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Brock H, Lambrineas L, Ong HI, Chen WY, Das A, Edsell A, Proud D, Carrington E, Smart P, Mohan H, Burgess A. Preventative strategies for low anterior resection syndrome. Tech Coloproctol 2023; 28:10. [PMID: 38091118 DOI: 10.1007/s10151-023-02872-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/11/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly understood and challenging to treat. Despite this, prevention strategies are commonly overlooked. Our aim was to review the pathophysiology of LARS and explore current evidence on the efficacy and feasibility of prophylactic techniques. METHODS A literature review was performed between [1st January 2000 to 1st October 2023] for studies which investigated preventative interventions for LARS. Mechanisms by which LARS develop are described, followed by a review of prophylactic strategies to prevent LARS. Medline, Cochrane, and PubMed databases were searched, 189 articles screened, 8 duplicates removed and 18 studies reviewed. RESULTS Colonic dysmotility, anal sphincter dysfunction and neorectal dysfunction all contribute to the development of LARS, with the complex mechanism of defecation interrupted by surgery. Transanal irrigation (TAI) and pelvic floor rehabilitation (PFR) have shown benefits in preventing LARS, but may be limited by patient compliance. Intraoperative nerve monitoring (IONM) and robotic-assisted surgery have shown some promise in surgically preventing LARS. Nerve stimulation and other novel strategies currently used in treatment of LARS have yet to be investigated in their roles prophylactically. CONCLUSIONS To date, there is a limited evidence base for all preventative strategies including IONM, RAS, PFP and TAI. These strategies are limited by either access (IONM, RAS and PFP) or acceptability (PFP and TAI), which are both key to the success of any intervention. The results of ongoing trials will serve to assess acceptability, while technological advancement may improve access to some of the aforementioned strategies.
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Affiliation(s)
- H Brock
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Western General, Melbourne, Australia
| | - L Lambrineas
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - H I Ong
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia.
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia.
| | - W Y Chen
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - A Das
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - A Edsell
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - D Proud
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | | | - P Smart
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - H Mohan
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - A Burgess
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
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Lim SL, Wan Zain WZ, Zahari Z, Zakaria AD, Hashim MNM, Wong MPK, Zakaria Z, Ramely R, Sidek ASM. Risk factors associated with low anterior resection syndrome: a cross-sectional study. Ann Coloproctol 2023; 39:427-434. [PMID: 35655395 PMCID: PMC10626329 DOI: 10.3393/ac.2022.00227.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Oncological outcomes following rectal cancer surgery have improved significantly over recent decades with lower recurrences and longer overall survival. However, many of the patients experienced low anterior resection syndrome (LARS). This study identified the prevalence and risk factors associated with the development of LARS. METHODS This cross-sectional study involved patients who were diagnosed with rectal cancer and had undergone sphincter-preserving low anterior resection from January 2011 to December 2020. Upon clinic follow-up, patients were asked to complete an interviewed based questionnaire (LARS score) designed to assess bowel dysfunction after rectal cancer surgery. RESULTS Out of 76 patients, 25 patients (32.9%) had major LARS, 10 patients (13.2%) had minor LARS, and 41 patients (53.9%) had no LARS. The height of tumor from anal verge showed an association with the development of major LARS (P=0.039). Those patients with less than 8 cm tumor from anal verge had an increased risk of LARS by 3 times compared to those with 8 cm and above (adjusted odds ratio, 3.11; 95% confidence interval, 1.06-9.13). CONCLUSION Results from our study show that low tumor height was a significant risk factor that has a negative impact on bowel function after surgery. The high prevalence of LARS emphasizes the need for study regarding risk factors and the importance of understanding the pathophysiology of LARS, in order for us to improve patient bowel function and quality of life after rectal cancer surgery.
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Affiliation(s)
- See Liang Lim
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Wan Zainira Wan Zain
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Zalina Zahari
- Faculty of Pharmacy, Universiti Sultan Zainal Abidin (UniSZA), Besut Campus, Besut, Malaysia
| | - Andee Dzulkarnaen Zakaria
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Mohd Nizam Md Hashim
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Michael Pak-Kai Wong
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Zaidi Zakaria
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Rosnelifaizur Ramely
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
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3
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Ream JM, Luk L, Sheedy S, Fletcher JG, Church JM, Baker ME. Dynamic ileal pouch emptying studies. Abdom Radiol (NY) 2023; 48:2956-2968. [PMID: 36732408 DOI: 10.1007/s00261-023-03811-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 02/04/2023]
Abstract
Although much radiologic literature has focused on the short-term post-operative complications associated with ileal pouches, as the number of patients with long-term pouches has grown, there is increasing realization of the functional deficits that may occur long after pouch creation. Dynamic pouch imaging using fluoroscopy and MRI can provide assessment of the underlying causes of symptomatic pouch dysfunction and can provide critical insight to the management of this complex patient population. In this paper, we provide an overview of the unique problems encountered in patients with long-term ileal pouches, and provide an overview of the techniques, interpretation, and reporting for fluoroscopic and MR pouch defecography.
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Affiliation(s)
- Justin M Ream
- Imaging Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Lyndon Luk
- Department of Radiology, Columbia University Medical Center, New York, NY, USA
| | - Shannon Sheedy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - J G Fletcher
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - James M Church
- Division of Colorectal Surgery, Columbia University Medical Center, New York, NY, USA
| | - Mark E Baker
- Imaging Institute, Digestive Diseases and Surgery Institute, and Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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4
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Liu H, Xiong M, Zeng Y, Shi Y, Pei Z, Liao C. Comparison of complications and bowel function among different reconstruction techniques after low anterior resection for rectal cancer: a systematic review and network meta-analysis. World J Surg Oncol 2023; 21:87. [PMID: 36899350 PMCID: PMC9999608 DOI: 10.1186/s12957-023-02977-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/27/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Anastomosis for gastrointestinal reconstruction has been contentious after low anterior resection of rectal cancer for the past 30 years. Despite the abundance of randomized controlled trials (RCTs) on colon J-pouch (CJP), straight colorectal anastomosis (SCA), transverse coloplast (TCP), and side-to-end anastomosis (SEA), most studies are small and lack reliable clinical evidence. We conducted a systematic review and network meta-analysis to evaluate the effects of the four anastomoses on postoperative complications, bowel function, and quality of life in rectal cancer. METHODS We assessed the safety and efficacy of CJP, SCA, TCP, and SEA in adult patients with rectal cancer after surgery by searching the Cochrane Library, Embase, and PubMed databases to collect RCTs from the date of establishment to May 20, 2022. Anastomotic leakage and defecation frequency were the main outcome indicators. We pooled data through a random effects model in a Bayesian framework and assessed model inconsistency using the deviance information criterion (DIC) and node-splitting method and inter-study heterogeneity using the I-squared statistics (I2). The interventions were ranked according to the surface under the cumulative ranking curve (SUCRA) to compare each outcome indicator. RESULTS Of the 474 studies initially evaluated, 29 were eligible RCTs comprising 2631 patients. Among the four anastomoses, the SEA group had the lowest incidence of anastomotic leakage, ranking first (SUCRASEA = 0.982), followed by the CJP group (SUCRACJP = 0.628). The defecation frequency in the SEA group was comparable to those in the CJP and TCP groups at 3, 6, 12, and 24 months postoperatively. In comparison, the defecation frequency in the SCA group 12 months after surgery all ranked fourth. No statistically significant differences were found among the four anastomoses in terms of anastomotic stricture, reoperation, postoperative mortality within 30 days, fecal urgency, incomplete defecation, use of antidiarrheal medication, or quality of life. CONCLUSIONS This study demonstrated that SEA had the lowest risk of complications, comparable bowel function, and quality of life compared to the CJP and TCP, but further research is required to determine its long-term consequences. Furthermore, we should be aware that SCA is associated with a high defecation frequency.
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Affiliation(s)
- Huabing Liu
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Ming Xiong
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yu Zeng
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yabo Shi
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Zhihui Pei
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Chuanwen Liao
- Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China.
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Mathew A, Ramachandra D, Goyal A, Nariampalli Karthyarth M, Joseph P, Raj Rakesh N, Kaushal G, Agrawal A, Bhadoria AS, Dhar P. Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis. Br J Surg 2023; 110:313-323. [PMID: 36630589 DOI: 10.1093/bjs/znac400] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/21/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Multiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques. METHODS A literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used. RESULTS Thirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD -2.06, P < 0.001; incontinence, MD -1.17, P = 0.007) and intermediate term (stool frequency, MD -0.81, P = 0.021; incontinence MD -0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012). CONCLUSION Because of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.
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Affiliation(s)
- Anvin Mathew
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Deepti Ramachandra
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Anuj Goyal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | | | - Princy Joseph
- National Health Systems Resource Centre, New Delhi, India
| | - Nirjhar Raj Rakesh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Gourav Kaushal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bathinda, India
| | - Abhishek Agrawal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Ajeet Singh Bhadoria
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Puneet Dhar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
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6
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Comparison of the colonic J-pouch versus straight (end-to-end) anastomosis following low anterior resection: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:919-938. [PMID: 35306586 DOI: 10.1007/s00384-022-04130-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 02/04/2023]
Abstract
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.
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7
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Ng KS, Gladman MA. LARS: A review of therapeutic options and their efficacy. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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8
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Valadão M, Cesar D, Véo CAR, Araújo RO, do Espirito Santo GF, Oliveira de Souza R, Aguiar S, Ribeiro R, de Castro Ribeiro HS, de Souza Fernandes PH, Oliveira AF. Brazilian society of surgical oncology: Guidelines for the surgical treatment of mid-low rectal cancer. J Surg Oncol 2021; 125:194-216. [PMID: 34585390 DOI: 10.1002/jso.26676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/08/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third leading cause of cancer in North America, Western Europe, and Brazil, and represents an important public health problem. It is estimated that approximately 30% of all the CRC cases correspond to tumors located in the rectum, requiring complex multidisciplinary treatment. In an effort to provide surgeons who treat rectal cancer with the most current information based on the best evidence in the literature, the Brazilian Society of Surgical Oncology (SBCO) has produced the present guidelines for rectal cancer treatment that is focused on the main topics related to daily clinical practice. OBJECTIVES The SBCO developed the present guidelines to provide recommendations on the main topics related to the treatment of mid-low rectal cancer based on current scientific evidence. METHODS Between May and June 2021, 11 experts in CRC surgery met to develop the guidelines for the treatment of mid-low rectal cancer. A total of 22 relevant topics were disseminated among the participants. The methodological quality of a final list with 221 sources was evaluated, all the evidence was examined and revised, and the treatment guideline was formulated by the 11-expert committee. To reach a final consensus, all the topics were reviewed via a videoconference meeting that was attended by all 11 of the experts. RESULTS The prepared guidelines contained 22 topics considered to be highly relevant in the treatment of mid-low rectal cancer, covering subjects related to the tests required for staging, surgical technique-related aspects, recommended measures to reduce surgical complications, neoadjuvant strategies, and nonoperative treatments. In addition, a checklist was proposed to summarize the important information and offer an updated tool to assist surgeons who treat rectal cancer provide the best care to their patients. CONCLUSION These guidelines summarize concisely the recommendations based on the most current scientific evidence on the most relevant aspects of the treatment of mid-low rectal cancer and are a practical guide that can help surgeons who treat rectal cancer make the best therapeutic decision.
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Affiliation(s)
- Marcus Valadão
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | - Daniel Cesar
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | - Rodrigo Otávio Araújo
- Division of Abdominal-Pelvic Surgery, Instituto Nacional de Cancer, Rio de Janeiro, Brazil
| | | | | | - Samuel Aguiar
- Department of Surgical Oncology, AC Camargo Cancer Center, São Paulo, Brazil
| | - Reitan Ribeiro
- Department of Surgical Oncology, Erasto Gaertner Hospital, Curitiba, Brazil
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9
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Abstract
Abstract
Introduction With improving survival of rectal cancer, functional outcome has become increasingly important. Following sphincter-preserving resection many patients suffer from severe bowel dysfunction with an impact on quality of life (QoL) – referred to as low anterior resection syndrome (LARS).
Study objective To provide an overview of the current knowledge of LARS regarding symptomatology, occurrence, risk factors, pathophysiology, evaluation instruments and treatment options.
Results LARS is characterized by urgency, frequent bowel movements, emptying difficulties and incontinence, and occurs in up to 50-75% of patients on a long-term basis. Known risk factors are low anastomosis, use of radiotherapy, direct nerve injury and straight anastomosis. The pathophysiology seems to be multifactorial, with elements of anatomical, sensory and motility dysfunction. Use of validated instruments for evaluation of LARS is essential. Currently, there is a lack of evidence for treatment of LARS. Yet, transanal irrigation and sacral nerve stimulation are promising.
Conclusion LARS is a common problem following sphincter-preserving resection. All patients should be informed about the risk of LARS before surgery, and routinely be screened for LARS postoperatively. Patients with severe LARS should be offered treatment in order to improve QoL. Future focus should be on the possibilities of non-resectional treatment in order to prevent LARS.
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10
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Gavaruzzi T, Pace U, Giandomenico F, Pucciarelli S, Bianco F, Selvaggi F, Restivo A, Asteria CR, Morpurgo E, Cuicchi D, Jovine E, Coletta D, La Torre G, Amato A, Chiappa A, Marchegiani F, Rega D, De Franciscis S, Pellino G, Zorcolo L, Lotto L, Boccia L, Spolverato G, De Salvo GL, Delrio P, Del Bianco P. Colonic J-Pouch or Straight Colorectal Reconstruction After Low Anterior Resection For Rectal Cancer: Impact on Quality of Life and Bowel Function: A Multicenter Prospective Randomized Study. Dis Colon Rectum 2020; 63:1511-1523. [PMID: 33044292 DOI: 10.1097/dcr.0000000000001745] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patient-reported outcomes associated with different bowel reconstruction techniques following anterior resection for rectal cancer are still a matter of debate. OBJECTIVE This study aimed to assess quality of life and bowel function in patients who underwent colonic J-pouch or straight colorectal anastomosis reconstruction after low anterior resection. DESIGN Bowel function and quality of life were assessed within a multicenter randomized trial. Questionnaires were administered before the surgery (baseline) and at 6, 12, and 24 months after surgery. SETTINGS Patients were enrolled by 19 centers. The enrollment started in October 2009 and was stopped in February 2016. The study was registered at www.clinicaltrials.gov (Identifier: NCT01110798). PATIENTS Patients who underwent low anterior resection for primary mid-low rectal cancer and who were randomly assigned in a 1:1 ratio to receive either stapled colonic J-pouch or straight colorectal anastomosis were selected. MAIN OUTCOME MEASURES The primary outcomes measured were quality of life and bowel function. RESULTS Of the 379 patients who were evaluable, 312 (82.3%) completed the baseline, 259 (68.3%) the 6-month, 242 (63.9%) the 12-month, and 199 (52.5%) the 24-month assessment. Bowel functioning and quality of life did not significantly differ between arms for almost all domains. The total bowel function score, the urgency, and the stool fractionation scores significantly worsened after surgery and remained impaired over time in both arms (p < 0.0032), whereas constipation improved after surgery but recovered to baseline levels from 1 year onward (p < 0.0036). All patients showed a significant and continuous improvement in emotional functioning (p < 0.0013) and future perspective (p < 0.0001) from baseline to the end of the study. LIMITATIONS Limitations of the study include missing data, which increased over time; the possibility that some treatments have slightly changed since the study was conducted; and investigators not blind to treatment allocation. CONCLUSION The findings of this study do not support the routine use of colonic J-pouch reconstruction in patients with rectal cancer who undergo a low anterior resection. See Video Abstract at http://links.lww.com/DCR/B328. BOLSA J COLÓNICA O RECONSTRUCCIÓN COLORRECTAL RECTA DESPUÉS DE RESECCIÓN ANTERIOR BAJA PARA CÁNCER RECTAL: IMPACTO EN LA CALIDAD DE VIDA Y LA FUNCIÓN INTESTINAL: UN ESTUDIO ALEATORIZADO PROSPECTIVO MULTICÉNTRICO: Los resultados informados por el paciente asociados con diferentes técnicas de reconstrucción intestinal después de la resección anterior para el cáncer de recto aún son tema de debate.Evaluar la calidad de vida y la función intestinal en pacientes que se sometieron a una bolsa en J colónica o reconstrucción de anastomosis colorrectal recta después de una resección anterior baja.La función intestinal y la calidad de vida se evaluaron en un ensayo aleatorizado multicéntrico. Los cuestionarios se administraron antes de la cirugía (basal) y a los 6, 12 y 24 meses después de la cirugía.Los pacientes fueron incluidos en 19 centros. La inscripción comenzó en Octubre de 2009 y se detuvo en Febrero de 2016. El estudio se registró en www.clinicaltrials.gov (Identificador: NCT01110798).Pacientes que se sometieron a resección anterior baja por cáncer rectal primario medio-bajo y que fueron aleatorizados en una proporción de 1: 1 para recibir bolsa J colónica con grapas o anastomosis colorrectal recta.calidad de vida y función intestinal.De los 379 pacientes que fueron evaluables, 312 (82.3%) completaron la evaluación inicial, 259 (68.3%) a los 6 meses, 242 (63.9%) a los 12 meses y 199 (52.5%) a los 24 meses. . El funcionamiento intestinal y la calidad de vida no difirieron significativamente entre los dos grupos en casi todos los dominios. La puntuación total de la función intestinal, la urgencia y las puntuaciones de fraccionamiento de las heces empeoraron significativamente después de la cirugía y continuaron con el tiempo extra en ambos grupos (p <0.0032), mientras que el estreñimiento mejoró después de la cirugía pero se recuperó a los niveles basales a partir de 1 año en adelante (p <0.0036). Todos los pacientes mostraron una mejora significativa y continua en el funcionamiento emocional (p <0.0013) y la perspectiva futura (<0.0001) desde el inicio hasta el final del estudio.Datos faltantes, que aumentaron con el tiempo; la posibilidad de que algunos tratamientos hayan cambiado ligeramente desde que se realizó el estudio; investigadores no cegados a la asignación del tratamiento.Los hallazgos de este estudio no respaldan el uso rutinario de la reconstrucción de la bolsa J colónica en pacientes con cáncer rectal que se someten a una resección anterior baja. Consulte Video Resumen en http://links.lww.com/DCR/B328. (Traducción-Dr. Yesenia Rojas-Khalil).
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Affiliation(s)
- Teresa Gavaruzzi
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy.,First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Ugo Pace
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - Francesca Giandomenico
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Salvatore Pucciarelli
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Francesco Bianco
- Department of Abdominal Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - Francesco Selvaggi
- Colorectal Surgery Unit, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Angelo Restivo
- Colorectal Surgery, Azienda Ospedaliero-Universitaria di Cagliari, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Corrado Rosario Asteria
- Colo-rectal Surgery Unit, Department of Surgery and Orthopaedics, ASST "Carlo Poma", Mantua, Italy
| | - Emilio Morpurgo
- Department of Surgery, Regional Centre for Laparoscopic and Robotic Surgery, Camposampiero Hospital, Padua, Italy
| | - Dajana Cuicchi
- General Surgery Unit, Department of Alimentary Tract, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Elio Jovine
- General Surgery and Emergency, Maggiore Hospital, Azienda Sanitaria Locale di Bologna, Bologna, Italy
| | - Diego Coletta
- Division of Emergency and Trauma Surgery, Emergency Department, Policlinico Umberto I, College of Medicine and Dentistry, Sapienza University, Rome, Italy
| | - Giuseppe La Torre
- Abdominal Surgical Oncology, Department of Surgery, IRCCS, Centro di Riferimento Oncologico della Basilicata, Rionero in Vulture, Italy
| | - Antonio Amato
- Department of Coloproctology, Sanremo Hospital, Sanremo, Italy
| | - Antonio Chiappa
- Innovative Techniques in Surgery Unit, European Institute of Oncology, University of Milan, Milan, Italy
| | - Francesco Marchegiani
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Daniela Rega
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - Silvia De Franciscis
- Department of Abdominal Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - Gianluca Pellino
- Colorectal Surgery Unit, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Luigi Zorcolo
- Colorectal Surgery, Azienda Ospedaliero-Universitaria di Cagliari, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Lorella Lotto
- Department of Developmental Psychology and Socialization, University of Padua, Padua, Italy
| | - Luigi Boccia
- Colo-rectal Surgery Unit, Department of Surgery and Orthopaedics, ASST "Carlo Poma", Mantua, Italy
| | - Gaya Spolverato
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Gian Luca De Salvo
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - Paolo Delrio
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - Paola Del Bianco
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
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11
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Franke AJ, Skelton WP, George TJ, Iqbal A. A Comprehensive Review of Randomized Clinical Trials Shaping the Landscape of Rectal Cancer Therapy. Clin Colorectal Cancer 2020; 20:1-19. [PMID: 32863179 DOI: 10.1016/j.clcc.2020.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/31/2022]
Abstract
Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one third of newly diagnosed cases. Surgery remains the cornerstone of curative therapy, with total mesorectal excision being the standard of care. Although minimally invasive procedures might be appropriate for a subset of patients with early-stage, superficial tumors, the standard of care for medically operable patients with nonmetastatic rectal cancer includes a comprehensive multimodality approach of neoadjuvant chemoradiotherapy, surgery with total mesorectal excision, and systemic chemotherapy. However, the morbidity and mortality related to both local and distant organ relapse have remained challenging. In the present review, we have discussed the trial-level evidence that has shaped the current clinical practice patterns in the treatment of curable, nonmetastatic rectal cancer. In addition, we have discussed the anticipated results of ongoing clinical trials and outlined pragmatic opportunities for future investigation to optimize the current status quo and, hopefully, provide prospective validation of novel approaches in the treatment of rectal cancer.
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Affiliation(s)
- Aaron J Franke
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL
| | - William Paul Skelton
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL
| | - Thomas J George
- Department of Medicine, Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Atif Iqbal
- Section of Colorectal Surgery, Department of Surgery, Baylor College of Medicine, Houston, TX.
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12
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Portale G, Popesc GO, Parotto M, Cavallin F. Delayed Colo-anal Anastomosis for Rectal Cancer: Pelvic Morbidity, Functional Results and Oncological Outcomes: A Systematic Review. World J Surg 2019; 43:1360-1369. [PMID: 30690655 DOI: 10.1007/s00268-019-04918-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Delayed colo-anal anastomosis (DCAA) has received renewed interest thanks to its reduction in anastomotic leakage rate without the use of stoma to protect a low rectal anastomosis. The aim of this review was to summarize the available literature on DCAA following rectal cancer resection and to report clinical, oncological and functional results. METHODS A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, clinicaltrials.gov and the Cochrane database of systematic reviews through July 2018. The review was conducted according to MOOSE guidelines. Quality was appraised with the methodological index for non-randomized studies (MINORS) tool. RESULTS Eight observational studies (409 patients) were included. Average MINORS score was 9.6/14 in seven non-comparative studies and 17/22 in one comparative study. Six studies reported no anastomotic leak. Pelvic sepsis/abscess ranged from 0 to 25%. Mortality rate was <3% in seven studies and 12.5% in one. Poor fecal continence was reported in <30% of patients. Need for permanent stoma was ≤2% in six studies. A five-year survival rate ranged from 63.8 to 81% (four studies). Loco-regional recurrence rate ranged from 4.8 to 14.3% at 3 years (four studies) and from 6 to 38.8% at 5 years (three studies). CONCLUSION DCAA offers an alternative to primary straight colo-anal anastomosis for low rectal cancer. The benefits include reduced risk of anastomotic leakage and pelvic sepsis, and no need for protective ileostomy, with good functional and oncological outcomes. Results of ongoing randomized controlled trials comparing DCAA with straight colo-anal anastomosis and protective stoma are awaited to draw definitive conclusions.
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Affiliation(s)
- Giuseppe Portale
- Department of General Surgery, Azienda ULSS 6, Cittadella, Via Casa di Ricovero 40, 35013, Cittadella, Padova, Italy.
| | - George Octavian Popesc
- Department of General and Visceral Surgery, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Matteo Parotto
- Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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13
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Pucciarelli S, Del Bianco P, Pace U, Bianco F, Restivo A, Maretto I, Selvaggi F, Zorcolo L, De Franciscis S, Asteria C, Urso EDL, Cuicchi D, Pellino G, Morpurgo E, La Torre G, Jovine E, Belluco C, La Torre F, Amato A, Chiappa A, Infantino A, Barina A, Spolverato G, Rega D, Kilmartin D, De Salvo GL, Delrio P. Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer. Br J Surg 2019; 106:1147-1155. [PMID: 31233220 DOI: 10.1002/bjs.11222] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 03/30/2019] [Accepted: 04/02/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Colonic J pouch reconstruction has been found to be associated with a lower incidence of anastomotic leakage than straight anastomosis. However, studies on this topic are underpowered and retrospective. This randomized trial evaluated whether the incidence of anastomotic leakage was reduced after colonic J pouch reconstruction compared with straight colorectal anastomosis following anterior resection for rectal cancer. METHODS This multicentre RCT included patients with rectal carcinoma who underwent low anterior resection followed by colorectal anastomosis. Patients were assigned randomly to receive a colonic J pouch or straight colorectal anastomosis. The main outcome measure was the occurrence of major anastomotic leakage. The incidence of global (major plus minor) anastomotic leakage and general complications were secondary outcomes. Risk factors for anastomotic leakage were identified by regression analysis. RESULTS Of 457 patients enrolled, 379 were evaluable (colonic J pouch arm 190, straight colorectal arm 189). The incidence of major and global anastomotic leakage, and general complications was 14·2, 19·5 and 34·2 per cent respectively in the colonic J pouch group, and 12·2, 19·0 and 27·0 per cent in the straight colorectal anastomosis group. No statistically significant differences were observed between the two arms. In multivariable logistic regression analysis, male sex (odds ratio 1·79, 95 per cent c.i. 1·02 to 3·15; P = 0·042) and high ASA fitness grade (odds ratio 2·06, 1·15 to 3·71; P = 0·015) were independently associated with the occurrence of anastomotic leakage. CONCLUSION Colonic J pouch reconstruction does not reduce the incidence of anastomotic leakage and postoperative complications compared with conventional straight colorectal anastomosis. Registration number NCT01110798 (http://www.clinicaltrials.gov).
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Affiliation(s)
- S Pucciarelli
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - P Del Bianco
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - U Pace
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - F Bianco
- Department of Abdominal Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - A Restivo
- Colorectal Surgery, Azienda Ospedaliero-Universitaria di Cagliari, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - I Maretto
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - F Selvaggi
- Colorectal Surgery Unit, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - L Zorcolo
- Colorectal Surgery, Azienda Ospedaliero-Universitaria di Cagliari, Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - S De Franciscis
- Department of Abdominal Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - C Asteria
- Department of General Surgery, Ospedale Carlo Poma, Mantua, Italy
| | - E D L Urso
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - D Cuicchi
- General Surgery Unit, Department of Alimentary Tract, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - G Pellino
- Colorectal Surgery Unit, Department of Medical, Surgical, Neurological, Metabolic and Ageing Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - E Morpurgo
- Department of Surgery, Regional Centre for Laparoscopic and Robotic Surgery, Camposampiero Hospital, Padua, Italy
| | - G La Torre
- Abdominal Surgical Oncology, Department of Surgery, IRCCS, Centro di Riferimento oncologico della Basilicata, Rionero in Vulture, Italy
| | - E Jovine
- General Surgery and Emergency, Maggiore Hospital, Azienda Sanitaria Locale di Bologna, Bologna, Italy
| | - C Belluco
- Department of Surgical Oncology, Centro di Riferimento Oncologico -IRCCS, National Cancer Institute, Aviano, Italy
| | - F La Torre
- Division of Emergency and Trauma Surgery, Emergency Department, Policlinico Umberto I, College of Medicine and Dentistry, Sapienza University, Rome, Italy
| | - A Amato
- Department of Coloproctology, Sanremo Hospital, Sanremo, Italy
| | - A Chiappa
- Innovative Techniques in Surgery Unit, European Institute of Oncology, University of Milan, Milan, Italy
| | - A Infantino
- Surgical Unit, Department of General Surgery, Santa Maria dei Battuti Hospital, San Vito al Tagliamento, Italy
| | - A Barina
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - G Spolverato
- First Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - D Rega
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
| | - D Kilmartin
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - G L De Salvo
- Clinical Trials and Biostatistics Unit, Istituto Oncologico Veneto IOV - IRCCS, Padua, Italy
| | - P Delrio
- Department of Colorectal Surgical Oncology, Istituto Nazionale Tumori - IRCCS Fondazione G. Pascale, Naples, Italy
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Abstract
BACKGROUND Low rectal tumors are often treated with sphincter-preserving resection followed by coloanal anastomosis. OBJECTIVE The purpose of this study was to compare the short-term complications following straight coloanal anastomosis vs colonic J-pouch anal anastomosis. DESIGN Patients were identified who underwent proctectomy for rectal neoplasia followed by coloanal anastomosis in the 2008 to 2013 American College of Surgeons National Surgical Quality Improvement Program database. Demographic characteristics and 30-day postoperative complications were compared between groups. SETTINGS A national sample was extracted from the American College of Surgeons National Surgical Quality Improvement Project database. PATIENTS Inpatients following proctectomy and coloanal anastomosis for rectal cancer were selected. MAIN OUTCOME MEASURES Demographic characteristics and 30-day postoperative complications were compared between the 2 groups. RESULTS One thousand three hundred seventy patients were included, 624 in the straight anastomosis group and 746 in the colonic J-pouch group. Preoperative characteristics were similar between groups, with the exception of preoperative radiation therapy (straight anastomosis 35% vs colonic J-pouch 48%, p = 0.0004). Univariate analysis demonstrated that deep surgical site infection (3.7% vs 1.4%, p = 0.01), septic shock (2.25% vs 0.8%, p = 0.04), and return to the operating room (8.8% vs 5.0%, p = 0.0006) were more frequent in the straight anastomosis group vs the colonic J-pouch group. Major complications were also higher (23% vs 14%, p = 0.0001) and length of stay was longer in the straight anastomosis group vs the colonic J-pouch group (8.9 days vs 8.1 days, p = 0.02). After adjusting for covariates, major complications were less following colonic J-pouch vs straight anastomosis (OR, 0.57; CI, 0.38-0.84; p = 0.005). Subgroup analysis of patients who received preoperative radiation therapy demonstrated no difference in major complications between groups. LIMITATIONS This study had those limitations inherent to a retrospective study using an inpatient database. CONCLUSION Postoperative complications were less following colonic J-pouch anastomosis vs straight anastomosis. Patients who received preoperative radiation had similar rates of complications, regardless of the reconstructive technique used following low anterior resection. See Video Abstract at http://links.lww.com/DCR/A468.
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15
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Ridolfi TJ, Berger N, Ludwig KA. Low Anterior Resection Syndrome: Current Management and Future Directions. Clin Colon Rectal Surg 2016; 29:239-45. [PMID: 27582649 DOI: 10.1055/s-0036-1584500] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Outcomes for rectal cancer surgery have improved significantly over the past 20 years with increasing rates of survival and recurrence, specifically local recurrence. These gains have been realized during a period of time in which there has been an increasing emphasis on sphincter preservation. As we have become increasingly aggressive in avoiding resection of the anus, we have begun accepting bowel dysfunction as a normal outcome. Low anterior resection syndrome, defined as a constellation of symptoms including incontinence, frequency, urgency, or feelings of incomplete emptying, has a significant impact on quality of life and results in many patients opting for a permanent colostomy to avoid these symptoms. In this article, we will highlight the most recent clinical and basic science research on this topic and discuss areas of future investigation.
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Affiliation(s)
- Timothy J Ridolfi
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicholas Berger
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kirk A Ludwig
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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16
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De Palma GD, Luglio G. Quality of life in rectal cancer surgery: What do the patient ask? World J Gastrointest Surg 2015; 7:349-355. [PMID: 26730279 PMCID: PMC4691714 DOI: 10.4240/wjgs.v7.i12.349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/13/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Rectal cancer surgery has dramatically changed with the introduction of the total mesorectal excision (TME), which has demonstrated to significantly reduce the risk of local recurrence. The combination of TME with radiochemotherapy has led to a reduction of local failure to less than 5%. On the other hand, surgery for rectal cancer is also impaired by the potential for a significant loss in quality of life. This is a new challenge surgeons should think about nowadays: If patients live more, they also want to live better. The fight against cancer cannot only be based on survival, recurrence rate and other oncological endpoints. Patients are also asking for a decent quality of life. Rectal cancer is probably a paradigmatic example: Its treatment is often associated with the loss or severe impairment of faecal function, alteration of body anatomy, urogenital problems and, sometimes, intractable pain. The evolution of laparoscopic colorectal surgery in the last decades is an important example, which emphasizes the importance that themes like scar, recovery, pain and quality of life might play for patients. The attention to quality of life from both patients and surgeons led to several surgical innovations in the treatment of rectal cancer: Sphincter saving procedures, reservoir techniques (pouch and coloplasty) to mitigate postoperative faecal disorders, nerve-sparing techniques to reduce the risk for sexual dysfunction. Even more conservative procedures have been proposed alternatively to the abdominal-perineal resection, like the local excisions or transanal endoscopic microsurgery, till the possibility of a wait and see approach in selected cases after radiation therapy.
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17
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Experience of colonic J pouch reconstruction following anterior resection. Eur Surg 2015. [DOI: 10.1007/s10353-015-0345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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Hüttner FJ, Tenckhoff S, Jensen K, Uhlmann L, Kulu Y, Büchler MW, Diener MK, Ulrich A. Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer. Br J Surg 2015; 102:735-45. [PMID: 25833333 DOI: 10.1002/bjs.9782] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 12/23/2014] [Accepted: 01/13/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Options for reconstruction after low anterior resection (LAR) for rectal cancer include straight or side-to-end coloanal anastomosis (CAA), colonic J pouch and transverse coloplasty. This systematic review compared these techniques in terms of function, surgical outcomes and quality of life. METHODS A systematic literature search (MEDLINE, Embase and the Cochrane Library, from inception of the databases until November 2014) was conducted to identify randomized clinical trials comparing reconstructive techniques after LAR. Random-effects meta-analyses were carried out, and results presented as weighted odds ratios or mean differences with corresponding 95 per cent c.i. A network meta-analysis was conducted for the outcome anastomotic leakage. RESULTS The search yielded 965 results; 21 trials comprising data from 1636 patients were included. Colonic J pouch was associated with lower stool frequency and antidiarrhoeal medication use for up to 1 year after surgery compared with straight CAA. Transverse coloplasty and side-to-end CAA had similar functional outcomes to the colonic J pouch. No superiority was found for any of the techniques in terms of anastomotic leak rate. CONCLUSION Colonic J pouch and side-to-end CAA or transverse coloplasty lead to a better functional outcome than straight CAA for the first year after surgery.
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Affiliation(s)
- F J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
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19
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Hallet J, Bouchard A, Drolet S, Milot H, Desrosiers E, Lebrun A, Grégoire RC. Anastomotic salvage after rectal cancer resection using the Turnbull-Cutait delayed anastomosis. Can J Surg 2015; 57:405-11. [PMID: 25421083 DOI: 10.1503/cjs.001014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Turnbull-Cutait abdominoperineal pull-through followed by delayed coloanal anastomosis (DCA) was first described in 1961. Studies have described its use for challenging colorectal conditions. We reviewed our experience with Turnbull-Cutait DCA as a salvage procedure for complex failure of colorectal anastomosis. METHODS We performed a retrospective cohort study from October 2010 to September 2011, with analysis of postoperative morbidity and mortality. RESULTS Seven DCAs were performed for anastomotic complications (3 chronic leaks, 2 rectovaginal fistulas, 1 colovesical fistula, 1 colonic ischemia) following surgery for rectal cancer. Six patients had a diverting ileostomy constructed as part of previous treatment for anastomotic complications before the salvage procedure. No anastomotic leaks were observed. All procedures but 1 were completed successfully. One patient who underwent DCA subsequently required an abdominoperineal resection and a permanent colostomy for postoperative extensive colonic ischemia. No 30-day mortality occurred. CONCLUSION Salvage Turnbull-Cutait DCA appears to be a safe procedure and could be offered to patients with complex anastomotic complications. This procedure could be added to the surgeon's armamentarium as an alternative to the creation of a permanent stoma.
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Affiliation(s)
- Julie Hallet
- The Division of General Surgery, University of Toronto, Toronto, Ont
| | - Alexandre Bouchard
- The Department of Surgery, Université Laval, Québec, Que., and the Department of Surgery, CHU de Québec (Hôpital Saint-François d'Assise), Québec, Que
| | - Sébastien Drolet
- The Department of Surgery, Université Laval, Québec, Que., and the Department of Surgery, CHU de Québec (Hôpital Saint-François d'Assise), Québec, Que
| | - Hélène Milot
- The Department of Surgery, Université Laval, Québec, Que
| | | | - Aude Lebrun
- The Department of Surgery, Université Laval, Québec, Que
| | - Roger Charles Grégoire
- The Department of Surgery, Université Laval, Québec, Que., and the Department of Surgery, CHU de Québec (Hôpital Saint-François d'Assise), Québec, Que
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20
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Rectal Cancer. Surg Oncol 2015. [DOI: 10.1007/978-1-4939-1423-4_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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The clinical results of the Turnbull-Cutait delayed coloanal anastomosis: a systematic review. Tech Coloproctol 2014; 18:579-90. [PMID: 24615720 DOI: 10.1007/s10151-014-1132-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 02/05/2014] [Indexed: 12/16/2022]
Abstract
Turnbull and Cutait described abdominoperineal pull-through followed by delayed coloanal anastomosis (DCA) in 1961. DCA could reduce anastomotic leaks, pelvic morbidity and use of stomas. Strong evidence about its clinical benefits is still lacking. This systematic review examined the clinical outcomes of DCA for the treatment of malignant or benign colorectal conditions. A systematic search of electronic medical databases was conducted. Two independent reviewers selected studies, extracted data and assessed risk of bias. The primary outcome was pelvic morbidity (anastomotic leak, pelvic abscess or sepsis, use of stoma). Fecal continence and survival data were also analyzed. From 1,251 citations, we included seven observational studies including 1,124 patients. All included studies were considered at high risk of bias. Two studies comparing DCA with immediate anastomosis reported a significant decrease in anastomotic leak, and pelvic abscess or sepsis. Low rates of pelvic morbidity were reported in the other five studies: anastomotic leak 0-7 %, pelvic abscess 0-11.8 % and pelvic sepsis 6.8-10 %. Rates of permanent stoma after DCA were low in six studies (1-6 %), with one study reporting an incidence of 25 %. Fecal continence was reported as satisfying in all studies. No differences were observed in a comparative setting. Survival data were reported in four studies. Clinical heterogeneity and methodological issues precluded meta-analysis. Based on retrospective evidence, DCA offers a low rate of anastomotic leak, pelvic morbidity and use of stoma, with reasonable fecal continence. Results are encouraging, but prospective studies are needed for comparison with standard of care.
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22
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Junginger T, Rassouli S, Goenner U, Lollert A, Blettner M. Correlation between fecal incontinence and quality of life after low anterior resection for rectal cancer. COLORECTAL CANCER 2014. [DOI: 10.2217/crc.13.77] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
SUMMARY Aim: The purpose of this study was to investigate the correlation between fecal incontinence and quality of life after low anterior resection and long-term follow-up. Methods: For 72 patients with coloanal or low colorectal anastomosis, the quality of life was determined by the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires C-30 and CR-38. The Vaizey score was used for assessment of fecal incontinence. Results: The risk of fecal incontinence significantly increased with a lower level of anastomosis (p < 0.001). The QLQ CR-38 did not discern differences between patients. The OLQ C-30 only found significantly worse social and role function in patients with coloanal anastomosis. There was a weak correlation between fecal incontinence and quality of life only. Conclusion: Determination of quality of life by EORTC QLQ C-30 and CR-38 cannot replace measurement of functional outcome. Severity of fecal incontinence and quality of life should be determined separately for assessment of functional outcome after low anterior resection.
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Affiliation(s)
- Theo Junginger
- Department of General & Abdominal Surgery at the University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.
| | - Susann Rassouli
- Department of General & Abdominal Surgery at the University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Ursula Goenner
- Department of General & Abdominal Surgery at the University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Andre Lollert
- Department of Diagnostic & Interventional Radiology at the University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Maria Blettner
- Institute of Medical Biostatistics, Epidemiology & Informatics at the University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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23
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Emmertsen KJ, Laurberg S. Impact of bowel dysfunction on quality of life after sphincter-preserving resection for rectal cancer. Br J Surg 2013; 100:1377-87. [PMID: 23939851 DOI: 10.1002/bjs.9223] [Citation(s) in RCA: 262] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bowel dysfunction after sphincter-preserving surgery for rectal cancer is a common complication, with the potential to affect quality of life (QoL) strongly. The aim of this study was to examine the extent of bowel dysfunction and impact on health-related QoL after curative sphincter-preserving resection for rectal cancer. METHODS QoL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, and bowel function using a validated questionnaire, including the recently developed low anterior resection syndrome (LARS) score. Assessments were carried out at the time of diagnosis, and at 3 and 12 months after surgery. RESULTS A total of 260 patients were included in the study. At 3 months, 58·0 per cent of patients had a LARS score of 30 or more (major LARS), which declined to 45·9 per cent at 12 months (P < 0·001). The risk of major LARS was significantly increased in patients who received neoadjuvant therapy (odds ratio 2·41, 95 per cent confidence interval 1·00 to 5·83), and after total versus partial mesorectal excision (odds ratio 2·81, 1·35 to 5·88). Global health status was closely associated with LARS, and significant differences in global health status, functional and symptom scales of QoL were found between patients without LARS and those with major LARS. CONCLUSION Bowel dysfunction is a major problem with an immense impact on QoL following sphincter-preserving resection. The risk of major LARS was significantly increased after neoadjuvant therapy and total mesorectal excision.
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Affiliation(s)
- K J Emmertsen
- Colorectal Research Unit, Colorectal Surgical Department P, Aarhus University Hospital, Tage-Hansens Gade 2, DK-8000, Aarhus C, Denmark.
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Coloanal anastomosis or abdominoperineal resection for very low rectal cancer: what will benefit, the surgeon's pride or the patient's quality of life? Int J Colorectal Dis 2013; 28:949-57. [PMID: 23274737 DOI: 10.1007/s00384-012-1629-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2012] [Indexed: 02/07/2023]
Abstract
PURPOSES Sphincter-saving operation with coloanal anastomosis (CAA) has become an established option for very low rectal cancer, but few studies have compared its functional results and quality of life (QoL) with abdominoperineal resection (APR) showing controversial results. PATIENTS AND METHODS Patients treated for low rectal cancer with APR or CAA, disease-free after a median follow-up period of 26.5 (8-84) and 52.5 (12-156) months, respectively, were retrospectively reviewed. General and disease-specific changes in QoL and severity of disease were evaluated by Karnofsky scale, EORTC-C30, EORTC-CR38, SF-36, PGWBI, FIQL, PAC-QoL, ICIQ-SF, Stoma-QoL, AMS, Wexner's score and obstructed defecation syndrome (ODS) score. RESULTS Twenty-six APR patients and 34 CAA patients entered the study. Karnofsky score did not show significant differences. The median Stoma-QoL was 58.2 (45-76.6), indicating a good stoma function in 95% of patients. EORTC-C30, CR38, PGWBI and SF-36 questionnaires did not show significant differences between the two groups except for sexual function (better after CAA, p = 0.01). Eleven patients after APR and eight after CAA had urinary incontinence, and its severity did not differ significantly. Eighteen of 21 CAA patients complained of faecal incontinence [AMS, 80 (15-120); Wexner, 13 (2-19)] with an impact on their QoL [FIQL: lifestyle, 1.75 (0-4); coping/behaviour, 1.3 (0-3.5); depression, 2.1 (0-5.2); embarrassment, 2 (0-4.6)] and 11 complained of obstructed defecation [7.5 (3-16)] with significant consequences on QoL [PAC-QoL, 30.4 (19.2-80.3)]. CONCLUSIONS QoL in patients with permanent stoma and in those after CAA did not differ significantly. APR patients had worse sexual function, while most CAA patients had faecal incontinence and sometime obstructed defecation, with important impact on their QoL.
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Abstract
Colorectal cancer (CRC) is one of the most common malignancies worldwide. Due to a higher incidence of CRC in the western hemisphere a significant amount of research was carried out and majority of the controversies could be resolved as far as management of CRC is concerned. Recently a number of significant advances were made in the field of CRC related to surgery, systemic therapy and radiotherapy. During the last decade we have witnessed introduction of minimally invasive surgery, incorporation of more effective newer chemotherapeutic regimes and targeted therapies and refinements in radiotherapy protocols. The demographics and clinical picture of CRC seems to be different in developing countries and there is paucity of CRC related studies from developing countries. In-order to update the practicing surgeons a review of conventional controversies of CRC surgery was performed and an update on the recent developments in the field of CRC was also presented in this article.
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Mehrvarz S, Towliat SM, Mohebbi HA, Derakhshani S, Abavisani M. Comparison of Colonic J-pouch and Straight Coloanal anastomosis after Low Anterior Resection. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:32-5. [PMID: 23486745 PMCID: PMC3589776 DOI: 10.5812/ircmj.3804] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 06/16/2012] [Accepted: 07/08/2012] [Indexed: 11/16/2022]
Abstract
Background The tendency towards sphincter preserving for low rectal cancers with low anterior resection, has led to the technique of straight coloanal anastomosis (SCAA) or colonic J-pouch anal anastomosis (CPAA). Objectives The aim of our study was to compare functional outcomes, complication rates and quality of life (QoL) after LAR with either a straight or colonic J pouch anastomosis. Patients and Methods In 88 patients with rectal tumors located in lower third, who were candidate for LAR with coloanal anastomosis. They were divided for reconstruction using either SCAA (n= 47) or CPAA (n= 41) from January 2007 to May 2009. Functional results were assessed after closure of temporary loop ileostomy, 6 months postoperatively. Quality of life (QoL) was measured using European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30. Results The two groups were matched for gender, age, and preoperative chemotherapy and radiotherapy. There were no significant differences between the SCAA and CPAA groups relative to anastomotic leakage. Among patients with CPAA, the mean of 24 hours bowel movements, daytime bowel movements, incontinence scores, and incidence of urgency were significantly lower than those in the SCAA group. Also, patients with a CPAA had a significantly better quality of life. Conclusions CPAA provided not only better functional results than SCAA, but also improved quality of life, thus may be the better choice.
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Affiliation(s)
- Shaban Mehrvarz
- Department of General Surgery, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Shaban Mehrvarz, Department of General Surgery, Baqiyatallah University of Medical Sciences, Tehran, Iran. Tel.: +98-2188033539, Fax: +98-2188033539, E-mail:
| | - Seyed Mohsen Towliat
- Baqiyatallah University of Medical Sciences, Research Center for Gastroenterology and Liver Disease, Tehran, IR Iran
| | - Hassan Ali Mohebbi
- Department of General Surgery, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | | | - Mahdi Abavisani
- Department of General Surgery, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
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Abstract
Up to 80% of patients with rectal cancer undergo sphincter-preserving surgery. It is widely accepted that up to 90% of such patients will subsequently have a change in bowel habit, ranging from increased bowel frequency to faecal incontinence or evacuatory dysfunction. This wide spectrum of symptoms after resection and reconstruction of the rectum has been termed anterior resection syndrome. Currently, no precise definition or causal mechanisms have been established. This disordered bowel function has a substantial negative effect on quality of life. Previous reviews have mainly focused on different colonic reconstructive configurations and their comparative effects on daily function and quality of life. The present Review explores the potential mechanisms underlying disturbed functions, as well as current, novel, and future treatment options.
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Affiliation(s)
- Catherine L C Bryant
- Academic Surgical Unit, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Kwaan MR. Bowel Function After Rectal Cancer Surgery: A Review of the Evidence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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The long-term gastrointestinal functional outcomes following curative anterior resection in adults with rectal cancer: a systematic review and meta-analysis. Dis Colon Rectum 2011; 54:1589-97. [PMID: 22067190 DOI: 10.1097/dcr.0b013e3182214f11] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Significant variability and a lack of transparency exist in the reporting of anterior resection outcomes. OBJECTIVES This study aimed to qualitatively analyze the long-term functional outcomes and assessment tools used in evaluating patients with rectal cancer following anterior resection, to quantify the incidence of these outcomes, and to identify risk factors for long-term incontinence. DATA SOURCES MEDLINE, Embase, and CINAHL were searched using the terms rectal neoplasms, resection, and gastrointestinal function. STUDY SELECTION The studies included were in English and evaluated adults with rectal cancer, curative anterior resection, and a minimum 1-year follow-up. Patients with recurrent/metastatic disease were excluded. Of the 805 records identified, 48 articles were included. INTERVENTION The intervention performed was anterior resection. MAIN OUTCOME MEASURES The main outcome measure was incontinence (gas, liquid stool, and solid stool). RESULTS The histories of 3349 patients from 17 countries were summarized. Surgeries were conducted between 1978 to 2004 with a median follow-up of 24 months (interquartile range, 12, 57). Sixty-five percent of studies did not use a validated assessment tool. Reported outcomes and incidence rates were variable. The reported proportion of patients with incontinence ranged from 3.2% to 79.3%, with a pooled incidence of 35.2% (95% CI 27.9, 43.3). Risk factors for incontinence, identified by meta-regression, were preoperative radiation 0.009 and, in particular, short-course radiation (P = .006), and study quality (randomized controlled trial P = .004, observational P = .006). LIMITATIONS The meta-analysis was limited by the significant heterogeneity of the primary data. CONCLUSIONS Functional outcomes are inconsistently assessed and reported and require common definitions, and the more regular use of validated assessment tools, as well. Preoperative radiation and, in particular, short-course radiation may be a strong risk factor for incontinence; however, further studies are needed.
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Armengol-Debeir L, Savoye G, Leroi AM, Gourcerol G, Savoye-Collet C, Tuech JJ, Vassilieff M, Roman H. Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum: a preliminary study. Hum Reprod 2011; 26:2330-5. [PMID: 21705371 DOI: 10.1093/humrep/der190] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Kruschewski M, Gröne J, Vogel N, Zimmermann M, Buhr HJ. Management and results of complications after anterior resection with colonic pouch reconstruction for rectal cancer. Colorectal Dis 2011; 13:284-9. [PMID: 19925491 DOI: 10.1111/j.1463-1318.2009.02140.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Colonic J-pouch reconstruction is widely carried out during low anterior resection. The aim of this observational study was to describe the complications and evaluate the results of adverse event management. METHOD A total of 128 patients underwent an elective anterior resection with colorectal or coloanal J-pouch reconstruction for primary rectal cancer between January 1997 and December 2008. RESULTS The overall mortality was 1.6%. Three (2.3%) patients developed pouch necrosis, one of whom died. The rate of anastomotic leakage was 11.7%. Other major complications included intra-abdominal abscess (3.1%), haemorrhage (0.8%) and abdominal dihiscence (0.8%). In all cases of anastomotic leakage, the pouch was salvaged, with 80% of patients undergoing surgical revision with relaparotomy and transanal suture. Patients with pouch necrosis underwent relaparotomy with removal of the pouch and a terminal colostomy. In all cases of intra-abdominal abscess without anastomotic leakage, radiologically controlled percutaneous drainage was carried out. CONCLUSION Anal function can usually be saved after anastomotic leakage by salvage surgery without increase in mortality.
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Affiliation(s)
- M Kruschewski
- Department of Surgery, Charité- Universitätsmedizin Berlin, Berlin, Germany.
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de la Fuente SG, Mantyh CR. Reconstruction techniques after proctectomy: what's the best? Clin Colon Rectal Surg 2010; 20:221-30. [PMID: 20011203 DOI: 10.1055/s-2007-984866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Sebastian G de la Fuente
- Division of Colorectal Surgery, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Park J, Neuman HB, Weiser MR, Wong WD. Randomized clinical trials in rectal and anal cancers. Surg Oncol Clin N Am 2010; 19:205-23. [PMID: 19914567 DOI: 10.1016/j.soc.2009.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This article reviews randomized clinical trials (RCTs) published between April 2001 and November 2008 on the management of patients with rectal cancer. In total, the authors reviewed 78 RCTs on therapy for rectal cancer. Of these, five met the authors' criteria for level 1a evidence. The article discusses the major RCTs and relevant findings that have impacted clinical management most and includes most but not all RCTs on therapy for rectal cancer published during this period.
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Affiliation(s)
- Jason Park
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Cheung YM, Lange MM, Buunen M, Lange JF. Current technique of laparoscopic total mesorectal excision (TME): an international questionnaire among 368 surgeons. Surg Endosc 2009; 23:2796-801. [PMID: 19551439 DOI: 10.1007/s00464-009-0566-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 04/19/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Current literature shows no consensus for the technique of laparoscopic total mesorectal excision (LTME). This study aimed to assess the current practice of LTME. METHODS From January to March 2008, members of the European Association for Endoscopic Surgery (EAES), the Indian Association of Gastrointestinal Endo-Surgeons (IAGES), and the Society of Laparoscopic Surgeons (SLS), together with renowned surgeons in the field of LTME, were invited to fill out an online questionnaire concerning aspects of LTME. RESULTS The 368 questionnaires showed that 77% of the study participants performed 1-20 LTMEs per year (low volume) and that 33% performed more than 20 LTMEs per year (high volume). Preoperative bowel preparation (PBP), Trendelenburg position, periumbilical insertion of a 30º laparoscope, medial-to-lateral dissection, ultrasonic hemostasis, high-tie ligation, splenic flexure mobilization, left ureteral identification, partial sigmoid resection, extraction of the specimen by a new minilaparotomy and wound protector, end-to-end stapled anastomosis using a 28- to 29-mm anvil with 3.5-mm staples, abdominal lavage, pelvic drainage, and diverting ileostoma were performed by a majority of the surgeons. Less consistency was observed in identification of the right ureter, dissection of Denonvilliers' fascia, location of the minilaparotomy, and construction of a colonic pouch. There were significant differences between high and low volume and between American and European surgeons. Significantly more low-volume surgeons indicated a preference for an open TME depending on the age and gender of the patient, the presence of comorbidity, previous laparotomy, and locally advanced tumor. More low-volume surgeons applied PBP (83.4% vs. 71.8%; p = 0.017). On the average, high-volume surgeons identified more autonomic pelvic nerves during dissection (2.6 vs. 1.8 nerves). The right ureter was identified by 66% of the American and 31.2% of the European surgeons. In the United States 91.5% and in Europe 61.2% created an end-to-end anastomosis. Pouches were created by 32% of the European and 6.8% of the American surgeons. CONCLUSION The respondents showed an apparent preference for several aspects of LTME. Differences were related to expertise and still more to continent.
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Affiliation(s)
- Y M Cheung
- Department of Surgery, Erasmus University Medical Center, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Lefevre JH, Parc Y. Colorectal/Coloanal Anastomosis Colonic J-Pouch, Coloplasty, Side-to-End Anastomosis: Techniques. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tomita R. Sacral Nerve Terminal Motor Latency in Patients With or Without Soiling More Than 2 Years After Low Anterior Resection for Low Rectal Cancer. World J Surg 2009; 33:1495-501. [DOI: 10.1007/s00268-009-0035-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Neorectal irritability after short-term preoperative radiotherapy and surgical resection for rectal cancer. Am J Gastroenterol 2009; 104:133-41. [PMID: 19098861 DOI: 10.1038/ajg.2008.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Preoperative radiotherapy followed by rectal resection with total mesorectal excision (TME) and colo-anal anastomosis severely compromises anorectal function, which has been attributed to a decrease in neorectal capacity and neorectal compliance. However, to what extent altered motility of the neorectum is involved, is still unknown. The aim of the study was to compare the motor response to (prolonged) filling of the (neo-)rectum in patients after preoperative radiotherapy and rectal resection with that in healthy volunteers (HV). METHODS Neorectal function (J-pouch or side-to-end anastomosis) was studied in 15 patients (median age 61 years, 10 males) 5 months after short-term preoperative radiotherapy (5 x 5 Gy) and rectal resection with TME for rectal cancer and compared with that of 10 volunteers (median age 41 years, 7 males). Furthermore, patients with a colonic J-pouch anastomosis (n=6) were compared with patients with a side-to-end anastomosis (n=9). (Neo-)rectal sensitivity was assessed using a stepwise isovolumetric and isobaric distension protocol. (Neo-)rectal motility was determined during prolonged distension at the threshold of the urge to defecate. RESULTS The neorectal volume of patients at the threshold of the urge to defecate (125 +/-45 ml) was significantly lower when compared with that of HV (272+/-87 ml, P<0.05). The pressure threshold, however, did not differ between patients (26+/-9 mm Hg) and HV (21+/-5 mm Hg) and neither did the pressure threshold differ between patients with a J-pouch and those with side-to-end anastomosis. In HV, no rectal contractions were observed during prolonged rectal distension. In contrast, in all 15 patients, prolonged isovolumetric and isobaric distension induced 3 (range 0-5) rectal contractions/10 min, which were associated with an increase in sensation in half of the patients. CONCLUSIONS Patients who underwent preoperative radiotherapy and rectal resection with TME, but not HV, developed contractions of the neo-rectum in response to prolonged distension. We suggest that this neorectal "irritability" represents a new pathophysiological mechanism contributing to the urgency for defecation after this multimodality treatment.
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Abstract
INTRODUCTION Rectal cancer is a common disease in Western populations. Improved treatment modalities have resulted in increased survival and tumour control. With increasing survival there is a growing need for knowledge about the long-term side effects and functional results after the treatment. AIM To describe the long-term functional outcome in patients treated for rectal cancer through a systematic review of the current literature and to provide an outline of the promising developments within this area. RESULTS Standard resectional surgery with loss of the rectal reservoir function results in poor functional results in up to 50-60% of the patients. New methods of surgery including the construction of a neoreservoir and improvement of the technique for local excision have been developed to minimize the functional disturbances without compromising the oncological result. The addition of chemo and/or radiotherapy approximately doubles the risk of poor functional results. During the last decades the techniques for chemo/radiotherapy has been markedly improved with a positive impact on functional outcome. New methods for treatment of functional disturbances e.g. bowel irrigation and sacral nerve stimulation are currently under development. PERSPECTIVES To improve the functional outcome in this growing patient population several approaches can be taken. The primary cancer treatment must be improved by minimizing the surgical trauma and optimizing the imaging and radiation techniques. Population screening should be considered in order to find the cancers at an earlier stage, hereby increasing the proportion of patients eligible for local excision without the need for chemo/irradiation. All patients recovering from rectal resection should be examined and registered systematically regarding their functional results and treatment should be offered to the severely affected patients. More studies are still needed to evaluate the efficacy of irrigation and nerve stimulation in this patient group.
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Ulrich AB, Seiler CM, Z'graggen K, Löffler T, Weitz J, Büchler MW. Early results from a randomized clinical trial of colon J pouch versus transverse coloplasty pouch after low anterior resection for rectal cancer. Br J Surg 2008; 95:1257-63. [DOI: 10.1002/bjs.6301] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Background
Patients with primary rectal cancer undergoing low anterior resection are often reconstructed using a pouch procedure. The aim of this trial was to compare colon J pouch (CJP) with transverse coloplasty pouch (TCP) reconstruction with regard to functional results, perioperative mortality and morbidity. As there is considerable uncertainty over the true anastomotic leak rate in patients with a TCP, the study analysed short-term outcome data.
Methods
Elective patients suitable for either procedure after sphincter-saving low anterior resection were eligible. Randomization took place during surgery. The primary endpoint was the rate of late evacuation problems after 2 years; secondary endpoints were anastomotic leak rate, perioperative morbidity and mortality.
Results
Between 21 October 2002 and 5 December 2005, 149 patients were randomized. All 76 patients randomized to TCP had the procedure compared with 68 of the 73 patients (93 per cent) randomized to CJP. Both groups were comparable with regard to demographic and clinical characteristics. Surgical complications (CJP: 19 per cent; TCP: 18 per cent) and the overall anastomotic leak rate (8 per cent) were equally distributed in both groups.
Conclusion
This trial demonstrated a comparable early outcome for TCP and CJP. This contradicts previous reports suggesting a higher leak rate after TCP. Registration number: ISRCTN78983587 (http://www.controlled-trials.com).
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Affiliation(s)
- A B Ulrich
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C M Seiler
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - K Z'graggen
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - T Löffler
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - J Weitz
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Anal Sphincter Asymmetry in Anal Incontinence After Restorative Proctectomy for Rectal Cancer. World J Surg 2008; 32:2083-8. [DOI: 10.1007/s00268-008-9602-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
BACKGROUND Total mesorectal resection (TME) has led to improved survival and reduced local recurrence in patients with rectal cancer. Straight coloanal anastomosis after TME can lead to problems with frequent bowel movements, fecal urgency and incontinence. The colonic J pouch, side-to-end anastomosis and transverse coloplasty have been developed as alternative surgical strategies in order to improve bowel function. OBJECTIVES The purpose of this study is to determine which rectal reconstructive technique results in the best postoperative bowel function. SEARCH STRATEGY A systematic search of the literature (MEDLINE, Cancerlit, Embase and Cochrane Databases) was conducted from inception to Feb 14, 2006 by two independent investigators. SELECTION CRITERIA Randomized controlled trials in which patients with rectal cancer undergoing low rectal resection and coloanal anastomosis were randomized to at least two different anastomotic techniques. Furthermore, a measure of postoperative bowel function was necessary for inclusion. DATA COLLECTION AND ANALYSIS Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers. Data from included trials was collected using a standardized data collection form. Data was collated and qualitatively summarized for bowel function outcomes and meta-analysis statistical techniques were used to pool data on postoperative complications. MAIN RESULTS Of 2609 relevant studies, 16 randomized controlled trials (RCTs) met our inclusion criteria. Nine RCTs (n=473) compared straight coloanal anastomosis (SCA) to the colonic J pouch (CJP). Up to 18 months postoperatively, the CJP was superior to SCA in most studies in bowel frequency, urgency, fecal incontinence and use of antidiarrheal medication. There were too few patients with long-term bowel function outcomes to determine if this advantage continued after 18 months postop. Four RCTs (n=215) compared the side-to-end anastomosis (STE) to the CJP. These studies showed no difference in bowel function outcomes between these two techniques. Similarly, three RCTs (n=158) compared transverse coloplasty (TC) to CJP. Similarly, there were no differences in bowel function outcomes in these small studies. Overall, there were no significant differences in postoperative complications with any of the anastomotic strategies. AUTHORS' CONCLUSIONS In several randomized controlled trials, the CJP has been shown to be superior to the SCA in bowel function outcomes in patients with rectal cancer for at least 18 months after gastrointestinal continuity is re-established. The TC and STE anastomoses have been shown to have similar bowel function outcomes when compared to the CJP in small randomized controlled trials; further study is necessary to determine the role of these alternative coloanal anastomotic strategies.
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Affiliation(s)
- C J Brown
- University of Toronto, Surgery, 449-600 University Avenue, Toronto, Ontario, Canada, M5G 1X5.
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Steffen T, Tarantino I, Hetzer FH, Warschkow R, Lange J, Zünd M. Safety and morbidity after ultra-low coloanal anastomoses: J-pouch vs end-to-end reconstruction. Int J Colorectal Dis 2008; 23:277-81. [PMID: 18071719 DOI: 10.1007/s00384-007-0414-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Anastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage. MATERIALS AND METHODS Fifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3-4 cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively. RESULTS/FINDINGS No influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (P = 0.023). INTERPRETATION/CONCLUSION Patient's safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.
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Affiliation(s)
- Thomas Steffen
- Department of Surgery, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland.
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de la Fuente SG, Mantyh CR. Outcomes Review of Reconstructive Techniques Following Proctectomy. SEMINARS IN COLON AND RECTAL SURGERY 2008. [DOI: 10.1053/j.scrs.2008.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Otto S, Kroesen AJ, Hotz HG, Buhr HJ, Kruschewski M. Effect of anastomosis level on continence performance and quality of life after colonic J-pouch reconstruction. Dig Dis Sci 2008; 53:14-20. [PMID: 17520367 DOI: 10.1007/s10620-007-9815-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 02/20/2007] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Susanne Otto
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany
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Koh PK, Tang CL, Eu KW, Samuel M, Chan E. A systematic review of the function and complications of colonic pouches. Int J Colorectal Dis 2007; 22:543-8. [PMID: 16969678 DOI: 10.1007/s00384-006-0187-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2006] [Indexed: 02/04/2023]
Abstract
PURPOSE This is a meta-analysis of randomized, controlled trials to compare the function and complications of a straight coloanal anastomosis to a colonic J-pouch after rectal excision at 1 year postoperatively. MATERIALS AND METHODS A search for articles from 1980 to 2005 was conducted on Medline, PubMed, and the Cochrane Controlled Trials Register using the keywords "colonic pouches, J-pouch, straight and coloanal anastomosis, rectal cancer, function and complications," either singularly or in combination. Reference lists from short-listed articles were also manually searched for relevant articles, journals, and conference proceedings. Randomized controlled trials (RCTs) in English publications comparing colonic J-pouches to straight coloanal anastomosis were selected. Trials with similar patient characteristics, duration of follow-up, and outcome measures were pooled for analysis. Stool frequency and fecal continence at 1 year postoperatively were used as measures of functional outcome. Complication rates in terms of anastomotic leak and stricture formation were analysed. RESULTS Ten RCTs with satisfactory methodology were identified. One trial reported the results at 2 years, while another reported results at 5 years only and were excluded from the meta-analysis, leaving only eight studies for further analysis. Overall, a colonic J-pouch appeared more favorable in terms of stool frequency (weighted mean difference of -1.21, 95% CI: -1.92 to -0.49) and continence (Odds ratio 0.23, 95% CI: 0.08-0.69), with a slightly lower risk of anastomotic dehiscence compared to a straight coloanal anastomosis (relative risk, RR 0.36; 95% CI: 0.12-1.08). Anastomotic stricture was reported in only two trials. They seemed more likely to occur after a pouch-anal anastomosis (RR 2.45, 95% CI: 0.79-7.57). However, the small numbers available for pooled analysis cannot allow these conclusions to be drawn with confidence. CONCLUSIONS A straight coloanal anastomosis resulted in poorer function due to loss of a rectal reservoir, while colonic J-pouches have improved frequency and continence up to a year. Although retrospective reports seem to favor the use of a pouch, there are limited longer term randomized trial data to suggest that the function and complications of a coloanal J-pouch is better than a straight coloanal anastomosis. Larger randomized studies are required to further verify the longer-term benefits of a coloanal pouch.
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Affiliation(s)
- Poh-Koon Koh
- Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
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Liang JT, Lai HS, Lee PH, Huang KC. Comparison of functional and surgical outcomes of laparoscopic-assisted colonic J-pouch versus straight reconstruction after total mesorectal excision for lower rectal cancer. Ann Surg Oncol 2007; 14:1972-9. [PMID: 17431725 DOI: 10.1245/s10434-007-9355-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 12/26/2006] [Indexed: 01/03/2023]
Abstract
BACKGROUND To compare the functional and surgical outcomes of colonic J-pouch and straight anastomosis in the context that both reconstruction procedures were performed laparoscopically. METHODS The present study was a randomized prospective clinical trial. Patients with lower rectal cancer requiring laparoscopic total mesorectal excision were equally randomized to either laparoscopic-assisted colonic J-pouch reconstruction or laparoscopic straight end-to-end anastomosis. The techniques of the laparoscopic-assisted colonic J-pouch reconstruction are shown in the attached video. The primary end point was the comparison of functional results in both reconstruction methods. The secondary end points included the safety (surgical morbidity and mortality), surgical efficiency, and postoperative recovery. RESULTS A total of 48 patients were recruited within 2-year periods, in consideration of statistical power of 90% for comparison. There was no marked difference between patient groups undergoing colonic J-pouch surgery (n = 24) and straight anastomosis (n = 24) in various demographic and clinicopathogic parameters. The anorectal function of patients by colonic J-pouch were better than those by straight anastomosis in 3 months after operation, as evaluated by stool frequency (mean +/- standard deviation: 4.0 +/- 2.0 vs. 7.0 +/- 2.4 times/day, P < .001); use of antidiarrheal agents (29.2% [n = 7] vs. 75.0% [n = 18], P = .004); and perineal irritation (45.8% [n = 11] vs. 79.2% [n = 19], P = .037). Because of the relatively better bowel function in immediate postoperative period, patients by colonic J-pouch reconstruction were less disabled after surgery and had quicker return to partial activity (P = .039), full activity (P < .001), and work (P < .001). Both reconstruction methods were performed with similar amounts of blood loss, complication rates, and postoperative recovery. However, the operation time was significantly longer in the colonic J-pouch group (274.4 +/- 34.0 vs. 202.0 +/- 28.0 minutes, P < .001). CONCLUSIONS Because laparoscopic-assisted creation of a colonic J-pouch achieved better short-term functional results of the anorectum and did not increase surgical morbidity, as compared with laparoscopic straight anastomosis, this reconstruction procedure could be recommended to patients with lower rectal cancer requiring laparoscopic total mesorectal excision.
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Affiliation(s)
- Jin-Tung Liang
- Department of Surgery, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan, Republic of China.
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Murphy J, Hammond TM, Knowles CH, Scott SM, Lunniss PJ, Williams NS. Does Anastomotic Technique Influence Anorectal Function after Sphincter-Saving Rectal Cancer Resection? A Systematic Review of Evidence from Randomized Trials. J Am Coll Surg 2007; 204:673-80. [PMID: 17382228 DOI: 10.1016/j.jamcollsurg.2007.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Revised: 12/26/2006] [Accepted: 01/02/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Jamie Murphy
- Centre for Academic Surgery, Bart's and The London, The Royal London Hospital, Whitechapel, London, UK.
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Tomita R, Igarashi S, Ikeda T, Koshinaga T, Fujisaki S, Tanjoh K. Pudendal Nerve Terminal Motor Latency in Patients With or Without Soiling 5 Years or more after Low Anterior Resection for Lower Rectal Cancer. World J Surg 2006; 31:403-8. [PMID: 17180566 DOI: 10.1007/s00268-006-0149-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND To clarify the neurological function with respect to external anal sphincter (EAS) muscles in patients with or without soiling after low anterior resection (LAR) for lower rectal cancer, we examined the terminal motor latency in the pudendal motor nerves (PNTML). MATERIALS AND METHODS Thirty-eight patients after LAR for lower rectal cancer were studied electrophysiologically and compared with 30 healthy volunteers as controls (19 men and 11 women, aged 44 to 76 years of age, with a mean age of 65.5 years). Patients after LAR were divided into two groups [18 patients with soiling (12 men and 6 women, aged 51 to 77 years with a mean age of 64.8 years), 20 patients without soiling (13 men and 7 women, aged 47 to 75 years with a mean age of 62.1 years)]. The mean follow-up time from LAR was 67.2 months (range 60-84 months). Bilateral (left-sided and right-sided) PNTML tests were performed on all patients in order to measure the latency of the response in the bilateral EAS muscle following digitally directed transrectal pudendal nerve stimulation. RESULTS The distance from the anal verge to the level of anastomosis in patients with soiling (mean, 2.2 cm) was significantly shorter than that in patients without soiling (mean, 4.1 cm) (P < 0.05). Conduction delay of the bilateral PNTML in patients with soiling was longer than that in patients without soiling and normal subjects, significantly (P < 0.01, respectively). There was no significant difference between the right-sided and left-sided PNTML. CONCLUSIONS These findings support the hypothesis that soiling after LAR may be partially caused by damage to the bilateral pudendal motor nerves.
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Affiliation(s)
- Ryouichi Tomita
- Department of Surgery, Nippon Dental University School of Dentistry at Tokyo, 2-3-16 Fujimi Chiyoda-ku, Tokyo, 102-8158, Japan.
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Abstract
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.
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