Straight Coloanal Anastomosis Research Articles

Transverse Coloplasty Pouch versus Straight Coloanal Anastomosis Following Intersphincteric Resection for Low Rectal Cancer: the Functional Benefits May Emerge After Two Years

PurposeThis study aimed to compare the oncological and functional outcomes following intersphincteric resection (ISR) with transverse coloplasty pouch (TCP) or straight coloanal anastomosis (SCAA) for low rectal cancer. MethodsA single-center retrospective analysis was performed on patients with low rectal cancer who received ISR between January 2016 and June 2021. The primary endpoint was to compare the outcomes of bowel function within 1 year, 1 to 2 years, and 2 years after ileostomy closure in patients undergoing two different bowel reconstruction procedures (TCP or SCAA). The postoperative complications and oncological results were also compared between the two groups. ResultsA total of 235 patients were enrolled in this study (SCAA group: 166; TCP group: 69). There was no significant difference in complications, including grades A–C anastomotic leakage (9.6% vs 15.9%), 3-year local recurrence rates (6.1% vs 3.9%), disease-free survival (82.4%vs 83.8%), or overall survival (94.1% vs 94.7%) between the two groups. Two years after ileostomy closure, 52.7% of patients in the SCAA group were assessed as having major low anterior resection syndrome (LARS), which was significantly higher than the 25.9% of patients in the TCP group (P = 0.014), but no difference was found prior to 2 years. Similar differences were seen in Wexner scores 2 years after surgery (P = 0.032). Additionally, TCP was an independent protective factor for postoperative bowel function as measured by both the LARS (OR, 0.28; 95% CI, 0.10–0.82; p = 0.020) and Wexner scoring (OR, 0.28; 95% CI, 0.09–0.84; p = 0.023). ConclusionThis study suggests that TCP is a safe technique that may decrease bowel dysfunction after ISR for low rectal cancer compared with SCAA 2 years after ileostomy closure.

Research progress of different bowel reconstructions for postoperative functional protection during low anterior resections of rectal cancer

Straight coloanal anastomosis (SCA), colonic J-pouch anastomosis (CJP), transverse coloplasty pouch anastomosis (TCP), and side-to-end anastomosis (SEA) are the most commonly used procedures of bowel reconstructions in the low anterior resections (LAR) of rectal cancer. Different bowel reconstruction procedures greatly affect postoperative bowel function, urinary function and sexual function. SCA is the most traditional procedure. CJP has been studied extensively and well-developed reconstruction method; however, recent studies have shown that CJP has the highest morbidity of complications, so the clinical application of CJP is limited. SEA is not inferior to CJP and SCA in the short-term and long-term defecation function, urination function, and sexual function, with reliable operational safety, so it is expected to become an alternative to SCA and CJP. The research on TCP is lacking, but there are some related clinical trials currently underway, and the results are worth expecting. The improvement and innovation of bowel reconstructions provide a bright prospect for better functional prognosis in patients with rectal cancer.

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.

Delayed Colo-anal Anastomosis for Rectal Cancer: Pelvic Morbidity, Functional Results and Oncological Outcomes: A Systematic Review.

Delayed colo-anal anastomosis (DCAA) has received renewed interest thanks to its reduction in anastomotic leakage rate without the use of stoma to protect a low rectal anastomosis. The aim of this review was to summarize the available literature on DCAA following rectal cancer resection and to report clinical, oncological and functional results. A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, clinicaltrials.gov and the Cochrane database of systematic reviews through July 2018. The review was conducted according to MOOSE guidelines. Quality was appraised with the methodological index for non-randomized studies (MINORS) tool. Eight observational studies (409 patients) were included. Average MINORS score was 9.6/14 in seven non-comparative studies and 17/22 in one comparative study. Six studies reported no anastomotic leak. Pelvic sepsis/abscess ranged from 0 to 25%. Mortality rate was <3% in seven studies and 12.5% in one. Poor fecal continence was reported in <30% of patients. Need for permanent stoma was ≤2% in six studies. A five-year survival rate ranged from 63.8 to 81% (four studies). Loco-regional recurrence rate ranged from 4.8 to 14.3% at 3years (four studies) and from 6 to 38.8% at 5years (three studies). DCAA offers an alternative to primary straight colo-anal anastomosis for low rectal cancer. The benefits include reduced risk of anastomotic leakage and pelvic sepsis, and no need for protective ileostomy, with good functional and oncological outcomes. Results of ongoing randomized controlled trials comparing DCAA with straight colo-anal anastomosis and protective stoma are awaited to draw definitive conclusions.

Intersphincteric Resection Is the Optimal Procedure for Very Low Rectal Cancer: Techniques, Morbidity, Oncologic and Functional Outcomes

Background: The intersphincteric resection the most extreme form of a sphincter-preserving alternative for the abdominoperineal resection. Aim of the Work: We investigated oncological, functional outcomes and morbidity after ISR. Methods: This retrospective study included 164 patients who underwent ISR with between 2010 and 2015, Male 56.1%, Female 43.9%, with a median age was 54.5 years, Median follow-up time was of 48 months, Average surgical time was 230 min, Median blood loss was 700 mL and median hospital stay was nine days. Mean tumour size was34 mm. The surgical procedure through a laparotomy (72.6%), laparoscopically (27.4%). Neoadjuvant radiotherapy 89.6% {long-course radiotherapy 74.4%, short-course radiotherapy 15.2%}, neoadjuvant chemotherapy 28.7% and adjuvant chemotherapy 70.1%. Colonic J-pouch 16.5%, Transverse coloplasty 15.9%, a side-to-end anastomosis 26.8% and straight coloanal anastomosis 40.9%. Partial-ISR 36.6%, subtotal-ISR 37.2%, total-ISR 26.2%, diverting ileostomy 6.7%. Results: Operative mortality 1.2%, morbidity 14.6% (anastomotic leakage 3.7%, anastomotic stenosis 1.8%, a recto-vaginal fistula 2.4% bowel obstruction 3%, surgical site infection 3%. Respiratory tract infection 1.2%, local 7.9%, distant recurrence 15.2%, 5-year overall 79.8%, disease-free survival 75.8%, R0 resection 95.1%. Pathologic complete response 11%. Circumferential margin involvement 2.4%. Median number of lymph nodes 17. Mean distal margin20 mm, after 12 months Median Wexner score 6. Incontinence for (flatus 11%, liquid 4.9%, solid 4.3%). Median bowel motions in a 24-h were 3. Faecal urgency 17.7%. Stool fragmentation 18.9%. Difficult evacuation 17.7%, lifestyle alteration 14.6%. Difficulty Feces/flatus discrimination 43.3%. Nocturnal soiling in 17.1%. Daytime soiling 11%. Pad wearing 23.8%. Anti-diarrhoea medication loperamide 14%. Conclusion: ISR is a feasible surgical procedure for low rectal cancer. Oncologic and functional, outcomes after are acceptable.

The Outcomes of Ultralow Anterior Resection or an Abdominoperineal Pull-Through Resection and Coloanal Anastomosis for Radiation-Induced Recto-Vaginal Fistula Patients

PurposeThe purpose of this study was to evaluate the outcomes of patients who underwent colorectal resections and coloanal anastomosis for radiation-induced recto-vaginal fistulas (RVFs). The effect of the surgical treatment technique on bowel function, fecal continence, and quality of life of patients was also evaluated. MethodsTwenty-one female patients, who received adjuvant chemotherapy and external beam pelvic radiation for cervix carcinoma after radical hysterectomy + pelvic/paraaortic lymph node dissection, having RVF but without tumor recurrence, were included. All patients underwent an ultralow anterior resection (n = 11) or an abdominoperineal pull-through resection and straight coloanal anastomosis (n = 10). A bowel functions questionnaire and a Fecal Incontinence Quality of Life (FIQLI) questionnaire were applied to patients pre-operatively and also 6 months after the ileostomy closure procedures. ResultsNo recurrent RVF was observed in a mean follow-up period of 20 months after ostomy reversal procedures. The FIQLI depression, lifestyle, and embarrassment scores were significantly improved on the follow-up questionnaire. The mean pre- and post-operative incontinence scores were not significantly different. ConclusionsThe spontaneous closure rate after a simple diverting stoma is quite low and local repair procedures usually result in failure. In selected patients, performing a nearly total rectum resection and maintaining the intestinal continuity with a coloanal anastomosis may be accepted as a safe and curative option. Recurrence-free outcome and the improvement of the quality of life of the patients represent the efficiency of this treatment modality.

SIDE-TO-END ANASTOMOSIS IN LOW ANTERIOR RECTAL RESECTION

The authors have launched a prospective randomized study aimed to make a comparison of functional results of formation of straight coloanal (control group) and side-to end (main group) anastomosis in case of low anterior rectal resection since 2012. Each group consisted of 40 patients undergoing operation concerning uncomplicated rectal cancer of medium-ampullar section of rectum. It was noted that patients of the main group had lower stool frequency in postoperative period. A function of the interior sphincter was less damaged and the rate of compliance of rectum was high.

Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer.

Options for reconstruction after low anterior resection (LAR) for rectal cancer include straight or side-to-end coloanal anastomosis (CAA), colonic J pouch and transverse coloplasty. This systematic review compared these techniques in terms of function, surgical outcomes and quality of life. A systematic literature search (MEDLINE, Embase and the Cochrane Library, from inception of the databases until November 2014) was conducted to identify randomized clinical trials comparing reconstructive techniques after LAR. Random-effects meta-analyses were carried out, and results presented as weighted odds ratios or mean differences with corresponding 95 per cent c.i. A network meta-analysis was conducted for the outcome anastomotic leakage. The search yielded 965 results; 21 trials comprising data from 1636 patients were included. Colonic J pouch was associated with lower stool frequency and antidiarrhoeal medication use for up to 1 year after surgery compared with straight CAA. Transverse coloplasty and side-to-end CAA had similar functional outcomes to the colonic J pouch. No superiority was found for any of the techniques in terms of anastomotic leak rate. Colonic J pouch and side-to-end CAA or transverse coloplasty lead to a better functional outcome than straight CAA for the first year after surgery.

The Functional Outcomes of Coloanal and Low Colorectal Anastomoses with Reservoirs after Low Rectal Cancer Resections

Nearly half of patients undergoing low anterior rectal cancer resection have a functional sequelae after straight coloanal or low colorectal anastomoses (SA), including low anterior rectal resection syndrome, which combines stool fragmentation, urge incontinence, and incontinence. SA are responsible for anastomotic leakage rates of 0 to 29.2 per cent. Adding a colonic reservoir improves the functional results while reducing anastomotic complications. These colonic reservoir techniques include the colonic J pouch (CJP), transverse coloplasty (TC), and side-to-end anastomosis (STEA) procedures. The aim of this literature review was to compare the functional outcomes of these three techniques from a high level of evidence. CJP with a 4- to 6-cm reservoir is a good surgical option because it reduces functional impairments during the first year, and probably up to 5 years, but is not always feasible. TC appears to perform as well as CJP, is achievable in over 95 per cent of patients, but still with some doubts about a higher anastomotic leakage rate and worse functional outcomes. STEA appears equivalent to CJP in terms of morbidity and even better functional outcomes. STEA, with a terminal side segment size of 3 cm, is feasible in the majority of nonobese patients, combines good functional results, has low anastomotic leakage rates, and is easy to complete.

Comparison of Colonic J-pouch and Straight Coloanal anastomosis after Low Anterior Resection

BackgroundThe tendency towards sphincter preserving for low rectal cancers with low anterior resection, has led to the technique of straight coloanal anastomosis (SCAA) or colonic J-pouch anal anastomosis (CPAA).ObjectivesThe aim of our study was to compare functional outcomes, complication rates and quality of life (QoL) after LAR with either a straight or colonic J pouch anastomosis.Patients and MethodsIn 88 patients with rectal tumors located in lower third, who were candidate for LAR with coloanal anastomosis. They were divided for reconstruction using either SCAA (n= 47) or CPAA (n= 41) from January 2007 to May 2009. Functional results were assessed after closure of temporary loop ileostomy, 6 months postoperatively. Quality of life (QoL) was measured using European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30.ResultsThe two groups were matched for gender, age, and preoperative chemotherapy and radiotherapy. There were no significant differences between the SCAA and CPAA groups relative to anastomotic leakage. Among patients with CPAA, the mean of 24 hours bowel movements, daytime bowel movements, incontinence scores, and incidence of urgency were significantly lower than those in the SCAA group. Also, patients with a CPAA had a significantly better quality of life.ConclusionsCPAA provided not only better functional results than SCAA, but also improved quality of life, thus may be the better choice.

Complete Surgery for Low Rectal Endometriosis

We conducted a prospective study to assess the long-term results of complete surgery for low rectal endometriosis (LRE), paying particular attention to surgical complications, functional results, and disease recurrence after a follow-up of at least 5 years. Deep infiltrating endometriosis (DIE) may infiltrate the midlow rectum and lead to severe pelvic pain. Complete resection of LRE is reluctantly considered by young women of childbearing age. From 1995 to 2003, 100 women with severe pelvic pain and previous incomplete surgery (n=82) underwent complete open surgery for LRE after thorough preoperative imaging work-up. This included total or subtotal rectal excision with combined resection of all extrarectal endometriotic lesions. Univariate analysis of predictive factors for transient neurogenic bladder and surgical complications was performed. Mean follow-up was 78+/-15 months. All patients underwent rectal resection with straight coloanal (n=16) or low colorectal anastomosis (n=84). A concomitant extrarectal procedure was required in all instances, including gynecologic procedures (n=100), additional intestinal (n=45), and urologic (n=23) resections. A fertility-preserving procedure was possible in 92% of the patients. Mean numbers of DIE and endometriotic lesions were 3.9+/-1.4 and 5.5+/-1.6 per patient, respectively. There were no deaths and the surgical morbidity rate was 16%. Sixteen patients developed a transient peripheral neurogenic bladder, which was more frequently observed after colonanal anastomosis (P<0.001) or concomitant hysterectomy (P<0.01) and in patients with more than 4 DIE lesions (P<0.05). At last follow-up, 94 patients had complete (n=83) or very satisfactory (n=11) relief of symptoms. Urine voiding and fecal continence was satisfactory in all cases. There was no recurrence of colorectal and/or urologic endometriosis and the overall DIE recurrence rate was 2%. Complete surgery for LRE provides excellent long-term functional results in 94% of the patients, provided all extraintestinal endometriotic lesions are resected during the same surgical procedure. In that setting, the overall 5-year recurrence rate is very low.

Differences in ano‐neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy

Restorative proctectomy with straight coloanal anastomosis (CAA) and restorative proctocolectomy with ilealpouch-anal anastomosis (IPAA) are options for maintaining bowel integrity after rectal resection. The aim of this study was to compare clinical function and anorectal physiology in patients treated with CAA and IPAA. Three-dimensional vector-manometry and neorectal volumetry were performed in straight CAA [53 patients (34 male)] and IPAA [61 patients (39 male)] for ulcerative colitis. Function was assessed using a 14 day incontinence diary. Function was similar in both groups, but neorectal compliance and threshold volumes for sensation, urge and maximum tolerated volume (MTV) were significantly higher after IPAA than after CAA. Mean pressure, vector volume and sphincter symmetry at rest were significant determinants of continence in both groups but squeeze pressure did not correlate significantly with function in either group. Threshold volume, MTV, and compliance were significantly correlated with frequency of defecation in patients with IPAA but not with CAA. A strong consistent resting anal sphincter pressure is one determinant of continence after both IPAA and CAA. Squeeze pressures do not influence the functional result. In IPAA but not CAA, the neorectum has a reservoir function which correlates with the postoperative frequency of defaecation.

Short-term outcomes of laparoscopic total mesorectal excision following neoadjuvant chemoradiotherapy

To investigate the feasibility of laparoscopic total mesorectal excision (TME) in mid and lower rectal cancers following neoadjuvant chemoradiation (nCRT). The laparoscopic approach for colon cancer has been widely accepted. A few studies have shown that there are advantages of laparoscopic over open TME surgery for rectal cancer. However, the role of laparoscopy has not been clearly defined specifically in cases following nCRT. All patients with rectal cancer who underwent nCRT were identified; no operations for rectal carcinoma were performed laparoscopically between 1997 and 2005. The laparoscopic cases were matched to open cases based on gender, procedure, age, and body mass index (BMI). The medical records were reviewed and short-term outcome was compared between these two groups. Statistical analysis was performed using SPSS 15 software. Between 2002 and 2008, 64 patients were identified, including 32 patients who underwent laparoscopic surgery and 32 who had a laparotomy. There was no difference between the two groups based on gender, procedure, age, BMI or American Society of Anesthesiologists (ASA) classification. The procedures performed within each group included 8 abdominoperineal resections and 24 anterior resections, which included 20 colonic J-pouch-anal anastomoses and 4 straight coloanal anastomoses. In the laparoscopic group, 12 patients underwent totally laparoscopic operations, 12 were either laparoscopic-assisted or hand-assisted procedures, and 8 were converted to laparotomy. The reasons for conversion included bleeding, splenic injury, and difficult anatomy. There were no differences in comorbidities, tumor location, tumor size, tumor stage or radiation dose between the two groups. Operative time was longer in the laparoscopic group (267 + or - 76 versus 205 + or - 49 min, p < 0.001). Operative blood loss, complication rate, and mortality rate were all similar between the two groups. However, the laparoscopic group benefited from shorter length of stay (6.1 + or - 2.4 versus 7.6 + or - 2.3 days, p = 0.012), earlier first bowel movement (1.9 + or - 1 versus 3.3 + or - 2.4 days, p = 0.006), and shorter time to regular diet (3.9 + or - 2.1 versus 5.8 + or - 2.5 days, p = 0.003). There was no difference in lymph node harvest (both positive node harvest and total lymph node harvest), distal margin or radial margin. In our experience, laparoscopic TME for mid and lower rectal cancer is feasible and safe. Patients benefit from the short-term advantages of laparoscopy, including shorter length of hospital stay, time to tolerating a regular diet, and time to first bowel movement or stoma function. Although there were no short-term differences in oncologic parameters, the long-term oncologic outcome requires further investigation.

6017 Retrospective analysis of resected primary colorectal cancer reveled no correlation b/w node harvest and node involvement

Background:The aim of this study was to compare retrospectively the longterm functional results of straight or J-pouch coloanal anastomosis and low colorectal anastomosis in patients operated for rectal carcinoma.Study Design:Of the 260 patients who underwent rectal resection for carcinoma in our department during a 12-year period, 105 were included in this study. Of these, 37 had straight coloanal, 15 J-pouch coloanal, and 53 low colorectal anastomoses.Results:At 1 year of followup, continence was significantly better after low colorectal than straight coloanal anastomosis (perfect continence: 81% versus 51%; p < 0.01). No significant difference was observed for continence after J-pouch coloanal and low colorectal anastomosis. Stool frequency during a 24-hour period was significantly higher after straight coloanal anastomosis than after either J-pouch coloanal (p < 0.05) or low colorectal anastomosis (p < 0.01). Night stools were significantly more frequent after straight than J-pouch coloanal anastomosis (p < 0.05). Three years after surgery, continence had improved in the three groups, as 70% of the straight coloanal group, 91% of the J-pouch coloanal group, and 94% of the colorectal anastomosis group had perfect continence (p < 0.02 versus straight coloanal anastomosis). No significant difference for continence was observed between the J-pouch coloanal and low colorectal anastomosis groups. Neither were significant differences observed among the three groups for urgency, gas/stool discrimination, stool frequency (including night stools), or the need for medication.Conclusions:The functional results of both J-pouch coloanal and low stapled colorectal anastomosis seem better than those of straight coloanal anastomosis. Both J-pouch and low-stapled procedures can safely be proposed for patients with rectal carcinoma requiring total mesorectal rectal excision; however, because low stapled colorectal anastomosis seems to us easier and faster to perform, we consider it the best option for rectal reconstruction after proctectomy for carcinoma, provided it is possible based on the level of the tumor.

Comparison of a colonic J-pouch and transverse coloplasty pouch in patients with rectal cancer after an ultralow anterior resection using fecoflowmetric profiles

Because the standard straight coloanal anastomosis for low rectal cancer tends to result in unfavorable outcomes in terms of defecatory function, colonic pouch reconstruction has therefore recently been adopted in many institutions. The colonic J-pouch (CJP)- and transverse coloplasty pouch (TCP)-anal anastomoses have been adopted worldwide. However, the comparative benefits and drawbacks of the two procedures are uncertain. This study was designed to analyze the functional and clinical outcomes after an ultralow anterior resection (ULAR) using the fecoflowmetry (FFM). Between November 1996 and July 2005, 18 patients were studied retrospectively. They were evaluated by FFM, together with Kelly's clinical score (KCS), and anorectal manometric assessments were also performed. The KCS directly correlated to the maximum fecal stream flow rate (Fmax). In this study, postoperative patients with good KCS as well as a high value of Fmax were seen more in the patients with CJP than in those with TCP. From the viewpoint of FFM, the patients with CJP had a more favorable functional outcome than those with TCP. FFM provided quantitative and qualitative evaluations concerning the anorectal motor activity in patients who had undergone an ULAR for rectal cancer.

Colonic J-Pouch, Coloplasty, Side-to-End Anastomosis: Meta-Analysis and Comparison of Outcomes

Preservation of rectal function after low anterior resection or proctectomy with formation of a neorectum has improved the quality of life of many patients with rectal cancers. This would mean preserving the anal sphincters and avoiding a permanent stoma while reconstructing a neorectum to improve the bowel function of patients. Following proctectomy, the traditional anastomosis will be a straight coloanal end-to-end anastomosis to restore bowel continuity. However, this is associated with very poor bowel function. The construction of a colonic J-pouch anastomosis is introduced to reduce this problem. While colonic J-pouch anastomosis is able to obviate some of the functional problems of straight coloanal anastomosis, it comes with an additional problem of pouch evacuation. Therefore, alternatives techniques, such as transverse coloplasty pouch and side-to-end coloanal anastomosis, have been adopted. The postoperative surgical and functional outcomes are discussed and appraised.

The colon J-pouch as a cause of evacuation disorders after rectal resection: myth or fact?

Colon J-pouch (JCP) reconstructions result in a better functional outcome than straight coloanal anastomosis (SCA) in terms of continence and frequency of defecation after rectal resection but might be associated with more evacuation difficulties. In order to evaluate this hypothesis, we systematically reviewed the literature to collect data on evacuation disorders after rectal resection in randomized or otherwise comparative trials. Randomized controlled trials and comparative trials evaluating CJP versus SCA, latero-terminal anastomosis (LTA), and transverse coloplasty pouch (TCP) were ascertained by methodical search using Medline, Embase, and PubMed. Pooled estimates of outcomes were calculated for early-, intermediate-, and long-term follow-up. Primary meta-analysis outcomes were sensation of incomplete evacuation, prolonged evacuation, use of laxatives, use of enemas and suppositories, and stool fragmentation. When compared to SCA, CJP was associated with significantly less "prolongation of evacuation" but more "use of laxatives" in the intermediate-term follow-up, while both less "sensation of incomplete evacuation" and less "fragmentation" was found after CJP in the long-term. When compared to TCP, CJP was associated with significantly less fragmentation in the intermediate-term follow-up. Evacuation disorders are a unique problem of low anterior resection and are not specifically related to the colon J-pouch.

Rehabilitation of Fecal Incontinence After Sphincter-Saving Surgery for Rectal Cancer: Encouraging Results

Some patients, having undergone sphincter-saving operations for rectal cancer, may suffer from fecal incontinence. This study was designed to evaluate the results of rehabilitative treatment in patients with fecal incontinence after sphincter-saving operations and to identify the negative factors that influence therapeutic success. Between January 2000 and June 2007, 88 incontinent patients (54 women; age range, 47-73 years; 69 had received a low anterior rectal resection; 19 a straight coloanal anastomosis) were included in the study. After a preliminary clinical evaluation, including the Wexner Incontinence Scale score, anorectal manometry was performed. All 88 patients underwent rehabilitative treatment according to the "multimodal rehabilitative program" for fecal incontinence. At the end of program, all 88 patients were reassessed by means of a clinical evaluation and anorectal manometry; their results were compared with the clinical and manometric data from ten healthy control subjects. Postrehabilitative Wexner Incontinence Scale scores were used for an arbitrary schedule of patients divided into three classes: Class I, good (score </=3); Class II, fair (score >3 to </=6); Class III, poor (score >6). After rehabilitation, there was a significant improvement in the overall mean Wexner Incontinence Scale score (P < 0.03) for both surgical operation types (low anterior rectal resection: P < 0.05; coloanal anastomosis: P < 0.02). Only 21 patients (23.8 percent) were symptom-free, and 37 (42 percent) were considered Class III. A significant postrehabilitative direct correlation was found between: 1) Wexner Incontinence Scale score and degree of genital relaxation (rrho (s) 0.78; P < 0.001); 2) Wexner Incontinence Scale score and irradiation (rrho (s) 0.72; P < 0.01); and 3) Wexner Incontinence Scale score and pelvic (rrho (s) 0.65; P < 0.01) or anal surgery (rrho (s) 0.68; P < 0.01). No significant differences were found between prerehabilitative and postrehabilitative anal pressures in low anterior rectal resection and coloanal anastomosis patients. After rehabilitation, some patients become symptom-free, many patients show an improvement in the Wexner Incontinence Scale score, and others exhibit the highest grades of fecal incontinence. Genital relaxation, radiotherapy, and previous pelvic, and/or anal surgery are impeding factors to rehabilitative success.

Reconstructive techniques after rectal resection for rectal cancer.

Total mesorectal resection (TME) has led to improved survival and reduced local recurrence in patients with rectal cancer. Straight coloanal anastomosis after TME can lead to problems with frequent bowel movements, fecal urgency and incontinence. The colonic J pouch, side-to-end anastomosis and transverse coloplasty have been developed as alternative surgical strategies in order to improve bowel function. The purpose of this study is to determine which rectal reconstructive technique results in the best postoperative bowel function. A systematic search of the literature (MEDLINE, Cancerlit, Embase and Cochrane Databases) was conducted from inception to Feb 14, 2006 by two independent investigators. Randomized controlled trials in which patients with rectal cancer undergoing low rectal resection and coloanal anastomosis were randomized to at least two different anastomotic techniques. Furthermore, a measure of postoperative bowel function was necessary for inclusion. Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers. Data from included trials was collected using a standardized data collection form. Data was collated and qualitatively summarized for bowel function outcomes and meta-analysis statistical techniques were used to pool data on postoperative complications. Of 2609 relevant studies, 16 randomized controlled trials (RCTs) met our inclusion criteria. Nine RCTs (n=473) compared straight coloanal anastomosis (SCA) to the colonic J pouch (CJP). Up to 18 months postoperatively, the CJP was superior to SCA in most studies in bowel frequency, urgency, fecal incontinence and use of antidiarrheal medication. There were too few patients with long-term bowel function outcomes to determine if this advantage continued after 18 months postop. Four RCTs (n=215) compared the side-to-end anastomosis (STE) to the CJP. These studies showed no difference in bowel function outcomes between these two techniques. Similarly, three RCTs (n=158) compared transverse coloplasty (TC) to CJP. Similarly, there were no differences in bowel function outcomes in these small studies. Overall, there were no significant differences in postoperative complications with any of the anastomotic strategies. In several randomized controlled trials, the CJP has been shown to be superior to the SCA in bowel function outcomes in patients with rectal cancer for at least 18 months after gastrointestinal continuity is re-established. The TC and STE anastomoses have been shown to have similar bowel function outcomes when compared to the CJP in small randomized controlled trials; further study is necessary to determine the role of these alternative coloanal anastomotic strategies.

Pouchanlage und andere Maßnahmen zur Verbesserung der Kontinenz nach tiefer anteriorer Rektumresektion mit TME

In 75 to 90 % of patients with rectal cancer, a sphincter-preserving resection can be performed without violating oncological principles. However, almost 50 % of the patients suffer from an anterior resection syndrome after total or subtotal rectal resection with a straight colorectal or coloanal anastomosis. This syndrome describes the characteristic complaints of minor or major incontinence. The anastomosis with the colonic pouch has been proved to result in better continence in the short- and long-terms compared to the straight anastomosis. Based on grade 1 evidence, the colonic pouch should be recommended as a standard procedure after low anterior resection with total mesorectal excision (TME). Both the colonic J pouch of 6-cm length and the coloplasty have been shown to be of equal value in respect to function and morbidity. With regard to the complicated procedure and the poorer functional outcome, the ileocecal pouch should only be applied in cases without the option of an alternative pouch design. The temporary loss of the rectoanal inhibitory reflex, the sphincter lesion caused by the instrumental dilatation in stapling or peranal hand-sutured anastomosis and the disturbed function of the internal sphincter due to the autonomous nerve damage additionally contribute to the anterior resection syndrome. In the intersphincteric resection, the loss of the transitional zone and the hemorrhoidal cushion as well as the removal of the upper part of the internal sphincter aggravate the incontinence. For better continence, two operative procedures should be recommended: By applying the inverse double stapling technique in anastomizing the colonic J pouch, the sphincter lesion as a consequence of the dilatation can be avoided. The nerve-sparing mesorectal excision helps to preserve the function of the internal sphincter.