Management of the Symptoms after a Resection of the Rectum

ABSTRACT

Many patients have functional disturbances after a traditional restorative rectal resection, complaining of urgency, frequent bowel movements, and occasional fecal incontinence. The rectal reservoir function is disturbed, and this is related to the size of the rectal remnant and the elastic properties of the neorectal wall. A straight anastomosis is recommended when the reservoir capacity of the rectal remnant is sufficient. A side-to-end anastomosis is probably preferable to an end-to-end anastomosis. If a straight anastomosis is considered, the descending colon is much better than the sigmoid colon. If optimal functional results are to be obtained soon after surgery, construction of a pouch is recommended when the rectal remnant is very short. There seems to be a balance between continence without urgency and evacuation ability. For patients with weak sphincter muscles and habitually loose feces, the surgeon should tailor the length of the pouch to be longer whereas it should be made smaller for patients with a pre-operative tendency toward constipation. In the long-term, bowel adaptation may also enable the function after a straight anastomosis to approximate that of a colonic J-pouch anal 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 that of the colonic J-pouch. Traditionally, poor bowel function has been managed expectantly. The colonic adaptation may take one or two years to occur after a low anterior resection. The patient is advised to take adequate soluble fiber in the diet and to avoid foods which aggravate the bowel dysfunction. Those with increased stool frequency are prescribed constipating agents to help control the symptoms. Patients with rectal evacuation problems are prescribed regular laxatives and enemas.