part of the small bowel, the caecum, ascending colon and a small part of the transverse colon

Left Hemicolectomy: Removal of the descending colon and sigmoid colon.

Sigmoid Colectomy: Removal of the sigmoid colon and nearby large bowel.
A number of different surgical procedures are available to treat tumours of the back passage, the choice depending on where the tumour is and how far it has spread:

Low Anterior Resection: Used for most tumours of the back passage, except when the tumour is very close to the anal muscles (sphincter). The bowel and the back passage are joined together so that the back passage is spared.

Abdomino-Perineal Resection: This is done when the tumour is in the lowest part of the back passage. The back passage and the opening to the back passage are removed and the area is stitched up and will remain permanently closed.
The waste collects in a disposable bag (a colostomy bag) which is stuck over the opening.

What do I need to do to prepare for this procedure?

Before surgery, the bowel must be prepared to lower the risk of infection. You may be told to have a low fiber diet 2-3 days before surgery. You will be then be on a clear fluid diet and given a medicated drink to help clean the large bowel. This can cause diarrhea and cramps, and may be tiring.
The medicated drink will completely empty your bowel. You will then fast for at least 6-8 hours before your surgery. If you are having a colostomy, the surgeon or a stoma nurse will discuss with you the best site for your colostomy and will mark the area with a marker pen. It is usually placed below your belt line, away from any other scars you may have and at least 8 – 10 cm away from your wound, depending on your size and shape.

My anaesthetic

This procedure will require an anaesthetic.
See About Your Anaesthetic information sheet for information about the anaesthetic and the risks involved. If you have any concerns, discuss these with your doctor.
If you have not been given an information sheet, please ask for one.

What are the benefits of having the procedure?

Removal of the diseased bowel is the first treatment for a tumour of the bowel. The goal of the surgery is to give you the best chance of cure through total removal of the tumour.
However, your recovery depends how far the disease has spread at the time of your operation. Surgery can also be used as a measure to ease symptoms.

What are the risks of not having the procedure?

Symptoms including pain and bleeding may become worse and your bowel may completely block or burst. Without surgery, the disease may spread to other areas of your body.

What are the alternative treatments?

Radiation Therapy has been used for some people as the main treatment for rectal tumours but is not normally used in colon tumours.
Radiation therapy is not as effective as surgery for patients who could normally be treated by bowel removal.
Chemotherapy (use of drugs to treat tumour) is usually used together with surgical removal and may not be offered as the only treatment.

What are the general risks of having a procedure?

There are risks and complications with this procedure.
They include but are not limited to the following.

General risks:

Infection can occur, requiring antibiotics and further treatment.
Bleeding could occur and may require a return to the operating room. Bleeding is more common if you have been taking blood thinning drugs such as Warfarin, Asprin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin).
Small areas of the lung can collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
Increased risk in obese people of wound infection, chest infection, heart and lung complications, and thrombosis.
Heart attack or stroke could occur due to the strain on the heart.
Blood clot in the leg (DVT) causing pain and swelling. In rare cases part of the clot may break off and go to the lungs.
Death as a result of this procedure is possible.

What are the specific risks of this procedure?

The Risk	What Happens	What can be done about it
Leakage of bowel fluid inside the abdomen	Leakage of bowel fluid at the site where the bowel was stitched or stapled back together. The rate of risk is about 1 in 22 to 1 in 20.	Further surgery may be required.
Ileus	The bowel is paralyzed leading to abdominal bloating, and vomiting. The rate of risk is about 2 in 100.	Treatment is to deflate the bowel with suction, using a tube (naso-gastric tube) put up the nose, down the back of the throat and into the stomach or bowel.
Wound Infection	The wound may become infected. The rate of risk is about 1 in 9.	This may be treated with antibiotics. These may be given by a drip into a vein or by mouth. The wound may need to be opened to drain.
Urinary Tract Infection	Germs enter the tube leading to the bladder and cause inflammation and infection. The rate of risk is about 1 in 20.	Mild cases may clear up without treatment. Usually antibiotics are used to treat the infection.
Possible stoma problems:
1. Loss of blood supply	1. The blood supply to the stoma may fail and cause damage to the bowel.	1. This may need further surgery.
2. Stoma Prolapse	2. Stomal prolapse when some of the bowel sticks out too far past the skin.	2. For minor prolapses, no treatment is needed. For more serious cases, more surgery may be needed.
3. Parastomal Hernia & Local Skin Irritation	3. Parastomal hernia when the bowel pushes through a weak point in the muscle wall and causes pain and bulging of the skin near the stoma.	3. Minor hernias may need no treatment. Larger hernias may need more surgery.
(Stoma is the opening of the bowel onto the skin) (Hernia is the same as a rupture)	4. Local skin irritation including reddening of the skin and a rash in reaction to the glue used to stick the stoma bag.	4. Changing the type of stomal bag usually treats this.
Postoperative bleeding	Bleeding inside the abdomen. The wound drain may measure this. The risk is about 1 in 35 to 1 in 28.	A blood transfusion may be needed to replace lost blood. Sometimes more surgery is needed to stop the bleeding.
Damage to the ureter (tube from kidney to bladder)	Rarely, during surgery, the ureter, which brings urine from the kidney to the bladder, may be damaged.	This may need more surgery.
Bladder may not empty properly or may empty without warning	A urinary bladder problem where there is abnormal emptying of the bladder. It may empty without warning or may not empty at all.	A tube (catheter) into the bladder may be used to drain the urine away.
Sexual problems	Men may be unable to get an erection or keep an erection. It may also mean that they cannot ejaculate. In women it may cause pain during or after intercourse.	For both men and women, time may improve the condition. Treatment for men may include counselling and medication. For women, counselling and use of water-soluble lubricants during intercourse may help.
Bowel blockage	Adhesions (bands of scar tissue) may develop inside the abdomen and the bowel may block. This is a short term and long term complication.	This may need more surgery.
Change in bowel habits	Bowel habits will change. Stools may be looser, smaller and more frequent. There may be some leakage of stools particularly at night depending on the type of surgery.	In most people, this improves with time, without further treatment.
Increased risk in smokers	An increased risk of wound infection, chest infection, heart and lung complications and thrombosis.	Giving up smoking before the operation will help reduce the risk.

30 day death rate: The rate of risk is about 1 in 63 depending on the type of surgery.

What happens after the procedure

After the operation the nursing staff will closely watch you until you have recovered form the anaesthetic. You may even be cared for in the intensive care unit immediatly following your surgery. The recovery period after colon surgery varies. It usually involves a stay in the hospital from 3-10 days in uncomplicated cases. On return from your surgery you will have a catheter (plastic tube) to measure and drain your urine. After surgery you will be given intravenous fluids (a drip) through which antibiotics may be given. The drip will remain in place until you are able to drink enough fluids.]

Diet

During the first few days of recovery, you will not be able to eat, until the bowel has begun to work again. You know the bowel has started to work again once you pass wind and/or have a bowel movement. You will then begin to take fluids by mouth and then solid food.

If you have a colostomy

The colostomy drains bowel waste from the bowel into the colostomy bag. Most colostomy waste is softer and more liquid than normal passed bowel waste. The thickness of the bowel waste depends on where the stoma is. You will be taught how to clean around the colostomy and change the colostomy bag.. The colostomy bag sticks to the skin around the stoma with special glue, and can be thrown away when dirty. This bag does not show under clothing and most people learn to take care of these bags themselves.

Wound

Your wound will have stitches and/or staples and is usually covered with a dressing, which may be adhesive plaster or a spray-on plastic covering.

Drain

You may also have a small tube that drains into a bottle or a bag from near your wound. This is called a drain. The wound drain removes fluid from your wound and helps with the healing process. It is taken out when the drainage has dried up.

Your lungs and blood supply

It is likely that on your return from surgery you will be wearing elastic (anti-embolism) stockings. These are tight fitting stockings that are used to reduce the risk of blood clots forming in your legs. It is very important that after surgery you start moving as soon as possible. This helps to prevent blood clots forming in your legs and possibly going into your lungs. This can be fatal.

Also you need to do your deep breathing exercises. Take ten deep breaths every hour to prevent secretions collecting in the lungs. If this happens you may develop a chest infection. At all costs, avoid smoking after surgery as this increases your risk of chest infection. Coughing is painful after abdominal surgery.

Exercise

Expect to feel tired for some time after surgery. You need to take things easy and gradually return to normal duties, as you feel able to. It usually takes at least 6 months to get over the operation. You should not drive during the first 2-3 weeks. Do not lift heavy weights for at least 6 weeks after surgery. This is to prevent a rupture where the cuts were made and allow healing to take place inside.

Tell your doctor if you have:

Large amounts of bloody leakage from the wound.
Blood in the stool.
Fever and chills.
Pain that is not relieved by prescribed pain killers.
Swollen abdomen.
Swelling, tenderness, redness at or around the cut.