Which operation for anal cancer?

Until recently, surgery was the main treatment for anal cancer. But research has shown that for most stages of anal cancer it is better to have a combination of chemotherapy and radiotherapy (chemoradiation). If the chemotherapy and radiotherapy treatment is successful it also means that you avoid having a permanent colostomy.

If chemoradiation doesn’t cure your disease, you will then have an operation. This surgery is sometimes called salvage treatment.

The type of operation you have depends on

• Where your cancer is
• The type and size of your cancer
• Whether your cancer has spread

Before your operation, your doctor will talk to you about the best type of surgery for your cancer.

If you have a very early cancer of the anal margin, you are likely to just need surgery to remove the affected area. Your surgeon may call this operation a local resection. This operation leaves the anal sphincter (muscle) so you can control your movements as usual after the surgery. You will need to have a general anaesthetic for this operation and to stay in hospital for a few days.

When your surgeon removes your cancer they will send it to the lab so a pathologist can examine the cancer cells under a microscope. They will also check to make sure that there is an area of tissue around the cancer that doesn’t contain any cancer cells. This is known as a clear margin of tissue.

Your surgeon may call this operation an abdomino perineal resection. You may have this surgery if the cancer has come back. Or if the cancer hasn’t gone completely after chemoradiation. The surgeon will remove

• Your anus
• Your rectum
• Part of your colon

They now aim to remove the muscle tissue around the rectum as well. This is called an extralevator abdomino perineal resection. Your surgeon will use other muscle or a synthetic mesh material to help support the tissues in the lower pelvis.

They may also remove

• Some of the lymph nodes near your anus
• Possibly the lymph nodes in your groin

You may have part of this operation as keyhole (laparoscopic) surgery. The surgeon makes several small cuts in your abdomen (tummy) instead of one large cut as you'd have with open surgery. The surgeon passes a long, narrow tube called a laparoscope, and other instruments, through the cuts. The laparoscope is connected to a fibre optic camera that shows pictures of the inside of the body on a video screen. The surgeon manipulates the instruments and watch what they are doing on the screen.

You may have one slightly larger cut in your abdomen through which the surgeon carries out some of the surgery and takes out the tumour. With both open and laparoscopic surgery you will also have a wound around the anus, in the perineum.

Keyhole surgery seems to be as good as traditional open surgery at getting rid of the cancer, but the operation can take slightly longer. We know from research that people who have keyhole surgery may have less pain and get back to normal more quickly. You may also leave hospital sooner. Your surgeon will discuss the risks and benefits of both types of surgery with you.

As part of this surgery, you will need to have a colostomy. This is when part of your bowel opens out on to the surface of your abdomen. The opening is called a stoma, and you wear a bag over the stoma to collect your faeces (stools).

A specialist stoma nurse will teach you how to care for your stoma, and how to change the bags. They will also arrange the equipment you’ll need at home. Your stoma nurse is a good source of support for you while you recover from surgery and begin to adjust to living with a colostomy. The stoma nurse is experienced in looking after colostomies and teaching patients. They will probably visit you on the ward before and after your operation and will help you to learn to look after your stoma. 

At the first visit, your nurse will answer your questions and show you the type of colostomy bag you will be using at first. You will learn how the bag works and how to fit and empty it. The stoma nurse or ward nurse will look after your colostomy and change your bag for the first few days. Gradually, you will be encouraged to take over.

If you have any questions about colostomy, contact the Colostomy Association. They will be happy to try to help you.