Colonic J-pouch Anastomosis Research Articles

Colonic J-pouch anal anastomosis after ultralow anterior resection with upper sphincter excision for low-lying rectal cancer

There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CAA) in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CAA in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vs the straight CAA. Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire (Fecal Incontinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales). We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo after ileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown. Furthermore, we found that FISI scores highly correlated with FIQL scales. This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE for low-lying rectal cancer.

Is routine pouchogram prior to ileostomy closure in colonic J-pouch really necessary?

Colonic J-pouch with coloanal anastomosis has gained popularity in the surgical treatment of middle and lower rectal pathologies. If a diverting ileostomy is performed, a pouchogram is frequently performed prior to ileostomy closure. The aim of this study was to assess the routine use of pouchogram prior to ileostomy closure in patients with colonic J pouch-anal anastomosis. All patients who underwent a colonic J pouch-anal anastomosis between 1990 and 2000 were retrospectively reviewed. Patients with temporary loop ileostomy who had pouchogram prior to ileostomy closure were included. Pouchogram results were compared to the patient's post ileostomy closure clinical outcome. Sensitivity, specificity and predictive values of pouchogram were assessed. Eighty-four patients had a pouchogram prior to ileostomy closure. Radiological abnormalities were evident in 6 patients, including 4 strictures, 1 pouch-vaginal fistula and 1 leak. Of these findings, 4 were false positives (3 strictures and 1 leak) and two were true positives (1 stricture and 1 pouch-vaginal fistula). The actual rate of pouch complications was 9.5% (8 complications) including 3 anastomotic leaks, all with normal pouchogram, 3 strictures requiring dilatation under anaesthesia, only one detected by pouchogram, and 2 pouch-vaginal fistulas, only one diagnosed by pouchogram. The sensitivity and specificity of pouchogram, respectively, was 0 and 98% for anastomotic leak, 33 and 96% for stricture, and 50 and 100% for pouch-vaginal fistula. Overall, pouchogram changed the management in only 1 of 84 patients. Pouchogram has a low sensitivity in predicting complications following ileostomy closure in patients after colonic J-pouch anal anastomosis and rarely changes the management of these patients. The use of pouchogram prior to ileostomy closure may be unnecessary and should be reserved in cases of clinical suspicion of complications.

Ultralow anterior resection with intersphincteric dissection--what is the limit of safe sphincter preservation?

In the treatment of low rectal cancer, the possibility of sphincter preserving surgery is increased by partial sphincteric resection which may allow an oncologically safe resection margin in some patients who would traditionally have been treated by abdominoperineal resection. The aim of this study is to evaluate the morbidity, mortality and the oncological and functional results of intersphincteric resection to determine whether the technique may be considered a safe means of sphincter preservation. Between May 1992 and December 1999, 26 patients (mean age 55 years, range 28-82) with adenocarcinoma of the rectum had partial sphincteric resection by an abdominal approach with a colonic J-pouch anal anastomosis. The mean distance between the tumour and the anal verge 4.25 (range 3.1-5.25) cm. Four tumours were T1, 14 T2 (3 N+), 7 T3 (3 N+), and 1 T4 (N+). Neoadjuvant radiotherapy was used in 10 patients. The distal resection margin was positive in one patient who then proceeded to safe abdominoperineal resection (APR). In the remaining patient the mean distal resection margin on the fixed specimen was 1.6 (range 0.3-3.5) cm. There were no deaths. Morbidity was 30% with an anastomotic leak rate of 11%. At mean follow-up of 39 (range 11-93) months the local recurrence rate was 3.4%. Functional results were evaluated in 25 patients at mean follow-up of 27 (8-66) months: 65% had 0-2 bowel motions per 24 h, 31% had 3-5 and 4% between 6 and 9. Nine patients (36%) had nocturnal defecation. Continence was normal in 50% with 23% reporting incontinence to gas and 27% reporting minor episodes of incontinence. None had major incontinence and 85% considered their outcome satisfactory. This study supports the current literature indicating that partial sphincteric resection is an oncologically and functionally safe alternative to abdominoperineal resection for some selected low rectal tumours.

Comparison of Defecatory Function After Colonic J-Pouch Anastomosis and Straight Anastomosis for Stapled Low Anterior Resection: Results of a Prospective Randomized Trial

Although defecatory function after low anterior resection for rectal cancer is reported to be better following colonic J-pouch than straight anastomosis, few prospective randomized trials comparing the two forms of anastomosis have been reported. We performed a prospective randomized trial comparing straight anastomosis with colonic J-pouch anastomosis both clinically and physiologically in patients undergoing stapled low colorectal anastomosis. A total of 42 consecutive patients were intraoperatively randomized to undergo either straight anastomosis or colonic J-pouch anastomosis. Clinical defecatory function was evaluated by a questionnaire answered preoperatively, then 6 and 12 months postoperatively. Anorectal physiological assessment was also carried out before surgery, then 12 months postoperatively. The clinical defecatory function assessed 6 months and 12 months after surgery did not differ between the two groups. However, while the length of high-pressure zone was significantly shortened, and (neo)rectal capacity was significantly reduced postoperatively in the straight group, none of these physiological parameters were significantly altered in the pouch group. Although the aim of colonic J-pouch to preserve reservoir function was physiologically achieved, the improvement in clinical defecatory function was not significant. Thus, further prospective studies are needed to confirm the functional superiority of colonic J-pouch anastomosis for stapled low colorectal anastomosis after low anterior resection.

Rectal excision and colonic pouch-anal anastomosis for rectal cancer: oncologic results at five years.

Preservation of the anal sphincter is now accepted as a primary aim in surgical treatment of rectal cancer. The use of colonic J-pouch-anal anastomosis after complete rectal excision is one method that permits retention of continence without compromising oncologic principles. This study aimed to assess carcinologic results of rectal excision followed by colonic J-pouch anal anastomosis, with particular reference to rate of locoregional recurrence. From 1984 to 1990 complete rectal excision and colonic pouch-anal anastomosis were performed in 167 patients for cancer of the middle or low rectum. A total of 154 patients were followed for this study for a minimum of five years, with evaluation of the frequency of locoregional recurrence. Sixty-five patients died during the period of surveillance, giving a five-year survival rate of 68.8 percent. Twenty patients (13 percent) presented with locoregional recurrence at an average of 31 months after surgery. In 11 cases (7 percent) the local recurrence was not associated with metastatic disease, and six of these patients underwent further curative surgery. These results confirm that coloanal anastomosis after complete rectal excision is a valuable option in the surgical treatment of rectal cancer and is accompanied by a frequency of isolated locoregional recurrence of less than 7 percent, of which half underwent surgical resection with curative intent.

Functional Results of Colonic J-Pouch Anastomosis for Rectal Cancer

Functional Results of Colonic J-Pouch Anastomosis for Rectal Cancer

Late functional outcome following pre or post-operative radiotherapy after rectal excision for cancer and reconstruction with colonic J-pouchanal anastomosis (CPAA)

Late functional outcome following pre or post-operative radiotherapy after rectal excision for cancer and reconstruction with colonic J-pouchanal anastomosis (CPAA)

Effects of Aging on the Functional Outcome of Coloanal Anastomosis with Colonic J-Pouch

Background: Many low rectal cancers can be treated radically by proctectomy with total mesorectal excision followed by colonic J-pouch anal anastomosis (CPAA). In elderly patients, the fear of poor function might reduce indications for CPAA in favor of abdomino-perineal excision with end stoma. Methods: Among 198 patients with CPAA operated on for low rectal cancer between 1984 and 1992, 20 patients over 75 years old were alive without recurrence at the time of telephone interview (July 1995). Minimal follow-up was 3 years (mean 8) for all patients. Their functional results were compared with those of 37 younger patients operated consecutively during the last 5 years of the study period. Results: The two groups were well matched for gender, tumor distance from the anal verge, histologic staging, and use of adjuvant radiotherapy. Follow-up was longer in the elderly group than in the young group (96 versus 63 months, respectively). The elderly group had a median of 1 bowel movement per day and the young group a median of 1.5 ( P = 0.13). The presence of irregular intestinal transit was reported in 48% of the aged and in 35% of the young group ( P = 0.6), but fragmented defecation was less frequent (25% versus 47%, respectively; P = 0.15). Urgency was noted, respectively, in 15% and 22% of elderly and young patients ( P = 0.7) and constipation in 40% and 22% ( P = 0.2). Incontinence for feces (15%) and for flatus (40%) in elderly were not significantly different from the younger group (14% and 46%, P = 1.0 and P = 0.8, respectively). Laxatives were used in 32% of elderly and 17% of young patients ( P = 0.3). Conclusion: Functional outcome may be good to excellent in elderly patients after CPAA and compares well with that obtained in younger patients. Constipation, however, may be more frequent in the elderly. Age is not a contraindication for CPAA if the sphincter tone is clinically normal.

Anoabdominal rectal resection and colonic J pouch-anal anastomosis: 10 years' experience

Coloanal anastomosis and radiotherapy for the treatment of lower rectal carcinoma have been receiving increasing attention. Patients with rectal cancer were divided into two groups: anoabdominal rectal resection and colonic J pouch-anal anastomosis (CAA) plus preoperative intraluminal brachytherapy (IBT) (group 1; 68 patients) and CAA without IBT (group 2; 23 patients). Group 3, comprising 59 patients who underwent abdominoperineal excision (APE), was examined as a control group. Comparative results were reviewed. Postoperative complications occurred more frequently in group 1 than in group 2. Actuarial 5-year survival rates were 73 per cent in group 1, 64 per cent in group 2 and 63 per cent in group 3. Cumulative local recurrence rates at 5 years were 11 per cent in group 1, 38 per cent in group 2 and 21 per cent in group 3. Intestinal continuity breakdown was seen in 14 per cent of all patients at 5 years after initial operation. The combination of CAA and preoperative IBT resulted in decreased local recurrence. IBT followed by CAA can be a good restorative option for combating lower rectal cancer.

Quality of Life Measurement after Rectal Excision for Cancer: Comparison between Straight and Colonic J-Pouch Anastomosis

Background: The patients in this study formed part of a multicentre randomized trial comparing the straight and colonic pouch anastomoses after rectal excision for cancer. The trial reflected an advantage of the pouch group regarding frequency, urgency and incontinence. We hypothesized that such differences in bowel function would be reflected in a general quality of life score. Methods: Forty-five patients were randomized. The Nottingham Health Profile was used to measure health-related quality of life before and 1 year after surgery. Results: There was no difference in quality of life score when the two groups were compared. When calculating the relative change after surgery, there was an improvement in both groups regarding the total score of the Profile (P< 0.0001). Conclusions: The Nottingham Health Profile was effective in showing an improvement in quality of life in both groups after surgery. The observed difference in clinical bowel function was not, however, reflected in an improved quality of life score as measured by the Profile.

Hemodynamics in the prone jackknife position during surgery

We examined the hemodynamic changes occurring with prone jackknife positioning during colorectal surgery. The operative procedure was restorative proctocolectomy with ileal J-pouch anal anastomosis in five patients with adenomatosis coli and six patients with ulcerative colitis and anoabdominal resection of the rectum with colonic J-pouch anal anastomosis in eight patients with rectal cancer. Nineteen patients (10 men and 9 women aged 41 ± 19 years) were monitored with arterial and Swan-Ganz catheters during positioning. Measurements were obtained in the supine and prone positions (1 minute, 3 minutes), and the jackknife position (1, 3, 5, and 10 minutes), as well as before and after adoption of the Lloyd-Davies position (1, 3, 5, and 10 minutes). Turning the patient from the supine position to the prone position resulted in a significant decrease in the cardiac index (CI). However, following head-down rotation, the CI increased and returned to the value seen in the supine position (p < 0.05). Heart rate (HR) slowed and mean arterial pressure (MAP) increased in the prone jackknife position. We concluded that the extent of the changes in cardiac function presented no serious problems.