Colonic J-pouch Reconstruction Research Articles

Comparison of the colonic J-pouch versus straight (end-to-end) anastomosis following low anterior resection: a systematic review and meta-analysis.

To evaluate comparative outcomes of straight (end-to-end) anastomosis versus colonic J-pouch anastomosis following anterior resection. A systematic search of multiple electronic data sources was conducted, and all studies comparing straight (end-to-end) anastomosis versus J-pouch anastomosis were included. Anastomotic complications, post-operative complications, re-operation, mortality, and functional outcomes were the evaluated outcome parameters. Revman 5.3 was used for data analysis. Twenty-seven studies reporting a total number of 3293 patients who underwent straight anastomosis (n = 1581) or J-pouch (n = 1712) were included. Anastomotic leak and re-operation rates were significantly higher in the straight group compared to the J-pouch group [RD 0.03, P = 0.03] and [OR 1.87, P = 0.003], respectively. Stool frequency per 24h at 6months and 12months was lower in the J-pouch group than the straight group [MD 2.13, P = 0.003] and [MD 1.44, P = 0.00001], respectively. In addition, the use of anti-diarrheal medication is lower at 12months in the J-pouch group [MD 3.85, P = 0.03]. Moreover, the two groups showed comparable results regarding SSI, sepsis, paralytic ileus, anastomotic stricture formation, anastomotic bleeding, and mortality. J-pouch anastomosis showed lower risk for anastomotic leak and re-operation. Furthermore, better functional outcomes such as stool frequency were achieved using the colonic J-pouch reconstruction over the conventional straight end-to-end anastomosis.

The transverse coloplasty pouch is technically easy and safe and improves functional outcomes after low rectal cancer resection-a single center experience with 397 patients.

Following resection for low rectal cancer, numerous patients suffer from frequent bowel movements, fecal urgency, and incontinence. Although there is good evidence that colonic J-pouch reconstruction, side-to-end anastomosis, or a transverse coloplasty pouch (TCP) improves functional outcome, many surgeons still prefer straight coloanal anastomosis because it is technically easier and lacks the risk of pouch-associated complications. The present single-center study aimed to evaluate the practicability of TCPs in routine clinical practice as well as pouch-related complications. All consecutive patients who underwent low anterior rectal resection with restoration of bowel continuity for cancer during the period September 2008 to June 2018 were included. A TCP in combination with a diverting ileostomy was defined as the hospital standard. The feasibility and safety of TCPs were assessed in a retrospective single-center study. A total of 397 patients were included in the study. A total of 328/397 patients underwent TCP construction (82.6%). Two pouch-related surgical complications occurred (0.6%); one case of pouch-related stenosis and one case of sutural insufficiency. Overall, leakage of the coloanal anastomosis was reported in 14.1% of patients with a TCP and in 18.8% of patients without a pouch (p=0.252). Diverting ileostomy was applied in 378/397 patients (95.2%). The 30-day mortality was 0.25%. The present study is by far the largest single-center experience with TCP construction for low rectal cancer resection. The study shows that a TCP is technically applicable in the vast majority of cases (82.6%). Pouch-associated surgical complications are sporadic events. In our opinion, the TCP can be considered an alternative to J-pouch construction after low anterior rectal resection.

Mo1751 Is There a Difference in Short-Term Outcomes When Colonic J-Pouch Anal Anastomosis Reconstruction is Performed following Laparoscopic vs. Open Low Anterior Resection?

Mo1751 Is There a Difference in Short-Term Outcomes When Colonic J-Pouch Anal Anastomosis Reconstruction is Performed following Laparoscopic vs. Open Low Anterior Resection?

Diverting ileostomy versus no diversion after low anterior resection for rectal cancer: A prospective, randomized, multicenter trial

This study sought to determine whether a protective diverting ileostomy improves short-term outcomes in patients with rectal resection and colonic J-pouch reconstruction for low anastomoses. Criteria for the use of a proximal stoma in rectal resections with colonic J-pouch reconstruction have not been defined sufficiently. In a multicenter prospective study, rectal cancer patients with anastomoses below 8 cm treated with low anterior resection and colonic J-pouch were randomized to a defunctioning loop ileostomy or no ileostomy. The primary study endpoint was the rate of anastomotic leakage, and the secondary endpoints were surgical complications related to primary surgery, stoma, or stoma closure. From 2004 to 2014, a total of 166 patients were randomized to 1 of the 2 study groups. In the intention-to-treat analysis, the overall leakage rate was 5.8% in the stoma group and 16.3% in the no stoma group (P = .0441). However, some patients were not treated according to randomization and only 70% of our patients with low anastomoses received a pouch. Therefore, we performed a second analysis as to actual treatment. In this analysis, as well, leakage rates (P = .044) and reoperation rates for leakage (P = .021) were significantly higher in patients without a stoma. In multivariate analysis, male gender (P = .0267) and the absence of a stoma (P = .0092) were significantly associated with anastomotic leakage. Defunctioning loop ileostomy should be fashioned in rectal cancer patients with anastomoses below 6 cm, particularly in male patients, even if reconstruction was done with a J-pouch.

Management and results of complications after anterior resection with colonic pouch reconstruction for rectal cancer

Colonic J-pouch reconstruction is widely carried out during low anterior resection. The aim of this observational study was to describe the complications and evaluate the results of adverse event management. A total of 128 patients underwent an elective anterior resection with colorectal or coloanal J-pouch reconstruction for primary rectal cancer between January 1997 and December 2008. The overall mortality was 1.6%. Three (2.3%) patients developed pouch necrosis, one of whom died. The rate of anastomotic leakage was 11.7%. Other major complications included intra-abdominal abscess (3.1%), haemorrhage (0.8%) and abdominal dihiscence (0.8%). In all cases of anastomotic leakage, the pouch was salvaged, with 80% of patients undergoing surgical revision with relaparotomy and transanal suture. Patients with pouch necrosis underwent relaparotomy with removal of the pouch and a terminal colostomy. In all cases of intra-abdominal abscess without anastomotic leakage, radiologically controlled percutaneous drainage was carried out. Anal function can usually be saved after anastomotic leakage by salvage surgery without increase in mortality.

Colonic J-pouch reconstruction versus straight colorectal anastomosis after low anterior resection for rectal cancer: impact on anastomotic leak, bowel function and quality of life. A multicentre prospective randomised trial

Colonic J-pouch reconstruction versus straight colorectal anastomosis after low anterior resection for rectal cancer: impact on anastomotic leak, bowel function and quality of life. A multicentre prospective randomised trial

Pouch operation for rectal cancer

Many retrospective studies have found that the functional outcome after a low anterior resection for rectal cancer is better with colonic J-pouch reconstruction than with conventional straight anastomosis. This advantage was demonstrated in prospective, randomized trials and meta-analyses. However, despite its increasing popularity there are several areas of controversy about the use of the colonic J-pouch reconstruction. These issues include anastomotic leaks, the part of the colon used for the pouch, the pouch size, causes of difficulty in evacuation, indications (the optimum level of anastomosis), appropriateness for the elderly, and long-term (2 years or more after surgery) functional outcome. All relevant articles identified from MEDLINE databases were reviewed. The incidence of anastomotic leaks is apparently reduced by colonic J-pouch reconstruction. A 5-cm colonic J-pouch using the sigmoid colon increases the reservoir function without compromising evacuation, and provides better functional outcome than straight anastomosis, even 2 years or more after surgery, in patients whose anastomosis is less than 8 cm from the anal verge. Patients with ultralow anastomoses, less than 4 cm from the verge, appear to benefit the most. At a time when the indications for abdominoperineal excision appear to be reduced for low rectal cancer, the demand for colonic J-pouch reconstruction (the best technique in pouch operations) is therefore likely to increase.

Effect of Anastomosis Level on Continence Performance and Quality of Life after Colonic J-pouch Reconstruction

Total mesorectal excision (TME) has become the recommended method for treatment of cancer in the middle or lower third of the rectum. Thus very low anastomoses are necessary to preserve continence, and pouch reconstruction is favored. It is unclear whether the level of anastomosis is important for continence and quality of life in colonic J-pouch reconstruction. In this investigation all patients were included who underwent curative elective anterior continuity resection with colorectal or coloanal J-pouch reconstruction for primary rectal cancer between January 2001 and December 2004. Exclusion criteria were distant metastases and any signs of recurrence at the time of investigation. Evaluation of continence performance by Wexner and Holschneider questionnaire and quality of life using the QLQ-C30 and QLQ-CR38 (EORTC) questionnaires was done 220 +/- 38 days after closure of the protective Ileostomy, which was performed 106 +/- 48 days after primary intervention. Fifty-two patients (79%) were analyzed. Colopouch rectal anastomosis was performed in eighteen cases and colopouch anal anastomosis in thirty-four cases. Fifty percent of the patients in both groups were continent for solid stool. Patients with a colopouch anal anastomosis had a significantly higher rate of incontinence for liquid stool, however. They took stool-regulating medicine more frequently and complained of fecal soiling and a restricted quality of life. Patients with a colopouch anal anastomosis had a significantly lower score on the most important points of the QLQ-C30 (emotional functioning, social functioning, pain, and quality of life). The same applied to the QLQ-CR38 for body image and problems with defecation. The quality of life of patients with a colopouch anal anastomosis was still considered acceptable compared with reference data for the normal healthy population, however. Both continence and quality of life are substantially affected by the level of the anastomosis after colonic pouch reconstruction. This suggests preservation of a small part of the rectum when oncologically feasible and performing a colopouch rectal anastomosis.

Comparison of Functional and Surgical Outcomes of Laparoscopic-Assisted Colonic J-Pouch Versus Straight Reconstruction After Total Mesorectal Excision for Lower Rectal Cancer

To compare the functional and surgical outcomes of colonic J-pouch and straight anastomosis in the context that both reconstruction procedures were performed laparoscopically. The present study was a randomized prospective clinical trial. Patients with lower rectal cancer requiring laparoscopic total mesorectal excision were equally randomized to either laparoscopic-assisted colonic J-pouch reconstruction or laparoscopic straight end-to-end anastomosis. The techniques of the laparoscopic-assisted colonic J-pouch reconstruction are shown in the attached video. The primary end point was the comparison of functional results in both reconstruction methods. The secondary end points included the safety (surgical morbidity and mortality), surgical efficiency, and postoperative recovery. A total of 48 patients were recruited within 2-year periods, in consideration of statistical power of 90% for comparison. There was no marked difference between patient groups undergoing colonic J-pouch surgery (n = 24) and straight anastomosis (n = 24) in various demographic and clinicopathogic parameters. The anorectal function of patients by colonic J-pouch were better than those by straight anastomosis in 3 months after operation, as evaluated by stool frequency (mean +/- standard deviation: 4.0 +/- 2.0 vs. 7.0 +/- 2.4 times/day, P < .001); use of antidiarrheal agents (29.2% [n = 7] vs. 75.0% [n = 18], P = .004); and perineal irritation (45.8% [n = 11] vs. 79.2% [n = 19], P = .037). Because of the relatively better bowel function in immediate postoperative period, patients by colonic J-pouch reconstruction were less disabled after surgery and had quicker return to partial activity (P = .039), full activity (P < .001), and work (P < .001). Both reconstruction methods were performed with similar amounts of blood loss, complication rates, and postoperative recovery. However, the operation time was significantly longer in the colonic J-pouch group (274.4 +/- 34.0 vs. 202.0 +/- 28.0 minutes, P < .001). Because laparoscopic-assisted creation of a colonic J-pouch achieved better short-term functional results of the anorectum and did not increase surgical morbidity, as compared with laparoscopic straight anastomosis, this reconstruction procedure could be recommended to patients with lower rectal cancer requiring laparoscopic total mesorectal excision.

Extending the horizons of restorative rectal surgery: intersphincteric resection for low rectal cancer

Radical resection of tumours of the distal rectum has generally entailed an abdominoperineal excision, but the recognition of shorter safe distal resection margins, neoadjuvant chemoradiotherapy and the application of the technique of intersphincteric resection (ISR) have led to the prospect of restorative surgery for patients with distally situated tumours. The present study examines the indications, techniques and outcomes following ISR. A literature search was performed to identify studies reporting outcomes following ISR for low rectal cancer. The outcomes of interest included short-term adverse events, functional and manometric results, postoperative quality of life and oncologic outcomes. Twenty-one studies reflecting the experience of 13 units and 612 patients were included. Operative mortality following ISR was 1.6% (inter-unit range 0-5%) and anastomotic leak rate 10.5% (inter-unit range 0-48.4%). The pooled rate of local recurrence was 9.5% (range 0-31% between units) with an average 5-year survival of 81.5%. Most studies recorded a significant reduction in resting anal pressure but not squeeze pressure following surgery, but urgency was reported in up to 58.8% of patients. Functional outcomes and quality of life may be improved using colonic j-pouch reconstruction. The use of chemoradiotherapy can offer benefits in terms of oncologic result, but at the cost of worse functional outcomes. Careful case selection and counselling is required if satisfactory results are to be achieved following ISR for low rectal cancers. In selected patients, however, the technique offers sphincter preserving surgery with acceptable oncologic and functional results.

Long-Term Functional Outcome of Colonic J-pouch Reconstruction After Low Anterior Resection for Rectal Cancer

To evaluate the long-term functional outcome of colonic J-pouch reconstruction after low anterior resection (LAR) for rectal cancer in a prospective study. We compared the functional outcome of 46 patients who underwent J-pouch reconstruction (J-group) and 49 patients who underwent straight anastomosis (S-group) after LAR for rectal cancer. We evaluated clinical function using a 17-item questionnaire about different aspects of bowel function. Physiologic reservoir function was evaluated by manovolumetry. Among the patients with an ultralow anastomosis (<or=4 cm from the anal verge), those in the J-group had fewer bowel movements during the day and at night, and less urgency, soiling, protective pad use, incontinence, and dissatisfaction with bowel function than those in the S-group. Among the patients with a low anastomosis (5-8 cm from the verge), those in the J-group had fewer bowel movements at night, and less urgency and soiling than those in the S-group. Moreover, reservoir function (reflected by the maximum tolerable volume, threshold volume, and compliance) was better in the J-group than in the S-group in both the ultralow and low anastomosis groups. J-pouch reconstruction after low anterior resection creates a better stool reservoir than straight anastomosis, especially when the anastomosis is less than 4 cm from the anal verge, resulting in a better quality of life 3 years after rectal cancer resection.

Defecation mechanisms after anterior resection with J-pouch-anal and side-to-end anastomosis in dogs

Colonic J-pouch-anal anastomosis or colonic side-to-end anastomosis is the reconstruction of choice after low anterior resection. However, the mechanisms of defecation after both reconstruction forms are still speculative. Low anterior rectal resections were performed in 12 dogs with six colonic J-pouch-anal (pouch) and six coloanal side-to-end (SE) reconstructions. Four months postoperative stool frequency, intestinal transit time, and neorectal compliance were determined by radiography and barostat. Defecation mechanisms were evaluated radiographically during expulsion of artificial stool. One dog with pouch reconstruction could not be evaluated due to an anastomotic leak, while the others had uncomplicated course. Spontaneous stool frequency was significantly increased with both reconstruction methods (control 2.0+/-0.9, pouch 2.7+/-1.2, SE 3.3+/-0.9 day; p<0.05). Intestinal transit time was significantly higher with pouch reconstruction due to storage of stool in the pouch and the descending colon compared to SE (control 760+/-82, pouch 592+/-97, SE 550+/-87 min; p<0.05). Compliance and functional capacity were higher in pouch than in side-to-end reconstructions (pouch 5.0+/-0.7 ml/mmHg, 124+/-23 ml; SE 2.7+/-0.3 ml/mmHg, 92+/-24 ml; p<0.05). During defecation, there were no contractions of the pouch detectable. The colonic J-pouch reconstruction results in better functional outcome than side-to-end coloanal anastomosis. Our results show that pouch evacuation is passive and independent from pouch motility. The functional principle of the colonic J-pouch is not its reservoir function but a delay of colonic motility.

Laparoscopic Sphincter-Preserving Total Mesorectal Excision With Colonic J-Pouch Reconstruction

To prospectively evaluate the oncologic and functional outcomes of laparoscopic total mesorectal excision (TME) with colonic J-pouch reconstruction. TME is considered the established gold standard in rectal cancer surgery. However, data on laparoscopic sphincter-preserving TME are limited. Patients with mid or low rectal cancer underwent laparoscopic TME with colonic J-pouch reconstruction by a single surgical team. Clinical and oncologic data were prospectively recorded and analyzed. From March 1999 to September 2004, 105 patients underwent laparoscopic TME with colonic J-pouch reconstruction. The mean operating time was 170.4 minutes and mean blood loss was 91.5 mL. The mean anastomotic distance from the anal verge was 3.9 cm. Conversion was required in 2 cases. The mean circumferential and distal margins were 17.1 mm and 3.4 cm, respectively. There was 1 case of microscopic circumferential margin involvement and 1 case of microscopic distal margin involvement. There was no 30-day mortality, and 6 patients underwent reoperation for major complications. There was no port-site metastasis. The mean follow-up time was 26.9 months (range, 1.3-65.6 months). The actuarial 5-year cancer-specific survival and local recurrence rates were 81.3% and 8.9%, respectively. Erectile dysfunction occurred in 13.6% of males, while 2 patients developed incomplete bladder denervation. Bowel function after ileostomy closure was satisfactory, with an average bowel motion of less than 3 times per day at 2 years after ileostomy closure. Laparoscopic TME with colonic J-pouch reconstruction is a safe procedure with reasonable operating time and does not appear to pose any threat to the oncologic and functional outcomes.

Straight and colonic J-pouch reconstruction after low anterior resection

A complication after restorative rectal surgery with a straight anastomosis is low-anterior resection syndrome with a postoperatively deteriorated anorectal function. The colonic J-reservoir is sometimes used with the purpose of reducing these symptoms. An alternative method is to use a simple side-to-end anastomosis or a coloplasty. Three-hundred fiftyseven patients with rectal cancer undergoing total mesorectal excision (TME). Three-hundred (84.0%) received a low anterior resection with primary anastomosis and colo-rectal n = 194 (64.6%) or colo-anal anastomosis n = 106 (35.3%). A colonic pouch using the descending colon was created in 24 patients and in 75 patients respectively. Surgical results and complications were recorded. Patients were followed with a functional evaluation at 6 and 12 months postoperatively. Patient characteristics in both groups were very similar regarding gender, age, tumor level, and Dukes' stages. A large proportion of the patients received short-term preoperative radiotherapy (72%). There was no significant difference in surgical outcome between the 2 techniques with respect to anastomotic height, perioperative blood loss, postoperative complications, reoperations, hospital stay or pelvic sepsis rates except the anastomotic stricture rate in the colonic J-Pouch group after coloanal anastomosis (p < 0.02). These data show that either a colonic J-pouch or a straight anastomosis performed on the descending colon in low-anterior resection with TME are methods that can be used with similar expected surgical and functional results.

Comparison of Long-Term Functional Results of Colonic J-Pouch and Straight Anastomosis After Low Anterior Resection for Rectal Cancer: A Five-Year Follow-Up

Few reports on the long-term functional outcome of colonic J-pouch reconstruction have been published, and data comparing J-pouch and straight reconstruction are contradictory. This prospective study compares the functional outcome of colonic J-pouch and straight anastomosis five years after low anterior resection for rectal cancer. Functional outcome was compared in 46 patients with J-pouch reconstruction (J-group) and 48 patients with straight anastomosis (S-group). Clinical status was evaluated with a 17-item questionnaire inquiring about different aspects of bowel function. Reservoir function was evaluated by manovolumetry. The Fisher's exact test and Wilcoxon's rank-sum test were used to compare categoric and quantitative data, respectively. Among patients with an ultralow anastomosis (< or = 4 cm from the anal verge), the number of bowel movements during the day (> or = 5, 4.3 vs. 29.2 percent; P = 0.028) and at night (> 1/week, 4.3 vs. 33.3 percent; P = 0.013) and urgency (4.3 vs. 33.3 percent; P = 0.013) and soiling (21.7 vs. 50.0 percent; P = 0.043) were less in the J-group than in the S-group. Among patients with a low anastomosis (5 to 8 cm from the verge), patients in the J-group had fewer bowel movements at night (> 1/week, 0 vs. 20.8 percent; P = 0.028) and less urgency (0 vs. 20.8 percent; P = 0.028). Reservoir function was better in the J-group than in the S-group in both the ultralow (maximum tolerable volume (mean), 101.7 vs. 76.3 ml; P = 0.004; threshold volume (mean), 46.5 vs. 30.4 ml; P < 0.001; compliance (mean), 4.9 vs. 2.5 ml/cm H2O; P < 0.001) and low-anastomosis (maximum tolerable volume, 120.4 vs. 97.9 ml; P < 0.001; threshold volume, 58.3 vs. 40.8 ml; P < 0.001; compliance, 5.2 vs. 3.1 ml/cm H2O; P < 0.001) groups. J-pouch reconstruction increased reservoir function and provided better functional outcome than straight anastomosis, even five years after surgery, especially in patients whose anastomosis is less than 4 cm from the anal verge.

Long-term functional outcome of low anterior resection with colonic J-pouch reconstruction for rectal cancer in the elderly.

Bowel function after low anterior resection for rectal cancer with colonic J-pouch reconstruction is more normal than after conventional straight anastomosis. However, few reports have examined the function of colonic J-pouch reconstruction in the elderly. Good function would obviate the need for colostomy, which is sometimes performed because of concern about fecal incontinence, which increases with age. This study evaluated the function of colonic J-pouch reconstruction in elderly patients aged 75 years or older. Functional outcome was compared in 20 patients aged 75 years or older (older group) and 27 patients aged 60 to 74 years (old group) and 60 patients aged 59 years or younger (young group), 3 years after colonic J-pouch reconstruction, using a functional scoring system with a 17-item questionnaire (score range, 0 (overall good) to 26 (overall poor)). The functional scores in the three age groups were satisfactory and similar. Among patients with anastomoses 1 cm to 4 cm from the anal verge, all 17 categories on the questionnaire in the three age groups were similar. Among patients with anastomoses 5 cm to 8 cm from the anal verge, only the use of laxatives or glycerine enemas was more common in the older group than in the old and young group (90 vs. 38.5 percent and 43.3 percent; P = 0.01). Low anterior resection with colonic J-pouch reconstruction provides excellent functional outcome, including continence, for elderly patients. Colonic J-pouch reconstruction is a highly preferable alternative to permanent colostomy in elderly patients undergoing low anterior resection.

Large contractions in the colonic J-pouch as a possible cause of incomplete evacuation

Restoration of neo-rectal capacity is of importance in obtaining better bowel function after low anterior resection for rectal carcinoma. However, evacuatory disorders, such as incomplete evacuation, have been reported in some patients undergoing colonic J-pouch reconstruction. Therefore, we conducted this study to explore the possible factor affecting incomplete evacuation following low anterior resection for rectal carcinoma. The subjects were 37 consecutive patients who had undergone low anterior resection for rectal tumor (colonic J-pouch in 13 patients, straight anastomosis in 24). Clinical and physiological outcomes were determined at a mean follow-up time of 12 months after the operation, and the parameters were compared between patients with and without postoperative incomplete evacuation. Although anastomosis level from the anal verge was lower in the J-pouch group (6.5 cm vs 3.9 cm, P<0.05), there was no significant difference between J-pouch and straight reconstruction regarding clinical and physiological outcomes. Postoperative incomplete evacuation was significantly more frequent in the J-pouch group than in the straight group (46% vs 25%, P<0.05). Postoperative large contractions on ano-rectal manometry were also significantly more apparent in the J-pouch group than in the straight group (31% vs 4%, P<0.05). Presence of postoperative large contractions (P=0.004), anastomotic stricture (P=0.019) and smaller postoperative maximum tolerable volume ( P=0.009) were significantly and independently associated with incomplete evacuation by multivariate analysis. Colonic J-pouch reconstruction following ultra-low anterior resection was comparable with higher level straight anastomosis from the clinical and physiological point of view. The presence of large contractions might be an important indicator of incomplete evacuation in patients who are undergoing rectal resection.

Functional outcome after intersphincteric resection of the rectum with coloanal anastomosis in low rectal cancer

Objectives. Anterior rectal resection with partial removal of the internal sphincter is an option for low rectal cancer. The objective of this study was to evaluate the functional outcome after this intersphincteric rectal resection. Methods. Anal continence was evaluated by anorectal manometry and a standardized questionnaire (Wexner Score) in 33 patients 28±15 weeks and 100±45 weeks, respectively, after intersphincteric resection. Nineteen of the 33 patients were reconstructed with a straight anastomosis; 12 received a colonic J-pouch. Results. Post-operatively, 25.8% of the patients were incontinent to solid stool and 54.8% were incontinent to liquid stool at least once a week. Mean and maximum resting tone (24±10 and 40±13 mmHg), maximum tolerable volume (77±28 ml) and rectal compliance (1.4±1.2 ml/mmHg) were reduced in anorectal manometry. Squeeze pressures remained unchanged. Only the maximum tolerable volume correlated significantly with the continence score ( r=−0.45, p<0.05). The Wexner score and maximum tolerable volume were significantly better after colonic J-pouch reconstruction than after straight anastomosis (9.9±4.5 vs 13.4±4.0, p<0.05; 65±20 ml vs 100±27 ml, p<0.01). Conclusion. Intersphincteric resection of the rectum leads to impaired post-operative continence. The functional outcome is improved with a colonic J-pouch.

Colonic J-pouch function in rectal cancer patients: impact of adjuvant chemoradiotherapy.

The colonic J-pouch technique of reconstruction optimizes functional outcome after proctectomy with coloanal anastomosis. However, the impact of adjuvant chemoradiation therapy on pouch function in rectal cancer patients has not been investigated. From January 1994 to December 1999, 74 patients with midrectal or low rectal tumors (less than 10 cm from the anal verge) underwent a proctectomy with coloanal anastomosis with colonic J-pouch reconstruction. Chemoradiation was offered in patients with Stage II and III disease. Radiation therapy was administered using a four-field technique including the anal canal, for a total dose of 50.4 Gy (1.8 Gy/fraction/day). Fifteen patients (20 percent) died with metastatic disease, five (6.8 percent) died of other causes without evidence of recurrence, and five (6.8 percent) were lost to follow-up. In addition, two patients had local recurrence (2.7 percent) at the time of follow-up. Forty-five of 47 eligible patients (96 percent) responded to a questionnaire designed to evaluate specifically the degree of continence and pouch evacuation. The mean age of patients was 68.9 (range, 42-88) years and the mean duration of follow-up was 28.8 (range, 1-69) months. There were 28 patients in the surgery alone group and 17 patients who received either preoperative (13) or postoperative (4) adjuvant chemoradiation therapy. Patients in the surgery alone group had a significantly better degree of continence (mean +/- standard deviation continence score: 18.1 +/- 2.9 vs. 13.3 +/- 4.1, P < 0.001) and were less likely to experience evacuatory problems (mean +/- standard deviation evacuation score: 21.3 +/- 3.7 vs. 16.4 +/- 3.5, P < 0.001). Use of a pad was more frequent in the chemoradiation therapy than in the surgery alone group (53 vs. 18 percent, P = 0.02). The incidence after functional disorders was also more frequent in the irradiated group of patients: incontinence to gas (76 vs. 43 percent, P = 0.03), to liquid stool (64 vs. 25 percent, P = 0.01), and to solid stool (47 vs. 11 percent, P = 0.01). Moreover, irradiated patients reported more frequent pouch-related specific problems, such as clustering (82 vs. 32 percent, P = 0.001), and sensation of incomplete evacuation (82 vs. 32 percent, P = 0.001). Finally, regression analysis demonstrated that radiation-induced sphincter dysfunction was progressive over time. Both preoperative and postoperative chemoradiation therapy adversely affects continence and evacuation in patients with colonic J-pouch. Because radiation-induced damage to the normal tissues is known to be cumulative over time, long-term progressive dysfunction of the anal sphincter and neorectum are causes of concern. Consideration should be given to excluding the anal canal from the field of irradiation in patients with Stage II and III rectal cancer, whenever a sphincter-preserving procedure is planned.

Functional Results in Patients with Coloanal Pouch after Low Anterior Resection of the Rectum

Functional results after low anterior resection of the rectum and straight end-to-end coloanal anastomosis are often poor. Patients are frequently troubled by the so called „anterior resection syndrome“ which comprises fecal incontinence, urge, frequency and fragmentation.To investigate the potential functional benefit of a coloanal pouch reconstruction we conducted a prospective study. Some 42 patients (23 men; median age 65 years [30 to 85]) underwent low anterior resection of the rectum followed by coloanal J-pouch reconstruction. Pouch size was 5 to 7 cm, a temporary stoma was fashioned in 32 patients. Indications for the operation were: 1. rectal cancer n = 38,2. recurrent adenoma n = 2, 3. recto-vaginal fistula n = 1 and 4. severe non-specific proctitis n = 1. We observed 5 anastomotic leakages of which 2 patients required reoperation. A pelvic abscess was encountered in 3 patients as well as 1 pelvic hematoma. Micturition was impaired in 4 patients. To date 35 patients have completed 12 months follow-up after reversal of the ileostomy. Patients were seen at 3-monthly intervals. Mean stool frequency/day was 3.9 after 3 and 2.2 after 12 months. After 3 months 24 patients (69%) reported complete continence which increased to 86% at 1 year. Nine patients (26%) complained of urge defecation initially, which decreased to 9% after 1 year. Fragmentation was observed in 40% and 20% at 3 and 12 months, respectively. In conclusion, our initial experience with colonic J-pouch reconstruction shows good functional results.