Rectal Cancer Surgery: Colostomy vs. Anorectal Function Preservation

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• Treatment Goals: Cure is the Primary Objective
• The Impact of Multimodality Treatment on Function
• Understanding Low Anterior Resection Syndrome (LARS)
• Patient Choice: Stoma vs. Impaired Function
• Tailoring Therapy for the Individual Patient
• The Crucial Role of Informed Consent

Treatment Goals: Cure is the Primary Objective

Dr. Torbjorn Holm, MD, states that the primary goal in rectal cancer treatment is always to cure the patient. This fundamental objective guides all subsequent decisions regarding surgery, radiation therapy, and chemotherapy. Dr. Torbjorn Holm, MD, explains that if a surgeon believes a good total mesorectal excision (TME) can be achieved without adjuvant therapies, this approach should be pursued to reduce postoperative morbidity and side effects.

However, when radiotherapy and chemotherapy are necessary to increase the chance of a cure, they must be used. This sets the stage for a critical discussion with the patient about the trade-offs involved, particularly concerning long-term bowel function.

The Impact of Multimodality Treatment on Function

The combination of radical surgery, radiation, and chemotherapy significantly impacts anorectal function. Dr. Torbjorn Holm, MD, is clear that there are no patients who undergo this full multimodality treatment and emerge with good anorectal function. The extensive therapy damages nerves and tissues, leading to inevitable impairment.

This poor functional outcome is a well-studied consequence. Dr. Torbjorn Holm, MD, notes that this reality makes it extremely important to avoid unnecessary radiotherapy and chemotherapy, using them only when the oncological benefit for the rectal cancer patient is unequivocal.

Understanding Low Anterior Resection Syndrome (LARS)

Low Anterior Resection Syndrome (LARS) is a common condition after rectal cancer surgery with anastomosis. It encompasses a range of debilitating symptoms, including fecal incontinence, urgency, clustering of bowel movements, and emptying difficulties. A clinical trial from Denmark developed the LARS scoring system to objectively measure this loss of function.

Dr. Torbjorn Holm, MD, references this study, confirming that the majority of patients score quite poorly, indicating a significant reduction in their quality of life. The symptoms can be so severe that they dictate a patient's daily schedule and social activities.

Patient Choice: Stoma vs. Impaired Function

Faced with the prospect of life with LARS, some patients actively choose a permanent colostomy. Dr. Holm observes that in Sweden, a number of patients prefer a stoma because it offers predictability and control, which can be easier to manage than the unpredictable and urgent nature of LARS.

This choice highlights a key paradigm shift: a permanent colostomy is not always viewed as a worst-case outcome. For some, it represents a preferable alternative to the constant anxiety and disruption caused by poor native bowel function after cancer treatment.

Tailoring Therapy for the Individual Patient

Dr. Torbjorn Holm, MD, emphasizes that treatment must be meticulously tailored for each individual with rectal cancer. The decision to use or omit radiation and chemotherapy is a delicate balance between maximizing the chance of cure and minimizing long-term functional morbidity.

This personalized approach requires sophisticated preoperative staging and a multidisciplinary team discussion. The surgeon’s skill in performing a precise TME operation is paramount, as a successful surgery alone can sometimes avoid the need for additional treatments that compromise function.

The Crucial Role of Informed Consent

The entire process hinges on thorough and honest patient information. Dr. Holm stresses that it is crucially important to inform patients about the high likelihood of developing LARS if they proceed with low anastomosis after multimodality treatment. Patients must understand the realistic outcomes for both anorectal function and the possibility of requiring a permanent stoma.

This informed consent conversation allows patients to participate in their care decisions. As Dr. Anton Titov, MD, discusses with Dr. Torbjorn Holm, MD, empowering the patient with this knowledge ensures they are prepared for life after rectal cancer treatment, whether that involves managing a stoma or coping with the challenges of LARS.

Full Transcript

Dr. Anton Titov, MD: When is colostomy a better alternative after rectal cancer surgery? When can permanent colostomy be avoided? What is the quality of anorectal function after radical surgery for rectal cancer? What is LARS (Low Anterior Resection Syndrome)? What are the alternatives to colostomy for rectal cancer? Permanent colostomy or not? Anorectal function after rectal cancer surgery.

Preserving anorectal function in colorectal cancer patients after surgery is very important. A stoma is not always needed. Anorectal function or the need for a stoma is a significant factor in the quality of life for colorectal cancer patients.

The surgical operation for colorectal cancer affects anorectal function. The type of surgical operation a rectal cancer patient has affects anorectal function or the need for a colostomy. Also, radiation therapy side effects and potential complications from radiotherapy for colorectal cancer treatment affect anorectal function or colostomy requirement.

Dr. Anton Titov, MD: How do you select the type of treatment for rectal cancer patients with the goal of preserving anorectal function after the treatment? When is colostomy required in rectal cancer?

Dr. Torbjorn Holm, MD: The need for colostomy after rectal cancer treatment is a very good question. It is a very difficult question because the primary goal in the treatment of colorectal cancer is to cure the patient. That's the primary goal.

Sometimes you need to give radiotherapy and chemotherapy to colorectal cancer patients to increase the chance of cure from rectal cancer. If you think you don't need radiotherapy or chemotherapy for rectal cancer, and you think you can do a good total mesorectal excision surgical operation without radiation therapy or chemotherapy, then you should do it because you reduce the postoperative morbidity.

You reduce the complication rate and side effects of multimodality treatment of colorectal cancer. But if you have to use radiotherapy and chemotherapy in colorectal cancer treatment, you should use it. Then you have to inform the colorectal cancer patient about this.

A combination of total mesorectal excision surgery with low anterior resection and anastomosis and radiotherapy with chemotherapy will result in poor anorectal function. It may require a permanent stoma.

There are no patients who had TME surgical operation and chemotherapy with radiotherapy who have good anorectal function after colorectal cancer treatment. All patients have some impaired anorectal function. This has been studied very thoroughly.

Dr. Anton Titov, MD: Recently there was a clinical trial on anorectal function after colorectal surgery from Denmark. They invented the low anterior resection syndrome system (LARS system). They developed a scoring system for the quality of anorectal function after colorectal cancer multimodality treatment.

You score the anorectal function in a rectal cancer patient after treatment. It is then obvious that the majority of patients have quite poor anorectal function.

Dr. Torbjorn Holm, MD: But on the other hand, it's very difficult to keep good anorectal function without a colostomy after extensive rectal cancer treatment. Extensive cancer therapy includes surgical operation, radiation therapy, and chemotherapy. That's why it is so important to inform the patient.

You inform the patient about the likelihood of poor anorectal function after rectal cancer treatment. Some patients may actually prefer to have the permanent colostomy placement, the stoma. Colostomy in many situations is easier to treat than this LARS (Low Anterior Resection Syndrome).

When a patient is without a colostomy, the patient has to go to the toilet very often. Patients without a stoma have to be aware everywhere of where the toilets are. Maybe patients without a stoma after rectal cancer treatment cannot go to the theater or to a dinner because suddenly you have to go to the toilet very quickly.

Sometimes the cancer surgeon informs the patient about this situation. Some patients, at least in Sweden, actually prefer to have a permanent stoma after rectal cancer treatment. It is better to have a permanent colostomy than to have poor anorectal function.

So it is extremely important to tailor radiation therapy and chemotherapy and surgery for the individual rectal cancer patient. Don't use chemotherapy and radiotherapy if you don't need it. But unfortunately, most patients with rectal cancer will need both surgery and radiation therapy and chemotherapy.

Anorectal function after such multimodality rectal cancer treatment will not be perfect. That's just the way it is. Sometimes it's better to have permanent colostomy placement. It is not good to have bad anorectal function after rectal cancer treatment. But the information of patients about stoma or no stoma options is crucially important.

Dr. Anton Titov, MD: What are the alternatives to colostomy for rectal cancer? Are you better with a permanent ostomy after rectal cancer surgery? How good is anorectal function in low anastomosis?