Proctectomy

What is a proctectomy?

A proctectomy is a surgical procedure to remove all or part of your rectum. Your rectum consists of the last six inches of your large intestine located just above your anus. In some cases, the procedure may include removing your anal opening as well.

There are a few reasons why a proctectomy might be necessary:

• Rectal cancer: This is the most common reason for a proctectomy.
• Severe ulcerative colitis or Crohn’s disease (inflammatory bowel disease): If medication and other treatments haven’t helped manage these conditions, a proctectomy may be necessary.
• Familial adenomatous polyposis (FAP): This is a genetic condition that causes polyps to form in your colon and rectum. These polyps can become cancerous, so your provider may recommend a proctectomy to prevent cancer.

A proctectomy is a major surgery, and there are some risks associated with it, like infection, bleeding and sexual dysfunction. But it can be a life-saving surgery for people with rectal cancer or severe inflammatory bowel disease.

How should I prepare for a proctectomy?

Before a proctectomy, your healthcare provider will give you a complete physical exam to check the status of your overall health. They’ll use the results of the exam to stage your cancer (if you have it) and plan your surgery. You may also need imaging tests, blood tests and an ECG. If you haven’t gotten one already, your provider will request a colonoscopy as well.

Before surgery, you’ll have to do a bowel prep. This is essential to ensure your bowels are completely clean and cleared out before surgery. Your provider will prescribe a specific bowel prep regimen, which may involve changes to your medications and what you eat. You may also need to take laxatives or enemas.

You may need to stop taking certain medications, like blood thinners, before surgery. Discuss all medications with your provider to receive specific instructions.

Smoking can slow healing after a proctectomy and increase your risk of complications. If you smoke, your provider will recommend quitting well in advance of surgery.

Remember, the most important aspect of preparation is following your provider’s specific instructions. They’ll provide detailed information on what to expect before, during and after your surgery.

What happens during a proctectomy?

First, an anesthesiologist will give you general anesthesia. This will make you fall asleep so you don’t feel anything during the procedure.

The type of proctectomy you have will depend on the reason for the surgery and the location and size of the problem in your rectum. There are three main types of proctectomy:

• Abdominoperineal resection (APR): This is the most extensive proctectomy, removing your entire rectum, anus and sphincter muscles. Due to the removal of your sphincter muscles, you’ll need an ostomy to remove waste from your body. An ostomy is an opening created surgically, either in your ileum (lower part of your small intestine) called an ileostomy or in your colon called a colostomy. You then attach an external pouch to the opening to collect waste. You’ll need to empty this pouch regularly. Providers typically perform APR when the cancer is located very low in your rectum or has spread to your sphincter muscles.
• Low anterior resection (LAR): This surgery targets the lower portion of your rectum, aiming to preserve your sphincter muscles when possible. Depending on the remaining function of your rectum and what your surgeon recommends, you may or may not need an ostomy. If you don’t need an ostomy, your surgeon will reconnect your remaining rectum to your anus (anastomosis) to allow poop to go through the natural passage. LAR is generally preferred over APR when possible because it avoids the need for an ostomy and its associated lifestyle adjustments.
• Robotic-assisted rectal resection: This is a minimally invasive approach to a LAR procedure. It uses robotic arms for greater precision and control during surgery. Your surgeon sits at a console and manipulates the robotic arms to perform the dissection and reconnection. Potential benefits of robotic-assisted surgery include less blood loss, faster recovery time and potentially improved surgical precision.

How long does a proctectomy take?

The amount of time a proctectomy takes can vary depending on several factors, including:

• Type of proctectomy: An APR surgery, which is more complex, will generally take longer than a LAR procedure.
• Surgical complexity: The extent of the surgery itself plays a role. If there are additional procedures you need during surgery, like removing nearby lymph nodes, this will add to the operating time.
• Health factors: Your overall health and any underlying medical conditions can influence the surgery’s duration.

With these considerations in mind, a proctectomy can typically take anywhere from two to five hours. It’s important to remember that this is just a general timeframe, and the actual duration for your surgery may differ.

What happens after a proctectomy?

You’ll likely stay in the hospital for several days, up to a week, depending on your progress. Pain management will be a priority, with medication to keep you comfortable. You may have a catheter to drain urine (pee) and surgical drains to remove excess fluids from the surgical site. These are usually temporary.

You might not be able to eat solid foods at first as your digestive system recovers. You’ll gradually progress to a liquid diet and then a soft diet as tolerated. Physical therapy will be crucial to help you regain strength and mobility.

Before discharge, your healthcare team will provide detailed instructions on wound care, pain management, dietary modifications and any medications you’ll need to take at home.

What are the benefits of a proctectomy?

The benefits of a proctectomy depend on the underlying reason for the surgery.

If you have rectal cancer, a proctectomy can be a life-saving surgery by removing cancerous tissue and preventing the spread (metastasis) of cancer. Early detection and surgery significantly increase the chances of a successful outcome. Removing the cancerous rectum also lowers the risk of the cancer returning (recurring) in the future.

If you have severe ulcerative colitis or Crohn’s disease that doesn't respond to medication, a proctectomy can significantly improve your quality of life. It can alleviate chronic pain, diarrhea and bleeding. Chronic inflammation associated with inflammatory bowel disease (IBD) can lead to complications like colon cancer. A proctectomy can eliminate this risk. But having an ostomy is still a big adjustment and may take some getting used to.

If you have familial adenomatous polyposis (FAP), a proctectomy can prevent colon cancer by removing your rectum before it develops.

What are the risks or complications of a proctectomy?

As with any major surgery, a proctectomy carries potential risks and complications.

Short-term complications may include:

• Infection: With surgery, there’s always a risk of infection at the incision site or within your abdomen.
• Bleeding: Bleeding can occur during or after surgery and may require additional treatments, like blood transfusions.
• Blood clots: Sitting or lying down for extended periods after surgery can increase the risk of blood clots forming in your legs, potentially traveling to your lungs (pulmonary embolism).
• Leakage: Sometimes, the connection (anastomosis) between your remaining bowel and rectum (or the newly created pouch) may leak, requiring further surgery.
• Urinary problems: Difficulty urinating can occur due to temporary nerve irritation or trauma during surgery.

Long-term complications may include:

• Sexual dysfunction: Surgery can affect the nerves responsible for sexual function, leading to erectile dysfunction or difficulty achieving orgasm (anorgasmia).
• Bowel urgency and frequency: You may experience more frequent bowel movements and a sense of urgency following the removal of your rectum.
• Bowel incontinence: Loss of bowel control can occur in some cases, particularly with APR surgery or if your sphincter muscles are significantly damaged.
• Scar tissue (adhesions): Internal scar tissue can develop after surgery, potentially causing bowel obstructions in some cases.
• Ostomy complications: An ostomy may require revision surgery if there are issues with leakage, blockage or hernia formation around the stoma (opening).

How do you poop after a proctectomy?

Your ability to poop after a proctectomy depends on the type of surgery you had.

Proctectomy with ileostomy

If you have an ileostomy, poop will no longer pass through your rectum and anus. Instead, it will empty into a collection pouch you wear externally (outside of your body) on your abdomen. You won’t poop in the traditional sense, but you’ll need to empty the ostomy pouch regularly throughout the day. Your healthcare provider will teach you proper ostomy care, including emptying and cleaning the pouch.

Proctectomy with j-pouch

With a j-pouch, poop goes into a newly created internal pouch before elimination through your anus. You’ll have bowel movements, but they may be more frequent and urgent compared to before surgery. It may take several months for your j-pouch function to regulate, and you might experience some trial and error during this period. Your provider will give you guidance on managing your j-pouch and strategies to adjust to the new bowel habits.

Low anterior resection (LAR) without ostomy

In some cases of LAR surgery, your surgeon may be able to preserve (save) your sphincter muscles and reconnect your remaining rectum to your anus. If this is successful, you’ll likely poop similar to before surgery. But you may experience some changes in frequency or urgency at first.

What is the recovery time for a proctectomy?

The recovery time for a proctectomy can vary depending on several factors, including:

• Type of proctectomy: An APR surgery, which is more complex, will generally have a longer recovery compared to an LAR procedure.
• Presence of an ostomy: Recovery with an ostomy may be slightly faster at first as it allows your digestive system to heal without poop passing through the anastomosis (surgical connection). But long-term management of an ostomy adds other things you need to worry about.
• J-pouch surgery: If you have a j-pouch created, the recovery process is typically longer, as it involves additional adjustments to bowel function.
• Your overall health: Underlying medical conditions or a weakened immune system can impact healing time.

Here’s a general timeframe for recovery:

• Hospital stay: The average hospital stay after a proctectomy is typically three to seven days, barring any complications.
• Initial recovery: The initial recovery period at home usually lasts for four to six weeks. During this time, you’ll focus on wound healing, pain management, dietary adjustments and regaining strength.
• Returning to normal activities: Gradually returning to your usual activities can take several months. It’s important to avoid strenuous activity or heavy lifting for at least six weeks after surgery.

When should I call my healthcare provider after a proctectomy?

Following a proctectomy, it’s crucial to be aware of signs that might warrant contacting your healthcare provider. Here’s a list of situations when you should call them right away:

• Fever: A fever of 100.4 degrees Fahrenheit (38 degrees Celsius) or higher could indicate an infection.
• Pain: While some pain is expected after surgery, if it worsens significantly or doesn’t respond to medication, talk to your provider.
• Redness, swelling or drainage from the incision site: These can be signs of infection.
• Bleeding: Excessive bleeding from your rectum or the incision site requires immediate medical attention.
• Trouble peeing: If you’re unable to pee or experience difficulty peeing after surgery, contact your provider.
• Nausea and vomiting: Persistent nausea and vomiting can be signs of complications.
• Shortness of breath: This could indicate a blood clot or other serious issue.
• Bowel problems: Severe constipation, bloody diarrhea or the inability to pass poop or gas could indicate a complication.
• Leakage from the incision site: If you have an ostomy, leakage around the stoma or from your abdominal cavity requires medical attention.
• Change in ostomy function: If you have an ostomy and experience a change in the color, consistency or amount of drainage, consult your provider.

What is a total proctectomy?

A total proctectomy is a surgical procedure that removes your entire rectum (not just part of it).

What is the difference between a proctectomy and a colectomy?

A colectomy and a proctectomy are both surgical procedures that remove parts of your large intestine, but they target different sections. A colectomy removes all or part of your colon. The colon is the main part of your large intestine, responsible for absorbing water and electrolytes from digested food and forming poop. A proctectomy removes your rectum. Your rectum stores poop until you have a bowel movement.

What is the difference between a proctectomy and a proctocolectomy?

The main difference between a proctectomy and a proctocolectomy lies in the extent of the surgical removal. A proctectomy removes only your rectum. A proctocolectomy removes both your rectum and colon.