Colonic J pouch neo‑rectum versus straight anastomosis for low rectal cancers.

AIM: The development of sphincter saving procedures for low carcinoma rectum has been the consequence of oncological and technological factors. The major disadvantage associated with these procedures is the development of anterior resection syndrome because of the resection of rectal reservoir. Colonic J pouch (CJP) neorectum has been practiced as an antidote to overcome this problem. We are working at a tertiary care center, which is a high volume center for rectal cancers. We thought it worthwhile to assess the efficacy of J Pouch neorectum viz.‑a‑viz. a straight coloanal anastomosis for low rectal cancers. MATERIALS AND METHODS: Hospital based prospective randomized study (June 2007‑December 2009) low rectal cancers (4‑12 cm from the anal verge). One group (20 patients) subjected to low/ultralow anterior resection with straight anastomosis (SA) and other group (22 patients) to CJP. The two groups were compared on the basis of functional outcome. RESULTS: Anastomotic leak, strictures, frequency of bowel movements, nocturnal bowel movements, use of retarding medication and incontinence to solids, liquids and gases were seen more in SA group. All these findings were statistically significant. CONCLUSIONS: We conclude that CJP has a significant functional advantage over SA and improves the overall quality‑of‑life in patients of low rectal cancers and the advantage persisted over a period of more than 30 months.

Application of sigmoid coloplasty after resection of middle or low rectal cancer / 中华消化外科杂志

Objective To investigate the feasibility of sigrnoid coloplasty for patients after resection of middle or low rectal carcinoma, and to evaluate the defecation function after the operation. Methods Forty-three patients with middle or low rectal cancer who had been admitted to the cancer Hospital of the Chinese Academy of Medical Sciences from January 2007 to January 2008 received sigrnoid coloplasty after rectal carcinoma resection (treatment group), and another 43 patients who had been admitted during the same period received colonic J pouch reconstruction (control group). The feasibility and safety of the 2 surgical procedures and postoperative defecation function were assessed. All data were processed by t test, chi-square test or Fisher exact probability. Results The sigmoid coloplasty was successfully performed in all patients in treatment group, while the reconstruction of the J pouch failed in 4 patients in the control group. Three patients in each group underwent temporary transverse colostomy. The incidences of postoperative complications in treatment group and control group were 7% (3/43) and 9% (4/43), respectively, with no statistical difference between the 2 groups (X2 =0. 282, P > 0.05). The median frequency of defecation in treatment group was 2.0 ± 1.5 per 24 hours, which was significantly less than 2.5 ± 1.0 in control group (X2 = 1. 242, P > 0.05). The fecal incontinence scores in treatment group and control group were 1.7 ± 0. 7 and 1.6 ± 0.8, respectively, with no statistical difference between the 2 groups (t = 0. 285, P > 0. 05). Conclusion Sigmoid coloplasty has similar benefits to colonic J pouch reconstruction, while sigmoid eoloplasty is relatively feasible, effective and safe for low colorectal or coloanal anastomosis.

Comparison of a Straight, a Coloplasty, and a Colonic J-pouch Anastomosis after a Proctectomy for Rectal Cancer

PURPOSE: Colonic pouches have been used to improve the reservoir function of the neorectrum after a ultra-low anterior resection for treatment of rectal cancer. The purpose of this study was to compare the safety and the functional outcome between a straight anastomosis, an anastomosis using coloplasty, and that using a colonic J-pouch in patients who had undergone an ultralow anterior resection. METHODS: From 2004 through 2006, 60 patients underwent a coloanal straight (straight group: n=23), coloplasty (coloplasty group: n=19), or colonic J-pouch (J-pouch group: n=18) anastomosis to the anal canal after a total mesorectal excision of the rectal cancer. We retrospectively reviewed the medical records of those patients for clinical outcomes according to the reservoir type. The median follow-up interval was 23.7 (4.4-40.9) mo. RESULTS: The anastomotic leakage rate was higher in the coloplasty group (21.1%) than in the straight group (8.7%) or in the J-pouch group (0%), but the difference was not significant (P=0.1). The mean number of bowel movements per day was significantly lower in the coloplasty group (3.6) and in the pouch group (3.1) than in the straight group (6.2) (P=0.015). No statistically significant differences were found among the three groups regarding other functional outcomes, including use of antidiarrheal drugs (P=0.971), gas incontinence (P=0.256), fecal incontinence (P=0.544), use of pads (P=0.782), difficulty of evacuation (P=0.496), and use of enemas (P=0.712). CONCLUSION: Reconstruction with a coloplasty or a colonic J-pouch in patients undergoing a low colorectal or coloanal anastomosis after rectal cancer surgery seems to decrease the number of daily bowel movements compared to a straight anastomosis. However, the anastomotic leakage rate of coloplasty group was higher than that of the straight-anastomosis group.

Clinical and Physiologic Anorectal Function after Low Anterior Resection in Patients with Rectal Cancer: A Prospective Randomized Comparison of Straight and Colonic J-Pouch Anastomoses

PURPOSE: The aim of this prospective study was to analyze anorectal physiologic and clinical outcomes of the colonic J-pouch-anal anastomosis compared with the traditional straight colorectal anastomosis after ultra-low anterior resection in patients with rectal cancer, thus to define if this method of modified reconstruction has a functional superiority. METHODS: After total mesorectal excision for mid or low rectal cancers, patients were randomized to either a straight (n=23) or a colonic J-pouch anastomosis (n=24) to the lowermost rectum or anal canal. Functional outcomes were compared between two groups using an anorectal manometry performed before and 1 year after surgery and a bowel function questionnaire administered 6 months and 1 year postoperatively. RESULTS: Except the arithmetic level of anastomosis which was significantly higher in straight group than in pouch group (5.1 +/- 1.2 cm vs. 3.8 +/- 0.9 cm; P=0.0001), the two groups were well matched for demographic distribution, pathologic stage, colonic segment used for neorectum and use of adjuvant therapies. Patients with colonic J-pouch anastomosis showed functional superiority in terms of frequency of bowel movements, degree of urgency at 6 months (P<0.0001 and =0.03, respectively) and 1 year postoperatively (P<0.0001 and <0.05, respectively). Functional parameters, including incontinence to liquid stool and impaired discrimination between gas and stool were more pronounced in straight group after 6 months (P=0.04, and <0.05, respectively), but the differences were not statistically significant after 1 year. Sensation of incomplete evacuation was not different statistically between groups at 6 months, but more common in J-pouch group at 1 year (39.1% vs. 8.3%; P=0.04). As well as the length of high pressure zone and presence of rectoanal inhibitory reflex, there was no difference in sphincter pressure parameters between groups either before or 1 year after surgery. Maximal tolerable volume of the neorectum in J-pouch group was 110.2 +/- 16.7 ml, which was significantly larger than that of 74.1 +/- 14.9 ml in straight group (P<0.0001), and the neorectum in J-pouch group was significantly more compliant than that in straight group (6.1 +/- 1.9 vs. 3.3 +/- 2.1; P<0.0001) in 1 year after surgery. CONCLUSIONS: Construction of a colonic J-pouch as a substitute for the rectum restores neorectal volume and compliance. Clinically it offers patients superior anorectal function compared with straight anastomosis. To minimize evacuation difficulty associated with the pouch, optimal size of the pouch should be defined, thus to achieve an ideal balance between stool frequency/urgency and evacuation problems through larger prospective studies.