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".
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
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.
