Colonic Pouch-anal Anastomosis Research Articles

S1811 A Rare Case of Synchronous Squamous Cell Tumors of the Rectum: Diagnosis and Management

INTRODUCTION: Colorectal squamous cell carcinoma (SCC) is an extremely rare form of colon cancer, accounting for 0.1–0.2% of the cases. It has a female predominance, with a mean age of 57 years old at diagnosis. It is often diagnosed at an advanced stage. We present a case of two simultaneous SCC tumors of the rectum which were managed successfully with multidisciplinary approach. CASE DESCRIPTION/METHODS: A 65 year old female with remote history of left breast ductal carcinoma in situ, in remission after lumpectomy and adjuvant chemoradiation therapy several years ago, presented with intermittent hematochezia. She denied having any constitutional symptoms. Her previous colonoscopy was eight years prior and was unremarkable. There was no family history of gastrointestinal cancer. She rarely drank alcohol and did not smoke cigarettes. During rectal exam, a large mass was palpated in the rectum, without any palpable anal abnormalities. Labs showed normal CBC, LFTs and renal function. She underwent a colonoscopy which revealed an exophytic and friable 4 cm mass in the distal rectum. A separate subepithelial mass was seen at the rectosigmoid junction, with ulcerated mucosa overlying the lesion. The intervening rectum between the 2 distinct masses and the portion of the rectum distal to the rectal mass were both normal. Separate biopsies were taken of the two masses, and pathology revealed invasive, moderately differentiated squamous cell carcinoma with HPV positivity (Image 1). Imaging for staging did not reveal any metastases. The patient received neoadjuvant radiation and chemotherapy (Mitomycin C and 5-Fluorouracil). Post-treatment abdominal imaging showed significant response to therapy (Image 2). Subsequently, the patient underwent a laparoscopic hand assisted proctosigmoidectomy with colonic pouch anal anastomosis and diverting loop ileostomy. Pathology showed complete resolution of tumor at primary sites while carcinoma cells were found in one of the resected lymph nodes (Image 3). DISCUSSION: Colorectal SCC occurs mostly in the distal half of the colon, mainly at the rectosigmoid junction. While isolated colorectal SCCs are rare, our case is even more unique given the presence of synchronous colorectal SCC tumors. HPV infection is associated with colorectal SSC in past literature. To decrease the risk of SCC recurrence, neoadjuvant chemoradiation followed by surgical resection is the mainstay of treatment while recent evidence suggests that chemoradiation alone may be definitive therapy in some cases.Figure 1.: Colonoscopy showing submucosal mass with overlying ulcerated mucosa (arrow) at the rectosigmoid junction (A) and exophytic, friable mass seen in the distal rectum (B). Rectal mass biopsy H & E stain (20X) showing full thickness squamous atypia with lack of maturation consistent with squamous cell carcinoma (C) while diffuse nuclear p40 stain positivity (10X) supporting squamous origin (D) and strong p16 staining (10X) indicative of HPV-associated squamous cell carcinoma (E).Figure 2.: MRI abdomen showing submucosal mass (see arrow) at rectosigmoid junction with compression of lumen (A) and intraluminal mass (see arrow) in distal rectum (B). After chemotherapy and radiation, the mass at rectosigmoid has reduced to scar tissue with T2 hypointensity (C) while mass in distal rectum has completely resolved (D).Figure 3.: H & E stain (20X) showing no residual tumor identified in treated colon of patient with history of squamous cell carcinoma in (A) while treatment effect shown with numerous macrophages, few multinucleated giant cells (black arrow), lymphocytes and small vessel with hyaline changes (blue arrow) in B, and CD68 stain highlights macrophages within the area of treatment response (C). H & E stain (20X) showing lymph node with metastatic carcinoma showing treatment effect and viable tumor cells (arrows) within necrotic debris in lymph node in (E) while CK AE1/3 immunohistochemistry stain (20X) highlighting/confirming metastatic carcinoma with both viable tumor cells and necrotic cells expressing pancytokeratin.

Use of colonic pouches in treatment of mid and low rectal cancer: Better patient selection results in better functional outcome

Background: Addition of a colonic pouch to an ultralow anterior resection or a coloanal anastomosis can improve the functional outcome, but may also cause evacuation difficulties. This study was conducted to evaluate the selective use of colonic pouches, based upon the diameter of the proximal colon. Methods: Twenty-nine rectal cancer patients underwent ultralow anterior resection or coloanal anastomosis, between July 1998 and January 2000. Seventeen had a stapled straight anastomosis, while 12 had a stapled colonic pouch-anal anastomosis. The method of reconstruction was selected intraoperatively based on the diameter of the proximal colon as measured by metal sizers. The colonic J-pouch was constructed with 6-cm limbs using GIA60. Median follow-up was 9 months (range 6- 23 months). Data about complications, tumour characteristics and height of anastomoses were collected. Postoperative bowel function was assessed at 3 and 6 months after surgery or closure of ileostomy using a standard bowel function questionnaire. Results: The 2 groups were comparable regarding age, sex, Dukes stage, resection margins and height of the anastomosis. All anastomoses were 2 - 5.5 cm from the anal verge. The operations were covered by a loop ileostomy in 2 of the straight anastomoses and 4 of the pouches. Two patients had intraoperative complications; splenic injury needing splenectomy and bleeding from pelvic side walls requiring packing. One patient died from multiorgan failure on the 6th postoperative day and was excluded from functional analysis. Four patients had postoperative complications including 2 adhesive bowel obstructions, major wound infection and a subphrenic collection. There were no clinical leaks or pouch-vaginal fistulae. Colonic pouches proved to result in superior functional result in the first 6 months postoperatively compared with straight anastomoses. Pouch patients had less frequency, urgency and need for constipating drugs. None of the pouch patients had evacuation difficulties. Adaptation of straight anastomosis patients resulted in comparable bowel function after 6 months in most patients. Conclusions: Patients with narrow proximal colon, not accepting 31 mm sizer need a colonic pouch added to ultralow or coloanal anstomosis to achieve good postoperative bowel function. Other patients with capacious proximal colon can be expected to achieve equally good functional results after 6 months without the need for a colonic pouch

Restorative proctectomy with colon pouch–anal anastomosis by laparoscopic transanal pull-through: an available option for low rectal cancer?

There are sporadic reports, with different verdicts, of restorative proctectomy by laparoscopic transanal pull-through (LTPT) without the use of a minilaparotomy for a part of the procedure. This study aimed to explore the applicability and advantages of LTPT with colon pouch-anal anastomosis for low rectal cancer, and to evaluate the results. From January 2002 to July 2003, 10 of 12 patients (6 men and 4 women) undergoing a laparoscopic procedure for low rectal cancer (<6 cm from the anal verge) underwent LTPT. The mean age of these patients was 58 years. The results have been compared with those for 12 similar non-pull-through procedures performed during the same period. There was no operative mortality. An anastomotic leakage and a hemorrhagic gastropathy occurred in the LTPT group. During a mean follow-up period of 18 months (range, 12-26 months), there was no local relapse. Four patients manifested moderate incontinence. No significant differences in functional outcome were observed between the LTPT and control groups. The authors' experience supports use of the LTPT procedure with colonic pouch-anal anastomosis for selected lower rectal cancers with indications for a laparoscopic approach as an appropriate and reproducible surgical treatment.

Laser Doppler blood flow measurement in rectal resection for carcinoma--comparison between the straight and colonic J pouch reconstruction.

Lower rates of anastomotic leakage have been reported after rectal resection with a colonic pouch-anal anastomosis than with a conventional straight anastomosis. The microcirculation in the bowel segment that was used for construction of a colonic pouch or a conventional straight anastomosis was examined. Transmural colonic blood flow was measured by laser Doppler flowmetry during the operation before the construction of a straight (n = 16) or pouch (n = 14) anastomosis. The blood flow recordings were first done before dissection of the bowel at one point close to the planned bowel end and at another point 8 cm more proximally. A second recording was done at the same sites after dissection and, where appropriate, after construction of the pouch, but before the anastomosis was completed. In the straight group (end-to-end anastomosis), blood flow levels at the site intended for the anastomosis were significantly decreased following dissection of the bowel. In the pouch group (side-to-end anastomosis), blood flow levels at the site of the anastomosis were similar following dissection of the bowel and pouch construction. It is concluded that unaffected blood flow at the site of the anastomosis of the pouch may be a favourable factor for anastomotic healing.

Results of anal or low rectal anastomosis and pouch construction for megarectum and megacolon.

Over a 16-year period 34 patients underwent surgery for idiopathic megarectum or megacolon; 18 had megarectum with or without megasigmoid, one megacolon only and 15 megarectum and total megacolon (nine with a previous colectomy). Ten patients underwent low rectal or anal anastomosis without pouch formation (colodistal proctostomy, eight; coloanal anastomosis, two), eight had colonic pouch-anal anastomosis (J pouch) and 14 had an ileal J pouch after restorative proctocolectomy; one underwent subtotal colectomy with ileorectal anastomosis and one loop ileostomy alone. There was one death, from intestinal obstruction 24 months after operation. Twenty-seven of 32 evaluable patients without a stoma became fully continent following resection and sphincter-saving procedures. Three of 18 had a poor result after resection for megarectum because of recurrent constipation. One of 14 patients became incontinent after restorative proctocolectomy for megacolon and megarectum and in a further four persistent abdominal distension and pain was treated by pouch excision.

Integrity of the Anal Sphincters After Pouch-Anal Anastomosis: Evaluation With Three-Dimensional Endoanal Ultrasonography

The aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch-anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with three-dimensional endoanal ultrasonography. Patients undergoing a colonic pouch-anal anastomosis or an ileal pouch-anal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three-dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI). Fifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three-dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch-anal anastomosis (53 percent) and in eight patients with an ileal pouch-anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch-anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch-anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores. Handsewn pouch-anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three-dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.

Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis.

Anal sphincter function is increasingly preserved following rectal excision for cancer and provides a better quality of life for patients than does a permanent colostomy. However, anastomotic complications may cause considerable morbidity and mortality. This retrospective study examined the incidence of anastomotic complications following two forms of reconstruction after resection for mid-rectal cancer: colonic pouch-anal anastomosis (CPAA) and low colorectal anastomosis (LCRA). Some 258 consecutive patients with mid-rectal cancers between 6 and 11 cm from the anal verge underwent proctectomy with mesorectal excision and either CPAA or LCRA. The incidence of clinical and radiological leaks was determined in these patients who were considered in three groups: LCRA (defunctioning stoma), LCRA (no defunctioning stoma) and CPAA (all defunctioned). In the LCRA group without a defunctioning stoma, a clinical leak occurred in 17.0 per cent, compared with two of 30 in the LCRA group with a defunctioning stoma. In the CPAA group a clinical leak occurred in 4.9 per cent of patients, which was not significantly different from the rate in those with a defunctioned LCRA. Patients with a non-defunctioned LCRA were more likely to suffer a clinical anastomotic leak (P=0.01), peritonitis (P=0.001) and require unscheduled reoperation (P=0.006) than those with a defunctioned LCRA and/or CPAA. The use of a protective defunctioning stoma is advocated in conjunction with LCRAs.

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.

Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis

Functional outcome after rectal excision with coloanal anastomosis is improved by construction of a colonic J pouch. Present prospective randomized studies lack follow-up beyond 1 year. The aim of this study was to assess the clinical outcome at both short- and long-term follow-up. Forty patients with low rectal cancer were randomized prospectively to either J colonic pouch-anal anastomosis or a straight coloanal anastomosis. Clinical assessments were performed 3, 12 and 24 months after colostomy closure using a standard questionnaire and physical examination. There was no significant difference in the complication rate between the two groups. There was a significant (P < 0.01) improvement in frequency of defaecation at 3, 12 and 24 months for patients with a reservoir. Similarly, fragmentation (clustering of stools) was significantly less at 3 and 12 months (P < 0.01) in the reservoir group, and incontinence occurred less frequently in the first year (P = 0.09). By 24 months no patient in either group suffered from major or minor incontinence. The functional improvement gained from a colonic reservoir in coloanal anastomosis continues to benefit the patient for at least 2 years.

Excision of the rectum with colonic J pouch-anal anastomosis for adenocarcinoma of the low and mid rectum.

The results of rectal excision with colonic pouch-anal anastomosis are reviewed from a series of 162 patients covering 7 years. All patients have been operated upon in the same institution and consecutively. The follow-up is now sufficient to allow an accurate evaluation of the outcome of the patients. The main goal of this study was to provide a detailed report of the functional results. Continence was satisfactory in 96% of the patients, with either a perfect continence or minor troubles that would not have been detectable other than by a rigorous questioning. The mean number of bowel movements was 2 per 24 hours. Fragmentation of the defecation and urgency were absent. Twenty-five per cent of the patients had to elicit the evacuation of the reservoir with a suppository or an enema. Improvement of function yielded by a reservoir over straight colo-anal and low colo-rectal anastomoses are significant and, as suggested by manometric studies, are directly related to the restoration of a reservoir function.