ozziej wrote:I had a supposedly benign sessile low rectal polyp removed by EMR. Turned out it was malignant, moderately differentiated but with no lymphovascular involvement, T1/2. Margins were clear. I was immediately referred to a colorectal surgeon. He gave me two options: ULAR or APR (would only know once he was in there), or watch and wait (no chemo or radiation). He emphasized that not harvesting lymph nodes meant there was a possibilty of microscopic invasion that couldn't be identified by scanning. He said that if it did return that the success rate of salvage surgery was about 50%. He asked me if i was a gambler. I wasn't, so i chose the surgery. Ended up with a ULAR so no permanent colostomy but I had a temporary ileostomy for about 12 weeks. O/25 lymph nodes positive. The ileostomy was relatively easy to manage. I had this reversed about 2.5 years ago. No sigmoid colon or rectum, straight coloanal anastomosis. Life since reversal has been a rollercoaster. LAR/ULAR carries a real risk of ending up with LARS (Low Anterior Resection Syndrome), which I now have. LARS of varying degrees is an outcome for about 80% of people with low rectal cancer who have an LAR/ULAR. The lower the anastomosis the more likely you will have LARS. Given that your polyp was in the sigmoid colon your odds of having normal function after surgery are better, though not 100%. Since my surgery i have done my own extensive research on low rectal cancer. Seems to me that most research is definitely being directed towards watch and wait, with chemo used for T1/2 where the plan is not to do a resection. There are also alternate full thickness procedures that fall short of resection but have good oncological outcomes without the risk of poor functional outcomes. There is very little research into improving treatment for LARS. Many people with LARS report that once the reversal is performed they receive little support from the colorectal world and are perhaps better served by gastroenterology.
This is an agonizing decision which only you can make. My heart goes out to you as i remember how difficult it was for me to choose. It is hard to find psychological support when many professionals are still operating under the belief that all colorectal surgery results in a permanent stoma. There is now a predictive tool available online called POLARS. It enables you to get an estimate of the likelihood of your surgery resulting in LARS. This may help in your decision making. I wish you all the best whichever option you choose.
I was stage 2 so I was not given many options. It was chemo/rad, surgery with temp ileo, chemo, then reversal. Well after the chemo/rad sigmoidoscopy showed only scar tissue remained. Surgeon said still do surgery as that the only way to know if lymph nodes are involved for sure, but may not need chemo after if no cancer cells remained. There were minimal residual cancer cells remaining so had to do chemo. That was disappointing. I did have a bowel blockage 4 weeks after my resection and spent 3 1/2 weeks in the hospital ending up with surgery to remove scar tissue and early ileo reversal since he was going in anyway. I was happy about the reversal but did make it more difficult during chemo as I had diarrhea issues. I dealt with LARS syndrome for awhile and finally went to University of Michigan bowel control clinic about 15 months after reversal and 8 months after finishing chemo. After physical therapy, working with a dietician, and a couple tests, the Dr. there suggested using enemas, suppositories, or daily miralax to try and get total evacuation once or twice a day rather than many small bowel movements. I chose to do daily enemas as I have complete control, takes about 30 minutes a day, and I am free the whole day.
I'm not sure if I would've been a candidate for watch and wait after chemo/rad. Since the sigmoid only showed scar tissue, and pet scan showed no cancer, I think if offered I may have done it. But now knowing there were still some cancer cells remaining I'm glad I had the surgery. Also, I agree there does not seem to be a lot of help regarding LARS. My gastro basically told me take citrucel, limit immodium and be patient. The bowel control clinic really helped me, but I had to research myself to find it as my cancer was not treated as U of M. Their solutions were very helpful, and when I told my surgeon I was incorporating the daily tap water enema and feel so much better he was okay with it. It did help me gain some weight back, not stress, just lead a normal life. So besides the fact I have to do it, it has been quite positive. It is difficult to make decisions and measuring possible outcomes. When I was told I should do chemo after surgery, my oncologist said even though my risk of recurrence was low, she didn't what me to wonder "what if" if there was a recurrence. So I went ahead. Good Luck.