Indications for colonic J-pouch reconstruction after anterior resection for rectal cancer: determining the optimum level of anastomosis

Reconstructive techniques following low anterior resection for carcinoma of the rectum

INTRODUCTION

Multiple reconstructive techniques have been described for reconstruction after a low anterior resection for carcinoma rectum. Colonic J pouch (CJP), Side to end anastomosis (SEA), transverse coloplasty pouch (TCP) and Straight Colo-rectal/anal anastomosis were the most widely studied.

EVIDENCE ACQUISITION

PubMed, Embase and Cochrane data base were searched for randomized, non-randomized studies and systematic reviews from inception of the databases till July 31st, 2023.

EVIDENCE SYNTHESIS

Considerable heterogeneity existed among different study findings. Reservoir techniques, including CJP, SEA, and TCP, exhibited reduced stool frequency, decreased urgency, and improved continence status compared to SCA, particularly in the short term. CJP maintained this advantage into the intermediate term. Other functional outcomes were similar among the techniques. However, these functional improvements did not translate into enhanced Quality of Life (QoL). TCP was associated with an elevated risk of anastomotic leaks. Other surgical outcomes remained comparable across all four techniques. Sexual outcomes also exhibited no significant variation. Some studies suggested that the size of the side limb in CJP or SEA may not significantly impact functional outcomes, implying that neorectum capacity may not be the primary determinant of improved function. The precise physiological mechanism underlying these findings remains unknown.

CONCLUSIONS

In the short and intermediate terms, reservoir techniques demonstrated superior functional outcomes, but long-term performance was comparable among all techniques. Notably, enhanced functional outcomes did not translate to improved Quality of Life. TCP, while effective, is linked to an increased risk of anastomotic complications, necessitating cautious utilization.

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

AIMS

To evaluate comparative outcomes of straight (end-to-end) anastomosis versus colonic J-pouch anastomosis following anterior resection.

METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing straight (end-to-end) anastomosis versus J-pouch anastomosis were included. Anastomotic complications, post-operative complications, re-operation, mortality, and functional outcomes were the evaluated outcome parameters. Revman 5.3 was used for data analysis.

RESULTS

Twenty-seven studies reporting a total number of 3293 patients who underwent straight anastomosis (n = 1581) or J-pouch (n = 1712) were included. Anastomotic leak and re-operation rates were significantly higher in the straight group compared to the J-pouch group [RD 0.03, P = 0.03] and [OR 1.87, P = 0.003], respectively. Stool frequency per 24 h at 6 months and 12 months was lower in the J-pouch group than the straight group [MD 2.13, P = 0.003] and [MD 1.44, P = 0.00001], respectively. In addition, the use of anti-diarrheal medication is lower at 12 months in the J-pouch group [MD 3.85, P = 0.03]. Moreover, the two groups showed comparable results regarding SSI, sepsis, paralytic ileus, anastomotic stricture formation, anastomotic bleeding, and mortality.

CONCLUSION

J-pouch anastomosis showed lower risk for anastomotic leak and re-operation. Furthermore, better functional outcomes such as stool frequency were achieved using the colonic J-pouch reconstruction over the conventional straight end-to-end anastomosis.

Side-to-end vs. straight stapled colorectal anastomosis after low anterior resection: results of randomized clinical trial

AIM

The aim of this study is to compare surgical, functional, physiologic outcomes and QOL after low anterior resection (LAR) with andside-to-end or straight colorectal anastomosis.

METHOD

Between 2012 and 2015, 86 patients with mid and low rectal tumors were enrolled into randomized trial. Wexner score, number of defecations, use of antidiarrheal medicine or laxatives, enemas, pads, episodes of nocturnal incontinence, and urgency were recorded. The Fecal Incontinence Quality of Life (FIQL) scale was used for assessment of QOL. Anal manometry and volumetric examination were performed.

RESULTS

Six patients were excluded from the study. There was no mortality. The morbidity rate was 6 (14.6 %) for side-to-end vs. 8 (20.0 %) for straight anastomosis (p = 0.57). The median Wexner score was 5 vs. 6 (p = 0.033), 4 vs. 5 (p = 0.006), and 2 vs. 3 (p = 0.1) at 1, 3, and 6 months after stoma reversal, respectively. Side-to-end anastomosis resulted in a fewer mean numbers of bowel movements per day at the same check points of follow-up: 5.8 ± 0.14 vs. 6.4 ± 0.15 (p = 0.006), 3.7 ± 0.1 vs. 4.2 ± 0.1 (p = 0.003), and 2.5 ± 0.1 vs. 3.0 ± 0.10 (p = 0.0002), correspondingly. Maximal tolerated volume was higher for side-to-end anastomosis at 3 and 6 months of follow-up: 152.0 vs. 137.8 cm(3) (p = 0.002) and 180.5 vs. 167.0 cm(3) (p = 0.006), respectively. Better FIQL score was found at 1 and 3 months in the side-to-end group.

CONCLUSION

Better functional outcomes and QOL were observed in a short period after stoma closure, but at 6 months of follow-up, the only benefit of side-to-end anastomosis was a lower number of bowel movements.

How low is low? Evolving approaches to sphincter-sparing resection techniques

Although advances in rectal cancer staging may ultimately be accurate enough to reliably exclude disease outside the rectal wall (thereby allowing local approaches to be more widely and safely applied) and advances in the use of neoadjuvant chemo- and radiation therapy may ultimately produce more "complete responders" that can be accurately identified and spared surgery altogether, as it stands, radical resection forms the basis of curative treatment for rectal cancer. However, the concepts that guide the surgeon in choosing the optimal approach in radical resection are changing. In the past, the decision as to how to proceed surgically with radical resection was based primarily on the level of the tumor above the anal verge or anorectal ring. The issue was primarily "How low is the tumor?" and "Is the distal margin safe?" A more modern approach focuses attention on achieving a negative circumferential margin despite what historically may seem to be a very minimal distal margin, the current issue is not "How low is the tumor?" so much as it is "How deep does the tumor go?". This shift in focus has been a major impetus in the evolution of sphincter sparing resection techniques.

Sphincter preservation for distal rectal cancer - a goal worth achieving at all costs?

To assess the merits of currently available treatment options in the management of patients with low rectal cancer, a review of the medical literature pertaining to the operative and non-operative management of low rectal cancer was performed, with particular emphasis on sphincter preservation, oncological outcome, functional outcome, morbidity, quality of life, and patient preference. Low anterior resection (AR) is technically feasible in an increasing proportion of patients with low rectal cancer. The cost of sphincter preservation is the risk of morbidity and poor functional outcome in a significant proportion of patients. Transanal and endoscopic surgery are attractive options in selected patients that can provide satisfactory oncological outcomes while avoiding the morbidity and functional sequelae of open total mesorectal excision. In complete responders to neo-adjuvant chemoradiotherapy, a non-operative approach may prove to be an option. Abdominoperineal excision (APE) imposes a permanent stoma and is associated with significant incidence of perineal morbidity but avoids the risk of poor functional outcome following AR. Quality of life following AR and APE is comparable. Given the choice, most patients will choose AR over APE, however patients following APE positively appraise this option. In striving toward sphincter preservation the challenge is not only to achieve the best possible oncological outcome, but also to ensure that patients with low rectal cancer have realistic and accurate expectations of their treatment choice so that the best possible overall outcome can be obtained by each individual.

Low anterior resection: alternative anastomotic techniques

Low anterior resection (LAR), with its numerous technical modifications, is one of the most commonly performed operations for rectal cancer. In the past, patients with locally advanced distal rectal cancer were most frequently treated by abdominoperineal resection and permanent colostomy. However, over the past two decades and with improved understanding of tumor biology and refinement in technique, use of LAR to treat rectal cancer has increased substantially. Yet, despite the significant increase in LAR and sphincter preservation, patients in many areas of the country have little access to these techniques and continue to commonly be treated with abdominoperineal resection. This article examines the surgeon's unique and critical role in the pretreatment evaluation and decisions leading to choice of surgical therapy for locally invasive distal rectal cancer. In particular, the authors focus on technical aspects to preserve the anal sphincter, and review methods to optimize functional outcomes in the setting of low pelvic anastomosis.

Reconstruction techniques after proctectomy: what's the best?

There are approximately 40,000 new rectal cancer cases diagnosed each year in the United States, representing the second most common gastrointestinal malignancy (behind colon cancer). With the advent of sphincter preserving techniques, patients with mid and low colorectal cancers enjoy the benefits of better postoperative functional outcomes and quality of life; however, controversy exists over which reconstructive technique is superior in restoring bowel continuity. Construction of a straight coloanal anastomosis is technically simpler, but functional outcomes are inferior compared with colonic reservoirs. The purpose of this review is to summarize the current data regarding reconstructive techniques following proctectomy.

Pouch operation for rectal cancer

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

Effect of anastomosis level on continence performance and quality of life after colonic J-pouch reconstruction

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

Techniques for restoring bowel continuity and function after rectal cancer surgery

A very low local recurrence rate of 3%-6% (associated with improved 5 year survival) is possible when proper oncological surgery is performed of mid and distal rectal adenocarcinoma. Restoration of bowel continuity is possible in most cases, without compromise of cancer clearance. Re-anastomosis can be performed with stapled, transabdominal hand-sewn or coloanal pull-through techniques. However after a direct (straight) anastomosis of the colon to the distal rectum/anus, up to 33% of patients have 3 or more bowel movements/d; some can be troubled with up to 14 stools a day. Construction of a 6-cm colonic J-pouch is likely to cause some reversed peristalsis which improves postoperative bowel frequency without causing neo-rectum evacuation problems. Colonic J-pouch-anal anastomosis patients have a median of 3 bowel movements a day compared with a median of 6 a day for straight anastomoses, at 1 year after surgery. In the longer term, bowel adaptation may enable the function after a straight anastomosis to approximate that of a colonic J-pouch-anal anastomosis. This probably depends in the former, upon whether the more rigid sigmoid colon or more distensible descending colon is used. An additional advantage of the colonic J-pouch-anal anastomosis is the lower risk of anastomotic complications. A more vascularized side-to-end (colonic J-pouch-anal) anastomosis is likely to heal better than an end-to-end (straight) anastomosis. Where the pelvis is too narrow for a bulky colonic J-pouch anal anastomosis, a coloplasty-anal-anastomosis is an option. The latter results in postoperative bowel function comparable with the colonic J-pouch. However, the risk of anastomotic complications is higher possibly related to its end-to-end anastomotic configuration. Laparoscopic techniques for accomplishing all the above are being proven to be effective. Restorative surgery for rectal cancer can be safely and effectively performed with methods to improve bowel function very acceptably; the future advances are likely in laparoscopy.

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

PURPOSE

To evaluate the long-term functional outcome of colonic J-pouch reconstruction after low anterior resection (LAR) for rectal cancer in a prospective study.

METHODS

We compared the functional outcome of 46 patients who underwent J-pouch reconstruction (J-group) and 49 patients who underwent straight anastomosis (S-group) after LAR for rectal cancer. We evaluated clinical function using a 17-item questionnaire about different aspects of bowel function. Physiologic reservoir function was evaluated by manovolumetry.

RESULTS

Among the patients with an ultralow anastomosis (<or=4 cm from the anal verge), those in the J-group had fewer bowel movements during the day and at night, and less urgency, soiling, protective pad use, incontinence, and dissatisfaction with bowel function than those in the S-group. Among the patients with a low anastomosis (5-8 cm from the verge), those in the J-group had fewer bowel movements at night, and less urgency and soiling than those in the S-group. Moreover, reservoir function (reflected by the maximum tolerable volume, threshold volume, and compliance) was better in the J-group than in the S-group in both the ultralow and low anastomosis groups.

CONCLUSION

J-pouch reconstruction after low anterior resection creates a better stool reservoir than straight anastomosis, especially when the anastomosis is less than 4 cm from the anal verge, resulting in a better quality of life 3 years after rectal cancer resection.

Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection

Background and methods

The comparative benefits and drawbacks of straight coloanal anastomosis (CAA), colonic J-pouch and coloplasty anastomosis after anterior resection are uncertain. Studies published between 1986 and 2005 of colonic J-pouch versus transverse coloplasty or straight CAA were analysed. Endpoints included postoperative complications, and functional and physiological outcomes measured within 6 months, 1 year and 2 years or more after the procedure. A random-effect model was used to aggregate the study endpoints and assess heterogeneity.

Results

Thirty-five studies containing 2240 patients (1066 straight CAA, 1050 J-pouch and 124 coloplasty) were included. There was no significant difference in postoperative complications between the three groups. There was a significant reduction in the frequency of defaecation per day by 1·88, 1·35 and 0·74 motions at the three time intervals in the J-pouch group compared with the straight CAA group. Faecal urgency was less prevalent in patients with a J-pouch than those with a straight CAA (odds ratio 0·27 at 6 months or less and 0·21 at 1 year). There was no difference in functional outcome between J-pouch and coloplasty anastomosis.

Conclusions

The colonic J-pouch provided functional benefits over straight anastomosis with no increase in postoperative complications. Coloplasty appeared to have similar benefits but further studies are required for validation.

Impact of lateral pelvic lymph node dissection on evacuatory and urinary functions following low anterior resection for advanced rectal carcinoma

BACKGROUND AND AIM

Lateral pelvic lymph node dissection (LPLD) has been reported to be beneficial in terms of survival for locally advanced low rectal carcinoma. However, the impact of LPLD on bowel function has not yet been determined by means of anorectal physiologic investigation.

PATIENTS AND METHODS

Fifty-seven rectal cancer patients who underwent low anterior resection were evaluated with clinical and physiologic parameters. Of these, 15 patients had LPLD. The postoperative bowel and urinary function were evaluated with patients' questionnaire and anorectal manometry before and after the operation.

RESULTS

The proportion of patients who had pouch reconstruction, adjuvant radiation therapy, and autonomic nerve dissection were significantly higher in the LPLD group. The incidence of evacuatory dysfunction was significantly higher (80% vs 45%) postoperatively in the LPLD group. There was no significant difference in anal sphincter pressures, sensory threshold, and neorectal volumes between the groups postoperatively. In terms of urinary function, use of medication for urination was significantly frequent in the LPLD group. Multivariate analysis identified the level of anastomosis as an independent affecting factor for evacuatory dysfunction and LPLD for urinary dysfunction.

CONCLUSION

Although LPLD affected urinary dysfunction, it did not impair postoperative evacuatory function in the early postoperative period.

Long-term functional results after straight or colonic J-pouch coloanal anastomosis

Proctectomy followed by straight coloanal anastomosis (CAA) often results in poor functional outcome known as the anterior resection syndrome. It is now based on evidence that a colonic J-pouch CAA improves outcome in the first 2 years. We assessed the very late functional outcome of CAA patients with or without a pouch. These results show that the functional benefit of the J-pouch anastomoses is sustained over the very long term.

Comparison of long-term functional results of colonic J-pouch and straight anastomosis after low anterior resection for rectal cancer: a five-year follow-up

PURPOSE

Few reports on the long-term functional outcome of colonic J-pouch reconstruction have been published, and data comparing J-pouch and straight reconstruction are contradictory. This prospective study compares the functional outcome of colonic J-pouch and straight anastomosis five years after low anterior resection for rectal cancer.

METHODS

Functional outcome was compared in 46 patients with J-pouch reconstruction (J-group) and 48 patients with straight anastomosis (S-group). Clinical status was evaluated with a 17-item questionnaire inquiring about different aspects of bowel function. Reservoir function was evaluated by manovolumetry. The Fisher's exact test and Wilcoxon's rank-sum test were used to compare categoric and quantitative data, respectively.

RESULTS

Among patients with an ultralow anastomosis (< or = 4 cm from the anal verge), the number of bowel movements during the day (> or = 5, 4.3 vs. 29.2 percent; P = 0.028) and at night (> 1/week, 4.3 vs. 33.3 percent; P = 0.013) and urgency (4.3 vs. 33.3 percent; P = 0.013) and soiling (21.7 vs. 50.0 percent; P = 0.043) were less in the J-group than in the S-group. Among patients with a low anastomosis (5 to 8 cm from the verge), patients in the J-group had fewer bowel movements at night (> 1/week, 0 vs. 20.8 percent; P = 0.028) and less urgency (0 vs. 20.8 percent; P = 0.028). Reservoir function was better in the J-group than in the S-group in both the ultralow (maximum tolerable volume (mean), 101.7 vs. 76.3 ml; P = 0.004; threshold volume (mean), 46.5 vs. 30.4 ml; P < 0.001; compliance (mean), 4.9 vs. 2.5 ml/cm H2O; P < 0.001) and low-anastomosis (maximum tolerable volume, 120.4 vs. 97.9 ml; P < 0.001; threshold volume, 58.3 vs. 40.8 ml; P < 0.001; compliance, 5.2 vs. 3.1 ml/cm H2O; P < 0.001) groups.

CONCLUSIONS

J-pouch reconstruction increased reservoir function and provided better functional outcome than straight anastomosis, even five years after surgery, especially in patients whose anastomosis is less than 4 cm from the anal verge.

Transverse coloplasty pouch and colonic J-pouch for rectal cancer--a comparative study

OBJECTIVES

The introduction of the colonic J-pouch has markedly improved the functional outcome of restorative rectal cancer surgery. However colonic J-pouch surgery can be problematic and may present some late evacuatory problems. To overcome these limitations a novel pouch has been proposed: the transverse coloplasty pouch. The purpose of our study was to compare the functional outcomes of these two different types of pouches--the transverse coloplasty pouch (TCP) and the colonic J-pouch (CJP)--during the first 12 months postoperatively.

PATIENTS AND METHODS

A prospective randomized trial was conducted in which a total of 30 patients with mid and low rectal cancer were submitted either to a transverse coloplasty pouch or a colonic J-pouch. Clinical defaecatory function was assessed and anorectal physiological assessment was carried out, pre-operatively and at 3, 6 and 12 months postoperatively, by means of a standard clinical questionnaire and by anorectal manometry.

RESULTS

No statistically significant differences were found between the two groups regarding bowel function. The postoperative frequency of daily bowel movements was lower in the TCP group in all the phases of the study (3.9 vs. 4.1 at 3 months; 3.1 vs. 3.4 at 6 months; 2.1 vs. 2.8 at 12 months), the same occurring with fragmentation (33% vs. 40% at 3 months; 26.6%vs. 33.3% at 6 months; 7.1%vs. 14.3% at 12 months). Less urgency was also seen in the TCP group during the first 6 months (20%vs. 26.7%), with identical values at 12 months (14.3% vs. 14.3%). No significant differences were also found concerning incontinence grading and scoring, with TCP patients having less nocturnal leaks. At one year two CJP patients (14.3%) needed the use of enemas to evacuate the pouch and provoke defaecation, a problem never seen in TCP patients. The anorectal manometry data was similar in both types of pouches. The local complication rates were also identical in the two groups (20%); more anastomotic leaks were seen in TCP patients (13.2% vs. 6.6%), without reaching a statistical significance.

CONCLUSION

The transverse coloplasty pouch has similar functional results but fewer evacuation problems than the J-Pouch, making it a safe and reliable alternative to the colonic J-pouch.

Multimodality Management of Locally Advanced Rectal Cancer

Despite the routine use of adjuvant chemoradiation for curatively resected stage II and III rectal cancer a significant percentage of patients ultimately fail locally and/or distally; this underscores the need for continued improvement in the efficacy of combined-modality therapy and quality of rectal cancer resection. The recognition of the significance of lateral or circumferential margins of resection has paralleled the widespread use of total mesorectal excision. In addition to facilitating negative margins of resection and local control, sharp mesorectal techniques also facilitate identification and preservation of pelvic autonomic nerves thereby greatly reducing the incidence of urinary and sexual dysfunction following radical resection. Lastly, restorative options can result in excellent bowel function in carefully selected patients undergoing a “very low” anterior resection. Efforts are currently directed at identifying the subset of locally advanced rectal cancer patients who may be adequately treated with a resection alone thereby avoiding the added morbidity of adjuvant radiation and chemotherapy.

Pouch reconstruction in the pelvis

ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.

The colonic J-pouch in colo-anal anastomosis

Anastomosis of the colon to the anal canal is now an accepted technique in the surgical management of low and mid rectal cancers. Although significant postoperative bowel disturbance is often seen with straight colo-anal anastomosis, controversy exists over the benefit of adding a colonic pouch for low anastomoses. Several short and long-term studies have demonstrated the early functional superiority of pouch-anal over straight anastomosis. Pouch construction does not compromise anal physiological parameters. It is recommended the pouch be constructed from a length of descending colon and be small (5 cm) in size to adequately act as a neo-rectum; long-term evacuatory difficulties are encountered with the construction of large pouches (10 cm). Anastomotic complications appear to be less frequent with pouch surgery; construction of a pouch does not significantly add to operative time, patient morbidity and mortality. At present there is no compromise to long-term oncological survival. The data supporting these statements is weak and based largely upon retrospective studies. Furthermore the impact of improved function with pouch-anal anastomosis on overall quality of life has been poorly investigated. Further prospective randomized studies are required to ascertain whether the potential benefits of a colonic pouch are realized in the randomized setting.

Comparison of J-pouch and coloplasty pouch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates

OBJECTIVE

To assess the efficacy of a novel coloplasty colonic pouch design in optimizing bowel function after ultralow anterior resection.

SUMMARY BACKGROUND DATA

A colonic J-pouch may reduce excessive stool frequency and incontinence after anterior resection, but at the risk of evacuation problems. Experimental surgery on pigs has suggested that a coloplasty pouch (CP) may be a useful alternative. Although CP has recently been shown to be feasible in patients, there is no randomized controlled trial comparing bowel function with the J-pouch.

METHODS

After anterior resection for cancer, patients were allocated to either J-pouch or CP-anal anastomoses. Continence scoring, anorectal manometry, and endoanal ultrasound assessments were made before surgery. All complications were recorded, and these preoperative assessments were repeated at 4 months. The assessments were repeated again at 1 year, and a quality of life questionnaire was added.

RESULTS

Eighty-eight patients were recruited from October 1998 to April 2000. Both groups were well matched for age, gender, staging, adjuvant therapy, and mean follow-up. There were no differences in the intraoperative time and hospital stay. CP resulted in more anastomotic leaks. At 4 months, J-pouch patients had 10.3% less stool fragmentation but poorer stool deferment and more nocturnal leakage. However, there were no differences in the bowel function, continence score, and quality of life at 1 year. There were no differences in the anorectal manometry and endoanal ultrasound findings.

CONCLUSIONS

Coloplasty pouches resulted in more anastomotic leaks and minimal differences in bowel function. At present, the J-pouch remains the benchmark for routine clinical practice, and due care (including defunctioning stoma) should be exercised in situations requiring CP.

Function of a colonic J pouch continues to improve with time

BACKGROUND

J pouch-anal anastomosis is thought to give superior functional results to straight coloanal anastomosis after rectal resection. Follow-up studies have suggested that this improvement is not maintained and that evacuatory difficulties may increase.

METHODS

Some 119 consecutive patients had a coloanal anastomosis after resection for rectal carcinoma over 113 months, 62 with a J pouch and 57 with a straight coloanal anastomosis. Functional results were determined by patient questionnaire. The two groups were compared for the first and second 5-year intervals of study.

RESULTS

Patients who had a J pouch had significantly better median Kirwan continence scores for the duration of the study and 5-9 years after surgery: 1 versus 2 (P = 0.05) and 1 versus 2 (P < 0.01), respectively. Some 5-9 years after surgery the median number of nocturnal bowel movements was significantly lower in patients who had a J pouch than in those with a straight coloanal anastomosis (0 versus 1; P = 0.02). Similarly, significantly better results were seen with regard to evacuation difficulties and urgency of defaecation.

CONCLUSION

The function of the J pouch was superior to that of the straight coloanal anastomosis and appeared to improve with time.

Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial

The colonic J-pouch (pouch group) functions better than the straight coloanal anastomosis (straight group) immediately after ultra-low anterior resection, but there are few studies with long-term follow-up. This randomized controlled study compared functional outcome, anal manometry, and rectal barostat assessment of these two groups over a 2-year period. Forty-two consecutive patients were recruited, of which 19 of the straight group [17 men with a mean age of 62.1 +/- 2.3 (SEM) year] and 16 of the pouch group (11 men with a mean age of 61.3 +/- 3.2 year) completed the study. Four died from metastases and two emigrated; there was no surgical morbidity or local recurrence. At 6 months the Pouch patients had significantly less frequent stools (32.9 +/- 2.8 vs. 49 +/- 1.4/week; p < 0.05) and less soiling at passing flatus (38% vs. 73.7%; p < 0.05). At 2 years both groups had improved with no longer any differences in stool frequency (7.3 +/- 0.4 vs. 8 +/- 0.2/week) and soiling at passing flatus (38% vs. 53%). Defecation problems remained minimal in both groups. Anal squeeze pressures were significantly impaired in both groups up to 2 years (p < 0.05). The rectal maximum tolerable volume and compliance were not different between groups. Rectal sensory testing on the barostat phasic program showed impairment at 6 months and recovery at 2 years, suggesting that postoperative recovery of residual afferent sympathetic nerves may play a role in functional recovery. In conclusion, stool frequency and incontinence were less in the Pouch patients at 6 months; but after adaptation at 2 years the straight group patients yielded similar results. Nonetheless, this functional advantage can be given to patients with minimal added effort or complications by using the colonic J-pouch.

Coloplasty in low colorectal anastomosis: manometric and functional comparison with straight and colonic J-pouch anastomosis

PURPOSE

After resection of the distal rectum with a straight reanastomosis, poor bowel function can occur. This is felt to be because of the loss of the rectal reservoir. To overcome this, a neoreservoir using a colonic J-pouch has been advocated in low colorectal and coloanal anastomosis. However, difficulties in reach, inability to fit the pouch into a narrow pelvis, and postoperative evacuation problems can make the colonic J-pouch problematic. Coloplasty is a new technique that may overcome the poor bowel function seen in the straight anastomosis and the problems of the colonic J-pouch. The purpose of this study was to compare the functional results after a low colorectal anastomosis among patients receiving a coloplasty, colonic J-pouch, or straight anastomosis.

METHODS

Twenty patients underwent construction of a coloplasty with a low colorectal anastomosis. Postoperative manometry and functional outcome of these patients was compared with a matched group of 16 patients who had a colonic J-pouch and low colorectal anastomosis and 17 patients who had a straight low colorectal anastomosis.

RESULTS

Maximum tolerated volume was significantly favorable in the coloplasty (mean, 116.9 ml) and colonic J-pouch group (mean, 150 ml) vs. the straight anastomosis group (mean, 83.3; P < 0.05) The compliance was also significantly favorable for the coloplasty (mean, 4.9 ml/mmHg) and the colonic J-pouch group (mean, 6.1 ml/mmHg) vs. the straight anastomosis group (mean, 3.2 ml/mmHg; P < 0.05) The coloplasty (mean, 2.6; range, 1-5) and colonic J-pouch (mean, 3.1; range, 2-6) had significantly fewer bowel movements per day than the straight anastomosis group (mean, 4.5; range, 1-8; P < 0.05). Similar complication rates were noted in the three groups.

CONCLUSIONS

Patients with a coloplasty and low colorectal anastomosis seem to have similar functional outcome along with similar pouch compliance compared with patients with colonic J-pouch and low colorectal anastomosis. However, the coloplasty may provide an alternative method to the colonic J-pouch for a neorectal reservoir construction when reach or a narrow pelvis prohibits its formation. Technically it also may be easier to construct.

Management of locally advanced rectal cancer

The treatment of rectal cancer typically involves a multidisciplinary approach. A minority of patients will have tumors that are full thickness, involve adjacent structures, or have metastatic disease to regional lymph nodes. The combination of adjuvant therapy and surgical resection is the mainstay of treatment for locally advanced carcinoma of the rectum. This article will review the role of adjuvant chemotherapy and radiotherapy in patients with high risk tumors. The operative considerations in advanced rectal cancers will be reviewed. In particular, the role of mesorectal excision and exenterative surgery will be discussed.

Colonic "coloplasty": novel technique to enhance low colorectal or coloanal anastomosis

After low colorectal or coloanal anastomosis, bowel dysfunction may exist. A colonic J-pouch has been proposed to reduce bowel dysfunction. We present an alternative technique to augment the reservoir function of the neorectum and reduce bowel dysfunction.

Ambulatory manometry in patients with colonic J-pouch and straight coloanal anastomoses: randomized, controlled trial

PURPOSE

Bowel function after ultralow anterior resection may be improved by a colonic J-pouch. The aim of this study was to compare the bowel function and ambulatory manometry in patients randomly assigned to straight coloanal anastomosis or colonic J-pouch.

METHODS

Forty-seven consecutive patients underwent ultralow anterior resection for adenocarcinoma. The colonic J-pouch was constructed with 6-cm limbs. A bowel function questionnaire was administered at one year after surgery. Ambulatory manometry was performed before and at one year after surgery.

RESULTS

Values are expressed below as mean and (standard error of the mean). Patients with colonic J-pouch were found to have less frequent stools (4.6 (0.3) vs. 7.1 (0.9) stools/day; P < 0.05) and stool clustering (35 vs. 63.2 percent; P < 0.05) and were less unlikely to soil when passing flatus (85 vs. 35.3 percent; P < 0.05). The ambulatory anorectal pressure gradient was better preserved in the colonic J-pouch group (30.3 (3.7) vs. 18 (2.6) mmHg; P < 0.05). Stool frequency was predicted by the mean rectal pressures (t = 3.368; P = 0.003). However, higher mean rectal pressures were tolerated by the colonic J-pouch for each daily bowel movement (6.7 (0.6) vs. 4.4 (0.5) mmHg/stool; P = 0.008). Anal sampling episodes and slow wave activity were impaired postoperatively in both groups. The minimal anal pressures were lower in patients unable pass flatus without soiling (12.4 (5.3) vs. 26 (2.3) mmHg; P = 0.004). Large contraction waves were not seen, and this may be related to the absence of severe defecation problems with 6-cm colonic J-pouches.

CONCLUSIONS

A colonic J-pouch resulted in better bowel function and more favorable ambulatory manometric findings at one year of follow-up.

Detection of a rectocele-like prolapse in the colonic J-pouch using pouchography: cause or effect of evacuation difficulties?

The functional outcome after a low anterior resection for rectal cancer is improved by a colonic J-pouch reconstruction. One functional problem with J-pouches is difficulty in evacuation, which is more common with large reconstructions. Since rectoceles are common findings on defecography in patients with evacuation difficulties, we proposed that a rectocele-like prolapse may be thus found in patients with large J-pouches. Pouchography was used to identify a rectocele-like prolapse (RP) in 26 patients with a 10-cm J-pouch (10-J group) and 27 patients with a 5-cm J-pouch (5-J group). Pouchography was performed at 3 months, 1 year, and 2 years after surgery. Functional assessments were performed 1 year postoperatively. Clinical function was evaluated using a questionnaire. The evacuation function was evaluated by the balloon expulsion and saline evacuation test. No patients had an RP at 3 months or 1 year after surgery. An RP was significantly more common in the 10-J group than in the 5-J group at 2 years after surgery (P = 0.0374). An evacuation difficulty was significantly more common in the 10-J group than in the 5-J group. The evacuation function in the 10-J group was also significantly inferior to that in the 5-J group. An RP appearing 2 years after surgery is more common in patients with evacuation difficulties and large colonic J-pouch reconstructions.

Horizontal inclination of the longitudinal axis of the colonic J-pouch: defining causes of evacuation difficulty

PURPOSE

Functional outcome after low anterior resection for rectal cancer is improved by the construction of a colonic J-pouch. One disadvantage of this type of reconstruction is evacuation difficulty, which has been associated with large pouches. The purpose of this study was to elucidate the causes of evacuation difficulty in large pouches using pouchography.

METHODS

The angle between the longitudinal axis of the pouch and the horizontal line (pouch-horizontal angle) on lateral pouchography was determined in 26 patients with 10-cm J-pouch reconstructions (10-J group) and 27 patients with 5-cm J-pouch reconstructions (5-J group). Measurement were made at three months, one year, and two years after surgery. Clinical function was evaluated using a questionnaire one year postoperatively.

RESULTS

The pouch-horizontal angle in the 10-J group was significantly smaller than that in the 5-J group at all three time points. In both groups the pouch-horizontal angle at one year was significantly smaller than that at three months. There were no significant differences between the pouch-horizontal angles at one and two years. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group.

CONCLUSIONS

The evacuation difficulty observed in patients with large colonic J-pouch reconstructions may be attributed to the development of a horizontal inclination within one year of surgery.

Enlargement of colonic pouch after proctectomy and coloanal anastomosis: potential cause for evacuation difficulty

PURPOSE

Although the functional outcome after low anterior resection for rectal cancer using colonic J-pouch reconstruction is superior to that using conventional straight reconstruction, the one drawback of colonic J-pouch reconstruction is difficulty with evacuation. Recently it has been suggested that construction of a larger colonic J-pouch causes the evacuation difficulty. The purpose of this study was to elucidate the cause of evacuation difficulty with colonic J-pouch reconstruction.

METHODS

We compared pouchography of 26 patients with 10-cm colonic J-pouch reconstructions (10-J group) and 27 patients with 5-cm colonic J-pouch reconstructions (5-J group) at three months, one year, and two years after surgery. Functional assessments were performed one year postoperatively. Clinical function was evaluated using a questionnaire. Evacuation function was evaluated by the balloon expulsion and saline evacuation tests.

RESULTS

The greatest width of the pouch in the 10-J group in the anteroposterior view was significantly greater than that in the 5-J group at all three measurement times (3 months, 4.9 vs. 4 cm; P = 0.0011; 1 year, 9 vs. 5.6 cm; P < 0.0001; 2 years, 9.2 vs. 5.8 cm; P < 0.0001). The value in the 10-J group at one year after surgery was 1.9 times that at three postoperative months; in the 5-J group this ratio was 1.4. There was a significant difference between these ratios (P < 0.0001). No significant difference existed between the values at two years and one year after surgery in either the 10-J or the 5-J group. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. Evacuation function in the 10-J group was significantly inferior to that in the 5-J group.

CONCLUSIONS

The evacuation difficulty observed in patients with larger colonic J-pouch reconstructions is associated with excessive distention of the pouch occurring within one year of surgery.

Surgical management of primary colorectal cancer

Surgery for potentially curable colorectal cancer most commonly involves resection of the primary tumor and regional lymph nodes. However, the site, extent and presentation of disease have an impact on surgical strategy and the use of combined modality therapy. For colon cancer, complex presentations such as obstructing or perforated colon cancer may influence surgical therapy, and issues pertaining to en bloc resection and oophorectomy remain unresolved. For rectal cancer, surgical management may range from local excision to radical resection. Extent of resection and relatively new operative techniques such as coloanal anastomosis with or without a colonic pouch reservoir are directed towards optimizing both oncologic and functional results.

Anastomotic integrity and function: role of the colonic J-pouch

Since the colonic J-pouch with a colo-anal anastomosis was first introduced in 1986, many reports have shown the superiority of this design as compared to a "straight" colo-anal anastomosis. These advantages have been demonstrated in retrospective, prospective, and prospectively randomized reports. Furthermore, these attributes are realized for at least 12 and possibly more than 24 months after surgery.