What is a Proctectomy?
A proctectomy is a surgical procedure that involves the removal of part or all of the rectum, which is the lower portion of the large intestine. This procedure is typically performed to treat conditions that affect the rectum, such as rectal cancer, inflammatory bowel disease (such as ulcerative colitis or Crohn's disease), or severe rectal prolapse.
Causes for Proctectomy
Several medical conditions may necessitate a proctectomy, including:
- Rectal Cancer: Proctectomy may be recommended for patients with rectal cancer, particularly in cases where the tumor is large, has invaded nearby tissues, or has spread to nearby lymph nodes. Depending on the stage and location of the cancer, either partial or total proctectomy may be performed.
- Inflammatory Bowel Disease (IBD): Severe cases of inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, may require proctectomy. In ulcerative colitis, for example, inflammation and ulceration can affect the rectum extensively, leading to symptoms like rectal bleeding, diarrhea, and pain. If medical treatments fail to adequately control symptoms or if complications such as dysplasia (precancerous changes) develop, proctectomy may be necessary. In Crohn's disease, proctectomy may be needed if the rectum is severely affected and other treatments are ineffective.
- Rectal Prolapse: Rectal prolapse occurs when the rectum protrudes through the anus, often causing discomfort, difficulty with bowel movements, and leakage of stool. Severe cases may require surgical intervention, including proctectomy, to repair the prolapse and restore normal rectal function.
- Trauma or Injury: Traumatic injuries to the rectum, such as those resulting from accidents or physical trauma, may require surgical removal of damaged portions of the rectum.
Benefits of a Proctectomy
Proctectomy with total mesorectal excision (TME) is a surgical technique used specifically for the treatment of rectal cancer. It involves the complete removal of the rectum along with the surrounding fatty tissue called the mesorectum, which contains the lymph nodes draining the rectum. Here are some of the benefits of TME proctectomy in rectal cancer treatment:
- Improved Oncological Outcomes: TME proctectomy is associated with improved oncological outcomes, meaning it offers better chances of removing all cancerous tissue and reducing the risk of cancer recurrence compared to other surgical techniques. By removing the rectum along with the entire mesorectum containing lymph nodes, surgeons can ensure thorough cancer removal and reduce the likelihood of cancer cells spreading to nearby tissues or lymph nodes.
- Lower Rates of Local Recurrence: Complete removal of the rectum and surrounding lymph nodes through TME proctectomy significantly reduces the risk of local recurrence of rectal cancer. By meticulously dissecting along the mesorectal plane, surgeons aim to remove the tumor along with a sufficient margin of healthy tissue, minimizing the chance of leaving cancer cells behind.
- Preservation of Anal Sphincter Function: TME proctectomy aims to preserve anal sphincter function whenever possible, allowing patients to maintain better bowel control and quality of life after surgery. Surgeons may perform sphincter-preserving techniques such as low anterior resection or coloanal anastomosis to create a new connection between the remaining colon and anus, avoiding the need for permanent colostomy (stoma).
- Reduced Risk of Distant Metastasis: By removing the primary tumor and nearby lymph nodes, TME proctectomy reduces the risk of cancer cells spreading to distant sites in the body (distant metastasis), thus improving long-term survival outcomes for patients with rectal cancer.
- Enhanced Pathological Staging: TME proctectomy provides a clear surgical specimen for pathological examination, allowing accurate staging of the cancer based on the extent of tumor invasion, involvement of lymph nodes, and presence of other features that may influence prognosis and treatment decisions.
- Potential for Neoadjuvant and Adjuvant Therapies: TME proctectomy is often performed as part of a multimodal treatment approach for rectal cancer, which may include neoadjuvant (preoperative) chemotherapy or radiation therapy to shrink the tumor before surgery and adjuvant (postoperative) therapy to reduce the risk of cancer recurrence. Complete tumor removal through TME proctectomy optimizes the effectiveness of these additional treatments.
Risks Factors of a Proctectomy
Proctectomy, like any major surgical procedure, carries certain risks and potential complications. Some of the risks associated with proctectomy include:
- Infection: There is a risk of developing infections at the surgical site or within the abdomen, which may require antibiotics and additional treatment.
- Bleeding: Bleeding can occur during or after surgery, which may necessitate blood transfusions or additional surgical intervention to control.
- Blood Clots: Blood clots (deep vein thrombosis or pulmonary embolism) can form following surgery, particularly if the patient is immobile for an extended period. Blood thinners and mobility measures are often used to prevent this complication.
- Anastomotic Leak: In procedures where the remaining bowel is reconnected (anastomosis), there is a risk of leakage at the site of the connection. This can lead to infection, abscess formation, and potentially require additional surgery.
- Urinary Dysfunction: Some patients may experience difficulty with urinary function after proctectomy, such as urinary retention or incontinence.
- Sexual Dysfunction: Proctectomy, especially in cases where nerves are affected, can lead to sexual dysfunction, including erectile dysfunction in men or pain during intercourse.
- Bowel Dysfunction: Changes in bowel habits, such as diarrhea, constipation, or urgency, can occur after proctectomy, particularly if the rectum is removed or the anal sphincter function is affected.
- Stoma Complications: In cases where a permanent or temporary stoma (artificial opening) is created, complications such as stoma prolapse, retraction, or skin irritation can occur.
- Chronic Pain: Some patients may experience chronic pelvic or abdominal pain following proctectomy, which may require ongoing management with medications or interventions.
- Scar Tissue Formation: Scarring at the surgical site can sometimes lead to adhesions, which are bands of tissue that can cause organs or tissues to stick together, potentially leading to bowel obstruction or chronic pain.
- Nerve Damage: There is a risk of injury to nearby nerves during surgery, which can result in numbness, tingling, weakness, or loss of function in the affected area.
- Anesthetic Complications: Risks associated with anesthesia, such as allergic reactions, respiratory problems, or adverse drug reactions, can occur during proctectomy.
What To Expect During a Proctectomy
A proctectomy can be performed using various surgical approaches, depending on factors such as the patient's condition, the extent of surgery required, and the surgeon's expertise. Here are the common surgical approaches for proctectomy:
- Open Surgery: In an open proctectomy, the surgeon makes an incision in the abdomen or the perineum (the area between the anus and genitals) to access the rectum and surrounding structures. This approach allows for direct visualization and manipulation of tissues but may involve a longer recovery time and increased postoperative pain compared to minimally invasive techniques.
- Laparoscopic Surgery: Laparoscopic proctectomy is a minimally invasive technique that uses small incisions and specialized instruments equipped with cameras to perform the surgery. The surgeon inserts a laparoscope (a thin tube with a camera) and other instruments through small incisions in the abdomen to visualize and manipulate the rectum and surrounding structures. Laparoscopic proctectomy offers advantages such as reduced postoperative pain, shorter hospital stays, and quicker recovery compared to open surgery.
- Robotic-Assisted Surgery: Robotic-assisted proctectomy is a variation of laparoscopic surgery where the surgeon controls robotic arms equipped with surgical instruments and a camera system from a console. This approach provides enhanced dexterity, precision, and visualization compared to traditional laparoscopy, potentially allowing for more complex surgical maneuvers and improved outcomes.
- Transanal Minimal Invasive Surgery (TAMIS): TAMIS is a specialized technique used for selected cases of early-stage rectal cancer or rectal polyps. It involves the insertion of an endoscope through the anus to visualize and excise lesions located within the rectum. TAMIS is minimally invasive and can be performed on an outpatient basis in certain cases.
Your surgeon will discuss the most appropriate surgical approach for your individual case and explain the potential risks and benefits associated with each technique.
Does Proctectomy Require an Ostomy?
Whether a proctectomy requires an ostomy depends on several factors, including the reason for the proctectomy, the extent of the surgery, and the surgical technique used. In some cases, no ostomy is required. In other cases, patients may require either a temporary ileostomy or a permanent colostomy.
- Low Anterior Resection (LAR): In some cases, only a portion of the rectum may need to be removed. In these situations, the colon can be reconnected to the remaining portion of the rectum (colorectal anastomosis) or to the anal canal (coloanal anastomosis). Depending upon certain risk factors (length of remaining rectum, radiation, malnutrition, tobacco use, diabetes, blood supply), your surgeon may decide the fecal diversion is necessary. Fecal diversion is typically accomplished with a temporary ileostomy. To create an ileostomy, a segment of ileum (small intestine) is brought through the abdominal wall as an ostomy to collect stool in an ostomy appliance.
- Abdominoperineal Resection (APR): In some cases, the entire rectum and anal canal may need to be removed. This may be recommended for patients with tumors involving the anal canal muscles or for patients with poor anorectal sphincter function for whom a low colorectal or coloanal anastomosis would result in unacceptable risk of fecal urgency or incontinence. In these cases, the entire rectum and anal opening are removed. Skin on the patient’s bottom is closed eliminating the anal opening. The upstream colon is brought through the abdominal wall as a colostomy to facilitate elimination of stool.
Your surgeon will discuss the potential need for an ostomy with you before the proctectomy and explain the implications and management of an ostomy if necessary.