Shah's Gastro, Cancer & Robotic Surgery Centre · Ahmedabad & Gandhinagar
The part of a lower rectal cancer operation that is explained afterwards far too often, and belongs in the conversation before it. Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad.
When a cancer in the lower rectum is removed and the bowel is joined back to the anal canal, the reservoir that used to hold stool has gone. What follows is called Low Anterior Resection Syndrome — LARS: stools that come more often, arrive with little warning, and cluster together over an hour or two rather than being passed once. To some degree it affects most people who have a join made this low. It settles substantially over the first year to two years, and there is real treatment for it. None of that is a complication or a surgical error — it is the predictable consequence of keeping the anus, and it is one half of the choice a patient is actually being asked to make at consent. This page explains what LARS is, what changes it, and how the choice between a low join and a stoma is put honestly.
Shah’s Gastro, Cancer & Robotic Surgery Centre. Training is in surgical gastroenterology specifically — a super-specialty in the gastrointestinal tract rather than general surgery with an interest in it. The rectum, colon, stomach, pancreas and food pipe are the whole of the practice. Bowel function after a low join is therefore not an unfamiliar conversation held once a year; it is part of nearly every rectal cancer follow-up.
Dr Harsh Shah
MS, MCh (Surgical Gastroenterology), DrNB (Surgical Gastroenterology)
Registered with Gujarat Medical Council, Reg. No. G-38738
Colorectal Cancer Surgeon · Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad
Google rating 4.89 from 216 reviews at the Gota clinic, and 4.94 from 17 reviews at Apollo, Bhat.
The surgeon who counsels you about bowel function before the operation is the surgeon who sees you in follow-up when you are living with it. That continuity matters here more than in almost any other operation, because the treatment of LARS is a series of adjustments made over months rather than a single prescription.
Every lower rectal cancer is discussed at a tumour board before any plan is offered, and function is part of that discussion rather than an afterthought to it: whether a patient will tolerate a low join is as much a part of planning as whether the tumour allows one.
The rectum is not just a tube. It is a soft, stretchable store that lets you know stool has arrived and lets you decide when to pass it. Remove the lower rectum for cancer and join the colon to the anal canal, and the store is gone while the sensing and the muscle remain. The result is urgency, frequency, clustering, occasional leakage and a feeling of never quite being finished. Those symptoms together are LARS.
Patients describe it more accurately than textbooks do. Stool comes in a rush. Two or three visits follow each other within the hour and then nothing happens for a long stretch. Wind and stool become hard to tell apart. Some people cannot reliably hold on long enough to reach a bathroom, particularly in the first months and first thing in the morning.
Two things are worth saying plainly. It is common — most people with a join made this low have some of it, a minority severely enough to shape daily life. And it improves: the colon adapts, sensation recalibrates, and the picture at one year is usually very different from the picture at one month. Improvement is not universal and not always complete, which is exactly why the conversation belongs before the operation.
Function follows the height of the tumour. The higher in the rectum a cancer sits, the more rectum is left behind to act as a store, and the less bowel disturbance follows. A cancer in the lower rectum leaves little or none — so a low join, a temporary ileostomy and a period of LARS are the package, while a permanent colostomy avoids the urgency altogether. Which package is even available is decided by an examination and a pelvic MRI, not by preference.
The distance from the anal verge is measured on a rigid scope, because a flexible scope follows the curve of the bowel and reports a tumour as higher than it is. The MRI must state whether the sphincter and the levator muscles are involved — the single line most often missing from a report sent to us. And the strength of the squeeze is assessed by hand before anything is planned, because a low join in someone whose continence was already poor buys the worst of both worlds.
| What is found | Operation considered | Bowel habit afterwards |
|---|---|---|
| Cancer in the upper or middle rectum, sphincter uninvolved | Anterior resection with part of the mesorectum removed and a join well above the anal canal | Some urgency early on; most people settle close to their old pattern |
| Cancer in the lower rectum, sphincter not invaded, squeeze good | Low anterior resection with total mesorectal excision, a join to the anal canal, and a temporary ileostomy | LARS expected — frequency, urgency and clustering, improving over the first year to two years |
| Cancer into the outer sphincter or levator, or continence already weak | Abdominoperineal excision | A permanent colostomy: predictable, no urgency, no join to leak |
| No tumour felt, nothing seen on endoscopy and no residual disease on MRI after treatment | Close surveillance instead of surgery, for a patient who can attend it | Normal bowel habit preserved, in exchange for a strict programme of examinations and scans |
The third row is the one patients push back on hardest, and the honest answer is that a permanent bag is not the worse outcome for everyone. A predictable appliance emptied on your own schedule is, for some people — a farmer far from a bathroom, a teacher who cannot leave a classroom, an older patient with a weak sphincter — easier to live with than urgency that cannot be planned around.
Where both operations are oncologically sound, the choice is not “stoma or no stoma”. It is a predictable appliance against unpredictable urgency. Put that way, patients choose well. Put as “we can save your anus”, they choose the words rather than the life, and some of them are unhappy a year later about a decision nobody explained to them.
The cancer operation itself does not change with that choice. In either case the rectum comes out inside its intact fatty envelope with a clear rim of normal tissue all around the tumour, and the pathologist grades that envelope afterwards — a grade Dr Harsh Shah treats as a personal audit rather than a formality. What the choice changes is what the next two years feel like, so the consent conversation covers work, travel, toilet access, who is at home during the day and how far you live from the hospital.
Nothing done in theatre abolishes LARS, because the cause is the loss of the rectum itself. What careful dissection protects is the nerves for bladder and sexual function, which run millimetres from the plane of dissection — the same plane that gives the better cancer specimen, which is why the operation is converted to open if that plane is being lost. Robotic and laparoscopic approaches are both used, the robot has a real advantage deep in a narrow male pelvis, and the choice is made after the examination and the MRI rather than promised in advance.
A loop of small bowel is brought to the skin so stool bypasses the healing join for some weeks. It does not prevent a leak; it changes what a leak means — a problem managed on the ward instead of an emergency operation. It is closed at a second, much smaller operation once healing has been confirmed and any chemotherapy is finished, usually a few months later.
The stoma is sited and marked by the stoma nurse with the patient sitting, standing and bending — a stoma placed in a skin crease is the commonest reason a bag will not stay on. Going home is then decided by whether you or your family can change the appliance unaided rather than by the state of the abdomen.
The part patients are least prepared for is the week after the ileostomy is closed. That is when LARS announces itself, because until then the join has not been carrying stool. People told about bowel function beforehand take that week in their stride; people hearing it for the first time understandably feel something has gone wrong. Ask at the first consultation for the closure to be planned in principle — a temporary stoma nobody has scheduled to close has a habit of becoming permanent by default, and that is a failure of organisation rather than of surgery.
Radiotherapy improves local control in a higher-risk lower rectal cancer, and it also has lasting effects on bowel, bladder and sexual function and on fertility. Where the risk profile allows it, chemotherapy alone before surgery — with radiotherapy held in reserve for a poor response — spares those effects. That is a real decision taken at the board, worth understanding rather than accepting silently.
Three consequences deserve stating. Radiotherapy makes eventual bowel function somewhat worse than the same operation without it. It affects fertility and can bring on early menopause, so fertility preservation must be raised before treatment starts and cannot be recovered later. And surgery is deliberately scheduled some weeks after radiotherapy ends, because operating into a freshly irradiated pelvis raises the risk to the join — the wait is part of the plan, not a delay in it.
★★★★★
“I was operated by Dr. Harsh Shah for rectal cancer, and I am extremely grateful for his expertise and care. He is highly skilled, very approachable, and explained every step of the treatment and surgery in detail, which gave me a lot of confidence. The surgery went smoothly, and my recovery has been excellent under his guidance. In my experience, he is truly the best rectal cancer surgeon in Ahmedabad, and I would strongly recommend him to anyone looking for the best cancer care.”
— Ramniwas Sharma, Google review
★★★★★
“One of my relatives was operated on by Dr. Harsh Shah, and we are very happy with the results. After the surgery, she is recovering well and doing great. Dr. Harsh Shah’s expertise, guidance, and care made a big difference throughout the treatment. He is truly the best rectal cancer surgeon in town, and we are grateful for everything he has done. Thanks for truly guidance and support 🙏Highly recommended.”
— Kamini Chaudhary, Google review
★★★★★
“My brother in law operated by Dr harsh shah. After surgery now he is fine. Thank u so much sir. Dr harsh shah is best Rectal cancer surgeon in Ahmedabad.”
— Kishorbhai Vaghasiya, Google review
Reviews are reproduced exactly as written on Google, including the original spelling and spacing.
A patient of Dr Harsh Shah describes his own recovery after rectal cancer surgery, in his own words. The account is in Hindi.
LARS is treated, not merely endured, and the treatment is a sequence rather than a single prescription: bulk the stool and slow the bowel, retrain the pelvic floor, then add irrigation or nerve stimulation for the minority who need more. Most people work through the first two steps and never need the third.
The first step is the least glamorous and the most effective. Loose, frequent stool is easier to hold when it is bulked with soluble fibre and slowed with a simple anti-motility medicine taken before meals rather than after an accident — timing matters more than dose. Identifying the two or three foods that reliably provoke clustering is worth more than a general diet sheet.
The second step is pelvic floor rehabilitation with a physiotherapist, with or without biofeedback. It works best started early and continued for months, and it is routinely skipped because nobody refers for it. Ask for the referral. For the few with severe symptoms after a year, rectal irrigation taught by a stoma nurse or sacral nerve stimulation makes a substantial difference; and for a very few, a stoma made later by choice is the right answer, offered without any suggestion of failure.
The questions that matter most are about function and about who decides. A second opinion on a lower rectal cancer is worth taking before treatment starts, because the hardest decision to reverse is one taken on an incomplete MRI report — and because a patient who was never told about LARS cannot consent to it.
Bring the MRI images on a disc or drive rather than the report alone, the colonoscopy and biopsy reports, and a list of current medicines. Expect a digital rectal examination at that consultation — a second opinion given without one is an opinion about a piece of paper.
The cost is not one figure. It moves with the room category, the length of stay, whether the operation is robotic or laparoscopic, whether intensive care is needed, and whether radiotherapy and chemotherapy fall in the same episode. A written estimate is given before admission, and the office states what is inside it and what is not.
Apollo Hospital, Bhat, is empanelled with the major insurers and cashless schemes and the office handles pre-authorisation directly; send policy details with the reports. Two costs are regularly forgotten and should be budgeted from the start: the second admission to close the ileostomy, and stoma appliances in between. Bring imaging on a disc or drive, previous discharge summaries, medicines with doses, insurance card and identification, and one family member as the point of contact.
No. It is the expected consequence of removing the lower rectum and joining the bowel to the anal canal — the store that regulated stool has gone. It is not evidence that anything was done badly, and it is one of the two things a patient is choosing between at consent.
Usually, and substantially, over the first one to two years as the colon adapts. It may not return completely to how things were. Bulking agents, timed anti-motility medicine and pelvic floor physiotherapy all help, and there are further options for the minority with severe symptoms.
Because until then the join was not carrying stool. The first week after closure is when the new pattern shows itself. Expecting that week makes it far easier to live through.
For some people that is the better life, and it is offered without any suggestion of defeat — particularly where continence was already weak, or where daily work makes urgency impossible to manage. The comparison to weigh is a predictable appliance against unpredictable urgency, and it is a decision to take with your family rather than in the last five minutes of a clinic.
No. No approach removes it, because the cause is the loss of the rectum itself. What careful dissection in the correct plane protects is the pelvic nerves, and therefore bladder and sexual function — a different and equally important thing.
Shah’s Gastro, Cancer & Robotic Surgery Centre — Gota, Ahmedabad
Consultations, examination, review of reports, bowel-function follow-up and surveillance.
Google: Dr Harsh Shah · 4.89 from 216 reviews
Directions to the Gota clinic
Apollo Hospital — Bhat, Gandhinagar
Admission, surgery and inpatient care.
Google: Dr Harsh Shah – Robotic GI Surgeon · 4.94 from 17 reviews
Directions to Apollo, Bhat
Patients travel to Ahmedabad for rectal cancer surgery from across Gujarat — Gandhinagar, Mehsana, Nadiad, Anand, Banaskantha, Bhavnagar, Rajkot, Jamnagar and Kutch — and from southern Rajasthan and western Madhya Pradesh. Send the MRI ahead on WhatsApp.
More on Dr Harsh Shah’s work in gastrointestinal cancer: rectal cancer treatment · colon cancer treatment · stomach cancer treatment.
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