[The Transverse Coloplasty Pouch (TCP)--function and subjective judgement in comparison with the surgically more complicated J-Pouch]

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

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

Reconstruction techniques after proctectomy: what's the best?

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

Early results from a randomized clinical trial of colon J pouch versus transverse coloplasty pouch after low anterior resection for rectal cancer

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).

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

Background and methods

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

Results

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

Conclusions

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

The transverse coloplasty pouch

BACKGROUND

The introduction of the total mesorectal excision (TME) and the use of modern staplers have improved outcome and increased the rate of sphincter-preserving low anterior resections in rectal cancer. Consequently, the interest in functional results after rectal reservoir reconstruction increased significantly.

METHODS

A review of the current literature was conducted on the development of colon pouch procedures with a particular focus on the transverse coloplasty pouch compared with the colon J-pouch and other current techniques of reconstruction after TME such as the side-to-end anastomosis.

RESULTS

The colon J-pouch (CJP) became the "gold standard" for rectal reservoir reconstruction owing to better early functional results compared with the straight coloanal anastomosis (CAA). However, 30% of the patients with CJP faced late evacuation problems requiring the chronic use of enemas or laxatives. This rate could be decreased by shortening the limb of the CJP from 8-10 to 5-6 cm, but the late evacuation problems remained in approximately 10% of the patients. An overview of the current knowledge on technical and functional aspects as well as indications and results of the transverse coloplasty pouch (TCP) is presented.

CONCLUSION

The TCP was developed to provide early functional results comparable to the CJP while avoiding the late evacuation problems. Functional results after TCP, small colon J-pouch and side-to-end anastomosis are similar. Evacuation problems after TCP have not been reported.

Functional results of the colon J-pouch versus transverse coloplasty pouch in Heidelberg

Within the last 20 years various achievements have been made in the treatment of rectal cancer, improving survival and quality of life of rectal cancer patients. Especially the introduction of the total mesorectal excision (TME) and the use of modern staplers, making anastomoses possible in the deep pelvis, have increased our ability to cure more and more low rectal cancers by sphincter-preserving low anterior resections. Consequently, the interest in functional results after rectal reservoir reconstruction has increased significantly. Various randomized controlled trials have shown that the colon J-pouch (CJP) as a rectal reservoir reconstruction leads to better early functional results compared to the straight coloanal anastomosis (CAA). However, 30% of the patients with CJP faced late evacuation problems, requiring the chronic use of enemas or laxatives. This rate could be decreased to 10% by shortening the limb of the CJP from 8-10 cm to 5-6 cm. The transverse coloplasty pouch (TCP) was developed to provide early functional results comparable to the CJP, while avoiding these late evacuation problems. We report the early postoperative and functional results of 106 patients undergoing low anterior resections with TCP due to rectal cancer between October 2001 and the end of September 2003. Furthermore, we report on a single-center randomized controlled trial to compare the new TCP technique with the gold standard technique of CJP, which we started in October 2002. The objectives were to compare the two pouch reconstruction techniques in terms of morbidity, mortality and functional results.

Transverser Koloplastik-Pouch nach tiefer anteriorer Resektion

INTRODUCTION

A colon J pouch (CJP) still represents the standard rectal reservoir after low anterior resection. Though the CJP shows favourable early functional results, pouch evacuation problems tend to occur in the long term. The transverse coloplasty pouch (TCP), developed by our group allows comparable early functional results while avoiding evacuation problems. We report our experience with the TCP at the University Hospital of Heidelberg, Germany, and examine the risk of anastomotic leaks with this technique.

METHODS

Between 1 October 2001 and 31 May 2003, 201 patients with rectal tumours underwent resection. Eighty-two patients with formation of TCP were enrolled in the study.

RESULTS

During the creation of the TCP, no technical problems occurred, and the overall morbidity was 28%, including anastomotic leaks in seven patients (8.5%) and bleeding in two. The reoperation rate was 8.5%. An association between postoperative morbidity and preoperative radiation therapy could not be established. The hospital mortality rate was 3.6%.

CONCLUSIONS

The use of TCP is a safe procedure which has gained worldwide acceptance in a short time, representing a technically straightforward procedure. Independently of patient size, habitus, and bulkiness of the colon, a TCP can always be performed after low rectal resection.