Factors that influence functional outcome after coloanal anastomosis for carcinoma of the rectum

Colonic transit in patients after anterior resection: prospective, comparative study using single-photon emission CT/CT scintigraphy

BACKGROUND

Bowel dysfunction after anterior resection is well documented, but its pathophysiology remains poorly understood. No study has assessed whether postoperative variation in colonic transit contributes to symptoms. This study measured colonic transit using planar scintigraphy and single-photon emission CT (SPECT)/CT in patients after anterior resection, stratified according to postoperative bowel function.

METHODS

Symptoms were assessed using the low anterior resection syndrome (LARS) score. Following gallium-67 ingestion, scintigraphy was performed at predefined time points. Nine regions of interest were defined, and geometric centre (GC), percentage isotope retained, GC velocity index and colonic half-clearance time (T_½ ) determined. Transit parameters were compared between subgroups based on LARS score using receiver operating characteristic (ROC) curve analyses.

RESULTS

Fifty patients (37 men; median age 72·6 (range 44·4-87·7) years) underwent planar and SPECT scintigraphy. Overall, 17 patients had major and nine had minor LARS; 24 did not have LARS. There were significant differences in transit profiles between patients with major LARs and those without LARS: GCs were greater (median 5·94 (range 2·35-7·72) versus 4·30 (2·12-6·47) at 32 h; P = 0·015); the percentage retained isotope was lower (median 53·8 (range 6·5-100) versus 89·9 (38·4-100) per cent at 32 h; P = 0·002); GC velocity indices were greater (median 1·70 (range 1·18-1·92) versus 1·45 (0·98-1·80); P = 0·013); and T_½ was shorter (median 38·3 (17·0-65·0) versus 57·0 (32·1-160·0) h; P = 0·003). Percentage tracer retained at 32 h best discriminated major LARS from no LARS (area under curve (AUC) 0·828).

CONCLUSION

Patients with major LARS had accelerated colonic transit compared with those without LARS, which may help explain postoperative bowel dysfunction in this group. The percentage tracer retained at 32 h had the greatest AUC value in discriminating such patients.

Long-term Anorectal Function after Postoperative Chemoradiotherapy in High-Risk Rectal Cancer Patients

Aims and background

After sphincter-preserving surgery for rectal cancer and postoperative radiochemotherapy, many patients have unsatisfactory anorectal functional results which are not considered by the most common toxicity scales. The aim of the present study was to retrospectively assess the long-term incidence of impaired anorectal function in rectal cancer patients who underwent anterior resection and postoperative radiochemotherapy.

Methods

Ninety-nine patients who underwent sphincter-saving surgery and postoperative radiochemotherapy for stage II-III rectal cancer from July 1991 to January 2002 were given a questionnaire on anorectal function. Postoperative incontinence was evaluated according to a scale proposed by Jorge and Wexner. Factors influencing anorectal function were examined.

Results

The median follow-up from surgery was 10 years. Ten (10.1%) patients reported ≥ 5 bowel movements per day and 26 (26.3%) experienced clustering. The median frequency of bowel movements per 24 h was 2 (range, 1–10). Stool fragmentation was recorded in 56 (56.6%) cases, and 36 (36.4%) patients experienced urgency to defecate with inability to delay defecation for more than 15 min. The mean continence score was 4.91 (median 1, range 0–18). Incontinence to flatus, liquid and solid stools was reported at least once a week in 24 (24.2%), 11 (11.1%) and 5 (5.1%) patients, respectively. According to the study criteria, 61% of patients had good functional results. None of the variables analyzed showed a significant correlation with functional outcome.

Conclusions

Although retrospective, the present study included a large selected series that had undergone uniform adjuvant treatment and was followed for a median of 10 years. Our data demonstrated that 39% of patients did not have good functional results and suffered some degree of urgency, increased frequency and occasional incontinence even many years after the surgery. Anorectal function assessment should enter routinely in clinical practice and should have importance in the therapeutic decisions.

Factors associated with low anterior resection syndrome after surgical treatment of rectal cancer

AIM

To assess factors independently associated with low anterior resection syndrome (LARS) following resection or rectal cancer.

METHOD

Cross-sectional study carried out in two acute-care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter preserving low anterior resection with curative intent, with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self-administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses.

RESULTS

The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis, total mesorectal excision (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.02-4.65), preoperative radiotherapy (OR 4.33, 95% CI 2.03-9.27) and postoperative radiotherapy (OR 9.52, 95% CI 1.74-52.24) were independent risk factors for major LARS.

CONCLUSIONS

In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy. This article is protected by copyright. All rights reserved.

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.

Risk factors for bowel dysfunction after sphincter-preserving rectal cancer surgery: a prospective study using the Memorial Sloan Kettering Cancer Center bowel function instrument

BACKGROUND

Until recently, no studies have prospectively evaluated bowel function after sphincter-preserving surgery for rectal cancer with the use of a validated bowel function scoring system.

OBJECTIVE

The aim of this study was to investigate possible risk factors for altered bowel function after sphincter-preserving surgery.

DESIGN

This was a prospective study.

SETTINGS

The study was conducted between January 2006 and May 2012 at the authors' institution.

PATIENTS

Patients who underwent sphincter-preserving rectal cancer surgery were recruited.

MAIN OUTCOME MEASURES

Bowel function was assessed 1 day before (baseline) and at 1 year after sphincter-preserving surgery or temporary ileostomy takedown with the use of the Memorial Sloan Kettering Cancer Center questionnaire. Multivariable analysis was performed to identify the factors associated with altered bowel function after surgery.

RESULTS

Overall, 266 patients were eligible for the analysis. The tumor was located in the upper, middle, and lower rectum in 68 (25.5%), 113 (42.5%), and 85 (32.0%) patients. Intersphincteric resection and temporary ileostomy were performed in 18 (6.8%) and 129 (48.5%) patients. The mean Memorial Sloan Kettering Cancer Center score was 64.5 ± 7.6 at 1 year after sphincter-preserving surgery or temporary ileostomy takedown. The Memorial Sloan Kettering Cancer Center score decreased in 163/266 patients (61.3%) between baseline and 1 year after surgery. Tumor location (p = 0.01), operative method (p = 0.03), anastomotic type (p = 0.01), and temporary ileostomy (p = 0.01) were associated with altered bowel function after sphincter-preserving surgery in univariate analyses. In multivariable analysis, only tumor location was independently associated with impaired bowel function after sphincter-preserving rectal cancer surgery.

LIMITATIONS

This study was limited by its nonrandomized design and the lack of measurement before preoperative chemoradiotherapy.

CONCLUSION

We suggest that preoperative counseling should be implemented to inform patients of the risk of bowel dysfunction, especially in patients with lower rectal cancer, although this study cannot exclude the effect of chemoradiotherapy owing to the limitation of study.

A novel animal model of long-term sustainable anal sphincter dysfunction

BACKGROUND

Although intersphincteric resection can avoid the need for permanent colostomy in patients with lower rectal cancer, it sometimes causes anal sphincter dysfunction, thus resulting in a lifelong, debilitating disorder due to incontinence of solid and liquid stool. The development of regenerative medicine could improve this condition by regenerating impaired anal muscle. In order to prove this hypothesis, preliminary experiments in animals will be indispensable; however, an adequate animal model is currently lacking. The purpose of this study was to establish a novel animal model with long-term sustainable anal sphincter dysfunction.

MATERIALS AND METHODS

Twenty male Sprague-Dawley rats were allocated into sham operation (n = 10) and anal sphincter resection (ASR) (n = 10) groups. The ASR group underwent removal of the left half of both the internal and external anal sphincters. Both groups were evaluated for anal function by measuring their resting pressure before surgery and on postoperative day (POD) 1, 7, 14, and 28.

RESULTS

The rats in the sham operation group recovered their anal pressure up to baseline on POD 7. The rats in the ASR group showed a significant decrease in anal pressure on POD 1 (P < 0.0001) compared with the baseline, and kept this low pressure until POD 28 (P < 0.0001). The defect of the anal sphincter muscle was confirmed histologically in the ASR group on POD 28.

CONCLUSIONS

The present novel model exhibits continuous anal sphincter dysfunction for at least 1 mo and may contribute to further studies evaluating the efficacy of therapies such as regenerative medicine.

Low anterior resection syndrome (LARS): cause and effect and reconstructive considerations

Between 25 and 80% of patients undergoing a low or very low anterior resection will suffer postoperatively, from a constellation of symptoms including fecal urgency, frequent bowel movements, bowel fragmentation and incontinence, collectively referred to as the low anterior resection syndrome (LARS). The etiology of LARS is multifactorial with the potential of sphincter injury during anastomosis construction, alterations in anorectal physiology, the development of a pudendal neuropathy, and a lumbar plexopathy with exacerbation of symptoms if there is associated anastomotic sepsis or the use of adjuvant and neoadjuavnt therapies. The symptoms of LARS may be obviated in part by the construction of a neorectal reservoir which may take the form of a colonic J-pouch, a transverse coloplasty, or a side-to-end anastomosis. This review outlines the factors contributing to LARS symptomatology along with the short- and medium-term functional results of comparative trials with the different types of neorectal reconstructions.

Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum: a preliminary study

BACKGROUND

Colorectal segmental resection is performed worldwide in a majority of women presenting with symptomatic deep endometriosis infiltrating the rectum. The aim of the present study was to investigate the pathophysiological mechanisms involved in post-operative digestive dysfunction.

METHODS

We selected patients managed by colorectal resection for rectal endometriosis, who had developed post-operative severe constipation and whose follow up was superior to 24 months. To assess the mechanisms involved in the pathogenesis of this complaint, we performed a step-by-step work up including: low digestive tract endoscopy, colonic transit time measurement and when appropriate anorectal manometry, electromyography and defecographic evaluation.

RESULTS

Five out of 25 (20%) patients, whose age ranged from 27 to 41 years, were investigated for severe post-operative terminal constipation. Four different mechanisms responsible for terminal constipation were identified: tight stenosis of the colorectal anastomosis, post-operative neurological sequelae, colonic intussusception through the colorectal anastomosis and transit constipation that developed post surgery.

CONCLUSIONS

Post-operative constipation is a frequent complaint in women managed by colorectal resection for rectal endometriosis. A multidisciplinary approach is mandatory as pathophysiologic mechanisms may vary and prove difficult to understand. The risk of post-operative bowel dysfunction following colorectal endometriosis must be taken into account whenever this technique is proposed in young women presenting with a benign disease such as deep endometriosis.

Damage to anal sphincter/levator ani muscles caused by operative procedure in anal sphincter-preserving operation for rectal cancer

BACKGROUND

Details of postoperative damage to anal sphincter tonus following sphincter-preserving operation for rectal cancer remain unclear.

METHODS

Postoperative anal tonus was measured using 3-dimensional (3D) vector manometry in 56 patients. Anal length with pressure from any direction was defined as total length (TL). Length with circular pressure (LCP), which is only measurable using 3D manometry, was also evaluated.

RESULTS

In operations associated with low anastomosis, both TL and LCP at rest were significantly shortened when compared with control (high interior resection [HAR]). In particular, degraded LCP at rest was obvious. Anal lengths in squeezing state were preserved except in cases with intersphincteric resection (ISR). Postoperative incontinence score inversely correlated with functional anal length at rest.

CONCLUSIONS

Although the sphincter muscles are mechanically preserved, function of the internal sphincter and subsequent defecatory function can be degraded in cases with operative procedures including surgical maneuvers at the pelvic floor.

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.

Functional outcome following restorative rectal cancer surgery

The trend towards preoperative adjuvant and neoadjuvant therapies in selected patients with rectal cancer has led to increases in sphincter preservation with a limited understanding of the factors governing unsatisfactory functional outcomes. Data would suggest the need for a more selective use of standard radiotherapeutic fields in low- to intermediate-risk cases where there appears to be limited survival or locoregional recurrence benefit and where there is under-reported toxicity. This article discusses the complex factors which impact on functional outcome following open rectal cancer surgery particularly when it is accompanied by adjuvant therapy.

Risk factors for faecal incontinence after rectal cancer treatment

BACKGROUND

Low anterior resection (LAR) may result in faecal incontinence. This study aimed to identify risk factors for long-term faecal incontinence after total mesorectal excision (TME) with or without preoperative radiotherapy (PRT).

METHODS

Between 1996 and 1999, patients with operable rectal cancer were randomized to TME with or without PRT. Eligible patients who underwent LAR were studied retrospectively at 2 years (399 patients) and 5 years (339) after TME.

RESULTS

At 5 years after surgery faecal incontinence was reported by 61.5 per cent of patients who had PRT and 38.8 per cent of those who did not (P < 0.001). Excessive blood loss and height of the tumour were associated with long-term faecal incontinence, but only in patients treated with PRT.

CONCLUSION

Faecal incontinence is likely to occur after PRT and TME, especially when the perineum is irradiated.

Prospective Evaluation of the Defecatory Functional Results in Patients Following Aorto-Aortic Reconstruction Surgery for an Abdominal Aortic Aneurysm

PURPOSE

Anterior rectal resections have been associated with postoperative bowel function abnormalities, a condition defined as anterior resection syndrome. Autonomic denervation could be one of the possible mechanisms underlying this complication. Damage to the preaortic tissue containing autonomic nervous plexus during abdominal aortic reconstruction surgery may affect the anorectal defecation function.

METHODS

The anorectal function was prospectively studied in 22 patients undergoing abdominal aortic reconstruction surgery. The patients were examined preoperatively and 6 months postoperatively by symptom-specific questionnaires.

RESULTS

Postoperatively, the patients showed no significant impairment of the anorectal functions in both constipation- and fecal incontinence-specific questionnaires. Self-estimation of the defecatory function was slightly lower compared with preoperative scores.

CONCLUSION

An injury to the intermesenteric, inferior mesenteric, and superior hypogastric plexuses does not significantly influence the defecatory functions in patients following abdominal reconstruction surgery for an abdominal aortic aneurysm.

Oncological outcome of ultra-low coloanal anastomosis with and without intersphincteric resection for low rectal adenocarcinoma

BACKGROUND

The value of ultra-low coloanal anastomosis (CAA) for rectal cancer is dependent on the oncological and functional results. The aim of this comparative study was to evaluate the long-term oncological outcome of CAA with or without intersphincteric resection (ISR) for low-lying rectal tumours.

METHODS

The study population comprised consecutive patients with low rectal cancer who underwent CAA in a single institution between 1977 and 2004. Patients were divided into two groups according to whether or not a partial ISR had been performed. Cox multivariate models were used for survival analysis.

RESULTS

Some 278 patients underwent CAA with curative intent; 173 had ISR and 105 had CAA without ISR. Mean follow-up was 66.8 months. The 5-year actuarial rate for local recurrence, regardless of tumour stage, was 10.6 per cent in the ISR group versus 6.7 per cent for CAA alone (P = 0.405), and the 5-year actuarial overall survival rate was 86.1 and 80.0 per cent respectively (P = 0.318). Cox multivariable analysis revealed that resection of the anal canal was not a prognostic factor for local or metastatic recurrence.

CONCLUSION

Sphincter-preserving surgery appears to be oncologically adequate for very low-lying rectal tumours.

Straight and colonic J-pouch reconstruction after low anterior resection

PURPOSE

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.

MATERIAL AND METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

A qualitative study of anterior resection syndrome: the experiences of cancer survivors who have undergone resection surgery

This study aimed to explore how individuals recovered and adapted following surgical resection of their rectal cancer and the syndrome that occurs as a consequence of this operation. This syndrome, 'anterior resection syndrome', consists of frequency, urgency, fragmentation and incontinence of faeces, and is thought to occur in 90% of patients who have received this type of surgery. Little qualitative research has been undertaken in this area, and this study adds to current quality of life data and explores supportive care strategies that nurses could use to assist patients. This study uses a grounded theory approach and in-depth interviews to explore patient's experiences. Participants were recruited from a cancer unit within the UK. Participants were recruited from a total population sample of 27 patients who had received surgery from 2001 to 2002. Following eligibility criteria to exclude those who had disease progression, seven patients were identified 1 year following surgery. Interviews were used to explore the experience of the syndrome. Three categories were identified: adapting to the physical changes, psychological adaptation and stigma. A secondary theme, running throughout all these categories, was the feeling of confidence and normality. Although the physical changes were expected as a consequence of surgery, most participants described the difficulty in controlling and managing symptoms in their period of recovery. Developing a philosophical stance was important in managing the lack of control and returning to perceived normality, despite the social stigma of bowel problems. Information on a range of strategies to manage physical symptoms is helpful in providing supportive care. Understanding that patients often rely on inappropriate strategies for management and are reluctant to discuss symptoms is important. The specialist nurse has a role in providing supportive care in managing chronic symptoms following cancer treatment.

The effect of neo-rectal wall properties on functional outcome after colonic J-pouch-anal anastomosis

BACKGROUND/AIMS

It has been suggested that normal function of both anal sphincters is essential for a good functional outcome after colonic J-pouch-anal anastomosis (CPAA). However, CPAA patients may have impaired continence despite adequate sphincter function. The present study was designed to identify those factors, which contribute to the functional outcome after a handsewn CPAA.

MATERIALS AND METHODS

Forty patients were studied before and 1 year after pouch surgery. Faecal continence was evaluated using the Rockwood faecal incontinence severity index (RFISI). At both occasions, maximum anal resting pressure (MARP) and maximum anal squeeze pressure (MASP) were recorded. In addition, sensory perception threshold-volumes (SPT-V) and compliance were assessed using an 'infinitely' compliant polyethylene bag connected to an electronic barostat assembly.

RESULTS

The median RFISI score 1 year after surgery was higher than the median RFISI score before surgery (13 vs 7 (p < 0.01). The median MARP dropped significantly (p < 0.01) whereas the median MASP remained unaffected. The mean compliance, calculated at three different sensation levels, and the pouch sensory perception threshold-volumes (PSPT-V) were lower than those of the original rectum (p < 0.05). The reduction of MARP showed no correlation with the post-operative change in RFISI scores. Low PC and low PSPT-V were associated with higher RFISI scores.

CONCLUSION

Low pouch compliance and low SPT-V adversely affect functional outcome after a handsewn colonic J-pouch-anal anastomosis.

Low anterior resection with total mesorectal excision for rectal cancer: functional assessment and factors affecting outcome

OBJECTIVE

Many patients experience disordered defaecation after low anterior resection of the rectum (LARR). We analysed the anorectal function of these patients to determine which factors might contribute to this problem.

PATIENTS AND METHODS

Between November 2002 and January 2004, 18 consecutive patients (11 males and 7 females) who underwent LARR with total mesorectal excision (TME) for rectal cancer were assessed by anorectal manometry, balloon proctometry and the Wexner continence questionnaire before operation and at 6 months and 1 year following stoma closure. Sixteen volunteers (11 males and 5 females) were evaluated for comparison. Stepwise logistic regression was performed for variables that were highly significant at univariate analysis.

RESULTS

The mean daily preoperative stool frequency was 2, mean basal pressure (MBP) 43.12 cm H(2)O, maximum threshold volume (MTV) 181.8 ml, length of high-pressure zone (HPZ) 3.11 cm and the rectoanal inhibitory reflex (RAIR) was present in all the patients. Twelve months after stoma closure, the stool frequency was 3.3, MBP 37.7 cm H(2)O, MTV 146.3 ml, length of HPZ 2.88 cm and Wexner score 4.37. Comparing patients having a good anorectal function (Wexner score > or = 5) with those having an unsatisfactory function, we found that, on multivariate analysis, the factors that independently contributed to a poor outcome at 12 months after operation were the absence of RAIR as well as an MTV and HPZ below the fifth percentile of normal individuals.

CONCLUSIONS

Many patients undergoing LARR with TME for rectal cancer experience an anterior resection syndrome that persists for at least 1 year. Those with no RAIR and subnormal MTV and HPZ lengths can be predicted to have an unsatisfactory outcome.

Transabdominal anastomosis after low anterior resection: A prospective, randomized, controlled trial comparing long-term results between side-to-end anastomosis and colonic J-pouch

PURPOSE

Colonic J-pouch has been constructed to overcome reservoir dysfunction after restorative rectal surgery, whereas no effort has been made for sphincter dysfunction. We conducted a prospective, randomized study comparing surgical and functional outcomes between side-to-end anastomosis and colonic J-pouch after low anterior resection in which the anastomosis was constructed from the abdomen.

METHODS

Fifty-six consecutive patients with middle-to-low rectal cancer undergoing low anterior resection were randomly assigned to side-to-end or colonic J-pouch group preoperatively. Surgical outcomes of all the patients were recorded. Patients underwent functional evaluation, including anorectal manometry and functional assessment, preoperatively and then 3 months, 6 months, 1 year, and 2 years postoperatively.

RESULTS

Twenty-four patients in each group completed the study. The demographic data and preoperative functional assessment did not differ between the two groups. There was no significant difference in surgical outcomes with regard to anastomotic height (5 cm), blood loss, protective colostomy, operative time, complications, and adjuvant therapy. Anal pressures showed no significant change postoperatively and during the follow-up period; there were no differences between the two groups. Temporal minor fecal incontinence was noted in the early postoperative period in both groups. With regard to bowel function, a significant reduction of volume of urgency and maximal tolerable volume was found postoperatively in both groups; however, a faster recovery was noted in the colonic J-pouch group. Stool frequency increased significantly after surgery in both groups; however, in contrast to rectal volume, a faster recovery was noted in the side-to-end group.

CONCLUSIONS

Anastomosis after low anterior resection for middle to low rectal cancer could be performed safely from the abdomen. It minimized sphincter injury and showed good continence preservation. On the other hand, the surgical outcomes and long-term functional results of side-to-end anastomosis were comparable with colonic J-pouch. Side-to-end anastomosis provides an easier, alternative way for reconstruction after restorative rectal surgery.

Estándares de calidad de la cirugía del cáncer de recto

The results of surgery for rectal cancer have classically been measured through indicators such as morbidity, mortality, and length of hospital stay. In the last few years other parameters have been included that evaluate healthcare quality such as the functional results of the surgical technique employed and quality of life. Total resection of the mesorectum, performed by experienced surgeons, is the surgical technique of choice. Currently, the sphincter can be preserved in 70% of patients. Anastomotic dehiscence after anterior resection of the rectum is the most serious complication and the most important risk factor is the height of the anastomosis. The overall dehiscence rate should be less than 15% and operative mortality should be between 2% and 3%. The colonic reservoir improves functional outcome and consequently it is the procedure of choice to reconstruct transit after low anterior resection. Local recurrence should be less than 10% and 5-year survival should be between 70% and 80%. In general, quality of life is better after anterior resection of the rectum than after abdominoperineal amputation, despite the functional deterioration presented by some patients.

Sacral nerve stimulation for faecal incontinence following a rectosigmoid resection for colorectal cancer

INTRODUCTION

Following recto-sigmoid resection some patients may become faecally incontinent and remain so despite conservative treatment. This multicentre prospective study assessed the use of sacral nerve stimulation (SNS) in this group.

METHODS

All patients had more than or equal to 4 days of faecal incontinence for solid or liquid stools over a 21-day period following recto-sigmoid resection for colorectal carcinoma. The operation had to have been deemed curative. They had to have failed pharmacological and biofeedback treatment.

RESULTS

Three male patients met these criteria. One had had a colo-anal and two a colo-rectal anastomosis for rectal carcinoma. All patients had intact internal and external anal sphincters. Two patients had a successful temporary stimulation period and proceeded to permanent implantation. Pre-operative symptom duration was 1 year in the permanently implanted patients. They were followed up for 12 months. SNS improved the number of faecally incontinent episodes in both patients. Ability to defer was improved in both patients from 0--5 min to 5--15 min. The faecal incontinence-specific ASCRS quality of life assessment improved in all four subcategories.

CONCLUSION

This study demonstrates that SNS may be effective in the treatment of patients with faecal incontinence following recto-sigmoid resection if conservative treatment has failed.

N/A

N/A

Denervation of the neorectum as a potential cause of defecatory disorder following low anterior resection for rectal cancer

PURPOSE

The aim of this study was to determine whether denervation of the sigmoid colon during low anterior resection contributes to the postoperative motility characteristics of the neorectum and to the defecatory function of patients.

METHODS

Sixty-seven patients who underwent either low or ultralow anterior resection for rectal cancer were evaluated. In accordance with the length of denervated neorectum, each patient was assigned to either the short-denervation or long-denervation group, determined by whether the inferior mesenteric artery was divided. Colonic propagated contraction was then measured by means of intraluminal pressure monitoring. Transit time was calculated with orally administered radiopaque markers.

RESULTS

Propagated contraction down to the neorectum was significantly less common in the long-denervation group (14/36) than in the short group (12/15, P < 0.05), whereas spastic minor contraction at the neorectum was significantly more common in the long-denervation group (21/36) than the in short group (3/15, P < 0.05). Colonic transit time below the sigmoid colon was significantly longer in long group (6.4 hours) than in the short group (3.4 hours, P < 0.01). Although motility disorder of the neorectum was correlated with clinical defecatory malfunctions, including multiple evacuations, urgency, and soiling, no significant correlation was noted between the length of the denervated neorectum and the defecatory disorders.

CONCLUSIONS

Motility of the neorectum following low anterior resection appears degraded by intraoperative maneuvers that cause denervation of the remnant sigmoid colon. Motility disorder of the neorectum, but not the length of the denervated neorectum causing the disorder, correlates well with several defecatory malfunctions. This finding suggests that postoperative defecatory disorder as a result of low anterior resection is caused by many factors in addition to denervation of the neorectum.

Evacuation of neorectal reservoirs after TME

Colon pouch reconstruction after deep rectal resection is functionally superior to straight colorectal/anal anastomosis. However, stool evacuation difficulties could jeopardize the functional benefit of neorectal reservoirs. Beside the well proven colon J-pouch, the transverse coloplasty pouch may represent a viable alternative. We examined evacuation and functional outcome after total mesorectal excision and transverse coloplasty pouch reconstruction. Thirty consecutive patients with cancer of the middle and distal third of rectum underwent a total mesorectal excision. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Eight months after surgery, video defecography, anal manometry and pouch volumetry were performed and the patients were interviewed according to a standardized continence questionnaire. Rectal resection and reconstruction with transverse coloplasty pouch anastomosis could be performed in all patients. No insufficiency of the pouch occurred. In the follow-up, no patient had difficulties to evacuate the pouch, none of these patients needed enemas or suppositories to facilitate defecation. All patients were continent for solid stools. Twenty-five of 27 patients had up to three bowel movements per day. Patients with reduced pelvic floor movement in the defecography proved more likely to suffer from urgency, fragmented evacuation and incontinence. Transverse coloplasty pouch reconstruction after total mesorectal excision is not associated with stool evacuation problems. Urgency and incontinence, which are rarely seen after this type of reconstruction, correlate with impaired pelvic floor movement rather than with pouch size or anal sphincter tonus.

Functional and physiologic assessment of the colonic reservoir or side-to-end anastomosis after low anterior resection for rectal cancer: a two-year follow-up

PURPOSE

Functional disturbances are common after anterior resection for rectal cancer. This study was designed to compare functional and physiologic outcome after low anterior resection and total mesorectal excision with a colonic J-pouch or a side-to-end anastomosis.

METHODS

Functional and physiologic variables were analyzed in patients randomized to a J-pouch (n = 36) or side-to-end anastomosis (n = 35). Postoperative functional outcome was investigated with questionnaires. Anorectal manometry was performed preoperatively and at six months, one year, and two years postoperatively.

RESULTS

There was no statistical difference in functional outcome between groups at two years. Maximum neorectal volume increased in both groups but was approximately 40 percent greater at two years in pouches compared with the side-to-end anastomosis. Anal sphincter pressures volumes were halved postoperatively and did not recover during follow-up of two years. Male gender, low anastomotic level, pelvic sepsis, and the postoperative decrease of sphincter pressures were independent factors for more incontinence symptoms.

CONCLUSIONS

Colonic J-pouch and side-to-end anastomosis gives comparable functional results two years after low anterior resection. Neorectal volume had no detectable influence on function. There was a pronounced and sustained postoperative decrease in sphincter pressures.

Transverse coloplasty pouch after total mesorectal excision: functional assessment of evacuation

PURPOSE

Colon pouch reconstruction after total mesorectal excision is functionally superior to straight colorectal/ anal anastomosis. In the long-term, stool evacuation difficulties could jeopardize the functional benefit. The transverse coloplasty pouch presents an alternative to the standard J-pouch. This study was designed to analyze functional outcome and defecography findings after total mesorectal excision and transverse coloplasty pouch reconstruction.

METHODS

Thirty consecutive patients with cancer of the middle and lower third of the rectum underwent a total mesorectal excision and were examined in a prospective study. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Patients were examined within eight months by means of defecography, manometry, pouch volumetry, and a standardized continence questionnaire.

RESULTS

Total mesorectal excision with transverse coloplasty pouch anastomosis was performed successfully in all patients. Symptomatic anastomotic leakage was observed in 2 of 30 patients and the radiologic leak rate was 4 of 30. All patients evacuated the pouch completely; none needed enemas or suppositories to facilitate defecation. Twenty-five of 27 patients had a maximum of three bowel movements per day, and all patients were continent for solid stools. Patients with abnormal findings on defecography proved more likely to have anal dysfunction.

CONCLUSIONS

Transverse coloplasty pouch reconstruction after total mesorectal excision leads to good functional results and is not associated with stool evacuation problems. Urgency and incontinence correlate rather with impaired pelvic floor movement than with pouch size or anal sphincter tonus.

Defecatory malfunction caused by motility disorder of the neorectum after anterior resection for rectal cancer

BACKGROUND

The correlation between postoperative defecatory status after anterior resection for rectal cancer and physiologic neorectal motility has not been well delineated.

METHODS

Sixty patients who underwent anterior resection were examined. Motility of the neorectum was examined with 4-sensor intraluminal pressure monitoring, and segmental colonic transit time was determined with radiopaque Sitzmarks (Konsyl, Fort Worth, Texas) capsules.

RESULTS

Twenty-eight patients experienced loss of propagated contraction waves down to the neorectum, which was closely correlated with a prolonged transit time through the neosigmoid colon and neorectum. In 26 patients, minor spastic waves were observed at the neorectum, which did not correlate well with the loss of propagated waves. The loss of propagation and the existence of spastic waves were significantly correlated with urgency of defecation and multiple evacuations. The latter was also associated with major soiling and with patients' assessments of impaired defecatory function.

CONCLUSIONS

The physiologic motility of the neorectum is one of the factors responsible for postoperative defecatory function after anterior resection for rectal cancer.

Pre-operative short-course radiotherapy is associated with faecal incontinence after anterior resection

OBJECTIVE

To determine the contribution of total mesorectal excision (TME), short-course pre-operative radiotherapy (SCRT), the level of the anastomosis and other putative contributory factors to the incidence and degree of faecal incontinence after anterior resection of the rectum.

PATIENTS AND METHODS

Survivors of anterior resection of the rectum performed between February 1996 and February 2001, with a functioning anastomosis, were asked to complete a telephone questionnaire regarding their current bowel habit. Faecal incontinence was scored using the St. Mark's Incontinence Score.

RESULTS

The median age of 124 patients who completed the questionnaire was 76 years. Of these, 104 patients had neoplastic disease, 66 (53%) patients exhibited some degree of incontinence, median St. Marks' Score 6, interquartile range 3-10. There was a significant association between the anastomotic level, and the St. Mark's Score (P < 0.0001, linear regression). Male sex (P = 0.047), SCRT (P = 0.0014) and an anastomotic leak (P = 0.038) were associated with significantly higher incontinence scores. Age, splenic flexure mobilization, TME, anastomotic configuration or use of a temporary stoma had no detectable independent effect on incontinence scores.

CONCLUSIONS

Poor functional outcome following anterior resection was associated with a low anastomosis, SCRT or an anastomotic leak. The finding that SCRT was a predictor of postoperative incontinence emphasizes the need for stringent patient selection for this treatment modality.

Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial

OBJECTIVES

To compare a colonic J-pouch or a side-to-end anastomosis after low-anterior resection for rectal cancer with regard to functional and surgical outcome.

SUMMARY BACKGROUND DATA

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.

METHODS

One-hundred patients with rectal cancer undergoing total mesorectal excision and colo-anal anastomosis were randomized to receive either a colonic pouch or a side-to-end anastomosis using the descending colon. Surgical results and complications were recorded. Patients were followed with a functional evaluation at 6 and 12 months postoperatively.

RESULTS

Fifty patients were randomized to each group. Patient characteristics in both groups were very similar regarding age, gender, tumor level, and Dukes' stages. A large proportion of the patients received short-term preoperative radiotherapy (78%). There was no significant difference in surgical outcome between the 2 techniques with respect to anastomotic height (4 cm), perioperative blood loss (500 ml), hospital stay (11 days), postoperative complications, reoperations or pelvic sepsis rates. Comparing functional results in the 2 study groups, only the ability to evacuate the bowel in <15 minutes at 6 months reached a significant difference in favor of the pouch procedure.

CONCLUSIONS

The data from this study show that either a colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results.

Options for sphincter preservation in surgery for low rectal cancer

BACKGROUND

Abdominoperineal excision of the rectum with a permanent end-sigmoid colostomy was the classical operation for cancer of the distal third of the rectum. A number of factors have recently led to a more conservative approach, allowing sphincter preservation when excising tumours that are not invading the anal sphincter.

METHODS

The review is based on the published literature of the treatment of low rectal cancers accessed by searching Medline and other online databases. It includes a description of all the surgical options currently available for low rectal tumours, and a discussion of the advantages and disadvantages of the types of anastomosis and reconstruction.

RESULTS AND CONCLUSION

It is now technically possible to remove rectal cancer that is extending into the anal canal with preservation of the anal sphincter mechanism and with a satisfactory oncological outcome. Ultra-low colorectal and coloanal anastomosis, together with a colonic pouch or coloplasty, produces acceptable function in many patients. However, there is still controversy about the risk of tumour implantation, the place of downsizing neoadjuvant therapy, and true long-term functional outcome. Despite these concerns, surgeons should strive to perform rectal resection with sphincter preservation for low-lying rectal cancer whenever possible.

Scintigraphic comparison of neorectal emptying between colonic J-pouch anastomosis and straight anastomosis after stapled low anterior resection

BACKGROUND AND AIMS

Colonic J-pouch anastomosis after low anterior resection of the rectum has been reported to be associated with an increased risk of evacuation difficulty. Using scintigraphy we compared neorectal emptying after stapled low anterior resection between colonic J-pouch anastomosis and straight anastomosis.

PATIENTS AND METHODS

We studied 19 patients after colonic J-pouch anastomosis and 22 after straight anastomosis. After the introduction of an artificial stool containing (99m)Tc-DTPA into the neorectum sequential lateral gamma images were obtained. From the time activity curve of radioactivity in the whole pelvis the time taken to evacuate one-half of the introduced artificial stool ( t(1/2)) and the percentage of artificial stool evacuated in 1 min (Evac(1)) were calculated. Fourteen volunteers were also studied as the reference group.

RESULTS

The t(1/2) was significantly longer and Evac(1) significantly lower in patients after low anterior resection than in the reference group. t(1/2) was significantly longer in the pouch group than in the straight group. Anastomotic height was significantly correlated with both t(1/2) and Evac(1). Neither t(1/2) nor Evac(1) was correlated with the severity of impaired defecatory function.

CONCLUSION

Although neither of the two parameters of neorectal emptying was correlated with the severity of impaired defecatory function, less effective neorectal emptying in patients after colonic J-pouch anastomosis than in those after straight anastomosis may be a factor causing evacuation difficulty after colonic J-pouch anastomosis.

A prospective evaluation of anorectal function after total mesorectal excision in patients with a rectal carcinoma

BACKGROUND

Rectum resection with total mesorectal excision (TME) and neorectal anastomosis often compromises anorectal function. Insight into the underlying mechanisms is lacking. Therefore, a prospective study was designed to investigate the relationship between clinical and functional outcomes preoperatively and postoperatively.

METHODS

Eleven patients with rectal cancer were examined before and 4 and 12 months after surgery and compared with 11 healthy volunteers (HVs). Anorectal (neorectal) function was examined by clinical outcome questionnaire, anal manometry, rectal compliance, and sensation. Six HVs also underwent barostat measurements in the sigmoid colon.

RESULTS

Clinical parameters of soiling and passive incontinence (loss of stool without sensation) increased significantly until 12 months postoperatively, whereas urgency and tenesmus increased temporarily, returning to preoperative values at 12 months. In anorectal measurements, anal sphincter function was grossly preserved; however, rectal-anal inhibitory reflex (RAIR) was decreased at 4 months but recovered after 1 year. Neorectal compliance was similar to that of HV sigmoid, increasing slightly after 12 months but still significantly lower than that of normal rectum. Neorectal sensation to pressure distention was similar to that of normal rectum, however accompanied by smaller volumes. Neorectal distention induced contractions of large amplitude at 4 months, returning to normal after 12 months.

CONCLUSIONS

Our results suggest that the transient increase in urgency and tenesmus after surgery results from a temporary increase in neorectal "irritability" accompanied by some adaptation of compliance in time. In contrast, episodes of incontinence and soiling are increased after 1 year most likely because of reduced neorectal capacity and RAIR recovery in the presence of a low basal anal sphincter pressure.

Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy

OBJECTIVE

Anorectal function is greatly disturbed after rectal surgery with or without radiotherapy (RT). To clarify the underlying mechanisms, we designed a prospective study to evaluate the effect of RT and surgery on anorectal function and clinical outcome of patients with a rectal carcinoma.

METHODS

Thirty-four patients with a rectal carcinoma participated in this study. They filled out a symptom questionnaire and underwent anal manometry, anal and rectal mucosal electrosensitivity testing, and a rectal barostat, before surgery, 4 and 12 months postoperatively. Thirteen patients were lost to follow-up, 14 underwent surgery alone (total mesorectal excision [TME]), and seven also received RT (RT + TME).

RESULTS

Functional outcome was disappointing in both groups, with at 4 months a significantly higher defecation frequency after RT + TME as compared with TME. Anal sphincter function and rectal sensitivity to pressure-controlled distention were not affected by either treatment. Rectal compliance, however, was significantly reduced after RT + TME at 4 and 1 2 months, resulting in lower rectal volumes at the thresholds for first sensation and desire to defecate. Rectal but not anal mucosal electrosensitivity was higher after TME + RT.

CONCLUSIONS

Anorectal function after rectal surgery with or without RT is greatly hampered because of a decreased rectal compliance. After 12 months, partial improvement is shown, especially in the absence of RT.

Strategies in the management of mid and distal rectal cancer with total mesorectal excision

In the last two decades, dramatic improvement in outcome has been made in the management of rectal cancer. This has been brought about mainly by advancements in surgical technique for radical resection. With the recognition of the importance of the circumferential margin and presence of spread in the lymphovascular tissues in the mesorectum, total mesorectal excision is now commonly recognized as the optimal surgical technique for cancer of the mid and distal rectum. Not only have local control and disease-specific survival improved with the practice of total mesorectal excision, but various bodily functions have also been preserved following surgery for rectal cancer. New issues have arisen with the practice of total mesorectal excision and the strategies for management of rectal cancer require re-evaluation. In this article, the rationale and the outcomes of total mesorectal excision are reviewed. Issues such as the high anastomotic leakage rate following sphincter-preserving surgery, the poor results of abdominoperineal resection, the role of adjuvant therapy and bowel function disturbances will be addressed. Lastly, the status of the laparoscopic approach to rectal cancer with the principle of total mesorectal excision are discussed.

Preservation of rectal function after low anterior resection with formation of a neorectum

Recent advances in surgery have enabled low rectal cancers to be resected, while at the same time restoring bowel continuity and preserving the anal sphincter. Although a permanent stoma is avoided and the operation is oncologically sound, function may be compromised. Many patients with a straight coloanal anstomosis suffer from urgency, incontinence, and bowel frequency-the so-called anterior resection syndrome. Over the last 15 years, surgical developments have aimed at improving function after restoration of bowel continuity, essentially by creating a neorectum. The best known and most widely practiced operation involves formation of a colonic J-pouch. The physiological and functional outcomes of the colonic J-pouch are discussed, along with controversies surrounding construction. Although a J-pouch improves some aspects of function, the results are not perfect. Alternatives to the colonic J-pouch are appraised, indicating future areas of development.

Posterior sagittal approach: megasigmoid resection and anal reconstruction for severe constipation and fecal incontinence after anoplasty

PURPOSE

The aim of this study was to present the technique of megasigmoid resection and anal reconstruction by complete posterior sagittal approach for the children with severe constipation and fecal incontinence after anoplasty.

METHODS

Six patients (age, 2 to 18 years) born with imperforate anus and originally treated with perineal anoplasty suffered from intractable constipation and fecal incontinence. Contrast enema showed massive dilated and aperistaltic rectosigmoid colon with fecal impaction. Resection of the dilated bowel and anal reconstruction were completely performed by posterior sagittal approach.

RESULTS

The mean operating time was 205 minutes (range, 125 to 265 minutes) and the average length of resected colon was 23.3 cm (range, 10 to 40 cm). There were no intraoperative or postoperative complications. By 2 to 4 months after the operation, all patients obtained voluntary bowel movement. On follow-up at 6 to 24 months postoperative, no patient had constipation or required use of the laxatives again. Four of 6 patients suffered from grade 1 soiling, and the other 2 had grade greater than 1 soiling. None had urinary retention or incontinence after the procedure.

CONCLUSION

Resection of dilated rectosigmoid colon and anal reconstruction for the patients with severe constipation and fecal incontinence after anoplasty can be performed successfully using a posterior sagittal approach.

Long-term results of low anterior resection with intersphincteric anastomosis in carcinoma of the lower one-third of the rectum: analysis of 31 patients

INTRODUCTION

Between 1985 and 1996, 190 patients underwent a low anterior rectal resection with coloanal anastomosis for adenocarcinoma of the lower one-third of the rectum.

METHODS

This article reports on 31 (17 males) of these patients with a very low localization of the tumor (distal tumor margin 1.3 +/- 0.9 cm above the dentate line). If the function of the sphincter was acceptable and we could exclude tumor infiltration into the sphincter through endosonography, we relocated the resection plane distally into the intersphincteric region to attain an acceptable margin of safety. In all of these cases, it was impossible for us to perform the usual surgical procedure of a mechanical anastomosis by means of a circular stapler. After intersphincteric rectal resection, the anastomosis was handsewn, using interrupted sutures from the perineal approach, 2.5 to 3 cm above the anal verge, implementing Parks' retractor. A protective stoma was performed in all cases. All data were documented prospectively.

RESULTS

COMPLICATIONS

Postoperative mortality was 0 percent. Postoperatively, none of the patients showed an indication for relaparotomy. The leakage rate was 48 percent. Only 16 percent later needed additional surgery for anastomotic strictures or for rectovaginal fistulas. Long-term observations showed that the anastomosis healed well in 27 patients (87.1 percent). Four patients (12.9 percent) decided to have a terminal colostomy performed (anastomotic stricture, 3 patients; anorectal incontinence, 1 patient).

FOLLOW-UP

During the follow-up period of 6.8 +/- 3.7 years, six patients (19.4 percent) developed a tumor progression (9.7 percent local recurrences and 12.9 percent distant spread). The five-year survival rate was 79 percent (Dukes A, 100 percent (n = 18); Dukes B, 67 percent (n = 4); and Dukes C, 44 percent (n = 9)). Continence: One-third of patients developed anorectal incontinence for liquid (29.6 percent) or solid stool (3.7 percent). Average stool frequency was 3.3 times per day. Resting pressure decreased significantly by 29 percent (preoperative, 105 +/- 37 cm H2O and postoperative, 75 +/- 19 cm H2O; P < 0.05), whereas squeeze pressure did not change.

CONCLUSION

In selected patients with tumors close to the dentate line, an intersphincteric resection of the rectum may help to avoid an abdominoperineal excision of the rectum with a terminal stoma, without any curtailment of oncologic standards. A protective stoma for three months is advantageous.

Misconceptions about the colonic J-pouch: what the accumulating data show

INTRODUCTION

Since 1986 when the colonic J-pouch-anal anastomosis was first described, it has gained increasing acceptance as the operation of choice for low rectal cancer surgery. However, there still exist several misconceptions about its use, namely anastomotic complications, alterations in anorectal physiology, and functional outcome.

METHODS

All relevant articles derived from MEDLINE databases from 1986 to the present were reviewed. Emphasis was placed on reviewing the features that are claimed to make the colonic J-pouch-anal anastomosis superior to a straight anastomosis.

RESULTS AND CONCLUSIONS

The colonic J-pouch has a role in ultra-low rectal cancer surgery, with an apparent reduction in the incidence of anastomotic leaks and reduced bowel frequency. Continence is unchanged and defecatory difficulties can be reduced by constructing a small pouch (< or =5 cm).

Physiological and functional outcome following ultra-low anterior resection with colon pouch-anal anastomosis

BACKGROUND

Low rectal cancer is usually managed by ultra-low anterior resection (ULAR) with total mesorectal excision and straight coloanal anastomosis. However, following this procedure patients often suffer from frequency, urgency of bowel action and, occasionally, faecal incontinence. To overcome such problems, a colon pouch may be fashioned and a subsequent colon pouch-anal anastomosis performed. The physiological and functional outcome following the use of a colon pouch are appraised.

METHODS

All relevant papers identified from a Medline search and papers from cross-referencing were reviewed.

RESULTS AND CONCLUSION

Creation of a colon pouch following ULAR results in reduced bowel frequency, and a lower incidence of urgency and faecal incontinence. Although there is a slightly increased incidence of evacuatory disorder and need for enemas or suppositories, this appears to be a minor problem which may possibly be overcome by using a smaller colon pouch. Compared with straight coloanal anastomosis following ULAR, the creation of a colon pouch produced a superior functional outcome.

Quality of life after treatment for rectal cancer

BACKGROUND

The studies on patient-reported symptoms and quality of life following the treatment of rectal cancer were evaluated; guidelines for future quality of life studies in this field are proposed.

METHODS

Relevant papers in the English language were identified via Medline from January 1970 to November 1997, supplemented by a manual search for similar articles.

RESULTS

Patients suffer various short- and long-term complications after treatment of rectal cancer, although the reported prevalence of such problems varies from study to study. Recent prospective studies have shown that, despite these problems, global quality of life scores as measured by generic questionnaires improve after surgery.

CONCLUSION

The methodological shortcomings of previous work must be rectified if quality of life studies are to have relevance in patient management.

Endosonographic evidence of injury to the internal anal sphincter after low anterior resection: long-term follow-up

PURPOSE

Transanal stapled anastomosis has been associated with continence disturbances and reduced postoperative anal sphincter function. The aim of the present work was to study the effect of transanal stapling on anal sphincter morphology by endoanal ultrasound.

METHODS

Thirty-nine consecutive patients undergoing stapled low anterior resection for rectal carcinoma were assessed. Each patient was assessed by endoluminal ultrasound before surgery, immediately after surgery, and at 3, 6, 9, 12, and 24 months after surgery.

RESULTS

There were no preoperative internal anal sphincter defects observed. Three female patients were observed to have preoperative evidence of external anal sphincter defects. After low anterior resection, seven patients were found to have internal anal sphincter defects, which persisted after the two-year follow-up. There were no additional external anal sphincter injuries. Three patients with internal anal sphincter injuries required the use of pads for poor bowel function.

CONCLUSIONS

Up to 18 percent of patients who underwent stapled low anterior resection had long-term evidence of internal anal sphincter injury. The external sphincter does not appear to be affected by the procedure.

Physiologic characteristics of straight and colonic J-pouch anastomoses after rectal excision for cancer

PURPOSE

The colonic J-pouch anastomosis has been advocated to obviate urgent and frequent defecations following a sphincter-saving rectal excision. Physiologic characteristics of the colonic J-pouch were compared with those of the traditional straight anastomosis and related to clinical function.

METHOD

Patients with total mesorectal excision for carcinoma were randomized to either a straight (n = 23) or a colonic pouch anastomosis (n = 23). The patients were examined before and at one year after surgery (n = 42), which included laboratory studies, and a questionnaire regarding anorectal function was completed.

RESULTS

Preoperative compliance of the rectum was restored after surgery in the pouch group, 2.9 (2.2-3.4) ml/cm H2O, but there was a significant decrease after surgery in the straight anastomosis group, 1.9 (1.1-2.3) P < 0.001 (median (interquartile range)). Sphincter pressures in both groups were similar. In a multiple regression analysis, high compliance was associated with favorable clinical function, and hypermotility of the anal canal was associated with adverse clinical function.

CONCLUSIONS

Colonic pouch-anal anastomosis restores neorectal compliance, which is important for good function after low anterior resection. Presence of an unstable internal sphincter is a negative factor for clinical function in both straight and pouch anastomoses.