Patient Information


The prospect of undergoing surgery or having tests can be frightening. At the Section of Colon & Rectal Surgery, we believe that greater understanding of medical procedures can allay many fears.

UNDERSTANDING SURGERIES & TESTS

At the Section of Colon & Rectal Surgery, we respect our patients and encourage them to ask questions. Below are answers to some of the most frequently asked questions.

ASK THE DOCTOR

The following links will help you and your family expand your knowledge of your illness and of the treatment options available to you.

Helpful Links

We know that medical terms can be confusing and difficult to remember, so we have provided a list of common terms and there definitions.

GLOSSARY OF MEDICAL TERMS

Is this Surgery Right for Me?

Every person is unique. That's why no two individuals will respond exactly the same to a specific medication, and not everyone is a candidate for a particular surgery.

For some people with disease of the lower rectum, an "anal sparing" operation may offer an alternative to a permanent colostomy.


During colorectal or coloanal anastomosis surgery, the surgeon removes all or part of the diseased rectum. However, the anal muscles are left intact so that elimination remains relatively the same.


This article will talk about the reasons for colorectal or coloanal anastomosis surgery, what you may expect, and the benefits and risks of this operation.

Be sure to explore your options with your physician.


What are the reasons for colorectal or coloanal anastomosis surgery?
Reasons for this surgery as well as some reasons not to have the surgery (contraindications) are summarized in the table below.


              Reasons for Surgery 

  • Cancer
  • Removal of giant polyps
  • Rectal prolapse
  • Reconstruction for people who have illnesses such as diverticulitis or Crohn's colitis and who have had a colostomy


             Contraindications

  • If cancer is present in the anal muscle
  • Damaged anal muscles in which the patient has no bowel control, (i.e., injuries due to childbirth, old age, or a combination of both)


What are the potential risks for patients undergoing colorectal or coloanal anastomosis surgery?
For people who are otherwise healthy, infections are considered the most common potential risks. They may include:

  • wound infections
  • urinary tract infections
  • pneumonia, and
  • intra-abdominal infections if the area of surgery doesn't heal properly.


What are the benefits of this surgery?
The absence of a permanent ostomy eliminates the concern of many people about their body image. Satisfaction with this procedure has been high.


Remember!
Life after colorectal or coloanal anastomosis surgery is different. It will take time, patience, and trial and error to adjust to this lifestyle change. See "Life After Colorectal or Coloanal Anastomosis Surgery" for tips on managing your pouch, follow-up screenings, and more.

If you would like, your surgeon can arrange for you to meet someone else who has had colorectal or coloanal anastomosis surgery. Often patients who have had this surgery offer to speak to other patients about their experiences.


Knowledge Is Power
Your surgeon, her nurse and assistants are always happy to answer any questions you or your family may have about colorectal or coloanal anastomosis surgery and the recovery process. Together, you and your doctor can determine whether this operation is right for you.


The Surgical Procedure

What can I expect during colorectal or coloanal anastomosis surgery?

Depending on your disease, either the upper part of the rectum (colorectal anastomosis) or the entire rectum is removed through an incision in your abdomen. If the entire rectum is removed, the surgeon connects the colon to the anus (coloanal anastomosis).


Generally, if more than half of the rectum is removed, a colon pouch ("J-pouch") is created. The J-pouch becomes a reservoir for waste and replaces the function of the rectum that was removed. The surgeon constructs the pouch from about 2-4 inches of colon (large intestine) and attaches it to the remaining rectum or to the anal muscle if the entire rectum has been removed.


In many cases, a temporary "loop" ileostomy is created. This allows waste to be diverted into an external pouch, while the surgical area heals without the danger of irritation or infection from bacteria in stool. The loop construction of the stoma allows for a simpler reversal of the ostomy with less pain and a shorter recovery time.


Remember!

A temporary loop ileostomy is just that: temporary. If you have a temporary loop ileostomy, it's important to protect the skin around the ostomy. Be sure to see "Going Home: Part III" for how to care for your temporary ileostomy.


What is the difference between colorectal and coloanal anastomosis surgery?

A brief comparison of each operation is outlined below.


              Colorectal Anastomosis

  • Disease limited to the upper half of the rectum
  • Only the diseased portion of the rectum is removed. The colon (large intestine) is connected to the remaining rectum.
  • Temporary loop ileostomy only occasionally necessary if the area of bowel connection is low, if there has been an infection, or if you had radiation to the surgical area because of rectal cancer.


              Coloanal Anastomosis

  • Extensive disease or disease involvement of the lower rectum
  • The entire rectum is removed-leaving the anal muscle intact. The colon (large intestine) is connected directly to the anal muscle.
  • Temporary loop ileostomy is usually created because the connection is extremely low-and the colon is actually sewn to the anal muscle.


How long will the operation take?

Generally, the amount of time required to perform the surgery can be as short as three hours or as long as six hours. This depends on your condition, the number of previous operations, and the complexity of the surgery.


How quickly can I expect to recover from surgery?

The speed of your recovery depends on many factors, including your disease state, your age, and your overall health.


Remember!

Everyone recovers at his or her own pace. Try not to compare yourself to others in similar situations because what may apply to one person may not apply to you.


To learn more about what you may experience post-operatively, check out "After Colorectal or Coloanal Anastomosis Surgery: Recovery in the Hospital."


Will there be a follow-up surgery?

If you have a temporary ileostomy, you will have a second surgery about eight weeks later to reverse it. You may be relieved to know that the second surgery is a much shorter operation with a more rapid recovery time. This is because the incision for the closure of the ileostomy, which is just around the stoma, is smaller-about two inches wide.


In some cases; however, your surgeon may have to reopen the first incision to clear out some scar tissue. It is common for scar tissue to form in the bowel as part of the healing process. Removing the scar tissue will help ensure that the intestine is able to function properly.


You'll find helpful information about preparation and recovery in "The Second Surgery".

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Preparing for Colorectal or Coloanal Anastomosis Surgery

Always Be Prepared
It's normal to feel anxious and to have questions when you are facing any kind of surgery. A little preparation can go a long way towards helping your surgery and recovery go as smoothly as possible.


First, jot down a list of questions in advance to discuss with your surgeon and nurse. Don't be shy: there are no "stupid questions." If it is important to you, it is important to your doctor.


Many people find it helpful to have a family member or friend attend the meeting with the doctor before surgery. When you are feeling anxious, it is natural to forget what the doctor tells you. By writing down his or her response to your questions or by having a friend with you, you can be sure to remember everything.


Second, be sure to carefully follow the instructions your surgeon gives you.


Third, inform your surgeon of any special needs you may have-from diet to medications.


             Medicines

  • Discuss with both your doctor and anesthesiologist (the physician who will be putting you under for the operation) any prescription, over-the-counter medicines, vitamins, and herbal supplements that you take.

    Aspirin and some other over-the-counter drugs can interfere with blood clotting and cause increased bleeding during surgery. This is also true some of herbal supplements, (i.e., St. John's Wort, Ginkgo biloba, and others).

    You may want to simply write out a complete list with the dosages. Make a few copies: one for the surgeon, one for the anesthesiologist, one for the nurse, and an extra that you should keep on hand. Or, if it is easier for you, bring all your medications, over-the counter medicines, vitamins, and herbal supplements when you visit the surgeon prior to your surgery.


  • If you are taking medications, check with your primary care physician to see if you must take the medication or if you can skip it on the day of surgery. For instance, if you are taking blood pressure medicine, your doctor may tell you to take it on the morning of your surgery with a small sip of water.

    If you have diabetes, be sure to check with your doctor about taking your medication - whether it be insulin or pills. Your doctor will tell you how to adjust your dosage for surgery.


  • Be sure to tell the anesthesiologist if you have ever had a bad reaction to any kind of anesthesia.
  • Let your doctor know what pain medication has worked for you in the past and which pain medicines have not.


             Allergies/Adverse Drug Reactions

  • Tell both your doctor and anesthesiologist if you have drug allergies or other allergies. Be sure to relate any bad reactions to certain medicines you have experienced in the past. For instance, some people cannot take the pain reliever codeine because it makes them nauseous. Other people are allergic to penicillin.

    You may want to write up a list of allergies and give copies of the list to the surgeon, anesthesiologist and the nurse.


             Exercises

  • Your surgeon may prescribe special exercises to help strengthen your anal muscle before your operation.


             Diet

  • The day before surgery, you will be on a clear liquid diet.
  • You also will be given a bowel preparation and an antibiotic. Be sure to follow the instructions for both.
  • Remember to have nothing to eat or drink after midnight before your surgery - unless your doctors have told you to take specific medications. This includes chewing gum, mints, and hard candies.


             Hospital Stay

  • In most instances, you will come to the hospital the day of your surgery.
  • The enterostomal therapist (ET) or ostomy nurse will see you that morning. She will mark the location of the temporary ostomy in case one is needed. Your ostomy nurse will discuss the operation and answer any questions you may have. After your surgery, she will instruct you on the care of your stoma.
  • You may want to have someone stay with you during the first night after your surgery. Ask your doctor or nurse if this is possible.
  • Plan on a five (5) to seven (7) day hospital stay.
  • If you have a stoma, home health nursing will be arranged while you are in the hospital. We strongly recommend home health care to ensure that you know how to care for your temporary ostomy in the postoperative period.


When it comes to your medical needs, you are your own best advocate. Be open and honest with your physician. Share your feelings about the operation. It may be reassuring to know that satisfaction with this procedure has been high. The absence of a permanent ostomy has eliminated the concern of many people about their body image.


Finally, remember to enlist the aid and support of family, friends, and qualified members of your personal healthcare team. Together, you can help to ensure the best surgical outcome. For any questions about your surgery, it is always best to contact your physician.


After Surgery: Recovery in the Hospital

Low colorectal or coloanal anastomosis surgery is a two-step process. Depending on your disease, the first surgery removes a portion of the rectum or your entire rectum and reconnects the bowel to the remaining rectum or the anal muscle.


During the procedure the surgeon also creates a temporary "loop" ileostomy to allow the bowel to heal. The second surgery, which usually takes place six to eights weeks later, reverses the "loop" ostomy.


In this article, we will talk about what you can expect to experience following the first surgery—colorectal or coloanal anastomosis surgery.


Everyone's experience is different. Much of what you experience will depend on your disease state, your age, and your overall health.


Be sure to give yourself time to mentally prepare for what you may experience postoperatively. Share your feelings about the operation with your doctor and nurse. Express your concerns before and after surgery. That's what your healthcare team is there to address.


Pain

Unfortunately, everyone will experience a certain amount of pain postoperatively. Yet, your medical team can do a lot to help make you more comfortable.


Most patients choose a PCA (patient controlled analgesia) pump to achieve optimum pain relief.


The pump allows you to administer pain medicine at set intervals—every 10 or 15 minutes—through your intravenous (IV) line. Your nurse can adjust your dosage up or down, according to your individual needs.


Some patients choose an epidural catheter for pain relief, as is commonly done for pregnant women who are in labor. A small tube is inserted into the back, and pain medication is delivered to this area.


Remember: There is no reason for you to suffer needlessly in pain. Let your surgeon or nurse know right away if your pain medication is not working effectively, so he or she can make the necessary adjustments.


Intravenous Lines & Tubes

  • Do not be afraid if you wake up with an intravenous (IV) line. It is there to provide fluids, medicines, and, in some cases, nutrients until you are well enough to take them orally.
  • You also will have a bladder catheter (tube) in place. The catheter is inserted during surgery to keep the bladder empty throughout the operation. Afterwards, it helps keep you comfortable until you are strong enough to get up and go to the bathroom. Usually, the catheter is removed on the second or third day after surgery.
  • Temporary drainage tubes are inserted during the operation to remove fluids or bloody drainage. These will help the area to heal properly. Drainage tubes are usually removed between the third and fifth day following surgery.
  • Lastly, you may have a sore throat because of a tube that helped you breathe during surgery. Lozenges and anesthetic sprays can help soothe your throat.


The tubes are only temporary. However, they are necessary for you to heal and help minimize the potential risk of infection.


Discharge from the Anal Area

Your anal muscles were stretched during surgery. Therefore, it is common to experience some anal leakage. Swelling can also contribute to anal leakage —much like a swollen hand, your anal muscles cannot grip tightly.


The drainage can be watery to bloody. This is normal. It can also have a strong odor and look like stool. This drainage may continue until the ileostomy is reversed in the second operation.


Remember: It takes time for the anal area to heal. For added comfort, some patients find that a cotton pad helps—especially at night. The most absorbent and least expensive pads are pressed cotton "make-up removal" pads that are sold in the cosmetics area of most grocery or drug stores.


Diet

Initially, after surgery you will not be allowed to eat or drink until bowel function returns. You will be able to have ice chips and will continue to receive intravenous fluids. In fact, most people are not hungry following surgery.


How soon bowel function returns varies among individuals, which is normal. For some people, bowel function returns in 24 hours, while in others it may take several days.


Most folks wonder how they can have a bowel movement when they have not eaten in days. This is possible because you produce a quart of digestive juices every day, whether you have eaten or not. The passage of this liquid waste is a sign that your bowel function has returned.


Once bowel function has returned and you are not nauseated, you can expect your diet to be gradually advanced - beginning with clear liquids (i.e., chicken broth, Jell-O, popsicles). You will graduate to full liquids (i.e., ice cream, milk, cream soups) and then soft, bland foods (i.e., eggs and toast). This is your meal ticket home.


Remember: Most people don't have much of an appetite at first. It is best to begin your intake slowly. Eat and drink what you can, but do not force yourself to eat. And be sure to chew your food thoroughly.


Restrictions

With a temporary ileostomy, it is best to proceed slowly with any bulky fiber in your diet. Non-digestible dietary fiber can cause a food blockage in the small bowel near the abdominal wall or stoma.


             Foods to Avoid  

  • Seeds
  • Nuts
  • Coconut
  • Popcorn
  • Raisins
  • Oranges
  • Food skins 
  • Meat with casings (i.e., sausages)
  • Celery
  • Carrots
  • Broccoli
  • Cauliflower
  • Raw mushrooms
  • Chinese vegetables


 

Remember: If you had to restrict your diet before your surgery because of diabetes, heart disease, high blood pressure or other medical reasons, you will have to continue to do so.


Getting Out of Bed
On the first day after surgery, your healthcare team will help you get up to walk. Pain medication might be given beforehand to make it more comfortable for you.

Even if you can only take a few steps in the beginning, walking is important for the recovery process. It also helps decrease the risk of pneumonia as well as other postoperative complications. Additionally, walking helps bowel function to return more quickly.


What You Should Do

  • To get out of bed, turn to your side and use your arm to push up, avoiding strain on your abdomen.
  • Deep breathing exercises are important to prevent pneumonia after surgery. Periodically, let out your breath and inhale as deeply as you can, let the air out slowly. Repeat 3 times in a row. You will probably be given a small breathing exercise device that will help you with this.
  • If you need to cough, bend your knees up, and press a pillow to you stomach and hug it as you cough.


Remember: Everyone heals at his or her own pace. Try to eat sitting up in the chair, rather than in bed. Walk as much as you can. Don't be shy to ask the nurse for assistance if you need it. Every step, however large or small, counts towards your recovery.


Ostomy Nurse
During your hospital stay the enterostomal therapist (ostomy nurse), will teach you how to care for your stoma, advise you where to buy your ostomy supplies, and address any other personal concerns you may have.

Remember: If you have any questions, your ostomy nurse is just a phone call away.


Reaching Out
You may have periods of depression, either while in the hospital or after your return home. It may be reassuring to know that your enterostomal therapist is there to provide support and can even arrange for you to meet someone else who has had colorectal or coloanal anastomosis surgery.

Sometimes, talking to someone who has "been there" and is now living a happy, active life may be a great source of comfort and encouragement to you.


Remember: You have just had a major operation—a grieving process is normal. Don't keep feelings bottled up—express your feelings and go with your emotions. Talk to your spouse, a close relative, or friend who can listen. Most importantly, be patient with yourself, adjusting to a different lifestyle takes time and perseverance.


We're Here for You
Your doctor, her nurse and assistants are always happy to answer any questions you or your family may have about colorectal or coloanal anastomosis surgery and the recovery process.


Remember: Read and discuss the postoperative instructions with your nurse. Ask questions if you are unsure about something or need further explanation. There is no such thing as a "stupid question." If it's important to you, it's important to your doctor.


Going Home
You will be discharged in four to seven days, when you are eating and not showing any sign of infection. You will be given a prescription for pain medication. Before you are discharged, your physician and nurse will arrange for home healthcare, if needed in your case.

You also should be given the name of the agency and its telephone number should you need assistance before the first visit.


Remember: Call your physician or nurse if you experience any problems after you get home.


Postoperative Appointment
Be sure to contact your surgeon's office if you have not received a postoperative appointment. Most appointments are within two to three weeks of discharge from the hospital.


Remember: You must bring all of your ostomy supplies needed for a change of your ostomy pouch with you to your surgeon's office so that he or she can examine your stoma. Your pouch will also need to be refitted.

Being informed about your surgery, asking questions, and sharing your feelings will help your recovery go as smoothly as possible.


Post-Operative Care at Home and Managing Your Temporary Ileostomy

When most people go home after colorectal or coloanal anastomosis surgery, they feel both tremendous relief and some anxiety. Glad to be home, they often worry about coping with the after effects of surgery and caring for their temporary ileostomy. Though all this is normal, try to relax.


Care at home is no different than what you were doing in the hospital. Moreover, thousands of people have gone through the same surgery and have successfully managed their homecare.


Remember: You are not alone. Help is only a phone call away. Home health agencies have someone you can talk to 24 hours a day, and they will send nurses out to assist you. You should also feel free to call your surgeon.

In most instances, you'll find answers to your questions in the guidebooks and instructions you received when you were in the doctor's office and the hospital.


The following links will provide you with some tips and suggestions that should help you through your post-operative recovery at home.


          Going Home: Part I 

  • Your Emotions
  • Talking with your Children
  • Pain
  • Gas
  • Diet
  • Fluids & Hydration


          Going Home: Part II 

  • Dehydration
  • Diarrhea
  • Infection


          Going Home: Part III 

  • Loop Ileostomy Care
  • The Stoma
  • Blockages


 Going Home: Part IV 

  • Activities
  • Hygiene
  • Sex


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The Second Operation

 

The second surgery to reverse the ileostomy is a much shorter operation with a more rapid recovery time. This is because the incision for the closure of the ileostomy, which is just around the stoma, is smaller —about two inches wide.


Following these tips and knowing what to expect can help you as you prepare for your second operation.


Toning Up
Usually, about four weeks after your initial surgery—when postoperative swelling has resolved—your medical team will encourage you to start to do exercises to improve the tone of your anal muscles. Strengthening these muscles will help you to regain control of your bowel function.


Anal Sphincter Toning Exercises

  1. Tighten the anus as you would when trying to hold back a bowel movement.
  2. Hold for a count of ten (10) and repeat five (5) times.
  3. Repeat this exercise four times daily.


Do not be discouraged if you can only tighten your anal muscles for a count of five at first. You will slowly be able to reach the count of ten.


Do not overdo this exercise. Too much exercise can tire the muscle and can keep it from working well.


The Second Operation
You may feel relieved to know that the procedure to reverse your temporary ileostomy is much easier on your body than the first operation because of the smaller incision.


Do not be alarmed if your surgeon tells you that he or she had to reopen the first incision to clear out some scar tissue. It is common for scar tissue to form in the bowel as part of the healing process. Removing the scar tissue will help ensure that the intestine is able to function properly.


You can expect to be in the hospital for about three or four days.


Preparation
Though you will not have to take a bowel cleansing preparation before the second surgery, you will have to begin a clear liquid diet (i.e., chicken broth, popsicles, and tea) the day before your surgery.


Remember: Unless doctors have told you to take specific medicines, you should have nothing to eat or drink after midnight before your surgery—including chewing gum, mints, and hard candies.


Postoperative Recovery
Pain medication will be given postoperatively; however, it may be comforting to know that the pain will be milder this time.


As with the first operation, a bladder catheter (tube) will be inserted during surgery. It is usually removed the first or second day after surgery.


Your first meal will be clear liquids—and will gradually advance to a regular diet.


Remember: The postoperative recovery time is shorter. Nevertheless, it's important to understand that life after colorectal or coloanal anastomosis is different. Try to be gentle with yourself—developing coping strategies takes considerable time and perseverance.


Life After Coloanal or Colorectal Anastomosis Surgery

 

It may be reassuring to know that satisfaction with this procedure has been high. The absence of a permanent ostomy has eliminated the concern of many people about their body image. However, it will take time, patience, and trial and error to adjust to this lifestyle change.


Anal/Pouch Bleeding
In the beginning, don't be afraid if you experience a small amount of bleeding around the anal area. This is normal and is usually caused by irritation at the suture line (your stitches).


Diarrhea
The frequency and consistency of bowel movements varies from patient to patient. Usually the first bowel movement occurs two to three days after the operation. Pressing a pillow against your abdomen can help ease the discomfort, from your incision.


What You Should Do

  • If you had a coloanal anastomosis, it is important that you continue to exercise your anal muscles. Begin this practice after you are discharged from the hospital. The stronger the muscle, the better control you will have.
  • Call your doctor if you have more than six stools a day. He or she will prescribe medication to help decrease the diarrhea and increase the bulk.
  • Thin or watery stools are difficult to hold. Bulking agents, (i.e., Citrucel) antidiarrheal medicines (i.e., Imodium, Lomotil) and change in diet—eating foods such as rice, that bind the bowel movements can often resolve this.


Incontinence
If you had a coloanal anastomosis, it is normal to have some incontinence and/or leakage—most frequently at night. It may be reassuring to know that over time, this will resolve.


Minor nighttime incontinence is the most common, and you should be prepared for this. The leakage will improve as the anal muscle strengthens. If you need added protection, pressed cotton makeup removal pads are the most absorbent. Place one of these in front of the anal area. Be sure to change the pad each time you urinate or have a bowel movement.


You may find that is difficult to tell the difference between gas and stool. This can be a frustrating experience. Be patient with yourself, you will gradually learn to tell the difference again.


Remember: It is common for it to take about six months to be able to tell the difference between gas and stool.


Irregularity
Irregularity, while bothersome, is common after this surgery. You may experience what's known as an "all or nothing" pattern of irregularity for about 8 to 12 weeks following surgery. This is because the colon that is connected to the lower rectum or anal muscles has not yet had a chance to stretch.


It is not unusual to have very frequent bowel movements one day and then none the next day. Do not be alarmed if it takes several hours to empty your bowels with multiple small bowel movements—this is normal.


This phase will pass. After surgery, it is important to use Citrucel (or other fiber products) and antidiarrheal medicines (i.e., Imodium, Lomotil) to adjust bowel frequency so that you have 2 - 4 bowel movements every day and avoid the "all or none" pattern. This will help the colon stretch more quickly so that your bowel movements become regulated.


Skin Care
It is very important to keep the anal area free from irritation and itching. An irritated anal area is more likely to send confusing signals and trigger more incontinence.


What You Should Do

  • Examine your skin and notify your surgeon's office if you see any rashes.
  • Do not wipe the anal area with harsh toilet paper. Use baby wipes instead, which are more suited for delicate skin.
  • Be sure to rinse the anal area with warm water and pat dry.
  • Wearing cotton underwear will allow air to get to the area so that your skin will not get too moist.
  • Your surgeon may recommend some soothing ointments. There are many products that might be helpful, (i.e., Calmoseptine or Criticaid).


Remember: Continue to follow this skin care routine for two to three months after surgery—when the number of bowel movements decreases.


Long Term Concerns
If you had a precancerous condition or had cancer, follow-up is very important. You should ask what the recommended follow-up is in your situation. Most often, your physician will recommend the following:


  • Blood Work: CBC (complete blood cell counts), CMP (a group of blood tests that measures kidney and liver function, as well as the level of protein in your blood), and CEA (a marker for colorectal cancer or recurrent colorectal cancer) every three months for the first three years. Then every six months the next two years, then annually thereafter.
  • Chest X-ray: Every six months for the first two years, then annually thereafter.
  • Colonoscopy: One year after surgery, then every two years thereafter if polyps are found.


Everyone who has had this procedure should be sure to carefully follow the advice your surgeon and nurse have given you. Don't be shy to ask for help when you need it. Enlist the support of family, friends, and qualified members of your healthcare team.


Remember: Motivation, determination, and regular follow-up screening are key to help ensuring the best surgical outcome.


For any questions about your surgery or your follow-up, it is always best to contact your physician.


 

Addendum: Life After Coloanal or Colorectal Anastomosis Surgery

The adjustment period following the closure of the temporary ileostomy can be a frustrating time. This phase will pass—usually within three months—and you will be able to enjoy what matters to you most: family life, work, and play.


Typically, during the adjustment period, you will experience irregularity and diarrhea. In this guide, we will discuss these problems and what steps you can take to help the recovery process.


First, it is important to understand why your bowels are not functioning properly.


The rectum, which is about the size of a melon, works as one single coordinated muscle to empty bowel contents. During your surgery, part of your rectum or the entire rectum was surgically removed, and the upstream colon was brought down and sewn to the lowermost portion of the rectum or to the anal muscle. As a result, the colon must now take over the function of your rectum. However, the colon normally has more of a mixing function than a pushing function—it sloshes bowel contents back and forth—and does not empty bowel contents as well as the rectum.


The goal of the adjustment period is to train the colon to take over the pushing function of the rectum, and to empty more completely and regularly.


Remember: Everyone is different. The adjustment period can be as brief as one or two months, but for most it is about three months.


Note: Chemotherapy causes a significant amount of diarrhea, so if you are taking chemotherapy, your adjustment period will take longer. Indeed it will likely begin after you have completed chemotherapy.


Keep a Diary
Your surgeon or gastroenterologist will be better able to regulate your bowel function if you keep a diary of how many times you move your bowels during the day and at night. It is also important to record if you are having accidents or problems controlling your bowel movements.

Be sure to document what kind of antidiarrheal medications you are taking—i.e., loperamide (Imodium®) or diphenoxylate and atropine (Lomotil®).


How to Improve Bowel Function
By working together with your doctor, you can help regulate your bowel function. Your physician may recommend any of the following, depending on your individual case.

  • Slow It Down
    If you experience diarrhea, your doctor may prescribe one of two common medications.

    Lopermide (Imodium®) is available over-the-counter without a prescription at most pharmacies and grocery stores. Your physician will tell you how many tablets to take. Usually you will start out with one 2 mg tablet daily, which your doctor may gradually increase, according to your response to the medicine. Lopermide works best if taken 15-20 minutes before a meal.

    Diphenoxylate and atropine (Lomotil®) is a prescription medication that is also effective for treating diarrhea. Typically, one lopermide tablet is equivalent to one diphenoxylate and atropine tablet; however, in some people, one medication may work better than the other. This medication also works best if you take it 15-20 minutes before a meal.

    Note: Frequently, people who have had radiation, for example, to treat a rectal cancer, will need the addition of an antidiarrheal. This is because the radiation may have caused a slight burn injury to the small bowel resulting in more frequent stools.


  • Add Fiber
    Most people have small hard bowel movements after total removal or resection of the rectum. The use of fiber products add bulk to your stool to make it easier for the colon to eliminate. Although capsule or tablet fiber products may be easier to take, they may not work as well as powder formulations. While most of these formulations work well, products such as psyllium (Metamucil®) tend to cause more gas than the ones that contain methylcellulose, (i.e, Benefiber®, Citrucel®).

    Note: Fiber products tend to work differently depending on how much water and other liquids you drink during the day. Too much liquid can increase the number of bowel movements, while less fluid will "chunk up" the stool making it difficult to eliminate. The goal is to have less frequent, fluffier, more consistent stools that are easier to pass. You will have to experiment with the amount of water or other fluids you take with the fiber to achieve this. If psyllium works well for you, it does come in the form of a “cookie” that allows you to take it with very little fluid and has the beneficial effect of increasing the bulk of bowel movements.


  • Enema Therapy
    If fiber products and antidiarrheals alone do not help adjust the ability of the colon to empty, small volume generic saline enemas (Fleet®) will help the colon empty more effectively. You may take these either every day or every other day. Importantly, you take these even if you move your bowels. This is because without the enemas, only a small percent of the bowel’s contents empty and stool backs up. In a few days, you would have severe diarrhea as the bowel empties out uncontrollably. Taking the enemas regularly prevents this problem from occurring.

    In many circumstances, enema therapy may be necessary in order to permit you to empty your colon completely and have the remainder of the day free from any bowel activity.

    Usually, enema use is only temporary. However, some individuals may have better results if they continue using enemas on a long-term basis.


  • Change the Consistency
    Sometimes it may be necessary to try a drug that changes the consistency of stool to make it more liquid to facilitate emptying, such as lubiprostone (Amitiza®). This is a prescription medication for constipation, which, in some people who have emptying problems, when taken in a low dose (8 micrograms) at bedtime will help the colon empty more effectively.


  • Get It Moving
    Rarely, it may be worthwhile to consider a "prokinetic" drug that helps the colon empty. Currently, the only way to obtain this medication is to apply to the Food & Drug Administration (FDA) for special permission to use tegaserod (Zelnorm®). This is extremely difficult to obtain. Still, tegaserod is very useful in patients with emptying problems that have not responded to conventional therapies.


Remember: Your recovery will take time and perseverance. Working in partnership with your physician will help ensure you have the best outcome possible. If you have any questions, your healthcare team is just a phone call away.

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