Yes, it is entirely possible to live without a rectum, though the body’s method of waste elimination must be surgically altered. The rectum, the last six inches of the large intestine, acts primarily as a temporary storage reservoir for stool before expulsion through the anus. This capacity allows for the controlled, voluntary timing of bowel movements, a function lost when the organ is removed. The surgical procedure to remove all or part of this organ is medically termed a proctectomy, requiring surgeons to permanently change the digestive system’s plumbing through diversion or reconstruction.
Reasons for Rectal Removal
The decision to remove the rectum is made when the organ is severely diseased, damaged, or cancerous. Rectal cancer is the most frequent reason for a proctectomy, especially when tumors are located low in the rectum near the anal sphincter muscles. Removing the cancerous tissue with a clear margin is necessary to prevent the disease from spreading.
Severe cases of Inflammatory Bowel Disease (IBD) are another common indication, particularly Ulcerative Colitis (UC) that has failed to respond to medical treatment. Since chronic inflammation and ulceration associated with UC can affect the rectum extensively, removal eliminates the risk of colitis-associated cancer. Crohn’s Disease may also necessitate removal if the rectum is severely affected or if perianal disease is refractory to other treatments.
Less frequent causes include Familial Adenomatous Polyposis (FAP), a genetic disorder that causes numerous polyps with a high risk of becoming malignant. A proctectomy may also be required following severe traumatic injuries to the pelvis or in cases of complicated infections where the rectal tissue is necrotic or beyond repair.
Surgical Procedures for Bowel Diversion and Reconstruction
Once the rectum is removed, the surgeon must create a new pathway for waste to exit the body. The choice of procedure depends on the underlying disease, the patient’s anatomy, and the condition of their anal sphincter muscles.
The primary form of diversion is the end ileostomy, often necessary after a total proctectomy that includes the removal of the anus and sphincter muscles, known as an Abdominoperineal Resection (APR). In this procedure, the end of the small intestine (ileum) is brought through an opening in the abdominal wall, forming a stoma. Waste, which is liquid or semi-liquid, passes continuously into an external appliance.
Alternatively, many patients are candidates for internal reconstruction, most commonly the Ileo-anal Pouch Anastomosis (IPAA), or J-pouch procedure. This option is preferred because it allows the patient to continue passing stool through the anus, avoiding a permanent external stoma. The surgeon constructs a new ‘J’-shaped reservoir from the ileum, which is then connected directly to the remaining anal canal, replacing the storage function of the removed rectum.
The J-pouch surgery is often performed in two or three stages. A temporary diverting ileostomy is placed for several months to allow the new pouch to heal completely without exposure to the fecal stream. Once healed, a second operation closes the temporary ileostomy and restores continuity, allowing waste to flow into the internal pouch. This reconstruction technique preserves continence.
Functional Outcomes and Lifestyle Adjustments
Life without a rectum requires adjustments, regardless of whether a stoma or a J-pouch is created. With an ileostomy, the output is liquid and frequent, requiring the patient to empty the external pouch several times a day. The primary daily task for an ostomate involves managing the appliance, including emptying, cleaning, and changing the pouch and wafer barrier on a regular schedule.
Patients with an internal J-pouch also experience frequent, loose bowel movements. Since the small intestine is not designed for stool storage, the pouch must be emptied more often than the original rectum, and the stool consistency remains soft. Medications like loperamide or fiber supplements are often used to reduce frequency and thicken the output, helping to improve continence.
A major concern for J-pouch patients is perianal skin irritation, as the small intestine’s output contains highly irritating digestive enzymes. Management involves meticulous hygiene, such as gentle blotting or washing with water instead of wiping, followed by the application of protective barrier creams. Dietary modifications are also necessary to manage output and avoid blockages, especially post-operatively.
Foods high in insoluble fiber must be limited, as they can cause a painful obstruction in the narrow opening of the stoma or pouch.
- Nuts.
- Seeds.
- Corn.
- Raw vegetables.
Highly acidic or spicy foods can increase the irritating nature of the output. Eating smaller, more frequent meals and limiting stimulating foods like caffeine and sweet items helps to regulate the flow and consistency of the waste.
Long-Term Health Considerations
While a proctectomy is life-saving, it introduces long-term health issues. For patients with a J-pouch, the most common complication is pouchitis, an inflammation of the internal reservoir that causes increased frequency, urgency, and abdominal discomfort. Pouchitis is usually treated with antibiotics, though chronic cases may require complex medical management.
Patients with a permanent ostomy face the risk of developing a parastomal hernia, where the intestine bulges through the weakened abdominal muscle wall adjacent to the stoma. Small bowel obstruction is a risk for both ostomy and J-pouch patients. These obstructions can be severe and may require further surgical intervention.
Nutritional deficiencies are a long-term concern, particularly for Vitamin B12, as its absorption occurs almost exclusively in the terminal ileum, the section of the small intestine often used in reconstruction or diversion. Up to 50% of patients may be affected by B12 deficiency. Regular monitoring and periodic B12 injections are necessary to prevent neurological complications.
The extensive pelvic dissection required during a proctectomy carries a risk of damaging the nerves that control sexual and urinary function. Men may experience erectile dysfunction, and women may experience dyspareunia or pain during intercourse. For women of childbearing age, the surgery can lead to adhesions that may block the fallopian tubes, potentially increasing the risk of infertility. Newer minimally invasive surgical techniques may help to reduce the incidence of these complications.